March 27th, 2020
Podcast 260: Interview with a Broward County, Florida, emergency room physician
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This time we talk with Dr. Julian Flores, who works in a Broward County, Florida, emergency room.
When he was interviewed, the count of Covid-19 cases stood at 412, less than 12 hours later, the new number was 505, as of this posting — on Friday near noon Eastern — it’s at 614. Flores is expecting the wave to hit hard there. Broward is home to Fort Lauderdale (think spring break) and Pompano Beach (think aging retirees). Couple those demographics with a lack of easy testing for the virus, and you’ve got a worrisome situation.
Links of interest:
Running time: 13 minutes
A TRANSCRIPT OF THE INTERVIEW (Please bear in mind that what follows is a conversation and not a polished essay.)
Joe Elia:
You’re listening to Clinical Conversations. I’m your host, Joe Elia, and I’m joined by my cohost, Dr. Ali Raja, Editor-in-Chief of NEJM Journal Watch Emergency Medicine. He’s in the Department of Emergency Medicine at Mass. General and an associate professor at Harvard Medical School.
We continue exploring the COVID-19 pandemic by heading south from our last interview with a first-year OB/GYN resident in Delaware to the State of Florida. Our guest is Julian Flores, an attending physician in the Emergency Department at Westside Regional Medical Center in Plantation, Florida, outside Fort Lauderdale.
Dr. Flores went to college in New York City and then on to Harvard Medical School. He trained in emergency medicine at the University of North Carolina and has been an attending physician at Westside since last July. Welcome to Clinical Conversations, Dr. Flores.
Dr. Julian Flores:
Hi. Good morning. Thanks for having me.
Joe Elia:
As of this morning, Broward County had 412 cases of COVID-19 and three deaths reported. Florida’s governor has mandated self-quarantine for travelers arriving from New York and New Jersey, so what are you seeing there on the ground?
Dr. Julian Flores:
I think the idea is a good start. Social distancing has been shown to work when you do it early. The idea is to prevent community spread. In the 1918 pandemic, it worked to at least stall some of the deaths and the morbidity, but we’re not doing it like that. We’re doing it very fragmentedly, and I understand the United States in and of itself there’s so much population to be able to control under one measure. Some people argue you can’t use the same instrument but the actual application of it, especially when a place is diverse like Florida — like South Florida — I think there’s a lot that goes into the actual implementation of this and for it to actually be realistic and effective. I can personally say that I live in Brickle, the financial district of Miami, and I’m seeing honestly anything but.
I’m seeing people in groups of five, 10, people out everywhere. You know, it’s unfortunate, and I worry honestly that as people start getting antsy-er and start wanting to go outside — more and more sort of unfettered — that’s going to coincidentally be arriving at the same time that we’re expecting our own wave in the next few weeks only leading to further community spread. Our testing hasn’t necessarily gotten that much better, frankly — the [amount] of testing that we’re doing — and it’s only going to lead, I think, to further undiagnosed cases and leading to potential more critical cases and more resource consumption within our hospitals down here.
Dr. Ali Raja:
Dr. Flores, how has your daily clinical practice changed in the face of this pandemic? Are you changing your practice even for those patients who don’t look like they have any respiratory issues when you first see them?
Dr. Julian Flores:
That’s a great question because as more data comes out, we’re seeing, as you may know, even as up to as high as 10 percent of cases do not come with cardiopulmonary complaints. It’s nausea, it’s vomiting, it’s abdominal pain, it’s fatigue.
Frankly, for my own personal practice, at this point, I am assuming you have it until proven otherwise. To the capacity that I will be able to continue doing so, I will at least wear a surgical mask when I approach your room.
It’s very interesting how people that I would have sent home without any sort of second guessing, at the very least if it doesn’t infiltrate my note it definitely infiltrates what I think of when I send them home with X and Y and Z instructions. How confident do I feel that that mild belly pain wasn’t an undiagnosed COVID-19 case that now is going to exponentially spread into their community. So it’s interesting how it definitely has affected all of us in what we thought were very confident algorithms to go by. Now we’re at least having some thought about it not being the case.
Dr. Ali Raja:
Wow. Aside from the clinical care, let’s talk about you and your team. Does your team have enough personal protective equipment, PPE, right now in the ED?
Dr. Julian Flores:
I could say that for my own particular hospital, thankfully, we are not at the point of having to recycle them. There are some hospitals I can say — some colleagues of mine that are working in nearby hospitals — that are at that point officially, where people are just at the end of the shift all putting their PPE equipment for the day in a collective bin. It’s undergoing some kind of sterilization procedure and they’re being sort of reused the next day. We are being asked to use…as an example, an N95 mask, one mask a shift. There is, from what I’ve heard among my colleagues, there is disparity among to what extent administration is okay with you bringing your own PPE gear.
We know at least from the standpoint of ASA and AAEM — the emergency medicine societies — that this is something that should be allowed but that sort of thought, I could say it hasn’t been a collective thought among the hospitals. That only leads to further sort of frustration, confusion, safety risks, etcetera.
I think I also wanted to make a comment about the fact that a lot of people, my friends, both medical and nonmedical, they like to hang their hat on the percent morality that we’re seeing with this pandemic. Some will argue that it’s much less than we’ve seen with waves of the flu or other related viruses, but I think a comment should also be made on the morbidity that this pandemic is presenting, particularly this COVID-19 virus is presenting.
When you have a virus that takes so long to incubate, I think it’s at least eight to 10 days I think of incubation is what the research suggests, and when you have the average patient that takes 10 to 11 days to wean off, take off the ventilator whether it’s alive or you finally decided to pronounce them as passing, that’s a lot of consumption of resources, of personnel, of equipment, of a bed that will not be available until two weeks from when that decision is made.
One, it falsely reassures you early on of the numbers and it makes it harder to implement thing like social distancing and more stringently a lockdown when you don’t have the numbers from the get-go sort of express what’s projected. Then you’re kind of caught behind the ball when those numbers finally proclaim themselves and you find yourself out of personnel, whether it’s because they’re sick because they didn’t take the appropriate measures or because you don’t have enough equipment anymore or because you never established the infrastructure that can maintain a good practice.
