Podcast: Queen’s ER Medical Director Daniel Cheng ’00

Dr. Daniel Cheng ’00 serves as a medical director of emergency medicine at Queen’s Medical Center, and is helping to battle COVID-19 on the front lines. He’s also dedicated the past three years towards building the Queen’s Care Coalition, an organization that serves the homeless population through a holistic approach that combines medical services with outreach like housing support.

Cheng – who graduated from the John A. Burns School of Medicine, did his residency at University of Southern California (USC) and has a master’s in public health (MPH) in epidemiology – was among the physicians who appeared in the 2013 critically acclaimed documentary, “Code Black,” which followed a dedicated team of young doctors-in-training at Los Angeles County Hospital.

Punahou’s Podcast Editor Allen Murabayashi ’90 spoke to Cheng about the current state of battling COVID-19 at Queen’s Medical Center and in Hawai‘i, as well as the prospects for opening school in the fall.

You can find Punahou’s Team Up podcast on Apple Podcasts, Spotify, Simplecast and Google Play.

Podcast Transcript

Allen Murabayashi: Like many of the Punahou alumni medical professionals we’ve had the opportunity to interview, Daniel Cheng is not only a front line responder to the COVID crisis in the ER, but also a leader within the local community. In 2018, Cheng was named Physician of the Year by the Health Care Association of Hawai‘i, for his leadership in creating the Queen’s Care Coalition to address homelessness with an integrated approach that considered not only healthcare, but housing and other outreach services. With both a medical degree and a master’s of public health in epidemiology, Cheng has focused not only on addressing the bedside care of individuals, but the health of the community at-large.

Daniel Cheng: My name is Daniel Cheng. I’m Class of 2000. Go Puns. I’m an ER physician, the current Medical Director at the emergency department at the Queen’s Medical Center at Punchbowl.

AM: It seems like for now, some of the worst case projections for Hawai‘i have been averted, but we’re still seeing a bunch of hospitalizations. And as of today, we have nine deaths in the state. What type of activity are you seeing in the ER right now?

DC: Yeah. So I work at the Queen’s Medical Center in our Punchbowl downtown facility, and I think we’re seeing that same trend is the acuity that is coming in, so the level of sickness is definitely higher, but the total volume has gone down. It’s tough – there’s all of these projections out there, some from Washington, some from Penn State, different university settings. We’re trying to input what we know we’ve done on the State level, or federal level, even institution level here at our own hospital, which is different from Kaiser, which is different from Pali Momi. And so it’s hard to take a national model and to make it make sense for our population. But I think, all of the things that’s been happening on the State level, and what we’ve been doing have definitely done the… What’s the term now? Flatten the curve.

AM: And does the patient population that you’re seeing match what we’re hearing nationally, in terms of older people with comorbidities like diabetes and hypertension?

DC: Yeah, we’re definitely seeing some of those. What we’re also finding, at least in the beginning part, were a lot of the more common risk factors. When I say more risk factors, given our geographical location and the fact that we have 70% tourism as our main source of income, a lot of the initial individuals that tested positive were more tourists, people who are travelers. At the end of the day, for us, it was the biggest risk factors and the kind of first wave were actually the, being a tourist coming from some of the locale, New York, the mainland, Asia, and then as it’s morphed, and there has been what we call community spread now. Then it’s infected a more general swath. We also saw a lot of bartenders, a lot of people up in Waikiki there had, again, that close contact, these individuals got infected.

I think the very first person that coined community spread was a worker at Kualoa Ranch that had none of the travel risk factors, right? But as you mentioned, are we seeing that higher acuity in people who have chronic disease, age? Definitely, but I can’t, I definitely will say that’s not the end all. We’re definitely nothing like Italy. We’ve definitely seen some really young, pretty healthy people come in very sick and be on a ventilator, or breathing machine, going to the ICU, so it’s been a little bit more of I think a mixed bag, I would say.

AM: And what’s the situation in regards to having enough equipment and PPE in the hospital?

