March 12, 2020

*FOR URGENT CONSIDERATION*

To: Governor Kate Brown

Re: The COVID-19 Outbreak in Oregon - Medical Recommendations for Immediate Action

Dear Governor Brown,

We appreciate the impossible situation you are in. You must balance people’s physical lives and people’s economic lives. You must balance your reputation, and our state’s place in history. You are surrounded by experts with vastly different opinions, because no one is an expert in a once-in-a-hundred-year event.

On a much smaller level, we see ourselves making decisions in the next two weeks on who will live and who will die because we don’t have resources sufficient to care for them. We have heard the stories second- and farther-hand from China and Italy and have no reason to think Oregon won’t suffer the same fate. We truly must flatten the curve of impact on our healthcare system. 

There are those who will judge you as being embarrassingly over-prepared or tragically under-prepared. We know which side we want you to be on - in this pandemic we cannot be over-prepared. Our citizens will step up in the face of the crisis. We will see the best in people come out. Be the voice that calls our citizens to action - donating salaries to those who make less at the local employer level, sharing childcare, neighborhood watches on our elderly, etc.

Here are the recommendations:

1. Establish and empower, with true autonomy to act on medical decisions, a full-time, multidisciplinary team of public health and medical experts (ID, ER, Fire/paramedic, Critical Care needed) who staff a central state-wide command center to direct a coordinated statewide response. This must include
   - A call center (Kaiser Permanente’s Regional Transfer Center is a good model for this) where front-line care providers across the state can call to coordinate transfers.
   - There should be an ethics team writing recommended guidelines for how to allocate resources when they become limited that is made public. First-come, first-served cannot be the answer. It will need to be utilitarian in nature.
   - A healthcare information line for front-line care providers with written, recorded and video updates that are meticulously kept up to date.
   - Expansion of the 211 call line with up to date recommendations for Oregonians across the state with translational services keeping all information immediately updated when changes are made. This is the information people need to know how to stay safe and where to go as things get worse.
2. Liberate state resources now to support families who will miss work and school. We will need our community to step up and staff childcare centers in schools that aren’t necessarily licensed. People should have ways to collaborate on childcare sharing in their homes where no old people are. This is an important call to action for the community that will help keep low-income families supported. This will NOT be perfect and it will be better than if we don’t do anything. Priority needs to be given in school-based care centers to children of essential workers including healthcare workers, environmental service workers, essential service providers and first-responders).
3. Close the schools after tomorrow. Across the state. You will need to have #2’s plan figured out with food and childcare services by then to avoid panic. The school districts can close them but not without significant harm unless you assure them that food and childcare services will be coming as much as possible.
4. Eliminate all evictions and mortgage foreclosures until this passes.
5. Establish paid leave support for all vulnerable families.
6. Establish shelters that house people with and without COVID-19. You will likely need to take over hotels to get everyone off the streets immediately.
7. Social isolation recommendations go into effect - No one should leave their homes except for medical care, essential supplies, essential work services and compelling other reasons you designate. Virtual work options encouraged.
8. Hand sanitizer and masks should be available at the entrance to all businesses. In Thailand there are workers at malls who check temperatures on everyone entering the mall, put hand sanitizer and masks on the people entering. It is mandatory going inside any public spaces.
9. Expansive, safely executed, reliable testing is needed immediately however we currently do not have sufficient reagents and an allocation plan for these should be instituted as soon as possible. We must be able to identify infected individuals to care for them and take steps to decrease risk to others. Mobile, drive through testing must be instituted and preferably self-testing at home kits (similar to kits in Seattle supported by The Gates Foundation). Testing needs to happen outside of the ER and hospitals as much as possible. See hyperlink for drive-through model being used in Seattle.
10. Hospitals must be able to test outpatients, inpatients, and emergency room patients commercially - outside of the OHA.
11. A tracking method at the state level for people self quarantined must be instituted for public health tracking and follow up.
12. We will need COVID-19 positive and negative nursing homes. They cannot stay in the same facilities without severe risks.
13. Healthcare workers, including first-responders, are at high risk for infection and even death according to China’s experience. We immediately need sufficient and appropriate protective attire and comprehensive testing availability for all at-risk healthcare workers.
14. Ask that Praxair start stockpiling/making oxygen. A physician from China reached out last night and said the hospitals ran out in their region. They have time to start stock-piling it if they make it now.
15. The state should have a record of all available ventilators in the state and will be able to shift them to the areas with the greatest need. Anesthesia ventilators can be used in the ICUs if the ORs aren’t being used. Firefighter transfer vents may also be used.
16. There will not be enough masks, mechanical ventilators and potentially other medical supplies (intravenous fluids, antibiotics, resuscitation medications) to treat this infection. We need tactical and massive increased production of these resources.
17. Temporary ventilators will be needed in the near future - we should contract with innovators to create these now.
18. Medical workforce expansion plans need to be created and implemented.
19. Washington and Oregon medical boards must work together for emergent and free licensing for medical personal so medical providers can cross states lines for patient care. 

