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NEJM Journal Watch Podcasts: Clinical Conversations

Updated 12 days ago

Rank #99 in Medicine category

Alternative Health
Health & Fitness
Medicine
Read more

Audio podcasts featuring the week’s top medical news plus pertinent interviews

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Audio podcasts featuring the week’s top medical news plus pertinent interviews

iTunes Ratings

39 Ratings
Average Ratings
29
6
3
1
0

Great news and interviews!

By MJH8 - Sep 11 2019
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This is a great way to get the week’s top medical news very succinctly, and Joe Elia’s conversations with researchers are highly educational and entertaining!

Is it coming back?

By nyhunter77 - Feb 13 2013
Read more
This is an awesome podcast, is it coming back for 2013?

iTunes Ratings

39 Ratings
Average Ratings
29
6
3
1
0

Great news and interviews!

By MJH8 - Sep 11 2019
Read more
This is a great way to get the week’s top medical news very succinctly, and Joe Elia’s conversations with researchers are highly educational and entertaining!

Is it coming back?

By nyhunter77 - Feb 13 2013
Read more
This is an awesome podcast, is it coming back for 2013?
Cover image of NEJM Journal Watch Podcasts: Clinical Conversations

NEJM Journal Watch Podcasts: Clinical Conversations

Latest release on May 19, 2020

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Audio podcasts featuring the week’s top medical news plus pertinent interviews

Rank #1: Podcast 247: Managing dyspepsia

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A “network meta-analysis” (we’ll explain that) finds that “test and treat” is the best way forward in managing this common condition. Patients, paradoxically, prefer immediate endoscopy to test-and-treat, but unless the patient has “alarm symptoms” (such as dysphagia, weight loss, and anemia), endoscopy is likely to add complications and costs without adding further benefit. Our guest is […]

Dec 20 2019

21mins

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Rank #2: Podcast 256 — Anthony Fauci: Talking with patients about COVID-19

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We have Dr. Anthony Fauci of NIAID to talk with us about COVID-19, the disease caused by the 2019 novel coronavirus (also known as SARS-CoV-2). He’s full of sound advice in the midst of a rapidly changing epidemic. We wanted to know, How do you talk with patients about this rapidly spreading infection? How do you […]

Mar 10 2020

13mins

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Rank #3: Podcast 251: Intermittent fasting

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Intermittent fasting has salutary effects. Listen how Dr. Mark P. Mattson, co-author of a recent NEJM review on the topic, assesses the practice — and how he’s managed to skip breakfast for the past 30 years or so. Dr. Ali Raja joins Joe as co-host again this time. Links: de Cabo and Mattson’s review in the New […]

Feb 07 2020

17mins

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Rank #4: Podcast 262: COVID-19’s larger lessons

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We talk with Colleen Farrell who’s doing her third year of an internal medicine residency in New York City.

Fortunately, we caught her during a one-week vacation (she was supposed to be taking two), and she chatted with us about how she and her colleagues are coping.

We asked her what she thought COVID-19’s larger lessons would be, and she gave an interesting, impassioned answer.

Running time: 12 minutes

Other interviews in this series on COVID-19:

  1. Dr. Anthony Fauci
  2. Dr. Susan Sadoughi
  3. Dr. Matthew Young
  4. Dr. Julian Flores
  5. Dr. Kristi Koenig

Joe Elia:

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

We’ve come to New York City this time, at least electronically, to talk with Colleen Farrell.

Dr. Farrell is a third-year resident in internal medicine at NYU in Bellevue Hospital. This July, she starts a pulmonary and critical care fellowship at New York Presbyterian-Cornell. I became aware of Dr. Farrell when a classmate of hers sent along a posting she’d made on social media. It read, in part, “I feel grateful that I am able to put my training to public service. I don’t do well being cooped up at home. I became a doctor to do this work, but I would be lying if I said I wasn’t scared. I am calm and committed but also deeply, deeply terrified.”

Welcome to Clinical Conversations, Dr. Farrell.

Dr. Farrell:

Thank you. Thank you for having me, Joe.

Joe Elia:

So there you are in New York City. How are you and your colleagues doing? Are you getting enough time away from the clinic to get sleep and get food?

Dr. Farrell:

Yeah. So I would say that the experience varies widely from week to week. So in this situation right now in the midst of the COVID pandemic it seems — like for everyone — you’re either fully on or totally off at home. So you’re catching me in one of those off periods. About two weeks ago, I started taking care of coronavirus patients at Bellevue. When you’re doing that work, the shifts are long and really tiring. Our whole residency schedule has been kind of recreated to meet the staffing needs of this crisis but built into that is some time off.

So right now, I was still due for a two-week vacation towards the end of this year, and so right now I’m getting one week of that. So I’m in this weird place of getting rest right now and knowing that I’m jumping back into it in just a few days.

Joe Elia:

Well you mentioned in that posting that I quoted from, you mentioned a patient. I wonder how that patient fared. Do you know?

Dr. Farrell:

Last I checked he was still in the ICU. He was intubated and requiring dialysis. Yeah. So this is actually the first coronavirus patient I met, and when I met him I was really worried about him. He was still breathing on his own but requiring a lot of oxygen. So it was the middle of the night. I called one of our ICU doctors and he was moved to the ICU where he still is. We’re seeing that with a lot of our patients, that when they get to the ICU it looks like it’s a pretty long course for a lot of them. It’s not needing to be intubated for a few days and quickly extubated, but it’s a long course with a lot of uncertainty. So I keep kind of checking in, hoping that he’ll get better, but it’s going to take time, I think, to see.

Joe Elia:

Yes. Let’s hope that he does get better. How are you keeping up with policy? Have you joined any of the private chat groups like the one described by Dr. Julian Flores during his interview here?

Dr. Farrell:

Yes. Right now, we’re dealing with so much information. So I’m getting information from several places. First of all, I think — especially in my role as a resident physician — decisions I make are about the patients I’m directly caring for, or managing my own team, and so it’s hyperlocal. So first I have to pay attention to the policies from my institution. We get multiple emails a day and like a lot of residents I’m not employed by just one. Well, I’m employed by an academic medical center, but I rotate at NYU Langone, Bellevue Hospital, and the VA. So those are three completely different hospital systems. They’re three different hospitals, for one, but they’re also a private hospital, a public hospital, and a federal hospital.

So just to do your job you have to keep track of those policies. So we have a lot of internal communication with documents: “This is the latest of the PPE standard. This is how long you have to be out of work if you have symptoms. This is when a patient is allowed to move to this place or that place.” Those are the policies I pay the closest attention to. Then I would say while I’ve been home this week on my “vacation” I’ve been tuning into New York Governor Cuomo’s updates and those actually help me understand kind of even what I’m seeing sometimes at the hospital.

He’s been talking about [transferring] patients from some hospitals in New York City to others to even-out the load, and that helps me understand [that] when I’m at work I might be getting transfers from other hospitals and understanding why that is. Then in terms of more informal mechanisms, I’m pretty active on Twitter. I get a lot of updates there from people on the frontlines and then I’ve also been reconnecting with colleagues from medical school that I haven’t been in touch with for years. My Harvard Medical School class Facebook group — I don’t think anyone touched it for three or four years but all of a sudden people are connecting on there, talking about what’s going on in their hospitals and just sending support to each other. We’re all thinking of each other and kind of reading what’s going on in different parts of the country.

Joe Elia:

Tell us a bit about your social media posts. Are you looking at maybe a career as a writer?

Dr. Farrell:

Yeah. I’ve loved writing at least since college and have been writing about social and ethical aspects of medicine since I was an undergrad 10 years ago and I was writing about the early years of the AIDS epidemic in the US. At that time, I was reading Atul Gawande and found his books captivating as so many do. I kind of even realized at that time that I wanted to do the kind of writing in medicine that spoke to audiences beyond the doctors and scientists in a hospital.

So then in medical school I was really closely mentored by Dr. Suzanne Covin, who’s the writer-in-residence at Mass. General Hospital, and she’s been a tremendous role model to me. I use writing as a way of both processing my own experiences and kind of sharing with a broader medical community — and more society at large — some of the social and cultural aspects of medicine. So sometimes that’s through essays that I publish but I actually really like using Twitter and sometimes Facebook as a way to send off little missives. I like that they’re informal. They feel real and authentic. They’re not filtered through an editor or someone else. It can be a really cool way to connect with people and it’s writing. Any time you’re using words you’re learning how to write.

Joe Elia:

Yes. I know those editors do get in the way…

Dr. Farrell:

I’m grateful for editors but sometimes it’s paralyzing knowing that you’re going to be scrutinized.

Joe Elia:

Sometimes they help… So you’re on vacation this week. Are you reading or binge-watching?

Dr. Farrell:

I mean it’s a very weird vacation. I’m just staying inside my apartment. My husband is home. He is a third-year NYU law student and is doing law school remotely this week. We’re watching movies. We take turns who picks the movie each night. So we watched Alien. We watched How to Survive a Plague, a really great documentary about the early years of AIDS and then we watched Indiana Jones. So we’ll see what we pick tonight.

Joe Elia:

Those are all consonant with your current experience…

Dr. Farrell:

And writing. That’s the other thing. Right now, it’s nice to have some time. I’m doing some writing about my experience in the ICU last week and also doing some writing reflecting on…I mentioned I wrote my senior thesis in college on the early years of the AIDS epidemic. I’ve been thinking about what I learned doing that historical research then and what lessons I might be able to take from it now. So it’s nice to have some time to think and marinate a little bit before I jump back in.

Joe Elia:

I want you to project yourself forward in time a bit. When this pandemic ends and you’re training other young clinicians, say 20 years from now, what will you tell them was COVID-19’s most important lesson?

Dr. Farrell:

Well, I think it’s a lesson about health inequities and existing injustices in healthcare. I think that we are seeing right now that the health of one person affects the health of the entire society and that health cannot be treated as a commodity only available to those who can afford it. It needs to be treated as a human right. Right now we’re hearing politicians say no one should be denied a COVID test or COVID treatment because of their ability to pay, well I agree with that, but why shouldn’t that be the case for cancer or diabetes or anything else? I think we’re going to see more that this pandemic doesn’t affect all communities — even within the US — equally. It is ravaging Rikers Island right now, where we have mass incarceration.

