For the last 10 months, Dr. Jacob Keeperman has been on the frontlines of the coronavirus pandemic.
As a critical care doctor, he’s accustomed to life in the ICU, the sedated patients, the constant beeping, the suction and air delivery sounds. What he isn’t used to is seeing so few of his patients making it out of the ICU alive.
“We are often able to save our patients. We see them get better, and we see them wake up and able to walk out of there,” said Keeperman, who is the medical director for Renown’s Transfer and Operations Center. “Right now is such a difficult time because so many of our patients are not making it.”
On one of those difficult days, Keeperman took a selfie inside the alternate care site set up in Renown’s parking garage, captioned it with, “Everyone is struggling to keep their head-up. Stay strong,” and tweeted it out. His tweet was then quote tweeted by an account that falsely accused the parking garage site of being a “scam,” which then went viral when it was retweeted by President Donald Trump.
“When I had that retweeted, I was really in disbelief,” Keeperman said. “How could anyone think that this is fake, think that this is unreal? Who would ever want to turn a parking garage into a hospital?”
Keeperman sat down for an interview with the IndyMatters podcast this week to talk about all of that and more. The written adaptation of the interview has been edited for length and clarity.
I’m sure there has been no regular day for you in the last nine months, but can you start off by walking us through what a typical day looks like?
I arrive at the hospital around 6 a.m. I do a quick walkthrough of the ICU to look at each patient to see how they might have progressed, talk to the nurses who were working overnight with those patients, do a quick check-in on them, then spend a significant amount of time reviewing laboratory data, vital signs, etc., going and really doing a thorough exam on each patient, talking with them, visiting with them.
Our patients are in an unprecedented time where they are not having visitors that they typically have — and visitors are so important for patients — but due to the mitigation aspects of this disease where we don't want to expose people, we are not having visitors at this time. So I really try to spend some extra personal time with each and every person.
Then it is doing multidisciplinary rounds — we're very much a multidisciplinary collaborative group, nurses, pharmacists, physical therapists, dieticians — where we really work hand in hand with one another, because we all have really valuable perspectives to share on each patient and to help guide their path.
Then the day is spent, unfortunately, admitting many patients, having many, many very difficult family conversations, updating them on everything that's been happening and, unfortunately, informing them often of worsening status with their loved one. Unfortunately, with COVID, we're seeing people developing multi-system organ failure where not only are their lungs affected, but it goes on to affect their heart, their kidneys, their liver.
It's really explaining that to people and trying to help families to realize that we need to make sure that everything we're doing is for the patient, not just to the patient. There are many things that we can do. I can give more medications, I can perform more procedures, but if it's not going to benefit the patient, it really isn't fair to them for us to do that. I try to learn about the patient, learn what their goals of life are, what they would consider quality of life, and then help the families understand if we're going to be able to get their loved one to that stage.
What does treatment look like for someone, from the point they come into the hospital with COVID-19 to the point where they end up in the ICU?
Patients are having a variety of presentations, but often patients who initially arrive at the hospital require a few liters of supplemental oxygen. They may not be ready to go home yet, although we have developed a very robust system where we can send people home directly from the emergency department on oxygen with remote monitoring because of our hospitals being so overwhelmed.
But, often, patients are admitted. We are constantly monitoring their oxygen levels. We are having them turn themselves onto their belly so they are face down, or what we call proning, which helps distribute oxygen to other parts of the lungs and can really help improve patient status. The number of medications we can give is quite limited with COVID. We are giving steroids to people, most commonly dexamethasone. There are some different treatments that you hear about, one is called remdesivir. We have been giving that to patients that are requiring persistent oxygen therapy or high levels of oxygen. The data on it is a little bit mixed. There is no clear evidence of harm, but also not significant evidence of improvement for most patients, although it does decrease some of the patients that need to go onto a ventilator.
Throughout this time, we are often having to increase the amount of oxygen these patients are on. For those who pretty quickly stabilize on the oxygen or are able to go down on the oxygen, they are quickly discharged. It can often happen within 24 to 48 hours. But then for some people, they're requiring more and more oxygen.
