COVID Incident Command: a day-in-the-life

The author, defended by his creature creations.

A recapitulation of a series of tweets about my recent experience at the UCHealth’s command center. I rotate the responsibility for the physician support position with about a half-dozen other docs. The command center has been up for almost 3 weeks now.

1/ A day @uchealth Incident Command Center. Constant stream of calls. Room is full of experts (infectious diseases, pulmonary, disaster) with a dozen other directors. Like being the frontal cortex of a massive organism…

2/ If you’ve never served in a Command Center, it is scary as heck, and also exhilarating. Things happen and decisions are made in minutes and hours, not weeks and months, as is more usual in a large organization… is that

3/ Sample incoming call: ‘ICU wants to know whether to send a second COVID test nasal swab on a patient whose test was negative yesterday but the team has high suspicion they have COVID.’ (Yes, not via nasal swab, but by tracheal aspirate for better sampling)

4/ Sample call: ‘Community organization purchased 10 COVID tests somewhere; would we send a medical assistant to perform swabs on their employees.’ (No, test performs poorly for patients with no symptoms.’ and, how do you choose who to swab? And, what would you do differently if you have a result? negative: stay home. Positive: stay home(!)

5/ Sample call: ‘Hey, if ventilators are scarce, we could build Iron Lungs faster: want some?’ (After internal discussion, no: COVID is associated with ARDS (adult respiratory distress syndrome). ARDS causes stiff lungs, unlike polio, and even then they didn’t work well), AND, how to manage IVs and catheters?

6/ Our converted conference room now is 24/7 staffed with executives, directors, nurses, doctors, staff who connect to every part of our 12-hospital, 600 clinic, 4000 provider system. Kinda like a neocortex…

7/ We sit and take calls from all over the system, clarifying the daily-changing policy, delivering nimble responses to moment-to-moment events in our EDs, our clinics, our hospital wards …

8/ We huddle in purposeful groups through the day: medical officers, informaticists, nurse leadership, respiratory therapists, ICU teams, hospitalists, data analysts, facility managers, tent-building teams(!) …

9/ We ‘run the board’ twice a day to ensure our top issues are addressed, re-prioritized, to keep our eye on the ball: racing ahead of the coming tsunami of COVID-infected patients collapsing on our doorstep…

10/ We marshal our supplies, build negative pressure rooms, re-allocate staff, negotiate new partnerships, create and dissolve projects to solve immediate problems…

11/ Dramatically expand our Virtual Health Center for Virtual Urgent Care, expand our nurse call line to handle COVID concern calls, go from 2700 virtual visits last year to 3000 virtual visits per DAY this week…

12/ Discover new trends: hypoxic COVID patients who are surprisingly not short of breath, patients who oxygenate better laying on their stomachs, how poorly bleach wipes interact with electronics(!) …

13/ We tearfully celebrate improvement: today a cluster of patients successfully extubated from the vent, a few patients de-cannulated from ECMO, a hallway of nurses applauding an ECMO survivor…

14/ And yet we have fun… Jurassic organisms battle for supremacy while modern organisms do the same.

15/ Our loyal administrative intern asked our Incident Commander at the end of her day shift: ‘How do you feel? How do you think we’re doing?’ …

16/ Her reply: ‘For the world, terrible. For our country, very worried. Here, we have prepped well, we have a great team, we forecast constantly, and we are going to meet this challenge.’ So proud of her, and us.

Laocoön, The Aeneid and Captain Picard

https://en.wikipedia.org/wiki/Laoco%C3%B6n_and_His_Sons

My high-school aged son is avidly devouring classic literature, and the echoes of those epic struggles from my own education, float back to me. On our winter break one evening, he had left the Norton Anthology of Western Literature out on the coffee table. Soon I was in the midst of battle at Troy, at Carthage, in Rome.

