Dr. Patrick J. Crocker is former chief of emergency medicine at Brackenridge Hospital and Dell Children's Medical Center. He also is the author of "More Letters from the Pit: Stories of a Physician's Odyssey in Emergency Medicine," coming this spring. Austonia.com's Rich Oppel spoke with him recently.
Q: Dr. Crocker, when the H1N1 epidemic hit in 2009, you were chief of the ER at Dell Children's. So this isn't your first rodeo. Is the U.S.—and Austin—ready for this pandemic?
A: Back then, we believed we were better prepared than we actually were.
After all, we were able to rely on the national defense stockpile of supplies and medications and the assistance of the CDC and other government agencies. As for this pandemic, our preparations in the U.S. have proven inadequate for the challenge. We were hampered by those who felt it was appropriate to downplay the obvious growing threat. So I can't say we were adequately prepared.
Q: Both China and South Korea reacted quickly, and both now have come out of the worst of it. Did we get off to a similarly fast start?
A: The U.S. response has been too slow. We attempted to deny the emergency away. That head-in-the-sand approach never works. Delaying forced social distancing allowed the COVID-19 virus to spread through our country under the radar. Transmission occurred among asymptomatic or minimally symptomatic people. This made true containment impossible. Now our best hope is mitigation and flattening the pandemic spread. And our inexplicable inability to respond with test kits like other countries really contributed to the problem of unrecognized spread in the community.
Q: How can your strategy in the 2009 epidemic be applied and updated for today?
A: We understood from the outset in 2009 we were facing a potential tsunami of patients and prepared early to use what was novel thinking at the time. We would triage and treat patients outside the hospital in medical tents, never bring them in unless it was medically indicated, and bring the necessary diagnostics to the patient outside. It worked wonderfully. Many hospitals took note and within a week or so tents were springing up outside ERs all over the country.
There is room for even more creativity today. We can save resources and staff. First, patients should be screened via telemedicine. Algorithms can be used to prevent the patient from coming to the hospital first. Remember, approximately 80% of these patients do not need hospital care. Once at the hospital, patients could again be screened and directed either to the main ER or to ER space in tents. All outpatient care for the COVID-19 could be delivered there. If patients need admission, they should all be segregated into COVID-19 floors. This would help minimize transmission to other patients and also allow staff to decrease use of personal protective supplies.
Q: Speaking of protective gear, the supply chain on everyday medical gear is challenged. The CDC has even mentioned the use of bandanas if masks run out. Does that make sense to you?
A: No, it doesn't. The shortage of supplies has meant that we have had virtually no ability to test early. We are running low on gowns, gloves, and masks. All prove the inadequacy of our preparation. And the CDC's suggestion of using a bandana saddens me. I'm not convinced adequate study of possibly reusing masks has been done. I suspect that they possibly could be fumigated, dried to 140 degrees, or sterilized with ultraviolet light rather than being thrown away after a few minutes of use. This needs investigation. I'm pretty darn sure a properly treated reused N95 mask will provide more protection than a bandana!
Q: New York Gov. Andrew Cuomo warned that we will run out of hospital beds. Are you concerned that could happen in Austin, and if so, how will we handle patients needing acute care?
A: Unfortunately, I think there are likely to be multiple epicenters with a high density of infected patients. Especially in large cities, hospitals are likely to run out of beds, ventilators and adequate staff. We need to do things differently, and preparation and training should start now. Bed space for the lower tier of patients should be secured. Hotels are an obvious choice: each room has a bathroom and would be superior to large open rooms without facilities. For these patients we don't need expensive monitoring. Low-cost blood pressure machines and oxygen saturation monitors are available and can be used. If we placed all COVID-19 patients together in such makeshift hospitals, the staff can work without fear of spreading the infection. Perhaps this would allow them to work in HAZMAT suits and greatly decrease the use of consumables in short supply. And yes, it will be different, uncomfortable and unfamiliar...but it beats being unable to provide care.
Q: Some people play down the mortality rate of COVID-19, saying that it may be only 2% of infected patients, compared to 0.2% for common flu. How concerned should we be?
A: These naysayers are part of the problem and have succeeded in slowing our response while spreading disinformation. Make no mistake, just because 80% of patients have a moderate clinical course as outpatients, that still leaves 20% that need hospital care, and 5% of those will need intensive care and a ventilator. This disease is 10 to 20 times more lethal than seasonal flu and if the spread continues at the current rate it will by far be the No. 1 cause of death in 2020 and 2021—maybe even double or triple the number of deaths of the next highest cause. But we can still lessen the impact of the disease through strict social distancing. If you conservatively apply a little arithmetic to World Health Organization and CDC "possible scenarios" you end up with staggering numbers of dead. How anyone can construe this as a minor problem is beyond reason.
Q: We read that even if ventilators were available, hospitals may not be able to afford them at a cost $25,000 and up. Will older people be wheeled into hospital corridors to die as ventilators are saved for younger people in distress?
