Eric: Welcome to the GeriPal podcast, This is Eric Widera.
Alex: This is Alex Smith
Eric: And Alex, we’ve got a lot to talk about today. It’s a COVID podcast.
Eric: Who are our guests?
Alex: Our topic is COVID in hospitals. We have Brian block who has been on the podcast before as assistant professor of pulmonary critical care at UCSF. Welcome back to the GeriPal podcast Brian.
Brian: Great to be back.
Alex: And we have Denise Barchas, who’s an ICU nurse at UCSF. Welcome to the GeriPal podcast Denise.
Denise: Thank you for having me.
Alex: And We have Sunita Puri, who is medical director of palliative care at University of Southern California and is author of the book, That Good Night: Life and Medicine in the Eleventh Hour. Welcome to the GeriPal podcast Sunita.
Sunita: Thank you for having me.
Eric: And I just want to put a plug in for Sunita’s book, it is absolutely fabulous. Is it on Kindle too?
Sunita: It’s on Kindle, there’s an audio book, part of which I read, and of course it’s in paperback and hardback.
Eric: I really encourage everybody to read it. Sunita is an amazing author. But before we go into other topics, we always start off with a song request. We got three people with us, I’m going to turn a Brian. Brian, have you got a song request for Alex?
Brian: Yeah. Alex, I’d like you to play Band On The Run by Paul McCartney and Wings.
Alex: And why that song?
Brian: Well, I think there’s a few verses that apply here, speaking to the experience of being stuck inside these four walls during the pandemic is one.
Eric: All right, here we go, here’s a little bit.
Brian: That was awesome.
Eric: I can see why that was the song choice for COVID in the hospital’s podcasts.
Brian: Yeah, I’m glad you didn’t start with the undertaker taking a heavy side, Betty aspects of the sun do speak to it and the band of healthcare workers, we were all on the run this year trying to meet this moment and take care of these patients in this novel pandemic setting. So there are many pieces of that, but thank you Alex, that was great.
Eric: So Brian, we’re going to start off with you. You just published a paper in Journal of Hospital Medicine. The title is Variation in COVID-19 Mortality Across 117 US Hospitals in High and Low-Burdensome Settings. We hear a lot about patient factors related to mortality in the community and in the hospital. We’ve actually talked about that in this podcast around prognostication, like in nursing home patients, about a month ago. How did you get interested in this and not as looking at the patient, but potentially looking at the healthcare infrastructure?
Brian: Yeah. So, we’re recording now just about a year after COVID really took off here, in the United States, last spring. And I know early in the pandemic there was all of this wonder about what was going to happen, what were things going to look like. And then in the US, this first signal out of the Northeast, as things started really taking off with many, many patients coming to the hospitals, all at the same time with acute onset of oftentimes very severe illness.
Brian: So here locally in the Bay Area, that was not the initial experience that we had, but I was speaking to colleagues and hearing about the experience, caring for patients with COVID-19 and of course everything else back in the Northeast. And then knowing what it takes to take care of patients with critical illness, the hands-on care at the bedside, I just started to wonder how could you possibly function in that type of environment. What kind of strain would that put on your ability to deliver care? And so, as you put it Eric, would there be hospital level factors that would influence outcomes for patients with COVID-19 beyond what are very obvious patient level risk factors for having worse outcomes.
Alex: Okay. Denise, about a year ago, I understand you went to New York to help out.
Denise: I did.
Alex: Could you tell us what that was like and what you were seeing a year ago.
Denise: Yeah, so we were lucky at UCSF, we had manageable levels. We were not experiencing the surge, so they let 24 nurses and doctors fly out to New York on April 11th, and I remember working in the hospital, my first day by myself, just overwhelmed. A lot of differences when you talk about hospital systems and why we saw what we did. I think I’ll explain the hospital, what it looked like first. They converted park use into ICU, so you would walk in, you would have a patient in the bed. On a tiny little chair you had your transport vent, patient vent, patient vent, patient vent, all the patients vented multiple drips proned and the nursing ratios were very, very different. Normally at home, it’s one nurse to one or two patients, in New York you had four to five patients. You would have had one of those patients by yourself back home.
