Recent Posts

RSS

April 15th, 2020

Podcast 263: Checking in with Connecticut and Michigan on medicine after COVID-19

(1 votes, average: 5.00 out of 5)

This week’s guests, Dr. Andre Sofair and Dr. William (“Rusty”) Chavey are physician-editors on the daily clinical news alert called Physician’s First Watch.

I went back through the recent issues and found this January 10 entry, which began “The CDC is requesting that clinicians ask their patients with severe respiratory disease about any travel to Wuhan City, China. That city has seen at least 59 cases of pneumonia caused by an unknown pathogen since December. Seven of the 59 are critically ill.”

How quaint that all seems now — so three months ago!

Both our guests are being kept busy by that mysterious pathogen, and I thought I’d check in with them.

Running time: 20 minutes

Other interviews in this series:

  1. Dr. Anthony Fauci
  2. Dr. Susan Sadoughi
  3. Dr. Matthew Young
  4. Dr. Julian Flores
  5. Dr. Kristi Koenig
  6. Dr. Renee Salas

TRANSCRIPT:

Joe Elia:     Welcome to Clinical Conversations. I’m your host, Joe Elia. This week’s guests, Andre Sofair and William Chavey are physician-editors on Physician’s First Watch, a daily clinical news alert. They are part of a larger group of clinicians collaborating with First Watch’s writers — people like me.

Dr. Sofair and Chavey have the unique task of looking back over the weeks’ stories and choosing the most important. Their choices and the reasons for them show up first thing in Saturday morning’s email edition. I went back through recent issues and found this January 10 entry, which began “The CDC is requesting that clinicians ask their patients with respiratory disease about any travel to Wuhan City, China. That city has seen at least 59 cases of pneumonia caused by an unknown pathogen since December. Seven of the 59 are critically ill.”

How quaint that all seems now. It’s so three months ago!

Both guests are now being kept quite busy by that mysterious pathogen and I thought I’d check in with them.

Dr. Sofair is a Professor of General Medicine at Yale Medical School where he also holds appointments in the School of Public Health, and Dr. Chavey is an Associate Professor and Service Chief in the Department of Family Medicine at the University of Michigan, Ann Arbor.

Welcome to Clinical Conversations, my friends.

Dr. William Chavey:     Thank you for having us, Joe.

Dr. Andre Sofair:     Thanks for having us.

Joe Elia:     Dr. Sofair, you’re in New Haven, so what are you seeing on the ground there? Connecticut’s cases have more than tripled since the beginning of April and now hover around 13,500. The universities have emptied of students, but what’s the atmosphere on the wards?

Dr. Andre Sofair:     I would say that the atmosphere is quite positive. Our hospital and medical school have done a really good job, I think, in terms of communicating the situation with all of the frontline providers — nurses, clinical techs, the physicians — and I think we have a very good supply of personal protective equipment, which has been critical. And I think that we started our planning process very early on before we started seeing cases, so I think that the frontline staff feels supported and I think that the atmosphere is as good as one would expect. given the circumstances.

Joe Elia:     And Dr. Chavey, you’re just west of Detroit, of all places, in Wayne County, and that’s a hotspot. Ann Arbor must also be pretty quiet with the students gone, but you’re in family medicine there, and that’s an area with lots of closed businesses because of the national quarantine that we’re in. What feels unique about this experience to you?

Dr. William Chavey:     Well. We could probably talk for hours on that, Joe. I think the first most unusual thing for us was the contraction of ambulatory services, so we went from having seven clinic sites to contracting them down to two. Scrubbing schedules and moving everything that was not urgent, either to be deferred for later or to be done by telemedicine, and as this happened everywhere the escalation of telemedicine has been remarkable and dramatic over such a short period of time once the barriers were removed. In juxtaposition with that, we are also active at the University of Michigan Hospital, so we were preparing for what we thought was going to be a surge of historic proportions at the hospital. I was on a planning committee for a field hospital and we were looking at having 1500-bed field hospital. At this point, we’re not planning to have a field hospital at all. We are going to obviously record the efforts that we put in place in case we have to do that at some point, but the social distancing has helped quite a bit.

Our numbers are relatively flat. We are now living in an eerie world where we have a hospital that’s typically about 95 to 98% at capacity, and by cancelling all of the elective surgeries and so forth we now have a hospital that’s at about 65% capacity, and an ER that is seeing patients at a much lower rate than expected. And no one really knows what’s happening with the strokes, and the heart attacks, and the trauma that were coming in before, because they’re not coming in now. And the other interesting phenomenon — because in family medicine we also do obstetrics — a very unexpected phenomenon has evolved there where, when women come in, the thought now is that during part of labor that is an aspect where healthcare professionals might be a particular risk from aerosolizing the virus, and so there have been some studies looking at what percent of pregnant women, when they present to labor and delivery, are positive even if asymptomatic, and those numbers are somewhere between the mid-teens and 30%, so there are some protocols where they were screening every woman who would come in.

Well. The interesting part is a lot of women were declining that, because if they get tested their husband may not be able to come in with them and they don’t want to labor alone. So you now have this odd tension between wanting to protect the healthcare professionals who want to know if a woman is positive and a woman not wanting to be tested because she would then have to labor alone. So from the family medicine perspective we have all of these different areas, all of which have very unique, very unexpected tensions and things that have evolved.

Joe Elia:     So, how are you navigating that, Rusty? How are some of those conflicts resolved?

Dr. William Chavey:     Well. I’ve described a lot of what people are seeing in the literature as “science, thinking out loud,” and I think what we’re also seeing is “medicine responding out loud.” Each of these is unique and idiotypic in its own way and something that we had…I mean, no one ever was anticipating this dynamic in labor and delivery, so the obvious question is how do you handle a woman who refuses to be tested, and how do you protect the healthcare personnel? This is a dynamic we had never considered before.

Joe Elia:     Andre, you’ve spent time in Rwanda setting up medical education facilities and other places, too. Do developing countries have lessons for the first world about how to behave during a pandemic?

Dr. Andre Sofair:     I’m sure that they do. You know, they have different pandemics. For instance, I was recently in Rwanda and they had an outbreak of dengue, the first significant outbreak that they’ve had in years, and so they’re able to mobilize things and do things in the hospital much faster than we’re able to, I think, because the hospitals tend to be smaller and the bureaucracy tends to be not as robust as ours, so I saw them mobilize the units and set up bed nets at the hospital very, very quickly for in-patients to try and prevent nosocomial transmission of dengue, for instance. They also have a lot of experience with the use of personal protective equipment that we don’t have as much, and as especially masking. For instance, they have a lot of tuberculosis and other infectious diseases that we don’t have here, so there are certainly things that they teach us that we can learn from them.

Joe Elia:     Now, in both places, Connecticut and Michigan, are visitors allowed into the hospital? I’m reading reports that for instance at Mass. General everybody’s got to be wearing a mask when they go into the hospital, whether you’re a visitor, or patient, physician. Is that true now, pretty generally?

Dr. Andre Sofair:     At our hospital, everybody is to wear a mask, healthcare providers, when they come into the hospital and wear it throughout the day. Those are typically surgical masks, the N95 masks are reserved really for people that are taking care of COVID-positive patients, or patients that are being evaluated for the possibility of COVID. We have a very strict visitor restriction policy at our hospital where visitors are only allowed to visit if people are dying or on hospice.

Dr. William Chavey:     And we’ve had the same, and we also see this in the ambulatory setting. We’re not allowing people to accompany patients when they are physically seen in the office unless it’s a young child or someone needing assistance in a wheelchair. Something of that sort.

Joe Elia:     Okay.

Dr. Andre Sofair:     I can say, Joe, just to add to that, it has made the stay for the patients very difficult, as you can imagine. They’re communicating with family and loved ones over the telephone. Physicians are doing the same, and it’s also very difficult to the family because of the fact that they don’t have the daily updates in person with their loved ones in the hospital, so it’s made the care of patients very challenging, I would say.

Joe Elia:     So, questions for the both of you. What do you fear will happen as a result of COVID-19.

Dr. William Chavey:     I think right now here is a great deal of uncertainty and health systems, private medical offices and clinicians about what the future holds, and I think one thing that is clear as we emerge is that the post-pandemic world will not resemble the pre-COVID world, and I think…and if it is I think that’s a shame. I think we need…I think one fear or concern I would have is that we pretend all of this is going to go away and things are going to operate the way they used to, and I hope and think that’s probably not going to be the case, but none of us really know, and I think we’ve had to realize that we’re not in control. None of us really know what that post-pandemic world is going to look like. There are health systems that are beginning to lay off staff and faculty and are cutting salaries. There’s concern that we will never have the same volume of patients, or in the same nature that we had before, and I think a lot of people are struggling to figure out what their role is going to be in this post-pandemic world.