Eventually, after high flow oxygen and still having increased work of breathing, we are admitting them to the intensive care unit where we often place them on a mechanical ventilator where we're putting in a breathing tube in, we are giving them sedating medications to make it so that they can tolerate the ventilator. Unfortunately, it's this population that is having an extremely poor outcome for them. Particularly the older population, really for those 70 or older, we're talking about less than 5 percent survival rate if they're requiring a ventilator.
Mostly the care we're providing is supportive for these patients because, again, there are not specific treatments for coronavirus. At one time we were using what's called convalescent plasma, or blood products, that we take from a patient who has already had COVID and recovered. Unfortunately, that has not panned out to be helpful for patients, so we have stopped that practice. It's been a really remarkable last year where we went from having zero data on this disease process to trying to apply knowledge that we would use for other diseases in the past to learning what did and didn't work and to now refining our processes, and we continue to talk to clinicians throughout the country and throughout the world on what best practices we're coming up with and how we can best serve our patient population.
What makes a patient one of the few who is able to come off of a ventilator? What are you looking for?
Often we do see that their body has kicked in and fought. Unfortunately, the majority of the people that are getting critically ill with this are developing multi-system organ failure, where their kidneys fail, then their liver fails. At least from that population, virtually no one is coming back. Really what we are working so hard to do is trying to prevent the multi-system organ failure for those. We can often continue to support the patient's lungs, but it's when so many different systems fail that it becomes a very large challenge.
Every day, we try to decrease the amount of support the ventilator is giving and see how somebody does with that. Once we are able to be successful with what we call “weaning trials” off the ventilator, we slowly ensure that the patient is becoming stronger and stronger and are able to remove the ventilator so that they can get back to functioning and having somewhat of a normal life.
Unfortunately, we're still learning about some of the long-term effects of COVID. People are having sometimes persistent fatigue, headaches, and other symptoms that we really don't understand why or how to treat, and, again, things that we just continue to learn and that we will keep trying our best to work through.
What is it like being in the ICU right now? What does it sound and look like?
ICUs are very foreign places to most people. As health care providers, in particular critical care health care providers, we take it for granted. I don't even think about how foreign it looks. Essentially you have patients, the majority of whom are on sedating medications, hooked up to machines. There's constant beeping, suction sounds, air delivery sounds. It is almost this very surreal environment where there is very little living going on.
In the best of times, we have moderate meaningful interaction with the patients because, again, they're often sedated, but we try to keep families at the bedside. Luckily, we are often able to save our patients. We see them get better, and we see them wake up and able to walk out of there.
Right now is such a different time because so many of our patients are not making it and we are not having the families that are able to tell us about the patient so that we can really see them as a person. We are having the same beeping and incessant machine noises that we've had in the past, we just don't have the more uplifting times that we had often had and that has been the most challenging.
As health care providers, we spend lots of time encouraging one another, interacting and trying to let off a little steam by joking around, playing around. With the social distancing and the lack of us being able to interact with one another in the ways that we're used to, it's been a huge challenge and often really demoralizing and sad. You see people now in the corner crying by themselves, where in the past you would go up to one of your teammates and talk and you would maybe see them a little bit sad, you'd give them a hug, and now you can't do that and it's awful.
The rare times when a family comes in is when a patient is dying and it's their last few minutes. I talk to the family about taking the risk of them being exposed so that they can hold their loved one's hand for the last few minutes of their lives. It's just a sad, rough time and while it's really sad and rough for the health care providers, it's worse for the patients. These patients have tubes and lines coming out of them. Many of them unfortunately have wasted away in bed as they've been sitting there for weeks or months on end as we've been doing everything we can to help them, but their bodies just can't overcome this terrible disease process.
What is the longest you’ve seen someone fight for their life with COVID in the hospital?
Seven months is the longest that I've seen. In the past, maybe once every five years, I would see someone in that long — someone maybe in the hospital waiting for a heart transplant or something very chronic where they just couldn't go home. This has just been staggering and, unfortunately, even that patient that was there seven months still didn't make it.
How often is it that families have to make the difficult decision to stop fighting and let their loved one go versus continuing to fight?
