Stuart Carlton 0:00
Hey everybody, it's Stuart Carlton host of teach me about the Great Lakes and assistant director of Illinois, Indiana Sea Grant. And I swore to myself that I was not going to record a disclaimer this week. But this is the disclaimer. It's a relatively short one this time basically, I just wanted to say that we had a number of audio difficulties when we're recording this episode, most of which were my fault, some of which I believe were the fault of the earthquakes that they just had in Utah where our guest lives. But so I apologize for that. Today's guest is a medical doctor and we're going to talk some more about the idea of going outside during cobit 19 and social distancing. Because as an ER doctor, or as an ER doc, our guest has an interesting perspective to add, I think and so I think this episode is a nice complement to the last one. But with that, let me stop just claiming and start episode. So and disclaimer begin episode right now. Welcome back, everybody to teach me about the Great Lakes. This is our second bonus Cove ID 19 episode. It's becoming increasingly common thing, unfortunately as viruses becoming increasingly common. And with that, ah, really hopeful introduction. My name is Stuart Carlton, I work with Illinois, Indiana. See grant and I am joined today, as always, by hope charters hope, how's it going?

Hope Charters 1:23
I'm doing well. I'm excited to ask him about vulnerable populations, because I am one of those people. And so hopefully our listeners will want to hear about that too.

Stuart Carlton 1:32
Yeah, I agree. And I think it'd be really interesting to get his perspective. So our guest today is an emergency room physician. He works in Utah. And he also has a background in epidemiology. And so he's out there on the frontlines of both, you know, the virus progression itself, but also on the frontlines of like doing stuff outside because nobody moves to Utah except to do things outside. No, that's not true. But one great thing about living in Utah is that you get to do a lot of stuff. Outside, you know, I've been on wonderful canoeing trips there and things like that. It's a beautiful state. So yeah, with that, let's just go ahead and bring on Dr. Satcher rich. Our guest today is Dr. Frank zadra Vich. He's an emergency medicine resident physician and an epidemiologist and he works in Utah. But he received his MD at the University of Illinois in Chicago. And he also got an MPH a Master's of Public Health at Columbia. So he is very familiar with Great Lakes states. Frank, thank you so much for joining us today.

Frank Zadravecz  2:39
Thanks for having me. You're welcome.

Stuart Carlton 2:41
So we're interested in talking through this idea of Cova 19 coronavirus in the outdoors. And I think that right now your position is an emergency medicine resident gives you a really unique perspective and a really important one. But first, I'm actually really just interested in that like what is your job right now? As a resident, like, are you dealing with coronavirus frequently and frequently What does what does that look like?

Frank Zadravecz  3:05
We are we're in an interesting position here in Utah. From a spatial perspective, we tend to be a little separated from the rest of the country. And so I think what's happening in New York City, what's happening in Washington State and California is probably several steps ahead of where we are right now. We're very used to dealing with anything at any time in the emergency department. And I think that this has definitely increased. Our are our focus on being able to handle any uptick in cases whether it's the things that we normally see heart attacks, motor vehicle accidents, other injuries, we're hyper aware now I think of the demand or services at the moment. hearing you talk We have split our emergency department into a respiratory only emergency department, as well as the everything else. And so we're dual tracking patients as they check into the Ed. It's done two things for us. It's allowed us to monitor the providers who are dealing with the respiratory only patients to make sure that we're keeping ourselves safe and that no one's getting sick, while also providing the same level of care that are patients who need us for general emergencies. We're slowly seeing increases in cases here in Utah. We've likely been seeing wide community spread the disease for some time here. But I think as people become more aware of their own symptoms, we're starting to see the majority of our patient volume shift towards respiratory and coded cases.

Stuart Carlton 4:52
So you think even now, you would say the majority of the people in the ER cobin related or respiratory anyway,

Frank Zadravecz  4:58
I would say it's probably evenly split here in Utah right now that we're slowly starting to see a majority of COPD patients speaking to some of my colleagues here in New York City right now I spoke with one yesterday, anecdotally, he shared with me that 80 to 90% of the patients he saw on emergency yesterday were likely coded related. So very high proportion.