Dr. Andre Sofair:     Yeah, I would agree with what Rusty said. I think there are too many unknowns at this point, in terms of how long it will last, what kind of immunity, and what kind of herd immunity, if any, we’ll have. What kind of vaccines, if any, will be available, and whether or not they’re effective in terms of preventing [spread in] the population, so I think there are a lot of unknowns.

But I do think that there will be some changes in the way medicine is practiced. I think that there will probably be more telemedicine than there was before. I think that our rounding procedures will probably be different. I think that our use of personal protective equipment will be different. I think that our attending of medical conferences, whether locally, nationally, or internationally will be different. I think there will be a lot of reliance on communication that is at a distance, as opposed to in-person. I do also share the question and concern about what will happen with out-patient practices because a lot of out-patient practices now have had to close because of lack of patients, and will they be able to reopen in the future because of staff having been laid off and maybe going to other types of work, so I think it’s still very unknown, but those are the changes that, at least, I see in the future.

Dr. William Chavey:     So, Joe, in response to what Andre said there was a…there’s a policy arm of the American Academy of Family Physicians, the Graham Center, and they published data that by June 60,000 family medicine offices would be either closed or would significantly cut back, and this would impact 800,000 employees of these offices, so this could be an existential threat to private practice in that regard, and as Andre said, will they come back online, will they be able to? If they don’t what will happen with the patients who have been going to those practices and can the hospital-based practices, absorb those patients when all of this is said and done.

Joe Elia:     It must be different to prepare yourself for the clinical day in these times. Is there something that…has your routine changed as you get up in the morning and you’re about to go in? Do you recall something that a favorite professor of medicine told you as a young resident, or is there anything different about it?

Dr. Andre Sofair:     I would say for me the major change is how I have led my life at home, so for instance for the past month I’ve been living in the basement and on a different floor from my family, and I’m eating my meals separately. I’m always, or at least try to be, six feet away, and the most notable thing for me is where I have my clothes, how I put them on in the morning, and then when I come back home how I take them off and how I try to make myself as clean as possible so I don’t run the risk of bringing anything home to my family, so that’s been a major change for me.

Dr. William Chavey:     I guess one report from the ambulatory setting yesterday, I think my first four patients were all done in different ways, and we have…we’re doing some drive-by or drive-thru testing so we’re seeing some patients. We walk out to the car…we put our personal protective equipment on and go to the car, and we’ll do sampling there, check blood pressures, do what we need to do with them in the car, and one of my patients was done via that approach. We have divided the clinic into two halves, one clean side, if you will, and one where patients who might have some sort of infectious symptoms come, and so I had to go on one side to see one of the other patients. Another patient was just via phone call and another patient was telemedicine, and so instead of getting into a groove I’m seeing patients in all of these different manners and having to adjust, and take off one coat and put on another coat and go into one office where I have a computer to do the telemedicine, and you don’t…the comfort level that you had, that you developed over the years gets lost because you’re in very unusual situations.

Joe Elia:     Yeah. What advice would you give to a young clinician just starting out in the middle of all of this?

Dr. Andre Sofair:     When I was in medical school, I went to medical school in the Bronx at Albert Einstein, and that was the very beginning of the HIV epidemic, and so people were very unsure about how it was transmitted, what you had to wear to go into the room, and I think that there are a lot of analogies to the way that we responded then and the way that we respond now. And I really think that medicine is still a wonderful profession, whether you’re starting now where there’s a lot of insecurity about where we’ll be in the future, but I think that the calling is still the same. We’re there to collaborate with one another, to do our best together, to take care of suffering patients and families that are afraid, and so I still think it’s a very exciting time to be in medicine, and it’s interesting that some of the house officers that are on our unit said that they’ve spoken with some of their young colleagues who are not in medicine now and wish that they were.

Dr. William Chavey:     I think if you buy someone a gift you can either buy them something you would like or you can buy something they would like, and certainly the latter would be the preferred. Medicine is still, at its core, a vocation of service. And I think the advice I would give is, don’t go into it with your own perspective, your own sense of what it ought to be. If this has taught us anything it’s that we have to be flexible, and if you’re going to be giving the gift of service to a patient it has to be what they need in that environment, and that environment may change, and you may have to put aside your own sense of how you might want to do it in order to be prepared to serve.

Dr. Andre Sofair:     You know, the one thing that has struck me about…at least at our hospital, the way things have gone, and it’s been very comforting to me, is just the preparation on the part of the medical school and also of the hospital. Our hospital had a lot of foresight and started the preparations a couple of weeks before we started seeing our first cases, and we’ve been going at this now for about six weeks, and we have daily calls with our chief of our department of medicine and lots of leaders in the department to brainstorm, to get information out. Nursing has the same thing. The hospital leadership has the same thing, and I think that that planning processes has given people a lot of comfort and has allowed us not only to take care of each other but also to take the best care that we can of our patients. We have teams of physicians and researchers that are working on protocols to make sure that we’re delivering the best medicine that we can, given the lack of evidence.

We have teams that are working on recycling the PPE to make sure that we have adequate PPE that’s safe for us to use, and all of that gets disseminated on a daily basis out to the hospital and to the workers, and so I think that it has been the best situation possible given the circumstances.

The other thing that I just wanted to say — that has really touched me — is the bravery of all of the staff. We have residents that are in pathology, that are in psychiatry, that are in dermatology, that are in neurology that have volunteered to help out on the medical service to take care of patients, and we’ve had attending physicians from all of those levels that have also pitched in to help out. The anesthesiologists have been very helpful, for instance, in our ICUs to helping out the critical care attendings that have been strapped because of all of the patients that have needed care, and there’s been just an extraordinary amount of collaboration between the physician staff, the nursing staff. And the nursing staff have also stepped up. We have nurses that have not worked in an ICU for years that are now working in an intensive care unit, taking care of very sick patients, COVID-positive patients and non-COVID positive patients just to pitch in, so that has been the greatest memory and experience that I’ve had through this whole epidemic.

Joe Elia:     I want to thank you, Dr. William Chavey and Dr. Andre Sofair, for spending time with us today and sharing the wisdom of your experience with COVID-19.

Dr. Andre Sofair:     Thank you, Joe.

Dr. William Chavey:     Thank you, Joe. Thanks, Andre.

Dr. Andre Sofair:     Thanks, Rusty.

Joe Elia:     That was our 263rd episode. All of the previous episodes are searchable and available free at podcasts.jwatch.org. We come to you from the NEJM group. The executive producer is Kristin Kelly. I’m Joe Elia. Thanks for listening.

 

April 6th, 2020

Podcast 257: Here comes the summer after COVID-19

(4 votes, average: 3.50 out of 5)

Four weeks ago — in early March — I interviewed Dr. Renee Salas about climate change and clinical medicine.

Back in those halcyon days, COVID-19 was very much a gathering storm, but it had not yet slammed into the United States.

Here we are, over 10,000 U.S. deaths later in early April, not having heard of much else but the disease.

I thought to use this interview now, both to give listeners a small break from “The Virus” — as President Donald Trump refers to it — and to remind us how quickly things can change on the planet.

We make mention during the course of the interview of the need to take the lessons from unanticipated disasters. We can only hope that the lessons the present crisis affords us won’t be lost.

Links:

Dr. Salas’ Perspective article in NEJM

Dr. Salas’ earlier NEJM editorial, written with Drs. Malina and Solomon, on “Prioritizing Health in a Changing Climate”

Harvard’s Global Health Institute

Running time: 18 minutes

TRANSCRIPT OF THE INTERVIEW WITH DR. SALAS

Joe Elia: This is Joe Elia. We’ve just turned the clocks forward here in the US and so summer is looming after a warm winter for Boston. If the past serves as a guide, we’ll have a warm summer, warmer than usual. Sleeping will get tougher, ticks will show up on our ankles, water will beckon us. Clinicians will work in comfortably air-conditioned suites, but their patients will often not be as lucky. Rene Salas reminds you all in a recent NEJM Perspective that hyperthermia is just around the seasonal corner. Our friends in the Southern Hemisphere have just had a horrible summer. Australia’s was unprecedented with an average temperature exceeding 30 Celsius or 86 Fahrenheit. We’ll talk about such things with Dr. Salas, who is a fellow at the Center for Climate Health and the Global Environment at the Harvard School of Public Health. She’s also in the Department of Emergency Medicine at Mass General Hospital and Harvard Medical School.

Welcome to Clinical Conversations, Dr. Salas.

Dr. Salas: Thank you so much for having me. I’m excited to be here.

Joe Elia: It used to be that summer was the time for bug spray and sunscreen. Everything’s changed, hasn’t it?

Dr. Salas: Yes. I think that there has been this growing recognition that climate change is not only happening in the world around us but it’s also impacting us as humans and it’s impacting our health. As this recognition has grown, there has been a goal to increasingly connect it to what we do every day to our clinical practice.