Denise: That was hard. I remember just wanting to cry thinking, “Oh my gosh, how am I going to do this?” It was very overwhelming. They had shortages of medications, supplies, basic stuff, blankets, no blankets, no pillows. I had to make up a restraint for a patient because I couldn’t find any, didn’t want her to pull out her ET tube. Even the providers, there weren’t enough ICU providers, so you would have an ortho doctor taking care of these ICU patients, I had a dermatologist who was writing ICU orders for me. One night in our converted, I think we were in a converted… I forget what kind of room it was, six patients and it was just two nurses and the doc all night taking care of maybe eight patients. Yeah, it was definitely a whole new nursing I had never experienced. Everyone did the best they could, they were flexible, you had to adapt really fast. We were just all overwhelmed and exhausted.
Eric: Did you feel like that impacted potentially patient care, like the outcomes of what was happening?
Denise: I mean, definitely. There were many close calls, these patients relied on Levophed to keep their pressures blood up. So if your patient is across the hall and you don’t hear that bag running low or empty, they potentially would lose their blood pressure and someone started compressions and I saw this a number of times. If the ratios were better, that probably would not have happened. You know what I mean?
Eric: And how was the PPE level for you? Were there shortages or did you feel like…
Denise: Definitely shortages. So you would walk in, you would put your bunny suit on, you would reuse your bunny suit. It was one N95 for the whole, you just wear it all day, all 12 hours, took it off for 10 minutes to eat and reused it the next day.
Eric: Yeah. Alex and I both did some virtual volunteering in New York, which sounds like a whole different world than what you experienced. But I thought it was just remarkable. We talk a lot about resource allocation and if we ever got to that, and I don’t think any hospital actually formally implemented a policy around resource allocation for things like ventilators, but it was happening all the time, like CVVH missing. So this continuous dialysis, people were on it one day, off at the next day, on in another day, off in another, just because it wasn’t enough machines and they didn’t have enough of the components of the dialysis, like the dialysate. So I just want to know, did you have that similar experience?
Denise: Oh, definitely. A week before we left, I think the chief of nephrology at NYP actually sent a tweet out and was pleaing, “Hey, send over dialysis nurses, send over CRT machines, send over dialysis.” They just didn’t have it. I went to get some dialysis bags and they’re in their storage, they were gone. And it was sad because if your dialysis machine, your CRRT, continuous renal replacement therapy ended on one of your patients they said, “Okay, well, if this stops because of whatever reason, it’s going to go on to the next patient.” So you felt a huge responsibility like, “Oh my gosh, I got to keep this machine running.” I know it could clot because these machines had a high tendency to clot. But then you also knew that another patient wasn’t going to get therapy. So they were triaging their CRT care and we had maybe two CRT patients per assignment on top of our other two patients. Where normally back home it was a one-to-one assignment.
Eric: And I’m also guessing you saw a lot of death.
Denise: I saw a lot of death, unfortunately. I worked the PM shift, I remember when I worked the AM shift you would just have a lot of code blues overhead, and their code blue response was different as well. Yeah. I’ll just say that.
Eric: Yeah. I’m wondering, Sunita, California did really well up until the winter. And I would say people always think about California as this one state. There’s really two states as far as COVID. You have Northern California and you had Southern California. And Southern California in the winter time just got crushed. Can you tell me a little bit about your experience during that surge?
Sunita: Absolutely. So when COVID first hit last March, I was on a number of calls with the hospital administration about how we were going to handle this. Mercifully we didn’t have huge numbers in the beginning, although we did have a surge in the summer and then as you mentioned, a huge surge in the winter. So our palliative care team actually saw every patient in the COVID ICU for weekly, if not bi-weekly or tri weekly family meetings, because people were not with their loved ones, visitors weren’t allowed in. We had a policy of just two people can come in for 10 minutes at the very end of life. And we were doing these meetings over Zoom. So we saw huge volumes of patients from families and all sorts of different situations, and especially in the winter, what we saw were large numbers of people who were mainly Latino, mostly immigrants, living in homes where many, many people were living and that was a particularly devastating part of our experience taking care of people, because the surge was not a uniform surge. It was a surge along the usual socioeconomic fissures that exist in our society.
Sunita: So we were having to contend with all of that, the grief around what families were experiencing, what teams were experiencing. And as Denise was saying, all of this was unfolding when fellows were getting sick. We were pulling surgical residents to help when the ICU providers were getting sick. There weren’t enough dialysis nurses. I was often on calls about CRRT machines. We got very, very close to implementing resource allocation, which was actually a policy I had to write for the hospital, and I just remember writing it and crying because just the very thought of having to potentially do this was devastating, even the thought of it. But it was a really, really, really overwhelming experience on multiple fronts.