DC: Yeah. I think, right now, at least I can speak for our hospital. We’re in a good place. Initially it was pretty unclear, as you imagine. We’re mostly two to four weeks out from our expected shipments. So I think when that real bomb hit on the mainland, there was a really, and there still is a little bit of a period of unclear, if some of these shipments would actually land. What’s still going on, from what I understand, is that FEMA are just confiscating equipment right off the docks. So even though it might be ordered for us, they’re trying to triage where the greatest national need is. So some of our orders of respirator masks, other equipments that we need for, just basic clinical care, initially were really just canceled by our suppliers, because they were prioritized to other parts of the nation. But we were able to go through other channels, look at other secondary sources and, and we’ve done some significant reutilization in our hospital. Huge, huge, just outreach from the community, donating, from the construction industry to ancillary health fields like dentistry, veterinary medicine, it’s just been phenomenal. And it’s kind of gotten us past over the hump, but we’re in a much more stable place. I will say, compared to, I’d say, three weeks ago.

AM: I’ve heard that doctors around the world had been communicating with one another regarding treatment protocols. Has the way that you approach treatment changed in the past few weeks, based on this type of information?

DC: So in the emergency room, not necessarily. There is no actual best practices for people that we are going to discharge currently into the community. There’s a lot of, I would say, off label use now that we have… At our hospital, we’ve enrolled in some of the clinical trials, have looked at more aggressive treatments for people who are really sick in the intensive care unit. But I think it was such kind of a wild, wild West in that first, end of February through March. But yeah, right now, there are no approved or even scientifically proven basic treatments for people who are diagnosed with COVID, and are okay enough to go home. It’s just the usual, typical, for the flu. Lots of fluids, lots of rest.

AM: So in that regards, we’ve heard about experimental treatments through the media, plasmapheresis, hydroxychloroquine, some anticancer drugs coming out of Israel. How should the public evaluate these proclamations?

DC: Yeah, I would just say, a huge dose of skepticism. I don’t want to say it’s like the old days of charlatan medicine, where you have these soothsayers promising medications. Back in the old days, it was because there was such limited science, people didn’t know what worked, and people were looking for an anecdote, right? So obviously, as a medical community, we’re trying to find the best and safest of, the key part, safest solution. But so far, what’s been done in a lot of small studies, in these bigger hit areas in China and Italy, nothing’s really panned out, as the clear alternative to the safe standard regimen of lots of rest, hydration, all those things they talk about. And yeah, I would just tell the lay public, where we’re seeing these things come out is, we have to be very skeptical, because there’s a lot of incentive. There’s a lot of incentives to claim that they find the cure for this pandemic. And there’s a lot of people working on it. And I think, once we find something safe, and I think there will be something coming out within the next, I know it sounds late, but I think next two to three months. But I think we need to, be very skeptical when you hear of some kind of wonder drug.

AM: There seems to be a trend of people avoiding the emergency room, for fear of contracting COVID, which has led to an increase of atypical deaths at home from heart attacks, for example. What’s your advice to people who are in some sort of health distress, and when should they head to the ER?

DC: That’s a great question. At least, I know, different institutions, we have our own hotline, if there’s any questions about COVID, and I’d encourage people to just call it. It’s for any, you don’t have to be a Queen’s member. If you’re a Kaiser member, it’s 691-2619. I can tell you from Queen’s, and from most institutions at this point, we have created systems in place to really minimize any exposure to a possible coronavirus patient to the other patient populations. So that was priority number one for our institution, and many institutions across the nation, if not world. So just for example, in our hospital, in the ER at Queen’s, there’s a separate exterior tent area, and those who are sick enough to have to be in the hospital in the main ER, they’re relegated or separated to a very specific portion of the ER that has a special ventilation setup. And all of the patients are set up in a different part of the ER. So there has been no known cases of hospital-based transmission, or spread of this infection, from one patient to the other in any hospital, at least on the island, that I’m aware of. The chance and risk is, I have to say, quite low given the extreme measures that’s been taken by most hospitals to prevent that.