Joe Elia: Your recent perspective article in the New England Journal of Medicine gives a useful table for various healthcare demands, starting with EMTs who are bringing overheated patients to the ER, all the way out to the management types who need to prepare for what they can’t predict yet. Can you talk a bit about that?

Dr. Salas: So we know that there are associations across a broad range of climate exposure. So that ranges from heat to rising pollen levels, wildfire smoke, infectious diseases as you noted in the introduction, changes in water quality, and the intensification of extreme weather, but I think that the recognition is that all of these have very practical implications no matter what your role is in the healthcare system. So there’s a case that I outline about a man who was brought into the hospital because he was confused, but we were in the middle of a record-breaking heatwave, and his wife had called 911 and the EMT said that when they opened the door that it was like they were being hit by the Sahara Desert heat.

They lived on the top floor of lower-income housing and they had no air conditioner. They only had one window that was partially cracked, and so I think that that shows that EMTs are on the front lines, and I think as medicine is increasingly embracing and trying to expand community paramedicine, recognizing that they are my extensions from the emergency department out in the community and so how can we use them to educate patients about the risk of heat, counsel patients on what to do if they lose power, even if they normally have air conditioning.

The National Climate Assessment put out by the federal government has shown that they anticipate that the intensification of extreme weather and extreme heat are going to amplify and intensify the power outages. We actually had one right down the street, in fact, a power outage at Mount Auburn Hospital. That actually caused them to have to bring patients down from the top floor of the hospital because it was getting so warm because the backup generators don’t actually supply cooling to all areas. Even when the power was restored actually a lot of the equipment was so hot that it couldn’t function so they had delayed ability to be able to resume their normal functions because they had to wait for technology to cool down and this was in Greater Boston in 2019.

Joe Elia: Pretty interesting. So, as we were saying before, there were things that administrators must prepare for that they can’t imagine yet. I guess the only way to imagine it is to experience it and say, “Oh, damn, we should have done it this other way!” I mean of course we could be jocular about it now but when it happens — boy, oh, boy. For instance (and I guess you can’t talk about anything including candy bars without mentioning coronavirus these days). What do you think? Do you see any connection at all between global warming, climate change, and this kind of spread of infection? Is that at all on your radar, or is it a strong signal?

Dr. Salas: Yeah. It’s a great question. I mean we know that vector-borne diseases, so diseases transmitted by mosquitoes and ticks, that those have been on the rise. So not only longer seasons but moving to new geographic regions, which makes it hard for clinicians because now suddenly they’re facing patients who come in potentially with infectious diseases that they haven’t been used to seeing. Lyme disease can present in a multitude of areas and one that has really been expanding, here in the Northeast. So every rash to me in the emergency department has to potentially be Lyme, but I think that that shows that we really need to have a dynamic education curriculum and work closely with our public health colleagues in order to ensure that we can stay up to date on emerging infections and also make sure that we can educate our clinicians on those signs and symptoms of diseases that they aren’t used to seeing.

There’s always this issue, right, that we face these situations and research, because of the sound scientific practice it has to go through is delayed. I have to admit, I feel that climate change is truly that meta-problem and that threat-multiplier. So I believe it connects to everything in some way, whether directly, indirectly or even if it’s minimal effects. So my concern is that climate crisis may be fueling coronavirus in some way, but we don’t know yet. It’s too early. I think that it just shows that there’s so much research that needs to be done because we can’t prepare for what we don’t understand.

Joe Elia: Yeah. So back to those poor administrators who are going to be held to account when things go wrong: Is it really possible, do you think, to have drills about power failure? I’ve noted before that the [Boston] Marathon bombings were made a bit less chaotic because Boston hospitals had practiced, and many cities do practice now for mass casualty events. How does an institution practice for a calamity like power failure?

Dr. Salas: Yeah. So this is interesting and I think I really want to promote that that table [in the NEJM Perspective] was more of a thought exercise, where I was hoping to take the reader with me in thinking through different things that we can potentially implement to help prepare us as clinicians for what the climate crisis has brought and will bring. I think we always are better served if we are as prepared as we can be for situations. I think recognizing that power outages create a limited-resource environment in a normally well-resourced hospital. Again, everything from cooling not being in every area and maybe perhaps limited imaging and all of these unintended and unforeseen consequences that if a hospital has already gone through that and knows exactly what to do when a power outage occurs then inevitably I’d like to believe that we would then be better prepared when we actually face that.

You always have to weigh kind of the number of drills versus the benefits and so kind of rely on my disaster preparedness expert colleagues to end up making that decision but it is something to think about.

Joe Elia: Speaking of that, if that happened at Mount Auburn — and it did — how efficiently are the lessons of that disseminated to the other hospitals in the region? Are you aware of any formal way that a hospital having undergone such a calamity is able to share that?

Dr. Salas: Yeah. It’s a great question, and I think one that I know myself and my colleagues and others are thinking about is how can we share these best practices? Even when you think about heat, for example, and the fact that certain areas of the country and even the world have been facing extreme temperatures that are extreme for areas like here in the Northeast but have been facing hotter temperatures and know how to operate in that environment so we can learn from them. But you bring up a good point that when something like this happens like the power failure at Mount Auburn that that isn’t currently disseminated. In fact, when I talk about it even to people in Boston, many people didn’t know that it happened.

Leadership, again, may be aware but again just creating this sense of dissemination of experience is enormously powerful so we can learn from one another. I always come back to my emergency medicine roots and think about when a patient is crashing in front of us and we save them that it’s not saved by one person — it’s a collective team that saves that patient. Everything from environmental services that cleaned the room to the pharmacist to the nurse to the doctor to everyone. I think I recognize that this climate crisis needs to collectively bring the medical community together, across all sectors and disciplines to learn from one another. I think we’re stronger together and that’s part of why we are building this climate crisis in clinical practice initiative where we’re actually going to have symposiums similar to the one that we actually held in Boston on February 13 in different regions around the US at flagship sites and even internationally.

We currently are going to hold one in Australia. The goal of that is to come up with a group of us that have different geographic experiences, are exposed to different climate change exposure pathways, and to build an initiative where we can get some expert consensus and ways to share best practices.

Joe Elia: Here’s a question, what do you say to people who are skeptical about the role of climate change in clinical medicine?

Dr. Salas: It is enormously hard to scroll through your newsfeed, since most of us nowadays digest our news through a phone or some tablet of sorts without seeing that there are new things that people are experiencing in the environment around us. I think personally the science is very clear that the climate change is happening, that it’s human caused, and we have solutions. Nothing is harder for me than having a patient in front of me where I don’t have a treatment. Thankfully, here we have the ultimate treatment and the ultimate prevention, which is a decrease in our production of greenhouse gases. But I think recognizing that if we want to try to minimize the human suffering that is already happening, especially for vulnerable populations, but recognizing that we also have to simultaneously adapt not only our public health infrastructure but our clinical practice. While some of the implications of the climate crisis are clearer than others now, I think there are these insidious changes that we have to recognize. If we want to put the health of patients first in order to deliver the best patient care that we can, we have to add a climate lens to it because historically we’ve always been able to look backwards and try to predict the future based off the past, but that’s no longer possible.

The climate crisis is creating this uncharted future, and we have to prepare and prepare now and work together to do that.

Joe Elia: I wanted to ask you how you got interested in this whole question of the clinical implications of climate change and global warming.

Dr. Salas: I learned about climate change and its impact on health about six-and-a-half years ago, and it was fascinating because I had not heard about it at all during medical school or residency. For me, it was really an epiphany moment where I recognized that I could not imagine focusing my career on anything else because I couldn’t imagine anything else impacting my ability as a doctor to protect the health of my patients and to do my job than climate change. So it really started me on a path that has put me on the course that I’m currently on. For me, you can call it a job hazard of spending all of my time outside of the emergency department focusing on climate change, but I increasingly began to see that it was harming my patients, again sometimes in small ways, sometimes in larger ways, but I quickly saw that there was a need to add a climate lens to what I did in my practice, and I think increasingly as I had more conversations with others recognized that we needed to have a larger conversation to really adapt our clinical practice in the era of climate change, which has led to the initiative that I spoke about.

Joe Elia: As a result of your efforts, Dr. Salas, what do you hope will happen?

Dr. Salas: I think first and foremost we need to recognize that the health sector and the voices of health professionals is the most trusted messenger to connect climate change and health. I think one thing that at least I personally believe is why we haven’t had as much action on climate change and engagement up to this point is that it hasn’t been personal. We have had visions of icebergs and polar bears. Trust me, I love polar bears but it’s really about our children. It’s about our aging parents, who are enormously vulnerable, our less fortunate neighbors, and if that’s not enough to motivate you then it’s about yourself because climate change is harming your health in some way, again, however small, however large.