Sunita: And I think the beauty of our team’s intervention was that every family had regular check-ins with us and the ICU team and we were all on the same call. If there’s one silver lining of Zoom, it’s that people in a family who might not be in the same place, could all be on the same call. So we really tried to push for that so no one family member had to be the messenger with a disease that’s so uncertain and still remains not as well understood as we’d hope. So that intervention, I think, helped a tremendous amount because it was a regular touch point. But I think what it meant for our team was that we were the constant witness of devastation, along with the ICU team, but the teams rotated whereas we did not. And so to bear witness to that, I think, is something that we’re all still processing because honestly, in the moment, I couldn’t feel anything about it. So in terms of the surges effect on our hospital, on individuals, certainly on patients and families, it was as though we were just like dogs trying to paddle in a very deep ocean or doggy paddling in a very deep ocean.
Eric: During the big surge, did you have to open up park use and other things like they did in New York for makeshift ICU’s?
Sunita: Yeah. We absolutely had to do that and floors that were usually tele units became units with surgical ICU patients, with medical ICU patients. So people coming in with non elective surgeries had to, post-transplant people for example, finding places for them was also challenging. People on [inaudible 00:16:49], people on VADs, it took a lot of coordination to figure out what will we do for the other sick people. And definitely seeing people coming in, in late stages of disease because they didn’t want to come in earlier due to COVID. There were a number of people who ended up in the non-COVID ICU for those reasons too.
Eric: Yeah. And Denise and Brian, the other California experience, the Northern California experience. Denise, did it feel very different between what you did in New York and what was happening in San Francisco?
Denise: Very, very different. So before I had left, I had taken care of some patients who weren’t yet confirmed with COVID and we have private rooms for them, you’re donning and doffing before you’re getting in. I mean, we were overwhelmed and stressed because we didn’t know what going on, there was a lot of unknowns, there just wasn’t the volume of patients. So yeah, it was very different, our numbers were low, I think. Brian, do you remember what our numbers were in April?
Brian: No, back in April last year I was mostly working at San Francisco general. And we had in the ICU between 15 and 20 patients, I think, at our peak in that first wave of infections. So order of magnitude lower than what we’re talking about, maybe even two orders of magnitude.
Eric: What did it look like during the winter peak Brian?
Brian: We had across UCSF about a hundred patients at our maximum, with about half of them in the ICU. Not because half needed ICU, but because the length of stay was so much longer for those with critical illness. But we were always practicing in the normal setting, the ICU patients were in an ICU physically. They had an ICU nurse, they had ICU trained team taking care of them. And in some settings, we actually were staffed in anticipation of surges. So we had extra staff relative to even our baseline staffing level. And so we were never at the situation of having the number of patients outstrip the person power that we had.
Eric: Now I remember early on in the pandemic, probably when you were still at the general, there were multiple grand rounds happening and one of them was around mortality and at the general they were saying, “We’re having these people but we’re not seeing that same mortality rate.” I think at that time they said, “Oh, nobody has died yet.” So there seemed to be this discrepancy as far as what we were seeing in these hard hit places like New York is. Mortality rates of 25, 30% and mortality rates in San Francisco, which seemed to be a lot less.
Brian: Yeah. The first reports out of Seattle, it was 50 to 80% on people who had required intensive care admission.
Eric: Maybe we can actually talk about what you found in your article as far as, is there variation in mortality rate and maybe we can talk about potentially if there is, why? So do you want to describe your article a little bit?
Brian: Yeah. So we collaborated with a company that collects data from hospitals in real time. So that made it available immediately to start asking these questions during the pandemic. And we looked at a sample of over a hundred hospitals all across the US in all regions, and asked the question, “For those patients admitted with a diagnosis of COVID-19, what was their mortality rate?” And we tried to adjust for known patient level risk factors for mortality, things like sex, age, comorbidities, diseases that patients had when they were coming in. And then we looked at the hospital level, was there a variation in mortality rates across these 117 hospitals? And there was, there was tremendous variation.
Eric: And real quick, you just looked during the April surge, is that right? The April of 2020?
Brian: Correct, this was during the time of April. Good point, so that we could have a somewhat circumscribed area in the Northeast that was facing the major surge and compare that to the rest of the country, which was not facing the same type of surge. And so what we saw was that across the whole sample of about 15,000 patients at 117 hospitals, the observed mortality rate was 21%. But that varied from some hospitals having mortality rates of 10 to 15%, others having rates in the 40% range. And this was for all commerce, not just those admitted to intensive care, so it could have included people admitted to the acute care setting. So first of all, there was quite a bit of variability. Then the question was, if we try to understand how much of a surge hospitals were seeing, did that seem to explain or be related to the variability that we were seeing?