Joe Elia:
So you mentioned other hospitals. Are you sharing information with others on social media? I talked with your classmate, Matt Young, and he mentioned a Facebook group where clinicians are communicating. Can you tell us anything about that? Is it finding it helpful?
Dr. Julian Flores:
Oh, it’s fantastic. I’m part of a private Facebook group called EM Docs. I’m also part of a Facebook group called COVID-19 Physician / APP Alliance or APP Group. I mean the amount of information we’re sharing amongst each other is amazing. Anything from truly understanding what other folks on their own front lines are dealing with — to novel ways of sterilizing equipment to ways to, for example, make a ventilator all of a sudden be able to vent two or three people. So if there’s anything good that’s come out of this it’s the amount of resource sharing that we’re seeing among all kinds of folks ranging from techs to nurses, doctors, et cetera.
Joe Elia:
Your population there runs to age extremes at this time of year, doesn’t it? I mean you’ve got college students at Fort Lauderdale on spring break and aging retirees in Pompano. Can you talk about the age-specific concerns that people have?
Dr. Julian Flores:
I can say that I hope that we are not hit with a strong of a surge as we’re expected to because, as you’re saying, we as a state have much more of a geriatric population than the nearby states, than even New York, I believe. So when you combine the fact that at baseline we have such a large geriatric population with the fact that we’re still allowing flights from harder-hit states to be arriving. You combine that chronologically with just the huge influx of younger folks that we had in Florida that we know on average are asymptomatic or mildly symptomatic along with an ongoing confusion as to truly how to handle this pandemic within the State of Florida. Frankly, it’s the perfect storm. We’re can still consider ourselves within the incubation period for many of these folks that potentially will go on to either have symptoms difficult enough for you to be hospitalized or even further to be put in an ICU.
From what I’m seeing, as an example, NPR yesterday or the other day published an article where you can essentially find how many beds your particular county has. If I’m not mistaken Broward County, as an example, between Miami and Fort Lauderdale has around two thousand, three thousand ICU beds max. I mean at baseline we already use some of those and we’ve already used some more with this growing pandemic. I hope I’m wrong.
There’s this sense of false reassurance. In a way, I can’t fully blame our governor for not acting even more stringently when you don’t really have numbers to work with. You can’t be convincing a population this dense that we’re in crisis when the numbers don’t necessarily yield that. In New York, thankfully, there was enough testing that at least on television you could say to your public, “This is what’s going on. This is why you should support whatever stringent measures I’m applying.” But when you don’t have that. When you have testing that, to this day, I’m still having to go through many loopholes to, at the end of it all, if I get a phone call back to get the confirmation to proceed with testing you can only expect there to be confusion and underreporting.
I can say we’ve all, I think, individually sent home dozens of patients that were not symptomatic [enough] to be hospitalized but definitely with a high suspicion of it — but not with the luxury of being able to swab all of them.
Dr. Ali Raja:
Dr. Flores, you mentioned that you’re expecting to see the surge hit in a couple of weeks and you’re worried about all the folks who have stopped physically distancing themselves. Let me ask, what are you and the hospital doing to prepare for this expected surge and what should the rest of our clinicians who are listening to this be doing with their hospitals?
Dr. Julian Flores:
Well, as an example, we put in place the policy to be mindful with our own PPE gear, as an example. Even though we’re not in crisis, per se, at our own particular hospital, we anticipate that. So being judicious with that, trying to limit the number of personnel that need to go into a given room, as an example as well, because for every time you go in and out, technically you should be changing your gear into a new set, for the most part.
Joe Elia:
Well, we want to thank you, Dr. Julian Flores, for spending time with us today. We wish you good luck and godspeed through the pandemic.
Dr. Julian Flores:
Thank you. I appreciate it. Honestly, I hope we’re wrong about what’s projected, but I know that at least we’re all in this together.
Joe Elia:
That was our 260th episode, all of which are available and searchable at Podcasts.JWatch.org. We come to you from the NEJM Group. We’re a publication of NEJM Journal Watch and Physicians First Watch. Our executive producer is Kristin Kelly. I’m Joe Elia.
Dr. Ali Raja:
And I’m Ali Raja. Thanks for listening.
March 25th, 2020
Podcast 259: A first-year resident tells us what he sees in the Covid-19 pandemic
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Dr. Matt Young is a first-year resident in obstetrics and gynecology in suburban Delaware. Between the day I invited him to be interviewed and the interview itself (a 36-hour span) things had changed a lot for him. Anxiety levels are up among his colleagues, and everyone in his hospital must wear a mask all the time.
A ground-level view of an incipient epidemic is what we offer.
Running time: 13 minutes
TRANSCRIPT OF THE CONVERSATION WITH DR. MATT YOUNG
Joe Elia:
You’re listening to Clinical Conversations.
I’m your host, Joe Elia. Like everyone else on the planet, we in the US are obsessing over the morbidity and mortality charts of the COVID-19 pandemic. We’ve done interviews with Dr. Anthony Fauci and Dr. Susanne Sadoughi and I wondered what the newcomers to clinical life are seeing through their fresh eyes.
So I’ve reached out to Dr. Matthew Young, who is completing his first year of an OB/GYN residency in suburban Delaware. I know Matt from working with him on a social media project for the NEJM Group. He was a Harvard medical student back then, finishing up law studies there as well. He’s kept pretty busy (but he admits he hasn’t practiced on his piano for many, many months).
Welcome to Clinical Conversations, Dr. Young.
Dr. Matt Young:
Hey, Joe. Thanks for having me.
Joe Elia:
So you’re finishing up your first year of an OB/GYN residency at Christiana Care in Newark, Delaware. As of this morning, March 24, the state had about 90 cases of COVID-19, so I’d like to ask, what in your experience of obstetrics and gynecology has changed between when you started last July and now?
Dr. Matt Young:
Really the big difference has been work shift and our scheduling. Basically, we’ve adopted a model I think other house staff has — a similar model across the country where we tried to cancel elective procedures and have residents who don’t need to be here, not be here.