So the recognition of making these connections and talking about climate change as a public health threat — and I would argue as something that is changing our clinical practice — is first and foremost what we need to do as a medical community. So the ultimate end goal of that, as we engage in this conversation is that we need to talk about the fact that climate action is actually action to improve health. I would say that the Paris Agreement is the world’s greatest public health pact. So recognizing and connecting these things:

That not only are there short-term benefits of reducing particulate matter from the combustion of fossil fuels (which we know will improve health, but also the driver of climate change and thus will decrease, again, the human suffering that we will experience both now and in the future) is really important and encouraging our transfer to renewable energy sources.

Then I think the second half of that is adapting. So ensuring that we can adapt our public health practice and our clinical practice to continue to provide the best care to our patients and our communities when they need it most.

Joe Elia: All right. Well, I want to thank you very much for talking with me today, Dr. Salas.

Dr. Salas: Oh, it was a pleasure. Thank you so much for having me and for lighting this topic.

Joe Elia: That as our 257th episode. The whole collection is searchable and available free at Podcasts.JWatch.org. Clinical Conversations is a production of the NEJM Group and we come to you from NEJM Journal Watch. The executive producer is Kristin Kelly. I’m Joe Elia. Thanks for listening.

March 31st, 2020

Podcast 262: COVID-19’s larger lessons

(27 votes, average: 3.00 out of 5)

We talk with Colleen Farrell who’s doing her third year of an internal medicine residency in New York City.

Fortunately, we caught her during a one-week vacation (she was supposed to be taking two), and she chatted with us about how she and her colleagues are coping.

We asked her what she thought COVID-19’s larger lessons would be, and she gave an interesting, impassioned answer.

Running time: 12 minutes

Other interviews in this series on COVID-19:

  1. Dr. Anthony Fauci
  2. Dr. Susan Sadoughi
  3. Dr. Matthew Young
  4. Dr. Julian Flores
  5. Dr. Kristi Koenig

Joe Elia:

You’re listening to Clinical Conversations. I’m your host Joe Elia.

We’ve come to New York City this time, at least electronically, to talk with Colleen Farrell.

Dr. Farrell is a third-year resident in internal medicine at NYU in Bellevue Hospital. This July, she starts a pulmonary and critical care fellowship at New York Presbyterian-Cornell. I became aware of Dr. Farrell when a classmate of hers sent along a posting she’d made on social media. It read, in part, “I feel grateful that I am able to put my training to public service. I don’t do well being cooped up at home. I became a doctor to do this work, but I would be lying if I said I wasn’t scared. I am calm and committed but also deeply, deeply terrified.”

Welcome to Clinical Conversations, Dr. Farrell.

Dr. Farrell:

Thank you. Thank you for having me, Joe.

Joe Elia:

So there you are in New York City. How are you and your colleagues doing? Are you getting enough time away from the clinic to get sleep and get food?

Dr. Farrell:

Yeah. So I would say that the experience varies widely from week to week. So in this situation right now in the midst of the COVID pandemic it seems — like for everyone — you’re either fully on or totally off at home. So you’re catching me in one of those off periods. About two weeks ago, I started taking care of coronavirus patients at Bellevue. When you’re doing that work, the shifts are long and really tiring. Our whole residency schedule has been kind of recreated to meet the staffing needs of this crisis but built into that is some time off.

So right now, I was still due for a two-week vacation towards the end of this year, and so right now I’m getting one week of that. So I’m in this weird place of getting rest right now and knowing that I’m jumping back into it in just a few days.

Joe Elia:

Well you mentioned in that posting that I quoted from, you mentioned a patient. I wonder how that patient fared. Do you know?

Dr. Farrell:

Last I checked he was still in the ICU. He was intubated and requiring dialysis. Yeah. So this is actually the first coronavirus patient I met, and when I met him I was really worried about him. He was still breathing on his own but requiring a lot of oxygen. So it was the middle of the night. I called one of our ICU doctors and he was moved to the ICU where he still is. We’re seeing that with a lot of our patients, that when they get to the ICU it looks like it’s a pretty long course for a lot of them. It’s not needing to be intubated for a few days and quickly extubated, but it’s a long course with a lot of uncertainty. So I keep kind of checking in, hoping that he’ll get better, but it’s going to take time, I think, to see.

Joe Elia:

Yes. Let’s hope that he does get better. How are you keeping up with policy? Have you joined any of the private chat groups like the one described by Dr. Julian Flores during his interview here?

Dr. Farrell:

Yes. Right now, we’re dealing with so much information. So I’m getting information from several places. First of all, I think — especially in my role as a resident physician — decisions I make are about the patients I’m directly caring for, or managing my own team, and so it’s hyperlocal. So first I have to pay attention to the policies from my institution. We get multiple emails a day and like a lot of residents I’m not employed by just one. Well, I’m employed by an academic medical center, but I rotate at NYU Langone, Bellevue Hospital, and the VA. So those are three completely different hospital systems. They’re three different hospitals, for one, but they’re also a private hospital, a public hospital, and a federal hospital.

So just to do your job you have to keep track of those policies. So we have a lot of internal communication with documents: “This is the latest of the PPE standard. This is how long you have to be out of work if you have symptoms. This is when a patient is allowed to move to this place or that place.” Those are the policies I pay the closest attention to. Then I would say while I’ve been home this week on my “vacation” I’ve been tuning into New York Governor Cuomo’s updates and those actually help me understand kind of even what I’m seeing sometimes at the hospital.

He’s been talking about [transferring] patients from some hospitals in New York City to others to even-out the load, and that helps me understand [that] when I’m at work I might be getting transfers from other hospitals and understanding why that is. Then in terms of more informal mechanisms, I’m pretty active on Twitter. I get a lot of updates there from people on the frontlines and then I’ve also been reconnecting with colleagues from medical school that I haven’t been in touch with for years. My Harvard Medical School class Facebook group — I don’t think anyone touched it for three or four years but all of a sudden people are connecting on there, talking about what’s going on in their hospitals and just sending support to each other. We’re all thinking of each other and kind of reading what’s going on in different parts of the country.

Joe Elia:

Tell us a bit about your social media posts. Are you looking at maybe a career as a writer?

Dr. Farrell:

Yeah. I’ve loved writing at least since college and have been writing about social and ethical aspects of medicine since I was an undergrad 10 years ago and I was writing about the early years of the AIDS epidemic in the US. At that time, I was reading Atul Gawande and found his books captivating as so many do. I kind of even realized at that time that I wanted to do the kind of writing in medicine that spoke to audiences beyond the doctors and scientists in a hospital.

So then in medical school I was really closely mentored by Dr. Suzanne Covin, who’s the writer-in-residence at Mass. General Hospital, and she’s been a tremendous role model to me. I use writing as a way of both processing my own experiences and kind of sharing with a broader medical community — and more society at large — some of the social and cultural aspects of medicine. So sometimes that’s through essays that I publish but I actually really like using Twitter and sometimes Facebook as a way to send off little missives. I like that they’re informal. They feel real and authentic. They’re not filtered through an editor or someone else. It can be a really cool way to connect with people and it’s writing. Any time you’re using words you’re learning how to write.

Joe Elia:

Yes. I know those editors do get in the way…

Dr. Farrell:

I’m grateful for editors but sometimes it’s paralyzing knowing that you’re going to be scrutinized.

Joe Elia:

Sometimes they help… So you’re on vacation this week. Are you reading or binge-watching?

Dr. Farrell:

I mean it’s a very weird vacation. I’m just staying inside my apartment. My husband is home. He is a third-year NYU law student and is doing law school remotely this week. We’re watching movies. We take turns who picks the movie each night. So we watched Alien. We watched How to Survive a Plague, a really great documentary about the early years of AIDS and then we watched Indiana Jones. So we’ll see what we pick tonight.

Joe Elia:

Those are all consonant with your current experience…

Dr. Farrell:

And writing. That’s the other thing. Right now, it’s nice to have some time. I’m doing some writing about my experience in the ICU last week and also doing some writing reflecting on…I mentioned I wrote my senior thesis in college on the early years of the AIDS epidemic. I’ve been thinking about what I learned doing that historical research then and what lessons I might be able to take from it now. So it’s nice to have some time to think and marinate a little bit before I jump back in.

Joe Elia:

I want you to project yourself forward in time a bit. When this pandemic ends and you’re training other young clinicians, say 20 years from now, what will you tell them was COVID-19’s most important lesson?

Dr. Farrell:

Well, I think it’s a lesson about health inequities and existing injustices in healthcare. I think that we are seeing right now that the health of one person affects the health of the entire society and that health cannot be treated as a commodity only available to those who can afford it. It needs to be treated as a human right. Right now we’re hearing politicians say no one should be denied a COVID test or COVID treatment because of their ability to pay, well I agree with that, but why shouldn’t that be the case for cancer or diabetes or anything else? I think we’re going to see more that this pandemic doesn’t affect all communities — even within the US — equally. It is ravaging Rikers Island right now, where we have mass incarceration.

