Megan Srinivas, MD: Well, thank you so much for joining us today, Josh. I know that this has been a busy time of year with everything going on in the ED, so thank you for taking the time out of your day.
Josh Leu, MD: Glad to be here.
Srinivas: Well, you have had a very unique experience in the pathway of your training with COVID, really landing smack dab in the middle of that from med student to resident. Can you tell us a little bit about. About where you were in life when the pandemic first really erupted here?
Leu: Yeah. So, I was a fourth year medical student at Saint Louis University. I think it was, March or April we were, everyone was in the middle of a clinical rotation.
And we basically all got this email as things were brewing and people were like, not sure what was happening. And so shortly after that everyone just woke up to this email that said, no student is allowed to step foot into a clinic or into the hospital. Everyone just go home. The fourth years, you're automatically graduated now.
Srinivas: So this, from what I recall, for me, it really went into high mode in the middle of March as you said.
So that would be about two months before you were supposed to graduate, right?
Leu: Graduation or actually that was like right a little bit before, I think Match Day. And then we, our school graduates in May. And so, everything got canceled, like nothing. All, everything just went, like everyone was trying to figure out how to do things virtually.
And so we have this virtual match thing. But from that point on, my class didn't get to have any event, didn't get to go walk at graduation and get a, you know, presented a physical diploma. Didn't get to have a real match day. Yeah.
Srinivas: I'm sorry about that. It's such a monumental moment in your life to have it interrupted and not really have a chance to make it up.
Srinivas: But, so when you were in that moment, in March before Match Day, how many courses or rotations did you technically have left that you were planning to still do before graduation?
Leu: I didn't miss too much, but there were like, I think some of my classmates like missed a legitimate like month and a half of some even core rotations. Some people put emergency medicine or like outpatient clinics at the end and they just didn't have to go.
Srinivas: So how about the people who are below you? I'm sure that you had a lot of friends who were Third Years. And I was always wondering, I mean, I know at UNC where I was at the time, our Third Years were no longer coming in anymore either. And that's when you do most of your rotations as a med student. What did you see happening from your perspective?
Leu: I think, I don't know the exact dates, but the Third Years, they were also, told like, we're not letting students come in, which I think my, the dean at the time, he drew some parallels between the COVID pandemic to the HIV pandemic. I remember this email that he mentioned that back in the HIV pandemic, like students were also involved on the frontline. And to him it felt a little silly because in for at least our, my year, like in, in two months or so, like we would be residents and we would be expected to show up and you know, for the third years they would be, they have to get some clinical experience eventually.
If I think if I think back to like my intern year, it was probably the summer or the fall. And so, I think they legitimately missed several months' worth of clinical education.
Srinivas: I know that part of the discussions that were happening at the time about letting trainees in also had to do with the amount of PPE that was available and the fact that a lot of places didn't have PPE, even for the core staff. And trying to not leave people vulnerable or at least, especially those that are at the bottom of the hierarchy, that could sometimes be taken advantage of. And we know that medicine is very much a hierarchy. What was your perspective of that in the discussions happening at your school?
Leu: I was also unique in that, like I stayed at SLU for residency. I know talking to my senior residents when I became an intern, interns weren't allowed to intubate any of these [COVID] patients.
And so, it was always a Second or Third Year or an Attending. And then that changed when, like I came in, like when I was my first month as an intern. I was allowed to intubate, I don't know if it was because of the PPE or because of, they just wanted to protect the intern from exposure to all these aerosolized droplets and things like that.
So I'm not sure, but I know that when I became an intern, we were like, conserving N95s, we would just reuse N95s.
Srinivas: You highlighted a second ago, a really interesting point that one day you're a med student, not allowed near any patient, and then the very next day you were suddenly a resident. How was that transition for you? Especially because you stayed at the same institution?
Leu: I think everyone was just like, you're a doctor now. We did some training with what we knew about COVID at the time. We had like charge nurses come in and fit us and tell us about the resources that me and my co-residents had in the ED. But yeah, it basically, it was one day, it was just like, "Here's the ED, now get to work."
Srinivas: So how much time did they spend training you before you were on the front line?
Leu: We had, I think in our intern year we had two formal weeks of orientation generally across programs, July is like an orientation month just for the ED. And so that's a time when we had like a reduced number of shifts and we had a lot of like lectures and things like that.
And so, and or training sessions. And so, we had a good full month. But intermixed with that was just like regular shifts where we just showed up.
