May 1st, 2020
Podcast 265: COVID-19 in skilled nursing facilities
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We (Dr. Danielle Bowen Scheurer and Joe Elia) talk with Dr. John Jernigan of the CDC COVID-19 Investigation Team, which recently published its findings on the spread of COVID-19 in a Seattle-area skilled nursing facility.
Most intriguingly, over half the patients who tested positive were asymptomatic at the time of their first testing, and a few hadn’t developed any symptoms a week after their positive tests.
The results are instructive to those working in facilities such as this, whose patients are vulnerable to bad outcomes.
Running time: 17 minutes
Links:
New England Journal of Medicine report
Links to other interviews in this series:
- Dr. Anthony Fauci
- Dr. Susan Sadoughi
- Dr. Matthew Young
- Dr. Julian Flores
- Dr. Kristi Koenig
- Dr. Renee Salas
- Drs. Andre Sofair and William Chavey
- Dr. Comilla Sasson
Transcript
TRANSCRIPT
Joe Elia:__________You’re listening to Clinical Conversations. I’m Joe Elia. I’m joined this time by Dr. Danielle Bowen Scheurer, a colleague from earlier podcasts. Dr. Scheurer is a hospitalist and professor of medicine at the Medical University of South Carolina where she serves as chief of quality, safety, experience, and population health. That’s kind of a full plate, Danielle. Welcome back.
Dr. Scheurer:__________Thanks.
Joe Elia:__________We’re talking about COVID-19 again this week. It’s the disease whose effects you can see just by looking out the window: People walking in the streets with masks now seem unremarkable. And speaking of streets, there are hardly any cars out there.
What you can’t easily see, however, is who’s infected and who isn’t, and that’s the point of our interview with Dr. John Jernigan of the Centers for Disease Control and Prevention. He and his team have studied an early focus of the pandemic in the US — a skilled nursing facility in King County of Washington State, which neighbors Snohomish County where another such facility had just recorded the country’s apparent first outbreak. Their recent reports in MMWR and the New England Journal of Medicine show how difficult this disease is to screen for.
Dr. Jernigan is an epidemiologist with the CDC COVID-19 Investigation Team, and he also has a teaching appointment at Emory University School of Medicine, both in Atlanta.
Welcome to Clinical Conversations, Dr. Jernigan.
Dr. Jernigan:__________Thank you so much. Pleasure to be with you today.
Dr. Scheurer:__________Hi, Dr. Jernigan. It’s Danielle Scheurer. I’ve read your study with a lot of enthusiasm. It’s very interesting and impactful, so we just wanted to kind of walk through it and ask a couple of questions. So in summary, your team tested almost 90 residents in this facility with really good technique and of those who tested positive, over half had no symptoms at the time of testing and even a few hadn’t developed symptoms even a week after the testing. So as this was all unfolding and you’re reflecting on what you found, how surprised were you and your team with these results?
Dr. Jernigan:__________Thank you, Danielle, for that question. We were pretty surprised. As a little background, I was part of the CDC team that was deployed to Seattle when the outbreaks were first recognized there, when the first cases in Seattle were being recognized. I was in charge of a team that was over infection control for both acute care and long-term care, but it became apparent pretty quickly that long-term care was the place where we were seeing large and rapid outbreaks. So we began to support the investigation of some of those outbreaks as a way of helping prevent transmission.
One of the early observations: we sort of learned that some of the cases we were finding didn’t seem to have a lot in the way of symptoms. This was a very important issue because most of our infection control strategies rely on symptoms to identify residents or patients who might have infection and where to guide your testing and where to guide your isolation and prevention strategy. So we said we need to find out how widespread this is.
So we started doing these point-prevalence surveys. As you point out, we were quite surprised to learn that over half of the infections that we identified in these populations were asymptomatic at the time of the testing. This is a big problem in infection control. How can you separate those that are infected from those that are not if you can’t really tell based upon your symptoms? So we were quite surprised, to answer your question.
Joe Elia:__________The takeaway from your studies, in my mind, seems to be if I can caricature it: “Listen, clinicians, this disease doesn’t announce itself. You have to assume everyone is positive.” Is that fair?
Dr. Jernigan:__________In this particular population in this particular setting, I think that once you identify a case in your facility, yes, you need to assume that every resident in that facility may be infected. If that’s the case then you have sort of two choices going forward in terms of any transmission. One, you treat everybody in the facility the same way with regard to use of, for example, personal protective equipment, which can be a burdensome thing to do. It requires a lot of personal protective equipment, which is an issue.
