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COVID-19 II: Henry Fraimow
49 Plays8 months ago
Dr. Henry Fraimow is an infectious disease physician at Cooper University Hospital in Camden, NJ. Listen to Henry discuss common patient questions about COVID-19, the early months of the pandemic and the challenges of conducting research during the peak of COVID-19.
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Transcript
Introduction to 'The Wound Dresser'
00:00:09
Speaker
You're listening to The Wound Dresser, a podcast that uncovers the human side of healthcare. I'm your host, John Neery.
Introduction of Dr. Henry Framow
00:00:21
Speaker
My guest today is Dr. Henry Framow. Since 2001, Dr. Framow has worked as an infectious disease physician at Cooper University Hospital in Camden, New Jersey. He is also a member of the Emergency Management Committee and chair of the High Consequence Infectious Diseases Committee at Cooper. In 2020, Dr. Framow was a key voice on Cooper's infectious disease team that helped guide the Greater Philadelphia region through the COVID-19 pandemic. Dr. Henry Framow,
00:00:49
Speaker
Welcome to the wound dresser. Oh, my pleasure to be here.
00:00:54
Speaker
So I wanted to start by just asking you about some sentiments that you might experience in the clinic or with your family or friends, just some common concerns.
COVID-19 Vaccine Safety and Efficacy
00:01:04
Speaker
And I'm curious to hear how you would respond to some of these things. So for instance, if a patient comes in saying, I don't want anybody requiring me to get the COVID vaccine when the long-term effects haven't been studied, how do you kind of respond to that?
00:01:21
Speaker
Well, I think it was a little harder to respond to that when the vaccine was brand new, when it rolled out in December of 2020.
00:01:34
Speaker
when those of us who couldn't wait to get our first dose of vaccine were thrilled to get it. But you could recognize that at that point the trials were done in 30,000, 60,000 people. And so people had legitimate questions. Now here we are years later. And I think that those concerns really
00:01:58
Speaker
should no longer be relevant. We've had tons of experience. We've had literally billions of doses of vaccine administered throughout the world. And I think the safety concerns are not an issue at this point.
00:02:15
Speaker
Another sentiment I hear from people is, why do I need the vaccine?
Need for Vaccination Despite Antibodies
00:02:20
Speaker
I've just recently had my antibodies checked and they are of a sufficient level. Because measuring quantitative antibodies doesn't tell you about qualitative antibodies. And we know this virus has changed.
00:02:36
Speaker
We know that there's continuing evolution of the strains of COVID that we're dealing with. And probably the most effective immunity is really a combination of natural immunity and vaccine-associated immunity.
00:02:54
Speaker
broaden and get more diverse epitopes that way. And the problem is just because you have high levels of antibody, if those antibodies are to an earlier COVID strain that the initial version of the vaccine was highly effective against, those antibodies may not be all that useful to some of the variants that have now taken over and become dominant in what we're dealing with. It's a very different virus than it was
00:03:24
Speaker
in the spring of 2020.
Origin of COVID-19: Natural vs. Manmade
00:03:28
Speaker
Another common sentiment you hear is the virus was manmade. How do you kind of respond to those inquiries? I think we do not have any compelling evidence that says that this virus was manmade.
00:03:46
Speaker
Is it possible that this virus was in a lab and escaped from a lab? I think that that is certainly not completely out of the realm of possibility, but I don't think there is any evidence whatsoever to suggest that this vaccine was
00:04:05
Speaker
human constructed. We know that strains of these types of coronaviruses are widespread in certainly in bats who are the primary reservoir of most of the coronaviruses that we've seen as well as in other animal reservoirs.
00:04:29
Speaker
We know that animals in markets in China had strains of virus that are very similar or identical to the strains that first appeared in humans. So I think that it's pure speculation without any evidence to suggest that this was constructed by people in a laboratory.
Challenges in COVID-19 Death Attribution
00:04:57
Speaker
And lastly, hospital reporting of COVID deaths was not accurate considering preexisting health problems. I think that COVID deaths, counting deaths is always tricky, right? Did people die of COVID or with COVID? I think in the very beginning, I think it was much clearer that people died of COVID rather than with COVID.