A: This frightening scenario may play out in our country just as it has in Italy and probably China as well. We need novel thinking about the use of ventilators. Emergency mini-ventilators are available but not used in the U.S. They don't have all the bells and whistles that the big machines have that allow for optimal care, but they are functional, cost around $650, and could be used for during a crisis. Further, existing ventilators can easily be refitted to service 2-4 patients simultaneously. This is not ideal medical care but again we may be facing "war-time field-expedient" medicine and this solution is better than no ventilators.
How you decide who gets a ventilator will be difficult. In my opinion, it cannot be based solely on a patient's age. Are you going to tell me a murderer, drug dealer, or rapist is going to get a ventilator because they are young? Are you ready to discard the elderly who are actually fit, never smoked and probably have a better chance of survival than some young patients based only on their age? While there will be some patients that as physicians we know are very unlikely to survive—making comfort care appropriate—this triage question causes all sorts of ethical dilemmas.
Q: Are we taking sufficient care of nurses and other hospital workers, the people on the front line of this battle?
A: No, and it's a tragedy to ask these heroes to put themselves directly in harm's way without providing appropriate protections. They should all be the first to be guaranteed full intensive care unit and ventilator support if needed.
Q: Is there a role here for retired physicians?
A: We could be very useful in staffing all of the telemedicine work that will be necessary and help alleviate hospital overcrowding by directing the care of many patients in their homes. If retired doctors are asked to pitch in, I'm there. I'm just not ready to roll over and play dead with only a bandana on my face.
Austin FC's opening match at LAFC has already gotten plenty of buzz, and not just because the team will be playing its first-ever match. The opener will also see two famous fans pitted against each other: Will Ferrell and Matthew McConaughey.
Since he joined the club as a part-time owner in 2019, McConaughey hasn't been quiet about going Verde. The Austin icon has been a hypeman for the team on the Jimmy Kimmel show, spoken with MLS Commissioner Don Garber at SXSW and is vocal about the club on Twitter.
On Tuesday, McConaughey talked all things Austin FC from what appeared to be an Airstream.
"We've been talking about this," McConaughey said. "We've been building this brick by brick. We understand it's Verde, it's listos, but now it's live."
"I just got some chills saying that," McConaughey added.
This weekend will put the club to the test for the first time against LAFC, which also happens to be part-owned by a big Hollywood name. Comedian and actor Will Ferrell will be on the other side of the pitch come Saturday, and he's ready to start a rivalry.
After talking to McConaughey about both teams, Ferrell told Spectrum News he's excited to watch his team play the so-called "Austin Cacti" this season.
"I can only hope for a rivalry," Ferrell said. "I think Austin is going to be a fantastic market for a brand new soccer team, and I can't wait to be there when LAFC plays the 'Austin Cactuses.'"
Talked to Will Ferrell about his connection w/ @McConaughey as @MLS owners. He welcomes a @LAFC rivalry w/ @AustinFC and has his own nickname for the team. 🌵⚽️ @SpecNewsATX #DownhillMovie pic.twitter.com/yTPfTzVchM
— Victor Diaz (@VictorOchoDiaz) February 14, 2020
Now with five days to go, McConaughey said that he and Ferrell had been having a "war with words" over the match and are planning on placing bets before game time.
It's not the first time the two have found themselves on opposing sides of a sport. Back in 2018, Ferrell made his way to Austin to see USC football duke it out with the Longhorns (psst,—UT won.)
McConaughey and Austin FC are hoping to see yet another loss for Ferrell as they head to their first game on Saturday, but the match will be quite the challenge.
The MLS set the opening schedule for more than fame; the newly-formed Austin FC has been one of the most talked-about teams this preseason, and LAFC is projected at No. 2 in the league's power rankings. Austin FC currently sits at No. 21.
Head Coach Josh Wolff has said LAFC has one of the best offenses in the league.
"LAFC has one of the best attacking teams in the league," Wolff said. "They will punish you. They've never been shy of putting up goals, and again, I expect them to be one of the best teams in the league this year."
The club has lived up to Wolff's words: in just their second season of existence, LAFC took first in the Western Conference and were Supporters' Shield winners in 2019.
Austin FC will need to hold off LAFC captain Carlos Vela, a versatile winger/attacking midfielder who won the Most Valuable Player title in 2019, as well as high-scoring forward Diego Rossi.
Meanwhile, LAFC will face challenges in DP Cecilio Dominguez and midfielder Alex Ring, the former NYCFC "ringleader" who has worn the captain's armband already for his newest team. Forward Rodney Redes may or not be playing Saturday due to a "ding" on his knee, but if he does, he'll be a force to be reckoned with as well.
Austin FC's inaugural match will be nationally broadcast on FOX and FOX Deportes and will be featured on Alt 97.5 FM.
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Starting Monday, Austin voters will decide whether to reinstate a ban on sitting, lying and camping in certain areas of the city. Proposition B is one of eight proposed city code or charter amendments on the May 1 ballot, but it is perhaps the most contentious.