When I call families and update them on their sick family member it’s totally different if they have a big apartment where they can separate within the apartment from those who have symptoms and those who don’t. But when you talk to a big family in crowded city housing they don’t have those possibilities. When government support doesn’t include undocumented immigrants you have a huge health justice issue on your hands. So I think that one of the biggest lessons from this time is to say that the social safety net and healthcare for all is not optional. It’s not a luxury. It’s a foundation of a functional society that has any degree of concern for the people within it. I think that we have been existing in a healthcare structure that is grossly unequal and oftentimes prioritizes profits over people, and I think that this pandemic is going to lay that bare for our whole society to see.

I hope that in 20 years I will be able to say maybe this is the last straw that helped our society change and provide healthcare to everyone. I hope that’s the story rather than we continue on or we return to the status quo after this ends.

Joe Elia:

Well, Dr. Farrell, I want to thank you for speaking with me today and I hope you’ll come back in 20 years and we’ll review that together.

Dr. Farrell:

That would be lovely. Thank you so much.

Joe Elia:

That was our 262nd episode. All the others live at Podcasts.JWatch.org. We come to you from Physician’s First Watch and NEJM Journal Watch — members of the NEJM Group. The executive producer here is Kristin Kelley, and I’m Joe Elia. Thank you for listening — and wear your masks and wash your hands.

Apr 01 2020

12mins

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Rank #5: 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 […]

Mar 19 2020

18mins

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Rank #6: 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 […]

Mar 06 2020

28mins

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Rank #7: Podcast 261: COVID-19 as a medical disaster

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San Diego County has Dr. Kristi Koenig as medical director of its emergency medical services. That’s fortunate for the county, because she’s co-edited a definitive textbook, “Koenig and Schultz’s Disaster Medicine: Comprehensive principles and practices.”

We’re fortunate to have her as our guest. She’s full of sound advice on organizing a community’s response (for example, setting up “incident command” structures) and evaluating patients as new threats emerge (the well-known “three-I’s” approach — Identify, Isolate, and Inform).

With the number of COVID-19 cases rising quickly there in San Diego, she’s been busy (as have all of you).

Running time: 19 minutes

Links:

Interview from 2016 with Koenig and Schultz on the second edition of their “Disaster Medicine”

Koenig, Bey, and McDonald’s article on applying the 3-i tool to novel coronavirus in Western Journal of Emergency Medicine (Jan 31 online)

Other interviews in this series on COVID-19:

  1. Dr. Anthony Fauci
  2. Dr. Susan Sadoughi
  3. Dr. Matthew Young
  4. Dr. Julian Flores

TRANSCRIPT OF THE CONVERSATION WITH DR. KRISTI KOENIG:

Joe Elia:

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

Dr. Kristi Koenig is Medical Director for Emergency Medical Services in the county of San Diego, which as of this afternoon, Saturday March 28, had about 420 confirmed COVID-19 cases with six deaths.

The county is lucky to have her, if I may say so, because she’s co-edited a definitive textbook on disaster medicine, and arguably the novel coronavirus epidemic qualifies for entry into that club.

Dr. Koenig is Professor Emeritus of Emergency Medicine and Public Health at the University of California Irvine, School of Medicine, and she was also, I should say, a long-time contributor to NEJM Journal Watch Emergency Medicine.

Welcome to Clinical Conversations, Dr. Koenig.

Dr. Kristi Koenig:

Thank you very much for having me.

Joe Elia:

What are you seeing there in San Diego?

Dr. Kristi Koenig:

Well, we are very concerned in San Diego, as is the rest of the country, and we’re taking a three-pronged approach on the ground in San Diego. Number one is to flatten the epidemic curve. Number two is to increase surge capacity for our healthcare system, and number three is to focus on using an incident command system to coordinate all of our needs and resources, and I can explain each of those in more detail if you’d like.

Joe Elia:

I recognize that, from having looked at your textbook a few years back, so go ahead.

Dr. Kristi Koenig:

In San Diego, we were very early to implement what’s called NPI, non-pharmaceutical interventions, to try to spread out the diseases over time so that we don’t have as a great a chance of hitting a peak number of diseases early on, which could exceed our healthcare capacity.

This so-called flattening of the epi curve, I’m sure people have seen. Even on the news people are getting educated in epidemiology these days.

The idea with that is we won’t necessarily decrease the total number of patients but if we can spread patients out over time we can potentially continue to care for everybody in our healthcare system. This is not only the COVID patients. This is also our regular emergencies.

We know that emergency departments are crowded on a day to day basis. So by using these interventions, which are called things like social distancing (although it’s not really social distancing it’s more physical distancing) we still can keep in contact with people. Other types of interventions to try to prevent the rapid spread of the disease, we can make a huge difference. It’s complicated because we may not see the effects for a week, two weeks, or even more because there are already people in our communities who are incubating the disease that have not had symptoms yet or not. Some people never have symptoms but who have not presented yet to our healthcare system.

The second thing would be for surge capacity, and we’ve developed a concept about 20 years ago along with my colleague, Major General Donna Barbish, for the 3-S concept of surge capacity, which is stuff, staff, and structure. We find it very helpful to organize everything around stuff, staff, and structure, and I can explain that in more detail if you’d like.

Joe Elia:

Yes. I would guess that the “stuff” is going to include things like masks.

Dr. Kristi Koenig:

Absolutely and ventilators and N95 respirators and surgical masks and other types of PPE (personal protective equipment) are very important in an epidemic of this nature. One of the challenges is that the news media and the politicians love to count stuff. You can see it. You can show it on TV. You can touch it. You can count it but one of my famous lines is “Ventilators don’t take care of patients.” Stuff is important but it’s not sufficient. While we do need, certainly, to protect our healthcare workers on the front lines and to have things like ventilators to care for patients in this setting, the stuff component of the 3-S is not enough.

So we also need the staff, which is all of us, the people, and we do know that some people unfortunately will get sick and even die and some people will not be able to come to work because they may be caring for a relative or other reasons. So we have to account for probably maybe perhaps 30 percent of people will not be able to come to work or not be willing to come to work. We also need specialists in the staff. So it’s not just the total number but we need people with specialized expertise. For example, infectious disease specialists, critical care specialists.

Then the third component is the structure and that is the physical location where we care for patients. What we’re seeing now is we’re being very innovative and I think actually this is going to help us after we get through all of this to have better capacity in our healthcare system. We’re seeing alternate care sites develop. We’re seeing field hospitals. We’re seeing the military, for example the Mercy just arrived in Los Angeles today I believe. We’re seeing things like tents being put up outside hospitals to do screening.

In San Diego, we’re also looking at behavioral healthcare centers outside hospitals. We’re seeing telemedicine, telehealth popping up. So lots of things for the structure piece as well where we care for patients. So again, stuff, staff, and structure is very helpful to organize all the components we need to increase the surge capacity of the system.

Joe Elia:

We’ve chatted before when the second edition of your textbook came out. You (or maybe it was Dr. Schultz) mentioned that the third edition should include a chapter on how to prepare oneself to participate in responding. Do you have any advice for clinicians now about to face the challenge of a surge in demand?

Dr. Kristi Koenig:

Yes. We definitely need clinicians. One of the most challenging things about this event is the psychological piece of it. People who are working on the front lines are seeing their colleagues get sick and unfortunately likely even die and it’s very difficult. Or they may have a situation where they don’t have enough resources, and we’re used to taking care of everybody. So keep focused on what we’re doing to take care of patients and take care of your own mental health. There’s lots of resources online for mindfulness and other types of techniques you can use. Make sure that even though we’re physically distancing that we’re still connecting socially with others.

Joe Elia:

When I was going through your textbook again, I noticed the mention of the incident command system. Talk a little bit about that if you would.

Dr. Kristi Koenig:

An incident command system is necessary to coordinate all of the resources that we need. What happens is, people want to help, and they have good ideas, and they try to work outside the established system. And we’re seeing it everywhere. It takes up people’s time to respond to well-meaning requests, spontaneous volunteers, spontaneous donations as opposed to if everything can be funneled into the incident command system it can be coordinated as needed to help manage the disaster.

These are systems that are practiced both in hospitals (we usually use something called the Hospital Incident Command System). In the prehospital setting in all levels of government and there are liaisons between the various incident command systems so that you can coordinate and do something that’s on a regional, statewide, and even national basis that otherwise would be overwhelming to try to manage.

Joe Elia:

At the beginning of an incident like this, what would you do typically with the incident command system, would you put out something immediately saying “We understand you’d like to volunteer” or “If you want to volunteer if you want to bring food, masks, or whatever…”

Dr. Kristi Koenig:

One of the portions of the incident command system would be the logistics section. So the incident commander could refer a volunteer idea to that section who could decide how to best integrate it into the overall response.

Joe Elia:

The US is in mitigation mode right now — as opposed to trying to prevent the entry of the virus into the country…

Dr. Kristi Koenig:

Actually, I wouldn’t agree with that.

Joe Elia:

Tell me how I’m wrong there.

Dr. Kristi Koenig:

The US has different phases right now of the disease. So for example, in New York and some other emerging areas at the time we’re making this recording such as New Orleans and Chicago and Los Angeles, they’re a little bit farther along that epidemiological curve in terms of the rise in cases. But there are some parts of the United States where there are very few cases — or at least few that we know of. So they’re probably earlier on in time. I would say in San Diego, for example, we’re not quite on the same upslope as they are in some other parts of the country like New York.

In places where there’s widespread community transmission, certainly we need to do mitigations and that’s probably most places, to be honest, because we see this disease being spread in asymptomatic or minimally symptomatic people and that’s why this stay-at-home message. This social distancing is so important to flatten that curve, but we also still need to isolate people that are sick. We need to identify them and isolate them so that we can prevent rapid spread by known people who are sick. So we’re doing more than just mitigation.

I’ll just say we’re doing identification and contact tracing to prevent spread of disease from known cases in addition to the mitigation.

Joe Elia:

I mean you started the month with one case in San Diego and now we’re up to many more than that. What have you seen over that time, Dr. Koenig, that has changed your mind?

