Parallax: COVID-19: Lessons and learning from South East Asia

In these unprecedented times, we provide an early release episode to gain insight on dealing with the COVID-19 pandemic from Deputy Editor in Chief of US Cardiology Review, a BDG interventional cardiologist, Bill Gogas, MD, PhD practising in East Asia.

Hear Bill’s take on how East Asia responded to and successfully managed the pandemic and how they are now seeing a significant reduction in cases outside the epicentre. Hear how the strategy resulted in only 93 patients in Bill’s city of Nanjing, testing positive for coronavirus with a city population of 8 million.

Learn about effective responses, the importance of early control and how as a cardiovascular physician your life and practice may be impacted from the virus.

View the podcast audio here:

Transcript Below:

[Ankur] Hello everyone, this is Ankur Kalra, and I have on the show with me a very special guest today. These are unprecedented times, as all of us know. We are in the midst of the coronavirus pandemic. I have with me Dr. Gogas, Bill Gogas, we call him Bill. He is the deputy editor of the "U.S. Cardiology Review". He's currently based in China. He has actually been in China for a while. He's an interventional cardiologist at, correct me if this is the wrong pronunciation, Bill, Nanjing First Hospital as I read. And he's actually, you know, quote-unquote an outbreak survivor, but I would say geographically a little far away from where the epicentre was in Wuhan in China. But he's an interventional cardiologist and he has been in the thick of action in China where this has unfolded and unfortunately has now taken the world by storm. So, I'm sure the listenership and the audience want to hear more from you, Bill, than from me, as U.S. is just starting to grapple with the pandemic situation here. You know, in the state of Ohio which I think has been at the forefront of dealing with this epidemic with Governor DeWine actually announcing closing of bars and restaurants as of nine p.m.yesterday which was a Sunday. So thanks again, Bill, for joining us, and we can't wait to hear more from you.

[Bill] Well Ankur, it's a great pleasure to be with you. I'm so glad I'm in your show, and indeed, yeah, the situation now. I'm following the situation in Europe but also in the U.S. You know, it looks like now this has been spread out. And it's very important, you know, to take measures, protective measures upfront in order, you know, to have very fast results because if we leave this, go away, we're not very careful from the beginning, this will have devastating consequences, in not only the healthcare but also in the whole society and also mentioning also the financial repercussions of this pandemic will be devastating after two or three months.

[Ankur] Yes, you know, one can only fathom the consequences from an economic or a financial standpoint, but also, you know, consequences from just the sheer number of people that have lost their lives and the families affected. You know, to the best of my knowledge I haven't seen anything of this magnitude in the 37 plus few months years of my existence.

[Bill] You're right, so am I; the virus was the first time, yeah.

[Ankur] It's important for a lot of us actually. I apologise; I touched my face there. You're not supposed to touch your face, right? That's the recommendation from the Centres for Disease Control.

[Bill] Right, a new thing, you will learn that, the new things that people learn. You know, and this, you know, no one was expecting that. And you know, we were writing books, we were watching movies, but, you know, this became reality. And you know, I'm really impressed by, you know, by what I have seen here in the place that I'm working, and I'm really impressed by how serious the whole situation was taken by the local authorities, but also how fast, you know, the local authorities moved in order to contain, you know, this virus. Of course, as you know I'm based in a city which is about 400 kilometres away from the epicentre. And imagine this is the distance between Atlanta and North Carolina, and I have to tell you Ankur, that now it's mid-March and since the outbreak, of course later on it was named as pandemic, in this city that it has eight million people, only 93 people were infected. And out of those 93 people, all these patients were successfully treated. There was no death. You know, this is miraculous. This explains the fact of how seriously, you know, all these protective measures were taken, number one, how obedient the citizens were to follow instructions by the local authorities, and also how the system moved so fast in order to contain you know, this devastating clinical entity, the coronavirus.

[Ankur] So thank you for bringing that up. So walk us through this, 'cause I think the initial reports that started coming out of China, out of Wuhan, were I think in December of 2019.