Aeneas of Troy, in the classic by Virgil, faces a long journey with many trials. Even in 20 BC, storytellers mastered Story. Sometimes the smallest moments are the best parts of a story:

  • Laocoön runs out from the city to warn his fellow citizens of Troy, that the large wooden horse left behind by hastily departed Greeks, was a trick: ‘beware of Greeks, even bearing gifts.’ To punish him, the gods send a pair of serpents to devour his sons and then kill him. The image above of Laocoön dying defending his sons is such a moment. The city elders, seeing him killed by the gods, are then convinced that he is wrong, and bring the Trojan Horse inside the gates. Of course, you know the rest: the city of Troy falls that night as hidden Greek solders pour out, open the gates and ransack the city.
  • Aeneas initially resolves to stay and defend his city to the death. His touching moment with his father and their resolve to stay together and flee is a pivotal moment of change for both of them.
  • Aeneas meets Dido, queen of Carthage, in his storm-tossed journey, and falls madly in love. Soon after, the gods send him a message that he and his lineage are to become the founders of Rome. He leaves immediately. Dido kills herself in despair.
  • With supernatural help, Aeneas journeys to the underworld to see the future: that his descendants establish Rome and create the Roman Empire.

These moments, to which I’ve summarized so prosaically, are told in verse and with rich detail and sensory imagery.

Interestingly, the Norton Anthology also included the ancient translation of Gilgamesh, perhaps the oldest recorded epic story. Being a science fiction geek, perhaps I should not have been surprised that my first exposure to this classic, written in antiquity, circa 1700 BC, first reached my ears via Captain Picard, on the all-time most popular episode of Star Trek, The Next Generation TV show called Darmok (no, not the new, apparently amazing show, that is behind the CBS paywall). Careful, don’t read the links unless you have time; you won’t come out for awhile.

CMIO’s take? Great storytelling captivating, and timeless. Smart people lived thousands of years ago. Sometimes Captain Picard teaches you ancient literature.

Take a breath! and try JOMO during our pandemic

from esteemed colleague George Reynolds, former CIO and CMIO

I was chatting with an informatics colleague last week, mentioning that our family had spent some time in Utah recently.

He sent me this photo he had taken in Utah recently. Beautiful, no?

Are you taking care of yourself? It looks like we are in this for the long haul. Colorado is now under a stay-at-home order, and it looks like our infection curve is more like Italy than it is like Taiwan or South Korea: it is still accelerating, and will be awhile before the worst is past.

So, take a break. I tried hard this weekend to step away, watch a movie, hang out with the family, go for a walk, a run, a bike outing, bask in the sun, get some sleep, in between online-work. Maybe JOMO is a good word to think of at times like this.

We wrote on our family white board some daily tasks:

  • Cap your news/social media at 30 minutes a day
  • Exercise: ping pong / walk / run / bike / dance
  • Play or listen to music!
  • 3 Good Things

CMIO’s take? Do you give yourself moments of beauty? of music? of laughter? play a game?

Please do.

Consider asking your family members to do the 3 Good Things exercise (see above) , thinking of things you’re grateful for.

Hand wash. Stay healthy, best you can.

Thanks for the photo, George.

Is this our Midway moment with COVID?

From John Lee’s article referring to: (Image: National Archives and Records Administration, 80-G-414423.) https://www.nationalww2museum.org/war/articles/battle-midway

In his lovely medium.com article, colleague John Lee MD writes about the World War II Battle of Midway, how it was a turning point in the war, and how this moment, in our battle with COVID-19, just might be our moment.

