A18 eZ re THE WASHINGTON POST.FRIDAy, MARCH 27 , 2020
the coronavirus pandemic
BY RACHEL SIEGELThe first time Andrea Austin,
35, considered her own mortality,
she was flying into Iraq aboard a
C-130 military plane. Though the
emergency-medicine physician
had set up a living will and power
of attorney before her seven-
month deployment with a shock
and trauma team, entering a war
zone crystallized the dangers of
her job.
Now, more than three years
later, Austin is again weighing
worst-case scenarios as she con-
tinues treating patients at Los
Angeles County+USC Medical
Center while the coronavirus cri-
sis expands at an alarming rate.
She wrote down which of her
fellow doctors she would entrust
with end-of-life care. She made
clear her preference for crema-
tion. And she compiled her funer-
al playlist, starting with Israel
Kamakawiwo’ole’s version of
“Somewhere Over the Rainbow.”
Then she stored the details on
Google Drive and shared the files
with her husband and brother.
“My fear of dying is worse now
than it was when I was in Iraq,”
she said.
As millions of Americans stay
home to limit their exposure to
the virus, health-care workers are
on the front lines of a deadly
outbreak that has yet to peak.
Doctors and nurses around the
world are posting photographs of
their faces, bruised from grueling
shifts in protective gear.
At the same time, physicians
are increasingly coming to grips
with the fact they could die, too.
They are routinely exposed to
harsher viral loads as the number
of patients flooding emergency
rooms and urgent care centers
mounts by the hour. On Thursday,
U.S. deaths from the coronavirus
topped 1,000 and confirmed cases
surpassed 75,000.
That means that health-care
workers, many in their 20s or 30s,
are making arrangements to ease
the burden on their loved ones.
Every day, d octors accept the risks
of treating people in need. But
rarely has their entire profession
been thrust into such a sweeping,
indiscriminate crisis.
For Austin, this is not an ab-
stract fear. Weeks ago, she saw
photographs of Chinese health-
care workers dressed head to toe
in protective suits as the outbreak
began its catastrophic expansion.
Then she learned of the deaths of
Li Wenliang, the Wuhan ophthal-
mologist who tried to sound the
alarm about the virus, and Peng
Yinhua, the 29-year old doctor
who put his wedding on hold to
treat the sick.
“It was the age that really stood
out to me,” Austin said.
In Italy, now the flash point of
the pandemic, 39 health workers
have died, according to the Italian
news agency ANSA. Marcello
N atali, a general practitioner inCodogno who railed against his
government’s response and the
dearth of protective gear, died this
month after reportedly having to
treat patients without gloves. A
34-year-old hospital nurse who
had been working in the intensive
care unit committed suicide after
contracting the virus. She “had
been living with heavy stress out
of the fear of having infected oth-
ers,” ANSA reported.
As U.S. states and hospitals
scramble for meager supplies,
many American companies — in-
cluding Ford, 3M and General
Electric — a re teaming up to make
ventilators and respirators. But
that process could take months.
The private sector’s voluntary ef-
forts may only go so far without
coordination from the federal
government.
That leaves doctors to make
grim calculations. Though estateplanning is a basic tenet of finan-
cial planning, such deeply person-
al and difficult decisions have
taken on a painful urgency, espe-
cially as doctors brace for a surge
in cases in the coming weeks.
“We can read mapping,” said
Michelle Au, an anesthesiologist
at Emory Saint Joseph’s Hospital
in Atlanta, who is also running for
a seat in the Georgia state Senate.
“People feel like they’re standing
on a hill, and you see the tsunami
coming in.”
With all non-emergency sur-
geries canceled, Au’s team has
been redeployed to emergency
care, which includes intubating
patients who cannot breathe. The
procedure is risky in that it can
cause patients to cough, aero-
solizing the virus as physicians
hover overhead.
Au’s husband, Joseph Walrath,
is a surgeon, doubling theirhousehold’s risk. They have taken
basic precautions: Au has gradu-
ally moved into the basement. S he
showers and changes clothes be-
fore she leaves the hospital and
repeats the cycle when she comes
home.