[Bill] Right, yeah, so to be honest, you know, the time I was hearing the news, I was not here. You know, I was for New Years celebrations outside East Asia. So I was hearing the news, and of course everyone was scared and I was scared. I mean, I was thinking, "oh my God what's going on now?" You know, when you don't have experience in certain things and you are exposed and things that you don't know, you are scared, you know, twice or more because you don't know how to handle the situation. It's a new situation that you have no idea how to handle. Anyway, you know, I landed in the capital and it was the first time that when we landed, I stayed within the airport for about 15 minutes, because, you know, regulators gave us papers to notify them if we have any flu-like symptoms and also if we had previously travelled to the epicentre. You know, I'm saying this in order to mention how seriously every step of this procedure worked, like a very well-oiled machine. So 15 minutes within the airport, this happened to me the first time. And of course, an aircraft that has a capacity of 250 people; we were only 65. Of course and then in the airports, you know, it was me and the other 64 passengers, it took me five minutes to go through the immigration, you know, clearance. And then of course coming home for about 35 minutes in the street, it was just me, no one else. This speaks to the fact that, you know, when there was instruction of 'stay indoors', you know, citizens stayed indoors, and this taken very seriously since the early beginning. Of course, you know, later on this time, at the end of, this was basically at mid-January, so as you know mid-January is the Chinese New Year. So it was the week that it was the week off, and as you know, during this time, millions of citizens are prevalent, and this was completely cancelled. So travelling was cancelled. That was a very, a very great protective measure in order to not disseminate and in order to stop the spread. You know, there were many protective measures, and I was really impressed also by the care that the authorities showed to the physicians, very protective equipment, the so-called PPE, instructions, drills, and actual handling of situations. And also there was no, in my opinion as I saw the situation, there was no calculation of any cost of what this will cost to the local economy. So all their resources became available in order to contain this devastating pandemic. This was amazing; this was impressive to me, and I think this speaks to the fact that we've seen 35 days as you saw Ankur, this started in January, and in February 16, the exponential growth of the curve sharply declined, and since February 15 until, you know, until March, in March as we are now, basically there are no other cases outside the epicentre. But also we think the epicentre, there are a small number of cases, maybe less than 10. So this speaks to the fact that, you know, all the system worked very fast and very efficient. And I think, you know, I believe that East Asia had this similar experience with SARS, and I think they have taken those lessons from this era, the era of the SARS, something that of course in Europe has just not been taken, you know, very seriously. As you know, I was born in Greece and also now Greece is in a very bad situation. Of course, Greece has very small amount of resources. It doesn't have, you know, the economy of countries like the U.S. or North Europe, and we think this situation is even harder now to contain a pandemic that will cost such a tremendous amount of money in the local economy which basically, you know, these funds do not exist. But anyway, indeed yeah, the spike that, the exponential growth that was going up until mid-February, it had a sharp decline at February 10 to 15. And after this time, everything was going better and better until March that we are doing now. And things, you know, are even better fortunately of course.

[Ankur] Thanks, thank you for walking us through the various steps which were undertaken at a societal level, from a policy level, and also from the execution standpoint.

[Bill] Right.

[Ankur] You know, by local authorities, as a cardiologist, as an interventional cardiologist, walk us through, you know, what happened in the past two months with your scheduling, with the ability to see patients in clinic, with the ability to perform procedures in the cath lab, and you know, like you just brought up the issue of personal protective equipment, which is PPE, which is an abbreviation that has being thrown out in all the emails and all the tweets

[Bill] Yeah, yeah.

[Ankur] And of course on the news. If you can just, 'cause and I think there is a lot to be learned from your experience in China, and I think it's something that we're going to see here in the U.S. very shortly as we are on the upswing of the curve, if you may. So walk us through what happened in your practise of seeing patients, evaluating patients, you know, cancelling clinics, scheduling.