Thinking back to that month was wild because like no one knew what they were doing. No one knew to give the correct amount of dex [dexamethasone], or, and we didn't have, certainly didn't have any of the antivirals. I'd be with one Attending and she'd be like, "I do this, you know, X, Y, and Z with this set of patients. I don't know if it works. No one has told me otherwise. No one has given us any guidelines." And then, you know, the next day I work with someone else and I'd be like, "This is what I want to do because of what happened yesterday." And they're like, "That kind of makes sense, but, you know, I want to do this." And just no one knew how, a standardized way of how to take care of these patients.
Srinivas: Yeah, that early COVID time, so honestly, I would say not even early even. Two years really. There was constantly fluctuations in the type of care because there was no data. We were figuring it out. At that point, by June, at least when you're starting up as an intern now on the front lines, we knew that we needed to have appropriate PPE. We didn't know, you know, for sure yet if things were airborne, what the route of transmission was. And even now there's this gray zone as we discuss it, especially with different procedures. But we knew at that point that we wanted to make sure everybody had an N95 if they're taking care of patients, that they were gowned and gloved. Did anybody talk you through all of that before you, you hit the floor running?
Leu: Yeah. I think we had one. So, obviously we were all fit for respirators and N95s. We had one session where one of our charge nurses came and taught us, one taught us how to like put on the PAPRs. Like those huge almost hazmat-ish looking things which we never used. I think they were like, we have four of these, and we're like, okay. So we never used them. But part of that like hour and a half training also included like N95 proper, PPE stuff, which wasn't foreign to us as med students.
But like thinking back to like, I don't know. So I was a med student, like pre-COVID, but I obviously wasn't practicing as long as you have. But I also, my girlfriend who her only like clinical education was like, post-COVID and I was like, yeah, we used to just walk in the rooms without a mask, like without, like gloves or anything. And if we put on a mask, like we would just toss it like immediately after we left the room. And they're so like, so antithetical to how we do medicine today. And it's just so odd. So I mean, we knew how to use and wear masks.
Srinivas: It's so true. I remember we used to discuss beforehand, Hey, should we reuse these? Especially, you know, being in ID, we're going in now these rooms for consultants. "Should we be reusing these masks, to save for the environment?" was our question beforehand, and now it's completely different world.
Leu: You had two patients with like influenza on your list and you would, your whole team would go in, like all the med students and the residents. You would just like cost 10 masks. In both rooms, like immediately it was just like weirdly wasteful but ...
Srinivas: And it's suddenly now we're like, oh my gosh, they're the most precious gold in the world.
Leu: I mean, I remember in early COVID, like we had, our charge nurse had to lock up like the PPE closet and like on shift, like before you came in, you had to check in with, and they would bust out the key and unlock the door. And there would be, because like people would steal them.
Srinivas: Did you ever feel like you as a trainee were put into an unsafe situation in the setting of all of this between PPE or clinical settings?
Leu: No. Really, I, we had enough. I don't think I ever showed up to a shift and didn't have an N95 or didn't have a surgical mask. So no, really, I think our ED like management and administration and my attendings, they ensured that we were safe and they, I've never felt unsafe in residency.
Srinivas: What was the process for you all if one of your residents ended up catching COVID?
Leu: There are some shifts where we just don't have an intern or a junior resident anyways, and it's just like a senior resident and Attending. But if a senior were to get sick again, that would be annoying. And they would've tried to fill that spot. Obviously, they would go on isolation per like employee health, which I think it was 14 days or something. But it was a bigger deal if an Attending got COVID, which it happened a couple times because that meant that like another Attending had to come in. So, yeah, it was a bigger deal if an Attending got it. Because those, they were harder to replace and to cover.
Srinivas: The public often has controversies around, is saying, "Hey, look, people who are using protection are still getting sick," but they don't realize the difference in the fact that you're also doing all of these procedures right in somebody's face and putting yourself in a high-risk situation, that changes the likelihood that you contract. What was the hit rate, so to say, of COVID in your, in that summer of 2020 when you first started?
Leu: So I've never got COVID, so I feel very fortunate. I don't remember a significant amount of losing residents to COVID. I know it happened. My, one of my co-residents the third year. He like got COVID as a med student and then got it again like later on and it wiped him out.
So, I know he had it. I only really remember two of my Attendings getting it on the job. Like one of 'em had to be told like, you need to go home, you're like sick. And they were both down for like at least a month each. But I don't remember a resident really getting it that bad.