Brian: So to ask that question, we looked at how many patients with COVID-19 were admitted to each of these 117 hospitals during the month of April, and then divided that number by the hospital size. We looked at data from Medicare data to ascertain the hospital bed count, acknowledging that if you’re a 800 bed, urban hospital, admitting 20 patients, that’s very different than being a 50 bed, rural hospital admitting the same number of patients. And so we use that to define what we call the burden of COVID-19 at each hospital, and then arrayed the hospitals by COVID burden to see if that was predictive of how they would do in terms of the observed mortality. And those hospitals in the highest quintile, meaning those hospitals that had the most surge, the adjusted odds of death at those hospitals were at 1.46. So it was about one third more likely after adjusting for all of your individual risk factors that you would die of COVID-19 if you were admitted to a hospital that was in that most burdened quintile.
Eric: So, to me, that seems to have some face validity, especially what we’ve been just talking about, that during the surges, resources get tighter and potentially mortality gets worse. So it actually does impact outcomes. Am I thinking about that right, Brian?
Brian: Yes. This isn’t exactly the question and I hadn’t had the benefit of learning about what it was like from people like we’re hearing today, but even from my colleagues there, I could see that the whole purpose of ICU is just to localize people near the resources and expertise that they’re likely to need. And if these needs meet the surge, meant that we could no longer do that. And so I think the clinical question was, “How could we deliver the same quality of care and this data suggests that maybe we can’t?” That trying to have the same outcomes, expect the same type of outcomes when you’re working with different staff, different staffing ratios, different equipment, maybe not using the standard ICU ventilator, but a ventilator that’s only designed to be used for half an hour at a time to transport a patient for a CT scan. And then relying on that for days at a time, maybe all of these things do add up, as we would fear they do, to mean that the outcomes can’t be as good.
Alex: Well on that last point, I don’t know about “can’t be as good.” I think there was also, in the top quintile, so top 20% of COVID burden, wasn’t there also tremendous variation even within that group?
Brian: Yeah. So this is a great point, and I should say that this is using data that we have based on diagnoses of patients. So there are some limitations to our analysis and that it could also be that there are other factors addressing what happened at the hospital level, such as maybe you were more likely to get turned away in non-surge settings, if you weren’t as critically ill. So there was some bias towards sicker patients at the hospitals in the most [bugging 00:25:43] settings. But Alex, what you’re getting to is another thing that we did find with our data, which is even among similarly burdened hospitals, there was still a lot of variability in outcomes.
Brian: So it is an oversimplification you’re putting out to say that it’s not possible to achieve these outcomes. And in fact, we did some sensitivity analysis to try to understand whether our results were impacted by other factors we weren’t measuring. And one factor for example, that turned out to seem relevant was hospital size. So larger hospitals did not see the same magnitude of effect and in fact, it was no longer statistically significant in only those largest of hospitals. So it could be that some hospitals have additional resources that they can mobilize to this type of care in this emerging surge situation, whereas other hospitals can’t meet that and it’s there that you’re going to start seeing the worst thing of outcomes.
Eric: Yeah. I was talking to, just last week, somebody else from a more outer borough of New York, and in part they were talking about, “Oh yeah, Manhattan was bad, but here it was devastating.” Like just even in a confined area, like New York City, the impact and the toll really did vary in a lot of other factors, including potentially not just hospital characteristics, but patient characteristics and the support we have for them potentially also impacts it. Denise, I’m wondering from your experience, how do you put together all this information that you’re hearing?
Denise: Yeah. Brian, I think you did a great job of summarizing why potentially even with the the staffing and the resources, I mean, when you were mentioning that I was thinking, “Yeah, with quality of care, our standards of care, how do you actually provide really good standards of care when you’re taking care of four to five patients?” And the truth is you don’t, and that was what was really distressing to me. I have high standards of care, when I can’t do the things for the patients, like turn them every hour, change central lines. We weren’t doing the best of infection control practices because we just didn’t have the time to do that. So I mean, it makes sense to me, not a lot of providers around that had the experience with vent management, I could just tell they were distressed because they didn’t know what to do. Just again, overwhelmed system. Yeah.