Dr. Kristi Koenig:

It’s been very interesting in San Diego because we’ve had several disasters within the disaster, if you will. Let me explain what I mean. We have the local military base, Miramar. You may have seen on the news that when we were repatriating people from Wuhan they came into a federal quarantine. So we’ve been closely collaborating and have a strong relationship with the federal entity such as the CDC and what’s called the ASPR, the assistant secretary for preparedness and response, which is located in HHS at the federal level and also the state. Because in the US, the way things are organized it’s local to state to federal in terms of how the resources work.

So we had people coming back from Wuhan that were on quarantine, and we helped support the quarantine on the base. I’ve actually been standing a little bit more than six feet away from a patient who ultimately turned out to be positive from that repatriation. We have systems in place where we have transported patients who became infected or became positive from the base to hospitals and potentially back. Then after we had that mission, which really helped us to get systems in place, we had people coming from the cruise ships. Same thing where we had positive cases in that cohort, and we were able to make sure that those cases did not spread out into the community and that those patients got care and ultimately once their 14-day quarantine was finished they were able to return to where they live.

So that gave us a lot of experience and we’re still actually having more cruise ships coming into San Diego and managing that along with our federal partners. So it’s incredibly complicated, but it’s given us a lot of experience of how to manage this. In addition, you mentioned at the beginning my role in EMS. We put in place screening so that when somebody calls 911, initially several weeks ago when it was more relevant to ask the travel history, we were asking about travel from China and some of the other hotspots, and we were identifying people potentially infected at the level of dispatch so that when our paramedics responded they were already wearing the appropriate personal protective equipment.

When they picked up the patient for transport, they were notifying the hospitals ahead of time, “Hey, we’re coming in with someone who might have COVID” and the hospitals were wearing PPE. Oftentimes, seeing them — if they were stable enough — outside of the emergency department first, to make sure that we weren’t transmitting infection to others.

Joe Elia:

So nothing that you’ve seen so far has changed your mind about the approach that should be taken. Would it be fair to say that it’s reinforced?

Dr. Kristi Koenig:

One of the most challenging things is that the recommendations are changing very frequently. That’s because this is a novel virus. It’s new and we are learning. I’ve actually been following this since December, believe it or not, and I can remember the first report was “It’s not transmitted from person to person,” which I didn’t believe. “Oh, it’s not transmitted to healthcare workers,” which I didn’t believe. But things have been evolving over time in terms of PPE recommendations.

Initially, it was very helpful to identify people traveling from certain international hotspots. Now there’s such widespread disease, that’s less useful at this point. So there is a challenge and there are things that are changing, but one thing that we worked with for all infectious diseases is the concept of the three “I”s. The identify, isolate, and inform. For people working in hospitals, we want to immediately identify patients who are potentially infected, and because this is a disease contagious from person to person we then would immediately isolate them. And the third “I” would be to inform both public health and your hospital infection prevention personnel.

Joe Elia:

Yes. I saw that you had written a paper on the application of the three Is to the epidemic. I’m going to put a link to that on the website.

Dr. Kristi Koenig:

Thank you. And the three-I concept actually developed during the Ebola outbreak in 2014. The idea is that we don’t necessarily think in our day-to-day work about the potential for a patient to be infectious to the point where we could contract the disease or other people in the waiting room to contract the disease, and we have to think about that immediately in something like this epidemic so that we can immediately isolate and protect the patient from exposing both healthcare workers and other patients.

Joe Elia:

As a country, what do you think we could be doing more of or less of at this juncture?

Dr. Kristi Koenig:

It’s important to know that every single person in this country is on the frontlines. For me, this epidemic and every single person’s actions are important to help us stomp out this disease. If you are a non-healthcare person just staying home and washing your hands, as simple as that sounds, can be incredibly helpful, as I talked about earlier, for flattening that epidemiologic curve. So everybody has an essential role in the entire country. As healthcare workers, I would encourage everyone to keep focused. Again, the approach we’re taking in San Diego is this three-pronged approach of the interventions to flatten the curve, coupled with increasing the surge capacity, and making sure we work within an incident command system structure.

Joe Elia:

I know it’s hard to look into the future. How do you think COVID-19 might change clinical practice? Do you see any indication that it might?

Dr. Kristi Koenig:

Absolutely. Once we get through this I think we’re going to have a much better healthcare system. It’s amazing the collaboration and the innovation we’ve had in such a short time. Things are happening you never would have thought could have happened. I mentioned earlier, telehealth as an example, increasing behavioral health resources, increasing resources for the homeless. There are incredible collaborations happening. We’ve had meetings with all the chief medical officers of our 20 hospitals including VA and military in our county. We’ve had meetings with all the CEOs of all our hospitals along with the board of supervisors and the chief medical officer of the county.

This kind of cooperation and collaboration would not have happened if it weren’t in the face of a crisis.

Joe Elia:

Is there one essential lesson that you want clinicians to take as they’re about to face this?

Dr. Kristi Koenig:

Keep focused. We will get through this if we organize our actions and our thinking. We can save lives. You are the heroes. You’re on the frontlines and we thank you for everything you’re doing every day.

Joe Elia:

I want to thank you for your time today, Dr. Koenig. I wish you good luck in the coming days.

Dr. Kristi Koenig:

Thank you very much. Stay safe.

Joe Elia:

Thank you. That was our 261st episode. Its predecessors are all searchable and available free at Podcasts.JWatch.org. We come to you from Physicians First Watch and NEJM Journal Watch — all part of the NEJM Group. My executive producer is Kristin Kelley and I’m Joe Elia. Thanks for listening and stay healthy.

Mar 29 2020

18mins

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Rank #8: Podcast 250: #MeToo in the OR

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It turns out that the disrespect starts even earlier — when women are questioned about their choice of a surgical specialty. Nor is the bad behavior the exclusive province of the “old guard.” We talk with Dr. Pringl Miller, a Chicago surgeon who’s compiled a collection of instructive stories from women surgeons who’ve had to dodge […]

Jan 30 2020

17mins

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Rank #9: Podcast 248: “Hotspotting” didn’t work in its home town — why?

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The process of identifying super-users of healthcare and reducing the frequency of their hospitalizations — so-called “hotspotting” — was subjected to a randomized, controlled trial in Camden, NJ, the birthplace of the idea. It failed there. Those in the intervention group had a readmission rate within 6 months that was statistically identical to those getting usual care. […]

Jan 17 2020

15mins

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Rank #10: 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 […]

Feb 28 2020

16mins

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Podcast 267: Acute kidney injury in COVID-19 — how one New York system dealt with it

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The novel coronavirus obviously has devastating effects on the lungs, but other, less immediately visible attacks occur — notably to the kidneys.

Dr. Steven Fishbane (a nephrologist) and his colleagues have just published their findings based on a survey of some 5500 patients with COVID-19 admitted to a metropolitan New York health system. Acute kidney injury developed in about one third of the group, and it was very common (almost 90%) among those requiring mechanical ventilation.

But beyond these clinical features, I wanted to ask Dr. Fishbane about how he and his staff prepared for the viral onslaught, and especially what lessons he takes from the experience.

Running time: 21 minutes

Links:

Kidney International study

Other interviews in this series on COVID-19

  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

TRANSCRIPT

Joe Elia:

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

Our first encounters with COVID-19 often focused on the lungs and respirators. Now, that view has widened to take in things like kidney and coagulation disorders.

One large study of kidney complications has recently been published in Kidney International, and we have one of its authors with us. Dr. Steven Fishbane and his colleagues looked at the clinical outcomes in some 5400 COVID-19 patients admitted to roughly a dozen hospitals in the Northwell Health system in metropolitan New York. Their report offers important clinical insights, which we’ll talk about, but it will also be interesting to hear how the group coped with the sudden sharp demand for kidney replacement therapy.

Dr. Fishbane is Chief of Nephrology at Northwell Health. He also serves as Professor of Medicine at Zucker School of Medicine at Hofstra/Northwell.

Welcome to Clinical Conversations, Dr. Fishbane.

Dr. Steven Fishbane:

Thank you. Pleasure to be with you.

Joe Elia:

The Kidney International paper spans roughly one month’s experience — March of this year — with COVID-19. Before we move on to your experience in preparing for it, would you very briefly tell us what you found, clinically, in your…?

Dr. Steven Fishbane:

Right. So, in this study, and to put it in perspective for you, so, COVID-19 moved into New York with such an explosive rate in March, in particular, that you know it greatly overwhelmed the ability of the health systems, which just managed to get their way through, but for us at the time of the writing of this article, it was based on the first 5,449 patients, which now we, as a health system, have treated 15,000 patients, but in the study, the primary findings, I think, which were important to us was first being able to describe the number of patients who have COVID-19 admitted to hospitals. That’s important to describe is that 36.6 percent developed acute kidney injury, and people had been kind of waiting on that number, in that out of China and Italy, the numbers for acute kidney injury look like they were lower, and anecdotally, we, in the US, were experiencing what we thought were higher numbers, and we were just waiting for a rigorous look at it.

So, yeah, and it turned out that we found that a substantially higher number of patients were at least being reported in our study as being higher. That now has come out in some other work out of the United States, and then we had a number of other findings, I think, that were really interesting, as well, but you know, I think the first really important point was to remember, as you pointed out earlier, this is a respiratory illness. It is a remarkably focused, serious respiratory illness, but we are learning that it does affect other organs, as well. So, here, it’s the kidneys that are being demonstrated, as you pointed out, coagulopathic problems. Here, it’s the kidneys that are turning out to be an important secondary problem.

Joe Elia:

So, the number of people with acute kidney injury were found to be roughly the same as yours in a paper being published later today in The Lancet, from New York City, from Columbia. So, same general catchment area and your numbers are very similar.

In reading [your] paper, and I want to focus on the paper a little bit more, 90 percent, roughly 90 percent of patients on mechanical ventilation developed acute kidney injury as opposed to about 20 percent of those not on mechanical ventilation, and so, and the concordance or the concurrence of those things, of people going on mechanical ventilation and requiring or being recognized as having acute kidney injury was pretty close, wasn’t it?

Dr. Steven Fishbane:

Yeah. Right, and so, you know, this is one of those areas in research that I find to be particularly interesting in that, you know, think of it: We are at that point as this research is being conducted, we are so deeply involved with the intense care for these very sick patients. So, you would think that something like that, the concordance of respiratory failure and acute kidney injury would be very self-evident and intuitive and obvious to us, and yet, although I think we might’ve been experiencing that clinically, it wasn’t really until I remember one moment looking at the data where it suddenly occurred to me this is really remarkable.

