COVID Vaccines at Colorado’s Epicenter from March 2020: JBS Greeley Beef meat packing plant.

Changing minds with Stories, not Data.

NEWS ARTICLE: https://www.greeleytribune.com/2021/03/05/jbs-workers-having-seen-the-largest-outbreaks-in-weld-county-receive-first-doses-of-covid-19-vaccine/

This was a remarkable event, and I’m glad I was there to see it.

For those who may not know or remember; Greeley’s JBS meatpacking plant was the center of Colorado’s first major outbreak of COVID illness, resulting in numerous deaths and hundreds of workers getting sick and hospitalized. Meatpacking requires close quarters, and one infection spread rapidly to many.

I watched on the news with horror as the disease spread, and Greeley, a small town in rural Colorado became national news. Greeley also led the state in COVID illness early in the pandemic.

Public Health Effort

The great news NOW, is that Colorado’s Public Health coordinated a multi-health-system effort to vaccinate the nearly 5000 employees there. When I heard of the opportunity, I dropped everything and headed up there last Friday to be part of the effort.

It would seem an insurmountable task: How do you coordinate nearly 100 volunteers who don’t know each other, in a noisy, unfamiliar plant? How do you incent workers who may have questions about the vaccine, to come discuss and be vaccinated? Will you have enough translators (at least 8 languages are spoken by employees)?

7 health systems coordinated

Soon, however, we got organized into 14 tables of 3 vaccinators, taught how to load vaccine syringes from defrosting Pfizer -70 degree vials, supplies distributed, and employees started rolling in, paper consents in hand.

Doctors, nurses, medical assistants, technicians, healthcare workers speak the same language. Despite the cold hallway, we buckled down and got to work.
Dr. Hoffenberg instructing each table on standard vaccine process.
Patients arriving by the hundreds

2500+ vaccinated

We vaccinated over 2500 employees on Friday, a great day and smooth operation. See above for the write-up by the Greeley Tribune, among many news organizations on site.

The “Education Room”: Stories NOT Data

Here is where it gets interesting. I found out that I was assigned to the “Education Room” upstairs. Management at JBS was serious about maximizing employee engagement with this big push for vaccination.

  • The plant was closed for 2 days.
  • All workers would be paid for 4 hours of shift work JUST TO SHOW UP.
  • All workers who got vaccinated would receive an additional $100.
  • All workers who declined vaccine could sign a paper … AFTER they went to the EDUCATION ROOM where Dr. Lin and other physicians and nurses were waiting
Image blurred intentionally

Hmm. I thought I had signed up to vaccinate today …

When I heard this, my life flashed before my eyes. Not really, but I had a rapid sequence of thoughts:

  • I hoped they had enough translators (turns out, yes: Somali, Spanish, Amharic/Ethiopian, many more)
  • I hoped I had heard most of the rumors and misinformation about the vaccine before and be ready to respond
  • I hoped that I could avoid STATISTICS and DATA, since most vaccine-decliners have (mostly misinformed) STORIES. Data never beat a compelling Story. Only Stories have a chance to fight Stories in the battle for feelings and changing minds.
  • I thought back to a book I read recently, The Righteous Mind, about values, moral thinking, and how those with liberal values, and those with conservative values see morality with very different lenses. Would I be able to speak a common language to connect with those who saw the world differently?

Reasons why NOT?!?

Yes, it turns out, we only had about 100 people come through for the 6 hours I spend there. Of the 100 we spoke with, I heard a dramatic range of reasons why people were declining the vaccine:

  • “Well, it’s not a real disease anyway.”
  • “I heard the vaccine kills people.”
  • “The vaccine is only 95% effective. So what is the point? Like, it doesn’t even work.”
  • “I heard it is made from dead babies.”
  • “Only old people have a problem with COVID.”
  • “I am healthy. I don’t live with old people. I don’t need it.”
  • “My roommates will make fun of me. We are not getting it.”
  • “My parents told me not to get it.”
  • “Why are WE the guinea pigs, before everyone else?”
  • “I’m going to wait and see.”
  • “I’m pregnant. I heard it is dangerous for my baby.”
  • “I already had COVID. So, I’m immune.”
  • “I never get ANY shots, flu, nothing. I don’t need it.” (and more)

This was a daunting task. However, we had a room full of translators for all languages, 3 tables set up with information sheets and 3 cultural ambassadors to explain the importance of the vaccine and WHY JBS managers and leaders thought this was important, and even Union Leaders who would show videos of themselves getting the shot themselves (thank you JBS; very organized!). THEN, if the participant was adamant about their decision, fine, go sign the paper and get paid.

