S2:E8 - "COVID-19 Pandemic Update for EMS - What we have learned, vaccines, and what to expect - with Dr. Steve McGraw and Dr. Russell Faust." Recorded November 24, 2020

In this episode, we welcome back Dr. Steve McGraw and Dr. Russell Faust.  Dr. McGraw is an ED physician at Ascension Providence Hospitals in both Southfield and Novi, Michigan.  Doc is also the current Oakland County Medical Control Authority EMS Medical Director which provides oversight to over 50 EMS agencies.  Dr. Faust is the Medical Director of Oakland County Health right here in Southeast Michigan.  Together, these guys have been major part of EMS’ understanding and response throughout the entire COVID-19 pandemic. 

Even though we are located in Southeast Michigan and we mention our home state a lot, most of the EMS on AIR content applies to EMS on the national and even the global scale.  This episode speaks to how our local system has been preparing for the availability of COVID-19 vaccinations.  We do address the topic from a national perspective, but we’ll be using Oakland County and many other areas of Michigan, as an example of how large systems are preparing for the next stage of this unfamiliar process.   

Dr. Faust will lead us off with an update of the current COVID trends, as of November 24, 2020.  Russ provides a nice overview of the national, state and local COVID updates and information.  Then, the docs compare and contrast the first wave of COVID in April 2020 to the current wave of COVID we’re seeing in late November early December 2020.  We wrap up the discussion with a focus on the current status of COVID-19 vaccinations and how EMS may be used in mass administration process to the public.  This is a very informative episode that I really enjoyed, and I hope you do, too. 

Visit EMSonAIR.com for the latest information, podcast episodes and other details.

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Please keep emailing your questions, comments, feedback and episode ideas to the EMS on AIR Podcast team by email at QI@OCMCA.org.  

Transcript

Geoff Lassers: 0:07

Hello and welcome to the EMS on-air podcast season two episode eight covid 19 pandemic update for EMS, what we have learned vaccines and what to expect with Dr. Steve McGraw and Dr. Russell Faust recorded November 24 2020. The mission of the EMS on-air podcast is to keep healthcare provider safe, informed and prepared. Today is December to 2020. I'm Geoff Lassers, and I'll be your host. Yep, I'm still a little behind in the editing process, but we're almost caught up. Lots of good stuff coming your way including cardiac controversies Part Two with Dr. Robert Swor. That one's going to be out this coming Monday, December 7. In today's episode, we welcome back Dr. Steve McGraw and Dr. Russell Faust. Dr. McGraw is an ED physician at Ascension Providence hospitals in both Southfield and Novi, Michigan. Doc is also the current Oakland County Medical control authority, EMS medical director, which provides oversight to over 50 EMS agencies. Dr. Faust is the medical director of Oakland County Health right here in Southeast Michigan. Together these guys have been a major part of EMS's understanding and response throughout the entire covid 19 pandemic. Even though we are located in Southeast Michigan, and we mentioned our home state a lot. Most of the EMS on-air content applies to ems on the national and even the global scale. Today's episode speaks to how our local system has been preparing for the availability of COVID-19 vaccinations. We do address the topic from a national perspective. But we will be using Oakland County and many other areas of Michigan as an example of how large systems are preparing for the next stage of this unfamiliar process. Dr. Faust will lead us off with an update of the current COVID trends as of November 24 2020, Russ provides a nice overview of the national state and local COVID updates and information, then, the docs compare and contrast the first wave of COVID in April 2020, the current wave of COVID we're seeing in late November and early December 2020. We wrap up the discussion with a focus on the current status of COVID-19 vaccinations and how EMS may be used in the mass administration process to the public. This is a very informative episode that I really enjoyed and I hope that you do too. Please keep emailing your questions, comments, feedback, and episode ideas to the EMS on-air podcast team by email at QI@ocmca.org. Also, check out our website emsonair.com for the latest information, podcast episodes and other details. Follow us on Instagram @ems_on_air and please, whatever podcast platform you use, subscribe to our podcast and leave us a rating and a review. It really helps us grow this project. I can't say this enough, please leave us a rating and review and help us get noticed on a much larger scale. Remember, the mission of the EMS on-air podcast is to keep healthcare providers safe, informed and prepared. So increasing our ratings and reviews gets us noticed by more listeners and more sponsors. And that will lead to increase in their reach resources, experts and abilities. Bottom line ratings and reviews are vital to our growth. And your contribution will give us what we need to serve those that serve our communities. The only cost to you is providing a few minutes to give us a rating and a review on whatever podcast platform you use. We're available on pretty much every platform you can think of. So it's super quick and easy for you. We really appreciate it. Thank you for your consideration. Enjoy the podcast. Everybody feel good?

Dr. Russel Faust: 3:44

Oh yeah.

Geoff Lassers: 3:45

Getting after. All right. Good morning, gentlemen. How are we?

Dr. Steve McGraw: 3:48

Morning. Well.

Dr. Russel Faust: 3:49

how are you?

Geoff Lassers: 3:50

Fantastic. To get started today. Dr. Faust why don't you provide us with an overview of the national state and county COVID-19 statistics.

