Jason Fleming ’94, a veteran emergency physician and a medical director of an emergency department in Honolulu, says he’s never encountered anything like the COVID-19 outbreak in his career. Although Hawai‘i has only recently begun seeing community spread of the virus, he said one of the primary concerns among Hawai‘i’s doctors right now is being flooded all at once with patients with the infection. “The concern is not so much that we can’t treat an individual who has this,” he says. “What we don’t have is enough volume to manage the volume of people that we anticipate are going to come in. Because as we see the numbers in other hotspots around the world…, we see the trajectory and it feels to us like we’re standing on the beach watching the tsunami come toward us.”
Allen Murabayashi ’90, editor of our Team Up podcasts, interviewed Fleming by phone to discuss the crisis and the situation local health professionals are facing. Listen to the podcast above, with the transcript of the audio interview below.
AM: Thanks for joining our Team Up podcast produced by Punahou School. I’m Allen Murabayashi, an alumnus from the class of 1990. As part of our #PunsUnited coverage of the COVID-19 outbreak, we are interviewing alumni working on the front lines of this global health crisis. They are out in force, playing instrumental roles in helping their communities across the world during this unprecedented time.
I’ve known Jason Fleming since high school. He was an accomplished singer who went off to Dartmouth where he received a bachelor’s degree in music and drama. He returned home to attend the John A. Burns School of Medicine at the University of Hawai‘i, followed by a residency in emergency medicine at the University of Massachusetts. He has lived and worked in Hawaii since 2002.
(Question to Fleming) The rate of spread and increase concern over COVID is pretty startling. You’ve been in the ER for many years. Have you encountered anything analogous to this?
JF: No. There’s nothing like this and in fact, I was just talking with somebody else this morning who had occasion to speak to some older members of our community. Folks in their 80s about whether or not they felt like anything that they had lived through, even wars or previous medical situations, if this situation reminded them of anything else. And the answer was, ‘no.’ They said there’s been nothing quite like this in their lifetimes either.
AM: Have you started to see an increase of patients to due to COVID-19 in the ER at all?
JF: Yes, we have. Now it’s important to understand that in this time of the calendar year, it’s kind of cold and flu season. So typically between maybe November and March or April, we see a higher kind of volume or higher percentage of our patients being respiratory illnesses. And that’s just because of seasonal flu and seasonal kind of upper respiratory infections that lead our more medically fragile or vulnerable people to have more serious disease. So things that typically cause the average Punahou student or Punahou parent a cold or maybe a fever and a cough for a few days, then they’re back at work. Those kinds of illnesses already are impacting our kupuna, folks that are in their 70s or 80s in a more serious way – and drives them to emergency departments and that leads to many hospitalizations. Sometimes they get very sick with those viral illnesses. Sometimes they have to go to the intensive care unit and be on ventilators.
The issue with this infection is that we’re seeing a very high volume coming right at us all at once. And the concern is not so much that we can’t treat an individual who has this. I mean we do have the technology to do that, right? With ventilators, with intensive care unit level of support. What we don’t have is enough volume to manage the volume of people that we anticipate are going to come in. Because as we see the numbers in other hotspots around the world, in China, in Italy and now even in other parts of the United States, particularly in New York City and in the Pacific Northwest, we see the trajectory, and it feels to us like we’re kind of standing on the beach watching the tsunami come toward us.
AM: I assume that everyone that walks in with a cough or a fever assumes that they have COVID-19 at this point. What is the testing protocol for you guys?
JF: If we had our way, we would be testing everybody, and would have been testing everybody for the last month or month and a half. The problem with the testing is there aren’t enough test swabs and there isn’t enough test reagent. The testing goes like this, there’s a swab that looks like a little cotton swab, but it’s not made out of cotton. And that swab has to be put into the patient’s nose all the way back to the back of their throat and then put into a specific reagent, a liquid that’s designed for this test alone. And then that little test tube of the swab inside the liquid gets sent to a lab. And the lab runs what’s called a PCR analysis, a preliminaries chain reaction, right? It’s a test where it amplifies pieces of RNA or DNA to the point where we can detect and identify what it is and the test comes back with either a positive or negative result.
Well, we’ve got problems with both the amount of reagent that’s available and the amount of the swabs. The swabs that are used in the test kits that were available to the Hawai‘i Department of Health are actually manufactured in an area of Northern Italy that’s currently being hit by this very virus. So that’s not just an issue of volume; it’s an issue of the supply chain. And are we going to even be able to get these test kits together, given the situation that’s going on where they’re being manufactured.