As you know, there have been shortages nationwide, and particularly for many long-term care facilities, they have had trouble getting enough personal protective equipment. So that’s one issue. Basically isolate everybody, treat everybody a if they’re infected. Or you test everybody so that you can tell, as you point out, who’s infected, who’s not. Separate those that are infected into a certain cohort so you can put them in the same place in the building, assign certain staff to them, focus a lot of your personal protective equipment use there. Then for residents who are not infected to another place where hopefully you can protect them a little bit better.
Dr. Scheurer:__________And a follow-up on that, in your experience, how prepared do you think most facilities are to do quick and reliable widescale testing?
Dr. Jernigan:__________So this has been a real issue. As you know, there have been testing shortages and in fact when we first made this observation that was a big problem. We felt like testing all residents — and for that matter all healthcare providers — could be very helpful but testing availability really didn’t allow that. Now even at a week since that time testing availability has improved substantially, and so some skilled nursing facilities find themselves in states and other jurisdictions who have testing capacity that will allow taking this approach. Others are still struggling to do that. We hope that testing capacity will continue to improve such that if it turns out that this strategy does prove to be effective that more and more facilities will be able to utilize this strategy.
Dr. Scheurer:__________Even the ability to do the actual test aside, the collection methods are pretty cumbersome as well, right?
Dr. Jernigan:__________It is pretty labor intensive to collect the specimen. Even that is potentially changing a little bit with changes and recommendations of how tests can be performed, whether or not you have to do a nasopharyngeal swab, which is originally that’s what the recommendation was. So it takes a certain skillset and level of training to acquire those. CDC has just amended its recommendation such that swabs to the anterior nares are probably acceptable, which simplifies things a little bit in terms of being able to collect the specimen, but still you have to have the swabs, and you have to have the viral transport media, and you have to have a laboratory who can process these specimens and process them quickly. So there have been challenges in all of those elements. It can be a pretty difficult thing to do. I will say that I believe that capacity is improving pretty rapidly.
Dr. Scheurer:__________Which is great and definitely welcome news for the vulnerable population. Can you expound also a little bit about how you guys define symptoms and how that definition is changing and evolving?
Dr. Jernigan:__________Right. So when we started out this investigation not much was really known about this disease. Originally, the symptoms that were used to guide testing and to identify people who had been exposed and who you thought might be infected were essentially fever, cough, and shortness of breath. So we used essentially that for our definition of kind of typical symptoms.
But part of this investigation (and many others) is showing that there are lots of other less typical symptoms that are a manifestation of this disease. So on the one hand, you have people with sort of kind of the classic, cough, fever, shortness of breath. On the other end of the spectrum you have people who have no symptoms and then in between you have lots of other things.
We think especially in the early phases the illness can present quite subtly with maybe just a headache or myalgias or a little bit of chills, sometimes a little nausea, sore throat. What we’ve learned since then, which wasn’t appreciated when we started the study, the sudden loss of smell or sense of taste may be associated with this. So the sort of menu of symptoms that can be a manifestation of early parts of this illness has expanded pretty substantially.
Dr. Scheurer:__________Do you think there is a logical role for serologic testing in long-term care facilities right now or in the future.
Dr. Jernigan:__________So I’m glad you asked that question. I think there is potential great promise from use of serology to help guide these sorts of strategies, but I don’t think we are there yet. There are a number of different platforms out there. Some perform better than others. There’s also the question of what the presence of antibodies means. Are they neutralizing antibodies or not? Does the presence of these antibodies confer a protection against reinfection? What are the correlates of protection? I think these are all ongoing questions that we need to answer. I think there are many, many people out there working very hard to answer these questions and we hope they will have answers in the relatively near-term. I think at this moment today, our stance — and I guess this is my personal opinion — is that I don’t think we’re ready to use the results of serologic testing to make clinical or infection control or public health decisions. We might be there very soon, but I don’t think we’re there today.
Joe Elia:__________The editorial in the New England Journal of Medicine argues that we must be especially cautious until we can test widely and reliably. Did your team have a reaction to the editorial? Did they share their…
Dr. Jernigan:__________No. We have no interaction with the authors. We saw it when it was published or shortly before. If your question is more broadly about how to relax social distancing measures, et cetera and so forth and the relationship between available testing and that, I’m really not the person to focus on that. My focus is specifically on infection control and long-term care facilities and the relationship of testing and testing availability to that with regard to controlling transmission in long-term care facilities, which, by the way is a really high priority thing, as I think I might have mentioned already.
