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Scott Webb: Since it appears that the COVID-19 pandemic is far from over, I'm pleased to be joined today by infectious disease specialist, Dr. Mahendra Poudel to discuss treatments for hospitalized COVID-19 patients and scheduled surgeries at Salinas Valley Memorial Hospital. This is Ask the Experts, a podcast from Salinas Valley Memorial Healthcare System. I'm Scott Webb. So Dr. Poudel, thanks so much for being on today. Let's talk about convalescent plasma. What is convalescent plasma? Where does it come from and what exactly does it do?

Dr. Poudel: Before we understand the treatment for COVID-19? I think it's important. We understand how the virus gets in the body and causes infection. That's a really complex process, but in a nutshell, as the virus enters your body, it then gets inside the cells and starts multiplying. So, you know, it's important when we talk about antivirals or other medications, as well as Convalescent plasma. So it Convalescent plasma, it is retrieved from individuals who have recovered from COVID-19 and it's also a very cumbersome and complicated process that's usually done in a blood bank and we give it to patients who are sick and hospitalized with COVID-19. And what essentially convalescent plasma does, is it neutralizes the virus, meaning it gets to the virus before the virus can get in the cell or start multiplying. So it's supposed to cut down the virus from causing trouble inside your body in an attempt to prevent further damage.

Host: Yeah, I think I've got it. That's pretty amazing. Pretty fascinating stuff. So who gets this treatment?

Dr. Poudel: So convalescent plasma is given through an intravenous route, so you have to be hospitalized, pretty sick with COVID-19 pneumonia or other manifestation. And like I said, it helps to neutralize the virus. So you want to really give it early before it is replicated and starts causing damage. So if you're sick, if you have a diagnosed COVID-19 infection and you're hospitalized, then you know, you'd be eligible to get convalescent plasma.

Host: Okay. And this seems like a, as you said, it's a little bit of a difficult process and it seems kind of revolutionary at least to my ears. So when did you start using convalescent plasma to treat patients at SVMH?

Dr. Poudel: Convalescent Plasma has been around for a while and it has been used to treat other infectious disease in the past during previous pandemics. And, you know, again, it is not a magic bullet for COVID-19 therapy, recognizing that since there are so limited treatments out there for hospitalized patients, we decided to pursue administration of convalescent plasma. Our first convalescent plasma will administered first, June 20. And then after that, we've given it to about eight to 10 patients who have been hospitalized

Host: And how have been the outcomes so far?

Dr. Poudel: Again, it is really limited number of patients. So it's really hard to give, you know, has it worked, has it made difference? Has it decreased mortality? You know, they started out there are all over the place looking at, you know, bigger trials and there are multiple trials going on through the NIH CDC. I can't give you an exact answer, but so far what we've seen are in a favorable outcome.

Host: You know, Doctor more and more people are testing positive for COVID-19 in Monterey County. The majority in Salinas and South County. So is there enough convalescent plasma to treat everybody if there were to be a surge in hospitalizations at SVMH and if not, how do you determine who gets treated with it?

Dr. Poudel: So we get our plasma from a third party vendor called Bivalent, who is based off San Luis Obispo. And so far we have been able to get enough plasma if we need to. Previously, they used to supply us with a bank here in the hospital and we had, we used to have it in our lab, but since there is so much demand going on and they are also distributed to other hard hit areas right now, you know, we are also kind of limited in terms of our supply, but Scott, I got to mention one thing is again, convalescent plasma is not a magic bullet, unlike any other medical treatments. And, you know, I don't think, you know, we should be giving it to all the patients that are hospitalized. Once we get a surge, you know, these are kind of unproven or not scientifically proven therapy that help, you know, people dying or getting out of the hospital quicker. It's still in a theory investigative phase. And, you know, we would be very careful in terms of choosing patients who would get it.

Host: Have people in Monterey County, whoever covered from COVID-19 been willing to donate their plasma?

Dr. Poudel: When I talk to patients who have recovered from COVID-19 at our hospital, a lot of them are enthusiastic about donating their blood so that somebody else who is sick hospitalized could use it. It is a very complex process in terms of harvesting. And we have not done it locally here. So we direct them to Red Cross and other you know, blood centers that are harvesting convalescent plasma, usually in the  bay area or San Luis Obispo.

