Clinical Conversations

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We interview Dr. Michael Gonzalez, a Houston-based emergency physician, who describes the situation there as “an ongoing, slow-rolling, level 6 hurricane that just isn’t gonna go away and, more importantly, isn’t gonna tell us when landfall is coming and when it’s gonna be over.”

How are his patients reacting to this surge? What does he do to prepare himself for a shift in the emergency department? Is there enough PPE to go around?

Listen in.

Running time: 25 minutes

Other interviews on Covid-19 in this series:

1. Dr. Anthony Fauci
2. Dr. Susan Sadoughi
3. Dr. Matthew Young
4. Dr. Julian Flores
5. Dr. Kristi Koenig
6. Dr. Renee Salas
7. Drs. Andre Sofair and William Chavey
8. Dr. Comilla Sasson
9. Dr. John Jernigan
10. Dr. Ivan Hung
11. Dr. Steven Fishbane

TRANSCRIPT 

Joe Elia:

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

 

Here we are still swimming in the sea of numbers generated by the COVID-19 pandemic: numbers of confirmed cases, numbers of tests, fatality rates per 100,000 population, et cetera.

 

With so many numbers you’d think your high school math teacher would suddenly appear and solve the equation — but there is no equation, only patients and clinicians. And that’s what Dr. Ali Raja, my cohost, and I are going to focus on this time. We’ll avoid numbers if we can.

 

We’ve invited a Houston emergency physician, Dr. Mike Gonzalez, to talk with us. As you’ve doubtless heard Houston and Texas in general have achieved the dubious achievement of being a new hotspot for COVID-19.

 

Welcome Dr. Gonzalez.

 

Dr. Michael Gonzalez:

Thank you. Great to be with you.

 

Dr. Ali Raja:

Hi, Mike. As a native Houstonian with lots of family still in town, I’ve got to ask, how are y’all doing down there?

 

Dr. Michael Gonzalez:

Yeah, thanks for asking. It is a challenge.

 

We are in the unfortunate position of sort of living the reality — of seeing the manifestations of what you know many of our colleagues, family members, brothers and sisters have gone through in other parts of the country. And you know it is disheartening to know that we’ve had months and months to prep, to learn and to now find ourselves in the situation of living through the very same problems.

 

So, you know, for a while there we were, I’ve got to tell you, somewhat optimistic that maybe we weren’t going to have the surge that everybody saw, that many of parts of the country kind of lived through. There was a lot of very hopeful optimism but many of us and I will fully admit to being one of the very sort of pessimistic “Hey we need to keep an eye on this and it’s not time to celebrate.”

 

So I think professionally, to break your question up into two parts, professionally I think like most emergency physicians who feel like, you know, we were built for this and this is our time to face the challenge head-on. My teams are ready. They have, you know like I said, been watching, waiting, learning, preparing. Professionally, I think we’re in about a good a place as we can be. Personally, for mostly the reason that I worry more about my family, friends, neighbors who are not medical and who have a really hard time, I think, parsing out the difference between what we know is the reality inside the four walls of the hospital and what they see on the news and what they hear in the community and what they see on the street. And I think one of the biggest struggles personally that I’ve faced is trying to get all of those things to align. And to really sort of get people to understand that this is serious, this is lethal, and it has longstanding implications that I think the world is still struggling with.

 

Dr. Ali Raja:

Right, we’re still figuring all this out. You mentioned being an emergency physician, and obviously you and I have known each other for a very long time. In addition to being an emergency physician you’re also an educator of other physicians, of paramedics, of EMTs. Can you tell us what it’s like for new residents, new paramedic students, new EMT students who are just starting in the journey? Can you tell us what it’s like for them — the ones you’re teaching right now?

 

Dr. Michael Gonzalez:

So I think I’ve honestly found that I pull, honestly, from my military training and really do sort of emphasize that this battle in many ways is fought on the front of preparation, and there is bedside care that we can certainly deliver optimally. Make sure we’re resuscitating, make sure we’re doing all the clinical things that as emergency physicians, like, as I said this is what we were built for and this is what we were trained for. But in many ways this battle, this virus is really confronted in all of the steps leading up to that in the form of the PPE that has, you know, become one of the major concerns, in terms of getting the rooms ready, in terms of getting enough hospital staff, enough, you know, equipment, enough gloves.