When SARS COV2 is introduced into these settings it can spread very rapidly and very widely and it can cause great morbidity and mortality in this very vulnerable population. But in addition, more than just protecting these residents and these patients it’s important for the regional healthcare system. What we observed in Seattle is that a large outbreak in even a single skilled nursing facility puts great strain on local hospitals in terms of their ICU bed capacity, et cetera and so forth. What’s more is that when a patient in a long-term care facility gets admitted to a hospital with COVID-19 sometimes it’s difficult to get them discharged, because long-term care facilities may be reticent to accept someone who is positive and may still be shedding virus, et cetera. So not just to protect those residents but it’s also to protect the local healthcare system.
So I think preventing transmission here in these settings should be a high priority. So back to the question of the relationship of that priority and testing. We think that our results suggest that testing can be an important tool to help control spread in these settings, and we agree with the writers of the editorial that the sooner that we can make improved testing capacity to the point that we can use it in these settings in that way the better.
Joe Elia:__________Thank you. I just wanted to ask a final question. What were your team’s reactions to the findings that you made? Were they astonished to see this?
Dr. Jernigan:__________I would say we were very surprised. The potential implications of the findings were immediately obvious to us. It seemed clear that a test-based strategy may be a very important approach and yet we were concerned that testing capacity at that point in time was not sufficient to allow that. We’ve been working since that time to partner with facilities and public health jurisdictions that have been increasing their test capacity and to partner with them in implementing this strategy and learning along with them about the best ways to actually go about implementing it.
For example, if you go out and you test everybody once, is that sufficient? There’s some early clues that that may not be sufficient, because if you test anybody on a given day and they’re negative it could be that they’re actually infected but they’re still in their incubation period and not shedding virus — at least to the extent that can be picked up by the test. That suggests that you may need to go back and do a repeat test and make sure that you haven’t missed any of those patients who are incubating. The findings from our study sort of hinted early on that that in fact was the case. So we were working with these partners to implement the strategy and learn lessons as we go with regard to the best way to implement it, the most efficient way to implement it, what the barriers to implementation are, what the facilitators to successful implementation are, and hopefully we can parlay all that information into better and refined guidance from CDC on how to proceed with this prevention strategy.
Joe Elia:__________My last question was going to be, what do you think your team would like to see as a result of your work? I think you’ve just answered that question.
Dr. Jernigan:__________Yes. I think that’s right. We would like to see testing availability that allows long-term care facilities the option of using a test-based infection control strategy. They have the resources they need to not only do the testing but it’s important to emphasize that they need to have the resources to take the appropriate action based upon the test and be planning about how to cohort patients or cohort residents, and make sure they have appropriate PPE, all these sorts of things. All the testing in the world…you can do all the testing in the world but it won’t help you if you can’t take the appropriate action that should be taken based upon the results.
Joe Elia:__________We want to thank you for your time with us today, Dr. Jernigan.
Dr. Scheurer:__________Thank you so much.
Dr. Jernigan:__________Thank you.
Joe Elia:__________That was our 265th conversation. This and all the others are available free at Podcasts.JWatch.org. We come to you from the NEJM Group. The executive producer is Kristin Kelly. I’m Joe Elia.
Dr. Scheurer:__________And I’m Danielle Scheurer.
Joe Elia:__________Thanks for listening.
April 19th, 2020
Podcast 264: Is COVID-19 pushing MIs out of emergency departments?
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Cardiovascular consults are way down. Is the threat of COVID-19 infection scaring people away from EDs?
We caught up with Dr. Comilla Sasson, the American Heart Association’s VP for science and innovation. She’s an emergency physician who teaches at the University of Colorado. She’d traveled to New York City to “help with the response,” and she talked with us from a field hospital that had been set up on a tennis court in Central Park.
She had lots to say about what’s driving patients away from emergency departments these days and what’s likely to happen in medicine (hello, telemedicine!) once the pandemic abates.