Host: So let's talk about Remdesivir. It's been in the news a lot. It's a little bit of a polarizing word, and I think there's a lot of confusion around it, but I know that you have been using it to treat some patients I'd like to have you talk about that and really explain how does the drug work and what does it do?

Dr. Poudel: So if you remember the pathogenesis that we call how the virus causes infection earlier, as it gets inside your cells it starts replicating. So Remdesivir is an antiviral medication that decreases viral replication in the cell, so it really should be given early on just like convalescent plasma so that the virus can't multiply and cause the implicative response that's really devastating to the patient. So it's an anti viral treated in viral replication. And it's a benefit if can be given early in the course of the illness.

Host: So when did you start using it to treat patients, how many people have been treated at SVMH so far?

Dr. Poudel: We started having access to Remdesivir really towards the end of May. And our supply comes from the state of California allocates us with extremely limited supply of Remdesivir. And what we have done is we have set for the call for who gets it amongst the four surrounding hospital together with infectious disease, critical care physician and pharmacist. So we get our supply from the state. We store it at SVMH, which has open access to all the other hospitals. And I believe we started using it towards the end of May. And since our supplies are extremely limited, we are being very selective of who gets Remdesivir. And if I remember correctly at SVMH, we have used it about a little bit more than 20 patients so far. And you know, again, convalescent plasma, our number of patients that we have used is extremely limited and it's really hard to point towards the outcomes. But based on studies, what we've seen is decreases hospitalization. It may not essentially, you know, save lives, but it will cut down the amount of time you stay in the hospital and you get discharged early on. Then from what we've seen, these are like anecdotal experiences, patients seem to get better. If we can get the medications early on.

Host: Anything else we need to know about Remdesivir?

Dr. Poudel: Both Remdesivir and convalescent plasma are not substitute for social distancing, using masks, or hand hygiene. These are medicine that we give to patients who are really sick and hospitalized. You know, both of them are IV medications. So in order to get it, you need to be hospitalized, really sick on oxygen, or on a ventilator. And, you know, because our supplies are so limited, you may not be able to get it even if you're hospitalized. So I would really urge individuals to maintain social distancing. Especially when you go out, please wear a mask, don't touch face or eyes, and continue to wash your hands because we know those common sense measures are going to decrease infection, help you stay safe, keep your family safe, and your community safe. So it's again, I really want to emphasize that. Please do not forget to use these simple measures that are life saving.

Host: Yeah, there's no doubt. I think I have washed my hands more in the last couple of months than I have my entire life. So let's talk about a scheduled surgeries, which I know for a lot of people, including my mom who was supposed to have knee replacement surgery, she had to push that back. So let's talk about that back in March, when the shelter and place orders went into effect, Salinas Valley Memorial and hundreds of other hospitals in the country had to postpone those scheduled surgeries. So exactly why did that happen?

Dr. Poudel: As we're getting deeper into the pandemic, we are preparing for what we call a surge, to take care of patients that would come in in large volumes into our hospitals. And what really that means is we got to be prepared in terms of our bed capacity and their capacity, personal protective equipment capacity, testing. And we were looking for ways to do this. And one of them would be to cancel our so-called elective procedures. And also this was in accordance to the mandate we received from the state of California. Again, what I need to remind is most of these so called elective procedures may not be elective. You know, I can give you an example of a patient that had colon cancer who needed his colon removed so that he can get a chemo radiation therapy and live longer. If we cancel his surgery, it's going to spread from his colon to other parts of the body. And it really, we take away the chance of his survival. So if you know, there's not a fine line between elective or emergency procedures. So recognizing that, you know, we didn't really cancel all the procedures. Our emergency procedures went as needed, and we have a taskforce that was looking at these semi urgent procedures and we continue to evaluate them on a case by case basis. And we were able to give that service for those patients that really needed it

Host: Sounds good. Yeah. And I understand how you would have to sort of prioritize and look at you know, all the risk factors and things like that. So when did scheduled surgeries resume?

