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Infectious Disease Doctor: Alaska ‘On the Edge’ With COVID

“There's a lot of general fatigue. ... I want to be able to leave the state and leave the country and see my family. I have pretty much chosen to self-hunker down. I think it would be irresponsible for me to get sick.”

by Marc Lester, Anchorage Daily News, Alaska / November 17, 2020
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Nov. 16—Not many people view Alaska's coronavirus situation with quite the same breadth and depth as Dr. Andrea Caballero, an Anchorage-based infectious diseases specialist. One of just five "I.D." doctors working in Alaska, she has treated more than 100 hospitalized patients for complex infections due to COVID-19. Caballero also consults with hospitals, including Providence Alaska Medical Center, Alaska Regional Hospital and St. Elias Specialty Hospital, about practices and protocols for responding to the pandemic. She also dedicates a portion of her time to staying knowledgeable on emerging treatment options and how to implement them here.
 
It's been a busy year since Caballero, 36, moved to Anchorage to begin her private practice here, after having worked on the Kenai Peninsula for two years prior. She spent most of her childhood in Guatemala, then lived in the New Orleans area for several of her high school, college and medical school years.
 
Caballero said she has remained hunkered at home in recent weeks, uncomfortable eating at restaurants or visiting with people who aren't in her household. I spoke with her as she walked her dog, Luther, around the Delaney Park Strip. That was during a week in which public officials pleaded with Alaskans to step up precautions to slow the surging community spread of the disease. It was eight months and one day since the first confirmed case of COVID-19 was announced in Alaska.
 
"I was the first one of my group to get a COVID patient," Caballero said. "It all seemed very fascinating then, and we all looked at the x-rays and oohed and ahhed...Ever since then, it's not as exciting."
 
How long prior to that had you been expecting it?
 
We started dealing with COVID in January, when we started hearing reports from China. I still remember, we didn't sleep the night that the Wuhan flight with expats was flying through Anchorage. We were all kind of told to hold our breath, because if somebody got sick, they would end up in one of the ( Anchorage) hospitals.
 
At the end of January, one of our partners texted us a meme that said something like "January was a long year, but we survived... We had no idea how much worse it was going to get, of course.
 
Did it seem inevitable? Or did it seem at first in January like something Alaska might miss entirely?
 
Our hope was that it would be like SARS and MERS, that it would be more geographically isolated...
 
I mean, this is unprecedented for most people who are alive today. I finished my training three years ago, and I think your biggest fears as an I.D. (infectious diseases) doctor are a pandemic, ebola and measles...And in my three years in Alaska, I've dealt with a pandemic and with measles. So, all my fears as a new I.D. doctor have come to fruition and I'm still standing, for the most part.
 
If you were writing the history book 50 years from now, how would you describe the stage that Alaska is in at the moment?
 
Precarious. We are on the edge of going one of two ways.
 
There's a lot of general fatigue. I'm exhausted. I'm over it. I want to be able to leave the state and leave the country and see my family. I have pretty much chosen to self-hunker down. I think it would be irresponsible for me to get sick for my patients and my partners.
 
I think that this can get very bad very quickly. We've had three, four weeks now of over three hundred cases daily. And we're holding on, but barely.
 
We have a lot of staff that are fatigued. We're seeing a lot of PPE fatigue. It's exhausting to wear a mask and a face shield all day long. And we have a lot of health care staff that are really in contact with (COVID-positive) patients...Our physical therapists, our nurses, our (certified nurses assistants, occupational and respiratory therapists). And they're tired.
 
And the concern is, if they let their guard down, then the number of health care workers could diminish rapidly?
 
Yeah. Right now we have multiple health care workers that are out. And it's not only in the hospital. When there's community spread, it's going to hit everybody, including health care workers. We're not immune from community spread by any means. So, the more community spread there is, the higher the number of patients, but also the higher number of staff that will potentially get exposed. And that's the perfect storm...
 
Our fear is always not being able to provide standard level of care. In this country, we have certain measures and expectations when it comes to health care. If our system gets overwhelmed, we can not give that. And that unfortunately ends in higher morbidity and mortality, which is what we all want to avoid.