There’s two things happening. One is that there’s a real concordance in terms of bad kidney injury right about the time that respiratory failure is occurring and that for patients with COVID disease at home, kidney disease is probably not an issue at all. For people with COVID disease who are in the hospital but without respiratory failure, it’s really not a very significant problem, but we found that bad kidney injury, severe kidney injury, kidney injury requiring dialysis was really limited to patients who required mechanical ventilation, and you know that is important in terms of some of the inferences that one can draw based on that. So, a long-winded answer to your question that, yes, very tied together, acute respiratory failure and kidney injury, as well.

Joe Elia:

Well, you know, as I was reading your paper, I was thinking, clinically, when somebody’s evaluating a patient, if that patient is having trouble breathing, you’re not looking at their kidneys. You’re looking at the fact that this patient is apparently drowning, and you’re trying to do something about it, but there were a lot of patients who were admitted to the hospital but who were not part of your study, and the reason for the exclusion was that they had had fewer than two creatinine measurements, I think, during their hospitalization. So, you didn’t feel that it would be fair to evaluate them, and it made me think, “Yeah, the clinicians are focusing on keeping the patient breathing, and those kidney functions are being evaluated in the course of further clinical care.” But I think what you’re saying is clinicians should keep an eye out on kidney function with COVID-19 patients.

Dr. Steven Fishbane:

Right. So, that’s clearly the case that although we need to be laser-focused on the care of the respiratory illness, because ultimately this is such a potent respiratory organism, but it does cause injury to other systems. We’re seeing this unusual syndrome in children right now, but you know to a much greater extent and not in the realm of rare conditions but rather a very common injury that goes along with the respiratory disease is kidney disease. We understand that now. We understand that patients need to be monitored very carefully in terms of the development of kidney disease and then the difficult decisions that go along with management, do you use dialytic support, et cetera.

Joe Elia:

Let’s move away from your findings regarding acute kidney injury and let’s talk about logistics a little bit. When did you realize that this kidney service might be overwhelmed, and how did you prepare for it?

Dr. Steven Fishbane:

So, it was in mid-March that we saw that New York was quickly just having an explosion in infections. New York was essentially becoming what Wuhan was to China in terms of the rate of infection, and you know, at that point, I think people understood the fact that there was a real risk of really overwhelming the health system, and if the virus has another surge in the fall, we’ve got to, again, be very careful with respect to that, but we recognized, I remember the moment when we realized that the rates were increasing so quickly that for the 10 percent of patients that have bad enough disease to require hospitalization and then for the percentage of those that are going to have bad kidney disease with it, we really had to model out what this could look like.

So, as we got into April and May, if it took a relatively benign course, what it might look like, if it took a middle-road course, and if it took a severe road, what it would look like in terms of potential resource needs. So, we modeled it out. It did end up being the most severe possible course that it could have taken, and at that point, we did a lot of purchasing based on our worst scenarios, renting, purchasing, but getting the types of equipment that were going to be very important in terms of being able to provide dialysis services, and the type of dialysis, also, that we do in the most critically ill patients, which is continuous renal replacement therapy, or CRRT therapy, and making sure that our hospitals would have enough of that type of equipment.

And we really strongly went with a mantra from the beginning here that we’ve got to be able to, to the greatest extent possible, try to cure the underlying respiratory infection, the respiratory infection, and we’ll succeed in patients. We won’t succeed in other patients, unfortunately, but that we never want this secondary problem of kidney disease to limit the patient’s outcomes. We want to make sure that we have the resources that we need to be able to treat the kidney part of it, and yet, by the middle of April, I think everybody through New York was running on fumes and came very close to hitting that point of not being able to keep up with the kidney aspects of the disease.

Joe Elia:

Yes, and you had to move clinicians around the system, too, didn’t you, to have enough nephrologists where you needed them?

Dr. Steven Fishbane:

Right. So, you know, I think a lot of health systems experienced this difficult and really painful issue in the New York area. I don’t know if this occurred a lot outside of New York but that there simply were not enough intensivists. There were not enough hospital medicine doctors. So, think of it, you know, this way, our largest hospital out of 23 hospitals is North Shore University Hospital. It’s 865 patients, you know, probably four intensive care units, and before you knew it, the whole hospital was basically an intensive care unit. I mean units that had been classic medical-surgical units were being converted into intensive care units, and there weren’t enough intensivists to be able to care for these patients. So, from specialties that were suddenly less busy, for example, gastroenterologists were not doing a lot of colonoscopies and other procedures, orthopedic surgeons and other surgeons were not doing a lot of elective surgery, and so a lot of people were brought out of necessarily areas of comfort for them.

Tom McGinn, who’s the chairman of medicine and associate chief of staff for the health system, you know, I think in a very touching way, put forth the fact in March that a lot of us were going to have to get out of our comfort zones and get into areas of treating patients, and you know it ended up, I think, for a lot of people that were redeployed into front-line care for intensive care and for hospital medicine care of less sick COVID patients, it ended up, I think, being a really energizing, a very, you know, I think in some ways exciting but very sad, very sad labor that people were involved in. For nephrologists, it was a little bit different. Some of our people got redeployed, but because so much of our work exploded in the hospitals that we were really redeploying our people from office into hospital care.

Joe Elia:

Did you have enough personal protective equipment, PPE, so called, and…?

Dr. Steven Fishbane:

Yes. So, I think that we were fortunate that for all aspects of protective equipment, there was enough. Now, you know, as you probably know, by late March, I think everybody was worried about would there be enough ventilators, would there be enough masks, would there be enough face guards, would there be enough of everything? And you know, I think that New York State was very helpful in this regard. Our health system senior leadership worked very, very hard and long hours to try to make sure that the PPE was there.

So many people, so many doctors, were making a sacrifice, so many nurses making a sacrifice to be at the front lines here and to be able to provide the PPE that was required was so important more in terms of just how people felt about the work and the confidence. So, it’s such an important question, and you know, I think the leadership in New York State, the senior leadership for this health system, and I think for most health systems in New York really did a very good job of keeping us there, but we have to remember, you know, that if you let this pandemic explode out again in too large of a way, there’s always that risk of running short on PPE, and you know I think we saw from some other countries just how bad that can get.

Joe Elia:

If you could advise systems that will be facing a second wave, which we hope will not happen, what lessons did you learn from this wave that you’re going to carry forward with you even into the non-pandemic world?

Dr. Steven Fishbane:

Yeah. So, I think there’s a few lessons here that are important. You know the first is that plan in advance. To the greatest extent possible, don’t try to manage something that is just pulling you along, you know, the proverbial tiger by the tail. Try to stay ahead of it. Use data. I mean we were at the point, at least on the renal side, of every single day, understanding how many nurses did we have available, how many machines, the amount of disposables that are available. At the health system level, that means understanding the number of doctors, nurses that you have to be able to care for critically ill patients.

And you know I would like to add, you know, a third part of it, not just that real-time awareness and management but communication, communication, because it, you know, did come at a time that physician burnout in the United States was already something of an issue, I think it’s fair to say, and having that great physician leadership, which we have a lot of in our health system, to really keep the spirits up of people, and I think, you know, as we’re getting late in the course of this, at least first wave. We had a call last night where we were talking, and there was really a lot of gratitude about the importance of just talking and talking and providing support for not just physicians, of course, but nurses and everybody who’s involved at the front lines of care to be successful. Now, if there should be a second wave, that’s going to be hard, right? That will be you ran on fumes and adrenaline the first time through. The second time through, it’s going to take a tremendous amount of support, but we learned a lot the first time through, I think, to help everybody around the country.

Joe Elia:

If you could say something to the staff that went through these couple of months with you, what would you say?

Dr. Steven Fishbane:

You know I just have learned and have developed such an incredible sense of gratitude for people that have left young children at home, babies at home, that have elderly parents that they’re caring for, that have spouses with medical conditions that have gone willingly to the front lines and very few people that were not willing to do that but just the amazing gratitude for the courage, for the fact that this reenlivens in us the reasons that us as physicians, as nurses, as other healthcare providers, went into healthcare in the first place. It’s terrible that we’ve had to go through this for the patients, most of all, of course, and their families, but you know, I think a real awakening in all of us and you know maybe it takes every once in a while a certain wake-up call about why, why this calling is so important, and I hope young people going into medicine understand that, Joe.

Joe Elia:

I wanted to ask you, Dr. Fishbane, what in your life prepared you for this challenge, do you think?

Dr. Steven Fishbane:

Maybe this is the best answer to your question. You know my training was during the AIDS epidemic, and I think that, at that point in my career, as a trainee, I didn’t really appreciate because this was the normal for me as a trainee, and yet, you know, I think for me and for some of my contemporaries, you know, that was very good preparation, but I think for everybody who has lived through challenges in their lives and they know they can get through it with courage and with, you know, working together, as a team, and feeling that camaraderie and collaboration of working together. It’s so important, right?

Joe Elia:

I want to thank you, so much, Dr. Steven Fishbane, for sharing your experience with us.

Dr. Steven Fishbane:

Great. What a pleasure to speak to you. Thank you.

Joe Elia:

That was our 267th episode. The whole lot is searchable and 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. Thanks for listening.

May 19 2020

21mins

Play

Podcast 266: Interferon and early treatment in COVID-19 bring good outcomes

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A combination of three antivirals — Kaletra (which is lopinavir plus ritonavir) and ribavirin — when given early and with interferon significantly reduces viral shedding, disease symptoms, and hospital stay in  patients with COVID-19 when compared with a control regimen of Kaletra alone. The drugs are active against other coronaviruses, but the key factors seem to be interferon and promptness of treatment.

When the triple-drug combo was administered without interferon 7 days or more after the onset of symptoms, the results were no better than with Kaletra alone. Prof. Ivan Hung, the lead author on the report, explains that the researchers were afraid of prompting a cytokine “storm” if interferon was given after 6 days of symptoms — they’re not sure that that reluctance was well founded now. In any case, no patients died in either group.

The study was conducted in Hong Kong and has just been published in The Lancet. (An earlier study by another group published in the New England Journal of Medicine found no special benefit from Kaletra alone — a result seemingly confirmed by this study in The Lancet.)