Stuart Carlton 5:22
Wow, that's, that's stunning. So is the reason for that. Is that because the the symptoms are so bad? Or is it because people are worried and they want to go in because they can't get a test or they just, you know, want to get sort of you go straight to the ER rather than then elsewhere?

Frank Zadravecz  5:37
Yeah, that's a great question. We are, I would say a healthy proportion, maybe 30%. are patients who are sick enough to need hospitalization or to need a higher level of care, so breathing machines, life support, etc. There is a percentage of those patients who are what we say that worried Well, people who have symptoms that are limited to influenza like or flu like symptoms, cough, cold fevers, body aches, etc, who may or may not have coded and are unsure of whether they meet the criteria for testing right now, unfortunately, alongside all of this across the country, we're seeing a spike in flu cases alongside all of this. And so, whether it's influenza or whether it's coded itself, a lot of people are bringing themselves into the ED even if they don't have severe symptoms.

Hope Charters 6:33
Is that the right move? Are you suggesting that people will kind of stay home until they get more severe symptoms?

Frank Zadravecz  6:39
That's a great question. We're actually recommending that if people are not in a high risk group, so if they don't have another, another baseline illness like diabetes, high blood pressure, known lung disease, like asthma, COPD, or if they're not in the elderly group, If they're able to manage their symptoms at home, or not having severe shortness of breath or feeling like they need a higher level of care, we're asking those people to stay home. And that's for a few reasons. One, I would say the first reason is, our ability to manage the volume of patients in the emergency department is slowly becoming more strained. The second thing is if any of us providers come down with a flu like illness, even if it's not covered, we're being asked to stay home and monitor cells for a week to two weeks. And so the more people that we're seeing that don't need to be in the emergency department, if they transmit a flu like illness to us, even if it's not coded, we're knocking a decent number of providers out of the workforce.

Stuart Carlton 7:49
Alright, so if you get something that could be coded, you're kind of out of the game for treating people. And right now maybe that's somewhat manageable but but if the numbers in Utah But if the numbers keep going up, that becomes a real problem.

Frank Zadravecz  8:02
That's exactly correct. Oh, geez.

Stuart Carlton 8:04
Okay. And so that brings us to kind of the main thing that I'm curious about because there you are, you're experiencing you know, ers that are got a lot of traffic right now. And you're expecting it to be a lot more in Utah, much less what it's like in New York right now. But we have listeners throughout the Great Lakes region, some of whom, like Indiana is going to be starting tomorrow, as we record this under shelter in place orders, some of whom are not, but a lot of whom were trying to socially distance. But the challenge with social distancing is that it can be really isolating, and it can drive you know, bonkers, essentially. And so one potential solution for that that is ordinarily really healthy is going outside. And so we think that, as best as I can tell from talking with other people, that going outside, if you stay socially distance, you know, you might not necessarily contract the virus. But do you think it's still a good idea to be doing that or what what's your opinion on that?

Frank Zadravecz  8:59
Yeah. So I think You know, if we touch base first on what social distancing is, it's deliberately increasing our physical space between people to avoid spreading illness. We say six to eight feet because this lessens your chances of catching anything that is transmitted with droplets which Kogut likely is. And so staying six to eight feet away from a person without touching any of any shared surfaces, etc, is likely to decrease your risk of direct transmission. So going outside, you're unlikely to directly either transmit or contract. corvid by being on a trail or near a body of water next to someone. The concern is that by going outside doing these activities that we normally do from a wellness perspective is that we're either touching shared surfaces or interacting more closely with people and other ways that increases our risk. Whether this be going through gas stations and using shared pumps, going to bait shops or outdoor shops, other things where we're connected with people that would not otherwise be in our immediate social circle, ie our families, our significant others, children, etc. And so the thought is that by giving people as strict of instructions as possible for social distancing, we decrease the deviations from from those recommendations. And the reason I say that is, a lot of a lot of us here in the states are not used to having these restrictions on our movements and place and so it's, I think, a lot easier for us to develop cabin fever and want to get out and back to our normalcy as quickly as possible. And so if just one of us goes out and deviates from these restrictions, we think that, okay, maybe we are the exception. But once you develop a critical mass and everyone starts thinking that they're the exception, we see a snowball effect. And essentially, social distancing becomes