Dr. Russel Faust: 3:58

start with the bad news, huh? Yeah, as of today, November 24, especially through yesterday 23rd. county wide, we have 36,000 total cases, and yet the fatalities have not continued to climb. So we're still at 1200 total fatalities, nearly 20,000 had recovered. The really scary news is when we start to look at the current surging cases and look at our seven day average. Compare that to what we were seeing back in mid April. You know, mid April, our 7 day average hit up to 300 per day, and we just peaked it 800 average cases per day. These are just crazy numbers. And I'm sure Dr. McGraw can speak to what they're seeing in the ED. I've mentioned this before. I'll just briefly touch on this. Back in April. We saw two weeks following that peak of cases we saw a peak and fatalities. We have not seen that in the subsequent Waves of case increases. So we didn't see that again in August. We're not seeing it now for this peak. And what is truly extraordinary and we're all grateful for is that our average fatality per day hovers right around 1. 0-1. It's one fatality a day in Oakland C unty. No fatality is good, but it's better than hundreds. So this is all good news.

Geoff Lassers: 5:28

That certainly sounds like good news, the fatality going down the deadly nature of this virus and tell me is it less deadly of a virus? Give me some context here is should I be less worried about it if there's less people dying

Dr. Russel Faust: 5:40

Good question. That's a great question. There's from it? no evidence that there have been mutations that result in decreased fatality, I think, you know, when we look at the demographics, and we break those out on our dashboard, here at Oakland County, but when we look at the demographics, early on those fatalities, the majority of infections of fatalities were in the elderly COVID would get into a nursing home and basically start wiping people out early on those that were super vulnerable in the population, chronic diseases, chronic pulmonary disease, renal disease, etc. Those were resulting in fatalities. I think, unfortunately, we had attrition of the super vulnerable ruling on back in March, April, May, what we're seeing now, especially after things kind of opened up, as colleges got back into session, and people went back to work and things open up just over the past couple months, what we're seeing is a flattening of the age peak. That is, it's no longer just the elderly, we're seeing down into the teens. And so anywhere from the high teens at 30 is our biggest demographic right now for case numbers of what we're seeing plenty in their 30s 40s 50s and 60s. And the fact is, those younger folks deal with it much more easily. That is the hospitalization of those younger generations is is much lower, when I talk to the hospitals and Dr. McGraw can speak to what they're seeing. But when I speak to the hospitals, the hospitalized, the severe disease continue to be in the over 60 range. The folks that are younger, clearly their physiology deals with it better. We also see it's it's pretty interesting, we're seeing the younger generations tend not to be heavy shedders that is even when they're symptomatic, we can barely detect shedding with PCR, they're not infecting those around them as readily. However, back to your question. Your question was, should I be worried The fact is, it can still kill you, you should absolutely be worried you should absolutely get a flu shot because the co-infection of COVID and influenza doubles your mortality rate, whatever mortality risk group you're in.

Dr. Steve McGraw: 7:50

you know, Dr. Faust, you make some great points. And I'll give you some completely what I call a swag:" Scientific Wild Ass Guess". But your first point is true, I don't think we have any evidence of a meaningfully different virus than when we experienced in August. And in the spring, I mean, they mutate, but I don't think it has mutations have provided a less lethality and I only have to point just to the west side of our state. I have friends that work in health systems over there in Grand Rapids and along the west coast who are really having our April now they have a lot more patients on ventilators, one of my good friends is an emergency physician over there, what he's going through sounds like what I went through back in the spring. So you're right, I think some of it is that we had already been through it. And some of our vulnerable people got infected. But I think there's also a learned cultural behavior, too. I think we had no testing and really no access to masks back in April and in the public. And now we do have testing and masks. So in a sense, we're as a group protecting the most vulnerable better than we did probably back then. And I would even say that, I think to some extent, they're protecting themselves. I think we see elderly people not doing the things that maybe they've learned by having someone in their circle either get sick or die. So that's been a sort of a group thing, subtle, but but I think contributing to it. And then it's one of my pet theories that whether you wear a mask all the time, or most of the time wearing a mask to any public place, just sort of slows down and maybe even decreases that dose with what you might become infected. I'm not saying you won't get infected or convert, but maybe you don't get as big a load of viruses in your system. Yeah, your body's immune system. You still are impacted, but you don't have this overwhelming bilateral pneumonia that I was seeing on seemingly everybody that came in and you're right, that just use the Providence hospitals in Oakland County as an example, in Southfield and in Novi, we've almost switched places to community of Southfield the Northwest Detroit was severely impacted back in the spring. And our numbers for even a campus that has more ER visits actually has fewer people in the facility than we do in Novi, and about the same number of people on the ventilator, which is also much less than we were back in April. On April 8, we had Dozens and dozens and dozens of people intubated laying everywhere.

Dr. Russel Faust: 10:04

And Dr. McGraw they're seeing the same thing of the Beaumont system. And they're seeing the same thing at the Henry Ford system, whereas previously it was kind of Central urban. Now the suburban sites are being slammed and the the urban sites are doing better.

Dr. Steve McGraw: 10:18

And you're right and we can actually see it even in within the Ascension system. You know, Kalamazoo really was spared in the spring and and now they're severely impacted. Same with Saginaw, St. Mary's or our Trinity colleagues in Pontiac, St. Joe's. It's interesting how communities that were mostly deeply impacted somewhat just as maybe culturally or through some sort of, you know, generalized awareness, they have more of a fear of it. They behave differently this time, and I'll tell you to have what we have just right now in Southfield, we have 40. Some patients in the hospital we have four on ventilators. And in Novi, we have 69 in the hospital. Now, again, Worse Novi for hospitalized patients than Southfield, but five on ventilators. I mean, that's one in 12. I have to tell you, it was nowhere near that favorable back in the spring and either campus. So that is exactly what I think you're describing. It's just a different expression of it. Even though the virus hasn't changed. We're just seeing people who are the ones that are infected on a sick and we're not seeing the numbers of truly vulnerable and elderly that made those numbers look so unfavorable back then however that's occurring I'm very grateful for.

