[Music]
Welcome to our virtual space
where thought leaders who, in a variety
of ways, have committed themselves to
improving our lives
share their work perspectives on current
affairs
and what brought them to where they are
today.
My name is Rob Lue and this is the
Xchange.
[Music]
So Bindu, thank you so much for joining
us in the Xchange.
For us, it's a real opportunity to hear
from someone
on the front lines that have been
working in a hospital setting,
at the Hackensack University Medical
Center, with
patients that have been affected by
COVID-19.
So one thing I'd love to sort of help
our audience understand
there is what happened with COVID, but
placing that aside for now,
what is it that you do as a physician?
What is your focus?
First and foremost, thank you for having
me.
It's been tough times, it has been
strange
times these last few months. And
as a background I am an infectious
disease physician.
I, um, I finished my
my studies, I did my fellowship at Robert
Wood Johnson in New Jersey, New Brunswick.
ID has been fascinating and
though the journey towards infectious
disease basically came along
in my second year of internal medicine
residency,
with my mentor being Dr. Fisher, who was
one of the ID physicians at our hospital,
just the the variety
of infections that we saw, um, at that
time during my training.
HIV was still very prevalent, it still is,
but it was that time where
the new proteus inhibitors were coming
out and we saw a lot of HIV patients
with very
varied diseases and I think what kind of
just stuck
with us was probably related to
the infections that we saw in my HIV
patients from Central America, for
example, was
very different than what we saw from the
patients who were coming in from US.
So just the various different infections
from different parts of the world
is probably what enticed me into
this particular field at that time
because I thought the whole concept of
history taking
was to the extreme, like, you really had
to know what the baselines were, where
they were coming from,
what their, what their, you know,
occupational history, histories, etc,
that made that epidemiological link to
get into where that particular diagnosis
was
from that particular patient. So that
kind of interested me into infectious
disease at that particular time in
internal medicine,
and then I followed it with my
fellowship and then once, I've been here
at Hackensack now for 20 years.
This particular event in March
was something that we had not
prepared for, not studied for, not
thought that we would actually see it
during a lifetime,
so it was it was something really
interesting.
I have to say that's a, that's a very
small word for what
we actually went through. No, of course. So,
um, Bindu, am I correct that you treated
the first confirmed COVID-19 case in New
Jersey?
That is correct. Wow. So, so can you tell
us,
I mean, what that was when you
encountered this patient,
um, what was that like? Was it
so puzzling, did you have a clue of what
this could be
already, or was it a complete mystery at
the time,
you know, what was that encounter like
as the attending physician? So
going back to early March
we were called for a consult for a
patient who had pneumonia.
Not every time does ID get called for
just a simple pneumonia patient, right,
so it was something, obviously, that
triggered the emergency room physician
to have a suspicion of some abnormality
that could be present. When we saw
our gentleman, you know, he had the fevers,
he had the shortness of breath, he had
the brea- breathing very fast, having the
cough,
having muscle aches and fevers, very
flu-like symptoms
that were present for about a couple
days. But he didn't have any travel
history, he didn't, he was not traveling
to China, he was not coming back from
China,
though he did mention he had been at a
big medical conference
and he himself is a healthcare provider
in Chinatown with exposure to patients
in Chinatown.
But again, that particular day
we had him on precautions for
possibility of
the disease, but never did we think that
he was going to have it positive. His, his
CAT scan was slightly bit abnormal, he
definitely had a pneumonic patch, a little
bit of whiteness,
um, that we noticed on his CAT scan, but
again, treated him for a regular
pneumonia.
But something obviously triggered our
staff
at our hospital in the emergency room
department itself as soon as he came in
to have him tested for COVID.
At that particular time there was really
no treatment offered at that point, given
the fact that we didn't have a diagnosis,
but just the overall
presentation of having a young healthy
adult
with a significant symptoms
of respiratory illness and yet not a
significant
x-ray finding, not a massive pneumonia,
just a small speck
of ground, ground-glass changes in the
pneumonia,
was a little unusual. We placed them on
routine antibiotics
thinking it would be a routine bacterial
pneumonia. While waiting for these
particular,
for these particular tests to come back,
when the test did come through
a couple days later, it was. um,
it was frightening, I have to admit it
was frightening, the upfront,
not knowing to how to manage a
particular patient
with this kind of illness. Never
experienced it, never
had any patients who had been here
before.