Srinivas: One other thing that always pops up too is people have different risks involved. Some people are immunocompromised, have health conditions, and even just, I mean, honestly, in residency, that's a time when a lot of people start to think about having families. And we know that people with pregnancy are at higher risk for complications if they get COVID, and so we're always very careful about their exposures.
Did any of those issues come up during your time dealing with this?
Leu: My class is like all guys. It's eight dudes, so none of us -- No one's getting pregnant. But I mean, some of my co-residents had, they had young kids, some of 'em had like newborns. They had, you know, spouses and significant others that weren't in the medical field.
Srinivas: Were there extra precautions taken for anybody who might be at higher risk?
Leu: We were like expected to do the standard PPE. But then, and wear a mask on shift and put a N95 if you're going to intubate or do some aerosolized procedure or something. But then after that I think everyone had a different approach to it. So, I was really like, I changed like scrubs after every shift.
I did that as a med student before COVID. I, and I don't know, something about it's just like super gross, like especially in the ED. Some people like go home in their scrubs. I'm just, it grosses me out. So, I've always been a person that I have to change scrubs into a fresh set, like every shift.
I also change shoes. Like I have a separate pair of like work tennis shoes that I don't let get in my house. Some people like, I wore goggles for a long time. Some people did that. Some people had like a surgical cap on the whole time. So I mean, everyone just took it at their own, like what they felt comfortable with.
Srinivas: And did the program help support you all with resources as in, if you wanted goggles, they would help get you goggles?
Leu: I think we had money set aside, for each resident to get stuff. At no point did I ever feel like we weren't supported by them. Which is one of the things that I've really cherished about my program is that all the attendings and all like the leadership are like willing to support us in very like many different ways.
Srinivas: Did you ever see situations, even if it wasn't you being impacted yourself, did you ever see situations, whether it was other patients, like in the waiting room or other staff, maybe some of the EVS staff, the environmental services staff, or people who just didn't seem like they had been given enough resources or didn't seem to know the information they needed to get safe. Did you ever see anything like that happen?
Leu: So I guess like I have like one story where I was like, this is the worst job in the hospital. It was like this specific like task. And we had a older, like East Asian patient come in with shortness of breath.
And sure enough, it was COVID and so he was isolated in the ED. I think this was a time when like it was super full and there was not, it was like boarding a lot the ED. So, he was like a ICU-ish player, like he was on, if I remember correctly he was on BiPap every now and then.
So he was, he had that going on in a medical sense, and then he, and I think looking back, this was cultural. He made some statements that sounded suicidal. And the team, we took it initially as, well, we should consult Psychiatry. But I think looking back, he was making statements more "This sucks so much that I would rather die," versus like "I am actively suicidal."
And so that mix held him in the department because now Psych weighed in and was like, he is making these suicidal statements and so he needs to have a sitter. And he needs to be placed on a involuntary hold. And that's when I realized that the worst job in the hospital was to be an involuntary sitter for a COVID-positive patient.
They just had to sit outside the door and if the patient was going to do anything, try to get up or wanted to go to the bathroom, like they'd have to like low key deal with it. That's when I realized that's probably the worst job just to be exposed constantly to someone with COVID for your entire workday.
Srinivas: Oh gosh. Did you feel like they were ever in an unsafe situation just because of the setting we were all in?
Leu: I mean, yeah, because like we would at least as a physician or as a nurse, like, yeah, you had some patients that had COVID, but not everyone had COVID. Someone would still come in with a broken bone. And but for that person they just had to sit there, be exposed to COVID for 12 hours a day.
Srinivas: And did they have the appropriate training? Did they make sure that they knew exactly how to protect themselves?
Leu: Yeah, they definitely had an N95. But I think up on the, I don't know how it was like on the floor. Like in that situation, they sat outside the enclosed room, so they weren't like inside the whole time. But I mean, they were the one to have to like, keep an eye on them and be close to them, you know. As a physician or as a nurse, you could sit in the "doc box" or like at the nursing station or something.
Srinivas: In normal settings, meaning non-COVID settings, sitters usually are there talking and helping entertain. So that's a really tough situation. I'm glad that they were able to get the protective gear that they needed, because you're right, that's probably one of the highest risks.
And I always say, you know, environmental services, people don't realize how much they were at risk, but they were probably far more at risk than many people in the hospital because they were cleaning up after patients every single day, actively, while they're still often in the room, directly exposed to every virus particle that comes out of that patient.
So, those are some of the areas that I always wonder, did we do enough to make sure that they were safe? And I hope we did as a nation, but, I always wonder that. Did you, did you notice anything in that regard?