Geoff Lassers: 11:29

this quick commercial break is brought to you by American CME. American CME is an online continuing education learning platform designed for EMS providers by EMS providers. Their mission is simple create and host high quality video based EMS CE content with the aim of improving the quality of EMS care while drastically reducing or eliminating the cost associated with EMS training. American CME courses focus on the most current topics and science related to the EMS industry and are available in a format that makes them convenient to access and complete. The EMS on-air podcast will continue to release more episodes on Americancme.com. This means that EMS providers can earn EMS continuing education credits by completing an entire podcast episode, a brief post course quiz and a survey. To do this, visit AmericanCME.com click on the courses link, then click on free courses. Scroll through the course list and look for the courses with the EMS on-air podcast logo. The first five episodes of season two will be available on American CME starting sometime in mid December. More details on that in the near future. If your EMS license is coming up, get on over to American cme.com and get you some credits. Did I mentioned that you can access all of American CME's content for free? Yeah, free. And now back to the show. I kind of have a theory that the possibility exists that the more vulnerable arrives the sheltering in place more responsibly than those that are vulnerable. There are also people that have a pre-frontal cortex that's fully cooked, right. So they're making good decisions compared to the early 20s and 30s. And I also think that we see an increase in these spikes, because the vectors, I want to get another house and go have a good time, during a time of year that it's easy to spread respiratory viruses. So I think we're spreading it like crazy through those of us that have the capacity to be fine with it if we got it. But then you go hug your grandma or your aunt. Don't tell them that you hung out with seven buddies last night that you have no idea where they were from. So it might be just that our older generation is acting responsibly because they know they can be affected. And those who might not be as affected might not be making similar decisions. But again, that's just my guess.

Dr. Russel Faust: 13:49

Let me um, let me give a shout out to a book that just came out by Nicholas Christakis title of the book is"Apollo zero". This guy is a sociologist and MD PhD is a sociologist and a historian of pandemics I believe at Yale. But I'll tell you, it's a great read in he basically reiterates the comments that Geoff and Steve just made with regard to changes in behavior, kind of the natural process of epidemics or pandemics moving through the society, you know, with or without a ready vaccine. This is going to be with us for a while due to rejection of vaccine due to poor decisions and poor behavior across cultures and societies. But anyway, check out the book Christakis and if you don't want to read the book, he actually did a really good interview a week ago as a three hour interview with Joe Rogan. He gets into the book and really does a good job of expressing this. it's a good. It was on fresh air.

Geoff Lassers: 14:50

It might have been when you write a book, I pretty sure they invite like 1000 different podcasts

Dr. Russel Faust: 14:55

for it. So he there was a there was an interview on fresh air, usually with Terry Gross, but there as a substitute or whatever, Anyway,

Geoff Lassers: 15:01

enough. Okay, so what about the difference in testing locations? Because early on, we were scrambling to create what is a testing location? What is the need in the rules, you know, 6,8,9 months into this, I feel like we're pretty good at the process. But what is different now testing COVID for people in the general public and healthcare?

Dr. Russel Faust: 15:18

Well, one of our frustrations continues to be testing by facilities that have not historically been routinely testing for diseases that are reportable diseases. So by that I mean pharmacies, urgent cares, physician groups, doctors offices now have these either cards for rapid antigen tests are little boxes that sit on their clinic counter for which they can bill or charge for tests, but they're not familiar with the process of reporting reportable disease test results. And so unfortunately, they don't. And so we are notified positive test results circuitous either by the patient themselves or by the school, or their place of employment. Instead of having all negative results and positive test results of diagnostic COVID test results being reported to us as mandated in the cares act. So thanks for tolerating my little rant. But that continues to be a frustration and challenge for us. Note that having all of the test results goes into the formula to calculate percent positivity in a community. And if all we have are positive test results, we have fewer of the negative test results and actually exist, the apparent positivity rate is higher than it is in reality, or an actuality in that community. So that continues to be a frustration, just know that percent positivity is always an over estimate, due to that lack of reporting. Now, I will tell you this, we have an easier time getting testing done now than we did back in March, April, May June, however, we at the county continued to be contracted with five or six different vendors that provide tests, we have several platforms in our laboratory here at Oakland County, for all those platforms, we continue to struggle to keep up with supplies. So we have some fairly rapid, very sensitive PCR machines, a logic Panther that we use, that can get us results, same day, but we have limited supply of reagents and supplies for those. And fortunately, we have people in the lab that are wheeling and dealing across the country and know that there are jurisdictions that have those machines that, frankly, are under utilizing them. And so we have folks in the lab that are bartering, begging, borrowing, stealing, to get those results in here so that we can continue to provide rapid turnaround for county employees, for frontline workers, for Sheriff's Department, etc. To keep folks on the job and keep the community protected.

Geoff Lassers: 18:02

What is the current PCR test that is the fastest? I mean, I have a PCR test I don't know a couple weeks ago, and it was 24-36 hours. I thought that was pretty good. considered good.

Dr. Russel Faust: 18:17

What the commercial labs are able to do is give you a turnaround of 24 to 48 hours. Okay, that's pretty standard. They'll put it on basically the machine that we have in the lab, they have a backlog. So they get them scheduled, most of those labs are running 24/7, they're running three shifts, so you can hope for 24-48 hours, but because of this current surge, they're becoming over committed, they're overwhelmed. And so occasionally, they will get pushed out the three to five days, five days doesn't do anybody good for surveillance. It doesn't do any good for you know, for epidemiological management. 24 to 48 hours is usable for us.