We were able to interview Prof. Hung over ZOOM from Hong Kong, where he was about to enjoy a Mother’s Day lunch with his mom. It was very generous of him.

Prof. Hung’s article in The Lancet

NEJM study on Kaletra’s ineffectiveness against COVID-19

Running time: 14 minutes

Links to other interviews 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

Transcript __________________

Joe Elia: ________You are listening to Clinical Conversations. I’m your host, Joe Elia.

A study out of Hong Kong, just published in The Lancet, shows that a combination of three antiviral drugs has the effect of shortening the time from the start of COVID-19 treatment to when nasopharyngeal swabs are free of virus. The researchers used a combination of three drugs, all of which have shown activity against coronaviruses related to SARS-CoV-2. Some patients also received interferon.

The regime was compared against a regime using only two of the antivirals and no interferon.

The study’s first author, Professor Ivan Hung, has kindly agreed to talk with us. Professor Hung is with the State Key Laboratory of Emerging Infectious Diseases, Carol Yu Center for Infection, at the University of Hong Kong.

Welcome, Professor Hung, and thank you for agreeing to talk with us.

Professor Ivan Hung: ________Thank you, Joe. Very kind of you.

Joe Elia: ________Previous work on 2003 SARS and 2012 MERS was key here, wasn’t it?

Professor Ivan Hung: ________Absolutely. Yes.

Joe Elia: ________And can you briefly explain the rationale for using the three drugs that you did?

Professor Ivan Hung: ________Yes, the choices of the three drugs are based on our previous research, published in 2003 and also in, subsequently in 2015. The two studies were based on…in 2003, we were using the Kaletra, which is the lopinavir/ritonavir, together with the ribavirin, in patients with SARS in 2003. And we were able to demonstrate that with that combination that patients clinically, they actually performed better with fewer complication of ARDS and also fewer mortalities. Nevertheless, it was a pilot study.

Subsequently, we did another study on marmoset, which is the, you know, the South American monkey, and we did, in that animal model, we were able to demonstrate by using either interferon or with the Kaletra, we were able to suppress the virus and with better survival in the monkey model. And that’s the reason why we choose to use the interferon beta-1b, the Kaletra, and also the ribavirin as our combination for this antiviral.

Joe Elia: ________And you say in the paper, the interferon jumpstarts the immune system. It can, it has that effect. So, you limited the use of interferon to those whose symptoms had emerged less than seven days before starting treatment.

Professor Ivan Hung: ________Yes.

Joe Elia: ________And why did you limit it to early diagnosis?

Professor Ivan Hung: ________We worried about the pro-inflammatory effect of the interferon, and as we know that from, you know, other studies, we know that the viral load actually peaks in the COVID-19 very early, 24 to 48 hours from symptom onset. So, that’s why we chose, we decided to use the interferon within seven days because we worried that if we would give it to patients who presented to us late, beyond seven days, there would be an adverse effect of having activating the inflammatory cytokine storm in these patients, and it might worsen their clinical presentation.

Joe Elia: ________Just because it, as you say, it jumpstarts the immune system, and you don’t want to put it into overdrive, I guess.

Professor Ivan Hung: ________Absolutely. Yes, that’s the reason.

Joe Elia: ________It seems very important to start treatments, at least with the triple regimen of antivirals, within seven days. Is it because the viral load peaks early?

Professor Ivan Hung: ________Yes. From our research in influenza and also other respiratory viruses, we know that if you have treatment very early on, within the seven days from symptom onset, we will be able suppress the viral load, you know, especially for the first few days. By suppressing the viral load, you actually prevent complication from happening in the second week, which is usually complicated with activation of the immune system and you have the cytokine storm, and that is when you get most of your complications, including your severe pneumonia, your respiratory failure, followed by multi-organ failures.

So, it is key, in fact, to treat COVID-19 or influenza within the first few days, or at least within the first week from symptom onset. So, that is very, very important.

Joe Elia: ________And some people who received the triple drug regimen started the drug regimen after the seven days of symptoms. They started…

Professor Ivan Hung: ________No, in this trial, we actually just give two drugs for those who were presented beyond, seven days or beyond. So, in fact, in the treatment arm for those who presented seven days or beyond, we did not give the interferon because of the adverse effects that we worry about from inflammatory effect. So, we only give the Kaletra and the ribavirin for those late presenters.

Joe Elia: ________Let me just be clear. Some of the patients received the Kaletra and ribavirin, but not interferon.

Professor Ivan Hung: ________Yes. Yes.

Joe Elia: ________Okay.

Professor Ivan Hung: ________That is within the combination group, but those patients who presented seven days or beyond, we only give the Kaletra and ribavirin without interferon because of fearing the pro-inflammatory effect of the interferon. In the control group, we only give the Kaletra as a control.

Joe Elia: ________In your table that you describe the results, I think it’s Table 3 or something, the people who received the triple drug regimen, the combo, the combination regimen, and not interferon, did not do significantly better than the people [on the two-drug regimen]…

Professor Ivan Hung: ________Absolutely.

Joe Elia: ________Okay.

Professor Ivan Hung: ________The table is based on subgroup analysis, so we actually split the group back according to when they actually presented with the symptoms, so…which was the fairer comparison, because for those who actually take the triple therapy with interferon, there are 52 of them within the combination group, and we compared these to the control, which is 24 of them who was also presented in the control group within seven days. So, that is the fairer control, a fairer comparison. Whereas, for those who only received the two drugs, that means that they present seven days or beyond, they are compared with the control, with the only-Kaletra group, and there’s no difference between the two groups.

Joe Elia: ________Right. Right. There were no statistically significant [differences]…

Professor Ivan Hung: ________Absolutely. And that actually proved that interferon probably is the big, you know, the backbone of the triple therapy.

Joe Elia: ________Yeah. Well, it’s either interferon or early treatment.

Professor Ivan Hung: ________Yes. As I say, I think it’s both.

Joe Elia: ________Yeah. Yeah. So, it’s…

Professor Ivan Hung: ________If you compared with the control, it would actually show a difference, so…which is also an extra treatment. So, that means interferon is likely to be the key factor.

Joe Elia: ________Yes. Okay. And so, you didn’t use a placebo, and you mentioned in the discussion that there’s a reluctance to use a placebo…

Professor Ivan Hung: ________No. We discussed this in our treatment panel or committee within our hospital authority, and in fact, all the panel members said, you know, placebo is…will not be accepted by the patient, given our painful experience in SARS. So, that’s why we have the Kaletra as the control rather than placebo.

Joe Elia: ________I see. And now, did the results surprise you? Were you expecting that interferon would have the effect that it did have?

Professor Ivan Hung: ________The result was more or less what we expected, although we were a little bit surprised in terms of the difference between the combo and the control in terms of the viral suppression.

Joe Elia: ________Yeah, the shedding was shortened among the combo receivers, recipients from seven days versus twelve days with the controls.

Professor Ivan Hung: ________Yes.

Joe Elia: ________The symptom alleviation, symptoms were alleviated in the combo group in four days versus eight days in the controls.

Professor Ivan Hung: ________Indeed, yes.

Joe Elia: ________And the hospital stay was much shorter. It was nine in the combo group and about fifteen in the controls.

Professor Ivan Hung: ________In the control, yes.

Joe Elia: ________So, yeah. Something was at work, and so…but the two variables seem to be time and interferon.

Professor Ivan Hung: ________Absolutely.

Joe Elia: ________That’s right. So, are you doing more studies on trying to resolve the, trying to get a finer…?

Professor Ivan Hung: ________Yes. Yeah. Yeah, several things we are trying to do in the, you know, in another trial, which we just started, even though we have no patients now in Hong Kong. I think the limitations in our first study is that is all mild cases, mild-to-moderate cases that we have. Most of them come in with the NEWS score of 1 or 2, and the other problem, of course, is that we have very few severe cases, probably because we hospitalize our patients very early on and treat them, most of them, within the first week. So, that’s why we have very few severe cases, including we have, you know, less than 1,000 cases in Hong Kong, confirmed cases. Less than 3% was in the ICU, so…and it’s also, you know, less than 0.4% in terms of mortality. So, it’s very difficult to…you know, we want to recruit severe cases, but we couldn’t.

So, the next step, of course, is to see whether this regimen works in severe cases, if we have more severe cases in the coming winter, or that is that we will be looking at whether we can actually use interferon in patients who presented beyond seven days, which we think that this is not a, you know…a lot of the pro-inflammatory adverse effect is not a problem anymore. We can actually give interferon for patient who present beyond seven days. So, we’ll be looking at that, as well.

Joe Elia: ________But if you were looking for severe cases, then you would need to look no further than Boston. So, are you working with colleagues internationally at all, or…?

Professor Ivan Hung: ________Yes, we have collaborators in Europe, in UK, and also in US, which we’ve communicated with. So, you know, we will be very happy to look for further trials with our collaborators, you know, in the coming winter when more cases evolve.

Joe Elia: ________Have you started using the regimen…you don’t, you say you don’t have any severe cases at the university now. Have you started using the regimen on other patients in other hospitals in Hong Kong?

Professor Ivan Hung: ________Well, in fact, for this trial, we have included six major hospital, public hospital in Hong Kong that actually cover around 75% of the population in Hong Kong. So, in fact, we actually recruited most of the patients in the first, you know, two months up to the 20th of March, of all our confirmed cases. We only have our second wave, you know, in the late March, where we have a surge of cases from about 200 up to, now, 1,000 confirmed cases a day, and so, we have recruited more or less all the patients, a majority of the patients that we have in Hong Kong. So, if we are looking for, you know, more severe cases, then probably we have to look somewhere else with collaborators in other parts of the world.

Joe Elia: ________You mentioned a term I’m not familiar with. You call it NEWS2. It’s a National Early Warning…

Professor Ivan Hung: ________Indeed. National Early Warning Score 2, which was developed in the UK for assessing especially respiratory illnesses affecting with…presented even earlier. And that allows us to compare, you know, the treatment and the control arm in subsequent observations.

Joe Elia: ________So, the severity of the pulmonary…

Professor Ivan Hung: ________Indeed.

Joe Elia: ________Okay. So, pardon my ignorance about that. I want to thank you for speaking with me today, Professor Hung.

Professor Ivan Hung: ________Thank you, Joe. Very kind of you. And Happy Mother’s Day.