Leu: Yeah, I, you're right.
It's one thing to intubate, but also to just be in this room that a patient had been in for 12 hours with COVID at that time, I've never thought about how high risk they were.
Srinivas: And making sure that we gave enough training to people. We're fortunate enough that, I mean, this is my area of study being an infectious disease doc. And for you, you've had infectious disease training as well, being in medicine, I always wonder if we overlooked the amount of training and took things to be an assumption that we needed to spread amongst all of our staff in the hospital that didn't necessarily come from the same backgrounds as us.
Leu: Yeah. I never thought about that privilege. ‘Cause everyone's kind of, “You're the doctor, you need to know.” But no, you're totally correct. I never thought about how that extended down to include other ancillary staff that are like, just very important too.
Srinivas: Well, and one thing that you touched on too with this gentleman, you started to get into that conversation a little bit, was the mental health of people who are involved in this pandemic as patients, but I'm also thinking about from your perspective as a student going to resident in the midst of all of this, how did you see people's mental health being impacted with that transition and having to be thrown into the frontline right away?
Leu: I can only say for like my residents and my program, I felt like we were, I guess to preface I do feel as an EM resident we have more time off and there's like better work-life balance than surgical or internal medicine residents. So like we, I say only, but our shifts are eight hours each and, we're fortunate enough to have a lot more time off than our surgical or internal medicine residents.
And that really helped because we saw a lot, but we also just had just a lot of time to recuperate and we just, you know, we just, that helps so much. Just having that extra time off is so good for your mental wellbeing and mental health. But we would like, I felt like my residency program was really good at checking up on each other.
My PD [Program Director], Dr. Krause, Craig Krause is really good at that. I think that's one of the things I admire most about him is that he has a pulse on how everyone's doing. You know, when it got to the winter, he was like, make sure you guys are checking up on each other. This is like really hard time for interns.
It's Seasonal Affective Disorder, and it gets cold, and people start to isolate and it's that lull in the middle of the year. And so, I just felt like my program just had a really good handle on mental wellbeing and mental health. And it's a very collegiate, it was a very collegiate group of residents and physicians and no one, we were all in the kind of like, we're all this together, we're going to look out for each other, we're going to hang out when appropriate, and when we can gather in a sense.
That was a weird thing too. It was like we would be on shift together, like intubating and seeing patients, and then suddenly we'd like, I guess we'll go home. Like I guess we're not really allowed to go hang out at a bar, but I guess we can do all this other stuff together.
Srinivas: Being on the front lines, especially during that time. You see happy moments where people, you know, of course recover and it's so joyous to see that, but you also see some of the toughest stuff on the frontline. How did people handle that? How did you see that impact around you?
Leu: So that story about that like East Asian patient, I think about that case a lot because ultimately that patient died in the ED. Like he was there for three or four days and did not get to see his family, didn't speak English, and so that was like another barrier. And then he was, I mean, basically isolated because of the like psychiatric component of his care. And I had been on shift with him basically like throughout that time. Like I, my runs of shifts, coincided with that. So I took care of him and just steadily watching him decompensate.
Like initially he'd get up and walk around but like by day three or four he was just like bedbound. And my Attending, we knew it was going to happen soon, but I remember like his family, like I wanted him to talk with his family because they obviously weren't able to go. And I was just in there with a phone, like the room phone and like going back and forth.
To die alone in a ED room where no one really can speak your language. I think that hit really hard about like how crappy that disease was and how horrible it is, situations that we place people in with like good reason. Yeah. If we had let his family in, they definitely would've probably gotten COVID and they could have gotten sick just as well. But that's such, such a hard way to go.
Srinivas: No, I completely understand that. It's the worst feeling knowing that somebody didn't get to die a happy death. Especially when, and as physicians, we're trained to try to do anything we can to help them, and that includes emotional wellbeing. Thank you for sharing that story. And that's the hardest part I think of the pandemic, is that there are so many moments like that we wouldn't have been exposed to, especially so early in your training. Just stay with you. And I don't think that we've had space in society to process that as people in this profession because it's just been constantly working. How do you feel like this is going to impact the future of medicine? Of those around you?
Leu: Clinics closed down and were reduced. And so, a lot of these patients who had a primary care doctor weren't able to get to one. And now these like chronic problems have built up to the point where they're now acute. For, now that the clinics are back open, there's like such a long wait list. I took over a patient about a month ago who, long story short, I was like I think you just need to see GI on an outpatient clinic.