Stuart Carlton 11:22
less useful. It would be just like we had not had any social distancing requirements in place. And so you mean if people start like gathering in groups that are sufficiently big that it just undoes all the hard work that everybody's doing a social distance, socially distance,

Frank Zadravecz  11:38
I would say sufficiently big is one way to look at it. The other way is what we're learning from countries like China, South Korea, but they were really able to effectively do is maintain social circles as small as possible. They recommended that people stay within their own family units and that individual family units did not interact with each other. And so it's not necessarily the size of the group. And so the number of connections between on activities Exactly. And so even if you know, let's say, Stuart, my family, my family of two, it's just myself and my wife, if one of us goes out and connects with even a single individual person, outside of our immediate group, who then has contact with three other members in their own household, if one of those people in that household deviates from recommendations to stay within their home, you can see how those degrees of separation can exponentially grow.

Stuart Carlton 12:45
No, I can't see that. But I guess my concern, is that right? You know, in two weeks, if we're still doing social isolation, I just I just worry that people are not going to be able to do that regardless. I don't know. Do you have thoughts on that? Like, is there some time limit after which you worry that you know People are going to get cabin fever. And just, you know, not revolt Exactly. But start to deviate as you put it.

Frank Zadravecz  13:06
Yeah, it's a very fair point. I think what we're seeing right now is that this is a stressful time for a lot of people. Not only are we seeing an increase in Kovac cases in the emergency department, but we're seeing an increase in people coming in with mental health complaints. So complaints of worsening depression, complaints of suicidal thoughts, etc. And so I think this is really hitting us all where we're most vulnerable. And that vulnerability is different for each of us. I think one of the things that we're seeing in Utah, that we'll have to see how it plays out is we seem to have put restrictions in place a lot more rapidly than some other places in the country in relation to the increase in number of cases. And so I think we're probably developing Cabin Fever maybe a little bit more quickly than other people. Because we're not seeing the the relative increase in cases that you guys maybe are seeing around the Chicagoland area etc. And so people here are seeing less of a reason to social distance at the moment. And I think that becomes dangerous because then you start loosening restrictions on yourself and your own family unit and that's when there's the potential for surge there. I think the answer to your question is doing trying to find those same opportunities for wellness in ways that are lower risk. The lowest risk things that we can do is you know, work out exercise experience the outdoors in our own backyards or even within within our own neighborhoods. So a several block radius of where we do. I say that's lowest risk because you are limiting the the sphere of social contacts. And going back to the interconnectivity that you and I just chatted about, it's really important to, to limit those interactions. I think that the further we do get out from these initial restrictions, we're going to have more deviations from those recommendations. And that's why being as strict as possible right now can actually limit the duration that we're experiencing this virus, which is critical to our own sanity and to actually making sure because cases drop off,

Stuart Carlton 15:36
is that because right now is like a really critical period in the spread. And so if we have this concentrated effort now, it will hopefully meet Well, I mean, that's the flattening the curve idea, right? That that or that we won't have it for as long as we might otherwise?

Frank Zadravecz  15:48
That's exactly correct. So I think you bring up two thoughts. The flattening the curve idea, it doesn't necessarily change the number of cases that we have of kovat but it's just changes the number of cases at any one time, which is really important for us in the healthcare field. The more cases that we have at any one given time, the more difficult it is for us to adequately treat and protect ourselves as providers of flattening the curve may mean that we're experiencing kovat for maybe even a longer period of time, but the intensity that at any one moment is lower than where we're at in the epidemic curve in the United States. Right now we're starting to see the initial exponential growth of cases. And social distancing is most important right now. Because we don't have the ability to vaccinate. We don't have herd immunity to this virus and our population at large has not experienced this virus yet. And so the number People who are actually at risk for contracting the virus as its highest. And so the more that we can socially, distance right now the the greater the efficacy of those measures.