Joe Elia: ________Happy Mother’s Day to you. I hope you enjoy it.

That was our 266th episode. All the rest can be found at podcasts.jwatch.org. We come to you from the NEJM group, and our executive producer is Kristin Kelly. I’m Joe Elia. Thank you for listening.

May 10 2020

13mins

Play

Podcast 265: COVID-19 in skilled nursing facilities

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We (Dr. Danielle Bowen Scheurer and Joe Elia) talk with Dr. John Jernigan of the CDC COVID-19 Investigation Team, which recently published its findings on the spread of COVID-19 in a Seattle-area skilled nursing facility.

Most intriguingly, over half the patients who tested positive were asymptomatic at the time of their first testing, and a few hadn’t developed any symptoms a week after their positive tests.

The results are instructive to those working in facilities such as this, whose patients are vulnerable to bad outcomes.

Running time: 17 minutes

Links:

New England Journal of Medicine report

MMWR report

Links to other interviews 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

Transcript 

TRANSCRIPT

Joe Elia:__________You’re listening to Clinical Conversations. I’m Joe Elia. I’m joined this time by Dr. Danielle Bowen Scheurer, a colleague from earlier podcasts. Dr. Scheurer is a hospitalist and professor of medicine at the Medical University of South Carolina where she serves as chief of quality, safety, experience, and population health. That’s kind of a full plate, Danielle. Welcome back.

Dr. Scheurer:__________Thanks.

Joe Elia:__________We’re talking about COVID-19 again this week. It’s the disease whose effects you can see just by looking out the window: People walking in the streets with masks now seem unremarkable. And speaking of streets, there are hardly any cars out there.

What you can’t easily see, however, is who’s infected and who isn’t, and that’s the point of our interview with Dr. John Jernigan of the Centers for Disease Control and Prevention. He and his team have studied an early focus of the pandemic in the US — a skilled nursing facility in King County of Washington State, which neighbors Snohomish County where another such facility had just recorded the country’s apparent first outbreak. Their recent reports in MMWR and the New England Journal of Medicine show how difficult this disease is to screen for.

Dr. Jernigan is an epidemiologist with the CDC COVID-19 Investigation Team, and he also has a teaching appointment at Emory University School of Medicine, both in Atlanta.

Welcome to Clinical Conversations, Dr. Jernigan.

Dr. Jernigan:__________Thank you so much. Pleasure to be with you today.

Dr. Scheurer:__________Hi, Dr. Jernigan. It’s Danielle Scheurer. I’ve read your study with a lot of enthusiasm. It’s very interesting and impactful, so we just wanted to kind of walk through it and ask a couple of questions. So in summary, your team tested almost 90 residents in this facility with really good technique and of those who tested positive, over half had no symptoms at the time of testing and even a few hadn’t developed symptoms even a week after the testing. So as this was all unfolding and you’re reflecting on what you found, how surprised were you and your team with these results?

Dr. Jernigan:__________Thank you, Danielle, for that question. We were pretty surprised. As a little background, I was part of the CDC team that was deployed to Seattle when the outbreaks were first recognized there, when the first cases in Seattle were being recognized. I was in charge of a team that was over infection control for both acute care and long-term care, but it became apparent pretty quickly that long-term care was the place where we were seeing large and rapid outbreaks. So we began to support the investigation of some of those outbreaks as a way of helping prevent transmission.

One of the early observations: we sort of learned that some of the cases we were finding didn’t seem to have a lot in the way of symptoms. This was a very important issue because most of our infection control strategies rely on symptoms to identify residents or patients who might have infection and where to guide your testing and where to guide your isolation and prevention strategy. So we said we need to find out how widespread this is.

So we started doing these point-prevalence surveys. As you point out, we were quite surprised to learn that over half of the infections that we identified in these populations were asymptomatic at the time of the testing. This is a big problem in infection control. How can you separate those that are infected from those that are not if you can’t really tell based upon your symptoms? So we were quite surprised, to answer your question.

Joe Elia:__________The takeaway from your studies, in my mind, seems to be if I can caricature it: “Listen, clinicians, this disease doesn’t announce itself. You have to assume everyone is positive.” Is that fair?

Dr. Jernigan:__________In this particular population in this particular setting, I think that once you identify a case in your facility, yes, you need to assume that every resident in that facility may be infected. If that’s the case then you have sort of two choices going forward in terms of any transmission. One, you treat everybody in the facility the same way with regard to use of, for example, personal protective equipment, which can be a burdensome thing to do. It requires a lot of personal protective equipment, which is an issue.

As you know, there have been shortages nationwide, and particularly for many long-term care facilities, they have had trouble getting enough personal protective equipment. So that’s one issue. Basically isolate everybody, treat everybody a if they’re infected. Or you test everybody so that you can tell, as you point out, who’s infected, who’s not. Separate those that are infected into a certain cohort so you can put them in the same place in the building, assign certain staff to them, focus a lot of your personal protective equipment use there. Then for residents who are not infected to another place where hopefully you can protect them a little bit better.

Dr. Scheurer:__________And a follow-up on that, in your experience, how prepared do you think most facilities are to do quick and reliable widescale testing?

Dr. Jernigan:__________So this has been a real issue. As you know, there have been testing shortages and in fact when we first made this observation that was a big problem. We felt like testing all residents — and for that matter all healthcare providers — could be very helpful but testing availability really didn’t allow that. Now even at a week since that time testing availability has improved substantially, and so some skilled nursing facilities find themselves in states and other jurisdictions who have testing capacity that will allow taking this approach. Others are still struggling to do that. We hope that testing capacity will continue to improve such that if it turns out that this strategy does prove to be effective that more and more facilities will be able to utilize this strategy.

Dr. Scheurer:__________Even the ability to do the actual test aside, the collection methods are pretty cumbersome as well, right?

Dr. Jernigan:__________It is pretty labor intensive to collect the specimen. Even that is potentially changing a little bit with changes and recommendations of how tests can be performed, whether or not you have to do a nasopharyngeal swab, which is originally that’s what the recommendation was. So it takes a certain skillset and level of training to acquire those. CDC has just amended its recommendation such that swabs to the anterior nares are probably acceptable, which simplifies things a little bit in terms of being able to collect the specimen, but still you have to have the swabs, and you have to have the viral transport media, and you have to have a laboratory who can process these specimens and process them quickly. So there have been challenges in all of those elements. It can be a pretty difficult thing to do. I will say that I believe that capacity is improving pretty rapidly.

Dr. Scheurer:__________Which is great and definitely welcome news for the vulnerable population. Can you expound also a little bit about how you guys define symptoms and how that definition is changing and evolving?

Dr. Jernigan:__________Right. So when we started out this investigation not much was really known about this disease. Originally, the symptoms that were used to guide testing and to identify people who had been exposed and who you thought might be infected were essentially fever, cough, and shortness of breath. So we used essentially that for our definition of kind of typical symptoms.

But part of this investigation (and many others) is showing that there are lots of other less typical symptoms that are a manifestation of this disease. So on the one hand, you have people with sort of kind of the classic, cough, fever, shortness of breath. On the other end of the spectrum you have people who have no symptoms and then in between you have lots of other things.

We think especially in the early phases the illness can present quite subtly with maybe just a headache or myalgias or a little bit of chills, sometimes a little nausea, sore throat. What we’ve learned since then, which wasn’t appreciated when we started the study, the sudden loss of smell or sense of taste may be associated with this. So the sort of menu of symptoms that can be a manifestation of early parts of this illness has expanded pretty substantially.

Dr. Scheurer:__________Do you think there is a logical role for serologic testing in long-term care facilities right now or in the future.

Dr. Jernigan:__________So I’m glad you asked that question. I think there is potential great promise from use of serology to help guide these sorts of strategies, but I don’t think we are there yet. There are a number of different platforms out there. Some perform better than others. There’s also the question of what the presence of antibodies means. Are they neutralizing antibodies or not? Does the presence of these antibodies confer a protection against reinfection? What are the correlates of protection? I think these are all ongoing questions that we need to answer. I think there are many, many people out there working very hard to answer these questions and we hope they will have answers in the relatively near-term. I think at this moment today, our stance — and I guess this is my personal opinion — is that I don’t think we’re ready to use the results of serologic testing to make clinical or infection control or public health decisions. We might be there very soon, but I don’t think we’re there today.

Joe Elia:__________The editorial in the New England Journal of Medicine argues that we must be especially cautious until we can test widely and reliably. Did your team have a reaction to the editorial? Did they share their…

Dr. Jernigan:__________No. We have no interaction with the authors. We saw it when it was published or shortly before. If your question is more broadly about how to relax social distancing measures, et cetera and so forth and the relationship between available testing and that, I’m really not the person to focus on that. My focus is specifically on infection control and long-term care facilities and the relationship of testing and testing availability to that with regard to controlling transmission in long-term care facilities, which, by the way is a really high priority thing, as I think I might have mentioned already.

When SARS COV2 is introduced into these settings it can spread very rapidly and very widely and it can cause great morbidity and mortality in this very vulnerable population. But in addition, more than just protecting these residents and these patients it’s important for the regional healthcare system. What we observed in Seattle is that a large outbreak in even a single skilled nursing facility puts great strain on local hospitals in terms of their ICU bed capacity, et cetera and so forth. What’s more is that when a patient in a long-term care facility gets admitted to a hospital with COVID-19 sometimes it’s difficult to get them discharged, because long-term care facilities may be reticent to accept someone who is positive and may still be shedding virus, et cetera. So not just to protect those residents but it’s also to protect the local healthcare system.

So I think preventing transmission here in these settings should be a high priority. So back to the question of the relationship of that priority and testing. We think that our results suggest that testing can be an important tool to help control spread in these settings, and we agree with the writers of the editorial that the sooner that we can make improved testing capacity to the point that we can use it in these settings in that way the better.

Joe Elia:__________Thank you. I just wanted to ask a final question. What were your team’s reactions to the findings that you made? Were they astonished to see this?

Dr. Jernigan:__________I would say we were very surprised. The potential implications of the findings were immediately obvious to us. It seemed clear that a test-based strategy may be a very important approach and yet we were concerned that testing capacity at that point in time was not sufficient to allow that. We’ve been working since that time to partner with facilities and public health jurisdictions that have been increasing their test capacity and to partner with them in implementing this strategy and learning along with them about the best ways to actually go about implementing it.