And they're like, we can't see GI till October. And I was like, excuse me? And they're like, yeah, like we're on this like long wait list. And I was like, I am sorry. Like I unfortunately I don't do scopes. But that's probably what would be most beneficial for you. So we're seeing like these long-term effects of people not getting to their primary care doctors and either really long wait times or they just weren't able to get good follow up for their diabetes or their COPD and now they show up in extremis. And it seems like it's happening all at once. It used to be a joke that like, oh, some people use this as their primary care, but it's like not an unreal thing anymore. Some people are just like, I ran out of my meds and I'm like, okay, I guess, you know, I guess I'll build a prescription, but you should really see your primary care for these issues. Again, I'm not a primary care doctor.
Srinivas: I want to ask you about that moment when you were first told, you and your co-residents, your colleagues were first told that you're about to get a vaccine. How did that feel?
Leu: Ooh, that was so surreal. I remember the day, I think it was December 13th. St. Louis had got a shipment and I think some of it went to Wash U and we got some of it, the other half,
Like our APD [Assistant Program Director] was like, there's vaccines now. Have all the residents in the program like sign up, like we qualify for the first batch, like we're first line. And so, we like all, he was like, email me now. And then like everyone just emailed, "I can go get the vaccine December whatever."
And then they're like, okay, you're confirmed. And then the day rolls by, and we go and stand in line and me and some coworkers and co-residents get the vaccine. I was very happy. I walked away. I was like, this is surreal. This is crazy. It finally happened.
I think another major hospital had a big controversy because, they were doing it by age, right? If you were a, like if you were above 50, you were in line to get it first, and then it like worked its way down. So by the time you got to where most residents were, they were like months away from the initial like rollout.
Srinivas: And that's a massive equity issue, especially with residents often and many specialties having the highest risk because they're the ones dealing with the patient in and out, on the floor. That, that's concerning. That's a huge issue. I'm glad that you didn't face that.
Leu: I felt very fortunate. I flexed that so hard, I texted all my non-medical friends "look what I got."
Srinivas: Oh gosh. Honestly, still thinking back on it I remember there were so many tears of joy amongst all of us and we're like, oh my God, the vaccines are here. We're getting the vaccine. It was that relief. I feel like it was a release after so long.
How do you think your training overall has been impacted by the pandemic? Do you think that there have been moments that you're glad that you got to experience or that you learned because of the pandemic? Things that you didn't get to learn because of the pandemic? What have you seen?
Leu: Obviously we're quite good at ARDS. Looking back, we're quite good at recognizing sick, viral illnesses.
I think as in, in my first and second year, I was like, oh man, I feel like, and my attendings and senior residents talking about, "oh, we've never seen flu. Like we haven't seen flu in years." But then this last winter, like everyone's got the flu. And so, I guess that kind of fixed itself. But I don't know if it was negatively impacted, but it plays a role. Cause at one point we were just like, everyone's differential included COVID.
Cause it could look like anything, chest pain, shortness of breath, just fatigue. And so it was that like fallback of just assuming everyone had COVID. I think pediatric medicine was a little impacted just because at one point, and this speaks to the effectiveness of like isolation and washing hands and things.
But like for the first two years, didn't see RSV because kids weren't in school. People were like, I'm going to wash my hands around kids and stuff. I remember as a med student being in the peds like rotation, like these peds residents would be just so much like horror as winter drew by and they would have to like just take care of like 30 RSV kids. But then in the first years it didn't happen. But then like last summer, there was just like a bunch of RSV for no, I don't know if people know why. And so, I guess that also like fixed itself. Like I got a bunch of RSV exposure.
But I. In the end, I don't think it was negatively impacted. Like when I first came, became an intern, like I was still able to intubate, put in central lines and take care of sick patients. That's also another really cool thing that like my program's really good at. But they don't, obviously if someone is dying, call for help, but they don't, I've never been told not to see a patient because they're too sick.
Like always be involved. First up to intubate. It's the junior resident. I don't think it's been negatively impacted. It's just different in the things that you see.
Srinivas: Thank you so much for sharing all of your insights and experiences. It's been a rollercoaster of a few years, especially for going through the transitions.
Anything that you want to share? Kind of parting words, parting thoughts?
Leu: I'm fortunate to have this job. There are times when it burns you out, but at the end of day, I enjoy what I do and being able to help people like this. Yeah, thanks for having me.
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Stories of Care is a publication of the AMA and CDC'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. For more information, trainings and other infection control resources, visit CDC.gov and AMAfirstline.org.