 

Like, all of those things that we for so long took for granted in the civilian world we are now facing. And the reason I say military training and from deployments where it was not an assumption that we had enough IV starting kits. It was not an assumption that we had the appropriate antibiotics. So all of that sort of training and background is really stuff that I had, in many ways, hoped to not face again [they] are right back on the forefront. And so for most of the time that I’ve spent with trainees at various levels it really is sort of reinforcing those lessons of preparation, right? And preparation, you know, in many clinical settings is one of the important P’s that we always emphasize, right?

 

Dr. Ali Raja:

Right.

 

Dr. Michael Gonzalez:

But in this setting it really is true and it’s down to the bedside level of “Do you have everything you need before you go in the room?” For the nurses, “Do you have all of your IV blood tubing starts, everything that you need before you walk in? Because you can’t come out again.” And so really I find myself, you know, going back to lessons that I learned way too long ago and really kind of reemphasizing basic important things like preparation and equipment.

 

Joe Elia:

Dr. Gonzalez, in this turmoil that you face it probably feels different now than it has recently. So has your routine changed over the past few weeks? How do you prepare for the clinical day?

 

Dr. Michael Gonzalez:

That’s a good question, Joe. I think that my routine probably hasn’t changed substantially in terms of getting ready for work. Getting ready is really, you know, unchanged I think for me. I think the only thing that probably has changed is, like for many of us, instead of wearing my own scrubs I change into hospital scrubs upon arrival in the clinical setting because I don’t want to take those things home. And so I find myself kind of, you know, still wearing scrubs generally into the department, but changing upon arrival. And then, again, kind of reminiscing back to military training and background in deployments, you know, I find myself [asking] “Do I have my scrub cap? Do I have my goggles?” And all those things have to be in place before I kind of get ready to go, you know, in the box or in the room or on the floor, depending on which part of the unit I’m working in.

 

And so I think a lot of that, again, is sort of familiar, to me at least, and for me it’s almost a warm blanket of “I know how to do this.” And I think I’ve heard it repeatedly from military colleagues that you know this is a very familiar setting in terms of facing an enemy that sometimes you can’t see, you don’t know where they’re coming from and it could be anywhere. It’s a sort of familiar feeling. The biggest thing, I think, is really afterwards. After a shift it is, you know, in a non-COVID time that you know I find myself sort of talking about now nostalgically, even though it was really only months ago. It’s really, you know pre-COVID you know you would get off shift, change quickly sometimes and go directly to meet family or friends for dinner, for a beer, or whatever the case might be. And now it’s truly sort of a more extended process.

 

And again I link it back to the checklist sort of mentality of, you know, “Did I take all that equipment off?” I’ve got my shoes off, I’ve got my scrubs off, I changed into you know whatever I wore into the hospital. In the car or once I get home certain things come off as I’m getting into the house. If my family members are awake, which I tend to work kind of a nightshift, you know, so that I don’t always cross over with my family — and that was even pre-COVID. So I don’t get a lot of the immediate need for hugs at the door, which I love, but in this time of COVID I think it’s really nice that I don’t have to deal with that. I get the dog barking sometimes when I get home, but otherwise it’s really more of I can kind of sneak into the house, get everything off and get immediately into the shower.

 

And then even before I get into the shower it’s a matter of getting the clothing bundled up separated from my family’s clothing so that I can make sure that we’re maintaining as many boundaries as we can from this thing. And again because having lived through a completely different world and a different environment it feels very much like the pre- and post-flight checklist of a previous world that I’ve done before and I can do. And I know, like, for me I know I can do it I’ve been through it. I see the struggles personally on my family and my spouse who is also a physician, but who is not in the emergency department.

 

And my kids, especially, like it’s really starting to wear on them. You know “Why can’t we go X, Y, Z? Why can’t we go to the movies? Why can’t we go to the arcade?” Like, that is getting hard.

 

Joe Elia:

This isn’t the question about whether you read the New England Journal of Medicine, so that’s not what we’re asking here. What I’d like to know is — and the information about this virus is changing all the time — is there a place that you’d go to just too brief yourself occasionally on “What’s the new stuff I should know about?”

 

Dr. Michael Gonzalez:

You know that’s a great question, Joe. I honestly read a variety of journals, the New England Journal one of them of course, and a couple of different emergency medicine sources. But really, honestly, lately because this has been moving so fast and, really, seems to be there was a period of time where I felt like it was changing by the hour, that honestly this is one of those times that social media has really come to the forefront. And I’m one of those people that’s fairly active on it. I absolutely have a group of trusted colleagues that we have formed both a public as well as a private discussion group to kind of update each other, follow-up on what’s going on and also provide the support that I think is just becoming more and more important as this thing seems to just morph and go from one area of the country to another. And I’m certainly hoping that we don’t, you know, send it back to other parts of the country but I have real fear and an anxiety about that, that this is going to just bounce back and forth as the fall and winter and more traditional infectious-like illness season comes back.