For example, if you go out and you test everybody once, is that sufficient? There’s some early clues that that may not be sufficient, because if you test anybody on a given day and they’re negative it could be that they’re actually infected but they’re still in their incubation period and not shedding virus — at least to the extent that can be picked up by the test. That suggests that you may need to go back and do a repeat test and make sure that you haven’t missed any of those patients who are incubating. The findings from our study sort of hinted early on that that in fact was the case. So we were working with these partners to implement the strategy and learn lessons as we go with regard to the best way to implement it, the most efficient way to implement it, what the barriers to implementation are, what the facilitators to successful implementation are, and hopefully we can parlay all that information into better and refined guidance from CDC on how to proceed with this prevention strategy.

Joe Elia:__________My last question was going to be, what do you think your team would like to see as a result of your work? I think you’ve just answered that question.

Dr. Jernigan:__________Yes. I think that’s right. We would like to see testing availability that allows long-term care facilities the option of using a test-based infection control strategy. They have the resources they need to not only do the testing but it’s important to emphasize that they need to have the resources to take the appropriate action based upon the test and be planning about how to cohort patients or cohort residents, and make sure they have appropriate PPE, all these sorts of things. All the testing in the world…you can do all the testing in the world but it won’t help you if you can’t take the appropriate action that should be taken based upon the results.

Joe Elia:__________We want to thank you for your time with us today, Dr. Jernigan.

Dr. Scheurer:__________Thank you so much.

Dr. Jernigan:__________Thank you.

Joe Elia:__________That was our 265th conversation. This and all the others are available free at Podcasts.JWatch.org. We come to you from the NEJM Group. The executive producer is Kristin Kelly. I’m Joe Elia.

Dr. Scheurer:__________And I’m Danielle Scheurer.

Joe Elia:__________Thanks for listening.

May 01 2020

16mins

Play

Podcast 264: Is COVID-19 pushing MIs out of emergency departments?

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Cardiovascular consults are way down. Is the threat of COVID-19 infection scaring people away from EDs?

We caught up with Dr. Comilla Sasson, the American Heart Association’s VP for science and innovation. She’s an emergency physician who teaches at the University of Colorado. She’d traveled to New York City to “help with the response,” and she talked with us from a field hospital that had been set up on a tennis court in Central Park.

She had lots to say about what’s driving patients away from emergency departments these days and what’s likely to happen in medicine (hello, telemedicine!) once the pandemic abates.

Running time: 15 minutes

Links (courtesy of the American Heart Association):

  1. Interim Guidance for Basic and Advanced Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19
  2. Oxygenation and Ventilation of COVID-19 Patients
  3. New COVID-19 patient data registry will provide insights to care and adverse cardiovascular outcomes
  4. COVID-19 Compendium for health care providers
  5. Coronavirus (COVID-19) Resources for CPR Training & Resuscitation

Links to other interviews 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

Transcript 

Joe Elia:     Welcome to Clinical Conversations. I’m your host, Joe Elia.

There is talk that COVID-19 is apparently scaring myocardial infarctions and other bothersome conditions away from emergency departments. Harlan Krumholz wrote about the phenomenon earlier this month in The New York Times. He pointed to studies suggesting that cardiovascular consultations have dropped by about 50 percent in the days of COVID.

My cohost, Dr. Ali Raja and I have asked Dr. Comilla Sasson to talk about this with us. You know Dr. Raja of the Mass. General and Harvard Medial School already. Dr. Sasson is an emergency physician and associate professor at the University of Colorado School of Medicine. She is also vice president for science and innovation at the American Heart Association.

When we scheduled this interview, she was on her way to New York City to, as she put it, “help with the response.”

Welcome to Clinical Conversations, Dr. Sasson.

Dr. Comilla Sasson:     Thank you for having me.

Joe Elia:     I’d like to ask you what the Heart Association thinks about this phenomenon of evaporating visits for cardiovascular diseases. Have you convened a panel to study it? What are you telling people who inquire about it?

Dr. Comilla Sasson:     You know, I think we’re all a little bit shocked and taken aback by just how quickly and precipitously we’ve seen such a huge drop in our volumes in our emergency department. Specifically, and I think it would be naïve to think that that’s just because we’re not having heart attacks anymore or strokes or other time-sensitive conditions. I think what it really boils down to — and I’ve personally experienced this with my own patients — is that people are afraid.

They are afraid that if they go to the emergency department they will get COVID. Even though we have separate areas for them, different places for them to be taken care of. I think what we’re realizing is that because we’ve done such a good job of getting the word out about make sure you’re appropriately utilizing the emergency department, I think the unintended consequence is maybe we’ve actually scared off some people who actually need to be there.

Dr. Ali Raja:     That’s interesting. Dr. Sasson, let me ask you, I’ve followed your research for years, and it really focuses on resuscitation, especially on educating non-clinicians and bystanders to begin resuscitation. You mentioned that people are scared. Are you concerned at all that that might actually translate to resuscitations and CPR? Do you think that people are going to be reluctant to actually go near and potentially help other in distress?

Dr. Comilla Sasson:     Yes. I think that’s actually something that we’re very, very both fearful of and mindful of, and I think what we’re trying to do, both as an organization as the American Heart Association, is get the word out about just how important it is to still go to the emergency department if you need to, call 911 if you have any kind of signs or symptoms of a heart attack. Then if you do see somebody drop, it’s okay to even do CPR. I think there’s so much fear right now of being even near people, touching people, let alone trying to actually do compressions — maybe even with breaths if it’s a household member. So I think we’re trying to get the word out.

I think we’re trying to also work with our partners in the community because we know there are huge health inequities as well. So can we use our reach as an organization, as the AHA who works in churches and schools and has a really big breadth and depth of work that we do in the community. How do we use our relationships to get that message out? I think we have to work in collaboration with all partners to do that.

Joe Elia:     Are you still in New York, Dr. Sasson? Can you tell us a bit about that experience?

Dr. Comilla Sasson:     It’s amazing. It’s wild. It’s something like I’ve never seen before. So I’m literally sitting right now in one of the field hospitals that have popped up. It was created just less than three weeks ago from scratch from a tennis court, literally.

So I think it’s been fascinating to see how a city responds. How do you coordinate care when you have to build a hospital from scratch; and then how do you bring people in and out of the system in a surge time; and then — even now as we’re plateauing here in New York — when do appropriately transfer folks here so that you can open up more hospital beds? And then how do you think about this in the next wave? So what happens when you hit surge two? What happens when you hit surge three? Is the field hospital the answer that could maybe help with all of those overwhelming videos and stories that we are hearing in New York City when the surge happened? How do you sort of think about this not only for the current COVID crisis but then for all the next waves that we know are going to happen?

Joe Elia:     So how long are you planning to be there to help out, as you put it?

Dr. Comilla Sasson:     For a month.

Dr. Ali Raja:     Wow.

Joe Elia:     So the people listening can’t see what we see. It looks like you’re sitting in kind of a tent-like facility. So do you have patients now in that facility?

Dr. Comilla Sasson:     We do. We’ve been ramping up for the last few days, and we’re continuing to ramp up and increase both our capacity to take care of patients but also to increase our acuity as well. So I think, again, as you’re building a hospital, I mean again from scratch, it’s about thinking about how to ramp up appropriately so that you can also make sure that your lab works, that your x-ray works, that you’ve got oxygen, that you’ve got the things that we take for granted in a real hospital, if you will, that has been there for years. You have to make sure everything works first and then I think that’s when you can start to really increase that acuity.

Dr. Ali Raja:     Dr. Sasson, let me ask you, right now we’re in the response phase. You’re setting up a hospital in a tennis court but we’re also generating a lot of data all over the world and this is happening everywhere at once. It’s not like the Boston Marathon where it happened in one city. This is happening all over the world and there’s a ton of data being generated not just around the world but also in the country. So let me ask you, this is obviously going to prompt a lot of data analysis and research at some point. Is the American Heart Association planning to collect and speak on the lessons learned?  Obviously they are — that’s what they do. But do you have any projects that you can talk about now about what’s going to come out of this from the AHA?

Dr. Comilla Sasson:     So I think our first responses that we had right away to this surge that we started to see in the global pandemic was to really increase our research funding. So we’ve allocated 2.5 million dollars of new research dollars specifically towards COVID research, and that’s generated a huge volume of applications, which just means that there’s a lot of people who have a lot of questions, right. We created a COVID data registry as well so that we can start tracking this and utilizing our expertise as an organization in terms of data collection.

We’ve had Get With The Guidelines for many, many years and so I think now we’ve got the ability to leverage that expertise that we had with Get With The Guidelines, precision medicine platform to build this data registry. So we can look at heart conditions specifically over the course of not just years but actually months and days, which is something different than what we normally do because most data analysis is a year later and then as an organization we are the biggest trainer of ACLS and BLS across the world.

So we just released our new interim CPR guidance for patients who are suspected or known COVID for both BLS and ACLS and PALS as well so that people can understand what are the caveats for resuscitation with those patients. Then we also released, just recently, our oxygenation and ventilation just-in-time training. So when you’ve go your medical student or maybe your ward nurse who’s now reassigned to the ICU, how do I learn how to manage a vent or a vented patient quickly? So really just trying to think about how do we build those educational building blocks that we’re really good at. How do we put those into place now so that people have what they need when the surge comes to their city, which we know it will.

Dr. Ali Raja:     If you don’t mind sending us the links to those, the new ACLS / BLS guidelines and the education that you just talked about we can actually put those in the website. [Done!]

Dr. Comilla Sasson:     And we had a huge, even in less than a week, we had over 38 thousand hits to that oxygenation / ventilation module. I can tell you, being here in the rapid response team for COVID, I’ve had a lot of people who are like I just don’t remember how to do a vent. It’s been a while for most of us, right. I can do 30 minutes of it. I don’t know if I could do six days. I can tell you, I took on a patient yesterday who was taken care of by a dentistry resident. You know, so if you think about what happens in a surge or when you have frontline workers who now have to very quickly increase capacity, that’s a real thing where you’ve got people who are very much outside of their clinical expertise who are just helping manage that surge so that’s what this is really all about.

Joe Elia:     The changes in referrals and ED visits that we’re seeing seem to be part of a larger phenomenon that’s happening in healthcare generally. The question is, would you agree that COVID-19 will be a kind of trigger for serious changes in how health gets taken care of in this country?