Geoff Lassers: 18:58

The big problem isn't necessarily spinning the blood. That's not the part that takes time. Oh, gosh, no, it's not the blood, the spitting the chambers of the snot for lack of a better term.

Dr. Russel Faust: 19:08

No, it's it's the backup.

Geoff Lassers: 19:10

and right the supply chain, you got human beings with only enough resources to spin them. It's not like you have a infinite Amazon factory sized place spin and stuff, right. So you got it. That's where the backup is. And I think people need to realize it's not the health care system. It's not, it's none of that. It's literally logistics.

Dr. Russel Faust: 19:30

It is literally logistics, being able to run the machine and get enough samples on it in a 24 hour cycle. And also being able to have a supply chain that can feed that process. And both of those are a challenge.

Dr. Steve McGraw: 19:44

We're really feeling it too but it's as you point out, it's not one thing, it's a bunch of little pieces that all have to be present and even if one is missing, you've got the personnel, you've got the patients, you've got the need, you've got the re-agent but then you don't have the swab or you have everything including the swab but the machine is waiting for the next cycle or six hours cycle to run, the PCR tests can take longer or shorter depending on a lot of different factors. It's confusing to people because we haven't had a lot of molecular tests available to the public for so it's a new thing.

Dr. Russel Faust: 20:13

We haven't had this kind of crush for the demand for anything before. And understand that what we're seeing in the community with this surge of cases, we're seeing it in our lab personnel, we have a small enough lab that if one person gets taken out, we're hurting, you know, we're just being crushed right now. And yesterday, we had a piece of equipment break down in the lab, everything that can go wrong is because you know, everything's stretched to the limit.

Geoff Lassers: 20:38

Well, you're kind of bringing up a point we talked about earlier, where we were talking about the people that are not so much in the demographic of I'm going to die from this disease in the near future. They are the workers that are doing this stuff. So as soon as they become infected, they remove themselves from the supply chain or their ability in in most cases, yeah. Could you work from home? Sure. But some jobs, you can't you can't spin these chambers from home. And so the more people get infected, that's more healthcare workers that are infected. And now forgive me if I'm wrong, but it seems like even more health care workers are infected during this wave than the first.

Dr. Russel Faust: 21:12

I think my opinion is people are being affected not at work, they're being affected by their activities outside work, you know, they're being affected by going to the the party that they're throwing for their kids hockey team win. They're being affected at a restaurant or in a bar. They're being affected by a party, you know, they have dinner party with friends, and they have a couple, two, three households over there. You know, next thing you know, all 12 of the people at the party are infected and they infect the three other people outside of that circle. We're careful enough, we're paranoid enough, then we're in full PPE when we're exposed on the job in health care, at least got my god I hope we are but that's where we're being affected.

Dr. Steve McGraw: 21:53

You know, Russ, it's so funny because our statistics of majority of the health systems in Southeast Michigan bear that out, the furlough rate and the infected rate is a little higher than it was in the spring, but it's also more widespread and the community was more isolated in certain locations. You could drive between Southfield and Novi where we were severely infected in the community in Southfield, Northwest Detroit, they weren't necessarily a Novi. But ironically, now that it's more widely spread, I think health care workers not on the job are at more risk. And it's counterintuitive for folks because in my own emergency room, I can be surrounded by people that are actively infected and very symptomatic. But as you suggest, I'm wearing the full protective gear, I would argue, and I think our statistics bear this out, I'm actually safer at work surrounded by symptomatic people in my equipment that I am wearing my simple mask at Kroger's. And I think we see that at less than 25% of the people infected in my health system. And I think most health systems can trace back to where they were infected taking care of patients. Ironically, one of the ways we get infected is when we go to our break room, and we take our masks off to have lunch with one person has in certain cases, and in fact, it's several coworkers. And that's happened and in multiple systems. Or we as you point out, we go home, we're all weary of wearing PPE everywhere we go to our brother in law's house to watch a football game and don't realize it but our brother in law's best friend brought the disease and everybody that watched the football game that Sunday now is infected. So we're seeing that more than we're seeing people get incepted while caring for sick people.

Geoff Lassers: 23:25

And now Doc, can we get into a little bit of the hospitals more or less impacted? I don't wanna say logistically, but over run, give me an idea because early on a lot more patients were being put on ventilators than they are now. So are you guys really stress tested currently compared to last?