In Alaska, how close are we to being stretched that thin?
 
(Because of) the unique geography of Alaska, even though we have a massive outbreak in the village of Chevak, when those patients need higher levels of care, they end up in Anchorage. There's no such thing as whatever happens in the Y-K Delta doesn't affect us here. We are a much more interdependent community as Alaskans. It's the nature of it. As much as we can feel so separated because of the distance and the difficulty of accessing certain areas, we are very interconnected.
 
If someone's going to get intubated or remain on the ventilator for a long period of time, they're going to be in Anchorage. So, Anchorage not only deals with the Anchorage population, but we offer higher level of care for sometimes Fairbanks and the ( Kenai) Peninsula and the Southeast and all the other remote areas you can think of. I've had patients from all over the state end up here.
 
So, it's not just thinking can we handle the 350,000 people from Anchorage, but can we handle the 700,000 from the state.
 
And the answer is, at this rate, no.
 
No right now, or no in the near future?
 
If we start seeing a rising number of hospitalizations, we're not going to be able to handle it.
 
Say things continue on the trajectory that they're currently on. What do things look like in one month or two months or three months?
 
That means we don't have enough staff to manage critically ill patients.
 
I don't like to think of that.
 
I think that (scenario) means we definitely cancel all elective procedures. We hopefully get a "hunker down" in the community. And in the hospital, you might get a non-trained physician to manage an ICU-level-of-care patient. That means that our nurses that are usually in surgery will be the ones working in the ICU.
 
I think it's every health care worker's nightmare of having to just work long hours and long days and knowing that we can't provide the best care that we potentially could.
 
It means we run low on treatments for COVID. It means our ethics department gets involved so that we pick and choose who gets what, who gets a vent and who doesn't, who gets remdesivir and who doesn't.
 
It's something that I don't wish on any of my patients or my family.
 
You said it could go one of two ways. What's the good route? How much optimism do you feel and what's the best case scenario?
 
I feel like I've been holding my breath for two weeks now.
 
Best case scenario? People take to heart social distancing and masking and we're able to decrease community spread. And our numbers, instead of increasing, start to decrease.
 
(Hypothetically) we have a vaccine by the end of the year, maybe December, maybe January, which isn't going to be the end-all unfortunately...We don't know how long immunity will last after the vaccine. It might be something that you get immunity for a couple months and then we're right back to where we started. Too many questions remain about it, but I think that it's a glimmer of hope.
 
Best case scenario? No one has large gatherings for the holidays. Everybody stays within their household.
 
I think that this idea of bubbles, it can lure you into thinking that you're being safe when you're not. Bubbles only work when they're self-contained. The moment multiple bubbles have become venn diagrams, that's when we have a problem.
 
What can you tell me about the state of hospitals at the moment? We see a lot of numbers about capacity, but that's only part of it, right? Because there's also the trained staff to think about and availability of treatments and various other things.
 
Correct. And I think that's where the numbers of capacity fall short (for the purpose of modeling, Caballero later clarified). It does not account for the fluctuations in staff that we have at any given time.
 
Any staff that are positive need to be out for (at least) ten days...That's if they test positive. If they get exposed, that's a 14-day quarantine...
 
We're trying to stratify which employees could come back sooner if we need them, because we're so short staffed, despite them being COVID-positive or having had an exposure. So it's sort of a risk-benefit equation at that point. (Caballero later clarified that she was referring to a hypothetical desperate-need situation, and that this is not something that is happening now.)
 
We need a certain number (of) staff to be able to function. We can only push individuals so far before we can't really give good care.
 
And would you say that's a more limiting factor right now than the actual bed space?
 
Absolutely.
 
Two things to that. I want to talk about recovered patients in a moment, but I just thought of something.
 
It's very hard to attract talent to Alaska. And both for physicians as well as every other health care worker, we heavily rely on locums companies.
 
What's that?
 
