‘In Montana, We Have The Luxury Of Skepticism’: Havre Doc Talks Coronavirus

On Wednesday, The Havre Herald stopped by Northern Montana Hospital to talk about COVID-19 with Dr. Kevin Harada, chief of staff of internal medicine.

Reporter, photographer, and doctor kept a healthy distance during the interview.

Dr. Harada addressed many aspects of the new coronavirus, including why it is believed to be so dangerous; the skeptical narrative that says we’ve gone too far in trying to mitigate the spread; the possibility of ventilator rationing; the controversial off-label use of certain drugs for treatment; and what it will take to get “back to normal.”

COVID-19’s impact has been inescapable. The death toll climbs daily, hourly. We’ve been asked to stay away from each other. Playgrounds have been taped off, large gatherings barred, and Walmart has implemented a customer limit. Schools, churches, restaurants, and bars have been closed. Law enforcement has lowered the bar for arrests. Courthouses have locked their doors, and some inmates have been released.

Another major change has been how health care facilities operate, even in areas with few cases like north-central Montana. Hill County has one confirmed case to date.

Starting about mid-March, Northern Montana Health Care facilities went into lockdown. Non-essential procedures were postponed. At the same time, NMHC also opened an alternative flu clinic on the east side of its campus, where medical professionals check patients with flu symptoms and possible COVID-19 symptoms. The clinic sees patients on a regular basis.

Back then, in the middle of March, Montana had four total confirmed cases — about 350 fewer cases than we do a month later, and two fewer than the state’s reported deaths as of Friday. But with hundreds of Montana cases and the nationwide total closing in on 500,000, some people question — and outright disagree with — how the pandemic is being handled.

Are we overreacting? Is the purported solution more harmful than the disease?

Hundreds of thousands of Americans die every year from the flu, diabetes, heart disease, and cancer. The Centers for Disease Control and Prevention reports that during this past influenza season, up to 62,000 people may have died from the flu. Thousands of Americans die from drug overdoses, suicides, and gang violence each year.

Yet, we’ve never considered halting life and possibly catapulting the economy into a depression for those reasons.

And now, new reports reveal what many already suspected: While social distancing and quarantining may be flattening the curve, their unintended side effect is an impact on our mental health.

So what makes this time, this disease, different?

That was one of our many questions for Dr. Harada. The interview has been edited for clarity and brevity.

Dr. Kevin Harada speaks to The Havre Herald. (Teresa Getten, The Havre Herald)

Havre Herald: What makes this disease unique?

Dr. Harada: I think the name of it says it all. It’s novel coronavirus, meaning it’s new.

With bacterial pneumonia, we have decades of data and antibiotics and how to treat it.

But with this new virus, we are learning as we go. Experiments and studies are ongoing. And things are being fast-tracked through the FDA like you have never seen before. A lot of this is experimental.

But not having a specific toolkit to fight a new virus, it’s kind of stressful sometimes.

What’s it like to be a physician during this once-in-a-lifetime pandemic?

It’s humbling to know that even with our advanced technology, our medicines and things like that, we still have to move forward and study medicines, review best practices.

It just shows that medicine is not stagnant. All it takes is four months to upend life and change medical facilities in what we would consider the most advanced societies.

Speak to the people who are skeptical, who believe the measures we’re taking — upending society — to prevent the spread have gone too far and may be doing more harm than good. How is COVID-19 dangerous and how is it different from, say, other diseases that kill tens of thousands of Americans every year?

I would first off say that, here in Montana, we have the luxury of skepticism. If you go talk to our colleagues in New York or Louisiana or Washington, they don’t have the luxury of skepticism because it hit them right in the mouth. Here in Montana, I think our forward preparation gives us the luxury to bring out the skeptics.

But the reason why it’s different, it’s because it’s new. Humans have not seen this virus before. So we have no built-up immunity to it. We have flu season every year, and yes, the flu virus changes every year, and yes, we vaccinate against it every year and it still never goes away. But most of us have had the flu before in some way, shape, or form, and we have some sort of immunity to it with the vaccine.

What we’re seeing is that the fatality rate with this virus is about 10 times that of the flu.

Coupled with a surge into the hospitals, overwhelming the hospitals, and a fatality rate that — we don’t know yet — but could be 10 to 20 times that of the flu, it just adds up to an unacceptable death rate.