00:05:27
Speaker
As we've learned more about the virus and learned that you can be relatively asymptomatic and have other comorbid conditions, it is harder to say what is attributable mortality specifically related to COVID.
00:05:46
Speaker
Um, but I think that it was pretty clear in the beginning that preexisting conditions made you more likely to die if you were infected with COVID. Um, and therefore COVID was really the cause of death. And I guess to follow up on that, there was kind of like a perception that there might be some sort of incentives for hospitals to over-report. Did you see any evidence of that? Not at all. Not at all. Okay.
00:06:13
Speaker
There were really no incentives for people to over-report COVID deaths.
00:06:23
Speaker
When you're reporting any kind of mortality, it is always hard to say, well, what's due to and what's associated with. But I think when something new comes along and you have excess mortality that was not seen before, and the only thing that's different is that these people had COVID, then COVID caused their deaths.
00:06:49
Speaker
Alright, so yeah, I wanted to just begin by asking some of those things. I feel like those are probably questions you've encountered 100 times, but it's it's nice just to hear it from the perspective of somebody who is like really knowledgeable, COVID and infectious disease in general. But take me back to the beginning, like.
Early Realization of COVID's Impact
00:07:09
Speaker
When were you like, oh crap, this is this is going to be big. This is going to be a big problem. I have to say that.
00:07:19
Speaker
early, very early January as soon as these reports started to come out of China.
00:07:26
Speaker
That was an oh no moment for me. Part of that is because some of what I do is that I have only for the last several years, I've been part of the emergency preparedness group at Cooper. And I run the group that looks at high consequence infectious diseases.
00:07:49
Speaker
And part of what we do is kind of scan the landscape and say, ooh, this could be a problem. Or that might be a problem, but probably less so. But it was clear that the disease was probably being underreported. And it was also clear, based on what we know from before, that there is no way to contain this type of respiratory virus.
00:08:18
Speaker
There was no way to have it in one place in the world. And with the way that people travel, that no matter what kind of screening measures you put in place, the virus is going to get out. And so by, I'd say mid-January, we knew that this was going to be bad, although I don't think we realized quite how bad it was going to be.
00:08:47
Speaker
So was the coronavirus like family of viruses in general, was that something you had studied like a lot before? Or was that like relatively like a new clinical phenomenon for you?
Lessons from Past Coronavirus Studies
00:09:00
Speaker
So there have been I mean, coronaviruses are respiratory viruses, there are many different types, and there had been minor
00:09:09
Speaker
Not minor, but there have been occasional causes of community-acquired pneumonia in the United States for as long as people have been looking for viruses. However, we knew from the first big wave of highly pathogenic coronaviruses was the SARS outbreak.
00:09:34
Speaker
Um, back in the, uh, back about 20 years ago and that started in China. Uh, and the only difference between that outbreak and this outbreak is that
00:09:52
Speaker
That virus, if you got the virus, there were no asymptomatic carriers and spreaders. If you got it, you got sick. So it was easier to contain than a virus where there are many people who can carry it asymptomatically and transmit it.
00:10:11
Speaker
But that was a bad outbreak. It spread from China to a number of other countries, including a couple of cases in the US, a lot of cases in Canada, very high mortality, no treatments that were really available for it. But because of the ability to contain it much more effectively, it didn't become the bigger problem that COVID-19 became.
00:10:41
Speaker
but we knew that was a bad virus. And we knew that outbreak had the potential to be even worse than it was. And so the pathogenic potential of coronaviruses has been sort of studied extensively since that time. And people have been looking at coronaviruses and the major reservoir for a lot of these more virulent ones, which are often bats who are
00:11:11
Speaker
bats are very, very, because of their body temperature and the way that they live, they seem to have a high tolerance for viruses. And if you go into bat caves, and that's what people were doing in China even well before this outbreak came out, and they were extracting coronaviruses from horseshoe bats,
00:11:36
Speaker
And they were finding strains that may not be identical to the strain that we see now, but strains that carry many of those building blocks that the current COVID-19 outbreak strain has.
00:11:52
Speaker
You mentioned some of the differences between the SARS outbreak in the early 2000s versus the COVID-19 virus and how a lot of the differences was based around the asymptomatic spreaders.
Initial Treatment Approaches and Research
00:12:06
Speaker
So was any of that research at all helpful? I feel like at some point people were trying to look back to research and things that were going on, but was a lot of that helpful in combating this new virus in 2019?