When I call families and update them on their sick family member it’s totally different if they have a big apartment where they can separate within the apartment from those who have symptoms and those who don’t. But when you talk to a big family in crowded city housing they don’t have those possibilities. When government support doesn’t include undocumented immigrants you have a huge health justice issue on your hands. So I think that one of the biggest lessons from this time is to say that the social safety net and healthcare for all is not optional. It’s not a luxury. It’s a foundation of a functional society that has any degree of concern for the people within it. I think that we have been existing in a healthcare structure that is grossly unequal and oftentimes prioritizes profits over people, and I think that this pandemic is going to lay that bare for our whole society to see.

I hope that in 20 years I will be able to say maybe this is the last straw that helped our society change and provide healthcare to everyone. I hope that’s the story rather than we continue on or we return to the status quo after this ends.

Joe Elia:

Well, Dr. Farrell, I want to thank you for speaking with me today and I hope you’ll come back in 20 years and we’ll review that together.

Dr. Farrell:

That would be lovely. Thank you so much.

Joe Elia:

That was our 262nd episode. All the others live at Podcasts.JWatch.org. We come to you from Physician’s First Watch and NEJM Journal Watch — members of the NEJM Group. The executive producer here is Kristin Kelley, and I’m Joe Elia. Thank you for listening — and wear your masks and wash your hands.

March 29th, 2020

Podcast 261: COVID-19 as a medical disaster

(18 votes, average: 4.61 out of 5)

San Diego County has Dr. Kristi Koenig as medical director of its emergency medical services. That’s fortunate for the county, because she’s co-edited a definitive textbook, “Koenig and Schultz’s Disaster Medicine: Comprehensive principles and practices.”

We’re fortunate to have her as our guest. She’s full of sound advice on organizing a community’s response (for example, setting up “incident command” structures) and evaluating patients as new threats emerge (the well-known “three-I’s” approach — Identify, Isolate, and Inform).

With the number of COVID-19 cases rising quickly there in San Diego, she’s been busy (as have all of you).

Running time: 19 minutes

Links:

Interview from 2016 with Koenig and Schultz on the second edition of their “Disaster Medicine”

Koenig, Bey, and McDonald’s article on applying the 3-i tool to novel coronavirus in Western Journal of Emergency Medicine (Jan 31 online)

Other interviews in this series on COVID-19:

  1. Dr. Anthony Fauci
  2. Dr. Susan Sadoughi
  3. Dr. Matthew Young
  4. Dr. Julian Flores

TRANSCRIPT OF THE CONVERSATION WITH DR. KRISTI KOENIG:

Joe Elia:

You’re listening the Clinical Conversations. I’m your host Joe Elia.

Dr. Kristi Koenig is Medical Director for Emergency Medical Services in the county of San Diego, which as of this afternoon, Saturday March 28, had about 420 confirmed COVID-19 cases with six deaths.

The county is lucky to have her, if I may say so, because she’s co-edited a definitive textbook on disaster medicine, and arguably the novel coronavirus epidemic qualifies for entry into that club.

Dr. Koenig is Professor Emeritus of Emergency Medicine and Public Health at the University of California Irvine, School of Medicine, and she was also, I should say, a long-time contributor to NEJM Journal Watch Emergency Medicine.

Welcome to Clinical Conversations, Dr. Koenig.

Dr. Kristi Koenig:

Thank you very much for having me.

Joe Elia:

What are you seeing there in San Diego?

Dr. Kristi Koenig:

Well, we are very concerned in San Diego, as is the rest of the country, and we’re taking a three-pronged approach on the ground in San Diego. Number one is to flatten the epidemic curve. Number two is to increase surge capacity for our healthcare system, and number three is to focus on using an incident command system to coordinate all of our needs and resources, and I can explain each of those in more detail if you’d like.

Joe Elia:

I recognize that, from having looked at your textbook a few years back, so go ahead.

Dr. Kristi Koenig:

In San Diego, we were very early to implement what’s called NPI, non-pharmaceutical interventions, to try to spread out the diseases over time so that we don’t have as a great a chance of hitting a peak number of diseases early on, which could exceed our healthcare capacity.

This so-called flattening of the epi curve, I’m sure people have seen. Even on the news people are getting educated in epidemiology these days.

The idea with that is we won’t necessarily decrease the total number of patients but if we can spread patients out over time we can potentially continue to care for everybody in our healthcare system. This is not only the COVID patients. This is also our regular emergencies.

We know that emergency departments are crowded on a day to day basis. So by using these interventions, which are called things like social distancing (although it’s not really social distancing it’s more physical distancing) we still can keep in contact with people. Other types of interventions to try to prevent the rapid spread of the disease, we can make a huge difference. It’s complicated because we may not see the effects for a week, two weeks, or even more because there are already people in our communities who are incubating the disease that have not had symptoms yet or not. Some people never have symptoms but who have not presented yet to our healthcare system.

The second thing would be for surge capacity, and we’ve developed a concept about 20 years ago along with my colleague, Major General Donna Barbish, for the 3-S concept of surge capacity, which is stuff, staff, and structure. We find it very helpful to organize everything around stuff, staff, and structure, and I can explain that in more detail if you’d like.

Joe Elia:

Yes. I would guess that the “stuff” is going to include things like masks.

Dr. Kristi Koenig:

Absolutely and ventilators and N95 respirators and surgical masks and other types of PPE (personal protective equipment) are very important in an epidemic of this nature. One of the challenges is that the news media and the politicians love to count stuff. You can see it. You can show it on TV. You can touch it. You can count it but one of my famous lines is “Ventilators don’t take care of patients.” Stuff is important but it’s not sufficient. While we do need, certainly, to protect our healthcare workers on the front lines and to have things like ventilators to care for patients in this setting, the stuff component of the 3-S is not enough.

So we also need the staff, which is all of us, the people, and we do know that some people unfortunately will get sick and even die and some people will not be able to come to work because they may be caring for a relative or other reasons. So we have to account for probably maybe perhaps 30 percent of people will not be able to come to work or not be willing to come to work. We also need specialists in the staff. So it’s not just the total number but we need people with specialized expertise. For example, infectious disease specialists, critical care specialists.

Then the third component is the structure and that is the physical location where we care for patients. What we’re seeing now is we’re being very innovative and I think actually this is going to help us after we get through all of this to have better capacity in our healthcare system. We’re seeing alternate care sites develop. We’re seeing field hospitals. We’re seeing the military, for example the Mercy just arrived in Los Angeles today I believe. We’re seeing things like tents being put up outside hospitals to do screening.

In San Diego, we’re also looking at behavioral healthcare centers outside hospitals. We’re seeing telemedicine, telehealth popping up. So lots of things for the structure piece as well where we care for patients. So again, stuff, staff, and structure is very helpful to organize all the components we need to increase the surge capacity of the system.

Joe Elia:

We’ve chatted before when the second edition of your textbook came out. You (or maybe it was Dr. Schultz) mentioned that the third edition should include a chapter on how to prepare oneself to participate in responding. Do you have any advice for clinicians now about to face the challenge of a surge in demand?

Dr. Kristi Koenig:

Yes. We definitely need clinicians. One of the most challenging things about this event is the psychological piece of it. People who are working on the front lines are seeing their colleagues get sick and unfortunately likely even die and it’s very difficult. Or they may have a situation where they don’t have enough resources, and we’re used to taking care of everybody. So keep focused on what we’re doing to take care of patients and take care of your own mental health. There’s lots of resources online for mindfulness and other types of techniques you can use. Make sure that even though we’re physically distancing that we’re still connecting socially with others.

Joe Elia:

When I was going through your textbook again, I noticed the mention of the incident command system. Talk a little bit about that if you would.

Dr. Kristi Koenig:

An incident command system is necessary to coordinate all of the resources that we need. What happens is, people want to help, and they have good ideas, and they try to work outside the established system. And we’re seeing it everywhere. It takes up people’s time to respond to well-meaning requests, spontaneous volunteers, spontaneous donations as opposed to if everything can be funneled into the incident command system it can be coordinated as needed to help manage the disaster.

These are systems that are practiced both in hospitals (we usually use something called the Hospital Incident Command System). In the prehospital setting in all levels of government and there are liaisons between the various incident command systems so that you can coordinate and do something that’s on a regional, statewide, and even national basis that otherwise would be overwhelming to try to manage.

Joe Elia:

At the beginning of an incident like this, what would you do typically with the incident command system, would you put out something immediately saying “We understand you’d like to volunteer” or “If you want to volunteer if you want to bring food, masks, or whatever…”

Dr. Kristi Koenig:

One of the portions of the incident command system would be the logistics section. So the incident commander could refer a volunteer idea to that section who could decide how to best integrate it into the overall response.

