On today’s episode, I am joined by Dr. Matt Salter and friend of the show Aaron Lewis, to talk about how they are combating the coronavirus from their private practice in Detroit. Matt and Aaron dive into how COVID is changing the community there, and the ways that their practice has been specifically effected.
Hello and welcome to another special episode of anesthesia success. I’m your host Justin Harvey. And this is a special episode, not only because we’re talking about the boots on the [inaudible]
Ground coronavirus experience in the anesthesiology community, but also because this is a happy hour episode. So cheers to all of you hardworking physicians out there. And so my guests and I are raising a glass and they’ve been working really hard doing some really interesting work in the Detroit area. So I’m excited to introduce Dr. Aaron Lewis, who was a friend of the show as well as dr Matt Salter. They are colleagues and working in the same private practice in the Detroit area. And I want to hear a little bit about the work that they’ve been doing to really, I think do some unique things with their practice, specifically in innovating and, and getting creative to be able to address the significant medical needs that exist in their community. So doctors, Salter, and Lewis, thank you for joining me today. I’m going to be hearing us. So I’m curious, tell us a little bit what it’s like right now. I know you’re in the Beaumont system, you’re in the Detroit area. How is your community experiencing the coronavirus epidemic?
Dr. Matt Salter (01:28)
You know, I think like many communities, the effect of the virus has, I know escalated as the diseases hit this country and we’ve seen kind of the wave start to ripple from the various coasts. I have a lot of friends out East. My brothers live out East, I have former colleagues that are out East and we started to hear about you know, people getting sick out there and their practices starting to change a little bit. My wife and I were actually supposed to travel to New York on a planned vacation and we canceled it at the last minute because we’re just starting to hear about things changing in New York city and, and so we stayed at home and really within a few days after that we started to hear about major, you know, increasing incidents here in this area. And it started to sink in that this was not a small issue that was going to be raised for us. Yeah.
So Matt, tell me a little bit about where you’re at right now. Cause I haven’t done many outside podcasts and so I’m gleaning that this is perhaps having a pretty intimate impact in your day to day existence.
Dr. Matt Salter (02:40)
Yeah, well like a every healthcare provider, whether you’re doctor, nurse, everybody faces this dilemma of what to do to protect their family when they come back home. My wife is a physician, she’s very well read and informed and I have two small children and we made the decision that I was going to be quarantined at home in a bedroom by myself and only be in that bedroom when I’m at home. She, you know, brings me three meals a day and I’m allowed to be outside the house on my patio. So it’s my first day off today in a well over eight days. So when the sun came up this morning, I’ve been outside ever since. And it is now, what is it, six o’clock at night.
Wow. So I’m envisioning a bedroom with like one of those little kind of like a doggy door where they like slide the stuff through it, like kind of like in a prison or something.
Dr. Matt Salter (03:38)
It’s not unlike that. My, you know, I have my daughter’s like making the pictures that I can hang up on the walls. You know I’m, I’m, you know, showering before I leave, work changing in his scrubs and not touching anything. You know, trying to be please my other half as well as, you know, be safe for the rest of my family. So,
So talk about the experience as with the sort of the rising tide at your hospital. How has the sort of the clinical model of all, and even like you’ve probably gone from like, okay, we’re busy to wow, we’re overloaded to Oh my gosh, this is, we’re making decisions and building systems that that could have never conceived even a couple of weeks beforehand.
Dr. Matt Salter (04:21)
Well, like I said, we could see this coming, you know, from a week away and we work at a really small hospital where we know more or less all the other doctors that work there. We work intimately with his people. It is a community of physicians as well as a community hospital because I have strong relationships with some of the other, particularly intensivists. I had offered my help to them well before this even affected our practice. One day we, you know, we have cases going in the operating room that afternoon. We get a communication that everything is going to stop. And it was such a significant drop in business that our practice divided up into two teams to, you know, one team was sent home for two weeks while the other team was going to trade off doing whatever small amount of work was there. But a weekend to that I got a call from the CMO said, Matt, I need your help. We need you in the ICU and this is a community place. It’s not unlike having a friend say, I need your help. And it was kind of, it was a no brainer. Of course we’re going to help. This is not out of my wheelhouse of knowledge to go and help. They know they’re, they’ve made themselves available to help in any way, but it was more of help. First we’ll figure out the details as we go.
Yeah. Talk a little bit about specifically like how big is the hospital and does your practice interact with the hospital in the context of what’s your practice like? And w how do you, you know, how do you serve there?