I know CMIO’s and physician informaticists around the country and world are scrambling to marshal our forces to meet the enemy:

  • Building predictive models for deterioration of COVID patients
  • Creating alerts to reduce prescribing of azithromycin and hydroxychloroquine to save our existing supplies in case this is a valid therapy
  • Building and deploying Virtual Visits throughout our organization to reduce COVID exposure to our patients, our staff, our providers
  • Teaching our colleagues and our patients how to use these new tools, using VIDYO, Epic MyChart, ECHO, ZOOM, SKYPE, Facetime, whatever tools you’ve got to connect with each other, with our patients. When everyone is working from home, and only some folks have wifi, or a smartphone, or a laptop, or …
  • Rewriting our documentation templates to keep up with federal and state requirements on what we have to say to live in this new world of virtual care
  • Implementing new COVID ICD10 codes to allow us to track COVID positive patients, as well as COVID PUI (patients under investigation while the test result is pending)
  • Figuring out what happens when we put 2 patients on a single ventilator if shortages occur, how we might automatically downlink ventilator settings directly to the chart. One unanticipated consequence is that the second patient gets NO data from the vent while the first patient might get incorrect (double volume?) data!
  • Building new rooms that are located in emergency tents set up outside the hospital for possible dramatic expansion next week (does wifi go that far? will our WOWs-workstations on wheels survive the winter weather? what is the room number for parking spot #4?)
  • Figuring out how to share resources between hospitals and health systems to see which of us is hit hardest and how to work together best we can
  • This is just off the top of my head for discussions this week.

CMIO’s take? Read Dr. Lee’s post. I like how it is challenging and hopeful at the same time. To my esteemed colleagues in informatics, in medicine. Take a breath. Get some rest. Lets GO.

Unified Theory of Design Thinking for Social Systems (thanks to d_school at Stanford)

I recently attended a 6-day course Designing for Social Systems at the Hasso Plattner d_school at Stanford University. We sent at team from our Wellness initiative at the University of Colorado Department of Medicine, cutely named “WellDOM” (more on this in a future post). It was … a mind blower.

What is design thinking and why is it so cool?

  • It is a system of thinking that both expands and focuses creative thought.
  • It encourages curiosity and diving into the ethnography of individuals
  • It also encourages thinking about positive and negative influences at many levels of social systems
  • It actively encourages play, physical manipulation of prototypes and sticky notes to build a joint vision
  • It uses storytelling, rapid cycle development, ‘what if’ and ‘how might we’ statements to spark ideas.
  • It is FUN.

I’ve been thinking and digesting what I learned over the past few months and came up with the graphic above. I’m a visual thinker, and although it is quite cluttered, I think it finally encapsulates the scope of what I now appreciate to be Design Thinking for Social Systems:

  • It is Human-Centered (focused on emotion, story, experience), the inner yellow circle
  • It is Systems-Aware (complex social systems impact your success), the outer blue circle
  • It is Strategy-Focused (keep your end-goals in mind)
  • The inner and outer circles interact, and the strategy lane underlies the whole group of activities.
  • There are perhaps 4 dozen specific activities that allow you dive deeply into every part of this diagram, in your pursuit of a creative, lateral-thinking solution to complex, ambiguous problems.

Don’t wait! Take one of these courses! And start applying it today!

CMIO’s take? Creativity, and NOT Computing Horsepower, is the next frontier.

Social Distancing: This is Not a Snow Day (Medium)

I support this, carefully written by a primary care physician and public health expert. This is a meme worth spreading to combat fear and the virus. Stay safe out there. CTL


I know there is some confusion about what to do next in the midst of this unprecedented time of a pandemic, school closures, and widespread social disruption. As a primary care physician and public…
— Read on medium.com/@ariadnelabs/social-distancing-this-is-not-a-snow-day-ac21d7fa78b4

CoronaVirus: is the Meme more dangerous than the Virus? Yes! and No!

