Megan Srinivas, MD: [00:00:05] Welcome to Stories of Care, a podcast from the American Medical Association and the CDC project First Line. On this episode, we're joined by Dr Benson Shu, professor of pediatrics at the University of South Dakota, Stanford School of Medicine and chair of the section on Critical Care at the American Academy of Pediatrics. We discuss how Dr Shu and his colleagues in the pediatric ICU adapted their practice to the COVID 19 pandemic, embracing uncertainty, demonstrating compassion and protecting themselves and their community.
[00:00:42] Hi, Dr. Benson. Thank you so much for joining us today.
Benson Hsu, MD: [00:00:46] Thank you. It's a pleasure to be here.
Srinivas: [00:00:48] So you are in pediatrics and critical care pediatrics in South Dakota, right?
Hsu: [00:00:54] Correct and correct. I'm a professor of pediatrics at the University of South Dakota, Sanford School of Medicine, which is based in Sioux Falls, South Dakota. We're an academic center. We serve a predominantly rural population in a lot of underserved communities, such as the Native American reservations that are in the state.
Srinivas: [00:01:11] Oh, so you have quite a diverse practice setting, you see both urban and rural and then also indigenous tribes, it sounds like.
Hsu: [00:01:19] Correct, correct. It's quite the spread of populations. And we do get to see the gamut of how this pandemic has impacted our population.
Srinivas: [00:01:27] And how about even before the pandemic? I imagine it was a really diverse array of people. How was your relationship with really infection control and infection procedures, even in general, having such a diverse population?
Hsu: [00:01:41] Well, the diversity of population as an intensive care doc is it really kind of hits us when once they're presenting the unit, you know, what do we do or how do we interact with that. So the diversity of populations actually doesn't impact me too much because the disease states are relatively the same. And I'll be honest to admit, as an ICU doc prior to COVID and having the sense of needing to know everything about it, a lot of times we rely on the experts in the hospital to tell us what exactly to do the hand-washing protocol, the contact isolation, the droplet isolation and so on. I grew up old enough to have experienced the H1N1, so I have some familiarity as an ICU fellow during that time of kind of picking up and learning about what kind of infection prevention were necessary with that pandemic. So it's an interesting experience to live through two sets, although similar but very different.
Srinivas: [00:02:37] It's interesting you kind of bring it back almost, you know, a little bit more than ten years ago to H1N1. What did you find that was different about COVID-19 compared to your prior experience?
Hsu: [00:02:48] Yes, I think, you know, in reflecting back to H1N1, it was the idea of influenza was a known entity. Although this is coronavirus, it was the coronavirus that was almost all the different in the way that we approached it. So at least with H1N1, there was some familiarity with the disease state. What we were expecting, the infection guidelines and the prevention aspect of it was a little amped up more than usual, but really wasn't out of the realm of possibilities. I think with COVID and, you know, thinking about what's happened with this most recent pandemic, there was a lot more uncertainty of what we were dealing and how we approached it. And I think that uncertainty really led to a lot of considerations that I didn't have to think about through the H1N1 process.
Srinivas: [00:03:33] And talking about uncertainty, I imagine in my world of infectious disease and infection control, we were always talking about how kids can get infected, but that was a huge topic of debate. So I imagine in your world, how did how did that manifest?
Hsu: [00:03:51] Well, I think early on and this is one of those things about uncertainty, is that if you don't know, people could skew one of most all ways you could become horribly amped up and want to do everything possible you could tailor all the way to 'well, they're not going to get sick. It's going to be okay. We don't need to do anything.' And as a provider in that space, it got really confusing, really quickly. I think early on we all decided to take the cautious approach. We just didn't know enough. So in the pediatric ICU, we prepared as if something bad was going to happen. We lived through the H1N1 pandemic. Most of us did, and we understood, at least at that time, that kids were going to be the population that was going to be targeted at the beginning of the pandemic. The data wasn't necessarily clear at the beginning that maybe kids did better, but we still prepared as if we were going to get the onslaught of patients. And we did things that, you know, in retrospect are kind of laughable now. There was an instance where we discussed, do we really need to intubate in a different way? And we had our engineering students and other people kind of create these plexiglass boxes with two arm holes so that when we intubated, we had the full PAPR gear on. We had the plexi blocks down. We were intubating through little holes and it got really difficult. And then over time, that kind of went away. We even got to a point early on that we put in policies and procedures that when we excavated a child that the box had to be over them in case there was some aerosolization with the excavation process itself. So that uncertainty really led to some extreme steps that we took early on.