Dr. Matt Salter (06:04)
Sure, sure. So we are completely a private practice. We get no dollars from the hospital to do what we do. Our nurse anesthetists don’t work. For us. They work for the hospital. We don’t get paid to take call. We get, we get paid based on whatever cases are or not done while we’re around. And that is the entirety of how we make money there. So if they’re not doing elective cases, we’re not getting any work. If they’re keeping people out of the hospital that are going to require any anesthesia services. But then that’s it. So the the hospital pays the nurse anesthetist, the hospital is having the nurse anesthetists do floor intubations and provide that service. They’re using the nurse anesthetist to provide some ICU level care. The rapid response team is done by the nurses, anesthetist, their employees. So you could see how very quickly our involvement with the hospital dried up in a day and an hour which is terrifying. And, and more importantly for me, the idea of being separated from the care that’s going on at the hospital that I work at was the primary motivation to try and continue to be involved in any capacity that we could.
Yeah. Tell me about how that sort of, how that felt for you as you’re sort of gradually probably realizing what this means. Like eventually like, Oh, this might be a problem to, okay, it’s here to, okay. Where there’s, there’s no elective cases left and we’re looking at either kind of working for free or doing nothing at all. How did, how did you kind of process that?
Dr. Matt Salter (07:54)
I’m terrified. It’s, I mean, it, it’s, it’s agony. I mean, I, I like to work. I liked it, you know, that’s why I chose to do this. And it, it’s, you feel powerless to change the reality of the situation. There’s some comfort in knowing that everyone is affected by this and I don’t want to draw attention to myself. And I would feel
Dr. Matt Salter (08:28)
Far worse about myself if in a time of need in my community that I didn’t put my own issues aside and go to work. I should tell you that, you know, this hospital is in the city that I grew up in. So I did my residency in different, different parts of the city. I did my fellowship in Manhattan. I worked for five years out East, but I, you know, I am now practicing and had been practicing for the last four years in this community hospital in my hometown where I’m very likely to take care of a patient that no, it was my parents or went to same high school or went to a ride. You know, you have history with these people just because you’re in the same community. And for that reason alone, my colleagues and I were just not going to walk away because we weren’t getting paid. Of course they could’ve said no, we’re fine. And then I’d just be sitting at home looking for something else to do.
Right? Yeah. I was just talking with a friend, a PA, an interventional pain guy down South who was just sharing some of the steps that he was taking. And we were reflecting on the fact that this is a time when leaders are either being born or discovered and people like the people willing to take initiative, willing to press in, willing to step into the difficulty often at great personal cost to say like, I’m here, I’m here to help, I’m here to work, sign me up. We’re, we’re seeing that all over the place. And it sounds like the story that you’re sharing is right in line with somebody who’s so deeply invested that you, you can’t not pull as hard as you can in the right direction.
Dr. Matt Salter (10:08)
I think that’s a very articulate thought on it. And I, I agree completely. One of my mentors, friends once told me that the day that I stopped caring is the day that I should quit. And I think that’s how I’ve been looking at it.
Dr. Matt Salter (10:33)
God forbid, something happens to me in the process of this. I want my children to know that just like every other doctor that went into this business to help people, I did what I could. And frankly these other doctors are my friends and I know what they’re going through. And if they wanted me to just, you know, do screening tests at the curb side to help them out. If that was going to be the only way that I could help them, I would do that too. But I’m not going to sit at home and do nothing and just flip through the news feed all day. There’s no way.
Yeah. So take me into that moment. You got that phone call from the CMO who said, we need you T what was going on in your mind and then what, what precipitated from there?
Dr. Matt Salter (11:23)
Dr. Matt Salter (11:26)
One, there’s that realization that I could definitely volunteered to put myself in harm’s way. Like there’s that moment too. And you know, my wife was very apprehensive about that. But you know, she’s also a very, very caring doctor and she gets it too. She knew that she couldn’t tell me I couldn’t go because I wouldn’t listen. So there’s that moment. The other was that, you know, we all have generations of family members that at one point were also called to war without them volunteering, they were going to be farther away from home. There was real risk, real uncertainty. They definitely didn’t want to go. They definitely didn’t know if they were prepared to make a positive impact on it. And they went and they might’ve died there. And their families are very proud of what they did. I’m volunteering to go 10 miles from home and maybe not every night come home, but most nights come home and I’m volunteering to do something that is 80% within what I am expert at. And further. And lastly, other people that I work with and like nurses, CRNs, janitors, they’re all there working [inaudible] and I’m going to be part of it. Yeah.