AM: So outside of the availability of the tests and the reagents to carry out those tests, what are your concerns from a healthcare provider perspective? Is it PPE (personal protective equipment)? Is it hospital beds? Is it ventilators?
JF: Yeah, it’s all of those things. Because the hospitals have some reserve, right? But these are all private hospitals that have a fiduciary duty and a fiscal duty to their boards or to their shareholders or just to the community to stay solvent. Right? So these private hospitals that we have in Hawai‘i, and every one of our hospitals in Hawai‘i besides Tripler is a private hospital. They don’t run the business typically in preparation for a surge of this magnitude, right? Because this is unprecedented. It was hard for people to see that something like this could happen. And the hospitals in Hawai‘i typically are running at a pretty thin margin anyway. They have to keep making fiscally sound decisions to stay solvent and stay in business for the betterment of the community. And so we’re not sitting on a huge stockpile of extra stuff.
Most of the hospitals that I’m aware of in Hawai‘i right now, as of this recording are under two weeks from being out of PPE for their providers. So that’s where we’re at right now. And that’s actually not out of the ordinary compared to my contacts across the country. That most places are either running desperately low, some places are already out. And so as it relates to PPE, that’s caused us to be forced to make some changes in the way that we operate with those things. PPE stands for personal protective equipment, and that means the masks, the goggles, the hair nets, the gowns, the gloves – the stuff that keeps a provider safe from whatever the infection is that the patient has. And so what we typically do with those is walk into a room with a patient who has a severe infection or we suspect has a severe infection with all of that stuff applied to ourselves.
JF: The CDC has long released guidelines on the different levels of PPE that are required for airborne infections, droplet infections or contact precaution kind of infections where you just don’t want to touch it. So we adhere to those and when we step out of the room, all that stuff gets thrown into the trashcan and we wash ourselves up and move on with the work of the day. But this situation and the impending shortage or the scarcity that we’re experiencing now has caused us to need to adjust all of that. Right? So now today doctors and nurses in emergency departments are being issued one mask for the day and they’re wearing that the whole day. And at the end of the day we’re going to put that in a baggy and we’re going to take that home and stick it someplace until we might need it again. Because if we run out, that might be the only thing we have left.
Now if we are in a procedure that’s particularly dangerous, there’s a lot of aerosolization of fluids or whatever, something serious is happening, then we have no choice but to throw away the PPE after that because it’s almost certainly going to be infected. But you can see that if we don’t get the shipments that the hospitals have ordered, we’re going to run into a scarcity situation that’s truly dangerous for the folks that are working on the front line and we’ve already been seeing that happening. Hospitals have been waiting for their shipments of PPE to come in over the last month and instead of 5,000 units, they’re getting 1000 units. And that’s because there’s scarcity across the whole globe because of this pandemic.
AM: I’ve seen other municipalities and cities commandeering space to erect temporary hospitals. Has there been any discussion amongst the doctors about doing that sort of action at this point?
JF: So the state or some overarching authority, the Hawaii Hospital Association, they are looking at solutions that would expand our capacity, but where are those are going to be – how we’re going to utilize some of our facilities that maybe have more space like Tripler for example that has areas that are underutilized or not utilized on a day-to-day basis, but it’s a huge facility? Those are still things that are being worked out. And our worry is that those of us on the front line is that the solutions are going to come late when we really need those solutions is now right before the volume hits. Because I think we all are having awareness that the next two weeks in Hawai‘i are going to tell us what the trajectory of this is going to be for the next month or two.
AM: I’ve seen a number of DIY projects to sew face masks or build open-source ventilators. Are these helpful at all? Do they have clinical applications or is it just busy work for people that are trying to stay engaged somehow?
JF: I don’t know yet. I think that things that are very complex – open-source ventilators and so forth. I mean we may find ourselves in a desperate situation where it’s take it and use it to save people or don’t. It’s hard for me to predict, but my guess is that if we’re at that level of desperation, we probably would be reaching for whatever is available to us, the smaller projects, the tabletop projects. It’s as a physician who is both working on the front lines, but also feels this responsibility because of the job that I have to a team of folks, a team of physicians and nurses as a medical director, it warms my heart. And we are experiencing such deep gratitude, that people in the community are looking for ways to help even simple ways like sewing surgical caps out of cotton material for donation to our team.