Less Helpful Conversations?

IF they had a question, one of us would get called over, and we could chat. I heard a few discussions in the room. Some less effective approaches:

Employee: “I don’t want the shot. I already got COVID. I’m immune.”
JBS Supervisor: “I haven’t got COVID. I’m not immune. You don’t care about me?”
Employee: “Nah man, stop talking. Where do I sign the paper.”
(Confrontational)

Employee: “I don’t want the shot. I’m healthy.”
Medical advisor: “You know, the shot is 95% effective. Even though it doesn’t protect everybody, the data shows that almost everyone gets immunity. Even if you DO get the infection, it is likely milder and you won’t have symptoms.”
(Data-heavy, confusing, and not addressing the issue)

Employee: “It is not a real disease.”
Medical advisor: “Yes it is. People die all the time. Here are 5 reasons the shot is safe and the evidence that it works…”
(Not enough reflective listening, eliciting thoughts, trying to find common ground, and too much talking)

Whew. I could see myself falling into each one of these traps. I set myself a goal to find STORIES to match and counter their STORIES and to suppress temptation to exhibit my command of the DATA (sooo hard).

Better Conversations?

Here are some of the better ones we came up with. Importantly, ALWAYS begin with “What questions do you have?” and “Tell me more about what you understand.” and “Anything else?” and “I like that you are trying to get good information before making a decision. This can be very confusing and scary. I would like to help.”

Employee: “I’m pregnant. I’m afraid for my baby.”
Me: “Yes, there is less information from the vaccine tests about pregnant women. HOWEVER, MOST of the women doctors and nurses at University Hospital who are pregnant have gotten the shot. And we are confident it is safe for the mom and baby.” (result: agreed to shot)

Employee: “I heard the shot makes you sick.”
Me: “Well, most people do not get sick. If they do, some get a sore arm, or a headache or fever, like getting the flu. Tylenol helps. For me, I had a fever for about 3 hours overnight.” (result: agreed to consider it later)

Employee: “Why are we the guinea pigs and getting it early?”
Medical advisor: “Actually, the doctors and nurses were the guinea pigs; they got the shot back in December and January. We are all healthy and staying safe, with no major side effects. We want YOU to be protected too.”

Employee: “I just don’t want to do it.” (unable to state a clearer reason)
Me: “I hope you see all the doctors and nurses in this room. We are all volunteers, took a day off to come here, because we WORRY about you and your community. You are Essential workers. Last year, many of your co-workers got sick and died, and we did not protect you. We don’t want this to happen again.” (result: thanked us for volunteering, and promised to consider vaccination)

Motivational Interviewing?

Of 100 people, about 20 agreed to the shot during our session, about a 20% conversion rate. Is this normal? I have no idea. One of my colleagues noted:

“Compared to vaccinating, this is soul-crushing. To do your best explaining why a crucial vaccine would save lives IN THIS PLANT, and not to connect. So hard.”

Nurse Practitioner in the Education Room at JBS

At the same time, we all agreed that many of the decliners also said they would think about it some more, and would consider getting it later. In motivational interviewing lingo, perhaps they were moving from “pre-contemplative” to “contemplative.” Even a mild attitude shift like that, is a win.

Some of the more effective strategies:

  • Listening more than talking
  • Finding common values: “The Broncos!” or “Protecting elderly parents”
  • Telling a personal story of COVID or getting vaccinated and how it felt
  • Talking about “looking out for each other” “protecting our community” “making Colorado safe” “keeping Covid out of your family”
  • Using metaphors: “Which vaccine? Its like, Dodge, Ford, Chevy. Just get in the car. We will all get there.”

Dr. Steve Hoffenberg, Emergency Medicine Physician, coordinated the vaccine efforts at JBS. Thank you, Steve.

FINALLY: Will you look over this document with me? I wrote a ONE PAGE summary of what I thought were the BEST STORIES to fight misinformation about COVID Vaccine. What do you think?

Download the document here: https://www.dropbox.com/s/k94xra38b4tmmst/2021-0309%20Why%20Should%20I%20Get%20the%20COVID%20Vaccine%20CTL.pdf?dl=0

CMIO’s take? Wow, there is a lot more to vaccine work than “give shot, call next patient.” Coordinating a public health effort: massive. Focusing on high risk populations: important. Listening, connecting and changing minds: some of the hardest work of all. In the coming months, THIS will be the conversation.