Is it worth the disruption we’ve allowed this disease to cause in our lives?

I think absolutely.

Some of the ethical things that are having to be adjusted are essentially wartime decisions that doctors are having to make in Italy and Europe, and other places where they’re truly short in ventilators. And even in New York, to some extent, they’ve had to make some of those difficult decisions.

Are you talking about rationing care?

Who gets a ventilator and who doesn’t. I think that’s what keeps us up at night. I don’t want to be in the emergency department at midnight, saying Patient A gets it and Patient B does not.

Have you heard they’re making those types of decisions in New York?

You know, New York is actually caught up. I can’t say personally if they’ve made those decisions, but that was their push of why they needed so many ventilators, so they wouldn’t have to make rationing decisions. But they definitely made those decisions in Italy.

Has the NMHC staff discussed what to do if there aren’t enough ventilators to go around?

We’ve been part of a group of hospitals that have been developing state ethics goals in conjunction with some other states to have protocols in place with ethicists and state representatives.

So yes, those are all things that have been discussed.

So should it get to a point where equipment must be rationed, there’s been discussion on how to do that, right?

There’s been some discussion, but even if you have a nice flow sheet, that discussion is going to be terrible.

How specifically does COVID-19 endanger our Hi-Line community?

The main challenge we are all trying to avoid is a surge of patients that can overwhelm the hospital. That’s the absolute worry that everyone has. If everyone gets it at the same time, you don’t have hospital beds, you don’t have enough ventilators, etc., to provide care to the patients.

And the other part is we don’t have any other treatments for it, other than supportive care. You hear about the treatments coming down the pipeline — they may work, but there’s nothing that’s been proven.

The president has expressed optimism about off-label use of drugs like chloroquine. Is that drug something doctors at Northern Montana Hospital would use to treat someone with the virus?

Chloroquine is an anti-malarial, and we don’t have a whole lot of that because we don’t have malaria. The brother to that is hydroxychloroquine, which is readily available. We have it. Hydroxychloroquine is used for lupus, for rheumatoid arthritis, and things like that.

Those are the guidelines I would say we review the most. There are ongoing studies showing there are some benefits to it, but, again, those are still not proven. This is part of the daily learning thing.

We follow larger organizations as well. We review guidelines from Massachusetts General Hospital, Harvard, Northwestern, Chicago, University of Washington.

So, as of right now, it is in treatment protocol.

You would use it?

I would use it, yes.

How prepared are we here in north-central Montana for an outbreak? Do we have ventilators, beds?

I think that we are prepared to the capacity of our facilities and our equipment. We have two meetings a week with the hospitals in our region and other hospitals in Montana. We’re up to date on who has beds, who has what. And we talk to them about transfers, how we’re going to do this.

I think we have a unique opportunity because we’ve seen what’s happened in other states. We’ve seen Washington and California, New York, and we’ve been able to learn some of those things. And actually, we’ve been able to start to implement and discuss those policies before we’re in the thick of it.

Is the medical staff equipped with masks and gowns?

That’s somewhat of a loaded question.

Yes, we have adequate personal protective equipment to protect our staff.

One of the things we’ve done upfront is we’ve conserved from Day 1. We knew supplies are short. So we’ve implemented a conservation policy from Day 1 because if we start seeing a surge in patients, you burn through it pretty quick.

So everyone is good until they’re not good.

How is Montana doing now compared to how bad we were supposed to be hit with COVID-19? One model in particular, if I recall correctly, had Montana peaking around April 16.

I will cautiously say that we’re holding strong. I truly believe that the shelter-in-place and some of the other things they’ve put in place have and are working.

The models are difficult. We actually looked at three or four different models yesterday, and you’re right, one model had us peaking here in the next couple of weeks. Another model has us peaking in four weeks, maybe even longer. So we’re watching multiple models to see where Montana fits in the whole scheme of things. We watch other states to see what their numbers look like.

We are hoping we’re going to be over or at that peak for two weeks, but we just don’t know.

Is it possible we may have peaked?

I don’t think we have peaked yet, but it is possible we are mitigating so that our peak isn’t as high. We may see a rolling hill rather than Mount Everest. That’s what we’re hoping for.

What are some of the advantages and disadvantages we have in north-central Montana?

