“As a physician anesthesiologist who has previously been on assignment for Doctors Without Borders in a resource-depleted region fraught with conflict, I’d like to say there’s little I haven’t seen. But now, after four weeks of staffing COVID intensive care units and emergency response teams throughout New York City, I struggle to distinguish between the exhaustion of a distant war-zone and the fatigue I see in state-of-the-art medical facilities. In some ways, my past experience treating war-wounded Syrian refugees mentally prepared me for my most recent journey where I dropped the comforts of life in California, booked a one-way ticket to the Big Apple, and secured emergency credentialing at multiple hospitals in the global epicenter of the virus outbreak. But in other ways, the campaign against COVID-19 is its own brand of horror, and I find myself worn down overseeing emergency intubations and debating the ethics of ventilator distribution, whether or not to initiate cardiopulmonary resuscitation, and how to help patients die with dignity when they are nearing end-of-life.”

Ajit Rai is an anesthesiologist and interventional pain physician and can be reached at his self-titled site, Ajit Rai MD.

He shares his story and discusses his KevinMD articles, “Opening America: Should we really have to choose between economic revival and human life?” and “Young physicians belong on the battlefront.”

Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi everyone, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. I’m Kevin Pho, founder and editor of KevinMD. Today we have Ajit Rai. He is an interventional pain specialist, medical ethicist, and humanitarian aid worker who has provided medical care all over the world. He most recently left his practice in California for New York City to provide disaster relief in the global epicenter of the COVID-19 pandemic, and almost as important as that, he is a KevinMD contributor. Before we get into that, I am fascinated by your story, and I want you to share a little bit about your journey to where you are today.

Ajit Rai: Thanks for having me, Kevin. I was born and raised in the Bay Area of California. I did my medical training in Los Angeles, medical school and residency. I did my fellowship training in New York City, and because of that I’ve always had a special place in my heart for New York City. So when the COVID pandemic blossomed in the epicenter, which is New York, I felt a strong calling to come back and help, and that’s where I am currently. I’m talking to you from a hotel room where I’ve been living for the last eight weeks to provide disaster relief.

Before I started private practice, right after I finished all my training, I left the U.S. for a few months and I did Doctors Without Borders. So I was living in the Middle East taking care of war-wounded refugees from Syria, Iraq, Palestine, and Yemen, and I built, or helped build, a pain management program for some of these war-wounded veterans and refugees. After that I started private practice in California, and I was doing that for a few months, but then this pandemic hit New York City and I rushed back here. I got emergency credentialing at my former hospital in Manhattan along with a few other hospitals, so I have been staffing COVID intensive care units along with emergency response teams throughout the city.

Kevin Pho: Well, that’s fantastic, and we’re filming this at Memorial Day weekend, so tell me, how are things on the ground now?

Ajit Rai: Things are a lot better than they were. Social distancing certainly works, and that’s one very reassuring thing about our overall global strategy. The patient volume is tremendously lower compared to what I saw eight weeks ago. Eight weeks ago you were swimming in patients. The emergency room hallways were intensive care units, the hospital administrators’ offices were intensive care suites, you had proned patients in every other room of the hospital, so it really felt like a war zone.

But progressively, as time went on, our volumes started to slowly normalize, and then repurposed intensive care units got converted back to their original purpose. So now the hospital is looking more normal, and I would say that now we’re under capacity and we are slowly starting to reopen things like elective surgery, for instance.

Kevin Pho: And how’s the situation with personal protective equipment?

Ajit Rai: The governor said about two weeks ago that the PPE supply had finally normalized. However, on the front lines I can’t always agree with that, because every day I come to an emergency, I have residents who are not wearing PPE, and when I query them about why they’re not wearing the appropriate masks or caps or gowns, they say they don’t have access to it.

So I don’t think it’s perfect. Maybe the supply is better, but I believe there’s probably a distribution problem, because there are administrators who may have too tight of a hold on PPE and they don’t necessarily know how to distribute it responsibly. Nevertheless, to circle back to your question, I think PPE remains an issue.

Kevin Pho: Now, is it only specific to your particular institution, or do you find that most of the institutions in New York City are undergoing the same conditions?

Ajit Rai: I’ve been helping at multiple hospitals in the city, so there are some hospitals that are very well equipped. To give you an example, when I first started, when we were surging and we were peaking in volume, I had one N95 mask per week. Fast forward to today, at this specific hospital that I’m referring to, at that same hospital, we now have access to five N95s a day. So that’s one particular hospital. Now, once again, I’m providing care at a few different places, and at some of the other hospitals the distribution is not as robust.