Srinivas: [00:05:30] With a pediatric population, what's also so unique in my mind is it's not like an adult who can just sit in a hospital by themselves. You really are dependent on kind of a family unit there, or at least a caregiver. How did that play in especially early on when it wasn't necessarily even COVID patients you were seeing in the ICU, but you were trying to think, how can we protect the patients who are here? How did that affect really the policies that you ended up putting in place regarding parents?
Hsu: [00:05:58] Yes. And I don't think personally speaking, I don't believe it was unique to the pediatric population. I think having that kid component in it really made it unique in itself. We still let one parent stay in the room. In the COVID rooms, we assumed that people who were exposed to that child had COVID as well. So we held them inside the room and didn't allow much chance, you know, the movement outside of the patient room itself. I think that led to a lot of kind of considerations of other immunosuppressed kids that may be in the hospital. What do you do with them? How do you protect them? And aspects of policies with that. The impact of visitor policy, I think, you know, hit the adult population exactly the same way, especially we think about end of life. I didn't have personal experience in this live in the pediatric world early on. A lot of my nurses split it over to the adult world because of staffing shortages and because of what they did, you know, in the ICU world, there was a lot of conversations held over iPads, as you may have experienced as well. So the lack of visitor policy because of the infectious state in the setting of pediatrics know it's very similar to adult. How do you limit that? How do you protect the other patients in the in the hospital itself? And how do you do it in a way that still gives the kids some comfort and some reassurance of familiarity with their family members?
Srinivas: [00:07:26] Did you end up creating separate pediatric ICUs that were just for COVID patients versus having kind of a general pediatric ICU? Or was the population infected not high enough for that?
Hsu: [00:07:36] Initially, not high enough. So initially we had negative airflow rooms within our pediatric ICU or kind of off in the corners that allowed us with an atrium space to really cool for those patients distinct from the other populations, and try to do the best that we can with our PPE, use infection prevention guidelines to kind of maintain that lack of transmission later on, especially around on the Corona Delta. We actually pushed that all the way into one half of our second floor. So the pediatric ICU was on one side generally, and we had a sedation clinic on the other, and we flipped all our sedation clinic room into a negative airflow space because the number of kids with COVID escalated enough that we ran out of negative airflow rooms in the ICU.
Srinivas: [00:08:23] So it seems like you really were trying to shift actively as this was all happening. But did you really have kind of a thought process? Were you able to put enough time before everything kind of hit to say, okay, if this happens, then we're going to create this and if being up and see or was this really kind of things that were being done impromptu almost, what was the flow?
Hsu: [00:08:48] It was a little bit of both. I think we had some preparation time before the escalation and that we put in a lot of rules and procedures, if you will, around infection prevention, infection control. Now, the issue with that was that early on when we had that time, we didn't have much knowledge about what needed to be done. So we put a lot of work into 'this is how we will intubate, this is how we will excavate, this is what will happen in a code.' But then as the data change, we had to change that on the fly. So I would say it was the combination of the two that we had a foundation put into place, but that foundation only lasted as long as the next recommendation showed up and we had to rapidly pivot.
Srinivas: [00:09:27] That makes sense. And I mean, early on, I imagine, as you're talking about different challenges depending on when in the pandemic you were early on was PPE a concern for you all, especially in your ICU setting?
Hsu: [00:09:43] I think it was concern for all of us in the hospital and our health system. There was this fear that we were going to run out. So I believe that we went through the same phase as a lot of other institutions did initially. You know, this is your PPE. Please take good care of it. Wear it a for day wear it for a shift, wear it for a week, put it in a bag, hold on to it for a little bit longer if it's not dirty. Keep using that. So we kept on having these movements of and I'll be honest, I lost track sometimes, you know, am I am I put into bags right now, am I holding it for a day, am I using, you know, once and throwing it away. And that kind of rapid shifts were sometimes a little hard to execute on, because the rules are changing so quickly on us. But yes, we went through the whole idea of PPE is from 'it's a desperately needed resource. Please be extremely careful,' to I believe what we were going through the Omicron process that we actually were able to go back to one use and tossing it.