So a lot of GYN entails elective surgeries and procedures, and we’ve basically shut those down. Our surgery center is quiet. I’ve never seen it that way. I was there last Monday and there were just no patients there. We’re just complying with CDC and national standards in that regard but it allows sort of this on-and-off model where we have some residents off at certain times. They’re sort of backup or taking home call while other residents who are considered essential and immediate — for example labor and delivery and our obstetrical triage unit — they need to be there because they’re absolutely essential, and certainly that allows patients who need to be delivered or who have obstetrical problems, they need to come in.
Of course, not all elective things are canceled. So elective induction of labor is still considered important and necessarily. So we are allowing all those folks who are scheduled for elective inductions or who want elective inductions to come in.
Joe Elia:
Okay. Labor and delivery, whether elective or not, is not something that you can’t opt out of for more than a reasonable amount of time. So OB/GYN is staying pretty busy I guess you’d say.
Dr. Matt Young:
Absolutely, but we are being very aggressive in terms of trying to curb potential exposure and infection. We are limiting the number of visitors, we’re only allowing one support person to accompany a patient postpartum. We’ve also adopted a new masking policy, and I’d be happy to tell you more about that.
Joe Elia:
Go ahead and tell me about this.
Dr. Matt Young:
So our hospital has been aggressive and followed that directive as well [Matt’s referring to a directive from Boston’s Partners HealthCare that mandates mask-wearing for all employees]. Basically in its initial days and weeks we were told do not consume or use surgical masks or N95 masks unless you’re interacting with a rule-out COVID patient or someone with symptoms or if you yourself have symptoms. Unless you’re dealing with somebody with symptoms you are not to wear or consume PPE (personal protective equipment) like N95 masks or surgical masks. Basically been a 180 degree reversal of that. I mean that policy probably was driven by severe shortages, folks who are calculating out that we’re going to run out in days to weeks, but there’s been a total reversal of that.
Basically, our hospital has adopted a mandatory mask-wearing policy. We basically made masks mandatory for all visitors and for all providers in any patient care areas. Partners Health in Boston is doing this and Christiana Care where I am at we’re doing this now, effective immediately, and we’re all really actually relieved because we got an email saying that we’re kind of lucky we don’t have such an acute shortage like major urban centers do, but even major urban centers like Mass General are adopting this mandatory mask-wearing policy. So I think that providers are getting…every day is a different day with new guidelines evolving, and I think that there’s a lot of provider anxiety.
There are a lot of labor and delivery nurses with families. Some of them are expecting, and that puts them at high risk. There are a lot of residents who are vulnerable or have exposures to vulnerable people. There’s a lot of anxiety among providers about protecting our healthcare workforce. So I’m so glad that major institutions like Mass. General and ours here at Christiana are adopting this.
Now, I have seen other measures being taken as well to sideline certain residents. So we usually have family medicine residents participate in our GYN and OB clinic outpatient ambulatory setting. Those residents are getting pulled and sidelined because there are concerns that because the family medicine residents are interacting with all kinds of populations that we may not necessarily want them interacting and possibly infecting our patients.
Now, all of this is in the setting of a concern about asymptomatic viral shedding or asymptomatic spread and that is what undergirded this new mandatory sort of making-masks-mandatory policy because providers are recognizing that there is serious concern of asymptomatic viral shedding, and we don’t know who has it and there’s so much uncertainty that we need to take universal precautions. It seems like the policy initially was not this way because of the severe shortage concern but we’ve now done a total 180, and I think that’s really important because we are now recognizing there really is asymptomatic viral shedding. So really this is a good policy because some of us — a lot of our attendings, et cetera — were wearing masks against hospital policy because we realized that there is a serious risk of asymptomatic viral shedding and we’re glad that our administrators have realized this and realigned policy.
Joe Elia:
I interviewed Susanne Sadoughi at Brigham and Women’s last week, and she said that they were doing most of their routine visits (now she’s an internist) but they were doing most of their routine visits via telephone and that that was working out well. Are you doing anything like that there?
Dr. Matt Young:
We are calling ambulatory patients and trying to triage and assess if we can just potentially diagnose them and write a script for them, trying to basically assess how urgent their needs are. We just got new policy today, which basically says we’re happy to see people for their follow-up postpartum visits but if they’ve had an uncomplicated vaginal delivery or an uncomplicated C-section, there haven’t been any blood pressure issues or major surgical issues, endometritis or any interventions that may require more aggressive follow-up we are just going to conduct phone postpartum visits instead. And I’ve had patients who…this really requires more advocacy on the part of the provider but I’ve tried to schedule for those more sick patients, routine follow-up with our service or other services, and I’m getting a lot of pushback saying, “We really aren’t scheduling right now until this is over.” And it really requires advocacy on our part to say, “Hold on a second, I really need you to see this patient, we really need your help.”
That has allowed me to sort of get around some of these policies saying we really aren’t going to see folks on an outpatient basis unless it’s urgent or necessary and really it requires advocacy to make that happen, but I think everybody’s trying to do their best. The problem is the situation is constantly evolving. I’m just glad that our healthcare system is adapting day to day and that we have a very responsive healthcare leadership. I will say I was just recently invited to join a Facebook group called SARS COV-2 House Staff Experience and it’s almost a thousand different house staff from across the country coming together in a private group to discuss our anxieties and our worries and our policies across various hospitals.
I’m shocked, frankly, to see that (I won’t mention who or where) but so many other institutions where other house staff and trainees and residents and fellows are, they are coming up with policies that either are misguided or lagging or just wrong-headed and I’m glad that our hospital and other hospitals we talked about are evolving their policies day to day but there’s so many other physicians and clinicians and residents that I’m hearing from that they’re still being told, “No, don’t worry about asymptomatic viral shedding. If you’re asymptomatic and the patient’s asymptomatic, save our PPE. Don’t wear masks.”
I had another resident who just told me that her hospital said to them that they don’t really believe that there is asymptomatic viral shedding, which is in direct contravention to what the national guidelines policies are, and they’re telling them not to wear masks. I just hope and pray that their hospitals are able to see the light and quickly revise and update their lagging policies.
Joe Elia:
I think that the light may be coming pretty quickly. When we had a telephone conversation two nights ago and I was inviting you to do this, Matt, things seems pretty quiet there then, and now I detect the urgency in your voice.