So in the last week or so, I know you’ve been doing something a little out of the ordinary in order to increase patient capacity. So tell me a little bit about the evolution of that journey and describe, because I’m sort of alluding to this thing that we both know about, but describe what that is.
Dr. Matt Salter (13:24)
Well, you know, this is a respiratory condition B, a lot of people on ventilators. You there for various reasons, you don’t have the intermediate sources of extra respiratory support that you might step through before you get to being on a ventilator. These patients go from being healthy to being mildly sick, to being on a ventilator with in very quick order. And you know, we happen to be in the business of also putting people on ventilators. We have that supply. It was a very logical step as they’ve done in other parts of the world to use whatever resources you can to help. And so by, you know, we have 14 operating rooms that we can put people on ventilators and that was a resource that we were going to offer. And we have space. We have recovery preop areas that we were gonna, you know, that we were not really using because there wasn’t any business.
Dr. Matt Salter (14:29)
So we made that available. That was, you know, that was one of the logistical concerns with how I could help. So I, you know, I was going to see staff patients that were in the preexisting ICU. And then we said, obviously we’re going to make an ICU out of all of the spaces that we had to go. So that was the first part, an enormous amount of work that went in after making that initial plan was how are we gonna staff it? How are we going to, how are we going to go from the idea of, you know, using this equipment as an anesthesia ICU or, or just a regular ICU, not staffed by anesthesiologists, do. Being able to perform the task of providing, you know, critical care. And that is, you know, what we have now is, is just the product of a lot of motivated, smart people that are willing to work with the goal of we have to find a way.
Dr. Matt Salter (15:35)
This is not a time where you say, I just can’t do it. This is, these are people who have the ambition and ability to find a way to do it. You know, our partner, a chairman, Josh Ferris, our other partner, Aaron Wood, really motivated people to help us find a way to do that and all of it has to be done at the same time. We have to get everybody kind of up to speed on the medicine, moving the equipment around. You have to find enough nurses to care for all these additional patients and do it. Make sure that it’s happening around the clock and make sure that you have enough nurses to maybe give people a day off here and there and have enough of Ivy sets and Ivy pumps. Everything that we are kind of on the edge of running short of, I mean we’re really pushing the ability of our hospital to stretch what people normally do to find a way to make it work and I am motivated enough.
Dr. Matt Salter (16:45)
My partners are motivated enough and confident enough to find a way to make it work. But not everybody who works in a hospital is used to that kind of thinking and confidence. And it’s a lot. And I personally, the experience of, you know, bringing our first few patients into our brand new ICU the other day was fairly terrifying but also really, really exhilarating because as we were preparing for it, as we’re getting the room ready to go, the finishing touches making sure that, you know, we have enough suction, do we have enough oxygen, has the room been inspected by infectious disease and everybody’s wearing all their garb to get ready. And you look at the faces of all these people that you work with that are well out of their element and clearly nervous, very nervous. I felt like, I don’t know if I should consider myself a general, but I considered myself a general looking at my troops as we’re about to storm the beach and they’re nervous because they know what’s coming and you, I want to be someone that they can rely on. I want to be that person for them and they want to be relied on to. That’s why they’re there. If they really didn’t want to be there, they probably wouldn’t be there, but they, they mustered the confidence too. I would hope based on the fact that they saw confidence from us.
Yeah. Take me to that moment when you’re looking around maybe before the first patient gets rolled in, but you’re kind of doing the inspections. You’d probably see a few of your colleagues kind of milling around looking like, Oh my gosh, like it’s about to all hit the fan. That nerve nervousness and unease. Was there a moment when you felt like you wanted to kind of share something to like, Hey guys, we can do this or what? What was your instinct in that? In that time?
Dr. Matt Salter (18:43)
You got to remember there was a lot of buildup. I mean it was over 24 hours of buildup where you’re getting text messages from different administrators and people in the hospital saying, can we bring the patient? Well, we just have to do this and okay, hours later. Okay, I think we’re ready. Nope, we got to do this. And that went on for over 24 hours and then it was, okay, we’re doing this at seven o’clock tomorrow morning. Okay. Everybody comes in, everybody’s there. I can’t, I don’t know who everybody is cause I can’t see them through everything. And you know, you’re by, my feeling was, and what I, what I told the people that I was talking with was this will work because we want it to work. Hmm. We’ve already gotten this far. We will find a way to keep going. There’s just too much pressure on all of us to stop now. It’s not. And it’s the same feeling for everybody else who’s there. There, it’s their community too.