Our main weapon is six feet.

So we have lots of space?

We have lots of space. And we have lots of space to spare.

I have friends who live in New York. If they want to go outside, they have to walk down a hallway, they have to meet people in the hallway. They have to use the elevator, they have to meet the doorman. To get outside, they have to interact with people, whereas we walk out our back door and we’re in our backyard and we can play with our family. We have that unique lack of population density.

We can distance ourselves from people quite easily, unlike in New York. One of the things that’s hurt New York is the population density. You’re just going to run into people.

Even in Montana’s more dense centers — our Billings and Missoulas and Gallatin — that population density still isn’t comparable to that of a big city.

If we are able to distance ourselves, I think we have a unique opportunity to prevent a big peak.

What are we learning about COVID-19, and are medical professionals adjusting in response?

To be honest, there’s almost too much information. They’re running studies in New York and Chicago right now. I have a friend who’s an infectious disease specialist in Chicago who’s right in the middle of it, who I speak with quite often.

All the studies were coming out of China, so we would review those studies.

But then as Europe got hit, those doctors and governments were running studies.

And now that the United States is in the thick of it, we’re creating our own data.

And where we’ll be in five, six, seven months is that all of this data from all these countries will then lead to treatment guidelines and best practices.

But, as of right now, we look to some of our bigger centers that are harder hit. University of Washington is one of our resources. Northwestern University in Chicago too. Soon we will be able to tailor most of our treatment recommendations off of fully U.S. data.

Are we still very strict about testing people here? If so, why?

We’re very strict.

We have sent out a total of about 30 tests. It’s why I referenced in my letter that there is almost assuredly another case.

Our flu clinic sees anywhere from 20 to 30 patients a day. On slower days, maybe 15. If you’re able to go home and take care of yourself, we ask you to isolate yourself and isolate your family until you get better.

We are mostly testing people with respiratory illnesses and people who have interactions with a lot of people.

Do you guys hear from a lot of people who believe they have coronavirus?

Yes. In this day and age, you have a cough and a fever — what comes to mind? So, yes.

We evaluate them, we evaluate their history, we evaluate where they’ve been, what symptoms they have, and then we determine if they need to be tested.

What would you like people to know about COVID-19?

I think it gets back to your question about skepticism. Could this really affect Havre, Montana, population 10,000?

I think our neighbors in Shelby are an indication that, yes, it can. They’re up to 18 cases, three deaths.

Our biggest threat here in Havre is an imported case. Our one confirmed case that we’ve identified here in Hill County was a travel case. It was brought in. That patient was isolated. The biggest threat to our community — Havre, the Hi-Line — is bringing it in. Someone traveling to Bozeman and bringing it back. Someone traveling to Seattle and bringing it back.

In other Montana communities, there’s been community spread, meaning I have it, I gave it to you, neither of us traveled and so we have transferred it in the community. We have not seen that here in Hill County. Taking the shelter-in-place seriously has helped.

Is the hospital still seeing patients? Are you busy?

Volume wise, we’re down. We have no nonessential surgeries. Our community has been great for using the ER for only essential things, truly emergencies.

Our patient volume is down but our staff remains busy. We’ve had a big repurposing. Everyone has chipped in excellently for a whole-team approach.

When can we go back to normal? What is it going to take to do that?

That’s a hard question.

I wish I had my crystal ball on that one.

(pauses)

Do we need a vaccine to go back to normal?

From a world and national standpoint, to go back to normal, yes, we need a vaccine — which is, at the earliest, at the beginning of next year.

When we can start lifting restrictions and things like that? I think the closer we see that curve peaking and going down, then we start slowing restrictions to what you can do.

I think we will see some sort of normality this summer — I think. That’s the question everyone has.

Does the governor consult with local physicians in his decision-making?

Absolutely. The Montana Hospital Association, the Montana Medical Association — he takes all of those groups’ information and then he takes all of that into consideration for his directives.

These next two weeks will really help us, because he extended the shelter in place to April 24. If by then, cases are still on the rise, I think his hand will be forced to prolong the shelter in place because we can’t lift anything that we have done if our cases are still escalating.

But if there are no new cases, we’re kicking people out of the hospital, then he starts loosening the strings, especially in the less-hit areas.

Write to Paul Dragu at [email protected]