Dr. Matt Young:
Yeah. I’m in touch with a number of my colleagues who are in emergency medicine, and there’s a tremendous amount of anxiety and they’re just saying this is just going to get worse. This is going to get much, much, much worse. I mean the curve will be flattened but it’s still, relatively speaking, exponential. So there’s a lot of anxiety among frontline emergency providers. Most of these conversations are happening in private Facebook groups and in physician-to-physician chat rooms and dialogues, but I will tell you there is a severe discrepancy or asymmetry between the public government narrative and what front-line providers at the healthcare work force is seeing and what we’re bracing ourselves for.
Joe Elia:
Okay. Well, I want to thank you very much, Dr. Matt Young for talking with me today. And best of luck to you.
Dr. Matt Young:
Thank you, Joe. And best wishes and thanks to all the healthcare providers and the entire healthcare workforce that is on the frontlines now.
Joe Elia:
That was our 259th episode, all of them are available free at Podcasts.Jwatch.org. We come to you through the NEJM Group. The executive producer is Kristin Kelly. I’m Joe Elia. Thanks for listening.
March 18th, 2020
Podcast 258 — One clinician’s experience of the early days of the COVID-19 epidemic in the U.S.
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We talk with Susan Sadoughi, an internist at Brigham & Women’s Hospital in Boston, about how quickly things have changed over the past week.
Last week, I introduced the Fauci interview by saying that I’d heard a clinician complain that she’d spent half her time answering questions about COVID-19. This week, she’s our guest, and she’s looking back from the vantage point of a completely changed health system. She describes that change as “enormous.”
She’s doing lots of telephone consultations with her patients, talking about sending her kids to be with relatives at the other end of the country, and being wistful about the sound of a cello in her hospital’s corridors.
She’s learning to live with uncertainty, she tells us.
Listen in, clinicians, and see whether these observations resonate with you.
LINKS:
Last week’s interview with Anthony Fauci
Running time: 18 minutes
TRANSCRIPT OF THE CONVERSATION WITH DR. SUSAN SADOUGHI
(Please remember, this is a conversation and not an essay. As such, it can seem incoherent when presented as prose, but perfectly understandable when heard. We present it essentially as spoken in order to get it to you quickly.)
Joe Elia:
You’re listening to Clinical Conversations. I’m your host, Joe Elia.
While many of us work from home, some of us — such as first responders, mail carriers, supermarket clerks, and cooks — continue working during the uncertain course of the COVID-19 epidemic. Clinicians, of course, also continue their services, and we have with us today Susan Sadoughi an internist in the division of General Medicine at Brigham and Women’s Hospital in Boston, where she teaches residents and medical students. Dr. Sadoughi is a deputy editor of the daily Physician’s First Watch and has a been a colleague of mine there for many years.
The other day, during one of her phone calls with the First Watch newsroom she expressed some frustration with the problems the COVID-19 epidemic has created, and I thought it would be useful for other clinicians to hear about those problems or to know at least they were not suffering alone. She’s kindly agreed to talk with us. Welcome to Clinical Conversations, Susan.
Susan Sadoughi:
Thanks for inviting me.
Joe Elia:
It’s my pleasure. Tell us a little bit about your experience these days. Last week, as I said, you said you were spending about half your time answering patients and possibly clinicians’ questions about COVID-19, and I’m guessing you’re probably spending much more time this week.
Susan Sadoughi:
I have to say a week’s span of time has been an enormous difference from last week to this week. A week ago, I would say my clinical experience, in a lot of ways, was similar to the week prior in that I still had scheduled patients. I was seeing patients in the office, and I was seeing 15 patients a day. And last week I was frustrated, I remember, primarily because added to the usual business of seeing patients and filling in regular questions there was all of the discussion around, “Doc, what do you think this is? Can you tell me more about it? How do I protect myself?” It blows my mind how much things are different this week compared to last week.
Suffice it to say, if I were to just highlight the fact that this week I had zero patients that I saw in the office for routine visits. So beginning on Sunday night we actually screened all of our patients for the next two weeks and contacted all of our patients to let them know that almost all patient visits will take place on telephone. So we sort of divided our patients into three categories. If you’re just here to get your physical and you have no complaints or no problems that have to be followed, we will reschedule you for a month from now.
And then there was this category of patients that had problems, that were going to see me for routine follow-up, and we converted it to phone calls. Now, we have been advocating for phone visits forever and we’ve been told about all the barriers of phone visit. Lo and behold, in the middle of crisis, today I had six visits that were phone visits out of the 12 that I was supposed to see in the morning. So six of the visits were completely rescheduled. Six of them were converted to phone visits. And then I had the third category of patients, which are the patients who are symptomatic and need to physically be seen.
We divided those patients into patients with respiratory symptoms, which go to a completely separate wing of our clinic for whom I have to completely use preventive protection. And then symptomatic patients who, say, if they had a headache or other things that are non-respiratory. So our clinic, in the span of one week, has been utterly transformed.
So last week, it was absolutely overwhelming because there was the routine stuff and then the added counseling of the patients around COVID concerns as well as 100 questions on the emails that I was getting via our gateway messages. Ninety percent of those questions are now being triaged by a separate group of clinicians and nurses. There’s a whole hotline that has been developed who basically screen all my messages and if they’re COVID-related questions they’ll triage those questions.
So I think the structure of the clinic is utterly different. The feeling around the hospital is absolutely eerie. You walk around and there are not many people around. All of us are on this standby. The residents have all been pulled off the clinic. No routine visits. Waiting in case they’re needed, and then all the attendings who don’t have urgent care responsibility…so for example, I had urgent care responsibility today so I physically came to the hospital but tomorrow all of my patients are going to be phone visits. So I don’t have to come to the hospital. So they’re not…it’s just absolutely surreal. There’s no other way to describe it.
Joe Elia:
So what do you do to protect yourself? I mean in the absence of readily available testing for the presence of the virus.