Right after this interview, I’m going to get in my car, drive across town to Kaimuki and meet a Punahou classmate who’s put together a package of things like that through her contacts that I will distribute to our team of doctors and nurses and paramedics in our community. And it’s so helpful because when we run out of things like a hair net or a surgical mask, what else are we going to have? And so the value there is not just in the object that is going to provide some value, right? The value is in the communication that the people on the front line are on the minds of the folks in the community – that the people are thinking of us, that they’re caring about the folks that are rolling up their sleeves and about to do this very tough work. And you can’t put a price on that kind of aloha – that kind of connection.
AM: So analogously a lot of people are sitting at home because we have to. What do you think’s the best way for them to help?
JF: Well everybody’s heard this, but the best thing that can be done is to limit the likelihood that you will spread a disease that you don’t realize you have or that you will pick up a disease that you don’t yet have and spread that to other people. Right? Hawai‘i is unique in so many ways. One way is that we have multiple generations intertwined all on the same little postage stamp of land in the middle of the ocean. The toughest thing for me about this situation right now is the fact that I cannot go over to my aging parents. My wife, who was also Punahou grad ’94, can’t go over to her aging parents and help them at a time when they need help anyway. But we can’t risk that kind of exposure. And so for the folks that aren’t walking into an emergency department every day or in an ambulance every day exposing themselves potentially to this infection, the best thing to do is to limit yourself being a vector to decrease the likelihood that you will inadvertently do anything that makes this situation worse.
Besides that, if you want to take action, then the lowest cost, simplest thing to do is to reach out through your own social networks to folks that are engaged right now, working on the front lines and give them a virtual high five. Tell them that you’re thinking about them and then these tabletop projects or different ways to help or mobilizing of resources. If you happen to have N95 respirators lying around your garage because of that DIY home project that you were doing last year, reach out and see if somebody could make use of that now. I bet you will find people to respond with deep gratitude and a drive over and give you an elbow bump under the circumstances, and you will know that you’ve contributed in a real way to this fight.
AM: I saw the Blood Bank of Hawaii put out a call for donations because so many corporate drives had been canceled due to COVID-19. Is it safe given the circumstances and the notices about staying home to give in this environment?
JF: Yeah, that’s a great question. I mean, I know you and I both care a great deal about the notion of giving blood and making sure that’s something that we see not just as a nice thing to do, but as our civic duty, our community duty. And I can tell you this, that the Blood Bank of Hawaii is desperate for donations. Our need for blood is probably higher in this kind of situation than usual because many of the patients that we are trying to save or are about to try to save are going to need blood or blood products as part of that. And so that’s going to mean that we’re entering a phase over the next several weeks where the blood bank’s availability is going to go down, and folks like us are going to find ourselves in a situation where we want to order blood to save a patient, and we are going to be told that it’s not available.
Now what do we do about that? Well, the Blood Bank of Hawaii is because of these current conditions is no longer taking walk in donations, but they will allow you to call and make an appointment. And that allows them to know that you’re coming to do some important pre-screening stuff. I’ve given blood at the facility here in Honolulu several times. It’s clean; they’re professional; they’re efficient. They are set up in a way where there’s a large space so that you’re not right up against other people. You can maintain safe social distancing. Wear a mask if if you want to or need to. But I would not have any hesitation myself of calling them, making an appointment and going in to give blood. In fact, I’m going to do that this week, and I would urge everybody else to find time to do that too.
AM: I’ve seen a lot of people hanging out on the beaches and doing the Koko Head hike. and it doesn’t seem like the message is getting across. I’m wondering whether you think the phrase social distancing is clear enough to the average person and to this wave of college kids who have just recently returned to Hawai‘i because of their school’s shutdown, and they’re going to online learning now.
JF: That’s a great question. I kind of wish that there was a better phrase. It’s interesting you brought that up. I mean it feels accessible in the sense that it’s not threatening – that phrase – but I don’t know that it conveys the urgency or the seriousness of what we’re talking about. And I think that the data is starting to show that while young folks, college students for example, folks in their twenties are less likely to get super duper sick from this, they still can. There are still 20-year-olds in this country who are on ventilators fighting for their life with this infection. And even the folks that don’t get super sick are going to leave this infection on a doorknob or on a bus handle or on a drinking cup that somebody’s grandparent or somebody’s parent is going to come along and touch. And that’s the way that this virus is being spread.