Kevin Pho: So I want to circle back to your first KevinMD article that you wrote at the end of April, and it was titled “Young physicians belong on the battlefront.” During the surge, did you find a lot of physicians just uproot themselves from wherever they were practicing and travel to hard-hit pandemic areas like New York City?

Ajit Rai: There were a lot of providers from all over the country, nurses and doctors. I met people from Florida, also from California, from Idaho, from Arizona, and I don’t know that many people who I think stayed for as long as I have. But what was really inspiring is that people from all over the country did as much as they could, and that was in terms of staffing intensive care units if they were ICU physicians, but even people who weren’t intensive care trained were filling in wherever they could.

I remember working with a dermatologist who was helping with end-of-life conversations with family members, because there was a point in time where we were so slammed and overwhelmed that taking the time required to have a thorough end-of-life goals of care conversation was just not possible, because we were so spread thin. So we needed that backup from someone who understood clinical science and understood the nuances of end-of-life. I remember this dermatologist, even though he wasn’t going to intubate anybody, he filled in and played a very critical role and helped with end-of-life conversations. That was perfect.

Kevin Pho: Wonderful. That’s pretty inspiring, just to see everyone band together like that. So tell me about the thrust of that article, “Young physicians belong on the battlefront.”

Ajit Rai: What we know from the disease course of the COVID-19 virus is that there is a disproportionate number of older patients who are affected. We are learning that a lot of age groups are hit by this, but disproportionately, overwhelmingly, it is the older populace that is most affected. Now, if we want to protect our health care workforce, we need to protect them as best as possible. So my personal belief is that younger doctors have a greater moral imperative to step up and be on the front lines and be on the battlefront, if you will.

So by us thrusting ourselves on the frontline, we can protect our older workforce, who can then fill in and still provide care to the country but in a different capacity. Maybe they can fill in telemedicine roles, but leave the high-risk stuff to people who can better tolerate the insults of this virus, i.e. the young. I do not mean to dismiss the expertise and wisdom of our older colleagues, but the purpose of my article was really just a call to action for people who were statistically more likely to tolerate this virus.

Kevin Pho: And have you received any pushback? I’ve published, as you could imagine, hundreds of articles on my site about the pandemic, and there’s a wide range of opinion, as you can imagine. Have you received any pushback from this point of view?

Ajit Rai: I’ve actually gotten a lot of support. I haven’t experienced a lot of pushback yet. I was expecting some, but no, people have been pretty supportive. And even on the clinical front, for instance, as an anesthesiologist I routinely respond to emergencies when patients are about to die. They need to be put on life support, so they need a ventilator, a breathing tube, they need resuscitation, they need lines. The way we addressed this was we created these high-risk intubation teams, so it would be typically two anesthesiologists, and if I was ever on a team with an older colleague, they were always very receptive and welcoming of my, I think, desire to take on more volume of cases, like, “Look, why don’t you hang out and why don’t I take this?” Because it is a very high risk exposure event, and if I have the ability and capacity to do that procedure, I believe it should be me. For the most part my colleagues were pretty welcoming of that.

And as a further comment on that, I’ve been working at a hospital that was aggressively hit by COVID, to the point where a large portion of the anesthesiologist workforce was out of work. So you can imagine how troublesome that is when an essential service line gets wiped out and everyone needs to be put on life support and you don’t have that service line. So this hospital in particular was very sensitive to how high-risk of a specialty it was, so they were much more welcoming of my volunteering to be there.

Kevin Pho: So you mentioned that you’re winding down your New York deployment shortly, and as I mentioned before, we are filming this on Memorial Day weekend and a lot of the country is opening up, and you did write an article on that. So I just want to get your general opinion in terms of how things are going.

Ajit Rai: The fact that the country is reopening, I certainly understand. I understand the desire to reopen, but I’m pretty apprehensive about a lot of the plans that are being employed nationally. The CDC unveiled very strict gating criteria and a phased reopening plan, and so did the White House. However, a lot of these expert opinions from the CDC, for instance, they constantly are reporting that they feel like they’re being muzzled, they feel like they’re being silenced, and a lot of that stems from this belief that we have two conflicting priorities. One is public health and the other is economic revival.

My personal belief is that we can actually have both. If you go back to the 1918 Spanish flu and you looked at the reopening policies of a variety of cities throughout the U.S., you’d actually find that the regions that had the strictest reopen policies, and the regions that were most aggressive about their shutdown measures, they actually responded better economically and they bounced back faster and more robustly than the regions who had softer shutdown measures. So that’s evidence from the 1918 Spanish flu pandemic.