Susan Sadoughi:
So essentially, I would say 80 percent of the patient visits have been converted into future visits or phone visits. The people who are being seen are the people who have acute respiratory symptoms. Those people, we pretend as if they do have COVID, and we have universal precautions for them. Other patients who are being seen in urgent care, which are very few…very few patients that are being seen in urgent care are not absolutely necessarily respiratory-type symptoms. Those people we stay away six feet. We wash our hands constantly. We have a ton of Purell and are wiping surfaces constantly. These are completely low-risk to no-risk for possible respiratory process.
And then all the other respiratory symptoms, be it that you have sore throat, be it you have some nasal congestion, be it you have some ear pain, we get dressed as if it could be COVID. So it’s so different this week.
Joe Elia:
So you’re kind of waiting around for the other shoe to drop, aren’t you?
Susan Sadoughi:
Yeah. I have to say, even my residents are like I can’t believe…because I see the same residents from last week to this week, and we were all saying I just can’t believe where we are in one week. Where we all are doing our phone visits and we’re sort of on this standby. Today, as I was going to a different section of the hospital, Brigham has this music-therapist cello player. They only usually come once every week or so. She’s been playing every day, it seems like, all day. And you walk around and I had ran into another colleague who was upstairs. You know, you vacillate between, oh, my God, this is so profoundly sad. Look at what is happening to our hospital.
Then you look around and there will be a message that makes you feel like, okay, I’m a soldier. I’m here. If something happens, I’m going to step up and I have to tell you, at times, I get so teary-eyed listening to that cellist playing because — I don’t know — there’s something incredibly patriotic about it. It’s so crazy because the whole atmosphere has changed.
Joe Elia:
You have a family at home.
Susan Sadoughi:
Yes.
Joe Elia:
And youngish children.
Susan Sadoughi:
Yes.
Joe Elia:
So how are you protecting yourself? Tell me a little bit, if you would, what that’s like.
Susan Sadoughi:
I’m in a little bit of a unique position, knowing that they have three weeks off and I have family in Florida we’re actually contemplating sending the rest of the family to Florida because there is very good chance I will be among the few urgent care doctors who will be assigned to see all the respiratory patients, meaning like every day I will be testing symptomatic people. I think that is high-risk enough that it might mean they’re better off distant from me. If they were home, I would probably, in addition to frequenthandwashing, etcetera, I’m in favor of keeping that six foot distance because what if I am one of those asymptomatic people who will contract it?
Luckily, the data around the young people are pretty encouraging every day, but I probably would be in favor of just keep a safe distance from me and in addition to the usual handwashing, the usual wiping off a surface. I’ve been really good about reminding the residents and also reminding the staff that we should consider ourselves as one of the scarce resources and we don’t want us to be quarantined or furloughed, never mind anything else.
Joe Elia:
The New Yorker has a daily newsletter. Benjamin Wallace Wells, in The New Yorker (who, by the way, lives in Boston) was talking with ethicists about some of the decisions that people might have to make about the use of respirators if things became as bad as they are, say, in Italy. I know that you’ve probably thought about that. Have you had conversations with your residents about that?
Susan Sadoughi:
Yeah. You know, to be honest with you, we’re in a different phase right now in the sense that we are commenting about how we’ve been able to reduce census in the hospital. The hospital feels empty because we really have been so proactive to divert patients who could be managed at home or elsewhere and also I think patients have been really good about trying to avoid the ER and keeping the staff available. So I think at this point, we’re just shocked by, “my God, we’re in this prep mode and we don’t know what to expect.” I think we haven’t prepared ourselves for the other side of the equation where we were totally overwhelmed. I don’t think we’re there yet. So I don’t think we played that scenario as much.
I’ll tell you one thing about my experience with these phone calls, which has been so unique. We’ve been asking to try and have phone visits for years, especially in primary care because so much of it can take place on the phone. Number one, the patients are so incredibly appreciative — Joe, I cannot even tell you — that they don’t have to come in. But also, just how much we can get done on the phone. Literally 90 percent of what we need to get done could get done on the phone for various patients. Then I was struck by every conversation at the end comes to a COVID discussion and the level of the discussion has changed, and it’s really interesting because last week the general public was uninformed. So a lot of the questions were very basic questions. What should I do?
Now, it’s so much different and it’s so unique to their own situation. I spoke to my 75-year-old who has to babysit for the grandchildren and what should he says to his daughter about limiting the little kids’ playdates. Then I had one other patient today, this woman who’s working from home, but she has some mental health struggles and she usually runs outside and exercises, and the gym has closed. And in talking to her about what you could do instead, “You could do this, you could do that, I want you to still do your exercise etcetera, it’s just a completely different discussion from last week. It’s much more advanced around how to protect themselves.
I think people…my own sense of it right now, the mindset is different. I think people have a mindset of what can I do instead? How can I protect myself? What can I do instead? I think there’s basic knowledge and then they’ve come to acceptance. It’s almost this is acceptance. If they’re worried, like I’ve been really trying to emphasize maybe you can do A, B, and C but you can do X, Y, and Z and you should feel good you’re being flexible. You’re being resilient. You’re still trying to find your way to do the things you need to do.
People have been so incredibly appreciative. I think it makes me much stronger and in a much better mindset this week compared to last week.
Joe Elia:
But for the clinicians who haven’t yet seen their first case or their first presumptive case yet, what’s the best advice that you could offer them?
Susan Sadoughi:
You know, I think the very first few times that I was seeing patients and trying to make decisions, should I send this person for COVID testing, should I not test them? It was so unsettling because it seemed like every two hours the guideline was changing. I would reach out to our infectious disease expert and after about the second or the third time where I heard them say, you know what, there is no clear-cut answer right now. Here’s what we need to deal with and there’s no easy answer, I finally realized as physicians we want certainty and in these times you have to understand the guidelines are changing. We don’t have the availability of testing all the people we want, and we have to be comfortable with some uncertainty. I’m better at that now because if the infectious disease person didn’t know the answer and says to me, “This is my best advice I can give you, and these are all hard decisions and we just have to live with that,” I think there’s something calming about that.
Whereas, last week I was terrified that I was making the wrong decision and now I realize this is such a fluid decision that there’s not a black and white answer and there is some comfort in knowing that we have to make decisions with some level of uncertainty, and it just feels different.