Srinivas: [00:10:46] Wow. Okay, that's really great. And you're talking about, you know, even the confusion that arose for you, who's lived through a previous pandemic, who's been in the ICU for so long, had so much training in it, not just medicine, but specifically in this field. How about other staff members, especially those that are not medically trained or have any type of health care background but are such a critical part of the team? Were there challenges arising around confusion with PPE among those populations? And how are some of the things, things that were done overcoming those challenges?
Hsu: [00:11:20] Oh, absolutely. Absolutely. I think my biggest worry, thinking about other staff members I'll talk about two groups in particular are respiratory therapists. You know, if I look across the whole hospital without having very specific data, it felt like our respiratory therapists were the populations that ended up getting infected early on. And we lost a lot of respiratory therapists who had to take time to isolate at home. And there was a lot of fear within that group because they were constantly going into the rooms, adjusting to that, helping with intubations, helping with codes and their exposure risk was quite high. So thinking about them and the rapid changes that were occurring within the rules and policies around them that required a lot of education, a lot of talking and what their comfort levels were. And while meeting them where they were at.
[00:12:11] The second population that I constantly thought about and constantly were fearful of where our house housekeeping be staff, especially in a post environment after a patient gets discharged. How many days is the room okay, you know, how long should they wait? How should they clean? Then we have periods where after ten days, after 14 days, after 21 days, depending on immunosuppressed state, the patient is no longer infectious. How does that impact cleaning? How does that impact our staff who are going in there because of that? And that, I think, required a lot of communication from leadership, whether our chief medical officer, whether, you know, organizational communication, public health communication come through the CDC societal guidelines. All those were sometimes hitting us at different times. And what was difficult was something that was hitting us differently.
[00:13:00] One group would say something in another group of say something. And ultimately it was I was trying to kind of piece through that and figure out what it is that we're going to be doing here in our own ICU. The first lesson is, I think, a little hard to conceptualize. It's this acceptance of uncertainty. And we go through medical school, we go through our training with this algorithm in mind of this disease state. This is where you should move forward on when H1N1 gown, gloves. We kind of know the process, but this is the first real new disease state that I have experienced in my career where there was such a constant changing literature. In the ICU, we started with 'don't do noninvasive' to 'intubate quickly.' Steroids you know all these therapies, 'try this, don't try this.' And then a week later, the exact opposite came across.
[00:13:52] The acceptance of uncertainty is a big lesson. Unfortunately, how do you balance that with the message into the community and to the public without eroding their trust to say that we're learning alongside you at the same time trust us in that process. So having some uncertainty while maintaining trust. The second big lesson that I really took away is the idea of balance and it comes across in two arenas for me, the idea of how do you balance regulations with compassion? And I'll give you an example: I had a pediatric patient who coded with COVID right before we intubated, so the parents we knew were COVID positive. We had them in an isolation room. The team ran into the room, we put on a appropriate PPE and we were there running the code and the mom couldn't take it anymore and needed to step out. So we allowed her to step out. But in the back of my mind was this idea of, 'Wait, does she have a PPE on? What about other people walking by? Am I exposing my other patients in the ICU?' How do you balance compassion in an environment of such as a code with infection prevention policies and regulations?
[00:15:10] The other balance that I really thought hard about is the balance between patient safety and staff safety and provider safety. We all recall that when AHA came out with the guidelines of CPR to say, forget about the PPE, just run into the room. And for my staff and other providers to go, 'Whoa, wait a second, we went from Protect Yourself before protecting, you know, taking others to No, don't worry about yourself. Just run in two, several months later. Oh, by the way. No, no, no. Put on the PPE first.' That constant flip between do I protect myself first? Do I protect my patient first? Where's that balance? We all want to do the right things. And I'll tell you, I have been in codes with COVID patients where my staff ran in without appropriate PPE because that's how they were trained and that's what was on their mind. And their safety went to the to the side. And part of me wonders about that balance in real time, often the balance goes to the patient so how do we create that infrastructure where that balance will make my team where the other providers are also protected as well?