Also, we can look at Sweden. Sweden is infamous now for not doing any sort of lockdown. They kept everything open, shops, churches, salons, restaurants, and the Swedish government simply said, “Hey, we trust our citizens to use common-sense social distancing guidelines.” However, their GDP is still projected to plummet this year, and compared to other countries, their finance minister and a bunch of other economists in Sweden, they still project being hit very hard financially and on par with a lot of their neighboring countries. And that didn’t come without a price. More than, I would say, 30 percent more Swedes died this year compared to years past. So they lost a lot more life and their economy has not been preserved.

Kevin Pho: Now, what would you change? Right now we have this state-by-state and disorganized approach when it comes to reopening. It’s almost like every state for itself. So if you were in charge, what would you do differently?

Ajit Rai: I do recognize that every region has their own nuances. Reopening New York City, you can’t do the same thing that you would do in Idaho, because of population density, the reliance on public transit, the sheer volume of people. So the policies that you would employ in a New York City are fundamentally different than what you would employ in Phoenix, Arizona.

That said, I think we have to look at very, very key objective virus metrics. Number one, we have to look at ICU utilization, we have to look at case incidence trends, we have to look at PPE volume, PPE supply chains. Bottom line, there are a number of objective virus metrics that have to be carefully evaluated prior to reopening.

And I’ll give you an example. Alabama right now, they had very loose shutdown measures and they were pretty aggressive about reopening, and right now they are projected to potentially be on par with New York City, because they’re, sorry, I should say that Alabama is experiencing ICUs that are over capacity, similar to what we experienced in New York. And I think we should as a nation get ready for a number of surges all over the country as reopen patterns continue. That actually points back to my initial article, that as we continue to open, as the curve flattens in one region, it’s going to be spiking somewhere else. So as the curve is now flattened in New York, it’s peaking in Alabama, and I believe that young, less attached physicians should be prepared to mobilize to these surge cities and provide care where it’s needed the most.

Kevin Pho: Now, what are your plans going forward? You mentioned that your deployment in New York City is ending shortly, so what are your next steps?

Ajit Rai: That’s a complicated question, because I do a lot of international work too with Doctors Without Borders, and Brazil is projected to be a very hard-hit region that could be the next epicenter. Yemen is getting hit very hard also. So I have a lot of desire to contribute internationally, but at the same time, because of international travel restrictions, what’s happening on the humanitarian aid front is that a lot of these humanitarian aid organizations, they can get you to one of these hard-hit regions, but they may not have a promised plan to get you back on time. So you might just be floating in Brazil for a while.

I have an interest to continue international humanitarian aid wherever the next epicenter might be, but for the time being, until travel restrictions are a little bit more fine-tuned, I think I want to continue providing care in the U.S. wherever it’s needed the most. So I might be bouncing around the country and chasing this virus around for a bit.

Kevin Pho: Over the last three months, I know a lot has happened. What’s something that’s surprised you over the last few months?

Ajit Rai: One thing that I think has surprised me but also inspired me is how resourceful the medical community is internationally. We collaborate with physicians from France, from Italy, from Wuhan in real time, and the ability to share knowledge and data and studies that have occurred in Italy, and we get to employ those practices and those findings here in New York City. I think that resourcefulness is something that’s really fantastic and has shown just how much the medical community can come together in times of need.

And for me, being here in New York, I routinely videoconference with my colleagues in California to help share best practices, because what we’re experiencing here, although it’s different, a lot of the lessons can be employed in terms of preparation. But overall, to answer your question, the resourcefulness of the medical community is very inspiring.

Kevin Pho: Well, that’s wonderful to hear. And my final question, what’s the take-home message that you have for my audience?

Ajit Rai: The take-home message that I have for providers, for doctors, for nurses, is I believe that we have spent our entire lives training and learning a very, very critical skill, and that is how to help save lives and how to enhance the health of our communities. And know this: These skills have never ever been more critical than right now. So even if that means us temporarily uprooting for a period of time to help regions in need, I think we need to be prepared to make those sacrifices, because we have such rare skills that are so overwhelmingly in need right now.

I just want to encourage other providers to be ready and available, to be a little bit more flexible than they previously ever had to be. And if that means we need you in Alabama in a few weeks, or if we need you in Arkansas in a few weeks, hopefully you’ll hear the call and you’ll make arrangements to come.

Kevin Pho: Ajit, thank you so much for sharing your story and your journey. Thank you for doing what you’re doing, and best of luck to you in the future.

Ajit Rai: Thanks a bunch, Kevin.

Kevin Pho: All right, take care. Bye.