Running time: 15 minutes
Links (courtesy of the American Heart Association):
- Interim Guidance for Basic and Advanced Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19
- Oxygenation and Ventilation of COVID-19 Patients
- New COVID-19 patient data registry will provide insights to care and adverse cardiovascular outcomes
- COVID-19 Compendium for health care providers
- Coronavirus (COVID-19) Resources for CPR Training & Resuscitation
Links to other interviews in this series:
- Dr. Anthony Fauci
- Dr. Susan Sadoughi
- Dr. Matthew Young
- Dr. Julian Flores
- Dr. Kristi Koenig
- Dr. Renee Salas
- Drs. Andre Sofair and William Chavey
Transcript
Joe Elia: Welcome to Clinical Conversations. I’m your host, Joe Elia.
There is talk that COVID-19 is apparently scaring myocardial infarctions and other bothersome conditions away from emergency departments. Harlan Krumholz wrote about the phenomenon earlier this month in The New York Times. He pointed to studies suggesting that cardiovascular consultations have dropped by about 50 percent in the days of COVID.
My cohost, Dr. Ali Raja and I have asked Dr. Comilla Sasson to talk about this with us. You know Dr. Raja of the Mass. General and Harvard Medial School already. Dr. Sasson is an emergency physician and associate professor at the University of Colorado School of Medicine. She is also vice president for science and innovation at the American Heart Association.
When we scheduled this interview, she was on her way to New York City to, as she put it, “help with the response.”
Welcome to Clinical Conversations, Dr. Sasson.
Dr. Comilla Sasson: Thank you for having me.
Joe Elia: I’d like to ask you what the Heart Association thinks about this phenomenon of evaporating visits for cardiovascular diseases. Have you convened a panel to study it? What are you telling people who inquire about it?
Dr. Comilla Sasson: You know, I think we’re all a little bit shocked and taken aback by just how quickly and precipitously we’ve seen such a huge drop in our volumes in our emergency department. Specifically, and I think it would be naïve to think that that’s just because we’re not having heart attacks anymore or strokes or other time-sensitive conditions. I think what it really boils down to — and I’ve personally experienced this with my own patients — is that people are afraid.
They are afraid that if they go to the emergency department they will get COVID. Even though we have separate areas for them, different places for them to be taken care of. I think what we’re realizing is that because we’ve done such a good job of getting the word out about make sure you’re appropriately utilizing the emergency department, I think the unintended consequence is maybe we’ve actually scared off some people who actually need to be there.
Dr. Ali Raja: That’s interesting. Dr. Sasson, let me ask you, I’ve followed your research for years, and it really focuses on resuscitation, especially on educating non-clinicians and bystanders to begin resuscitation. You mentioned that people are scared. Are you concerned at all that that might actually translate to resuscitations and CPR? Do you think that people are going to be reluctant to actually go near and potentially help other in distress?
Dr. Comilla Sasson: Yes. I think that’s actually something that we’re very, very both fearful of and mindful of, and I think what we’re trying to do, both as an organization as the American Heart Association, is get the word out about just how important it is to still go to the emergency department if you need to, call 911 if you have any kind of signs or symptoms of a heart attack. Then if you do see somebody drop, it’s okay to even do CPR. I think there’s so much fear right now of being even near people, touching people, let alone trying to actually do compressions — maybe even with breaths if it’s a household member. So I think we’re trying to get the word out.
I think we’re trying to also work with our partners in the community because we know there are huge health inequities as well. So can we use our reach as an organization, as the AHA who works in churches and schools and has a really big breadth and depth of work that we do in the community. How do we use our relationships to get that message out? I think we have to work in collaboration with all partners to do that.
Joe Elia: Are you still in New York, Dr. Sasson? Can you tell us a bit about that experience?
Dr. Comilla Sasson: It’s amazing. It’s wild. It’s something like I’ve never seen before. So I’m literally sitting right now in one of the field hospitals that have popped up. It was created just less than three weeks ago from scratch from a tennis court, literally.
So I think it’s been fascinating to see how a city responds. How do you coordinate care when you have to build a hospital from scratch; and then how do you bring people in and out of the system in a surge time; and then — even now as we’re plateauing here in New York — when do appropriately transfer folks here so that you can open up more hospital beds? And then how do you think about this in the next wave? So what happens when you hit surge two? What happens when you hit surge three? Is the field hospital the answer that could maybe help with all of those overwhelming videos and stories that we are hearing in New York City when the surge happened? How do you sort of think about this not only for the current COVID crisis but then for all the next waves that we know are going to happen?
Joe Elia: So how long are you planning to be there to help out, as you put it?