Joe Elia:

The US is in mitigation mode right now — as opposed to trying to prevent the entry of the virus into the country…

Dr. Kristi Koenig:

Actually, I wouldn’t agree with that.

Joe Elia:

Tell me how I’m wrong there.

Dr. Kristi Koenig:

The US has different phases right now of the disease. So for example, in New York and some other emerging areas at the time we’re making this recording such as New Orleans and Chicago and Los Angeles, they’re a little bit farther along that epidemiological curve in terms of the rise in cases. But there are some parts of the United States where there are very few cases — or at least few that we know of. So they’re probably earlier on in time. I would say in San Diego, for example, we’re not quite on the same upslope as they are in some other parts of the country like New York.

In places where there’s widespread community transmission, certainly we need to do mitigations and that’s probably most places, to be honest, because we see this disease being spread in asymptomatic or minimally symptomatic people and that’s why this stay-at-home message. This social distancing is so important to flatten that curve, but we also still need to isolate people that are sick. We need to identify them and isolate them so that we can prevent rapid spread by known people who are sick. So we’re doing more than just mitigation.

I’ll just say we’re doing identification and contact tracing to prevent spread of disease from known cases in addition to the mitigation.

Joe Elia:

I mean you started the month with one case in San Diego and now we’re up to many more than that. What have you seen over that time, Dr. Koenig, that has changed your mind?

Dr. Kristi Koenig:

It’s been very interesting in San Diego because we’ve had several disasters within the disaster, if you will. Let me explain what I mean. We have the local military base, Miramar. You may have seen on the news that when we were repatriating people from Wuhan they came into a federal quarantine. So we’ve been closely collaborating and have a strong relationship with the federal entity such as the CDC and what’s called the ASPR, the assistant secretary for preparedness and response, which is located in HHS at the federal level and also the state. Because in the US, the way things are organized it’s local to state to federal in terms of how the resources work.

So we had people coming back from Wuhan that were on quarantine, and we helped support the quarantine on the base. I’ve actually been standing a little bit more than six feet away from a patient who ultimately turned out to be positive from that repatriation. We have systems in place where we have transported patients who became infected or became positive from the base to hospitals and potentially back. Then after we had that mission, which really helped us to get systems in place, we had people coming from the cruise ships. Same thing where we had positive cases in that cohort, and we were able to make sure that those cases did not spread out into the community and that those patients got care and ultimately once their 14-day quarantine was finished they were able to return to where they live.

So that gave us a lot of experience and we’re still actually having more cruise ships coming into San Diego and managing that along with our federal partners. So it’s incredibly complicated, but it’s given us a lot of experience of how to manage this. In addition, you mentioned at the beginning my role in EMS. We put in place screening so that when somebody calls 911, initially several weeks ago when it was more relevant to ask the travel history, we were asking about travel from China and some of the other hotspots, and we were identifying people potentially infected at the level of dispatch so that when our paramedics responded they were already wearing the appropriate personal protective equipment.

When they picked up the patient for transport, they were notifying the hospitals ahead of time, “Hey, we’re coming in with someone who might have COVID” and the hospitals were wearing PPE. Oftentimes, seeing them — if they were stable enough — outside of the emergency department first, to make sure that we weren’t transmitting infection to others.

Joe Elia:

So nothing that you’ve seen so far has changed your mind about the approach that should be taken. Would it be fair to say that it’s reinforced?

Dr. Kristi Koenig:

One of the most challenging things is that the recommendations are changing very frequently. That’s because this is a novel virus. It’s new and we are learning. I’ve actually been following this since December, believe it or not, and I can remember the first report was “It’s not transmitted from person to person,” which I didn’t believe. “Oh, it’s not transmitted to healthcare workers,” which I didn’t believe. But things have been evolving over time in terms of PPE recommendations.

Initially, it was very helpful to identify people traveling from certain international hotspots. Now there’s such widespread disease, that’s less useful at this point. So there is a challenge and there are things that are changing, but one thing that we worked with for all infectious diseases is the concept of the three “I”s. The identify, isolate, and inform. For people working in hospitals, we want to immediately identify patients who are potentially infected, and because this is a disease contagious from person to person we then would immediately isolate them. And the third “I” would be to inform both public health and your hospital infection prevention personnel.

Joe Elia:

Yes. I saw that you had written a paper on the application of the three Is to the epidemic. I’m going to put a link to that on the website.

Dr. Kristi Koenig:

Thank you. And the three-I concept actually developed during the Ebola outbreak in 2014. The idea is that we don’t necessarily think in our day-to-day work about the potential for a patient to be infectious to the point where we could contract the disease or other people in the waiting room to contract the disease, and we have to think about that immediately in something like this epidemic so that we can immediately isolate and protect the patient from exposing both healthcare workers and other patients.

Joe Elia:

As a country, what do you think we could be doing more of or less of at this juncture?

Dr. Kristi Koenig:

It’s important to know that every single person in this country is on the frontlines. For me, this epidemic and every single person’s actions are important to help us stomp out this disease. If you are a non-healthcare person just staying home and washing your hands, as simple as that sounds, can be incredibly helpful, as I talked about earlier, for flattening that epidemiologic curve. So everybody has an essential role in the entire country. As healthcare workers, I would encourage everyone to keep focused. Again, the approach we’re taking in San Diego is this three-pronged approach of the interventions to flatten the curve, coupled with increasing the surge capacity, and making sure we work within an incident command system structure.

Joe Elia:

I know it’s hard to look into the future. How do you think COVID-19 might change clinical practice? Do you see any indication that it might?

Dr. Kristi Koenig:

Absolutely. Once we get through this I think we’re going to have a much better healthcare system. It’s amazing the collaboration and the innovation we’ve had in such a short time. Things are happening you never would have thought could have happened. I mentioned earlier, telehealth as an example, increasing behavioral health resources, increasing resources for the homeless. There are incredible collaborations happening. We’ve had meetings with all the chief medical officers of our 20 hospitals including VA and military in our county. We’ve had meetings with all the CEOs of all our hospitals along with the board of supervisors and the chief medical officer of the county.

This kind of cooperation and collaboration would not have happened if it weren’t in the face of a crisis.

Joe Elia:

Is there one essential lesson that you want clinicians to take as they’re about to face this?

Dr. Kristi Koenig:

Keep focused. We will get through this if we organize our actions and our thinking. We can save lives. You are the heroes. You’re on the frontlines and we thank you for everything you’re doing every day.

Joe Elia:

I want to thank you for your time today, Dr. Koenig. I wish you good luck in the coming days.

Dr. Kristi Koenig:

Thank you very much. Stay safe.

Joe Elia:

Thank you. That was our 261st episode. Its predecessors are all searchable and available free at Podcasts.JWatch.org. We come to you from Physicians First Watch and NEJM Journal Watch — all part of the NEJM Group. My executive producer is Kristin Kelley and I’m Joe Elia. Thanks for listening and stay healthy.

March 27th, 2020

Podcast 260: Interview with a Broward County, Florida, emergency room physician

(8 votes, average: 4.13 out of 5)

This time we talk with Dr. Julian Flores, who works in a Broward County, Florida, emergency room.

When he was interviewed, the count of Covid-19 cases stood at 412, less than 12 hours later, the new number was 505, as of this posting — on Friday near noon Eastern — it’s at 614. Flores is expecting the wave to hit hard there. Broward is home to Fort Lauderdale (think spring break) and Pompano Beach (think aging retirees). Couple those demographics with a lack of easy testing for the virus, and you’ve got a worrisome situation.

Links of interest:

NEJM Perspective article

NEJM Sounding Board

Running time: 13 minutes

A TRANSCRIPT OF THE INTERVIEW (Please bear in mind that what follows is a conversation and not a polished essay.)

Joe Elia:

You’re listening to Clinical Conversations. I’m your host, Joe Elia, and I’m joined by my cohost, Dr. Ali Raja, Editor-in-Chief of NEJM Journal Watch Emergency Medicine. He’s in the Department of Emergency Medicine at Mass. General and an associate professor at Harvard Medical School.

We continue exploring the COVID-19 pandemic by heading south from our last interview with a first-year OB/GYN resident in Delaware to the State of Florida. Our guest is Julian Flores, an attending physician in the Emergency Department at Westside Regional Medical Center in Plantation, Florida, outside Fort Lauderdale.

Dr. Flores went to college in New York City and then on to Harvard Medical School. He trained in emergency medicine at the University of North Carolina and has been an attending physician at Westside since last July. Welcome to Clinical Conversations, Dr. Flores.

Dr. Julian Flores:

Hi. Good morning. Thanks for having me.

Joe Elia:

As of this morning, Broward County had 412 cases of COVID-19 and three deaths reported. Florida’s governor has mandated self-quarantine for travelers arriving from New York and New Jersey, so what are you seeing there on the ground?