Fight Disinformation. Journalists, Scientists Unite!

From wired.com

https://www.wired.com/story/opinion-disinformation-researchers-must-work-with-journalists/

I find it does not serve the needs of the community or the world to be merely a scientist. One must also be a communicator. In this age of disinformation, we are drowning in the social media morass. The voice of science, of reasoned, thoughtful scientifically based research is too quiet. Our Filter Bubbles allow us to read online articles that only confirm our biases instead of finding objective, reports that speak to actual evidence. This article is a clear explanation of why journalists and scientists should work hand in hand to raise our voices and be heard.

SNAFU tent: Optimizing a Covid-19 Mass Vaccine effort at Many Levels

Dancin’ away troubles at UCHealth’s SNAFU tent for Covid Mass Vaccination

Optimizing the Mass Vaccine Event

This will be a fun exploration from a CMIO’s perspective. Let’s think about individuals and work our way up to national optimization, from a personal perspective. And, don’t miss the SNAFU Tent Vaccine Dance at the end…

Seven Levels of thinking

  • Level 1: Make myself efficient
  • Level 2: Make my pit-crew efficient
  • Level 3: Make all pit-crews efficient
  • Level 4: Make the entire Mass Vaccine efficient
  • Level 5: Optimize Mass Vaccine for volume or cost
  • Level 6: Optimize Health System Vaccination plan
  • Level 7: Optimize National Vaccination

1. Make myself efficient

Readers may remember recent writeups where I incrementally overcome my lack of skill as a physician at vaccinating. I’m a quick study, and when great nurses and medical assistants are around to teach, I got better quickly. See above, with the pre-peeled bandaid/ vaccine/ alcohol swab grip, and second hand to manage the smartphone electronic documentation. I’m MOB-ILE.

Here’s the set up: have an assistant play “keep ahead” by peeling bandaids. The hardest part of the job is peeling bandaids with gloves on.

The next hard part is that vinyl gloves stiffen in cold weather. So, use the sani-wipe jug to elevate your glove box closer to the propane heater. Smart! Actually even that wasn’t really warm enough, so I took to doing this:

I call this “praying to the propane gods.” Or, holding the gloves up for 5 seconds of warmth: makes a huge difference in the ease of putting them on (150 times that day).

Handwarmers: Even better idea

Of course, Bernice comes to me near the end of the day and tells me “Dr. Lin, put 2 handwarmers in your coat pockets and put your next pair of gloves in them, so you always have warm gloves to swap.

“D’oh!” as Homer Simpson would say. Why didn’t I think of that?! Thanks, Bernice.

Colorado Rockies’ Dinger drops by

2: Make my pit-crew efficient

This section is actually mis-labelled. My pit crew made ME efficient. Unlike previous days, where I built up such an efficient process that I was able to stay ahead of my pit-crew colleagues in our 4-car pit-stop, today I was teamed up with 3 outstanding medical assistants from Lowry Internal Medicine, my own UCHealth clinic in Denver: Marina, Yanira and Bernice. The tables were turned: now, every time I looked up from my completed vaccination, the other cars in my pit had already gone! Too fast, gals! You’re too fast for me. 😦

Team Lowry, with my BFF’s.

View of the Mega tent with 4 of the 8 rows, and the pharmacy (vaccine reconstitution tent to the right). The other 4 rows are out of sight to the right of the pharmacy tent. We can vaccinate 32 cars in 8 rows at a time this way. Furthermore, we would huddle and learn from each other “How are you going so fast? What is your set up? How do you ask the screening questions? Where do you put the sharps container?” etc. Thank you, smart colleagues, for teaching me.

3: Make all pit-crews efficient

To further smooth the process, given what we had learned on previous weeks, we posted 4 SNAFU tents after the Mega-tent that we would refer to for any slow-downs or technical concerns. For example, one car pulled up with 3 people to be vaccinated. I would perform one vaccination, and since my row was ready to roll by then, I would place a red card on the windshield, indicating SNAFU and the flaggers would direct the car to receive the remaining 2 shots about 100 yards away. This simple workflow adjustment (4 SNAFU tents for all 8 pit-crews) kept ALL 8 lines moving. This was a difference (for me) between vaccinating 124 people one day and 158 the next. Super smooth.

Another example: a patient drove up and their Electronic Record account showed “second vaccine already administered.” I couldn’t solve it with my smartphone Rover app, so I referred him to the SNAFU tent.