Dr. Comilla Sasson: For a month.
Dr. Ali Raja: Wow.
Joe Elia: So the people listening can’t see what we see. It looks like you’re sitting in kind of a tent-like facility. So do you have patients now in that facility?
Dr. Comilla Sasson: We do. We’ve been ramping up for the last few days, and we’re continuing to ramp up and increase both our capacity to take care of patients but also to increase our acuity as well. So I think, again, as you’re building a hospital, I mean again from scratch, it’s about thinking about how to ramp up appropriately so that you can also make sure that your lab works, that your x-ray works, that you’ve got oxygen, that you’ve got the things that we take for granted in a real hospital, if you will, that has been there for years. You have to make sure everything works first and then I think that’s when you can start to really increase that acuity.
Dr. Ali Raja: Dr. Sasson, let me ask you, right now we’re in the response phase. You’re setting up a hospital in a tennis court but we’re also generating a lot of data all over the world and this is happening everywhere at once. It’s not like the Boston Marathon where it happened in one city. This is happening all over the world and there’s a ton of data being generated not just around the world but also in the country. So let me ask you, this is obviously going to prompt a lot of data analysis and research at some point. Is the American Heart Association planning to collect and speak on the lessons learned? Obviously they are — that’s what they do. But do you have any projects that you can talk about now about what’s going to come out of this from the AHA?
Dr. Comilla Sasson: So I think our first responses that we had right away to this surge that we started to see in the global pandemic was to really increase our research funding. So we’ve allocated 2.5 million dollars of new research dollars specifically towards COVID research, and that’s generated a huge volume of applications, which just means that there’s a lot of people who have a lot of questions, right. We created a COVID data registry as well so that we can start tracking this and utilizing our expertise as an organization in terms of data collection.
We’ve had Get With The Guidelines for many, many years and so I think now we’ve got the ability to leverage that expertise that we had with Get With The Guidelines, precision medicine platform to build this data registry. So we can look at heart conditions specifically over the course of not just years but actually months and days, which is something different than what we normally do because most data analysis is a year later and then as an organization we are the biggest trainer of ACLS and BLS across the world.
So we just released our new interim CPR guidance for patients who are suspected or known COVID for both BLS and ACLS and PALS as well so that people can understand what are the caveats for resuscitation with those patients. Then we also released, just recently, our oxygenation and ventilation just-in-time training. So when you’ve go your medical student or maybe your ward nurse who’s now reassigned to the ICU, how do I learn how to manage a vent or a vented patient quickly? So really just trying to think about how do we build those educational building blocks that we’re really good at. How do we put those into place now so that people have what they need when the surge comes to their city, which we know it will.
Dr. Ali Raja: If you don’t mind sending us the links to those, the new ACLS / BLS guidelines and the education that you just talked about we can actually put those in the website. [Done!]
Dr. Comilla Sasson: And we had a huge, even in less than a week, we had over 38 thousand hits to that oxygenation / ventilation module. I can tell you, being here in the rapid response team for COVID, I’ve had a lot of people who are like I just don’t remember how to do a vent. It’s been a while for most of us, right. I can do 30 minutes of it. I don’t know if I could do six days. I can tell you, I took on a patient yesterday who was taken care of by a dentistry resident. You know, so if you think about what happens in a surge or when you have frontline workers who now have to very quickly increase capacity, that’s a real thing where you’ve got people who are very much outside of their clinical expertise who are just helping manage that surge so that’s what this is really all about.
Joe Elia: The changes in referrals and ED visits that we’re seeing seem to be part of a larger phenomenon that’s happening in healthcare generally. The question is, would you agree that COVID-19 will be a kind of trigger for serious changes in how health gets taken care of in this country?
Dr. Comilla Sasson: Yes. I think if we want to think about what are the positive things that have happened because of the COVID pandemic, the number one most important thing that we have done that will absolutely change the way in which we function as a healthcare system is to increase our utilization in telemedicine. It’s so funny because I think for the last 10 years we’ve kind of been struggling trying to get people to get excited about it, getting payers to pay for it, trying to get physicians and advanced care providers to sign on for it to say, yes, this is a valuable tool. I think overnight we kind of flipped the switch, just like they did in Wuhan, China, and moved so much of our care to telemedicine that I don’t think we’re going to go back.