Dr. Julian Flores:

I think the idea is a good start. Social distancing has been shown to work when you do it early. The idea is to prevent community spread. In the 1918 pandemic, it worked to at least stall some of the deaths and the morbidity, but we’re not doing it like that. We’re doing it very fragmentedly, and I understand the United States in and of itself there’s so much population to be able to control under one measure. Some people argue you can’t use the same instrument but the actual application of it, especially when a place is diverse like Florida — like South Florida — I think there’s a lot that goes into the actual implementation of this and for it to actually be realistic and effective. I can personally say that I live in Brickle, the financial district of Miami, and I’m seeing honestly anything but.

I’m seeing people in groups of five, 10, people out everywhere. You know, it’s unfortunate, and I worry honestly that as people start getting antsy-er and start wanting to go outside — more and more sort of unfettered — that’s going to coincidentally be arriving at the same time that we’re expecting our own wave in the next few weeks only leading to further community spread. Our testing hasn’t necessarily gotten that much better, frankly —  the [amount] of testing that we’re doing — and it’s only going to lead, I think, to further undiagnosed cases and leading to potential more critical cases and more resource consumption within our hospitals down here.

Dr. Ali Raja:

Dr. Flores, how has your daily clinical practice changed in the face of this pandemic? Are you changing your practice even for those patients who don’t look like they have any respiratory issues when you first see them?

Dr. Julian Flores:

That’s a great question because as more data comes out, we’re seeing, as you may know, even as up to as high as 10 percent of cases do not come with cardiopulmonary complaints. It’s nausea, it’s vomiting, it’s abdominal pain, it’s fatigue.

Frankly, for my own personal practice, at this point, I am assuming you have it until proven otherwise. To the capacity that I will be able to continue doing so, I will at least wear a surgical mask when I approach your room.

It’s very interesting how people that I would have sent home without any sort of second guessing, at the very least if it doesn’t infiltrate my note it definitely infiltrates what I think of when I send them home with X and Y and Z instructions. How confident do I feel that that mild belly pain wasn’t an undiagnosed COVID-19 case that now is going to exponentially spread into their community. So it’s interesting how it definitely has affected all of us in what we thought were very confident algorithms to go by. Now we’re at least having some thought about it not being the case.

Dr. Ali Raja:

Wow. Aside from the clinical care, let’s talk about you and your team. Does your team have enough personal protective equipment, PPE, right now in the ED?

Dr. Julian Flores:

I could say that for my own particular hospital, thankfully, we are not at the point of having to recycle them. There are some hospitals I can say — some colleagues of mine that are working in nearby hospitals — that are at that point officially, where people are just at the end of the shift all putting their PPE equipment for the day in a collective bin. It’s undergoing some kind of sterilization procedure and they’re being sort of reused the next day. We are being asked to use…as an example, an N95 mask, one mask a shift. There is, from what I’ve heard among my colleagues, there is disparity among to what extent administration is okay with you bringing your own PPE gear.

We know at least from the standpoint of ASA and AAEM — the emergency medicine societies — that this is something that should be allowed but that sort of thought, I could say it hasn’t been a collective thought among the hospitals. That only leads to further sort of frustration, confusion, safety risks, etcetera.

I think I also wanted to make a comment about the fact that a lot of people, my friends, both medical and nonmedical, they like to hang their hat on the percent morality that we’re seeing with this pandemic. Some will argue that it’s much less than we’ve seen with waves of the flu or other related viruses, but I think a comment should also be made on the morbidity that this pandemic is presenting, particularly this COVID-19 virus is presenting.

When you have a virus that takes so long to incubate, I think it’s at least eight to 10 days I think of incubation is what the research suggests, and when you have the average patient that takes 10 to 11 days to wean off, take off the ventilator whether it’s alive or you finally decided to pronounce them as passing, that’s a lot of consumption of resources, of personnel, of equipment, of a bed that will not be available until two weeks from when that decision is made.

One, it falsely reassures you early on of the numbers and it makes it harder to implement thing like social distancing and more stringently a lockdown when you don’t have the numbers from the get-go sort of express what’s projected. Then you’re kind of caught behind the ball when those numbers finally proclaim themselves and you find yourself out of personnel, whether it’s because they’re sick because they didn’t take the appropriate measures or because you don’t have enough equipment anymore or because you never established the infrastructure that can maintain a good practice.

Joe Elia:

So you mentioned other hospitals. Are you sharing information with others on social media? I talked with your classmate, Matt Young, and he mentioned a Facebook group where clinicians are communicating. Can you tell us anything about that? Is it finding it helpful?

Dr. Julian Flores:

Oh, it’s fantastic. I’m part of a private Facebook group called EM Docs. I’m also part of a Facebook group called COVID-19 Physician / APP Alliance or APP Group. I mean the amount of information we’re sharing amongst each other is amazing. Anything from truly understanding what other folks on their own front lines are dealing with — to novel ways of sterilizing equipment to ways to, for example, make a ventilator all of a sudden be able to vent two or three people. So if there’s anything good that’s come out of this it’s the amount of resource sharing that we’re seeing among all kinds of folks ranging from techs to nurses, doctors, et cetera.

Joe Elia:

Your population there runs to age extremes at this time of year, doesn’t it? I mean you’ve got college students at Fort Lauderdale on spring break and aging retirees in Pompano. Can you talk about the age-specific concerns that people have?

Dr. Julian Flores:

I can say that I hope that we are not hit with a strong of a surge as we’re expected to because, as you’re saying, we as a state have much more of a geriatric population than the nearby states, than even New York, I believe. So when you combine the fact that at baseline we have such a large geriatric population with the fact that we’re still allowing flights from harder-hit states to be arriving. You combine that chronologically with just the huge influx of younger folks that we had in Florida that we know on average are asymptomatic or mildly symptomatic along with an ongoing confusion as to truly how to handle this pandemic within the State of Florida. Frankly, it’s the perfect storm. We’re can still consider ourselves within the incubation period for many of these folks that potentially will go on to either have symptoms difficult enough for you to be hospitalized or even further to be put in an ICU.

From what I’m seeing, as an example, NPR yesterday or the other day published an article where you can essentially find how many beds your particular county has. If I’m not mistaken Broward County, as an example, between Miami and Fort Lauderdale has around two thousand, three thousand ICU beds max. I mean at baseline we already use some of those and we’ve already used some more with this growing pandemic. I hope I’m wrong.

There’s this sense of false reassurance. In a way, I can’t fully blame our governor for not acting even more stringently when you don’t really have numbers to work with. You can’t be convincing a population this dense that we’re in crisis when the numbers don’t necessarily yield that. In New York, thankfully, there was enough testing that at least on television you could say to your public, “This is what’s going on. This is why you should support whatever stringent measures I’m applying.” But when you don’t have that. When you have testing that, to this day, I’m still having to go through many loopholes to, at the end of it all, if I get a phone call back to get the confirmation to proceed with testing you can only expect there to be confusion and underreporting.

I can say we’ve all, I think, individually sent home dozens of patients that were not symptomatic [enough] to be hospitalized but definitely with a high suspicion of it — but not with the luxury of being able to swab all of them.

Dr. Ali Raja:

Dr. Flores, you mentioned that you’re expecting to see the surge hit in a couple of weeks and you’re worried about all the folks who have stopped physically distancing themselves. Let me ask, what are you and the hospital doing to prepare for this expected surge and what should the rest of our clinicians who are listening to this be doing with their hospitals?

Dr. Julian Flores:

Well, as an example, we put in place the policy to be mindful with our own PPE gear, as an example. Even though we’re not in crisis, per se, at our own particular hospital, we anticipate that. So being judicious with that, trying to limit the number of personnel that need to go into a given room, as an example as well, because for every time you go in and out, technically you should be changing your gear into a new set, for the most part.

Joe Elia:

Well, we want to thank you, Dr. Julian Flores, for spending time with us today. We wish you good luck and godspeed through the pandemic.

Dr. Julian Flores:

Thank you. I appreciate it. Honestly, I hope we’re wrong about what’s projected, but I know that at least we’re all in this together.

Joe Elia:

That was our 260th episode, all of which are available and searchable at Podcasts.JWatch.org. We come to you from the NEJM Group. We’re a publication of NEJM Journal Watch and Physicians First Watch. Our executive producer is Kristin Kelly. I’m Joe Elia.

Dr. Ali Raja:

And I’m Ali Raja. Thanks for listening.

 

March 25th, 2020

Podcast 259: A first-year resident tells us what he sees in the Covid-19 pandemic

(18 votes, average: 4.39 out of 5)

Dr. Matt Young is a first-year resident in obstetrics and gynecology in suburban Delaware. Between the day I invited him to be interviewed and the interview itself (a 36-hour span) things had changed a lot for him. Anxiety levels are up among his colleagues, and everyone in his hospital must wear a mask all the time.

A ground-level view of an incipient epidemic is what we offer.