[Bill] I believe as a first step it's important, you know, the hospital to halt the elective cases. You know, elective cases, you know, imagine that someone comes, let's not talk about cardiology, let's talk about someone who comes with an abdominal pain, and you know, he is coming with another four or five people, with his family. You know, you check him; he is corona negative, but what about his family and the people that he brings in the hospital? You know, and of course elective cases in my view should be cancelled immediately. And there should be measures to only serve the emergency situations. For example, emergency situations now, our specialty is STEMI and a dissection. You know, I believe also I haven't seen it here but this is what I was proposing to some of my colleagues in Greece, that those specialties like, you know, dermatology, psychiatry, those wards need to be converted in special wards that can accommodate ventilators. So you need to increase the capacity of a healthcare facility in order to support patients who are infected for the COVID-19. You know, all the resources should be drive toward this effort, and of course to serve some emergency situations. Now as you know, it's important also to discriminate the healthcare facilities in facilities who can serve patients who are COVID-19 negative, and those who are COVID-19 positive. So there should be hospitals that should be the hospital-hub hospitals. These hospitals can treat only patients who are coronavirus positive. So for example, if a patient comes to the emergency, of course you will need to, first of all you need to see if it's a situation that needs to be immediately taken care, or you know, he needs to go. Because the more you stay within the hospital, you increase your chances if you are negative to become positive. So as long as a patient is in an emergency situation, you have to ask some clinical questions. For example, if he had fever, if he was coughing, if he had dyspnea, shortness of breath, or if he had immediate contact with someone who was positive. These are some clinical questions. Then as you know Ankur, there are data that assuming that the PCR then to detect the nucleic acid of the virus is less sensitive than the CT scan, the chest CT scan. So and this happens because maybe the viral load at the time that you do the test is too small. This happens also because the nasopharyngeal swab that, you know, the certified registered nurse is taking maybe is not taken very properly. And also it depends on the technology. You know, there are different technologies. Now I hear that, you know, there is a consistent CDC-based coronavirus testing, but I'm not sure, you know, if other vendors also supply, you know, the coronavirus testing. So it depends also on the technology. And it has been shown that early signs of the opacities, of the ground glass opacity that we are seeing in the lungs which of course are not specific for the COVID-19. We can see it also in other diseases of the lung, and are showing very early, earlier also than the PCR. And also as a matter of fact, the PCR takes about three to six hours, while the chest CT that can be done also with a portable CT scan, it takes 10 to 20 minutes. So there's a very very very big difference. And of course, you know, as long as the patient is positive of course, he needs to be referred to the hospital that is responsible to handle positive COVID-19 positive patients, and this hospital is equipped, has trained the staff, the physician, the nurses how. You know, the PPE, in order to wear the PPE it's not an easy thing, but also to take out the PPE is not an easy thing. You need to be trained, and also you need to have, you know, a cath lab room with a negative pressure because this is very important. Then you need to disinfect. You know, there are many things of course that need to be taken care. And then the patient needs to go to a CCU that is also specifically for COVID-19, COVID-19, you know, positive patients. And also the staff at the CCU should be also take care with specific precautions these patients. So number one to summarize: number one, we need to see only emergency cardiovascular situations like a STEMI and dissections, STEMIs for primaries and dissections for CT surgery. We need to divide the hospitals in hospitals which can treat COVID-19 positive patients, and also hospitals can treat COVID-19 negative patients, and also thousands now of patients and many doctors have been infected. Some have died. The same happened also in East Asia. It's very important, you know, to protect the nurses and the doctors who you know are the first-line responders, and have, you know, the first impacts of this emergency.

[Ankur] Yes, so I think I lost you somewhere in between there, but we're back now, so just for the sake of summarising and also repetition because this is all new to all of us, you are recommending training for cath lab personnel and also training for intensive care unit nurses and doctors who are taking care of acute cardiac care patients with regard to using personal protective equipment, 'cause you know, like you said, it requires training to put that equipment on, and then it also requires training to take that equipment off. We have to do it in a secure safe fashion. So that's one take-home. The second take-home obviously is dedicating a negative pressure room for you to be able to do cases in the cath lab because cath lab cases, typically cases that we do either structural heart or coronary cases that we do on a day-to-day basis are done in positive pressure rooms. They're not negative pressure rooms. I believe N95 or N100 respiratory masks for everyone.

[Bill] Right, this is coming together with a PPE. Yeah, every PPE should have also N95 masks, double gloves, and protective glasses. It's very important, very important.

[Ankur] Okay, so those are again very important points. So the N95 masks, protective eyewear, and you know, like you said, gowns.

[Bill] Correct.

[Ankur] Are healthcare professionals taking any prophylaxis before getting in active contact with these patients? 'Cause you know, obviously we're at the front-line. Was there any system-wide prophylaxis, recommended prophylaxis for the healthcare provider for taking care of these patients?

[Bill] I'm not in a position to answer this question because the hospitals, excuse me, the patients that were checked and they were positive, they were going to a hub hospital. In this hospital that I was employed, we treated, you know, primary PCIs in patients that they were confirmed negative. So, yeah, I'm not in the position to answer this question. Not sure, I guess, yeah, I guess there should be instructions for that, yeah.

[Ankur] Okay so that's good to know, but in the hospital that you are working, did you come up with negative pressure rooms at all, or were you just shipping these patients to a dedicated COVID-19 hospital where, okay.

[Bill] Right, dedicated, that was much larger capacity. I heard that the dedicated hospital had the capacity of over 1,000 beds. These numbers are, yeah, these are regular numbers for East Asia, yeah. The numbers are very different of Europe and the West obviously, yeah different numbers, different populations.

[Ankur] So overall, you know, has China been able to curb the mortality from this?