I have a five-year-old son who got strep throat a week-and-a-half ago, even though we were on quarantine, so it happens. But we did two telemedicine visits from my house. I’ll be honest, I don’t think I ever want to go back unless we absolutely have to go see my pediatrician. It was amazing. We had everything that we needed at home. I think that’s one of the biggest innovations that I see both not just for the COVID post era but hopefully into perpetuity.
I did have a personal story of a patient who I took care of on telehealth. It was mind-boggling to me — absolutely mind-boggling. A woman who had multiple comorbid conditions with chest pain, who I was literally chatting with online first, because it started out as just a very normal interaction. It escalated into “Oh, my gosh, I’m really worried about you. You need to go to the emergency department right now.” She said no. I said, “Can I talk to your family member?” So then we had escalated up to her family member and yet her family remember said, “She refuses. She said she would rather die than go to the emergency department right now because she does not want to get COVID.”
I kept telling her there’s different sections. If you’ve got a non-COVID respiratory complaint you’ll be fine. We can keep you separate and she refused, absolutely refused, and said she’d rather die. So those are the people that keep me up at night, because you kind of wonder how many other folks never even bother to call or check in or even say that they have these symptoms. How much EMS volume has gone down for 911 calls because people are just afraid. So I think the more we can do to get the message out that “If you have to call 911, if you have to go to the hospital we can keep you safe.” I think that’s going to be key.
Dr. Ali Raja: Many of us are starting to plan our health system’s response after we start opening society back up, and one of the things that I and many others — including potentially you — are worried about is that we’ll see a surge in patients with delayed presentations or we’ll see more patients rebounding from non-COVID diseases, the diabetic that hasn’t been well managed for the past few months, the patient whose high blood pressure hasn’t been well taken care of because they didn’t take advantage of the telemedicine that you just talked about. What should we be doing now to prepare for a potential surge in patients with cardiovascular disease presentations coming in when we finally do open things back up?
Dr. Comilla Sasson: I think that’s a great question. I think you might actually have a better answer than I do, but I think everyone’s vantage point is a little bit different. I think what’s been interesting to me is that we’ve been in a very reactionary mode I think for most…most of medicine has always been about sort of treating the condition. So we wait until you develop heart disease to really plug you into the system and take care of you. So I think hopefully we get back to the idea of prevention and hopefully we go out and actually start being proactive about people’s care. To me, that seems like that’s such an important piece that has always been missing because we’re always just trying to put out the latest fire rather than really thinking about there is a CHF patient right now who’s sitting at home who is probably on the verge of having an exacerbation and may be frightened to come into the hospital. So what are health systems really doing to think about those very vulnerable patients right now to say what can we do while you’re at home, while you’re in the middle of your shutdown? What can we do to make you better so that we don’t have those unintended consequences of the flood gates open on whatever day it is, April 26 in Colorado and all of a sudden all these patients who’ve been waiting to be let out because now all of a sudden they think it’s safe to be let out because we’ve said there’s no shutdown anymore.
We’re going to see all those patients and April 26 for the CHFer may be too late. So I think we have to be much more proactive, and I worry that we’re not as proactive as we could be about reaching out to those folks. We know who they are in our healthcare systems, right.
Joe Elia: I want to thank you very much, Dr. Sasson, for talking with us today about this.
Dr. Comilla Sasson: Thank you, guys, for having me. This is really important work, and I’m very fortunate to be part of the Heart Association in that we’ve always looked at the sort of great opportunity both to be within the professional sector but then also with the general public in trying to increase everybody’s knowledge and getting everybody on the same page. So I’m hopeful, again, that through all of this what we’re learning, we can actually work with all of our different partner organizations, especially in the community to get the message out that it’s okay. It’s okay to go to the emergency department. It’s okay to use healthcare. Just because you’re in a shutdown doesn’t mean that you need to ignore your health condition until you’re not in a shutdown, and I think we all need to work together to get that message out.
Joe Elia: That was our 264th episode. All 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 Kelley. I’m Joe Elia.
Dr. Ali Raja: And I’m Ali Raja. Thanks for listening.
April 15th, 2020
Podcast 263: Checking in with Connecticut and Michigan on medicine after COVID-19
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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:
- Dr. Anthony Fauci
- Dr. Susan Sadoughi
- Dr. Matthew Young
- Dr. Julian Flores
- Dr. Kristi Koenig
- 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
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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
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
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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:
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
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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”
Other interviews in this series on COVID-19:
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.
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