We ask you to take action now. Only you have this power. Our country and state have overcome adversity before.  We need the tools to do it again. 

In solidarity and gratitude,

Maxine Dexter, MD; Pulmonary and Critical Care Medicine
Smitha R. Chadaga, MD; Hospital Medicine
Vesna Jovanovic, MD; Family Medicine
Melissa Rockefeller, MD; Emergency Medicine
Krysta Schlis, MD; Pediatric Oncology
Kristina Haley, DO; Pediatric Hematology/Oncology
Alexandra Butler, MD; Pediatrics
Mary Turner, MD; Psychiatry 
Colleen McCormick, MD MPH; Gynecologic Oncologist 
Benjamin Waschmuth, MD
Heather Bently Offerstein MD
Emily Huber, MD; Hospice and Palliative Medicine 
Trevor Phillips, MD; Emergency Medicine
Jasminka Mujcic MD
Richard Jenkins MD
Linda Deppe, DO; Family Medicine
Mona LaBar, MD; Pathology
Angela Marshall Olson, D.O., MPH, AAHIVM, Outpatient Internal Medicine and HIV Medicine
Brooke Holmes MD
Rob Dexter MD
Sharon D’Souza, MD, MPH, Radiology
T.Domi Le, MD; Gastroenterology 
Gloria Marlow, MD; General Surgery 
Larry Mak, MD; Child and Adolescent Psychiatry 
Sumi Chandra, MD; Hospital Medicine
Lisa Reynolds, MD Pediatrics 
Sarah green, MD
Sasha Mallet, MD MPH
Anne Weinsoft, MD, Internal Medicine
Megan Zaander, MD; OB/GYN
Marissa Huebner MD
Brianna Da Silva MD
Kathryn Glassberg, MD; Internal Medicine
Amanda Kim, MD
Karla Hennebold, MD Pediatrics
Joan Nelson, PA-C
Nilana Gunasekaran MD
Jennifer Lin MD
Rachel Rackow MD MPH, Palliative Care
Christine Cha, MD Radiation Oncology
John Anderson MD
Brittany Mastin DO
Monique Carroll, DO
Kathryn Kolonic, DO MPH; Longer Term Care
Gloria Alexander, MD; Hospital Medicine
Laila Sheikh Sroujeih, MD; Pulmonary Critical Care
Jill Edminster DO, Hospital Medicine
Wendy Hasson, MD; Pediatric Critical Care
Elizabeth Sokoloski, MD
Renee Prins, MD; Hematology Oncology 
Madhavi Murthy, MD; Internal Medicine
Esther Yue MD; Pediatric Emergency Medicine
Ted Huang MD, Medical Oncology
Emily Bronec, MD; Pediatrics
Naomi Fishman MD; Child and Adolescent Psychiatry
Katie Dempster, MD Outpatient Internal Medicine 
Sandra Barton MD; SNF and Home Health MD
Dave Andrews, DO; Hospital Medicine
Kate Clayton MD
Kim Vigil MD
Lindsay Stanley MD; Internal Medicine
Allison Abraham, DO; Hospital Medicine
Jennifer Brady, MD; Internal Medicine
Kathy Shaw, MD; Family Medicine
Mikeanne Minter, MD; Hospital Medicine. 
Ameet Jhooty, MD; Hospital Medicine 
Suzanne Deschamps MD; Family Medicine
Catherine Kent, MD; Pediatrics 
Wendy Jin, MD MPH; Ambulatory Pediatrics
Skye Hidden, DO: Hospital Medicine
Payal Shah, MD; Emergency Medicine
McKaila Allcorn, DO; Emergency Medicine
Michelle De Gest, MD; OB/GYN
Shauyene Hseih, MD; Ophthalmology
Sarah Copeland, MD; Pediatric Neurology
Anna Raphael MD
Ambar Faridi, MD; Ophthalmology
Jeffrey Healey, MD; Ophthalmology 
Edward Kim, MD
Terry Moy-Brown, DO; Emergency Medicine
Shirin Doratotaj, MD; Pediatric Hematology and Oncology 
Sharon McNeill MD, Family Medicine
Elise Newman MD; Palliative Care
Shannon Brigman MD, Pediatrics
Jillian Schmunk, MD; Emergency Medicine
Susie Bobenreith MD
Robin Telerant MD; Internal and Geriatric Medicine 
Claudia Taylor, MD; Dermatology