So, I think, with that frame of mind, you’re absolutely right. I think that’s the biggest fear. There’s, on average, 40 to 50% drop in volume in emergency visits. We’re trying to set up processes for tele-health, so that if people are unsure, and you know it’s one in the morning and they can’t get ahold of their primary care doctor, is there some alternative, other than calling, number one, to at least get a face-to-face with the physician? So it does show, I think, one of the big factors, that this pandemic has been a real stress test on the healthcare system. And for us as a community on the middle of the Pacific, we need to do better in finding other alternatives to care, besides going to your primary care office, or going to an emergency room.

AM: A few years ago, you spearheaded an effort called the Queen’s Care Coalition in response to the homeless population in Hawai‘i. Can you describe that program and what drove you to create it?

DC: Yeah, absolutely. I think, the one minute Marvel DC kind of origin story would be, I was born and raised in Kaimuki to immigrant Chinese parents, and I remember growing up and going to Chinatown every weekend with my mother and father to buy groceries. And at that time, you would maybe see one person, who will suffer from homeless, and that’d be a very, very rare sight.

When I came back with my wife, it was just a complete different world. And I didn’t know where to start. I started working here at Queen’s, and it really hit me one day when that patient I was taking care of in the emergency room, who really just had no good place to go. It was just a revolving door, and I felt so frustrated and defeated as a physician, that when I thought, “Same person,” when I went out shopping with my wife in Chinatown, and he recognized me. He was actually a farmer out in Waianae, and this was after the recession had lost everything, had had a leg amputated, had no ability to get back to actually, Cambodia, where he was from. He recognized me as I was walking down out of my scrubs, and he asked me for help. So it really struck me as saying, “Wow, how do we change the system?”

So it was actually just a Google search from there, on best practices on, how do we find a financially incentivized process for both, all stakeholders? And then, how do we make sense of, how do we at least start somewhere? And the model that I settled on was a model that looks at making kind of a win-win. So for health insurance, they don’t really like, I want to say, “like these patients,” because they end up costing a lot. So we can pair with them by saying, “Hey, let’s work together on these highest utilizers of the system that end up being 90% of the time homeless, and let’s find solutions. Let’s find solutions to pay for housing.”

Because, actually, housing is way cheaper than paying for the healthcare. I mean, on average, the highest person was about a million dollars a year, just for their ER care alone. And then, the other part of this was, really how fragmented and siloed the system of providing care for these patients. And what I mean by that is, as a hospital institution, we don’t see housing as a core tenant of their medical needs. And that was the key process of forming a team that had these, what’s called “navigators.” These are people that have limited postgraduate education, but I really focused in on connecting these patients, and pairing that with a structured way of approaching their care. So the best example I can give you is, we have a homeless person that has severe mental illness out in Aala Park, out by Chinatown. They’re dialysis patients, to give you an example, and they’re missing their dialysis appointments every two days because they have severe behavioral illness, they can’t make it their appointments, non-transportation, so forth. And then the insurer will pay for this, we’ll call it, a navigator to go and meet this person, out in the park, and then getting them into the system to apply for free housing or grants through HUD, or through the city and State monies that they put in, about $25 million. And it just has steamrolled into an amazing program over the past three years.

AM: Is it really seeking to be a bit interventionist, and use, I guess, prophylaxis, in a way, before they enter the ER, to kind of intercept them?

DC: Well, that would be, we’re not quite at the vaccination stage, prophylaxis stage of it. That would be stage two. I mean we’re still in the, “Oh my God, this is like, we’re trying to serve a tsunami right now.” And ideally, like you mentioned, is we get to that point where that person walks in, this is a first year visit, because they just lost their job, they just lost their house, and now they’ve developed an skin infection in their foot. You know, there’s so much that that person needs is, rather wait until that person has lost the leg, and they’re on their hundredth ER visit, let’s get this all taken care of now. So that’s where I would love to be, that’s at that prophylactic stage, but we’re probably, honestly, three to four years away from that.

