Clinical Conversations

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Back in late March (people often tell me that, these days, 4 months ago might as well be 4 years ago) we talked with emergency physician Julian Flores, who was working out of Broward County. Covid-19 cases were modest in number but threatening to get worse, and indeed they did.

The county’s cases jumped 100-fold, from about 600 to over 50,000. Just south of Broward, Miami-Dade has double that caseload.

We revisit Dr. Flores (who was sheltering from the rains of a coastal near-hurricane in his car). He confesses bewilderment and counsels skepticism — especially of one’s biases — in evaluating this thing we’re facing.

 

Running time: 16 minutes

 

Other interviews on Covid-19 in this series:

1. Dr. Anthony Fauci (NIAID, Bethesda, MD)
2. Dr. Susan Sadoughi (Boston, MA)
3. Dr. Matthew Young (suburban Delaware)
4. Dr. Julian Flores (Broward County, FL)
5. Dr. Kristi Koenig (San Diego, CA)
6. Dr. Renee Salas (Boston, MA)
7. Drs. Andre Sofair and William Chavey (New Haven, CT, and Ann Arbor, MI)
8. Dr. Comilla Sasson (volunteering in New York City)
9. Dr. John Jernigan (Centers for Disease Control, Atlanta, GA)
10. Dr. Ivan Hung (Hong Kong)
11. Dr. Steven Fishbane (metropolitan New York)
12. Dr. Michael Gonzalez (Houston, TX)

TRANSCRIPT:

Joe Elia: 

Welcome to Clinical Conversations. I’m your host, Joe Elia, and I’m joined by co-host, Doctor Ali Raja, of the Mass. General Hospital, and Harvard Medical School.

Back in March, Ali and I interviewed an emergency medicine physician, from Broward County, Florida. Back then, Broward had just over 600 cases, and as of this afternoon, August 2^nd, confirmed cases there stand at nearly 100-fold higher. It’s some 58,000, with some 750 dead.

So, we’re checking back in with Doctor Julian Flores, who is still working there, in Broward County, as an emergency medicine physician.

Welcome back, Julian.

Dr. Julian Flores:

Hi, guys. Thanks again, for having me.

Dr. Ali Raja:

Hi, again, Julian. Thank you for chatting with us today, especially on your day off. How are you doing? What are you seeing clinically there, right now?

Dr. Julian Flores:

So, I’m seeing a resurgence of cases, of COVID-related complications. Also, essentially, paired up with just volume of ER patients, in general, and you know, it is in the background of us, as a state, in Florida, pulling back the restrictions that, essentially we were, quote unquote, forced to put in the first place, after we were delayed, related to the rest of the country, in doing so, which makes it that much tougher to deal with.

Essentially, both situations, right? Because you know, you can only increase your staff, or your resources, or just sort of, your energy, so much, right, to meet those multiple needs. Hindsight’s 20/20, but it’s kind of hard to imagine the alternative, when we’re just so early, still, relatively, even if it’s been — what? since around January — that we’re dealing with this? It’s still relatively early for us to know what trend the virus is going take, as a virus in general, us as a society, the other things that are inevitably altered, as well, economics, the schooling system, familial structures, et cetera.

Joe Elia:

Back in March, I remember you telling us that although you were working Broward County — and I understand you’re also working in Miami, as well, now — you were living in Miami’s Financial District, and you told us that you saw many groups of people, together in the street, without masks. I’m guessing, and hoping, that things have changed, since then.

Dr. Julian Flores:

Yes. It’s essentially, it’s not the stark opposite of that. I’d say something at least in the middle of those two scenarios, right? Of no mask, versus everyone with masks. I will say that Miami-Dade County has implemented what I believe, a fee of sorts, or some sort of penalty, if you are seen in public, without a mask. We, at least, collectively, have seen that as an important measure, against, at least, the exposure to the virus, or you know, giving it to someone, and transmitting it.

Dr. Ali Raja:

That makes a lot of sense, and like the rest of the country, I think we’re seeing that shift. Let me take you back to March, again. When we spoke, you were using one N95 mask, per shift. So, what about now? What’s the availability of masks, of gowns, of other PPE, in your experience?

Dr. Julian Flores:

Well, because I feel like, or rather, I know that even as a country, in most states, we’ve seen sort of, I would say almost a bimodal peak, in that we saw a surge…speaking of ER volume, in general, we saw a peak of COVID-related cases. We then saw, generally speaking, a dip in just ER volume, in general, from what you can infer, most people just being scared to be at all associated with an environment that, in any shape or form, can expose you to a virus, just by you physically being there, to now, a resurgence of truly related, both primary complications, and secondary complications of COVID, with just volume, in general.