Melissa Hemphill MD; Family Medicine
Heather Dryden MD; Internal Medicine 
May Wang MD; Family Medicine 
Kelsie Storm MD; Pediatric Oncology
Chandni Merchant, MD; Internal Medicine
Allison Loh, MD; Pediatric Ophthalmology
Anika Denali Luengo, MD; OB/GYN
Amanda Holland-Yang, MD; Emergency Medicine
Wei-Lin Yang, DO; Internal Medicine
Amber McPherson, DO Emergency Medicine
Chantelle Baldwin; DO ND; Integrative Medicine and Primary Care
Tricia Rotter, MD; Emergency Medicine
Andrea Matsumura MD; Sleep Medicine 
Lorri Wilson MD; Pediatric Ophthalmology
Julie Knoll, MD; Hospital Medicine
Steve Andescavage, DO; Emergency Medicine 
Laura Davies, MD; Rheumatology
Nisha Nagarkatti-Gude MD, PhD; Ophthalmology 
Ann Marie Paulsen MD; Internal Medicine
Zheyan Chen, MD, PhD; Anesthesiology
Emily Puterbaugh, MD; Pediatrics
Rachel Young MD; Family Medicine
Erika Kempler Meyer, MD; Pediatrics
Emmanuelle Pare, MD; Maternal Fetal Medicine
Shari Sanders, MD; Internal and Geriatric Medicine
Jeffrey Stanely MD, Internal Medicine
Cassie Gabriel, MD; Anesthesiology
Catherine Caruso, DO; Neonatology
Emily Coombes, DO; Hospital Medicine
Amy Anderton, MD; Hospital Medicine
Andrea Buckler, DO; Family Medicine
Krystal Samuel, DO; Cardiology
Ronda Keller, DO; Internal Medicine
Carrie Frederick Miles, MD MPH; OG/GYN
Siobhan Gray MD; Emergency Medicine
Danna Ogden DO; Hospice and Palliative Medicine 
Michelle Thompson, MD; Internal Medicine
Sarah York, MD; Internal Medicine
Barbara Rajska MD; OB/GYN
Jeremy Kim, MD; Internal Medicine
Faith Galderisi, DO FAAP; Pediatrics
Stephanie Duckett, DO
Lydia Raney MD
Jaleh Rahimi MD
Rose Heuser, MD; Internal Medicine
Jamie Skreen, DO; Family Medicine
Jessica Schemm, MD; Psychiatry
Andrea Ferreio, DO; Physiatry 
Arija Iverson, MD; Pediatric Hospital Medicine
Richard Hall, MD; Internal Medicine
Ganesh Devendra, MD; Internal Medicine
Megan Moody, MD; Internal Medicine 
Zarya Rubin, MD; Neurology
Alison Christy, MD PhD; Pediatric Neurology
Stefan Christison, DO; Internal Medicine
Alia Paquette, DO; Internal Medicine
Daniel Toms, MD; Internal Medicine 
Richard Bowes, MD Internal Medicine
Anne Smeraglio, MD; Internal Medicine
Leigh, Hedrick, MD; Child and Adolescent Psychiatry
Mini Zhng, MD; Child and Adolescent Psychiatry
Marissa Maier, MD; Internal Medicine
Anne Houff, MD; Hospice and Palliative Medicine
Amanda Bailey, MD; Pediatrics
Annie Mack, MD; Internal Medicine/Pediatrics
Regan Duffy; MD MPH, Medical Oncology
Mara Hegel, DO; Pediatrics
Anne-Marie McCoy, MD; Family Medicine
Aoife O'Sullivan MD; Family Medicine
Amy Gilicrist MD; Internal Medicine, Director Outpatient Primary Care
Jacqueline Brady, MD; Orthopedic Surgery
Punam Hugo, DO; Emergency Medicine
Jennifer Saxer MD, Pediatrics
Kellie Schenk, MD; Radiology
Ling-An; MD; Pediatrics
Jim Warner PA-C
Debbie Murphy, MD; Family Medicine
Pejvak Salehi, MD; Internal Medicine
Bruce Goldberg, MD
Talia Khan, MD Internal Medicine
Robin Tittle, MD; Internal Medicine
Brooke Kyle, MD; OB/GYN
Sarah Powers, MD; Pediatrics
Laura Pennavaria, MD; Family Medicine
Kathleen Olread MD; FAAP
Lauren Champion, DO; Hospital Medicine
Allison Allen, MD, Maternal-Fetal Medicine/Genetics 
