Clinical Conversations

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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:

NEJM Perspective article

NEJM Sounding Board

Running time: 13 minutes

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

Joe Elia:

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

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

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

Dr. Julian Flores:

Hi. Good morning. Thanks for having me.

Joe Elia:

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

Dr. Julian Flores:

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

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

Dr. Ali Raja:

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

Dr. Julian Flores:

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

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

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

Dr. Ali Raja:

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

Dr. Julian Flores:

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

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

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

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

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

Joe Elia:

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

Dr. Julian Flores:

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

Joe Elia:

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

Dr. Julian Flores:

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

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

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

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

Dr. Ali Raja:

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

Dr. Julian Flores:

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

Joe Elia:

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

Dr. Julian Flores:

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

Joe Elia:

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

Dr. Ali Raja:

And I’m Ali Raja. Thanks for listening.