 

Dr. Ali Raja:

Let me ask. Taking it back a little bit to social media, because you and I have talked about this on Twitter and other places, you mentioned PPE recently and how it’s become a concern and you just talked about that. I understand that there’s a lot of connotations and background here, but let me just ask do you have enough PPE for your staff? And even if you do what’s the situation like in Houston? Are hospitals having to reuse it yet?

 

Dr. Michael Gonzalez:

I thank you for the question, Ali. I think that there has been a lot of work that has gone into making sure that we have the equipment that we need across multiple fronts, agencies, hospitals. I think that we, for now, and I always say that with excruciating care and in every meeting and every chance I get to express a concern or voice about this topic it’s always “for now” because it’s an important caveat that we are looking at what the numbers are doing. And they are constantly changing and they are looking worse than ever and so for me it is a constant. I do feel like as one of the leaders in various organizations, I do feel like that is my job. That is my responsibility to sort of speak up, make sure that people know that I really want to know what models are you using?

Because if you’re looking at a trend from the last two weeks that’s not going to work.

 

We’re in a completely different place now and so our modeling, our structures in terms of our supply chain, I think have been worked out. The single biggest thing that I worry about and this is true that we’ve heard from colleagues all over is the N-95 mask. I think we are good in terms of other very equally vital components but the N-95, as you know, is our unique sort of last line of defense before we inhale this virus. And so it is exceedingly important and I do worry that we are only okay in our supply status because of the reprocessing programs that are going on all over the country. And I certainly appreciate the people that worked that out and demonstrated it could be done safely. But I do have some anxiety and worry for my team about an instrument that was, as everybody knows, never designed to be reused. It was never designed to be reprocessed and so if you ask me about a single thing that keeps me up at night that’s it.

 

Dr. Ali Raja:

What about bed space? And I say that because earlier today I heard that, I don’t know if it’s level two or surge level two, but I’ve heard that Houston’s in the situation. I keep up with this because as I mentioned my parents live in town and if they get sick they’re going to need an ICU. I’ve heard that now you’ve reached ICU capacity and you’re starting to get creative around making new ICU space at least citywide, if not individual hospitals. How are things looking in terms of ICU and floor bed capacity?

 

Dr. Michael Gonzalez:

Yeah, we have attracted a lot of attention nationally and regionally for all the wrong reasons. I think that the bed capacity situation has certainly been on the radar for both myself and a variety of other leader’s way above me, right? And so this is something that we are closely monitoring for sure. The phases have been something that has been developed by the leadership out of the TMC organization that I don’t have direct links to. So it has been interesting to watch their messaging and how that has been perceived and understood or perhaps misunderstood. I do think that at a more local level and speaking to colleagues we are absolutely seeing adjustment inside the hospital of both elective surgery patterns, outpatient procedures, to make space available. As an emergency physician, right, we want our patients to get — once we’ve stabilized them —  diagnosed or at least [having] gotten the diagnostics done and we can hand off to our in-the-hospital colleagues. We want those patients to go upstairs as quickly as possible.

 

Because as has been well documented over multiple years of research and well proven that the single biggest obstacle of ED throughput is boarding time and how many patients are waiting. And so we, for the most part in the City of Houston, have hospitals that operate pretty darn efficiently. And so our board times are pretty limited in most facilities. We certainly have challenges here and there and you know different events, different periods of time where maybe due to staffing upstairs that there may be obstacles, but this is the first time that we’ve really been faced with a complete regional attack on those resources. And all of those resources are being demanded everywhere at the same time. So even during the closest other example is Harvey, which is not that long ago, and we had hospitals that were completely taken offline because of plumbing problems or disaster flooding — people couldn’t get in there or out.

 

But even then we are fortunate in the region to have 40 plus hospitals that we were able to flex and move patients around so that, for the most part, there was only a couple of days where certain facilities were really pushed to the limits on capacity. This as many of our colleagues from all over the country have already faced this, as you know better than anyone, right, this is an ongoing, slow-rolling, level six hurricane that just isn’t gonna go away. And more importantly, isn’t gonna tell us in advance when landfall is coming and when it’s gonna be over. And so, you know, there’s a dire need for the resources across the entire community. I know that many of our hospital partners and hospital colleagues all over the city are absolutely being creative in terms of freeing up existing bed space, both ICU, step-down, floor beds and freeing that space up from other procedural-type settings. And they are also looking at creating additional capacity.