Telehealth Visit (nounproject.com)

https://denver.cbslocal.com/2020/03/09/coronavirus-colorado-consumers-telemedicine/

Okay, everybody, take a breath. We’re in the midst of a storm of Coronavirus news, and it is bombarding us 24-7. As a physician, an informaticist, a parent, and a son of aging parents, I (like many of you) wear lots of hats and have lots of perspectives relating to this pandemic. Boiling it down, here is what I’m aware of, followed by my take:

  • BIOLOGY/HEALTH SYSTEM
  • The Coronavirus – COVID 19 has arrived in the US. Although it is orders of magnitude smaller (fewer infected, ill) than the Influenza virus, there is no vaccine, the duration of asymptomatic (no symptom) incubation is longer, and the infectivity is higher, and so spread is inevitable.
  • It is unclear as yet what the biology of the virus is, as the weather changes, will it gradually dissipate with the warmer months, as others have.
  • Countries like China, Italy and others have large numbers of seriously ill patients, mostly elderly, in cases overwhelming the capability of the health services there.
  • Areas taking severe measures to quarantine, limit exposure, travel, gatherings have had some success in reducing spread.
  • Our health service capability also has a limit, and should a pandemic accelerate here, our ICU / ventilator / hospital capacity could easily be overwhelmed resulting in rationing, having to choose “which patient gets the next ventilator that is available?”
  • It has been, apparently, 100 years since the last major pandemic will major mortality: the Spanish Flu following World War I. Most folks alive have no “gut feel” for what a real pandemic is like.
  • SOCIOPOLITICAL/MEMES
  • A Meme is an IDEA that can spread from human to human even more quickly than actual viruses, especially with the INTERNET. There are VIRUS memes and there are FEAR memes. Lets look at them separately.
  • Hmm, you might even consider THIS BLOG POST A MEME. Consider it a COMMON SENSE MEME (according to me).
  • I’m aware that toilet paper, hand gel, and other items are running out in many stores, as people stockpile. This is a symptom of anxiety/panic.
  • I’m reading about toxic interpersonal interactions as asians are targeted by others as being a source of infection, based on appearance rather than reason.
  • I’m aware that large gatherings are being cancelled, schools and large organizations switching to virtual-meetings to avoid gatherings.
  • Our organization has just put in place a travel ban related to work and the automatic cancellation of all internal gatherings >75 persons, with daily adjustments and announcements.
  • I’m aware of many folks stating “this is ridiculous; I’m going to go on with usual business and ignore these outrageous restrictions.”
  • I’m aware of physician colleagues stating (on the other hand) “This is ridiculous, why are we restricting the testing of any patients for COVID? I’m going to refer EVERYONE for screening because we need to know what the community prevalence is, regardless of symptoms.” At risk: exhausting the testing supply for those at highest risk (symptoms, and recent travel, or exposure to known case).

Whooo. Calm down everyone. Lots of valid viewpoints here.

CMIO’s take:

  • Handwashing, soap and water, as often as you can think of it. Hand-gel is a nice to have, but soap and water please.
  • Avoid touching the face (like saying … don’t think about an elephant. What do you think about?).
  • Consolidate your trips out of the house as possible. Grocery shop for somewhat more, and go out less often. Virtual meetings! Face-time! Skype!
  • Toilet paper shortage? OK, lets try to use less for now. Geez.
  • N95 masks? Save them for the healthcare providers taking care of hospitalized patients. Most plain folk don’t need them. If you desire, ok to get REGULAR masks and then use them to REMIND YOU NOT TO TOUCH YOUR OWN FACE (the major way to transmit is hand to your own face). It does nothing to avoid virus in the air, which is already incredibly unlikely in the community.
  • Go about your business and take prudent common sense measures.
  • I will be going to work at the clinic for our usual work, and screening patients, just like we always do. There are very few cases in Colorado and we are extra vigilant, but still going to work, with no masks UNLESS we encounter a high risk patient with symptoms.
  • We are scaling up our Virtual Visit capability to see patients by online 1:1 meetings over secure connection.
  • Yes, cancelling large gatherings and meetings and moving to virtual when possible is a great idea despite the inconvenience; if we can influence and slow down the pandemic spread/infection curve for our elderly relatives so that we don’t slam and overwhelm the health system, this will save many lives. I’m all for it.
  • Stay safe everyone. Be kind to each other. The FEAR meme can be more dangerous than the VIRUS, but also lets be prudent.