[00:16:18] And then the last thing that I never thought I would say as an ICU doctor that I realize more and more is that my space isn't just the ICU anymore, that the stories of the ICU, the stuff that we talk about today, matters in the dialog with the community. For them to hear that this really does happen, that kids are actually dying, that they are getting really sick, although that number is small compared to adults, it's small compared to the number of kids overall infected. That number does exist. And how do I become involved in the community? How do I get that message out? How do I do so in a polarized environment while bringing trust? So really, you know, this idea of accepting uncertainty and this idea of balancing compassion with regulation; of patient safety, with provider safety, and really realizing that my world isn't just the ICU anymore, that it's out in the community as well.
Srinivas: [00:17:13] And especially I mean, in a place like Sioux Falls, too, there are so many different health care systems and with so much mixed messaging coming from all over the world, like you're alluding to right now, I can imagine that especially those who are not part of the decision-making process are getting so confused. I practice also in Des Moines, Iowa, which isn't too far from you all, but we actually had some of that confusion ourselves. And so we ended up doing a lot of in our hospital dialog and trying to make our protocols really uniform among the hospitals. Did you end up doing a lot of that among your ICUs as well?
Hsu: [00:17:52] You know, among the different systems in Sioux Falls. We have two major health systems here. There was a lot of collaboration that felt like from a distance for our chief medical officers across the two systems, especially when it came to kind of public messaging with the local mayor, with the state leadership as to what do we need to do. And this involved outside of the ICU process, what about masking, you know, social distancing or what to close, what to keep open? Aspects of that. I think we're involved from the health system perspective. So it was great to see. We never got to a level of a cross system, ICU collaboration. We were always kind of relatively doing our own things, assuming that it was pretty consistent across, but I guess never confirming for sure.
Srinivas: [00:18:39] Well, it's still great to see kind of the communication going across, at least at the higher level where they can make sure there's some level of uniformity in the messaging. And really going back to that messaging, I'm really curious kind of that evolution that you saw happen, especially among the pediatric population that you're treating. It's been two and a half years now. And what are kind of the ups and downs that you saw along the way?
Hsu: [00:19:06] (laughing) Yeah, it's--
Srinivas: [00:19:06] Not a loaded question at all.
Hsu: [00:19:08] It's constantly up and down. You know, I was just trying to figure out like where there are one or two peaks, but it feels like there's been like 20-year ups and downs throughout this timeframe. Early on there was this year, how are kids going to be affected? We found that not a lot of kids ended up in the ICU, so maybe we got a little bit more comfortable early on. We went through idea of keeping kids out of school because the transmission, those aspects of concern of how do they transmit to their care providers who are sometimes elderly adults, and what does that mean for them being in school and being close together? So, you know, the lack of data really impacted how we message that. And often we had to rely on the best guess, if you will, and a previous understanding of infection. And so we knew H1N1 spread a lot in pediatric populations in schools so poorly, kids out of school for that first year and then slowly reintroducing them back and then saying we need masking in schools there's a up and down, you know, was masking necessary and what was the infectious rate how did that in fact actual outcomes? And then waiting for the literature to really catch up as we did a real time experiment in some schools had masking and some didn’t. Our community decided not to mask. And, you know, we were able to see some of the impacts of that and it's hard to tease out the exact implications of that. And the communities will always make their own determination.
[00:20:37] The vaccine was a whole different story as well, with the idea that, you know, vaccination data come down creeping down to younger and younger ages. And the timing of the research got done getting pushed out longer and longer was supposed to come out a little bit earlier, took a little bit longer. It impacted it going back to school. And then once that happened, once the vaccine was released for our younger population. Then there was a push back. Is this really necessary now that we have a body of experience, that they were maybe ending up in the ICU as much? I ultimately saw a lot of the other aspect of things, which was worrisome to me about, you know, these are the ups and downs we’re living in. We continue to live through them. The data within the pediatric world of vaccine uptake is, could be better. And a lot of that is some preconceived notions of what this may mean. As an ICU doctor, I've seen kids die from COVID. And to me, as a pediatrician, one death is one too many. So to weigh that against vaccines, it's a very clear equation for me.
Srinivas: [00:21:41] Yeah. And especially because a large portion of the population you take care of still aren't even eligible for vaccines. Are you still, are you still seeing more numbers than you would like to see at this point in the sense of we haven't had the decline in that age population we have in those that are eligible. What are some of the things that you're still taking into account when you're taking care of the population that's not eligible yet?