Even though we had read so much and we
had heard so much of the news,
never did we think that a virus is going
to come from China to New Jersey,
um, to our hospital, to my patient,
so just digging down to that particular
concept
that this could be happening right here,
right now, was
a little scary. He definitely
over the next few days had increasing,
worsening shortness of breath and cough
and fevers that persisted
that led to us reaching out
to the experts in the field at CDC. So Dr.
Tim Uyeki basically helped me out with my
decision plan, um, knowing that it's a
brand new disease
I didn't want to take a chance, I don't
want to jeopardize the health of my
patients,
so obviously getting access to
the gurus was the way to go.
The other thing I have to admit, and I
humbly admit,
obviously the patient taught me a lot, um,
the patient's access
to, to the world wide web actually helped
us a lot.
His, his associations with
his family members and friends way back
in China,
who were actually dealing with this
situation,
gave us input and insight,
having, they, you know, have, they having
experienced so many patients up front
already
obviously gave us a way to help us
help this particular gentleman in our
hands. As a few days progressed his
fevers and his cough
still progressed, his breathing got,
definitely got worse,
his CAT scans got worse, unfortunately,
but simultaneously, as soon as we had the
diagnosis
of the disease process, we simultaneously
based upon the data that we had, applied
for
availability of medications to Gilead to
try and help get Remdesivir for
him.
We had already started the process, and
his family also started the process
simultaneously,
by, um, trying the other social media and
all help that they could get
to try and get access to
the antiviral agent, which at that
particular time, was still all,
all in experimental, investigational
product,
it still is an investigation product,
even though it's, you know, received
the emergency use application, it's still
a drug that has been
approved in an emergency basis knowing
the positive outcome that we have.
So having applied to Gilead again, it's a
brand new process
for us, for me, and for my pharmacy staff
who helped us out getting through this
particular process.
We applied for his
medication through the Gilead,
it came through, he got the medicines,
he did very well subsequent to receiving
the antiviral
therapies and I'm glad to say he is
doing
a lot better at home. So,
so yeah, he had a really good outcome
during this whole process, so
it was, it was, it was a very,
I guess, indelible experience in my mind.
Nothing that can obviously, you know, take
away from that first patient,
but, um, thanks to him and thanks to
learning through the process I
definitely was
able to help my team members
subsequently
in this process which was tough the next
few months.
Yeah, so we, you know, with New Jersey
ultimately having
more than 300,000 cases, did you
then at the medical center see this
gradual
tsunami of cases? Oh yeah.
Oh yes. Um, gradual, I don't know.
Those six to nine weeks,
up until middle of May, so nearly three
months,
uh, two weeks was an intense
change that we saw throughout
the hospital fields, like in the first,
maybe the first
two weeks where we still had regular
patients coming in,
that patient, suddenly the whole concept
of any patient walking in could now have
COVID.
Any side effect that we saw
change in the respiratory status, no
longer were we thinking of routine
pneumonias as first line, it was COVID.
To prove another way,
anybody walking in had to be on
precautions
till we knew for sure that they didn't
have any particular problems.
Those first few weeks of
just the unknown, I have to say
was scary, but
it was the the collaboration
between all the modalities that we had,
between both clinical and non-clinical
administration, ID,
pathology lab, um, housekeeping,
janitorial services, you know, biomedical
engineering,
everybody had to have,
had a say in what needed to be done
to make the hospital and our center
adapt to that particular infection that
we had
over these next few months. So did your
center
experience some of the shortages of the
personal protective equipment, the PPE,
that, that other hospitals had? So
luckily, we didn't. Not to say that I
don't think we had it, I think we
definitely,
if, if you were to ask the same question
to a supply chain person I'm sure
they're going to say,
you don't know what we went through to
get the medical, to get the supplies for
you guys,
but yes, were there periods where
there was nothing available? No. Were
there periods that
it was rationed that we had to reuse
our supply?
Yes. So again, I think
also having the the administrative and
the, um, the biomaintenance, etc, people
tell us on a day-to-day basis as to what
we had and what we didn't have
and how to adapt to that on a day-to-day
basis, sometimes even hour-to-hour basis,
was important. Testing strategies and
testing availability shortage,
yes, but PPE I have to say we had it.
We were, we were given the supplies that
we needed.
How did the, how did the hospital acquire
the supplies
and did they have to scramble for it? I'm
sure they did.
Yeah, yeah, no, I'm sure. So um, what, so
you know a lot has been made of just the
enormous stress
that this placed on physicians, on nurses,
on all the health caregivers,
and so I mean, can you speak a little bit
to what that was like? Because the way
it's been described,
it's almost like a combat sort of
situation.