Dr. Steve McGraw: 23:43

Yeah, you know, it's a great question, and I will answer how I would answer the the neighbors that asked me and what we're really seeing is that it is more diffusely infecting wider geographic areas. So while the numbers are clearly worse, what's happened to individual healthcare settings is not as bad. I'll even use more evidence of that there is no way we could have continued to care for people as we did in April in Southfield had the hospital not cancelled under the governor's order all elective surgeries. As of this morning, we're doing almost all the elective and semi elective surgeries that we would do on any other Tuesday morning that we are now currently performing. And the reason for that is, although it does cause some delays for bed assignments out of the ER, and we have patients waiting for beds, and that's even worse in Novi than Southfield. We're not having to divert all those resources to inpatient beds, because as we've already described, people that are getting sick are not in the hospital as long, they're not intubated as frequently which adds You know, sometimes days and weeks to their hospitalization and their ICU stay, we're actually functioning much better. Now. Maybe that's not as true when you get out west to the west side of the state, but even they many of them have diminished some elective surgeries, but not entirely as we did before. cancel all active surgeries in every hospital. I think that was because we didn't know what to expect. We're learning we're getting a lot smarter and how to utilize our resources, our inpatient beds. And just to give you some window into it, they are assessing our operative boarding schedule. Every morning, the people in the in the surgical services, the nurses, anesthesiologists, crnas, and our surgical leadership are going through every case to make sure that based on what we feel that day on the campus, can we do everything that we have scheduled and so far, and the vast majority of days the answer has been Yes. But even more fine tuning. They've encouraged some of the hips or knees that need to stay overnight to go from Novi and have their surgery in Southfield, which is a little bit of an inconvenience made of that patient. But we say we need you to move to this location, because we have more capacity today at this campus than we do at that campus. And you know, surgeons have been incredibly willing to do that patients have been willing to do that everyone's more nimble and more sort of real time decision making then we could possibly have been able to do so back in April. And it's reflected in the fact that even hospitals that are more severely impacted, are still being able to do some of their elective cases. Yeah. So yeah, we're impacted, but we're smarter about it. We've added more rooms that have scrubbers and are negative pressure, we have our COVID units, and we're up to four at each campus, both Southfield and Novi, for instance. And to give you some scale, we had way more than that in Southfield back in April. So four is a good number. But having said that, we're using them more wisely. We know how to discharge people we're much more aware of when they can go home and where they can go, we're better getting them the services they need. Everything about this virus is more evident to us now. And so we are impacted, but we're much more learned in what we need to do and what we don't need to do. And that's helped us perform the needs of our communities much better than I can say we did. So in April.

Dr. Russel Faust: 26:47

I think that might be what you just described as kind of a silver lining, and that all systems, all healthcare systems now, and frankly, a lot of businesses are streamlined, they are so much more streamlined, and so much more capable now goes beyond just the great Ascension system, which has resources that can be drawn on from a wide catchment area, even smaller systems or smaller hospitals that are part of a system have now developed relationships with other larger systems. So there is that flexibility exactly as you described, and, and the willingness within this pandemic to be able to shift and redeploy resources, whether that's personnel or equipment. And I just want to emphasize one point you skipped over. You mentioned it earlier, I think is we have PPE now, which we just did not have back in March, April, May, which is just maddening back then. But we're pretty comfortable. Now. We have fresh PPE.

Dr. Steve McGraw: 27:44

To your point. Also, we don't have the uncertainty, one of the things that I think weighed the heaviest on some of us, whatever PPE we had, we were not 100% certain that it was going to work because we had never faced this virus before.

Dr. Russel Faust: 27:58

Yeah, we were just stringing it out for you were in N95 for a month, that's just not really appropriate. But we did what we had to do.

Dr. Steve McGraw: 28:08

I wrote a letter to the staff. And I reminded them why this was going to be different about a week ago. And one of the things I mentioned was that back then we didn't have the equipment and the equipment we did have, we had no certainty, we hoped and we believe that would help us. But we didn't have the certainty that we do now. We know we can protect ourselves. And we also know the behaviors that will cause us to fail. So instead of that we've gotten so much smarter, and have so many more resources that we're using more wisely. I just don't want people to think that the lack of mortality per case or a decrease thank, goodness in indicates in any way that this isn't a still a terrible indiscriminate killer it is and to take it just as seriously, as we did before and continue to do the things that we know make us successful.

Geoff Lassers: 28:54

Yes, 100% agree. And the data is confusing sometimes. Because when we say the data, the fatality rate, decreasing the infection rate going up, it can be very confusing, but we got to remember that human beings are the vectors for this insidious virus that likes to take opportunities on people that are vulnerable. Now our preparedness is steeped in our open communication, our training, our logistics, and our experiences that we put together. And these things add up to tell us what we've learned and what we're going to do. So when it comes to treatments that we were doing pre hospital lead the very beginning of this, there was a lot of differences than than there are now we seem to have a lot more pieces of equipment in place like HEPPA filters in line with a lot of airway treatments. And we're mitigating a lot of that we have about a third as many protocols dedicated to the virus, as we did before. So we're very well organized now based on the data we have pre hospital. But in hospital, we're hearing more and more changes in treatments. We are not putting people on vents anymore, but now in the media. We're hearing more about these infusion type treatments. Can you kind of give me an overview You have these things I'm hearing in the media give me context as to what's currently available so that when I encounter patients and they asked me, I have a little bit of knowledge.

Dr. Steve McGraw: 30:10

I'll say, I know that people know about the monoclonal antibodies, two companies that make it regeneron makes one version and Eli Lilly makes another. So monoclonal antibodies are similar to the kind of antibodies our immune system makes to fight this virus, its ability to enter cells and attack healthy cells and regenerate itself. But what I think people have to appreciate is that these are not magic cures, these are really only appropriate for patients with sort of the front end of disease that doesn't have their body so racked with virus, that they even have to be admitted to the hospital. So these are outpatient medications, they're infused being given IV, but they're given IV and the patient is discharged home. And they do require some particularly significant preexisting conditions to be present. So it can't just be Oh, you have COVID, here's an infusion of monoclonal antibodies to make you feel better. That's really not what these are designed for these in testing have really shown that they have an effect on trying to accelerate the rate at which people get better, but most of whom would get better anyway. And the notion that they change you from potentially dying to not dying, has not really been borne out in the data, but we do see is that to some extent, they make it less likely that you'll ultimately have to be admitted to the hospital. It's not without benefits, that is good. But it's not something that you'll typically see a patient transported to the hospital. And because they have COVID, that alone will get them monoclonal antibody infusion and be discharged. It's a lot more painstaking than that. And they have to actually meet quite a few criteria in order to be a candidate for the treatment in partly due to the fact that the treatment is in very limited quantities right now.