00:12:20
Speaker
Well, it gave us a couple of clues as to some of the early treatments, although some of the things that actually, so when COVID-19 emerged, I mean, all of a sudden we were seeing some people who were getting mildly ill, but some people who were getting severely ill and dying of an illness that we had no specific therapies for.
00:12:47
Speaker
So the first place you look is, well, what did we try? What might have been effective against the SARS virus? And so the first things you take off the shelf are the things that either in small clinical trials or in the lab may have been effective. Turns out most of those things were useless, but those were the first things that you go to.
00:13:13
Speaker
But I think there was, uh, those were like some of the drugs like early on that people were really pushing, but didn't prove to yield any evidence that they were effective. Is that right? Right. So I remember the first patients that we saw in March of 2020.
00:13:33
Speaker
And, you know, people were throwing, there was studies that had looked at some of the HIV antiretroviral regimens like ritonavir or calitra as treatments for the original SARS virus. People were using hydroxychloroquine as a treatment.
00:13:56
Speaker
There were others that kind of rolled out later on and all of these things ultimately were shown by sort of more exhaustive research and real clinical studies to show that they conferred no benefit to treating COVID-19.
mRNA Vaccine Development
00:14:17
Speaker
And then so from there, I'm kind of curious to hear about, you know, the vaccine kind of came about very quickly, like what percentage of the way was that technology there when we were right at the beginning of the COVID-19 pandemic?
00:14:31
Speaker
So the mRNA vaccine technology had been around for a couple of years and had, there had been other mRNA viruses that had been vaccines, I'm sorry, that had been developed that had done so, so in clinical trials, but the technology for developing mRNA vaccines had been widely studied prior to this.
00:14:59
Speaker
And in some ways, it is an ideal strategy for rapid development of vaccines. If you look at it, it's completely different than the way we've traditionally done things like making flu vaccine, where you grow it up in large vats or in animals or in chicken eggs. Whereas this, you can start in the laboratory with a DNA sequence or a RNA sequence.
00:15:29
Speaker
and use that alone to start to make what you're looking for. I think how successful the vaccine was, I think it was as successful or more successful than people had anticipated. But the real advantage of the technology is the ability
00:15:50
Speaker
It is a very flexible technology that lets you rev up and get vaccine material very quickly. I want to shift gears and talk a little bit about just your experiences in the hospital when COVID-19 started really becoming a problem.
Hospital Response and Resource Management
00:16:11
Speaker
Was it like all of a sudden the ID team became like the superstars of the hospital? Were you really look to kind of find solutions and kind of find a way forward for your hospital system? We were a big part of the response, but the reality is that the burden of care of these patients fell on
00:16:38
Speaker
the critical care departments for people who were critically ill. I mean, when this exploded in March, April of 2020, when that first wave hit,
00:16:49
Speaker
You had a large number of people who were critically ill that you were trying to support and keep alive, that you had really no effective strategies or no proven strategies other than supportive care to try and keep them alive and get them through this.
00:17:09
Speaker
And that burden fell on our ICUs. In fact, one of the problems was that all of our ICU beds were quickly exhausted. We were converting other units in the hospital to the equivalent of ICUs to try and care for these patients.
00:17:29
Speaker
The resources to staff these units was challenging. We didn't have enough ventilators. We didn't have enough personal protective equipment. And so there were many, many challenges. And unlike other infectious diseases where our expertise is how to treat,
00:17:52
Speaker
It was really being part of the system of trying to figure out how to manage and how to deal with this. And yes, we were looked to for our expertise, but we didn't have any answers any more than anyone else, but at least we were able to help organize the questions and help people think systematically through how to approach these things.
00:18:20
Speaker
Was it really hard to come up with a system of triaging? You have people who have COVID, who have severe COVID, and then you also have people of other conditions that still need care. So was it kind of hard to create that system of triage that could give the best care to everybody? Yes. I mean, and that's the problem. And I think what people who don't work in hospitals
00:18:41
Speaker
don't fully understand the impact of when your system is overwhelmed that way. Because it's challenging to care for those people with COVID, but it's also equally challenging to make sure that you're adequately caring for people with other severe diseases that require treatment.