It was. It was total war zone for us.
Um, so let's talk about physicians first.
From physicians' perspective, it was
the, the number of staff that were coming
in, the number of, er, the number of people
who were coming in
to the hospital had
skyrocketed so fast, that walking into
the hospital, the emergency room,
physicians, the first responders that
they were there,
there were lots of patients, lots of
physicians who got
sick on initial
during this whole 12-week course of
illness that we had.
So again, the staffing at that particular
emergency room
was affected. People had to be deployed
within the emergency room
to different areas. We had a huge triage
tent that was put out specifically for
COVID,
because obviously the the prep that we
had to do, the PPE that we had to do,
had to be well utilized in the same spot.
So there was this on-site unit, which is a
mobile unit,
that we had, that the physicians were
constantly
in the PPE for the full eight hours, uh,
the nurses were full PPE in eight hours,
so that
those patients had to be in one
particular area to
be able to be visualized, taken care of
simultaneously.
Going in and out again causes a lot of
PPE loss,
as well as the number of exposure to
nurses as well as
the physicians to come into play, so
again, monitoring the number of people
coming in
on the staff, on the shift had to be very
rigorously taken, because the number of
doctors and nurses available at any
given time point was very few.
Based upon the number of patients coming
in, the workload
with the patients coming in was
extremely high.
The ICU shortage, the ICU requirements
was extremely high itself. People were
coming into the emergency room and we
were intubating them.
It seemed to us everybody coming in was
getting intubated.
It was a very high flux of patients in a
very
severe respiratory illness that require
intubation which,
which meant one-to-one patient and nurse
ratio, which meant a very close
possibilities of the nurses' and, uh,
physicians' associations with them, it
also meant
going into an ICU unit, so our IC
unit suddenly became, from a simple
20 bed ICU for medical ICU
and CCO ICU, to 116, I think, or 117 patients
on ICU at one day. So the number of
beds and the number of units which
required ICU care
was very high, which meant we needed to
have ICU doctors, which we didn't have
ICU doctors. So many,
so many of the internal medicine doctors
were deployed
to work as ICU physicians. Many of the
surgical ICU doctors were pulled in
to manage medical ICU patients, many of
plastic surgeons,
many of the pediatric doctors, pediatric
ICU doctors
were pulled in and deployed as adult ICU
doctors,
so there was a lot of redeployment of
physicians from different fields
to come and manage COVID. We also had,
I think, one very important piece of
information that,
one piece of physician, um, recruitment
that we did was
there were physicians who were
volunteering their time to us,
either they had retired or they were not
seeing patients because the patients
were closed and they wanted to give
a time to us, we actually just had
physicians communication doctor. There
was one special
physician communication doctor who was on
the floor all the time,
whose main job was just to call the
family,
update the family constantly, so they
would hear from the treating physicians,
get the data, deploy them out, and then,
you know, have the physicians
speak to the family on a regular basis.
So all these physicians were deployed.
These were voluntary physicians, some of
them had retired physicians,
but they came in to help us with it so
we
had a lot of
new physicians on board and everybody
became, with regardless of their
specialty, everybody became an infectious
disease doctor.
Everybody became a COVID doctor during
those times. Same thing with the
residents also,
you know, there were lots of residents
who had to take time off and get
furloughed because
of illnesses, but then they came back in
and
put in their 100, 150,
during that time frame. Yes. And that was
the nurses.
Yeah. And then the nurses. We had a lot of
travel nurses from all over, from Utah,
from Arizona, from Florida,
who came in to help because there was
just a very big need
of nursing care that was required. So of
course all of this is,
all of this is so fresh, right, and while,
um,
New Jersey has certainly improved in
terms of its, its,
its, um, situation, as we all know there are
fears about another spike,
etc, what may possibly happen.
Um, it's maybe a little bit early to ask
this kind of question,
but Bindu, in the system, and maybe
focusing on the medical center
that you're at specifically,
is there one thing in particular that
you or the centers learned about what
happened
that you feel now has you better
prepared
for this? Is there a new
protocol, a new way of thinking about
mobilizing stuff, a new way of thinking
about
even mobilizing PPE and how you get PPE?
Have there been changes in the supply
chain,
both human and otherwise, so that you're
more
able to respond to something like this?
So I think
yes, absolutely yes,
from the physician's point of view, from
the physicians' deployment point of view,
this particular protocol that we use
during this time frame has now
been pretty much written up that in case
if a surge occurs we already know
what to emp- what, which doctors or which
physicians, to
re-employ, redeploy, and how do we do that.