Hope Charters 17:14
So really what you're saying is this all comes down to trust. So it's like a big test of trust for everyone to see if you trust everybody else, like if you and like you said, you and your wife, you decide to maybe only see both sets of parents and then like, that's your little bubble. But then you have to trust everybody to not go outside that bubble, right?

Frank Zadravecz  17:36
That's so true. I mean, I think to put it succinctly, social distancing isn't about us individuals or limiting the risk of us contracting it. It's about our society working as a single unit. And understandably, there are many points of potential breakdown in that and so the more strict That each of us can be individually. The less that there's a potential lapse in that system.

Stuart Carlton 18:04
That makes sense. So, so listening to you, I think that I hear you saying that, you know, you recognize that people might go stir crazy cabin fever or whatever, because we're not used to being cooped up and not used to being socially isolated in this way. And so you're recommending, you know, maybe walks in your neighborhood, versus going on like a super long hike, or certainly on a mountain climber or something like that. Is that is that fair to say?

Frank Zadravecz  18:28
I think that's fair to say stirred. And, you know, that's for several reasons. I think one is limiting the interconnectedness of our units and our spheres right now and you hit you hit that perfectly. I think the second part is, we're at a really interesting time. If you think about the time of the year that we're in, you know, we're places in the Northern Hemisphere are starting to get warmer, we would naturally see an increase in outdoor activity for most populations or groups of people at this point. Interestingly, in the emergency department, we, we see a lot of this seasonality right about now and into the summer, we'll start to see more injuries related to outdoor activity, more broken bones, more motor vehicle accidents here in Utah, we start seeing a lot of ATV accidents, mountain bike accidents, climbing, accidents, etc. Because of that. And so I think when you think about where you are getting your outdoor experience at the moment, it's really important to think about those additional risks. Those additional risks are potentially overburdening emergency departments because of other reasons to visit the end.

Stuart Carlton 19:46
So this is something you've actually brought up two different times and it just had never occurred to me. So we just had we had a podcast that I if you haven't listened to I encourage everybody listening to listen to with Dr. Ron Herschelle, who's an epidemiologist with the University of Illinois, Chicago, and we talk A lot about the benefits of going outside and getting exercise and things like that. And that's true. But but you got to be careful in what you do not to basically take out somebody right is the thing. And so you talked about in terms of getting doctor sick with your flu like symptoms, but also in terms of, if you go out and get yourself injured, that's an ambulance that you know, can't treat somebody with a coven right there and a doctor they earn England's they can't transport somebody and a doctor, they can't treat somebody. And so I think that that's a another factor, I guess, when you're thinking about choices of what to do that, that you need to think about, but that had never occurred to me.

Frank Zadravecz  20:37
That's correct. I think you know, we're everything that we should be thinking about right now in terms of our individual actions should be about decreasing risk. accidents are called accidents, because they're not planned for and even the, even the most prepared amongst us, things can happen and so we have to weigh the benefit of our our or experience at the moment against the risk of potentially involving a fire department or emergency medical services provider like a paramedic, or a search and rescue team, etc. Those are all people who are going to be critical when we're responding to the peak of this crisis.

Hope Charters 21:23
I have two questions. So I'm a type one diabetic. So technically I fall under the immunocompromised you know, area. Um, so is it true that it's more likely for people who are vulnerable to actually contract cobit 19? Or is it just that you'll have more serious health consequences if you do contract it?

Frank Zadravecz  21:44
I would say both things, anything, you know, the, your, your type one diabetes is is interesting from that standpoint, because your immune system may have less of an ability to To mount a sufficient response at the beginning of contracting a virus like kovat, 19. And so it's true that you may be higher risk for contracting it. One, and then two higher risk when you do get it because of your body's ability to sustain that immune response. And so, we are cautioning people who fall on either side of that curve or either higher risk for contracting it because of their contacts, like us healthcare providers, or to people who have medical conditions which make the virus more dangerous when they actually contract it. That's a great question.