But they still wrestle with
what-ifs: Who would care for
their 14-, 11- and 7-year-old chil-
dren? Or be executor of their
wills? Or be given power of attor-
ney?
For years, Au and Walrath had
three people lined up for each
role. But some of those loved ones
are now in their 70s and are
themselves at heightened risk of
infection. Another is also an anes-
thesiologist. On Sunday, A u called
a longtime friend — a law profes-
sor — to ask whether he would
step in.
“It’s a difficult conversation
with a high school friend,” Au
said. “We needed someone, some-
one who is not in the line of fire.”
Au and Walrath have not talked
about these contingencies with
the younger children. But they sat
down their teenage son and gave
him limited access to some ac-
counts and passwords.
“He’s 14, he’s a kid,” Au said.
“You don’t want to put it on him,
really. But he’s old enough that he
could maybe facilitate something
getting done.”
Jane van Dis, 51, is an obstetric
hospitalist in Los Angeles and a
practitioner at t he Maven Clinic, a
major telehealth provider for
women. The single mother of
1 2-year-old twins said she final-
ized her will after her divorce six
years ago.
But the pandemic has forced
her to reckon with how quickly
health-care workers can become
incapacitated and lose the ability
to make basic decisions. Last
week, she had a frank conversa-
tion with her sister and decided to
organize her bank accounts, pass-
words, automated bills, disability
insurance and life insurance for
her sister’s records. She plans to
ship it via FedEx.“I realized how hard it would be
for my sister to have to try to do a
lot of detective work,” van Dis
said. “I thought if I take some
really preventive steps now, in the
event the worst-case scenario
happened, she wouldn’t have to
suffer through trying to figure my
life out.”
Christine Sigal, 49, is an
OB/GYN, and her husband is an
ER doctor at a l arge trauma center
in Reading, Pa. Every day, they
read about doctors and nurses
testing positive for covid-19, fall-
ing ill and even dying.
The couple tended to wills,
powers of attorney and life insur-
ance policies once they had chil-
dren, but they are now going back
with updates. After the pandemic
took hold, they reviewed their
bank and retirement accounts,
passwords and the college funds
they had set up for their 20-year-
old daughter and 17-year-old son.
Then they spoke with relatives in
New Jersey and Chicago to go
through their arrangements.
“This is the first time it’s more
real,” Sigal said. “It’s not ‘What if
we both die in a car accident?’
This is the first time, going to our
jobs, that you’re thinking, ‘I could
come home from work and be
sick.’ ”
Austin, the emergency-room
physician, had planned to be on
vacation this week. Instead, she is
resting at her San Diego home in
preparation for what will soon be
extra shifts, sleepless nights and,
in all likelihood, a relentless
c aseload of coronavirus patients.
“I am not naive to the risks of
being a physician,” Austin said. “I
have spent more time thinking
about my personal preparedness,
but my devotion to my specialty
and my patients is not impacted.”
So, Austin made plans. If there
is a slide show played at h er funer-
al, she wants it set to Meghan
Trainor’s “Badass Woman.”
For the end of the ceremony, she
chose Stevie Wonder’s “Ave
M aria.”
[email protected]Medical workers are updating their wills, funeral plans
sANdy HUffAKer/THe WAsHINgToN PosT
A ndrea Austin, a doctor who works in Los Angeles, finalized her will during a tour of duty in Iraq.
Now, in the wake of the coronavirus, she says her fear of dying is worse than when she was overseas.mICHAel s. WIllIAmsoN/THe WAsHINgToN PosTCustomers dine Feb. 6 at a Waffle House in Durham, N.C. Officials see the company as having a model
risk-management plan. More than 400 of its 1,992 locations are now closed because of the pandemic.
are ready to go. Home Depot and
Walmart have similar reputa-
tions.
“They know immediately
which stores are going to be
affected, and they call their em-
ployees to know who can show up
and who cannot,” Panos Kouvelis,
director of the Boeing Center for
Supply Chain Innovation at
Washington University in St.