After some investigation, we found out later that day, it turns out that another organization in town had incorrectly registered that patient (a common first and last name and somehow erroneously documented date of birth) so that the mistaken vaccine APPEARED in OUR system on this patient (our separate Epic EHR’s share vaccine records now) that he had already had his second shot (incorrectly). We presume this was because some institutions are still using a paper-vaccination process with “document later” staff (as we did last month, in favor of speedy vaccinations). This re-introduces errors that the EHR was supposed to eliminate (bad handwriting and transcription errors). Hmm.

We are glad we are now using the Rover smartphone app. We’ve tinkered with it so that it is now possible to be as fast with Rover as with paper (AND eliminating the transcription step). 50 seconds with paper, and 50 seconds with Rover. Ha!

4: Make the entire Mass Vaccine efficient

We had lots of competing concerns to keep in mind, when thinking about the entire effort. Police were concerned about backing up waiting cars into nearby streets. (whew, we avoided this). How many total staff were needed to register patients? (too many in version 1) How many tents to rent for these events? (originally 1 mega and 18 cabana-style tents, now 1 mega and 2 cabanas) How would we deal with inclement weather? (snow, rain, black ice, wind: the mega-tent is superior to cabanas for keeping staff out of the weather and minimizing wifi and cell-booster mesh network issues; FYI, my new 5G iPhone 12 pro max was awesome in our pilot testing for speedy smartphone documentation)

Our diligent road crew out there dodging and managing tent-avalanches.

We have been pleased to constantly drive down out patient-throughput times, down to 22 minutes (including the 15 minute observation period)! And this past week on Sunday, we drove our total time down to 16 minutes in some cases: 1.5 minutes for registration, vaccination, a couple minute driving time, and then a 10-minute observation period. Wow. We believe we are the fastest Mass Vaccine service in the country at this rate. Even better, we are making observation OPTIONAL going forward, because of our non-existent severe reaction rate.

We believe we can expand beyond 10,000 per weekend, and believe we can do 20,000 or possibly 26,000 per weekend, if the State has vaccine supply and would like us to.

5: Optimize Mass Vaccine for volume or cost

So, what is the goal of a Mass Vaccine event? Publicity for vaccination? Sure, we had news helicopters circling, lots of press, lots of people commenting on how easy it was, and how much they’re looking forward to hugging grandkids.

We can optimize for convenience for frail elderly. Sure, stay in your car from home, back to home, no walking. Can we help people avoid healthcare settings? Sure.

We can optimize for speed: in which case, bring more vaccinators, and rent a second mega-tent. There is room in this massive parking lot for more staff, we can create more lanes and instead of 32 at a time, we could do 48 cars or more. 20,000 per weekend is entirely conceivable, if vaccine supply were up to it (not yet).

Or, we can optimize for lower cost. With our original full teams in the early weeks, we overstaffed and calculated a per-vaccine operating cost in the mid $20’s. Of course, the vaccine itself, is free to us and patients, paid for by the feds. But, tents, staff, project managers, coordinators with police, state, county and city government, vaccinators, training team, pharmacy team, coolers and vaccine supply chain management, traffic tents, snow removal, medical observation team, volunteer-coordinating managers, paramedics, command center coordinators, walkie-talkies, workstations on wheels, smartphone devices, wifi repeaters, cellular repeaters, scheduling of appointments, design of vaccine clinics… pretty soon it is a big operation. After a couple days, and constant re-design, we were able to trim operations down into the $17 range.

6: Optimize Health System Vaccination plan

First Covid Mass Vaccine design, last month, at Coors Field, Denver

Vaccinating patients on-site at University of Colorado Hospital, Bruce Schroeffel Auditorium

Outdoor vaccine guy vs Indoor vaccine guy

AND THEN. We compare our Mass Vaccine efforts to our ongoing (but less splashy) vaccine clinics in 10 facilities across UCHealth, spread across the entire state of Colorado, at even lower per-vaccine cost, with the capability of 5,000 to 10,000 per day. We are hiring permanent staff to run these vaccine clinics and stop borrowing from clinical teams across our system, as we think we will be doing this for quite some time.

Volunteers?

It is gratifying that we have lots of folks (many retired) willing to volunteer their time. The challenge with accepting this help is: it can be more expensive to run a scheduling calendar and training for hundreds (?thousands) of part-time (or one-time) volunteers than it is to have a reliable, skilled steady crew to take care of business. For the rare volunteer who COULD come regularly (for 8 or 10 hour shifts!) (for months!), that would be a blessing. And, as this vaccine saga goes on, we may indeed need more help.