Hope Charters 22:44
That's really good to know. Because I know I'm part of a bunch of different Facebook groups that are specifically geared toward my disease, and I'm sure a lot of other people are for their diseases too. And so this is something that's really been going around in those conversations is like what's going on with us? Are we going to be okay? So thank you for that answer. And then the next question I had is someone with a background in epidemiology in medicine? How do you see this crisis ending? Like when do you think we're all going to be okay? And it'll be over and we can go outside? If, if

Frank Zadravecz  23:18
no, I watching this very closely, both from the nerdy epidemiologist side of things where, you know, this is both a scary and fascinating disease to watch. But on the medical side, I think we're watching it a little bit more anxiously because we realize that our ability to respond is emitted. I think watching Asia and Central Europe right now I see that we're on the the early part of the epidemic curve here in the United States. A lot of countries have been very quick to pull the trigger on strict Social distancing, and a lockdown laws. And they, when or when those are enacted appropriately, are very efficacious. I think the thing that makes me a little more nervous here is, you know, we're a massive country in terms of landmass as well as population. Were segmented because a lot of our laws are more heavily enforced at the state and local level. And we're seeing a little bit more of a disjointed response here in the us right now. I'm hopeful that when that once across the border, most restrictive measures are in places that this will likely be a few months. What we're starting to see in China right now is that even when the curve is on the back end, when we're seeing cases decline and people recover, there still is the potential for small upticks. And so In response, I guess more directly to your answer. I'm hopeful that this first initial response will likely be two to three months. And then we only see small surges afterwards that are a little bit more easily manageable.

Stuart Carlton 25:17
Okay, I know you're busy, but you said nerd. And so I have a question for you. I apologize. So you mentioned like, our landmass is so big and our population size or whatever. So, you know, my favorite thing to do every day is to go and look at like, all these graphs that are on social media or the Financial Times or wherever. And, and there's sort of two different ways of doing these graphs for like, you know, Kovac cases in the United States. One has absolute number of cases. And you look at our curve compared to you know, South Korea, hopefully or China or Italy, hopefully not. But then the other way is doing it by capita, right, per you know, million people a population or something like that. And so by capita, I feel like, you know, is a better representation of like the density of where it is. versus just the sheer numbers which can, you know, have infections? Do you have a thought on? Like, is it better to, you know, graph this stuff by Capita? Or is it better on the absolute number of cases in terms of being a better representation of kind of where we are in the threat to us?

Frank Zadravecz  26:14
Yeah, I think the the most easily digestible piece of data for the population at large is a sheer numbers, but so just numbers, proportions, simple rates that I agree with you, Stuart, I don't think that gives the full picture. I would say that per capita is probably a more accurate representation at this point. Some of the more interesting graphs out there were ways to graphically represent this would be heat maps. And so you could easily overlay population data where you obviously have greater numbers of individuals and in big city centers like New York City, Los Angeles, Seattle, Houston, Miami. Me, Chicago, etc. And looking at the number of cases there another interesting piece that I think may start to come out as our ability to collect data around, this becomes a little better. For instance, if we're testing a larger number of the population, one of the more interesting things to see would be the, the rate of increase of cases in these places. And so I think if we're watching Johns Hopkins and the CDC and some of these other really reliable sources, some of that data may come out in a more useful way.

Stuart Carlton 27:42
Yeah, and I was thinking about that. And I don't wanna get too bleak. But it seems to me like we're starting to see some more data around the number of deaths, which I think is frankly, because of the testing situation, we had probably a more reliable thing to look at because that as we increase the number of tests, of course, the number of cases are going to end increase them. So it's a, it's not necessarily comparing like to like there.

Frank Zadravecz  28:04
That's true. I think one interesting point for your listeners, there's been a lot of confusion about terminology. In this outbreak, one important one that often is used interchangeably and incorrectly, case fatality rate versus mortality rate. So, case fatality rate looks at the number of deaths over the number of infected persons, you can easily see how this is affected by our ability to test right now we're thinking that there are many asymptomatic are pre symptomatic individuals who have the disease but are not getting tested because of our algorithms. The second is mortality rate. So this looks at the number of deaths attributed to a specific disease over the population at risk. And so these are very different numbers. epidemiologically about a rock used interchangeably. But you're exactly right to point out that a lot of our understanding about this is going to change as we're testing more people throughout the epidemic curve.