Yeah. So I’m curious, you know, something like this, and obviously healthcare is, so I’m in the finance industry also, very regulated. Healthcare was one of those things where there’s a lot of rules, a lot of laws, a lot of things by which you must adhere. And obviously with like HIPAA and Jayco, we’ve seen some relaxing or some modification of those rules to be able to get care to, to places that’s most desperately needed. Talk a little bit about your experience with trying to navigate that kind of minefield or those challenges as well as coordinating with the administrative staff to say like, how do we build a thing that is unconventional as quickly as possible? Get it up to speed, not get caught up in the red tape that might cost people’s lives, but also make sure that it’s safe and that that we have the infrastructure that we require.
Dr. Matt Salter (20:34)
I am doing what I know how to do in this circumstance. Aaron’s doing what he knows how to do. My other partners are doing what they know how to do and you know when when someone, this TMO calls me and says, I need your help. He knows what his plan is. He knows that he wants to open up a new ICU. Right. He knows that that’s coming and so do the other administrators. They’ve all kind of been tasked with this is what we need to do, so I need infection control to get on it and they’re, yeah, we’re going to have their task of making sure the room is acceptable. The nursing manager is going to get on. Finding the staff, getting the money together and making a phone calls to make sure that people are there working with people at different skill sets to put them in the place that they need.
Dr. Matt Salter (21:29)
Kind of saying, well, I need, how many beds are we talking about? So I need X number of people so that you know, that’s, that’s their task. Mine was, I need to get up to speed on critical care medicine as fast as possible. So I just started showing up on rounds and asking questions and seeing how culture in the hospital had changed in the 10 days that I had been sent home and to get a handle on how to be an intensivist again, that’s not my normal workflow. I come into work and it’s, you know, my case with a nurse anesthetist, that’s the end of the chain, right there is we worked together there. This is totally different. I, you know, rounding, writing notes, working with residents not being immediately with, you know, my patients all the time. All of that. In addition to what are, how are people treating coven, what protocols are we using?
Dr. Matt Salter (22:41)
How do I enter that order set into the computer, all of that. That was what I was focusing on so that I could be the doctor that they needed there. My partners were working on issues of working with the biomed people and the engineer’s for the events and getting them ready to go. And others we’re working with some of the administrative things. How are we gonna, how are we gonna write our notes and do our billing and organize the other responsibilities that we have? We still have a responsibility to cover the operating room. That’s a very small responsibility right now. But we had to also make sure that we’re still protecting that. So then that evolved to this scenario. This this plan where one or two of us were going to be covering the ICU, the anesthesia ICU and the rest would be covering the operating room and then we’d take it from there because it was pretty clear that, well, we need it. Monday is going to be different than what we need on Wednesday and we need to continue to be flexible.
Yeah. Talk a little bit about doing, so I was talking with Sarah, I’ve been getting like a crash course on some of the basics of like anesthesia, machine dynamics and anesthetic gases and things like that. Talk a little bit about what does it like to have to keep somebody alive for two weeks on anesthesia machine because they’re not usually designed for that. Although some of the functions, similar functionality exists with I guess a traditional ventilator.
Dr. Matt Salter (24:18)
I don’t know what it’s like yet to keep somebody alive for two weeks. We are day five. Every day has been hard. One of the issues that we were facing was that we had been told that oxygen was possibly in a short supply and our anesthesia machines run on oxygen to the machine to work, not to give to the patient for actual machine. It’s, you know, think of it like, well that’s succinct enough. So we were working with the manufacturer of the, of the ventilators to reconfigure the machines to run on air. That was a days worth of work. And then you have to by that to all of the machines. And again, that was a local issue that we were facing that might not face everybody else. The other was would be making sure that we have the right filters and protection in the for the machine to make sure that any virus doesn’t get into the machine.
Dr. Matt Salter (25:27)
So that was, I think we got guidance from that either from, you know, from the anesthesia societies because again, we were a week behind New York and the West coast and there, you know, some knowledge had been accrued already on this. Our ventilators are a lot more sensitive to patients trying to help. When they’re on our ventilators. We need more sedation, we need more continuous presence. Their ICU ventilators tend to tolerate patients not behaving as well as much as what the, what the mental later wants to do, which means that we have to have people that are familiar with our ventilators around 24, seven in order to in order to make it work. I think we’ve had problems with a lot of moisture retention within the ventilator circuit because where running low, very square circulating very low flows of oxygen through our circuits in order to conserve oxygen. It’s, it’s minute by minute with them. Yeah. I mean it’s, yeah, it’s minute by minute.