Joe Elia:
All right. Well, I want to thank you very much, Susan, for talking with me today about all this.
Susan Sadoughi:
Sure. Sure. There’s a lot to be learned over the next week or so.
Joe Elia:
Or maybe the next several months.
Susan Sadoughi:
Yes.
Joe Elia:
I wish you and your family well.
That was our 258th episode, all of which are searchable and available free at Podcasts.JWatch.org. We come to you from the NEJM Group. Our executive producer is Kristin Kelley, and I’m Joe Elia. Thanks for listening.
March 5th, 2020
Podcast 255: Salt talks — transcript included
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Here we have an interview with Prof. Feng He, whose English is much better than my Mandarin. Thus, I’ve attached a transcript to make her ideas on salt intake (no level is too low) and blood pressure (there’s a dose-response relation with salt) more immediately available than it might be to your ears alone.
She’s coauthor of an article in The BMJ — a meta-analysis — that finds the effect of salt is greater with age, and in non-white populations and those with hypertension.
Links to articles mentioned and apps:
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The BMJ meta-analysis discussed
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Salt reduction in England from 2003 to 2011: its relationship to blood pressure, stroke and ischaemic heart disease mortality https://bmjopen.bmj.com/content/4/4/e004549
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Formulas to Estimate Dietary Sodium Intake From Spot Urine Alter Sodium-Mortality Relationship https://www.ahajournals.org/doi/full/10.1161/HYPERTENSIONAHA.119.13117
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Role of salt intake in prevention of cardiovascular disease: controversies and challenges https://www.researchgate.net/publication/324874931_Role_of_salt_intake_in_prevention_of_cardiovascular_disease_controversies_and_challenges
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Salt Reduction to Prevent Hypertension and Cardiovascular Disease, JACC State-of-the-Art Review http://www.onlinejacc.org/content/75/6/632
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Salt reduction lowers cardiovascular risk: meta-analysis of outcome trials https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)61174-4/fulltext
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Foodswitch app: http://www.foodswitch.co.uk/
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SaltSwitch app: https://www.ncbi.nlm.nih.gov/pubmed/28631933
Running time: 28 minutes
Here is a transcript of the interview:
TRANSCRIPT OF INTERVIEW WITH PROF. FENG HE WHO HAS REVIEWED AND CORRECTED IT
Joe Elia:
Salt and sodium intake have challenged medical researchers for generations. What seems indisputable is that too much salt is not good, especially in hypertension. After that things get fuzzier. National advice on restricting salt intake has been challenged by findings that restricting salt too much can increase cardiovascular risk.
Professor Feng He and her colleagues looked at the question of whether existing studies showed a relation between reductions in dietary sodium and changes in blood pressure. They performed a meta analysis of 133 studies comprising some 12 thousand 200 participants. Those studies all randomly allocated participants to either reduced sodium intake or usual (and thus higher) intake. All studies collected 24-hour urine sodium data to estimate those intakes. In short, they found a dose – response relationship between intake and blood pressure change.
Professor He works at the Wolfson Institute of Preventive Medicine at Barts and the London School of Medicine and Dentistry, Queen Mary University of London. Welcome to Clinical Conversations, Dr. He.
Dr Feng He:
Thank you. Thank you for having me.
Joe Elia:
You have been researching salt for about 25 years. What have you observed about the research over that time? Have you changed your mind about the effect of dietary salt and health and blood pressure?
Dr Feng He:
No, I haven’t changed my mind, because when you look at salt reduction as a public health strategy, you need to look at the totality of evidence. You need to look at all different types of studies, including epidemiological studies, population-based intervention studies, randomized trials in humans, animal studies, and also physiological studies.
So all of these different types of studies have consistently shown that a high salt intake is a major cause of raised blood pressure. Salt intake is also an important determinant of the increase in blood pressure with age. I remember when I was in medical school, we were taught that systolic blood pressure increases with age — that this is a normal physiological phenomenon. But later scientific evidence has clearly shown that this is not normal, and that high salt intake is an important contributor for the increase in blood pressure with age.
If you look at the societies now, you know, there are still some societies isolated to tribes. They don’t have added salt in their diet, and that’s like our human ancestors, And their blood pressure, their average blood pressure for the adult population is only 90/60 mm Hg, and their blood pressures do not increase with age and these populations do not have cardiovascular disease at all. You may say, “No, people in isolated tribes die at a much younger age.” However, if you compare those isolated tribes with Western populations of the same age group, in Western societies so many people suffer or die from cardiovascular disease.
Joe Elia:
Yeah. The fact that the research is ongoing tells us that not everyone believes that the results are final yet. Would you agree with that?
Dr Feng He:
No. Actually you know, you never get a final result because you know what? For any dietary factors, it is extremely difficult to do randomized outcome trials. Remember, for salt reduction you have to randomize many thousand individuals to the high-salt or the low-salt diet and keep these two groups for many, many years to see whether there’s a difference in cardiovascular outcome.
The problem with this is, firstly, there’s overwhelming evidence that shows that a high salt intake is harmful to human health. It’s unethical to put a group of people on a high-salt diet for so many years.
Secondly, you know, on the lower-salt group in the current food environment, it is extremely difficult for individuals to keep to the lower-salt diet for many, many years. That’s almost impossible in the current food environment.
And thirdly, many countries have started salt reduction initiatives — governments and NGOs have programs as do health professionals. Even in the media — in the control group if you want them to be on the high-salt diet, they’ll receive all these messages from the media — from the radio, from television, from newspapers. They [high-salt controls] will lower their salt intake, too. So in the end you wouldn’t see a difference in salt intake between the two groups and then there’s a severe contamination between the two groups.
So it’s difficult to do such outcome trials you know, to keep two groups on the low and the high salt there for many, many years.
Joe Elia:
I see. Is it possible to lower salt intake too much?
Dr Feng He:
No, if you look at those isolated tribes, they don’t have added salt to their diet. You know, there’s lots of food, and some of the food naturally already has sufficient salt, like meat. Our ancestors, they did not have added salt, but they lived healthily. Now in the isolated tribes, they are still living in the lifestyle of hunter-gatherers. They don’t have added salt. Their salt intake as measured by 24-hour urinary sodium excretion is less than 1 g a day. It’s much lower. You know, they live perfectly well. They don’t have cardiovascular disease.