Dr. Russel Faust: 31:53

Well, it's also talking about the the antiviral, remdesivir, and others kind of in the pipeline. Early on, it was only available for those most severely infected with the most severe symptoms, those on a ventilator, etc. And then as time went on, it became more and more readily available to those less and less severely impacted with symptoms. And now any hospitalized patient diagnosed with COVID has access to remdesivir. Prior to discharge.

Geoff Lassers: 32:22

just real quick, the Remdesivir. For those of us listening, it prevents viral replication.

Dr. Russel Faust: 32:27

Yeah, right. Anti-viral prevents viral replication. And so it makes sense that the earlier you got it during the clinical course, the more benefit there would be. And that's borne out in the clinical studies only to the extent that it decreases length of hospital stay. So far, the early report suggests that it doesn't decrease mortality. So again, I it's great to have fewer days in the hospital, but it doesn't seem to really impact the ultimate outcome with regard to fatalities.

Dr. Steve McGraw: 32:58

You know, because it's in such short supply, I can tell you that when hospitals have someone in multi organ failure, basically clean to life on a ventilator, they're not the people that typically get Remdesivir anymore, because it hasn't demonstrated an ability to resuscitate them sort of like the damage to the body's inherent systems is so great by that point, that decreasing the replication rate of the virus in their body doesn't really seem it's sort of like closing the barn door after the horses are gone.

Dr. Russel Faust: 33:26

Yeah, the earlier you get it, the more sense it makes, obviously, decrease that replication.

Geoff Lassers: 33:31

so the amount of treatments have increased our knowledge about what the treatments do expanded rapidly, and what we know available to these people. And we all know that not every treatment is the same for every virus for every human being we all act a little bit differently. We're all at different stages of this infection when we encounter it. But for those people that have not had it or for in the future, we're talking about vaccines now. And if we can move on to the treatments currently to vaccinating, and kind of give everybody an update the last time we talked about vaccines, we talked about them in the conceptual if and when they're made in the near future. And now it seems that there's a number of options that are being looked at, I think Oakland County and Dr. Faust, you can kind of walk us through what we're selecting here. But could you please describe the current status of the COVID-19 vaccinations as of today, November 24.

Dr. Russel Faust: 34:18

I'd be glad to So right now, the first that will be likely distributed to us is the Pfizer vaccine, which requires two doses. Dr. McCraw, you can correct me here. I don't recall whether the Moderna vaccine also requires two doses.

Dr. Steve McGraw: 34:36

It does and they may even be one of those where they're saying that you give a smaller dose and the second one is bigger. Right.

Dr. Russel Faust: 34:43

That's how they got that one up to the 90-95% effective level. So both of those should be available soon. In anticipation, both of those companies ramped up production quite some time ago. Kind of having the foresight of their early trial results. Both of those have now completed phase one, phase two, phase three clinical trials, the level of adverse effects for both of those is virtually non existent. These are the safest vaccines in human history in vaccine history. They're just absolutely the safest. As far as I'm concerned, as soon as we have it, and I have access to it. I'm getting it. But let's talk about that. Let's talk about the access. So because how do I say this diplomatically, guys?

Geoff Lassers: 35:31

You don't you just say it?

Dr. Russel Faust: 35:33

Yeah, because CDC was very much politicized,

Dr. Steve McGraw: 35:37

unnecessarily, so

Dr. Russel Faust: 35:38

unnecessarily. So just as masks had been unnecessarily politicized. I was skeptical about the information we were receiving from CDC that we were going to be receiving vaccine any moment now. And that was a month or two ago. And of course, that never came about. I'm still entirely uncertain when we will receive vaccine CDC, the federal level pushes down to the state level MDHHS. State level mdhhs informs us to prepare. We've been prepared since August with our vaccination plan and the details of particulars will depend on what we receive. As of the 30th of this month, our three testing sites are going to be split out into five testing sites, in an attempt to better cover the needs of Oakland County and those testing sites. At any time we receive vaccine can be converted to drive through vaccination sites, I will tell you that the change in locations is due to our attempt to be more humane to our staff. That is they've been out there in the frozen tundra in the freezing rain or the 90 plus days and full PPE in tents in a parking lot. So we have contracted with partners in the community. Places like fire stations that have brick and mortar facilities we can drive through we can have one or two drive through lanes where people are covered. We are contracting to take over abandoned auto dealerships that have garages and we can have two or more drive through lanes anyway, we're going to have five sites for testing as of November 30. And again, those can be converted into vaccination sites. The moment we have vaccine, let's talk about our capacity to vaccinate each one of those sites can conduct 800 vaccinations per site per day. So times five sites, we have the ability to conduct or perform 4000 vaccinations every day of five days a week, that is not going to be the limitation that is not going to be the rate limiting step, the rate limiting step early on is going to be how much vaccine we receive. And so depending on who you listen to which news station you follow, and which of these companies you believe is ready to distribute. There's a limited finite amount that's going to be distributed globally. The US will get some portion of that each state will get some portion of that each county will get some portion of that.

Geoff Lassers: 38:16

And it all depends on which one because they're all different substances.

Dr. Russel Faust: 38:20

Yeah. So that. Yeah, you bet. So the logistics becomes fairly challenging. And again, the team here, emergency preparedness team materials management is really stepped up to the plate. They're just they're doing a mind blowing job in preparing for this. The vaccination plan is out we have an order due fairly soon. We have 10 minus 80 degrees Celsius freezers to accommodate the Pfizer vaccine. We have routine freezers and these freezers can accommodate the Moderna vaccine for the next one down the line. We're ready.