Hsu: [00:22:05] Yeah. So luckily, as you know, across the US right now, the COVID is just low everywhere. So within that construct, we're not seeing that many patients with COVID in the ICU. What I can tell you is that in the timeframe on the Crown and Delta, when it was escalating and it was high and there were kids that some road able to get vaccine and some weren't, what I was seeing were the patients that were getting admitted who were teenagers that had vaccine accessibility and decided not to. And we would admit these kiddos into the ICU, they would be profoundly sick. And as we get their history, we hear from parents, the caregivers, saying, I never knew this would happen. I thought kids didn't get sick. I thought, of course, they were going to get sick. I was told that this was just going to be a cold. And the realization in their eyes when I told them, when I tell them that, you know, this could have been preventable, I can't promise you that this would have been preventable with the vaccine, but it could have been preventable that vaccines decrease the severity of illness, that either they have gotten COVID with the vaccine, that there's a higher chance that they wouldn't be in the ICU and the loss of life that occurs with that that that real is when it hits there. When it hits, it's hard to see, but it's that message that comes from the community, the message that kids do well. But even when it's well in the population so big, there's in a population, there's going to be a group that gets us.
Srinivas: [00:23:40] Yeah. It's, it's that whole relative number versus absolute number phenomenon that. I think that can be painted to make it look like it's a smaller issue than it really is. And I would just like to point out that this directly impacts the doctors, nurses and everyone else in the ICU for whom working with unvaccinated patients and families carries additional risk. The more people who are vaccinated, the safer it is for everyone in the health care setting. We have a vested interest in seeing the maximum number of people vaccinated to avoid tragic situations like the one that you're describing and keep everyone safe regardless of what brings them in. But of course, how you communicate this to the general population is key. So I'm really curious, how do you think we can combat this in the future if we do have another variant or hopefully if the vaccine does become available for the singer population? What do you think would be the most effective way to kind of promote it and guard against the same assumptions witnessing?
Hsu: [00:24:44] Yes. I wish I knew the answer. Yeah, I wish there was a nice clean. You know, this is what we need to do. And unfortunately, I think it's targeting from all perspectives. It's ensuring that the right information is getting out there. It's ensuring that trust this is available with the community. And to me, having lived through this pandemic in South Dakota, taking care of a large American Indian Native American population, reservations with a long history of intergenerational trauma even prior to the pandemic hitting. What we found is that a lot of what we consider routine care that sometimes is not done, isn't done because of any particular reason outside of trusting the system. Do they believe what we're trying to do is in their best interest and for what? Whatever reason, in our polarized environment these days, there is an erosion of trust in the medical community. Words such as, well, you're just doing this because you're out of the pockets of pharmaceutical companies. The data is not that good. You're doing it for X, Y and Z. Other reasons. We have to overcome that somehow. We have to regain that trust in providers. We could tell all the stories we want of kids getting sick, but until that, I think it was my personal belief. Until that trust is regained, a lot of that messaging gets lost. What we try to do here in South Dakota is often stand together as a medical community. The American Academy of Pediatrics in South Dakota worked with North Dakota to put out several letters in the last year or so advising families to really talk to their providers about vaccines, to get to the person that they trust, whoever that may be in their local community. And to get that information from that trusted individual and to really consider vaccinating their kids. And we start with a message of trust and we hope for the best.
Srinivas: [00:26:44] No. And what you say makes so much sense. I mean, in the past, physicians have always been looked at as that that person that you could always trust to always want to be doing something in your in your well-being. But then you also alluded to the fact that, unfortunately, a lot of rhetoric over the last couple of years has eroded that perception. And I can imagine you working with health care providers every single day, you've probably seen that have a toll on people's morale. How has. Have you seen it affect the morale of your coworkers? And what can we do to resurrect that?
Hsu: [00:27:19] Yes. The burnout of the health care worker is there's already so much been spoken to about this. I could talk to you about my personal experiences in the time that I've been working as an ICU doc. A lot of providers that I see take a lot of happiness and derive a lot of meaning from the work that they do. Having that sense of satisfaction that they've helped somebody in the time of COVID when there's that animosity truck to for us, when we're trying to do the right thing, that anger, when we're saying, please put a mask on, at least in the hospital of all places so that you don't transmit. And that vitriol that's directed at us for even suggesting something as straightforward as a mask. It takes a toll. And that idea of burnout is definitely pervasive throughout, and it makes engagement of the providers less and less. And I don't have a good answer as to what needs to be done. I just see that something needs to be done. And whether it's taken a break, finding some other ways to fill in come to find inspiration. But a lot of care providers are hurting, and you have to take that hit constantly over and over again from the community, from your patients, from the family. It gets overwhelming.