Our physician prevention
and PPE guidelines that have come up has
definitely
also been put into notes now because
obviously this whole COVID situation
that came along
made us make sure
that we had something in writing for the
next time round which was protocolized,
so that we didn't have to strive again
to the same
way that we had to do at this point. Our
learning of wearing, you know, the wearing
the masks, which wasn't the case earlier
on,
has become a guideline at this
particular time. We at the center
are wearing, regardless of whom we are
seeing and whom we are
examining, everybody who is in patient
contact
has to wear shields, have to wear eye
shields, has to wear
masks, etc, for prevention. Policies for
prevention of both the healthcare
workers
and more importantly prevention of
transmission
of diseases amongst, in the healthcare
facility,
amongst the patients, providers,
and health staff itself. Regarding the
PPE management, I think, um,
definitely the supply chain is very well
aware
as to what is to be expected and what is
to be anticipated
to be able to
hopefully have enough
to maintain X amount of months in
advance.
So I think they all have learned the
lesson of knowing
exactly, you know, what is required. And
also what we learned was how much
amount was used to be able to predict
the next time around, like this time was
literally
arbitrary, you know, how many did we use
last week,
how many patients are we expecting next
week, and then kind of come up with a
rough calculation as to what we're going
to be needing.
But now having gone through this
particular peak, if God forbid this peak
occurs again,
we know exactly what inventory we're
looking into to be able to, um,
think about and plan accordingly as to
what's going to be needed
down the road. So yes, all those are put
into writing
in, you know, in the protocol that we have
to be able to adapt for
next time. So, um,
you've really shared with us insight
into,
sort of, the emergence if you will of
COVID-19,
um, in New Jersey specifically,
um, but I'm sure our audience is probably
a little bit curious about you
as well. So going back in time to when
you were a child, etc,
were you always interested in things
medical?
Was, was becoming a doctor a very
long-standing goal of yours, Bindu?
Is that a, uh, a path you've been on for
some time?
So I have to say yes, but I have to go
back again a little bit more. So if you
say, as a child,
I would say in India
you are either a physician or you are an
engineer. So that's the two most common,
two common options that are kind of put
to you. So if you are going into a
science field, you're going to be either
an engineer or you're going to be a
physician.
So in our home it was going to be, oh, my
kids are going to be physicians. That was
my parents' field.
But um, but having said that, I definitely
wanted to be a physician.
Starting when I was in my sixth grade,
I met with an accident, I had, had, um,
I had a six-month stay in the hospital
so I had a very close association with
the hospital at that particular time.
And then my orthopedic doctor at that
particular time kind of made me feel,
who got me back on my feet, was my mentor.
My first
step, I think, of why I like medicine,
and I always wanted to be, I'm going to
be an orthopedic physician when I grow
up,
and that was, that's about the way I kind
of went through my whole schooling,
my undergraduate years, and then even in
my medical school.
So in, in India, we, and I did my medical
school in India,
so in India we have to,
when we're doing our final years and
we're doing our studies and our subjects
in the final years,
we really have to rank really high up on
that particular
field that you're interested in for your
postgraduate studies.
So surgery was my, I'm going to be an
orthopedic surgeon, was what I'd always
thought about.
So surgery was my
favorite subject, orthopedic subject,
orthopedic surgery was my favorite
subject.
And we went through that route but,
but during my clerkship, when I had to
actually rotate,
through, uh, the orthopedic rounds,
seeing the stamina, seeing the
seeing the time and the hours that the
the doctor, orthopedic
doctor had to physically address,
taking care in the operations, I kind of
said, okay, maybe I should look at
something else.
Also, so and then then came along that,
okay, we're going to be coming to US,
because my
dad had transferred over, had retired
from his army
position, and he'd come to US and we
were all going to be joining him here.
So my sister, who's also in the physician
field,
she started, she was two years ahead of
me, so she
joined in, into a family practice
residency program when she came here to
US.
And thinking about my options
I said either family practice or
internal medicine would be
probably more likely for a foreign
medical graduate
than a surgical field, because at that
particular time,
surgery for a foreign graduate was,
was a little difficult. And then also
during that time I'd also done my
clerkship
in surgery, and I kind of thought, okay,
maybe I want to get something
non-surgical from that perspective also.
So when I came here, I applied,
after my USMLEs I applied for
internal medicine residency,
and then the first thing that the doctor
asked me is, okay, why do you want to join
this particular residency?