Brian: And I’ll say its… sorry to interrupt, but as an ICU physician, when I’m in the ICU, I’m in the ICU but I’m not in the room all the time. And I see the nurses and the respiratory therapists, physical therapists, other team members there at the bedside all the time and that’s really what it takes to give some of the best quality care. And I think the initial focus a year ago, there was so much talk about ventilators and the strategic stockpile, and did we have enough and how are we going to send them from one place to another? But it was really the human capital that, I think, you’re alluding to, Denise, is that you can’t replicate an ICU nurse.
Denise: And not only that but we didn’t even have enough ICU nurses. I mean, I was giving report to a cath lab nurse, to an OR nurse, to an ED nurse. They were taking care of the sickest of the sick patients and they were doing the best they could, I applaud them, they did amazing work, but if the care it’s going to be different. They don’t have that expertise as an ICU nurse who’s helping with managing these drips and the proned patients.
Eric: Yeah, I guess another question is, we have learned a fair amount over the last year with COVID, there’s still varying things that we don’t know. And whether, I’m going to turn to Sunita, whether or not the winter experience felt different in that regard than the early spring surges.
Sunita: Mm-hmm (affirmative). That’s a great question, and I think the winter surge was just so overwhelming that even though we knew more about the virus and potentially how to provide better supportive treatment, it was still the angst and craziness of just the number of patients who are coming in that made it feel, if anything, almost more chaotic. I think for those of us who were seeing these patients, we felt more protected because now we had the PPE, now we had a better understanding of what precautions we need to take, but the winter surge was indescribably overwhelming and it gave me ,at least, somewhat of a sense of what New York must have been, like both in terms of patient volume and with the initial uncertainty about what is this virus and how are we going to deal with it.
Sunita: The other thing I wanted to just add in here again, because I’m a palliative doc, one of these big sources of distress I think a lot of people felt, and certainly some colleagues in New York told me about this, was just never having had goals of care conversations, with people, for example, in the ED and now some of them needing to jump into that space and not knowing how to do it. So asking questions like, “Do you want to be on a ventilator?” Which we know is not the way to ask that question, but it was the only way to ask that question. One thing I think our staff has learned is even to appreciate what our service does even more, because we were stepping into a space where we were able to support people and hopefully impart a little bit of teaching about how do you do this when you have five minutes, how do you not do this when you have an hour.
Sunita: And so I think in the midst of that surge, that was something I think, caused a tremendous amount of distress and chaos of, “Should we send this person to the ICU, they have metastatic pancreatic cancer and now they have COVID, and what should we really be doing for them?” And it was those kinds of dilemmas that if there’s any silver lining to something so horrible that we’ve gone through as a country, it’s that understanding the importance of advanced care planning and have these conversations in a timely fashion, I think was highlighted. I think that provided just a modicum of relief during the pandemic, that there was a group addressing that.
Eric: Yeah. I think you potentially highlighted another issue. I think Denise brings it up too, it’s like for the patient that they have metastatic cancer, should we do this, should we do not? Am I providing the care that I see myself as like, I value the highest best possible care and I feel like I can’t deliver it. The moral distress that comes with that, and I’m wondering how both of you have dealt with that, Denise in New York, Sunita during the winter surge.
Denise: That was the hardest thing for me. I was actually angry for when I first got there, I’m like, “Oh my gosh, this isn’t nursing care, how am I going to do this?” But I had to do it and wasn’t the type of care I wanted to give. I didn’t feel really good about it because again, I didn’t provide the highest standards of care that I wanted to provide, I struggled with that. So when I came back home, UCSF had counselors, I went and I talked to a counselor to help understand how I would talk about these feelings. It’s still something, I’m ashamed of the care I gave and that’s hard to talk about because again, you just don’t have the time to do it and yeah, I struggled with that a lot. But now that I have the time with my patients, and I value that time, I do not take it for granted at all. And I try to do all the things you can, the little things that we do for our patients, I am so grateful for.
Eric: Sounds like it gave you some new or fresh perspective.
Denise: Very much so.
Eric: About you Sunita? How did you deal with the moral distress? Or the moral distress of the teams that you were being consulted with or on.
Sunita: There was a lot of just global distress going on from the emails about we have no CRRT machines left, what do we do? To some of the fellows or advanced practice… the nurse practitioners who were recruited to work in the ICU who may never have worked in an ICU before, it was helping people with their distress around navigating new situations that they were thrown into, like a surgical resident managing medical issues for the first time in a long time, there was that piece of it. And then of course, there’s the piece of not, as Denise said very well, not being able to do your best work or hold yourself to the standard you’ve previously held yourself to, and then losing people in mass. That amount of death and loss, I think, was very, very hard for everybody.