[Bill] Well, from what I'm reading, Ankur, is that outside the epicentre for two consecutive weeks, there're not new cases of coronavirus. As I'm telling you, in the city that I am in Nanjing, 93 patients were detected, and those 93 patients were successfully treated. And this is, you know, an area with a population of eight million people. Can you imagine that? Also now I'm hearing that cases from outside are coming, so now there's a fear that, you know, the cases which are growing so much exponentially you know, outside the country, unfortunately, aids will be taken care of very well at the borders because, you know, they may infiltrate the gap. And this is a big problem, and I think this is a big problem for every country. As long as there was containment, and as long as, you know, you see positive trends of flattening the curve, you know, at this point, you know, the measures should retain very strict because you are afraid of reinfection and re-spread. There is, of course, these are lessons that everyone is learning, you know. These are not written in the books, you know, this is experience that you are gaining in such a short period of time. And to be honest Ankur, I'm hearing about experts and experts. You know, this is something that we didn't know three months ago, you know, this coronavirus. You know, it was only in animals, you know, and basically what we know now is what we're doing for every viral infection, you know, take care of your personal hygiene, wash your hands very well. Keep your distance from others. These are some basic measures that we are following. But this must be followed very strictly, very strictly because, you know, if this is not controlled at the early, at the early time, it looks like, you know, there will not be a bend. Usually we expect a bend in 30 or 45 days, but, you know, if this is not taken very seriously from the early beginning, since the early time, you know, this can take more and more. And I'm listening also about the fact that the temperature is going up and so let's see how this will facilitate the situation because now Europe and the U.S., in the U.S., you know it's mid-March, I hope by the end of March and April, you know, this rise in the temperature will help the situation to go down. But I'm telling you Ankur, you know, you need to be prepared to live for 25 or 30 days a different lifestyle. You need to be prepared, and you need to accept that for the next 25, 30 days that your life will change. Now you must protect your family indoors, must have very selective outside activity, you know, your personal hygiene, and of course all those protective measures that are suggested by also your local authorities, it's very important.

[Ankur] So were the local authorities in China very proactive when it came to like instituting lockdown for example? You know, closing health fitness centres or gyms or coffee shops, bars, restaurants, cinema halls.

[Bill] Right, yeah, you know there was, as I told you there was not any second that this is how I'm seeing. I'm seeing that, you know, the impact that this will have as small businesses it will be tremendous. It will for the employees of those small businesses will be tremendous, and of course I heard that in the U.S. there is such large packets that has been allocated to support those impacted businesses and this population but I'm telling you, you know, this must happen. Otherwise, you will not be able to contain the whole phenomenon. This must happen; this must happen. Yeah, there are many repercussions as you see, you know, stock market. There, you know, many companies are suffering right now. That's true.

[Ankur] Yep. Any cardiovascular effects of the coronavirus infection that you saw, or?

[Bill] Personally, yeah, I was not, I was not. I didn't, but I've heard from other colleagues and also I read at the an interview with a very prominent Chinese cardiologist from Shanghai, and I read also some articles that maybe those patients are dying from fulminant myocarditis, but you know, this is not something that is an established knowledge. I think we're at the phase that we're at the learning curve. You know, after four, five months when all those data have been gathered and analysed, we will precisely know what is the course of the disease and what is the actual fatality rate which so far looks like is about 3%. And also we will be more precise on what is the impact on the cardiovascular system.

[Ankur] True, very true. Well Bill, any closing thoughts from you? I know you've been generous in sharing all the details and the details of quarantine and also, you know, how to reschedule patients, take care of yourself, you know, be used to a different way of living. Any closing remarks from you as we sign off? And I know it must be pretty late in China, so thank you for your time.

[Bill] Yeah, for sure. You know, this is something transient. This will finish in 35 days to 40 days. There will be a lot of lessons that we will learn, but my overview and my personal experience says that unless you act very fast and very aggressive, you know, you will not see the results you anticipate fast. So if you act fast and aggressive, then you will have results in the next 35 to 40 days. Otherwise, you know, this will go further. And, you know, this is not good for the society, for the whole society, for the healthcare system. So the faster that you act, the better to leave this behind.

[Ankur] Very true; Bill, thanks again for being with us, and thank you for sharing your experience and your knowledge, and we wish that you remain safe and healthy.

[Bill] Yeah, I hope also for your guys, my close friends now, that, you know, this has spread out and comes together continents. Please take it very seriously, and I think you as physicians must be proactive. You also need to, you are part of the organisation and you need to advise the organisation. You are the physicians; you are the front-line, you know, front-line workers. You have responsibility to do that. And it's a team effort, and you need to follow instructions, but also you need to be proactive. The system depends on you. The system depends on you. You will win this situation, but, you know, I hope you will win with the least consequences.

[Ankur] Absolutely, Bill, thanks again for your time and we wish you safety and health. Thanks again.

[Bill] Thanks so much. Thanks so much Ankur; have a good day.

[Ankur] You too, bye bye.