00:19:04
Speaker
On the other hand, the other challenge is that some people were so afraid of getting COVID that they didn't come to the hospital to get treatment for things. They didn't come to the hospital for their heart attacks or they delayed treatment for their cancer because they were so afraid of getting COVID in the hospital.
00:19:26
Speaker
And we took a year or two to catch up with that for all of the disease diagnoses that were delayed and treatment that was deferred because of dealing with COVID.
00:19:40
Speaker
You wrote a piece with Dr. Elizabeth Treteo called Lessons from the Frontline. Can you explain why you wrote that piece and what you found? We were commenting on a study that had come out of China looking at ways to provide better oxygenation for people with
00:20:07
Speaker
severe COVID pulmonary disease and whether you could use what we call non-invasive ventilation or non-invasive enhanced oxygenation strategies of things like giving very high flow nasal oxygen
00:20:27
Speaker
or putting masks on people but without having to intubate them to see if those strategies could be effective or as effective as immediately putting everybody on a ventilator. And this was really from a large database in China where they looked at outcome. And these were the types of studies that helped to shape
00:20:55
Speaker
What what people were doing you know these studies were being done some places better than others i mean a lot of what people were doing was sort of haphazard but as you got data like this that show this strategy maybe potentially better.
00:21:13
Speaker
and in the end lead to better outcomes than the traditional strategy of putting everybody on a ventilator, then that helps shape practice. And a lot of these studies from people who were actually good observers of what they were doing and actually trying to take that information and turn it into something that other people could learn from was very important.
00:21:39
Speaker
I want to hear more about your personal experience through all this.
Personal Safety and Public Misconceptions
00:21:44
Speaker
Throughout the pandemic, were there moments where we were just acknowledging yourself and maybe your family and your loved ones, like, I'm putting myself in harm's way here to help treat patients?
00:21:57
Speaker
I think I made that decision very early on that I was going to wear the personal protective equipment that would try and protect me. I would do everything I could to make sure that I didn't bring things home to my wife and to my family.
00:22:19
Speaker
but that it was my responsibility to provide the best care that I could for the patients that we were seeing. And I think that that went through a lot of people's minds at the time is I don't want to get sick. I don't want to bring something home to my family. And especially in the very beginning where we had no idea who was going to get severely ill.
00:22:47
Speaker
and die. We would see people who were relatively young who didn't seem to have any of those risk factors that predicted mortality who ended up on a ventilator and died. And when you look at that, you can't help but think, well, that could be me. And that was a challenge for people to come to work every day,
00:23:09
Speaker
care for all these people and still worry about what they were going to do at home. And we did all kinds of crazy things at home, right? Nobody knew about how it was transmitted. People would bring their produce home from the supermarket and wash it all and then not touch it. Or there are people who wouldn't pick up their mail for three or four days, leave it lying on the counter.
00:23:36
Speaker
because they thought if there was a virus on it, it would be gone by then and it would be safe to... So there was a lot of weird stuff because we didn't fully understand what we were dealing with or how easy or difficult it was to get this. And yeah, that impacted. And one of my personal roles in the hospital was acknowledging that there are a lot of things that we didn't know
00:24:07
Speaker
but that I would be going around through the critical care units, through the other units in the hospital, talking to the frontline physicians, because I'm not a critical care doctor. I wasn't going to be going in there and intubating patients, but I could at least provide that support, help answer questions, provide new knowledge as it came out,
00:24:30
Speaker
and try and make sure they understood that we were all in this together, and that we were all supporting each other. As a member of the ID staff, do you think you were you and your colleagues were kind of looked upon to keep morale high into kind of
00:24:49
Speaker
show a light at the end of the tunnel for the rest of the healthcare team? I think so, yeah. I mean, I think that now we're, are we specially trained to do that? I don't think so. But I think we were looked at in that way as to provide some of that rational thought.
00:25:09
Speaker
and to sort of provide that objectivity of where we're at and where things are going and to help people understand what we were actually dealing with and what might happen next.
Feelings of Inadequacy and Historical Parallels
00:25:23
Speaker
Through this whole saga of COVID that I guess is still ongoing will probably be with us for forever or a long time. What was the biggest thing that surprised you along the way?