Thankfully, I feel like that sort of dip in volume, and in resource utilization has allowed us to, in a way, catch up, with PPE, at least, I can say, in my hospitals, and you know, speaking for other hospitals in the area, as well. So, I can say that the resources in the two shops I work for are thankfully there, but I can’t speak, you know, for every hospital in Florida.

Dr. Ali Raja:

That makes sense, and you just spoke about the hospitals. What about the hospitals, in total? How are ICU beds doing? Have they started bringing elective procedures back, or are they still holding out on them?

Dr. Julian Flores:

That’s also, from what I know, sort of, a hospital-by-hospital scenario. I know that as a state, that’s not a sort of, a uniform, now, limitation. My hospitals are allowing that to happen. Of course, there’s always, I can imagine, that back thought, in an interventionalist’s mind, that if it doesn’t need to happen now, and it doesn’t harm the patient, then maybe in the spirit of just limiting exposure in general, that it can be delayed, somewhat. At the very least, that’s being allowed to happen.

Joe Elia:

Do you have enough ICU beds? I mean, are…

Dr. Julian Flores:

Yeah. That’s also regional, when thinking about Florida. There are some ICUs that I know are at easily 90-something percent capacity.

Joe Elia:

Yeah. Okay.

Dr. Julian Flores:

And if not that, at the very least, we are holding more patients, in general. That’s something I feel like I can more easily generalize, to the state of Florida, that there are just more patients being held in the ER, secondarily, to just folks either in an ICU setting, or in what we call a PCU setting, taking a little bit more time to be discharged.

Joe Elia:

Okay. How are you keeping informed? There’s so much information, just bouncing off the walls about these things, and I don’t think that hydroxychloroquine was an issue, when we first talked. But I mean — and we don’t need to talk about that — but there are lots of advisories out there, and you had mentioned a private Facebook group, in our earlier chat. Are you still active in that, and finding it useful?

Dr. Julian Flores:

Definitely. I’m still a part of those, a couple of Facebook groups — private groups — I mentioned before, one of them being EM Docs, and the other one being the COVID-19 Physician Alliance. You know, there’s always going to be a lot of mixed messages, and comments that could be … in a way, you can say, they’re true. But there could also be another truth that’s mutually acceptable, right?, because as we all know, data can be presented — consciously, or subconsciously — how we want it to be presented, without altering numbers, or methods, as to how we acquired the data points, to begin with.

So, and of course, it’s hard to divorce the emotional sort of, drive, to be presenting that data, to begin with, right?, and to come up with a conclusion, whether you’re, you know, pro, or anti anything, really, in general, especially in regards to the pandemic, and how we’re handling it, and how the virus is going to be projected to continue affecting us.

Essentially, at least, what I do, is every time I look at, sort of, even a study that was well done, I try to think of if, in any way, the alternative could be true, right?, and if I’m already biasing myself pre-meditatedly, before I’m reading the study, because that’s going to color how I see it, going through. That’s going to color how I’m going to be spreading it to my colleagues, and to my friends, and family.

Again, we’re relatively pretty early into COVID-19. You know, and because of that, as much as you would like to, you can’t always make a study as diverse as possible, or as extrapolatable as possible, right? You can only do so much, when you’ve been in a pandemic for what?, eight months, or so, right? So, they may all come from a good heart, or a good, sort of, intention in mind, but I always try to read the opposite viewpoint, or a journal that would refute that.

So, you know, in many ways, in regards to things like hydroxychloroquine, or certain other related medications, sometimes the safer thing, I think, going into it, is to just have no opinion on it, because sometimes, we just don’t know, and we can’t apply every single patient, every single demographic, every single hospital to that end point, because I mean, for any study in general, for any medication, the number of days that you use it matters. If you use it at the beginning, during, or after, the height of, the peak of symptoms, et cetera.

So, it’s tricky, and I feel like we all, you know, reflexively want to have an answer, and we’re not going to convey it, always, that unambiguously, especially if we have an emotional drive to put that home.

Joe Elia:

Or a political drive, as well.

Dr. Ali Raja:

It could be either.

Joe Elia:

Yeah. Yeah.

Dr. Julian Flores:

And those are mutually not exclusive, either, right?

Joe Elia:

That’s true. That’s true. We want to believe what we want to believe, and so, I think we all face that, as human beings.

Have you been hearing from colleagues who haven’t faced a surge yet? There aren’t too many places in the country that aren’t, but have you heard from any, and do you have advice for them? We interviewed you in March, and now, here we are in August. And what was the big lesson that you’ve learned, over those months, if you had to give one?