Dr. Poudel: So once we got the mandate from the state of California towards the end of April we put together a opening service task force with physician nursing and administrative leadership to evaluate how we can move forward. And so we clearly come up with policies and plans and our first patient for elective surgery, we started in the first week of May. And then we have gradually increased our volume with the balance of operational capacity.

Host: Okay. So let's talk about what precautions the hospital's taking pre surgery. So how are you protecting patients and staff, whether that's testing self isolation, you know, that kind of thing?

Dr. Poudel: That's a great question. I think, you know, a lot of listeners are familiar with the word called asymptomatic carrier or presymptomatic carrier and transmissent. And a lot of the patients that come in for these elective surgery, they are usually symptom-free, that does not mean that they may not be carrying the virus and they could still be infectious, so recognizing that, you know, we need to protect our healthcare staff and other hospital staff from COVID-19 transmission. So based on the data and what other institutions were doing, what we have decided is we would screen those patients before their surgery, about four to five days prior to the scheduled date. And we would ask them to self isolate at home until their surgery is done. So that way we know that they will not be infected outside of the hospital in the community. And also the testing would significantly cut down on the amount of transmission to our healthcare staff.

Host: When we talk about the pre-surgery testing, where's that taking place is that at the hospital or someplace nearby?

Dr. Poudel: It is done at a nearby spot, close to the hospital at 420 East Romy lane. It's a drive through process and it's really easy to navigate and it's open seven days a week. So, you know, there is not a long wait line and it's really easy and free flowing for our patients.

Host: Now, what if a person does test positive, who's scheduled for a surgery? How long do they have to wait then to undergo the surgery after they recover from COVID-19?

Dr. Poudel: If you are positive, that means, you know, your surgery will get canceled. I think that's the most important thing that we need to make sure is patients who are symptomatic or have tested positive, do not come into our operating room. Once you tested positive, based on the recommendation from CDC, our modern health department guidelines, we wait at least 14 days from the onset of symptoms. And we would reschedule you for surgery, we do not retest them, recognizing the limitation of retesting. And we go by symptom-based timeline.

Host: I wanted to follow up with, if a person is scheduled for surgery, just to say in the next couple of days, what else do we need to make sure that they know before they go through this process?

Dr. Poudel: One of the thing that's really important to let our patients know is we are taking all the precautions to protect yourself, our healthcare staff and your community. And we really are concerned about all our patients and we want to operate at the most safe environment. So, you know, that way we have taken careful measures so that there is a positive patient experience with the workflow. And we recognize that this is a tough period for our community. As we all are going through this pandemic, I would urge them that they will be taken care of here. They do not need to be scared and we will do everything we can to protect you and also protect our staff.

Host: Yeah, that's great. You know, protect the patients, protect the staff and, you know, lastly doctor, as we wrap up today and thanks so much for your time, as you say, people are fearful of going to doctors appointments or going to the ER, you know, for emergency care. So what do you want those people in the community to know about going to the doctor, going to the hospital? What do we need to let them know? As we wrap up here today,

Dr. Poudel: I have to upend them. It grows bigger and bigger. Patients are scared to go out, not just to go to doctor's office, to go out about their lives and healthcare is such a priority in everybody's life. And, you know, there are certain conditions that if you do not seek early medical attention, it could be really life threatening and our clinics, our emergency, our doctor's office, we have a protocol in place to keep you safe. So please do not hesitate to seek medical attention in the emergency or in the doctor's office. We also have telehealth available for our clinic patients. So there is that option that you can call the clinic to set up if phone visit or, you know, FaceTime is it. So please do not hesitate to take, take care of yourself and seek medical attention before I end, again, I want to reemphasize that simple measures, like using a mask, social distancing, washing your hands are known to decrease infection and save lives. So please, I urge everybody to follow this recommendation.

Host: Absolutely. Well Doctor, thanks so much today, you know, for your time and your expertise and great explanations. I feel like I really understand some of this stuff better and I hope the listeners do as well. So again, thanks so much for being on and stay well. For more information on the Coronavirus, please visit svmh.com/coronavirus. And we hope you found this podcast to be helpful and informative. This is Ask the Experts, a podcast from Salinas Valley Memorial Healthcare System. I'm Scott Webb stay well. And we'll talk again next time.