 

So everyone in the medical community knows that capacity is one of those really difficult things to define because of how many patients move back and forth ICU to IMU, IMU to ICU and that is not always predictable. So I totally understand how difficult it is to put numbers — especially numbers reported to the public — around something that is so complicated. But at the same time I also feel like the public deserves to know that we are doing everything we possibly can and now including cancelling or postponing elective procedures to make room where I think there may have been some perceived resistance to do that from some of the hospitals in the Houston area.

 

Joe Elia:

Dr. Gonzalez, tell me about your patients. For instance, are they older or younger than you imagined that they would be and what’s their attitude? Do they come in surprised to find themselves in this “hurricane”?

 

Dr. Michael Gonzalez:

Yeah. So let me give you a little perspective on that, that early on I think there was a lot of surprise, so I’m talking very early April, May there was surprise: “I’ve heard about this and didn’t know it could happen to me.” And that was predominantly older, let’s say, over the age of 50.

 

And I think that, that has really dramatically changed to we are seeing a wider swath of age groups that are coming in because they feel terrible. And largely the people that we are seeing in the emergency department are not coming asking to be tested; they are coming because they feel awful.

 

And overwhelmingly, most of those people have now, at this stage in the past month, they know or they have an idea of where this came from. Either in the form of I’ve heard now that, “That person that I was with was positive” or “I went to this event, this party, this thing and it’s two weeks later or 17 days later and here I am. And I worried about it but I did it anyway.” I’ve heard it repeatedly and I can tell you that it is of course always an honor to take care of our patients and try and do the best we can to treat them medically, comfort them.

 

But this thing and because of the way this virus works it is a challenge to provide the same level of what I think all of us want to do. Because sometimes all you can is hold their hand and although we do that, we continue to do that, sometimes looking people in the eye, holding their hand, patting their shoulder and particularly not having family members available to help in the comfort and sometimes even, you know, providing just reassurance that we’re doing everything we can has been a real challenge. And that, I think, is taking a huge toll on healthcare providers all over and we are just sort of uncovering this raw nerve of we are really putting ourselves out there emotionally further than, I think, we’ve ever been asked to do because family members can’t be at the bedside. And so, back to your question, I think yes for sure we’re seeing a slightly skew younger over the past two weeks, let’s say, I’d use that as a timeline. But it is absolutely people come in who feel just awful and scared and you can see it in their faces when they arrive.

 

Dr. Ali Raja:

So, Mike, this is a really tough time but we know that like all things this will pass. And whether it’s a temporary lull or whether or not we finally get a handle on this we’re going to have a time at some point, weeks, months from now where things are better. Have you promised yourself a little bit of a reward after this? A new bicycle, a vacation in remote Canada far, far away from large medical centers? What are you going to do when all this calms down?

 

Dr. Michael Gonzalez:

I have given myself pause and freedom to think about that only because it has become a frequent topic around the dinner table. I told you my family and my kids have really sort of been struggling with this and as I have mentioned on social media I have become a Fortnite player with my kids.

 

Dr. Ali Raja:

Nice.

 

Dr. Michael Gonzalez:

Terrible, terrible, subpar they would tell you, Fortnite player. But that has been one of the things that you know we introduced them to, hesitantly, but now we enjoy playing together. And so that has been one of the joys of this thing, one of the small victories. They’ve admitted me to their team, so that’s a nice little…

 

Dr. Ali Raja:

That’s a win. That’s a dad win right there.

 

Dr. Michael Gonzalez:

Yes, exactly, a dad win. Exactly. But I think to your question, yes, we are really looking forward and are actively discussing and exploring options all the time about a vacation. And you know I am very mindful of my colleagues who both, you know, every team member in the hospital. And so I want to make sure that they’re obviously taken care of before I even think about taking my own time off. But there will be a long vacation at some point at the end of this, on the other side of this, let me say. And I am very optimistic, Ali, yes we will all get there.

 

Joe Elia:

Dr. Gonzalez, thank you very much for speaking with us today and good luck in the coming weeks.

 

Dr. Michael Gonzalez:

Thank you both. Thanks so much for giving me a chance to share our experience in Houston.

 

Joe Elia:

Of course.

 

That was our 269th podcast and they’re all available free at podcasts.jwatch.org. We come to you from the NEJM Group and our executive producer is Kristin Kelley. I’m Joe Elia.

 

Dr. Ali Raja:

And I’m Ali Raja. Thanks for listening.