And I said, uh, I don't know how to drive
and this is the closest residency I can
find.
My, it was, it was not
all true, but was quite a bit true, too.
The,
the place that I joined was literally
five minutes away from home.
Um. So I was dropped to the residency in
the morning with my parents and they
would come pick me up in the night
till I could learn how to drive, but that
also happened,
but so yeah, I did my internal residency
here,
and then in the second year, as I
mentioned before,
my ID mentor, who
I think was, who is a
fantastic physician, a, a really great
diagnostician, was
very much into medical history taking.
I think I learned a lot from him and
amongst my other mentors,
the history taking part that came
through with this
disease, this particular field of medicine
I think is what
kind of got me into infectious disease,
just the way to kind of
do the detective work in finding out why
the fever was occurring, where the fever is
coming from,
and the very quick gratification that
you get on getting the diagnosis,
getting, addressing the problems, and, and
taking care of it and having a good
outcome
really got me into infectious disease in
my internal medicine round.
And then here I am.
Fantastic, yeah. So, so this is a question
I often ask. Either, well, I'm not sure,
um, that I have a feeling I know what
your answer will be.
Um, you know, quite often as we look back
over,
over our lives, we come to crossroads,
where we turn left or turn right,
and sometimes you can come to a
crossroads and let's say you turned
right,
but if you had instead turned left, in a
parallel universe, an alternate universe,
you could have become a completely
different person
and done something completely different.
So I'm wondering, is there, if there are
alternative,
um, universes, is there a universe where
if Bindu had turned left instead of
right,
you'd be doing something totally
different?
Is that possible? I don't think so.
I really don't think so. I loved medicine.
Your pathway to medicine was clear. Uh, it
was so clear to me and even today,
even after, oh my God, I have to do all
these paperwork, I have to do this,
the EMR, and everything has to be
electronically done,
at the end of the day, you know, I am just
super satisfied with what I do.
So will I ever do anything different? I
don't think so.
Even in the parallel world, I'm sure I would
have found my path this way too.
I really knew that this is what I wanted.
Fantastic. That's great.
Um, so well, so here's another question,
then. When you're not being a physician
what do you do? Ah, that's a different
subject.
Um, so I like to paint,
I like to draw, I like to sketch.
I do that. I've not had so much time into
it, but yes that's something that i do
like to do.
Arts and crafts has been something fun
for me always, so when my kids are
out drawing or whatever, I said oh, I'm
going to try that too, and then I usually
sit down with them and do something else,
whatever they're doing.
Oh, that's great. That's one thing that
I've definitely loved.
The other thing is I'm trying my hand at
gardening.
Uh, not many things are coming out of
that particular garden,
and it's been a very expensive tomato
garden and very expensive organic garden
that I'm trying to make,
but it's fun, it is really fun to,
um, to do that part so that's something,
that's a new love that I've
started this past couple years.
And I like to
dance, if what I dance is called dance,
but yeah, I like to listen to music and
move around, so that's something, that's
fun to do.
I do enjoy that and I love to watch
Hindi Bollywood movies.
That sounds great. So by the way I kind
of love the,
the fact that as a physician, of course,
there's a lot of making with your hands,
etc, that happens,
and of course the element of pastoral
care,
it transfers into gardening, I think very
well. Right. So yeah.
Yes, that's true, that's true. Fantastic.
Well, Bindu, thank you so much for
spending this time with us. I think that
you have given us,
sort of, a wonderful on the ground
insight into what happened
when this first case of COVID-19 appeared
in,
appeared in New Jersey, and of course,
we're all at this moment
holding our breath that we don't have
another
really terrible surge, though I think
across the Sunbelt,
it's looking poor
right now. Um, the question is
the degree to which that will percolate
into the northeast, right, and will we
start to see
numbers again. Um, yes. We are all worried
about it, we are all
actively looking forward for it, but I
think,
I think we have a good handle on
what we're looking at. We are hoping with
the new vaccine studies that's going to
be starting soon,
um, with the newer agents, the newer
clinical trials that are currently
present, we hope
not to have that much of,
uh, a surge again and definitely,
hopefully, if we can get people to get
vaccinated,
you know vaccine trials is one thing but
getting them vaccinations is another thing,
so how, if we can get people in the
clinical trials
to get them vaccinated, we hope, um, that
we would have this particular surge
attenuated,
and not as, um, and not have this
second war zone again.
Absolutely. So Bindu, thank you so much
for joining us
on the Xchange. It's really been a
pleasure. Thank you very much for having
me.
Thank you.
[Music]