Srinivas: [00:28:47] Yeah. And I have to say, I always think about this issue and when I discuss it with friends or colleagues, the solutions that have always been provided to providers is you have to be resilient or things that you have to do to fix yourself. And I just think that that's such a harmful approach where we put more work upon the person who's already burnt out because we've given them so much work and doubt in their abilities. It's a very interesting psychological phenomenon we take in in the world of health care that I really hope that we reverse.
Hsu: [00:29:20] Yeah, it's almost an idea of just taking a break. Not another initiative, not another thing. Going back to the core of connecting with your families in a way that hopefully regains our trust is by regaining that trust, a lot of care providers will feel satisfaction and re-energized and feel like they're doing the right things again. And it's not to say that they're not doing the right things, but you have that constant message of, you know, you're from the communities that that really erodes that dependency.
Srinivas: [00:29:52] What does that does? And then and then it also makes me wonder, because we definitely want people to take breaks, especially if they need it. They need to have those resources to help them. And it shouldn't be just upon themselves. But I also am curious, you know, in the next few months, as we see things calm down from a pandemic standpoint, at least for a period of time, if it's not permanent, are we going to start seeing a huge drop off in staffing as people realize that they are burnt out, that they need to take some time away? And how is that going to impact patient care where it is such a shortage in rural areas like South Dakota and Iowa?
Hsu: [00:30:32] I don't know. You know, I can't anticipate the future. What I could tell you is that, you know, the scenario that you describe we definitely see in the nursing staff right now with a limited nursing staff, there's this move toward travelers and then the mood for travelers burns out the existing staff some more, and then so on and so on. There's this belief that we'll return back to normal with the idea of normal being one or two years ago, staffing ratios being the way they are, but there's just not enough nurses to go around. We're fighting for a limited resource right now. We all are. All the health systems and hospitals are seemingly fighting for a constrained resource. I worry that that may move into the provider space that as people take a step back and say, I just can't do this much anymore, that they take themselves down to part time work just to have some space for themselves. What does that mean? And to me, I think that really requires us to think hard about how we deliver care. And maybe it's time that we could renovate, reinvigorated, reengage our communities. Telemedicine is something that kind of came up to the forefront early on. I have my own personal feelings about its impact on health equity, but I know that it's had some impact in the way that we deliver care, in the way that providers see care being deliver, in the way that certain populations of patients see that care being delivered. Well, how do we engage that differently? How do we move that forward in a way that is equitable at times and ensure that that delivery care across all populations? I think it's time to innovate, but I do worry that it may become the provider issue as well as the nursing issue that we're already seeing now.
Srinivas: [00:32:18] And I do worry about, you know, we work a lot of telemedicine resources, especially, you know, things like Project Echo that are trying to aim at the equitable division of access to health care. But at the same time, I worry about some of those inequities that arise, who has access to even being seen by someone who has the technology to do that or in a place that has broadband. So that way you can actually jump on the computer or on your phone or have the affordability of that. There are so many.
Hsu: [00:32:47] Especially in the rural health care setting. Absolutely.
Srinivas: [00:32:51] Yeah. So it's I think we have a lot to learn. I am hopeful, though, for the future. I really am. Thanks again. Well, thank you so much for being here and sharing today.
Hsu: [00:33:04] Thank you. Thank you for the opportunity. This is such an important topic and glad to have time to talk with you.
Srinivas: [00:33:13] Stories section of the AMA and CBC's Project Firstline. Project Firstline is a national infection control training collaborative, working to provide all health care professionals with the foundational infection control knowledge they need and deserve to protect themselves, their patients, their coworkers and their communities. This episode was produced in collaboration with the American Academy of Pediatrics, a Project Firstline partner. Visit them at AAP dot org slash project first line. For more information, trainings and other infection control resources, visit CDC dot gov slash project first line and AMA first line dot org.
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