Locums are companies that specialize in bringing temporary work. We often have the travelers. We have a nurse that comes up from the Lower 48 for six months. And we do that for respiratory therapists, for physicians, any kind of specialty... So these are people that have no investment in our community that bring a very much-needed level of expertise, but are only here temporarily.
 
And the problem is that the demand is so great everywhere that it is hard for us to attract even locums at this point. So what we have is what we have.
 
Does this have to do with the nationwide demand from the same talent pool?
 
Yes. Correct. At baseline, it's hard. In a normal year, it would be very hard to attract permanent people to move to Alaska. I think you have to have a certain level of "je ne sais quoi" that you're like, "Oh, I'd love to live in Alaska." And now that everybody else is looking for locums, we are by no means top priority.
 
The second thing that I'd like to talk about is recovering COVID patients. The way that epidemiology works is that we have strict definitions of what constitutes a case and what constitutes a recovered case. We're trying to fit the real world into a statistical analysis, and it has its limitations.
 
One of the things that I think is underappreciated is that even though we have a seemingly low mortality level, some of these patients that are surviving are not surviving (and simply) walking out of the hospital back home. We're talking about ending up with tracheostomies, which is a tube in your throat to help you breathe, a PEG (percutaneous endoscopic gastronomy) tube in your stomach to feed you, and then months and months and months of in-patient therapy.
 
These are COVID cases?
 
Yeah.
 
I don't hear about those.
 
You don't, exactly.
 
You'd think a recovered patient means you walked home, you recovered, you're back at work, you're walking the dog.
 
That is certainly not every recovered COVID patient. And I think that these cases might seem extreme, but it's honestly what I see mostly these days. These are patients that are in the hospital for...I mean we've had some that have been there for three months. And the problem is that the hit that your body, especially the immune system, takes is that then you're prone to other infections.
 
So, I've had patients who have such severe immune suppression that it's one infection after the next after the next after the next. They don't have COVID anymore. They're no longer contagious. The virus probably cleared. (But) the immune system hasn't recovered, and then you have all this damage that's left behind in the lungs...
 
These things are happening. I think there's a lot about everybody's own genetic and phenotypic composition that we don't know (regarding) how it affects how you respond to COVID. We've had young, healthy people show up with complications...And then we've had some elderly folk that come in and then a couple days later they go home like nothing happened. I don't know why.
 
Let me ask about you. How are you feeling?
 
I'm tired. I'm very tired. I think I'm a little bit numb as well, because I've been dealing with it for so long.
 
But I'm also hopeful. This isn't the first pandemic that has happened in history, and it's not going to be the last. I think that, in general, this too will pass. And I think that for the most part I'll be able to look back and be proud of what we did.
 
As you look towards the next few months, what is your message? What do you want people to know about where we are in Alaska right now?
 
I think about empathy and vulnerability a lot.
 
Empathy for your fellow humans in the community. Like I said earlier, we're all very interconnected, as big and sparsely populated as we think of ourselves.
 
And then vulnerability. We don't know it all, but we do know that certain things work. Today versus January, we have better guidelines of treatment. We know that steroids work. We know that remdesivir works really well. We also know that masks work. They're not perfect, but nothing in medicine has ever been perfect. We know that social distancing helps.
 
Especially with the upcoming holidays, it's tough. I haven't seen my parents in over a year. But this will pass, and I think that the more solidarity we have with each other, the better off we'll all fare at the end.
 
Two days after we first spoke, I talked to Dr. Caballero once more to get her reaction to the most recent daily case counts.
 
It's been 48 hours since we talked. What has changed? What are you thinking?
 
I think the weekends that I'm on call, when you're the only infectious disease doctor in the hospital for two days in a row and you get all of the calls, and you see the newspaper reporting 745 new cases, and you walk into your COVID unit and you see that you have a ton of patients, it kind of grapples at your heartstrings a little bit. Because I don't see it slowing down and I see our unit getting bigger every day...It's terrifying.
 
The conversation has been edited for length and clarity.
 
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(c)2020 the Alaska Dispatch News (Anchorage, Alaska)
 
Visit the Alaska Dispatch News (Anchorage, Alaska) at www.adn.com
 
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