Pop-up Outreach Clinics for the medically Under-served

Another effort I’m grateful for, are our Pop-Up vaccine clinics. We are taking our show on the road to multiple community centers and churches in medically under-served neighborhoods, where leaders are helping us schedule thousands of vaccination appointments among their neighbors. I’m heading to several in the coming weeks. (stand by for more posts from the front lines!)

UCHealth has given 270,000 vaccines, about 20% of Colorado’s total to date.

Yup, you read that right.

From this graph, you see our green Mass Vaccination events occurring on 2 weekends. Dark blue is University Hospital with over 13,000 vaccines given per week, and our other regions similarly. Light blue is South region, Purple is North region. Red includes our small hospital and outreach clinics at about 10,000 a week. Again, limited by supply.

7: Optimize National Vaccination

A rising tide lifts all boats.

For those interested, UCHealth has published a playbook for other organizations: https://www.uchealth.org/covid-19-mass-vaccination-planning/ with lots more details.

And Finally: a SNAFU Tent Vaccine Dance?

Is this real? Apparently, yes. Dr. Jonathan Pell and our elite crew of SNAFU tent staffers put together a dance invitation for upcoming cars.

I was surprised to find out how many younger colleagues had never heard of the term SNAFU.

The good news? Our process worked so well, the SNAFU team did not have much to do, a few cars here and there during the day. So much time, in fact, that they came up with their own DANCE.

I have no words.

CMIO’s take? How to get better in Seven Different Ways. Let’s go!

“Please do your best today”. Not a dry eye in the house.

We need to focus on bringing humanism back into healthcare, to combat the temptation of the e-patient (EHR computer chart and electronic or telehealth communication) numbing us to the suffering of real patients out there. This is a terrific read.

Kevin Kelly: 68 bits of advice (Technecium)

From amazon.com and Kevin Kelly

https://kk.org/thetechnium/68-bits-of-unsolicited-advice/

Kevin Kelly: co-author of the defunct but world-changing Whole World Catalog, publisher of Cool Tools, author of What Technology Wants, and generally smart guy, is 68 (or was when he posted this). Brilliant observations. This is me Plus-one-ing his post. Some teasers:

  • Learn how to learn from those you disagree with, or even offend you. See if you can find the truth in what they believe.
  • Being enthusiastic is worth 25 IQ points.
  • Always demand a deadline. A deadline weeds out the extraneous and the ordinary. It prevents you from trying to make it perfect, so you have to make it different. Different is better.

CMIO’s take? Happy new year. Go read it, link above.

News: (WIRED) 30 lines of code blew up a generator

from wired.com

https://www.wired.com/story/how-30-lines-of-code-blew-up-27-ton-generator/

In what is an insider’s view of what our cyber warfare unit, and the cyber-criminals out there are working on, a view of the inner workings. I believe this may have been part of that the STUXNET attack on Iran’s nuclear facilities (and centrifuges) reported in 2010 (WIRED.com article).

CMIO’s take? The real world and the cyber-world are colliding in more intricate ways.

Oumuamua: the edge of reason?

from The New Yorker article

https://www.newyorker.com/magazine/2021/01/25/have-we-already-been-visited-by-aliens

A nicely written discussion by Elizabeth Kolbert at the New Yorker. In it she discusses the details of recent findings of the Oumuamua object that blasted through our solar system at 4x the speed of usual asteroids, did not move as expected, and must have been “an interstellar object”. Some are calling it an alien artifact, others are pooh-pooh’ing such a description as “unscientific.”

Farhad Manjoo at the NYTimes also comments. Fermi’s paradox talks about how to calculate the very large number of planets out there and the unknown fraction of those that might support life.

 In 1992, NASA spent $12 million on a project to listen for radio signals from other planets; the next year, Congress cut the funding, with one senator joking that “we have yet to bag a single little green fellow.”

In years since, scientific funding in this area has been paltry.

Here is the Fermi Paradox equation about the likelihood of extraterrestrials: https://www.space.com/25325-fermi-paradox.html

Why not consider alien life? Is it so ridiculous? As a scientific community, we pride ourselves on being open-minded, but our history sometimes indicates otherwise.

Is this is the edge of reason? Does our group-think ridicule those on the edge?

Some of what we do in healthcare is also at the edge of reason (see: Open Notes, APSO Notes). It is often ridiculed. Until it is not.

CMIO’s take? Perpend.