Sunita: I’m going to be honest, I almost feel like what I had to do over the past year was go numb. And I’m just going to tell it as it is, because I don’t know that I’m alone in this, but I didn’t cry last year. I think I’ve learned, especially in this job, that I have to hold a lot of sorrow and there’s almost no space for my own. And it was only two weeks ago that I started weeping, and I did it because I read a book, which I highly recommend, called The Friend by Sigrid Nunez, it’s fiction. But she talks, she’s navigating this territory of grief and loss, especially sudden things that change in your life and how you deal with them. And that to me just set off, I felt like she was speaking to me. The book is about something different, but also not different than, because she’s looking at death, grief, loss, how we move on if we move on.
Sunita: I just felt like that’s what I needed to really start feeling again. So I think of myself like I’m in a process of falling, that I had to ice myself so that it wouldn’t get to me. But it’s only now, in the past month or so, that I’m starting to understand what a toll that takes, what the toll it takes on the rest of your life, when you come home so depleted that you don’t want to talk to anybody. And that didn’t happen to me during the pandemic or during the huge surge, we debriefed a lot as a team about the difficulty of seeing, for example, a husband and wife both die in the ICU and that fallout with their children, or somebody who was a marathon runner getting sick and dying within two days. And the debriefs were helpful to acknowledge it, but it was almost always, for me at least, the acknowledgement of other people’s struggling. And it’s only now that I’m coming to understand mine.
Alex: Yeah. Let me just say my hearts go out to you Sunita and to you Denise for the incredible challenges you face during these surges. And what a powerful analogy Sunita of, you had to put yourself on ice and it’s only now that your emotions are falling, that you’re able to process some of the deep, deep, deep grief and moral distress of those moments. And I also want to say thank you for doing your best under such trying circumstances, and doing what you had to do to make it through, for volunteering, for working incredible hours and for sharing your experiences on this podcast. We’re coming towards the end and I’d like to give each of you the opportunity to say if you have any final thoughts, before we get to the end of the hour, of lessons learned or takeaway messages or, “Boy if we could have done this differently, here’s what I think we should have done.” Brian, why don’t we start with you?
Brian: There’s a lot of focus on technology and advanced devices, and I think what we’re all talking about here is really the human experience of being a caregiver, and then how integral hands-on touch is to taking care of patients. And so I think this stress to the system in trying to accommodate the surge of patients really showed us that it’s not, even though devices can be these things that we’re worried of running out of, like the CRRT machines, it’s the humans involved in the patient care that they’re so necessary for patients to get better.
Denise: I agree with you Brian. I mean, the thing that was most distressing to me was not being able to humanize patients and that’s what we learned a lot of. And we need people to do that and then we just didn’t have the people to spend the time with the patients to do that, so you did a great job of talking to that point.
Eric: And Sunita?
Sunita: Yeah. So I want to thank Brian for his paper. I actually think I’m going to use this in my next journal club, for our team, because I think it’s so important. So thank you for doing that work. And Denise, thank you for being willing to go into the eye of the storm, I don’t know that I could have done that, so thank you for what you’ve done. I think one of the things, when I think about the last year, is the importance of taking care of each other in the hospital too. I certainly echo what Denise and Brian have said about the humanity in medicine or seeing the human side of our patients and tending to that. I think sometimes we lose sight of the fact that those of us providing the care are also human and in need of a thank you or in need of just someone asking, “How are you doing?” And listening to the answer. I know that I have not always been great at that and so that’s something that I personally took away from this time as well.
Eric: Well, I want to thank all three of you for sharing your stories, both how you dealt with it and how you’re dealing with it now. And Brian, thank you for sharing your paper too. But before we end, Alex, do you want to give us a little bit more of that song?
Alex: A little more of the hospital team on the run. (singing).
Denise: That was great.
Eric: Thank you Alex. Again, thank you all three of you for joining us for this podcast. In some ways having lived through 2020, I feel a little bit of survivor’s guilt, of not being in similar situations as a healthcare provider. It’s good for me also just to hear your story. So a big thank you. And thank you Archstone Foundation for your continued support. And to all of our listeners, thank you for your support, and for making it through 2020 and almost half of 2021. Goodnight everybody.