Tricia James MD; Internal Medicine
Ehrine DeLoriea, MD MPH; Hospital Medicine
Monica Michelotti, MD; Ophthalmology
Tracy Peck. MD; Pediatrics
Sarah Moore, MD MPH; Hospital Medicine
Swetha Singh, MD; Pediatrics 
Daniel Gilden, MD; Hospital Medicine
Paige Pfunder, DO; Hospital Medicine 
Cherie Long MD; Anesthesiology
Kathrin Meyers, DO; Hospital Medicine 
Sarah Green, MD; Pediatric Hospital Medicine
Rebecca Lindsay MD, MS; Family Medicine
Ian Hoffman, MD MPH; Family Medicine
Torree McGowan MD, FACEP
Katie Woods, MD PhD; Pediatric Endocrinology 
Bronwyn Baz, MDFAAP; Pediatric Hospital Medicine
Su Liu MD; Hospital Medicine 
Amarprit Bains, MD; Internal Medicine
Alison Ma; MD: Internal Medicine 
James Webb MD; Family Medicine
Marilyn Replogle MD; Hospital Medicine
Evan Bilstrom MD; Internal Medicine
Behareh Keith DO, MHSc Public Health Pediatric Hospital Medicine
Kerry Rhyne, MD; Internal Medicine
Brandi Spence MD; OB/GYN
Asha Jetmalani DO; Psychiatry
Mary Olson, DO; Pediatrics
Anna P Peter MD; Internal Medicine
Fernanda Huang, MD; Family medicine
Lyndsey McCartney MBBS; Family Medicine
Cory Ogden, MD MPH; Family Medicine
Eliza Peavey DO; Family Medicine
Amy Bednar, MD; Maternal Fetal Medicine
Karin Ljungquist MD; Orthopedic Surgery
Clair Kassakian MD; Nephrology
Cidgem Toroslu, MD; Pediatrics 
Abby Furukawa MD; OB/GYN
Alina Geller, DO; OB/GYN
Pilar Bradshaw, MD FAAP Pediatrics
Rachel Zubko MD; Hospital Medicine 
Elizabeth Lai, MD; Pediatric Cardiology
Mandilin Hudson, DO; Psychiatry
Benjamin Hudson, DO; Cardiology 
Avital O’Glasser, MD FACP FHM; Hospital Medicine
Bruce Thomson, MD, Family Medicine and Public Health
Gabrielle McGrew MD; Internal Medicine
Rowan Casey-Ford; Internal Medicine
Eileen McCarty MD; Child/Adolescent Psychiatry
April Crofut MD; Psychiatrist 
Lorinna Lombardi, MD; Ophthalmology
Annie Kuo MD, Ophthalmology
Jennifer Hickman MD; Anesthesiology
Lidija McGrath, MD; Cardiology
Robert Duffy, DO; Psychiatrist
Anya Bailis, MD; Maternal Fetal Medicine
Winnie Liu, MD; Endocrinology
Chau Le DO; Family Medicine
Margaret Pattison MD; Emergency Medicine
Laurel E Schwingel, DO; Osteopathic Manipulative Medicine; NeuroMusculoskeletal Medicine
Erin Allen MD; Dermatology
Amelia Baker; MD/PhD; Family Medicine
Melissa Novak, DO; Family Medicine
Penelope Lang MD; Orthopedic Surgery
Erin Wallace, MD; Psychiatry
Madhvi Wanchu, MD; Internal Medicine
Kara Connelly, MD; Pediatric Endocrinology  
Katherine R Black MD, Gastroenterology
Peter O’Hanley MD; Internal Medicine
Kyle Kent MD; Internal Medicine
Bryann McGhee MD; Internal Medicine
Karen Weis, DO; Hospital medicine
Christina Bright MD: Rheumatology 
Michelle Noelck MD; Pediatrics
Hilary Redden MD: Neonatology
Cloe Allen Maycock MD; Anesthesiology 
LIsa Carden MD: Emergency Medicine
Michelle Mills MD; Pediatrics
Phoenix North MD: Family Medicine
Kristin Bradford, MD, MPH Family Physician and Medical Director, Community Health Centers Benton and Linn Counties
Cynthia Worden DO; Family Medicine
Melanie Gipp MD: Pediatric Anesthesiology
Tamara Barstow MD; Pediatrics
Laura Burke MD; Ophthalmology
Karin Delva MD; Pediatric Endocrinology 
Lisa Bayer, MD MPH OB/GYN