Running time: 13 minutes

TRANSCRIPT OF THE CONVERSATION WITH DR. MATT YOUNG

Joe Elia:

You’re listening to Clinical Conversations.

I’m your host, Joe Elia. Like everyone else on the planet, we in the US are obsessing over the morbidity and mortality charts of the COVID-19 pandemic. We’ve done interviews with Dr. Anthony Fauci and Dr. Susanne Sadoughi and I wondered what the newcomers to clinical life are seeing through their fresh eyes.

So I’ve reached out to Dr. Matthew Young, who is completing his first year of an OB/GYN residency in suburban Delaware. I know Matt from working with him on a social media project for the NEJM Group. He was a Harvard medical student back then, finishing up law studies there as well. He’s kept pretty busy (but he admits he hasn’t practiced on his piano for many, many months).

Welcome to Clinical Conversations, Dr. Young.

Dr. Matt Young:

Hey, Joe. Thanks for having me.

Joe Elia:

So you’re finishing up your first year of an OB/GYN residency at Christiana Care in Newark, Delaware. As of this morning, March 24, the state had about 90 cases of COVID-19, so I’d like to ask, what in your experience of obstetrics and gynecology has changed between when you started last July and now?

Dr. Matt Young:

Really the big difference has been work shift and our scheduling. Basically, we’ve adopted a model I think other house staff has — a similar model across the country where we tried to cancel elective procedures and have residents who don’t need to be here, not be here.

So a lot of GYN entails elective surgeries and procedures, and we’ve basically shut those down. Our surgery center is quiet. I’ve never seen it that way. I was there last Monday and there were just no patients there. We’re just complying with CDC and national standards in that regard but it allows sort of this on-and-off model where we have some residents off at certain times. They’re sort of backup or taking home call while other residents who are considered essential and immediate — for example labor and delivery and our obstetrical triage unit — they need to be there because they’re absolutely essential, and certainly that allows patients who need to be delivered or who have obstetrical problems, they need to come in.

Of course, not all elective things are canceled. So elective induction of labor is still considered important and necessarily. So we are allowing all those folks who are scheduled for elective inductions or who want elective inductions to come in.

Joe Elia:

Okay. Labor and delivery, whether elective or not, is not something that you can’t opt out of for more than a reasonable amount of time. So OB/GYN is staying pretty busy I guess you’d say.

Dr. Matt Young:

Absolutely, but we are being very aggressive in terms of trying to curb potential exposure and infection. We are limiting the number of visitors, we’re only allowing one support person to accompany a patient postpartum. We’ve also adopted a new masking policy, and I’d be happy to tell you more about that.

Joe Elia:

Go ahead and tell me about this.

Dr. Matt Young:

So our hospital has been aggressive and followed that directive as well [Matt’s referring to a directive from Boston’s Partners HealthCare that mandates mask-wearing for all employees]. Basically in its initial days and weeks we were told do not consume or use surgical masks or N95 masks unless you’re interacting with a rule-out COVID patient or someone with symptoms or if you yourself have symptoms. Unless you’re dealing with somebody with symptoms you are not to wear or consume PPE (personal protective equipment) like N95 masks or surgical masks. Basically been a 180 degree reversal of that. I mean that policy probably was driven by severe shortages, folks who are calculating out that we’re going to run out in days to weeks, but there’s been a total reversal of that.

Basically, our hospital has adopted a mandatory mask-wearing policy. We basically made masks mandatory for all visitors and for all providers in any patient care areas. Partners Health in Boston is doing this and Christiana Care where I am at we’re doing this now, effective immediately, and we’re all really actually relieved because we got an email saying that we’re kind of lucky we don’t have such an acute shortage like major urban centers do, but even major urban centers like Mass General are adopting this mandatory mask-wearing policy. So I think that providers are getting…every day is a different day with new guidelines evolving, and I think that there’s a lot of provider anxiety.

There are a lot of labor and delivery nurses with families. Some of them are expecting, and that puts them at high risk. There are a lot of residents who are vulnerable or have exposures to vulnerable people. There’s a lot of anxiety among providers about protecting our healthcare workforce. So I’m so glad that major institutions like Mass. General and ours here at Christiana are adopting this.

Now, I have seen other measures being taken as well to sideline certain residents. So we usually have family medicine residents participate in our GYN and OB clinic outpatient ambulatory setting. Those residents are getting pulled and sidelined because there are concerns that because the family medicine residents are interacting with all kinds of populations that we may not necessarily want them interacting and possibly infecting our patients.

Now, all of this is in the setting of a concern about asymptomatic viral shedding or asymptomatic spread and that is what undergirded this new mandatory sort of making-masks-mandatory policy because providers are recognizing that there is serious concern of asymptomatic viral shedding, and we don’t know who has it and there’s so much uncertainty that we need to take universal precautions. It seems like the policy initially was not this way because of the severe shortage concern but we’ve now done a total 180, and I think that’s really important because we are now recognizing there really is asymptomatic viral shedding. So really this is a good policy because some of us — a lot of our attendings, et cetera — were wearing masks against hospital policy because we realized that there is a serious risk of asymptomatic viral shedding and we’re glad that our administrators have realized this and realigned policy.

Joe Elia:

I interviewed Susanne Sadoughi at Brigham and Women’s last week, and she said that they were doing most of their routine visits (now she’s an internist) but they were doing most of their routine visits via telephone and that that was working out well. Are you doing anything like that there?

Dr. Matt Young:

We are calling ambulatory patients and trying to triage and assess if we can just potentially diagnose them and write a script for them, trying to basically assess how urgent their needs are. We just got new policy today, which basically says we’re happy to see people for their follow-up postpartum visits but if they’ve had an uncomplicated vaginal delivery or an uncomplicated C-section, there haven’t been any blood pressure issues or major surgical issues, endometritis or any interventions that may require more aggressive follow-up we are just going to conduct phone postpartum visits instead. And I’ve had patients who…this really requires more advocacy on the part of the provider but I’ve tried to schedule for those more sick patients, routine follow-up with our service or other services, and I’m getting a lot of pushback saying, “We really aren’t scheduling right now until this is over.” And it really requires advocacy on our part to say, “Hold on a second, I really need you to see this patient, we really need your help.”

That has allowed me to sort of get around some of these policies saying we really aren’t going to see folks on an outpatient basis unless it’s urgent or necessary and really it requires advocacy to make that happen, but I think everybody’s trying to do their best. The problem is the situation is constantly evolving. I’m just glad that our healthcare system is adapting day to day and that we have a very responsive healthcare leadership. I will say I was just recently invited to join a Facebook group called SARS COV-2 House Staff Experience and it’s almost a thousand different house staff from across the country coming together in a private group to discuss our anxieties and our worries and our policies across various hospitals.

I’m shocked, frankly, to see that (I won’t mention who or where) but so many other institutions where other house staff and trainees and residents and fellows are, they are coming up with policies that either are misguided or lagging or just wrong-headed and I’m glad that our hospital and other hospitals we talked about are evolving their policies day to day but there’s so many other physicians and clinicians and residents that I’m hearing from that they’re still being told, “No, don’t worry about asymptomatic viral shedding. If you’re asymptomatic and the patient’s asymptomatic, save our PPE. Don’t wear masks.”

I had another resident who just told me that her hospital said to them that they don’t really believe that there is asymptomatic viral shedding, which is in direct contravention to what the national guidelines policies are, and they’re telling them not to wear masks. I just hope and pray that their hospitals are able to see the light and quickly revise and update their lagging policies.

Joe Elia:

I think that the light may be coming pretty quickly. When we had a telephone conversation two nights ago and I was inviting you to do this, Matt, things seems pretty quiet there then, and now I detect the urgency in your voice.

Dr. Matt Young:

Yeah. I’m in touch with a number of my colleagues who are in emergency medicine, and there’s a tremendous amount of anxiety and they’re just saying this is just going to get worse. This is going to get much, much, much worse. I mean the curve will be flattened but it’s still, relatively speaking, exponential. So there’s a lot of anxiety among frontline emergency providers. Most of these conversations are happening in private Facebook groups and in physician-to-physician chat rooms and dialogues, but I will tell you there is a severe discrepancy or asymmetry between the public government narrative and what front-line providers at the healthcare work force is seeing and what we’re bracing ourselves for.

Joe Elia:

Okay. Well, I want to thank you very much, Dr. Matt Young for talking with me today. And best of luck to you.

Dr. Matt Young:

Thank you, Joe. And best wishes and thanks to all the healthcare providers and the entire healthcare workforce that is on the frontlines now.

Joe Elia:

That was our 259th episode, all of them are available free at Podcasts.Jwatch.org. We come to you through the NEJM Group. The executive producer is Kristin Kelly. I’m Joe Elia. Thanks for listening.

Clinical Conversations

About the Podcast

To subscribe:

Comments, suggestions, and story ideas welcome. Learn more about Clinical Conversations.