Louis, told occupational health
and safety magazine EHS To day
in 2011. “They have temporary
warehouses where they can store
food and most importantly, they
know they can operate without a
full menu.
In the past, the index has been
used during responses to natural
disasters, including hurricanes,
floods and tornadoes. For exam-
ple, when a tornado ripped
through Joplin, Mo., in 2011,
killing 158 people and injuring
more than 1,000 others, the Waf-
fle House Index remained green.
But this is the kind of crisis
that’s not restricted to certain
towns or states or even regions.
Waffle House’s hardest-hit loca-
tions are along the Gulf Coast
and in the Midwest, the company
said. Most of the restaurants in
Florida are still open, though, as
are most of the 188 locations
around Atlanta.
[email protected]way to help people understand
how big of an impact this virus
has had on the restaurant indus-
try,” its statement continued.
“The reference to ‘code red’
also highlights the tremendous
impacts that are being felt by
many of our associates and their
families. With so few customers
visiting our restaurants, we are
rapidly losing the ability to offer
enough work hours for our asso-ciates to earn money needed to
live their lives and pay their bills,”
it said.
That means things must really
be bad, as Waffle House is one of
the companies disaster-response
officials look to as a success story.
The Federal Emergency Man-
agement Agency considers Waf-
fle House a business with a model
risk-management plan. Supply
chains are shored up. WorkersBY JACOB BOGAGEThere exists in emergency re-
sponse industry circles some-
thing called the “Waffle House
Index.” It’s a measurement of
how the greasy-spoon breakfast
chain is faring in an emergency
situation. If the local Waffle
House is open and serving a full
menu, the index is green; open
with a limited menu: yellow;
closed: red.
And the Waffle House Index
almost never hits red.
Well, now it has. More than
400 of the company’s 1,992 loca-
tions are closed because of the
novel coronavirus. Public-health
orders forbidding gatherings of
more than 10 people in some
jurisdictions have made it next to
impossible for restaurants to op-
erate. Sales are down 70 percent
nationwide, Waffle House said in
a statement to The Washington
Post.
“Hour by hour, Waffle House’s
reality is changing,” the company
said.
For the first time, the index is
being used to measure the im-
pact of a non-weather-related
event.
“This week, we posted infor-
mation on the number of Waffle
House closures related to covid-
- We referred to the index as a
Amid closures, ‘Waffle House Index’
suggests a disaster like few others
For the first time, the
index is being used to
measure the impact of a
non-weather-related
event.
BY JULIET EILPERIN,
MICHAEL SCHERER,
JOSH DAWSEY
AND SEUNG MIN KIMLate last month, M ick Mulva-
ney, who was still the acting
White House chief of staff at the
time, told a crowd of conserva-
tive activists that the media was
exaggerating the threat posed by
covid-19 because “they think this
will bring down the president,
that’s what this is all about....
It’s not a death sentence, it’s not
the same as the Ebola crisis.”
But unbeknown to attendees
at the Conservative Political Ac-
tion Conference, Mulvaney had
already received a coronavirus
test, at the recommendation of
the White House physician. The
test, which has not been report-
ed until now, was followed by a
second this month after a niece
with whom Mulvaney shares an
apartment was around members
of a Brazilian delegation who
later tested positive for the vi-
rus.
Mulvaney is one of t hree Pres-
ident Trump confidants to get a
coronavirus test while exhibit-
ing no symptoms of the disease.
And on Sunday, Sen. Rand Paul
(R-Ky.) announced he tested pos-
itive despite being asymptomat-
ic, declining to disclose how he
was able to get tested in Wash-
ington on March 16.
The easy access Paul and
other high-ranking politicians
have gotten to coronavirus tests
highlights the extent to which
members of America’s elite con-
tinue to have greater access to
medical care during the pan-
demic, even as federal officials
emphasize that testing should
be reserved for health care pro-
viders and people who are seri-
ously ill. Even in the nation’s
capital, hospitals are reporting a
shortage of tests and the protec-
tive gear needed to administer
them.
“It’s a horrible flouting of our
public health recommenda-
tions,” Robyn Gershon, a clinical
professor of epidemiology at the
New York University School of
Global Public Health, said in a
phone interview.