00:25:41
Speaker
I can't but help think back to those first couple of months and think it was the first time in many years where I felt very impotent in my ability to deal with an infectious disease. The last time I had felt that way,
00:26:11
Speaker
was 40 years, you have to go back 40 years to the early days of the HIV epidemic. I started my internship in New York City in 1982.
00:26:27
Speaker
which is we didn't even have a name for the HIV virus at the time. We didn't even know what caused HIV. And young people were coming into the hospital and dying of weird opportunistic infections. And other than try and treat their infections, we didn't know what else to do for them. The difference was that rolled out on a much slower timeframe.
00:26:55
Speaker
as opposed to COVID where people would come in quickly and within 10 days they would be dead. And I think that it is the most inadequate I had felt in maybe 30 years of practicing medicine by that point.
00:27:18
Speaker
Yeah, I guess you can feel like you're a very senior faculty member, senior clinician, and then all of a sudden this new situation comes out and you feel like you're an intern again, or you feel like you don't know what the heck's going on. And unfortunately, I guess the buck kind of stops with you. There's no other upper level of people that you can kind of go to for guidance.
00:27:43
Speaker
Right. And so I felt my responsibility was to try and learn as much as I could and take whatever I could learn and transmit it both to my group, to the other infectious disease doctors, and to the rest of the hospital so that they could have some better sense of what they were dealing with.
00:28:07
Speaker
So then during that time was it was like, like a lot of your day, like, you know, hours spent on just like, looking up like the newest research and just kind of staying
Research and Logistical Coordination
00:28:17
Speaker
abreast of that. Was that a long part of your day? That was part of my day when I went home. The days were too busy with meetings about some of this stuff or, you know, we were meeting constantly about how to deal with, you know, shortages in the hospital, how to deal with, uh,
00:28:37
Speaker
How do we safely take people who might have COVID and get them to an operating room if they have an emergency surgery? And what processes do we need to have in place to do that? What do we do with all these patients who
00:28:55
Speaker
are not ready to go home, but the hospital's stuffed to capacity. And where do we put those people so that we can take in more sick people who really need the most critically ill beds that we have? So there was just hours of meetings to deal with all of these logistical issues. In addition to trying to learn what you could and then pass that information on to other people,
00:29:24
Speaker
so that they could also share that knowledge with the people they worked with. I want to get your thoughts on a surprise or something I've taken away from COVID.
00:29:39
Speaker
science is often portrayed as just this very objective, very neat, clean-cut thing that sort of pushes away any ideas of faith or trust or things like that.
Trust and Misinformation in Science
00:29:55
Speaker
I felt like throughout the COVID pandemic, I had to learn that faith is almost part of science. You have to have faith in other people that they're conducting their trials ethically and correctly. If one group of infectious disease physicians is saying, this is what we found, and then you have another group fighting fire with fire and saying, the science says this, you at the end of the day have to say, who do I trust? Who do I have faith in? And I think
00:30:23
Speaker
going to the pandemic thinking, oh, we're just going to follow what the science says. And we're just going to, well, when you have two groups of people saying opposite things and saying that science supports their opinion, you know.
00:30:35
Speaker
I'm kind of, at the time I had a job, I had things to do. I didn't have time to go like search through the literature and do a full, you know, PubMed search of all the literature about COVID. So at some point I have to just say, you know, I trust these people. I have faith in these people that their science is good and science is correct. Is that something that you kind of continue to see throughout the process, that faith was really a part of what was going on? Right. You had to have or accept some sources of
00:31:04
Speaker
quote, truth, even if those sources are flawed because data changes, we learn as we go. You know, the CDC said this on, you know, March of 2020 and said something different, you know, August of 2020. Is that because they were wrong and didn't know what they're doing? No, you have to accept the fact
00:31:30
Speaker
that you get more data and you have to be able to readjust your decisions. And I think that's, some people have a problem with that and some people have difficulty admitting that whatever position they took in the beginning, that they stuck to it and had, it's hard for people to change their minds or incorporate new information
00:31:57
Speaker
And I think that has been a challenge. For example, the whole debate about, well, is this virus airborne or not? That's still being argued two years later, three years later, when the data is pretty inconclusive that in some instances it clearly is an airborne virus. But because that
00:32:21
Speaker
decision impacted on policies that hospitals used and isolation procedures. You know, it was very hard for people to come around to accepting something different than that they had believed. And I think that that's what's always surprising to me is how hard it is for people to assimilate new information.