Yeah. What are the biggest, is there maybe one or two big challenges that you faced in the course of doing all this? He thought that was like our real hurdle that either I wasn’t sure we were going to be able to clear or it took the most effort of all the other challenges to be able to, to, to push through.
Dr. Matt Salter (27:02)
You know, I, I would have to get consensus from my, you know, my other partners because I think we’ve all faced other challenges. I mean, we’ve all faced our own challenges and getting this up and going. I think that the, the challenge of recognizing what the limitations were with the ventilators was a, was a big one. And then the oxygen shortage did not help that just, that made it that much more complicated. Right. For me, I, I needed a, I needed a ramp up. I needed, I needed a few days of being on rounds, starting with a small handful of patients. And then the next day I had 12 patients and we’re off to the races. And, and you know, another component of this is, is that, you know, I mentioned working with residents, well, we have residents that, you know, they’ve only been doing neurology for four years or their orthopedic surgery resident or, you know, they’re just an intern and they’re, they’re my residents right now.
Dr. Matt Salter (28:09)
I don’t have people that have been devoted to practicing critical care or plan to do critical care as part of my team. I have residents that are not paid very much that are brought back from what they want to be doing to be doing this in a, in a part of the hospital that doesn’t do this and I have to mold that team, you know, so learning to motivate that and they’ve been awesome by the way. I’ve never, there’s been no push back from any of them. I could not speak more highly of the house staff at this hospital. They’ve done a great job within what they’re comfortable with. My job is I think is clearly to identify what they can and cannot do and follow all the links in the chain to patient care and to see how I can impact that. And I’m a very involved provider.
Dr. Matt Salter (29:11)
I always know what’s going on with my patients and learning how to apply that to this new realm has, you know, then it’s own small challenge. But on the flip side, all of the, the people that are staffing this new ICU are people that I work with all the time. So while everybody is nervous, there still is that relationship there that we try and use to our benefit. That being said, I still have patients you know, throughout the rest of the hospital with nurses that I don’t know, nurses that are not critical care nurses, just parts of the building that are not used to seeing my face and we’d just do the best we can. Yeah.
So there’s a lot of people probably listening to this podcast who are going to be part of an effort to turn ORs into ICU over the coming few weeks. So if there’s maybe two or three things like words of wisdom or things to think about, perhaps things that you wouldn’t find in the one page or from the ASA of like here’s the one-on-one on how to do this, is there anything from your perspective it’s like this is something to look out for or something to think about as you’ve gone through that process?
Dr. Matt Salter (30:22)
I think that anybody in my shoes would do the same thing. You would see, you would see the, the risks, you would see the weaknesses. Anybody in my shoes in another part of the country is, is going to be just as concerned about not being there to make sure that everything happens. They’re going to be involved, they’re going to be at the bedside, they’re going to find a way to make it work, make a team, find a way to communicate with each other, and ultimately, if you want it to work, it will work. But I think that’s the expectation. You’ve created the expectation. We’re going to find a way to make this work. We understand that if we’re not communicating with each other, we’re not going to be effective. I read the recent guidelines and get to work. I don’t know if I could whittle it down any more than that. I think that I’m pretty lucky to be going through this in a place where I am because it could be much harder somewhere else. It’s hard here. I couldn’t imagine it being more difficult.
Well, Matt, I really appreciate you taking the time to share your story with us. Aaron, thank you for facilitating this introduction. Anything in closing, any reflections or words of wisdom you want to share with our listeners out there?
Dr. Matt Salter (31:43)
I just want to come out of this thinking that I, I did everything that I could. I didn’t, I didn’t leave any money on the table or I left all the money on the table. I don’t, I don’t know
Dr. Matt Salter (31:56)
I, I try not to stand on titles. I try and just be there helping doing what I can. I want everybody to take that kind of philosophy and you know, whatever. In whatever shape we come out of this, I just want to be able to walk away and say that I did everything. Yeah, that’s all. Great.
Well Matt, thank you very much for your time today. It’s been a pleasure having you on the anesthesia success podcast. Hey, thanks man. If you liked what you heard this week, head on over to anesthesia, success.com where you can find more content and free resources to help you build a successful career in anesthesiology and pain management. If you want to a review in iTunes, I
Would also really appreciate it. Thanks for using some of your valuable time to join me today on the anesthesia success podcast.