Geoff Lassers: 38:56

You're setting up for the possibility of any vaccine and you're not making any hard plans until you are so you really have to prepare for three different options.

Dr. Russel Faust: 39:05

All eventaully.

Geoff Lassers: 39:06

turn off two of them or one of them or whatever you have to do and who knows maybe the first wave of vaccines we get is one thing and the second is another you know.

Dr. Russel Faust: 39:15

and the the other consideration is you know there's a global shortage on pharmaceutical grade glass. So the bottles they pack it in instead of packing into you know,

Geoff Lassers: 39:25

of course there is, the rubber stoppers there's no rubber stoppers.

Dr. Russel Faust: 39:29

Ya exactly so there they're packing into larger vials, multi dose files, that means it's not being sent to us in single use syringes, which is how most vaccines come these days. There's less of a needle injury.

Geoff Lassers: 39:45

It goes in these pretty packaging, you break one vial, you break 10 doses right?

Dr. Russel Faust: 39:51

in part as you point out, every item in that supply chain, as this becomes global is going to be in short Supply. So syringes are going to be in short supply, those rubber stoppers are going to be in short supply, pharmaceutical grade glasses and global short supply. There will be challenges over the next year, but we're prepared,

Geoff Lassers: 40:12

the challenges show up. And then we start actually poking people with this vaccine. Give me the batting order. What is the plan currently in a system like Oakland County, and again, we're just getting open county as an example. As you know, what is our plan is that healthcare providers and hospital pre hospital long term care, what is the current thought?

Dr. Russel Faust: 40:30

So CDC hasn't actually defined fully, completely fleshed out those categories, but 1A is frontline providers. So that's Fire Rescue EMS. That's frontline in the hospitals, Ed, physicians, nurses, etc, that's going to be our personnel that are out there on the testing and vaccination line, the challenge, again, is going to be that there won't be enough vaccine to go around in that first supply. Again, we need to remain vigilant. It's not rocket science, it's masks its distance. It's not going to the party with 20 of your buddies to watch the ballgame. We need to remain safe and healthy, as we wait for more vaccine to hit the supply chain.

Dr. Steve McGraw: 41:17

such an important message. I'm really glad you mentioned that Dr. Faust, because truly we have the ability now, we know what works. And we have the ability to hang in there long enough for the production processes to meet our demand. It won't happen in a couple of weeks or a couple of months. But it will happen. That's what we can now feel really good about. The speed with which this vaccine group and technology has been developed is just unimaginable.

Dr. Russel Faust: 41:41

Extraordinary. Right? The previous record for developing a vaccine was four years before that it was 10 years.

Dr. Steve McGraw: 41:53

As someone said to me, it's the equivalent of you know, we we said we were going to go to the moon in 1960. And we landed on the moon in July of 69. This would be like we decided to go to the moon in 1960. And we're on the moon in 1963. This was wildly accelerated use of molecular biology to its best effect. And we should take great pride that we've been able to do that. Now, however, comes the important part, don't spike the ball in the five yard line, get to the point where we protect ourselves in an ongoing way, stay healthy, and get your vaccine as soon as you possibly can, as soon as it's made available. And that's frontline workers and then ultimately, even our general public, maybe starting with the most vulnerable or the people most likely to, you know, have a negative outcome. But eventually we can all get it. We just we have to not lose focus now and stick with the program.

Geoff Lassers: 42:41

Absolutely, I think we have to finish the mission. And that's a big part of this is following through to the end, you know, when I'm at a fire, I don't take my SCBA off when the fire is out. I take it off when all the gases are gone, because those things can still hurt me. And I need to be cognizant that is no different here, that the fire certainly isn't out. And what we do get these vaccines going, it's just going to be off gassing a little bit. We still have a long road and to steal a phrase from Jimmy. I mean, we need to stay in the saddle. And we need to continue this on until we finish this mission. I would be remiss if I didn't at least ask what is your scientific wild ass guess on when a vaccine might first be rolled out in Oakland County.

Dr. Russel Faust: 43:25

Again, I am having difficulty believing the information that's getting fed to us. So the information is getting fed to us has always been and it has been this for like nearly two months now. vaccine expect vaccine be prepared for vaccine in about two weeks.

Geoff Lassers: 43:44

Ah, the old two week rule.

Dr. Russel Faust: 43:45

I keep hearing that. And they keep moving. They keep moving the the goalposts but I would expect there to be some vaccine distribute to the state sometime in the next month.

Dr. Steve McGraw: 43:59

Interesting is the ability to complete the phase three trials, who is actually if you're looking for a silver lining actually aided by the increased community transmission, because when you do the phase three and you guys, we all talked about this before you've got 30,000 in placebo 30,000 getting the vaccine, nobody knows who got what except the scientists, you have to see what happens to those that got the vaccine versus those that got the placebo to demonstrate its effectiveness. We already have results from phase one and phase two.

Dr. Russel Faust: 44:27

They completed early because of the surge. It looks crazy, right?

Dr. Steve McGraw: 44:33

our lack of ability to control ourselves actually had this weird benefit on phase three trials. Because of that. Now we have the emergency use authorization through the FDA. So even though they kept promising it and let's be candid, a lot of those promises were politically motivated. They weren't based on the science and they weren't based on the companies announcing it. It was people that had their own reasons for you know, misstating truth on the ground. Now However, we do have emergency use, we do have the phase three trials that demonstrate effectiveness. It's simply a matter of the mechanics of safe production and distribution, which my goodness, to be able to say that less than a year from when this came to our shores is simply attributed to the men and women working so diligently seven days a week in these laboratories, doing the unglamorous work of molecular biology, God bless them and all that they did to provide this to us.