Dr. Julian Flores:

Yeah. I would say to my colleagues, that haven’t been dealing with COVID-19 related symptoms, or complications, as much as the rest of us, to just keep your eyes peeled, because it’s hard to say that a specific ER, or a specific region, within Florida, or within any state, is going to be inherently immune to it, when we’re still allowing transportation within the state, across the states. And conversely, folks that have been dealing with only COVID-19 related, you know, pulmonary symptoms, or other organ system complications, not everything is COVID-19 related, either, right?

We’re still going to have our strokes that are just related to a vascular complication, independent of COVID, or heart attacks, or trauma-related complications. So, I think in either extreme, we just always have to, in these times, remember to just keep our eyes peeled.

Dr. Ali Raja:

That is a great way to look at things, and a good reminder for all of us. Let me ask you, Julian, we’ve been asking all the questions. So, do you have any questions that you wish that we had asked? Or, a point that you’d like to make, that we haven’t gotten the opportunity to do, yet. What’s on your mind, that we haven’t yet covered?

Dr. Julian Flores:

I have a lot of opinions, and ironically, on a lot of COVID-related topics, and the conclusion, in those opinions of mine, is that I have no opinion — if that makes any sense.

Joe Elia:

It does.

Dr. Julian Flores:

Or, no. I have no, sort of…I can’t say with legitimacy, or with, you know, pure confidence, that it’s one way or another, especially something like this virus, that again, is a specific strain of coronavirus. As we’re coming to know, it’s not only pulmonary-related complications. It sort of, evokes all your organ systems, and any of them could be altered short term, or long term, at any given time. We’re still, you know, trying to figure that out. And with the mindset of always trying to see what the opposite team is saying, it has sobered me quite a bit, when coming to terms with what I think I know, or what I want to know, and what I want to convey to the general public, all while trying to keep a word choice, a spirit of, per se, it doesn’t have to be the end of the world, and at the same, this is not something we’ve dealt with before, at any level that you want to talk about it.

At the medical level, at the societal level, political level. It’s just, it’s not, and I think we’d be lying to ourselves to say that it is, in either way.

And everything is relative. That’s a main point I would want to drive home, and we have to see what terms we’re talking with, what truth we’re believing, before we speak, and are we allowing room for that alternative explanation to be said? Because there’s a lot of common ground, that can be found, and sometimes, it can feel weak, or it can feel, sort of, in a way, insulting, especially to us physicians, or healthcare-related folks, that are the main, sort of, proponents to driving home knowledge, of any kind of sort, to sort of, quote unquote give in to the other side, and again, because these points touch on a lot of things besides just logic, right?

We cannot deny that sometimes, subconsciously, or consciously, there is a political side-motive. There is an inherently, sometimes, again an emotional cord that’s being strummed in some way or another. So, I would just like to advocate for us all, sort of, being honest with ourselves with what we’re reading, what we’re deciding to read, what we’re coming out of, you know, getting from these articles, from these posts, from the news channels. And are we leaving room for the alternative explanation? If so, are we deciding to paint one picture, or another, based on something else besides just the facts at hand of COVID-19.

Joe Elia:
Julian, we’re very grateful to you, for doing this with us, today, and we want to extend our best to you, and your colleagues, and especially, to your patients. Thank you.

Dr. Julian Flores:

Thank you so much, and you know, as I finished, I believe, the last podcast we enjoyed, and collaborated in, together, you know, keep the hope. Keep the positivity. I think that’s, at least, what drives me, to keep reading, to keep wanting to know more for myself, and my peace of mind, and for our patients.

Trying to leave, you know, pride aside, and collaborating with, and you know, coming to terms with what could be the alternative of what we thought of, to now, in this, and just in medicine in general, because again, they’re not mutually exclusive, right? Especially in this sort of, wave of the virus where, especially as ER doctors, where we can’t afford to just see one thing, or another. I mean, we’re rolling the dice with every patient, with every, you know, clinical presentation. So, collaboration is what’s gotten us even this far.

Dr. Ali Raja:

That’s a great way to end this, Julian, to remind us, all of us, who are seeing patients right now, in this unprecedented time, to keep an open mind, and to be willing to collaborate, even when we might have initial doubts. That’s how we’re going to really move the treatment of this disease forward. So, thank you for that really important reminder.

Joe Elia:

That was our 271^st episode. All are available, free, at podcast.jwatch.org. We come to you through the NEJM group, and our executive producer is Kristin Kelley. I’m Joe Elia.

Dr. Julian Flores:

I’m Julian Flores.

Dr. Ali Raja:

And I’m Ali Raja. Thanks for listening.