When the patients develop multi-system organ failure, those discussions really become more robust with the families, explaining what the death process looks like and trying to let them know why it's important to let their loved one die with dignity and to have a death of compassion versus a death that involves multiple people performing chest compressions, breaking their ribs. While CPR can be incredibly beneficial for certain conditions, it can't fix COVID. It can't fix an underlying multi-system organ failure. When we get to that point, chest compressions are frankly not going to be beneficial because it just can't change what is going on underneath.
Case numbers in Washoe County have improved since the fall, but does it feel like the situation has improved in the hospital? Does it still feel dire?
In the last week, week and a half, our numbers have certainly gone down significantly in the hospital. Yesterday, when I was walking through the halls and seeing many empty beds in the ICU, it was this feeling of impending doom, this kind of creepy feeling that I was feeling and that I overheard many of the staff talking about.
We know that we are just starting to see the significant ICU patient population from Christmas now, and soon, over the next week, week and a half, we'll start to see the effects of New Year’s. Even the small family gatherings that people thought were pretty innocuous, unfortunately with so many asymptomatic spreaders, people still get exposed during those times. We are expecting a significant surge in the coming few weeks. I'm also quite concerned as people start returning to schools how that's going to spread among the teachers, the students, and then to their families when they go back home.
We are still in for a bumpy road. Certainly, things look better than they did a month ago, but I am also routinely getting phone calls to transfer patients from hospitals in Las Vegas, hospitals in Bakersfield, throughout the San Joaquin Valley, Southern Nevada, because they don't have capacity and the closest available bed is up here in Reno.
You gained some national attention this fall after one of your tweets, with a selfie of you in the alternate care site set up in Renown’s parking garage, was quote tweeted by an account that falsely said the parking garage site was “fake and a “scam,” which was then retweeted by President Donald Trump. Where were you when you found out about the tweet, and what was going through your head?
I was at home when I found out I had been retweeted by the president. I had finished a long week in the ICU and was trying to really recognize my colleagues who had been working so hard and are often under-recognized. The amount of despair among the staff at that time was so palpable. People were daily walking to their cars with their head down. Nothing could really cheer us up because all we were thinking about was our patients dying and the fear that we were going to get sick or we were going to get our family members sick if we brought this home.
When I had that retweeted, I was really in disbelief. I didn't believe it at first. I thought, “This must be a joke.” Then I started getting more and more calls from friends and colleagues throughout the world, informing me of this, and I thought, “Well, they can't all be working together to trick me on this one,” and found it and I started reading stuff. It was just utter disbelief. How could anyone think that this is fake, think that this is unreal? Who would ever want to turn a parking garage into a hospital? That is never something somebody would elect to do. That is something that was forced out of necessity.
I really decided to try to develop a message and to send a sign that health care is not political — health care is a right, not a privilege — and that we really need to address this crisis that is facing the world so that we can go on with our lives. We need to move past the us versus them mentality and move towards the, how can all of our lives be better? I want to offer my help and support as a frontline caregiver, helping politicians on any side of the aisle develop policy that will make it so we can provide the very best care to all of our population.
A lot of it has to be done on the federal level, but with the Legislature meeting here in a couple of weeks, what policy would help you in your role right now?
No doubt there is more funding needed for public health. That is not an issue unique to Nevada, but throughout our country. Public health funding has been decreasing over the last many decades, which is somewhat of a testament to what an incredible job our public health officials have done and the success of so many different vaccination programs and disease mitigation programs they have put into place, but certainly we have a ton of work left to do.
There's an incredible need for further funding and resources going towards emergency management, towards care coordination, and resource coordination. Like I said, I am accepting patients from the Las Vegas area into a hospital bed in Reno. There's likely resources in between or resources that could be bolstered in between that could provide better care for these patients and better coordination of the actual resources available in the state and, frankly, in the surrounding states. It's not unique to Nevada. They need to be working with the emergency management departments of all of our surrounding states so that we can truly address this pandemic and, frankly, any future pandemic in a collaborative and efficient way.