So, you know, in our current food environment in Western societies there’s no way you could reduce salt intake to such a level. Currently in most countries the average salt intake is about 10 g per day and the WHO recommended level is 5 g per day. And for the US it’s 6 g per day and for the UK it’s also 6 g per day for the general population.
However, for the US, in almost half the population, the target actually is much lower. It’s 4 g per day for individuals with high blood pressure, people of African origin, and people with kidney disease, because they are at increased risk. So their target should be even lower — to 4 g per day.
Joe Elia:
Well, what prompted you and your colleagues to undertake this meta-analysis?
Dr Feng He:
This actually is an updated meta-analysis. I don’t know whether you know, we have published a meta analysis in 2013 in the same journal, The BMJ. At that time what we looked at was a modest reduction in salt intake and over a longer duration as the current public health accommodation. For example, from 10 g per day to 5 g per day to see whether that had significant effects on blood pressure. What we showed was that a modest reduction in salt intake for a longer term, like for a duration over a month or longer, there’s a significant effect on blood pressure in both hypertensives and normotensives.
So for the new meta-analysis, not only did we update it to include many more trials but also there’s a focus on the dose-response relationship with salt reduction and blood pressure. And we also looked at duration, whether the duration [of reduction] has any effect on the effect of the salt on blood pressure.
So this time the inclusion criteria were different. We basically included almost all of the salt reduction trials with 24-hour urinary sodium measurement. So with these many studies we have shown a clear dose-response relationship; so the greater the reduction in salt intake, the greater the fall in blood pressure.
The current public health recommendation is from the current level of approximately 10 g per day to the WHO-recommended level of 5 g per day. That will have a significant effect on lowering blood pressure. However, if you lower salt intake further, down to 3 to 4 g per day, the effects on blood pressure would be bigger. So there’s a clear dose-response relationship: the greater the reduction in salt intake, the greater the fall in blood pressure.
Joe Elia:
So you found that lowering salt intake is good for blood pressure, even among people without hypertension. But you were careful to limit your findings to blood pressure and not cardiovascular disease or other things, and…
Dr Feng He:
This is very good question. Because as I mentioned earlier, it’s extremely difficult to do a randomized trial for cardiovascular outcomes. Hardly any trials have looked at the longer-term salt reduction on cardiovascular outcome. And having said that, I don’t know if you have seen our previous meta-analysis published in the Lancet. Basically because there’s an insufficient number of studies looking at long-term salt reduction on cardiovascular outcome, what we looked at in that meta-analysis was the trials whose aim was to look at the blood pressure.
However after the trials completed, the researchers followed this population up for many years after the trial, so even that type of study you know, wasn’t exactly a long-term outcome trial; but still, that type of study has indicated that a reduction in salt intake has a significant effect on reducing cardiovascular events.
Joe Elia:
But the question that you asked was a simpler one and in addition to lowering blood pressure across the board, you found that studies that were of a short duration, for instance two weeks or less, didn’t show the effect as much as those studies that were longer-term. Is that right?
Dr Feng He:
That’s right. That’s right. Basically these studies show that the dose-response relationship is much stronger in the longer-term trials compared to short-term trials. So it’s likely that the shorter-term studies have underestimated the impact of salt reduction. The problem with looking at the duration and looking at the effect of duration on the effect of salt reduction is quite difficult, because at the moment not many longer-term salt-reduction trials, only a few trials have had a duration lasting six months or longer.
The problem with this type of trial is, initially, people achieve their reduction of salt intake, but with time you know, with the current food environment it’s impossible for individuals to keep the lower-salt diet for long term. So by the end of, say, a few years their salt level has already gone back to the higher level, so that’s why longer-term studies cannot see a greater effect. Because over the longer term they have not achieved a greater reduction of salt intake.
So if you really want to look at the long-term effect, the duration, the effect of duration on blood pressure, we should have longer-term trials, with the individuals kept on the low-salt diets throughout with multiple measurements of blood pressure throughout. The only study that can show this is the DASH Sodium study. I do not know whether you have heard of the DASH Sodium study. In this DASH-Na study the compliance is perfect because it’s a feeding study. All of the food and the drinks are provided to the participants. So the individual can keep the lower salt diet over the whole study duration. That study has shown that, with a longer duration the effect of salt reduction on blood pressure is bigger, compared to short-term study.
A footnote: Dr. He wanted to add this observation after her comments on DASH: “Countries that have achieved a reduction in salt intake for several years, for example, Finland and the UK, have demonstrated a much greater impact of salt reduction on population blood pressure”.
Joe Elia:
The effects seemed especially stronger in older people, non-white populations, and those with higher baseline systolic pressures.
Dr Feng He:
That’s right.
Joe Elia:
Okay. And so I guess that’s the population it would seem that would have been exposed, especially older people, to this kind of food environment as you describe it, that is going to have loaded their bodies up with salt over many years, isn’t it.
Dr Feng He:
That’s one of the reasons but there are other reasons. In our human body we have these hormonal systems like the renin-angiotensin system, and this system is actually maintaining our blood pressure. And because for individuals with older age and people of African origin and also people with high blood pressure, their renin-angiotensin system is suppressed. And so usually, like in young people, if you reduce your salt intake, the renin-angiotensin system would react and then there’s an increase in plasma renin activity and increase in angiotensin II.
This is like a compensatory mechanism to maintain our blood pressure. So for elderly and for people of African origin and also for those with high blood pressure, this system is not as active as in young people or compared to their counterpart in the white population or people with normal blood pressure. That’s one of the mechanisms for those subgroups to have a greater fall in blood pressure for a given reduction in salt intake.
Joe Elia:
What do you think these findings mean for people who are skeptical about over-restricting salt intake? There have been some researchers in Europe — I know of one group — that have data saying that over-restriction of sodium leads to greater cardiovascular risk.