Stuart Carlton 29:12
And we'll, we'll put links to some of those terms in the show notes, which you'll be able to find at teach me about the Great Lakes comm slash six.

Hope Charters 29:20
Yeah, thanks so much for joining us, Frank. And, as a last thing, what kind of gives you hope in this situation?

Frank Zadravecz  29:27
I think right now, knowing that a lot of this is, is in our own hands gives me hope. I think we've seen this play out in war times looking back at previous generations of Americans and others around the world that you know, there are examples of us being able to band together and do what's under our own control to make a huge difference here. I think that we as healthcare providers are taking this seriously. Many people are using their individual social circles. To get accurate information out there, and I'm seeing a lot of examples of people watching out for each other and taking care of neighbors, and I think the constellation of those things together really gives me hope.

Stuart Carlton 30:15
Well, Dr. Franco, zadra rich, thank you so much for coming on to teach me about the Great Lakes and where can people find you on social media?

Frank Zadravecz  30:21
So I would say I'm most regularly on Instagram at the moment, people can find me at Frank Sergeevich. So at my first and last name, I'm happy to reach out to people when I'm not in the emergency department.

Stuart Carlton 30:36
Right, that could be more important. Excellent. Well, Dr. Frank Sergeevich thank you so much for coming and talking with us about this and stay safe out there.

Frank Zadravecz  30:47
Excellent. Thank you.

Stuart Carlton 30:52
I'm really glad we had him on as some very interesting food for thought for me because coming from my background, you know, I think of like going outside as being unambiguously healthy. And and really important in these times of where we're otherwise cooped up. And I still think that To tell you the truth, but but there turns out there are broader considerations that are in play, right?

Hope Charters 31:14
Yeah. So I thought it was interesting that he was talking about the idea of extra people going into the emergency room for non kovat related illnesses, you know, they could potentially spread the illness still, to doctors and nurses and take those people off the frontlines. And so it's really important that, you know, we're all staying inside as much as possible, or at least social distancing as much as possible to keep everybody safe, and especially the medical experts that need to be in hospitals.

Stuart Carlton 31:45
Yeah, and the injury part of it was something I hadn't thought about either the other day. It was snowing here in West Lafayette, because it snows in March in West Lafayette, Indiana, in late March, very late March, but and so I went with my one year old daughter We were going to go on a bike ride, like through the snow. And as we were like getting mounted up, I was like, wait a minute, do we want to wind up in the hospital right now? And the answer is no, incidentally, but but so it's that same idea. It's like, you know, think about the doctors and what their needs are, too and don't take them out. And so even things are maybe lower risk, there's still some risk associated with it. Right, exactly. Well, that was interesting to think about. So I don't know listener. I mean, you have to make your own choices, right? Of course, we would never recommend that you violate shelter and place policies because you shouldn't. Those are there for important reason. But for those of you who aren't in there, there's a lot to think about when you're making choices. And so I hope with this episode, combined with episode number five with Dr. Ron Herschelle, we've given you kind of the context that you need to make an informed choice. I know it gives me a lot to think about Alright, hope well, uh, people should find us on social media. They should find the podcasts at teach me about the Great Lakes calm and you can follow up on twitter at teach Great Lakes,

Hope Charters 33:03
and you can follow Illinois Indiana secret and we will share this podcast episode. I Oh, I see grant on Facebook, Twitter and Instagram.

Stuart Carlton 33:14
And thanks again for tuning in. And like I said before, I think we'll be releasing a few episodes in March because it's something that we can do from home. Or at least I thought we could prior to the audio issues we had today. Regardless, stay safe out there and thanks for listening.

Hope Charters 33:27
Stay safe, wash your hands.

Transcribed by https://otter.ai