AM: This might be a naive question, but how would a homeless person get COVID-19? And why are they such a susceptible population to disease in general?

DC: Yeah, I don’t think that’s a naive question at all. So what we do know is that COVID loves populations that are in close proximity to each other, and that’s, by definition, what we find in our homeless population. Because, except for the few individuals that are lone wolves, homeless individuals congregate together out of safety, and out of necessity. So these, we call it congregate living situations, you have a homeless encampment, you have prison systems, a nursing home is a great example, COVID really prays on these close, intimate, prolonged contacts that you see in homeless encampments. The other reason why homeless people are not only more susceptible, but are more likely to have a poor outcome, just has to do with the fact that they’re more likely to have a poor outcome if they had a pneumonia, right? Because these are people that have had long standing, untreated, unmanaged chronic diseases like diabetes, hypertension, and so forth. So they’re definitely a high risk population on multiple fronts. And that’s what makes it, we’ve prioritized testing for a homeless person, if they exhibited symptoms of COVID. So that’s been a guideline that we’ve been following here at Queen’s, because we see the majority of homeless people in the State of Hawai‘i.

AM: I know you’re not an epidemiologist, but I’ll ask you as a medical professional. In the past week or so, we’ve started to hear about plans for the “post mitigation phase,” and most scientists have suggested that the next step is impossible, without significantly more testing and technological solutions to contract tracing, like the coalition that Google and Apple announced to install software on your phone. What are your thoughts on how we emerge from this current phase of COVID?

DC: Yeah, I think, with a big caveat, right? I’m not an epidemiologist, although I did get an MPH in epidemiology is, the contact tracing is just so key. And one of the biggest, I’ll just say right now, the scandal that still has not yet been published out, and I’m sure The Washington Post and The Wall Street Journal will have this huge expose on it is, just the lack of available testing. Up until only about a week ago, the State, our State, was only able to do about 50 coronavirus tests on Island per day. We only had that many reagents. And now that’s been up to 180 or so, just for O‘ahu. But we’re already way deep into this pandemic. Our hospital, the major tertiary hospital for the State, just recently has been able to gain access to some of these reagents, right?

So I mean, before, and you can imagine the very first two weeks, we were sending all of these tests to the mainland, and it was taking up to two weeks to come back. Two weeks, that’s a lifetime. I mean, that’s like 30 new cycles for coronavirus, right? And it’s just such a, I mean, such a scandal in terms of the unavailability to have the basic access to these tests. We’re just flying blind, right? And to be honest, we’re still nowhere near the capacity as we should be, but testing results that we do have had, has been still very encouraging. I think everything that’s been put together has been very encouraging. So I think we’re very close to the day where we have zero positive, despite our increased testing. I think we’re very close to that. And I think, now that we’ve had a combination of slowly increased test results, lower positives, and now, more staffing and support to our Department of Health’s ability to do contact tracing, I think it’s actually not completely unreasonable, that we actually start considering the topic of how do we incrementally reopen up society?

AM: And do you think, I mean, I’ve heard some discussion around, you can open restaurants again in sort of limited fashion, but big gatherings are probably going to be impossible until we really have vaccinations in place. Do you see schools reopening in September or August?

DC: Yeah. You know, I think the nice thing will be is that Hawai’i loves to, as a local, we love to see what happens in other places before we jump in. That’s a Hawai’i thing. And I know Sweden is one of the international locations that have had a lot of press about going out, starting with the children. We do know that children, for some reason, it’s not, well quite understood yet, have some protective something about the fact that you’re a young child that’s protective of having really bad outcomes with a coronavirus. So it seems pretty reasonable. I think starting school in the fall is, at the trend we’re going, at the trajectory, is a probably a very reasonable assessment, and I think it will be nice. And I’m sure that the DOE and our State government is going to be looking at how other states, at least in the U.S., and other similar settings, be it Singapore or Japan, how they do it, and their outcomes. I think we’ll be watching

AM: Oh, how they do it and their outcomes. I think we’ll probably be watching really close.

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