Dr Feng He:
Yes, I’m fully aware of these publications. We have published several papers and there’s lots of debate about this. The problem with their studies is that there are severe methodological problems. For example, their study measured salt intake using spot urine. Spot urine measured sodium concentration. For example, if I just have two glasses of water now, and two hours later I collect spot urine. If you measure my sodium concentration in that spot urine, it’s much lower because it’s diluted.
And also this spot urine, they converted spot urine sodium concentration to 24-hour urine sodium to estimate individuals’ daily salt intake.
Joe Elia:
I see.
Dr Feng He:
They used a formula to convert this spot urine sodium to 24-hour urine sodium. This formula included age, gender, sex, height, weight. We all know age is an important determinant of any health outcome and death, and that age is also associated with salt intake. And also the other factors — gender and body weight and a 24-hour urine creatinine — all of these factors are important confounding factors because they both related to salt intake, and also related to health outcome.
So in this study you know, they can’t control such confounding factors.
Joe Elia:
I see. Okay.
Dr Feng He:
So there’s a lot of methodological [errors]. We call it measurement errors. Using spot urine is one of the contributing factors for the J-shaped findings. We published a paper in the International Journal of Epidemiology and another one in Hypertension, and clearly showed that this formula — the variables like age and gender, height and weight, the creatinine concentration — they all are important contributors to the J-shaped findings.
That’s the only one of the factors. Another factor in lots of cohort studies is that they included people who are not well, who are sick. And this is called “reverse causation,” because we know that if you are not well you can’t eat, and then you have lower salt intake. And then because you’re not well, you have a chronic disease, you’re more likely to die, so the lower salt intake in these individuals is the consequence of their underlying disease and it’s [lower salt intake] not the cause. So there are lots of problems with the J-shaped findings. And so you see our recent paper [which] clearly shows that these different factors have contributed to the J-shaped findings.
If you use accurate measurements of salt consumption like we did, we analyzed the Trials of Hypertension and Prevention [TOHP] follow-up data. Actually that study was done in the US, and we collaborated with Professor Nancy Cook at Harvard University [Brigham and Women’s Hospital]. In the TOHP study, all the participants had multiple nonconsecutive 24-hour urine measurements and measured their salt intake, and so if you look at it, this salt intake, you can see there’s a clear linear association. So the lower the salt intake, the lower the risk of death, down to a salt level of actually 3 g per day. There’s no J-shaped or U-shaped relationship.
Joe Elia:
There is none. Okay. What do you hope will happen as a result of your continuing work on this and your current published analysis?
Dr Feng He:
I hope definitely there’s a clear message that salt reduction is extremely beneficial to the whole population, not only in those with high blood pressure but also in individuals with blood pressure in the normal range. So firstly, the general public need to be more salt-aware and also reduce their salt intake. And for the clinicians, they need to give their patients appropriate advice on how to reduce their salt intake, because in our clinic, sometimes the patient will say “Oh, my salt intake must be low because I never use salt in my cooking or at the table.”
But when we measure it, you know that salt intake is extremely high. The patients, they did not know that the food they usually eat — bread, breakfast cereal — are really high in salt. So in most of the Western countries like the US, UK, and in many other developed countries, about 80 percent of salt in our diet is added to our food by the food industry.
So for the food industry, they needed to make a gradual and sustained reduction in the amount of salt they add to all of their products. And the UK has been very successful in reducing the population salt intake. In 2000, 2003 we [the UK] started a salt reduction program in collaboration with the Food Standards Agency and also our group Action on Salt. What we did is to set incrementally lower salt targets for over 85 categories of food.
And the principle is a small reduction — a 10 to 20 percent reduction — and then you repeat it at two- to three-year intervals. And if you do it gradually, you know, small reductions, the general public wouldn’t notice any difference in their taste. And they can continue to buy the food that they usually buy and their salt intake will come down. The UK salt-reduction program has been really successful. From 2003 to 2011 salt intake in the population was reduced by 15%, from 9.5 g per day in 2003 to 8.1 g per day in 2011.
So this you know, 15% reduction in population salt intake has led to a significant reduction in population [systolic] blood pressure by 2.7 mm Hg, and this was associated with a significant reduction in population mortality from stroke and ischemic heart disease.
Joe Elia:
Oh. I think we should all be reading labels more carefully when we buy food.
Dr Feng He:
Definitely. For individuals in developed countries it’s important that when we do shopping, we choose the lower salt option, and actually now there’s an app available. You can use this app and scan the bar code and then it will give you the lower salt option and you know, there is a similar product that tells which ranks high in salt, which ranks low in salt.
Joe Elia:
What is the name of that app?
Dr Feng He:
It’s [Salt Switch]. Actually there’s a more comprehensive one, it’s called Food Switch.
Joe Elia:
Just a footnote here, Dr He contacted me after our interview and wanted to be clear that she had misspoken about the name of one of the apps. They are Salt Switch and Food Switch and I’ve included links to both on the website, podcasts.jwatch.org.
Dr Feng He:
And then in the UK, Australia, and in China, and in India, there’s an app, freely available for download and when you go shopping you just scan the bar code and it will give you the “traffic light” labelling. It tells you which one is healthier, and it gives you alternatives to buy.
Joe Elia:
Well, I want to thank you very much for talking with me today, Dr He.
Dr Feng He:
Thank you. Thank you very much. It’s so good to talk to you.
Joe Elia:
That was our 255th episode. All of them are available free at podcasts.jwatch.org. We come to you from NEJM Journal Watch and the NEJM group. The executive producer is Kristin Kelley, and I’m Joe Elia. Thank you for listening.
Page 4
February 27th, 2020
Podcast 254: Old malpractice liability strategies need rethinking
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JAMA recently published a review of some 40 papers examining the relation between malpractice liability strategies — tort reform, increased insurance premiums, etc. — and the quality of care. Apparently the efforts had no discernible effect on mortality rates, length of hospital stays, and the like.
An editorial accompanying the paper sketches out a vision of where future efforts should lead, especially given the shift in U.S. medicine from private to institutional practice.
The coauthor of that editorial — surgeon and law professor William Sage — is our guest.
Links:
Malpractice liability and health care quality article in JAMA
Sage and Underhill’s editorial in JAMA
Running time: 17 minutes
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