In the cases of Mulvaney,
Trump’s incoming chief of staff
Mark Meadows and Rep. Matt
Gaetz (R-Fla.), White House
medical staffers arranged for
their tests on the grounds that
they risked infecting the presi-
dent. Both Meadows and Gaetz
came into contact with someoneat last month’s CPAC gathering
who then learned he had con-
tracted covid-19.
People close to Mulvaney and
Meadows said it was necessary
to get a test because they spend
so much time with the president
and other powerful lawmakers
and advisers.
William Schaffner, a profes-
sor of preventive medicine and
infectious diseases at Vanderbilt
University, said in an interview,
“We continue to emphasize that
we test people who have a fever,
and have some evidence of the
lower-respiratory-tract infec-
tion.”
For individuals who might
have been exposed to the virus
through personal contact,
Schaffner a dded, “The recom-
mendation would be to continue
and be very rigorous about so-
cial distancing, to shelter at
home, to monitor yourself for
symptoms, and to take your
temperature twice a day.”
Meanwhile, the U.S. Capitol’s
Office of Attending Physician
has declined multiple test re-
quests from senators and mem-
bers of Congress because they
did not show symptoms, accord-
ing to people familiar with the
matter who spoke on the condi-
tion of anonymity to discuss
private medical consultations.
The Office of Attending Physi-
cian has applied a stricter crite-
ria for testing than the White
House medical office, according
to a screen shot of its internal
website obtained by The Post.
“A t the OAP, individuals con-
sidered for testing must exhibit
symptoms,” t he site states. “They
must have no alternative expla-
nation for illness (such as influ-
enza A), and they must have a
nexus to risk.”
That statement was added to
the website Monday, a day after
Paul tested positive, amid grow-
ing concern inside the Capitol
complex that the 57-year-old
senator had either received spe-
cial treatment from the doctor
or had shown symptoms despite
his public denials. Paul and his
advisers have refused to say who
provided the test, beyond that it
was completed in Washington
on March 16. An adviser to the
attending physician did not re-
spond to a request for comment
on whether Paul had been tested
there.
The statement also made
clear that no exceptions have
been made to the “exhibit symp-
toms” rule, and that anyone whoreceives a test should self-isolate
while awaiting results, which
Paul did not do.
“The OAP has never per-
formed a test on an asymptom-
atic patient,” the statement read.
Paul, who has a damaged
lung, defended his decision not
to self-isolate in a statement
Monday.
“For those who want to criti-
cize me for lack of quarantine,
realize that if the rules on test-
ing had been followed to a T, I
would never have been tested
and would still be walking
around the halls of the Capitol,”
Paul said.
Mulvaney received two tests
— even though he never showed
symptoms. One took place be-
fore the president went to India
in late February, because Mulva-
ney was scheduled to go but felt
sick.
He tested negative for the
coronavirus but skipped the
trip. After Mulvaney’s niece
showed symptoms after being
around Brazilians at Mar-a-La-
go, Mulvaney consulted the
White House medical office and
received a second test.
Even as some politicians are
getting rapid diagnoses, local
and state officials in the Wash-
ington area say they lack enough
materials needed for coronavi-
rus testing. Trump officials have
said for weeks that tests should
be widely available any day. But
right now the country is testing
at a rate of 1,220 per million
residents — or 0.12 percent.
South Korea is testing at a per
capita rate more than five times
that.
Even when a patient can get
tested, delays in results have left
some in limbo, unsure whether
they have exposed friends, fami-
ly and co-workers to the virus.
One 27-year-old woman who was
tested for the coronavirus at
Washington’s MedStar George-
town University Hospital did
not learn her results for more
than a week.
“President Trump was tested
after me and got his results
before me,” she said. “NBA play-
ers were tested after me, and
they’ve gotten their results be-
fore me.”
[email protected]
[email protected]
[email protected]
[email protected]rachel Chason, Kyle swenson and
Andrew Ba Tr an contributed to this
report.Politicians jockeying to get tested find
proximity to president is fastest route