Spearheaded by the political action committee Save Austin Now, Prop B is a direct response to City Council's 2019 decision to overturn a 23-year-old ban on such activities. This is the second time the group has tried to get the issue on the ballot since the first petition was ruled invalid by the county clerk for duplicate signatures and other issues last year. Homeless advocates campaigned against the ban, arguing that it criminalized homelessness and led to citations and tickets that prevented homeless people from accessing housing, employment and other resources. Since then, the city's homeless population has grown in size and visibility.
SAN, advocates and council members generally agree that the situation is untenable, but they disagree about the ban's merit. Austinites who are directly impacted—including people who live near camps, downtown business owners and homeless residents—feel similarly embattled, telling Austonia that, regardless of how they plan to vote, not enough is being done to house the homeless.
Word on the street
Lisa Novak bought a condo in the East Riverside neighborhood in 2013, drawn in by its affordability and Guerrero Park. She attributes the increase in camping along the Riverside Drive median to council's decision to repeal the ban. "It turned into open season," she said.
Lisa Novak took this photo of campers along the Riverside Drive median, near where she lives. (Lisa Novak)
Novak worries about the recent spate of fires and how camps affect area business owners and incoming tourists. After her husband witnessed a violent exchange between two panhandlers, the couple stopped walking to their neighborhood H-E-B. She will vote for Prop B and disagrees with advocates who say it criminalizes homelessness. "I'm sorry, but as a member of society there are certain rules and regulations," she said.
Kevin Ludlow's Windsor Park home sits right behind a long-time homeless camp along Little Tannehill Branch Creek. He estimates he has spent hundreds of hours talking to city staff, council members, nonprofits and police about trash and safety concerns.
Ludlow is undecided on Prop B. He thinks a ban will address these issues, but he also feels police could be more responsive to reports of theft, vandalism and other crimes without penalizing campers who are otherwise law-abiding. "There's no winning hand, and I feel it's by design," he said.
Longtime Downtown business Kruger's Diamond Jewelers often has homeless residents camping outside the entryway. (Emma Freer)
David Kruger, fourth-generation owner of Kruger's Diamond Jewelers on Congress Avenue, is similarly ambivalent. Although homeless residents often camp out in his entryway, his issue is with city leadership, whom he feels are incapable of developing solutions. "I'm probably going to vote in favor of it, I guess, but I'd feel better if there was another item that addressed the problem," he said, comparing Prop B to trying to put toothpaste back in the tube.
Christopher Carr, a member of the Austin Homeless Advisory Committee who has been intermittently homeless since graduating from the University of Texas at Austin in the 1990s, is more decisive. A poet who loves opera and has bipolar disorder, he camps near the intersection of 15th and San Antonio streets. When the ban was in effect, he was often harassed by police he says. "You felt like you might have a few seconds before the cops showed up (if you sat down on a sidewalk)," he said.
Christopher Carr attends a meeting of the Challenger Street Newspaper, for which he is a contributor and distributor, outside of City Hall on Sunday. (Emma Freer)
Since the ban was lifted, Carr feels Austin's housed residents have turned against the homeless: "If you don't like seeing all these tents everywhere, why don't you not like the country where this level of indigency exists?"
A stopgap measure
Save Austin Now argues that repealing the ban has adversely impacted public safety, residents and businesses and left homeless people to live in unsafe conditions. Ken Casaday, president of the Austin Police Association and SAN board member, added that the council vote left residents out of the process. "For me, the big issue is 'let the citizens vote,'" he said. "If the citizens vote down Prop B, we'll live with it."
But the May 1 election is likely not the end of this debate. Texas lawmakers are considering a statewide ban on public camping in a clear rebuke of local policy.
Chris Harris, director of Texas Appleseed's Criminal Justice Project and an activist who helped overturn the ban in 2019, argued that the decision has made homelessness more visible, leading to greater investment by the city and nonprofits. "No matter what happens with Prop B or with these bills at the Legislature, our community can't forget about this issue," he said. "We decriminalized homelessness not because we saw it as a solution to homelessness but because we thought it was (an issue of) right-or-wrong."
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University of Texas students can expect a "near normal" fall semester this year.
The plan, sent to the Daily Texan via email from communications manager for the Office of the Executive Vice President and Provost Kathleen Harrison, is to hold 91.7% of classes in person, 4.2% of classes in a hybrid format and the remaining 3.1% of classes will stay online.
The announcement is a stark increase from last fall, during which over 60% of classes were online, 24% were hybrid and only 16% were in-person. President Jay Hartzell said last month he expects the upcoming semester to look more similar to fall 2019 than fall 2020.
The new schedule is not set in stone—Harrison said UT will continue to monitor the COVID-19 situation on campus and that safety of the community is a top priority.
"The University's decisions are based on the latest data and information available," Harrison said. "If conditions change, we will continue to keep the safety of our community a top priority and adjust as needed."
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