We're also going to need to use those resources to get the vaccination out to our population. There's a few things that I think are super-important. One, we need to really have a more robust education campaign that goes out via all channels to people representing all walks of life — doesn't matter political party, economic level — we have to reach everyone and we need to get to a critical mass of people being vaccinated. Education is the first part of that. Two is actually getting the vaccines to those people that are willing to get it. I've been really fortunate here in Washoe County where the public health department and the hospitals have really worked incredibly well together to deliver the vaccines. But it's mostly been done through drive-thru venues, which are super convenient, provide a lot of social distancing, but we can't forget our population that don't have vehicles, people that rely on the Indian Health Service, making sure that we are having vaccines go to them, and that we are really providing this to rural Nevadans.
We must keep funding remote patient monitoring and hospital-at-home concepts that allow patients to stay closer to home. We are working on developing that program here in Reno through Renown, which we want to offer throughout the state, but really trying to be innovative in how we can provide health care to our population, no matter where they live or how far they may be from a facility.
You tweeted recently that you received your second dose of the vaccine. What was your experience getting vaccinated? Did you experience any side effects?
I have received both doses of the vaccine. I received the Pfizer vaccine. After I received my first dose, I had a sore arm for approximately 18 hours. That was it. I felt great. Other than that, I waited in anticipation greatly for the three weeks to come before I was able to receive my second vaccine, which I received on Friday. Again, I had a sore arm. This time it lasted for closer to 36 hours. Again, the only side effect that I had. I was very fortunate. Some people are having some fevers, some people get some muscle aches. Those are normal. It is normal to get that after virtually any vaccination — that actually indicates that your body is having an immune response — so those are positive signs. The symptoms can fairly easily be treated with over-the-counter medications like ibuprofen or acetaminophen.
I highly recommend everyone get the vaccine. Like I said, I was first in line for the first dose and the second dose. Everyone in my family will be getting the vaccine as soon as their name is called and their tier comes up. We need to get the vaccine. Until we get a significant number of our population vaccinated and our community vaccinated, we need to continue to wear masks, we need to continue to wash our hands and avoid gatherings, because what we don't want to do is get COVID during that time or spread it to other people.
We are not done yet, but there is certainly light at the end of this extremely long and very dark tunnel, and we can get there together, but we need to stay strong for a bit longer. We need to continue to work together. We need to make sure that our public health officials, county health departments, have the resources they need to get the vaccines out to the population, and we need to make sure that we continue providing education and support to those so that they can get the vaccine, understand that people might get some symptoms, and might have to miss a day or two of work, and make sure that our employers understand that and that our population isn't afraid of the financial ramifications of that, and that that doesn't prevent them from getting vaccinated.
Thinking about that light at the end of the tunnel, looking forward to the summer or the end of the year, what is your hope for what life will look like, both inside the hospital and outside it?
I can't wait to go to Northern California, where my family is, and hug my mom and dad and see my nieces and nephews. I moved from the Midwest out to Reno at the beginning of November, and I haven't been able to see my family yet, even though I am thousands of miles closer. That's my very first goal and hope and the very first thing I will do. But really what I'm looking forward to is us getting back to a day-to-day routine where we can interact with one another, where we can show affection where needed, where we can go about our day-to-day lives without being in constant fear.
I think we've probably learned some extremely valuable lessons from this COVID pandemic. We all could wash our hands more, and I hope that we continue to do that into the future. We all need to be much more cognizant about staying home and avoiding people when we are sick. That will help with our yearly flu season, with all viral transmissions. But I think we can get back to a place that is "more normal."
In the ICU, and in hospital settings in general, times have changed, and I think we are going to be wearing some sort of masks or face shield for a long time to come. In a health care setting, I'm not sure when, or if, that will end. Maybe someday, but it might not. I think we'll start to have visitors back in hospitals. We're going to start having more and more celebrations.
It was really interesting over the past week when I was working in the ICU how many times I heard the jingle on our overhead speakers when a baby was born. If you think about the timing, it's about nine months from when we started our initial lockdowns.
In the future, I hope we are able to love one another more. I hope that families become closer, friends become closer. I hope that those of us with differences of opinions are able to talk and have dialogue. I hope that health care becomes a non-political issue but is addressed as the humanitarian issue that it is, and I just look forward to getting back to normal.