So the best advice for all folks of all ages right now is to behave as if you have the virus that’s going to kill folks. And if you behave that way, you’re going to alter your behavior, right? You’re going to avoid going into crowds because you might spread this to people. You’re going to wash your hands more often because you might have some of that virus on your hands already. And you will take those actions that social distancing encompasses and encourages to try to limit folks getting close to each other so that this virus continues to spread.
AM: I know you’re not a psychologist, but you are the parent to two kids. What have you been telling your children during these uncertain times?
JF: I have two children, a 13-year-old boy and a 4-year-old boy, and they’ve got a lot of questions. The 13-year-old has talked about this virus in his health class. It’s something that his peer group has already started sort of discussing, joking about. There is an awareness in that group. The 4-year-old really doesn’t understand why we can’t go to the skate park, why he can’t climb the jungle gym, what this is, why he can’t see his grandparents right now. And I think what I would say to parents is, number one, your kids know more about what’s going on than you probably think they do. So whatever you think your kids know about this, they already know more than that. Number two, kids are uniquely qualified to detect BS from their parents and from other adults.
So even if you lie to them even a little bit, they may smile, they may nod their head at you, but you might inadvertently erode some trust between the child and the parent by not being honest with them. Now, that doesn’t mean you have to tell them everything that you read on social media, but I think it’s reasonable to explain to the children in an age-appropriate way that the reason we’re doing this is because there’s an infection out there and infection is a kind of an illness. If people get it, some people get a little bit sick like that time that you had a cold, but some people get really sick, and it’s hard to predict who that’s going to be. And so we’re sticking together as a family, right? We’re going to look for ways to help, and one of the most important ways to help is that we can participate in this community effort to limit the transmission, limit the risk.
AM: And to end on a somewhat of a somber note. I’m wondering whether you’ve talked with the other doctors about the notion that you’ll just inevitably get COVID-19 as a result of working in the hospital.
JF: Yes, I think that we have watched this unfold very, very closely. And we as physicians and nurses, folks that that work in emergency departments, we could see the future a little bit. We see what’s coming and the primary problem here is the lack of resources, the lack of available resources. We as human beings who are trained to do this could treat every single person who has it if we had enough equipment to do that. And the fact that we’re running low of the very equipment that’s designed to protect us when we walk into the room is disheartening. And we have no choice but to wrestle with that. I think that many of us believe or have come to terms with the notion that we’re going to get this. I just don’t see how we’re going to be able to protect ourselves as well as we should if we don’t have the gear to protect ourselves, and yet, we still have to walk into the room and do procedures on folks to help save their lives that are going to put ourselves at risk.
Now that’s a burden that we sign up for early on in our career, right? We’ve made these choices to put the welfare of our community, of our fellow human, even before our own welfare. What’s tough about that is that we all have other folks that we also owe our ourselves too, right? Our own families, our own loved ones, children, spouses, parents, and this is a tough time for us. It’s wrestling with these issues of the anticipation of the traumatic event that’s about to happen is one of the toughest things about all this.
Which is why, just circling back to a previous thing that we talked about during this interview, that what can regular folks do who are forced to sit at home right now? Reach out to the nurses, to the doctors, to the paramedics, to the first responders, the police officers, firefighters, even the folks who are deemed essential, right? The folks who are grocery store clerks, janitors – all of these folks that are in it right now, and tell them you appreciate that because that gives us just a little boost to keep going.
AM: The day after I conducted the interview with Jason, I received a voice memo from him with one additional thought that I wanted to share with you.
JF: Hey Allen, this is Jason. Just had one additional thought to tag on the end of our interview yesterday, which by the way, was very enjoyable, and I really had a great time chatting. I was thinking about your last question – about how we’re doing in terms of our own mental health, coming to grips with walking into this coronavirus situation. And also thinking about the previous question about how do we tell our children. And something happened after that conversation, which is why I wanted to reach out and share it with you now.
My son, my 13-year-old, had made a comment, he said, “Hey dad, are you going to work today?” And I said, “No, not today kiddo. I am staying at home.” And he was visibly relieved and said, “Oh that’s good.” And I realized he’s worried about this too. So I paused and I told him, “Listen, when it comes to be your turn to make a difference in this world, I hope that you answer that call. When it’s your time, I hope you rise to the occasion.” If there’s anything that we can all hope for our children in uncertain times and scary times like this, I think it is that we hope that we will be good examples for them no matter what happens. Come what may.
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