Geoff Lassers: 45:26

Absolutely. You know, a bunch of episodes ago and season one, I asked, I think it was the vaccine episode we talked about conceptually, what is this going to look like? And I asked you what you thought that it was, I think he said, April ish, you were really hopeful that we would be seeing one show up. And so I'm going to stick with like, early spring is when we actually see it, although I like Dr. Faust guests better, but our guests are only as good as our hopes here. So but hope it's not a strategy. But the nice thing is our emergency system is preparing strategies to roll it out when those things do become real.

Unknown: 46:00

Well, I actually think Dr. Faust spot on, I think we've hoped that it would be available by the end of the year for a while my April ish guess was when it would be widely available to the public. And that's probably a little optimistic. I'm thinking more like May June, considering the logistical needs.

Dr. Russel Faust: 46:19

I honestly think a lot of it depends on how confident these companies were six months ago, when they started to produce this stuff. Are they confident enough in their clinical trial results, kind of forcing those results that they've already stockpiled? a certain number of doses?

Dr. Steve McGraw: 46:37

That's a great point. They were making it landing on it? Yeah, that's part of the was the Gates Foundation is supplied millions of dollars for that, as did operation warp speed. The Pfizer example is that they have been stockpiling. I think they have over 20 million doses. When they have emerged to use, they indicate that they're going to be able to start rolling that out what I think is important to point out however, just because you've made these 20,000 doses, and they're frozen, doesn't mean they're in glass vials for distribution and injection, you're exactly right, we have a couple of steps yet to go. But that's a heavy bet to make, right? You're so confident in phase one and phase two outcomes, seeing maybe plasma cells and memory cells being created, knowing that highly indicated the good outcome that we would have barring any unforeseen untoward events, which thank god haven't occurred, they bet on themselves in your right to the extent that they did. So we'll all be the beneficiaries of that.

Geoff Lassers: 47:29

And future episodes, we're definitely going to come back to this and keep hitting these bite sized chunks of information, because I think the next step is going to be logistics. And we're going to utilize this platform to really help spread the word about how things are being rolled out through the vaccination process. It's helped get the word out so far, so why quit now?

Unknown: 47:45

Geoff, one of the things I think is really helpful is that we have partnered with such great camaraderie with our colleagues in public health, that I think our EMS providers are going to be able to play a role as we more widely distribute this. And I really want to tip my hat to Dr. Faust and all his partners at public health because I don't think ems in general, if you think about across the state of the country, is is widely recognized at large like they are in Oakland County is an asset with whom they can partner. I'm really proud of that. I'm really proud of the fact that we've done things whether it was measles, or swabbing people or even just getting information out, we've proven before and I think we'll do so again that we can be hip to shoulder together and face what was otherwise a really difficult human resource challenge.

Dr. Russel Faust: 48:33

If every county had an MCA group like McGraw and Kincaid and Lassers helping to liaise those groups, they would all be better off, trust me.

Geoff Lassers: 48:47

I'm very fortunate here that we have the human beings number to select from. And I really appreciate that we got a lot of good resources, we got a lot of understanding throughout the whole community. We have a good team, if you add up all our hospital systems, a good team came together, you know, multiple teams coming together as one job were agreed. So gentlemen, until next time, do we have any final thoughts for everybody listening?

Dr. Russel Faust: 49:11

Gosh wear a mask? Would ya?

Dr. Steve McGraw: 49:13

You stole my thunder. Yeah, Don't take off the mask. Don't be like that. There's a famous guy. His name is Livermore or something. He was the last soldier killed in the end of World War One. And if you guys remember your history, it ended at 11 in the morning on the 11th day of the 11th month, that was Armistice Day, and he died. He was actually killed about nine minutes before that hour before the official ceasefire. yet he's one of the guys that had been rolled out like in the Foreign Legion way in the beginning before the United States was even in the war. He survived and endured this horrific I don't have the name right. I don't know that it was delivered or something like that. But he survived this whole long arduous combat experience lost. Countless friends got wounded multiple times. And he was within sight of the armistice and did some dumb things actually got killed. And it was like how unfair is that. So we're not like that we're not being shot at. But I think we've endured so much since March, now is not the time to let our guard down and get sick when we can see the vaccines are on the visible horizon, that the ability to really have a different 2021 is at hand. Don't make the mistake now, when you've done so much to protect yourself and your family. Don't miss the opportunity to now to hang in there. And as you say, Geoff finished the race

Geoff Lassers: 50:34

Thank you guys. You guys. Have a good day.

Dr. Russel Faust: 50:36

Thanks. Have a great Thanksg ving.

Dr. Steve McGraw: 50:38

Happy Thanksgiving, gentlemen. See you guys.

Geoff Lassers: 50:43

That's all for the show today, everyone. Thank you for listening. Thank you, Steve. Thank you, Russ. You guys are rock stars. Please keep emailing your questions, comments feedback episode ideas to the EMS on air podcast team b email at QI@ocmca.org. Als, check out our updated web ite emsonair.com. For the latest information, podcast episod s and other details, follow us on Instagram @ems_on_air an please please please whatever odcast platform you use, subs ribe to our podcast and leave us a rating and a review be ause it really does help us g ow so that we can keep making a ositive impact in the National MS and healthcare communitie. Thank you for listening o the EMS on-air podcast. tay safe and have a great day