00:32:48
Speaker
If they start off with a preconceived belief, then it's really difficult to change that, even if they're scientists, right? People are invested in what they believe. And not everybody is able to step back and look at other people's data without the perspective of, well, this is different than what I think.
00:33:12
Speaker
How do you combat misinformation, I guess, particularly in this case, COVID-19 misinformation, when the misinformation claims to be evidence-based? I think that's a huge... Because in the beginning, we were talking about the early SARS virus and how people were saying, well, there's literature that literally says hydroxychloroquine and other drugs work for this.
00:33:33
Speaker
And that misinformation was then kind of claiming to be evidence-based. How do you counteract misinformation that claims to be evidence-based? The problem is that you are, if you are trying to be truly scientific, you're fighting with one hand tied behind your back.
00:33:56
Speaker
because people can claim anything and who is vetting, I mean, who is, you know, I may look at that and say, well, yes, but that's not relevant to this argument or to this discussion or it's a different virus or that data has been retracted or those studies were never replicated.
00:34:17
Speaker
But it is hard for people who are vehement about what their position is to be able to be just as vehement when you know that science is never black and white. So it is hard to fight misinformation with good information.
00:34:44
Speaker
I think we did a terrible job during the COVID outbreak of effectively communicating what we knew. And I think that we were also, we being the scientific establishment in the US and the CDC,
00:35:04
Speaker
had a hard time shifting gears and admitting that, well, we did this and now we're doing something different because we've learned more. And it's hard to do that. But because we did not communicate effectively, it gave people the opportunity to then doubt everything that those sources of truth are supposed to be providing for them.
00:35:31
Speaker
With that, it's time for a lightning round, a series of fast-paced questions that tell us more about you.
Personal Interests and Universal Healthcare Support
00:35:37
Speaker
Or during COVID, what was one thing you used to distract yourself from all the tough stuff that was going on? So we would do a lot of long walks in the neighborhood. And that's where I started to pay a lot more attention to birds and wildlife, and now much more bird obsessive than I ever was back pre-COVID.
00:36:06
Speaker
And the other thing was baking. I've always enjoyed baking, but there was an opportunity to bake stuff and then bring it into my teams. And, you know, again, just showing that, you know, you cared about. Yeah, that leads me into your, to my next question. I've been a recipient of a lot of those baked goods. So what's your favorite thing to bake?
00:36:32
Speaker
Well, I think the thing that I sort of have think I've mastered pretty well are scones. And I can attest to that. Yeah, the scones are good. But I mean, baking, baking is a lot of fun.
00:36:49
Speaker
I'm not probably the best technical baker so you know I'm not always so good about exactly measuring every single ingredient to make a very
00:37:03
Speaker
delicate, you know, for example, macarons are very difficult to make. And I just, you know, that's just too tedious for me to do that. I like to have a little more leeway to experiment and throw things in and modify things and see what comes out. If you were to be on a game show, what would you want to be on?
00:37:31
Speaker
I have to think about that for a second. I am not very fast on a game show. So much as I enjoy watching Jeopardy, I just can't answer the questions that quickly. So game shows where speed is an issue,
00:37:50
Speaker
I'm never going to be the one who pushes the bus budget or faster because my circuits just don't fire that quickly. So it would have to be a more thoughtful game show that you have a little more time to process your answers. Okay. Yeah. I'll, I'll watch a GSN, the game show network and figure out something for you. And lastly, in one sentence or so, uh, what's one change you'd like to see in healthcare?
00:38:20
Speaker
I would like to see universal healthcare for all. I mean, I think that universal subsidized healthcare for all with a single payer system. I think that the system we've created is just too convoluted
00:38:42
Speaker
too difficult to navigate and has so much bureaucracy that it just gets in the way of trying to change anything or improve anything. All right, Dr. Henry Reimau, thanks so much for joining the show. Oh, my pleasure. And if you have any other questions, you know where to find me.
Conclusion and Sign-off
00:39:15
Speaker
Thanks for listening to The Wound Dresser. Until next time, I'm your host John Neery. Be well.