Dr. Comilla Sasson:     Yes. I think if we want to think about what are the positive things that have happened because of the COVID pandemic, the number one most important thing that we have done that will absolutely change the way in which we function as a healthcare system is to increase our utilization in telemedicine. It’s so funny because I think for the last 10 years we’ve kind of been struggling trying to get people to get excited about it, getting payers to pay for it, trying to get physicians and advanced care providers to sign on for it to say, yes, this is a valuable tool. I think overnight we kind of flipped the switch, just like they did in Wuhan, China, and moved so much of our care to telemedicine that I don’t think we’re going to go back.

I have a five-year-old son who got strep throat a week-and-a-half ago, even though we were on quarantine, so it happens. But we did two telemedicine visits from my house. I’ll be honest, I don’t think I ever want to go back unless we absolutely have to go see my pediatrician. It was amazing. We had everything that we needed at home. I think that’s one of the biggest innovations that I see both not just for the COVID post era but hopefully into perpetuity.

I did have a personal story of a patient who I took care of on telehealth. It was mind-boggling to me — absolutely mind-boggling. A woman who had multiple comorbid conditions with chest pain, who I was literally chatting with online first, because it started out as just a very normal interaction. It escalated into “Oh, my gosh, I’m really worried about you. You need to go to the emergency department right now.” She said no. I said, “Can I talk to your family member?” So then we had escalated up to her family member and yet her family remember said, “She refuses. She said she would rather die than go to the emergency department right now because she does not want to get COVID.”

I kept telling her there’s different sections. If you’ve got a non-COVID respiratory complaint you’ll be fine. We can keep you separate and she refused, absolutely refused, and said she’d rather die. So those are the people that keep me up at night, because you kind of wonder how many other folks never even bother to call or check in or even say that they have these symptoms. How much EMS volume has gone down for 911 calls because people are just afraid. So I think the more we can do to get the message out that “If you have to call 911, if you have to go to the hospital we can keep you safe.” I think that’s going to be key.

Dr. Ali Raja:     Many of us are starting to plan our health system’s response after we start opening society back up, and one of the things that I and many others — including potentially you — are worried about is that we’ll see a surge in patients with delayed presentations or we’ll see more patients rebounding from non-COVID diseases, the diabetic that hasn’t been well managed for the past few months, the patient whose high blood pressure hasn’t been well taken care of because they didn’t take advantage of the telemedicine that you just talked about. What should we be doing now to prepare for a potential surge in patients with cardiovascular disease presentations coming in when we finally do open things back up?

Dr. Comilla Sasson:     I think that’s a great question. I think you might actually have a better answer than I do, but I think everyone’s vantage point is a little bit different. I think what’s been interesting to me is that we’ve been in a very reactionary mode I think for most…most of medicine has always been about sort of treating the condition. So we wait until you develop heart disease to really plug you into the system and take care of you. So I think hopefully we get back to the idea of prevention and hopefully we go out and actually start being proactive about people’s care. To me, that seems like that’s such an important piece that has always been missing because we’re always just trying to put out the latest fire rather than really thinking about there is a CHF patient right now who’s sitting at home who is probably on the verge of having an exacerbation and may be frightened to come into the hospital. So what are health systems really doing to think about those very vulnerable patients right now to say what can we do while you’re at home, while you’re in the middle of your shutdown? What can we do to make you better so that we don’t have those unintended consequences of the flood gates open on whatever day it is, April 26 in Colorado and all of a sudden all these patients who’ve been waiting to be let out because now all of a sudden they think it’s safe to be let out because we’ve said there’s no shutdown anymore.

We’re going to see all those patients and April 26 for the CHFer may be too late. So I think we have to be much more proactive, and I worry that we’re not as proactive as we could be about reaching out to those folks. We know who they are in our healthcare systems, right.

Joe Elia:     I want to thank you very much, Dr. Sasson, for talking with us today about this.

Dr. Comilla Sasson:     Thank you, guys, for having me. This is really important work, and I’m very fortunate to be part of the Heart Association in that we’ve always looked at the sort of great opportunity both to be within the professional sector but then also with the general public in trying to increase everybody’s knowledge and getting everybody on the same page. So I’m hopeful, again, that through all of this what we’re learning, we can actually work with all of our different partner organizations, especially in the community to get the message out that it’s okay. It’s okay to go to the emergency department. It’s okay to use healthcare. Just because you’re in a shutdown doesn’t mean that you need to ignore your health condition until you’re not in a shutdown, and I think we all need to work together to get that message out.

Joe Elia:     That was our 264th episode. All the previous episodes are searchable and available free at Podcasts.JWatch.org. We come to you from the NEJM Group. The executive producer is Kristin Kelley. I’m Joe Elia.

Dr. Ali Raja:     And I’m Ali Raja. Thanks for listening.

Apr 20 2020

14mins

Play

Podcast 263: Checking in with Connecticut and Michigan on medicine after COVID-19

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This week’s guests, Dr. Andre Sofair and Dr. William (“Rusty”) Chavey are physician-editors on the daily clinical news alert called Physician’s First Watch.

I went back through the recent issues and found this January 10 entry, which began “The CDC is requesting that clinicians ask their patients with severe respiratory disease about any travel to Wuhan City, China. That city has seen at least 59 cases of pneumonia caused by an unknown pathogen since December. Seven of the 59 are critically ill.”

How quaint that all seems now — so three months ago!

Both our guests are being kept busy by that mysterious pathogen, and I thought I’d check in with them.

Running time: 20 minutes

Other interviews in this series:

  1. Dr. Anthony Fauci
  2. Dr. Susan Sadoughi
  3. Dr. Matthew Young
  4. Dr. Julian Flores
  5. Dr. Kristi Koenig
  6. Dr. Renee Salas

TRANSCRIPT:

Joe Elia:     Welcome to Clinical Conversations. I’m your host, Joe Elia. This week’s guests, Andre Sofair and William Chavey are physician-editors on Physician’s First Watch, a daily clinical news alert. They are part of a larger group of clinicians collaborating with First Watch’s writers — people like me.

Dr. Sofair and Chavey have the unique task of looking back over the weeks’ stories and choosing the most important. Their choices and the reasons for them show up first thing in Saturday morning’s email edition. I went back through recent issues and found this January 10 entry, which began “The CDC is requesting that clinicians ask their patients with respiratory disease about any travel to Wuhan City, China. That city has seen at least 59 cases of pneumonia caused by an unknown pathogen since December. Seven of the 59 are critically ill.”

How quaint that all seems now. It’s so three months ago!

Both guests are now being kept quite busy by that mysterious pathogen and I thought I’d check in with them.

Dr. Sofair is a Professor of General Medicine at Yale Medical School where he also holds appointments in the School of Public Health, and Dr. Chavey is an Associate Professor and Service Chief in the Department of Family Medicine at the University of Michigan, Ann Arbor.

Welcome to Clinical Conversations, my friends.

Dr. William Chavey:     Thank you for having us, Joe.

Dr. Andre Sofair:     Thanks for having us.

Joe Elia:     Dr. Sofair, you’re in New Haven, so what are you seeing on the ground there? Connecticut’s cases have more than tripled since the beginning of April and now hover around 13,500. The universities have emptied of students, but what’s the atmosphere on the wards?

Dr. Andre Sofair:     I would say that the atmosphere is quite positive. Our hospital and medical school have done a really good job, I think, in terms of communicating the situation with all of the frontline providers — nurses, clinical techs, the physicians — and I think we have a very good supply of personal protective equipment, which has been critical. And I think that we started our planning process very early on before we started seeing cases, so I think that the frontline staff feels supported and I think that the atmosphere is as good as one would expect. given the circumstances.

Joe Elia:     And Dr. Chavey, you’re just west of Detroit, of all places, in Wayne County, and that’s a hotspot. Ann Arbor must also be pretty quiet with the students gone, but you’re in family medicine there, and that’s an area with lots of closed businesses because of the national quarantine that we’re in. What feels unique about this experience to you?

Dr. William Chavey:     Well. We could probably talk for hours on that, Joe. I think the first most unusual thing for us was the contraction of ambulatory services, so we went from having seven clinic sites to contracting them down to two. Scrubbing schedules and moving everything that was not urgent, either to be deferred for later or to be done by telemedicine, and as this happened everywhere the escalation of telemedicine has been remarkable and dramatic over such a short period of time once the barriers were removed. In juxtaposition with that, we are also active at the University of Michigan Hospital, so we were preparing for what we thought was going to be a surge of historic proportions at the hospital. I was on a planning committee for a field hospital and we were looking at having 1500-bed field hospital. At this point, we’re not planning to have a field hospital at all. We are going to obviously record the efforts that we put in place in case we have to do that at some point, but the social distancing has helped quite a bit.

Our numbers are relatively flat. We are now living in an eerie world where we have a hospital that’s typically about 95 to 98% at capacity, and by cancelling all of the elective surgeries and so forth we now have a hospital that’s at about 65% capacity, and an ER that is seeing patients at a much lower rate than expected. And no one really knows what’s happening with the strokes, and the heart attacks, and the trauma that were coming in before, because they’re not coming in now. And the other interesting phenomenon — because in family medicine we also do obstetrics — a very unexpected phenomenon has evolved there where, when women come in, the thought now is that during part of labor that is an aspect where healthcare professionals might be a particular risk from aerosolizing the virus, and so there have been some studies looking at what percent of pregnant women, when they present to labor and delivery, are positive even if asymptomatic, and those numbers are somewhere between the mid-teens and 30%, so there are some protocols where they were screening every woman who would come in.

Well. The interesting part is a lot of women were declining that, because if they get tested their husband may not be able to come in with them and they don’t want to labor alone. So you now have this odd tension between wanting to protect the healthcare professionals who want to know if a woman is positive and a woman not wanting to be tested because she would then have to labor alone. So from the family medicine perspective we have all of these different areas, all of which have very unique, very unexpected tensions and things that have evolved.

Joe Elia:     So, how are you navigating that, Rusty? How are some of those conflicts resolved?

Dr. William Chavey:     Well. I’ve described a lot of what people are seeing in the literature as “science, thinking out loud,” and I think what we’re also seeing is “medicine responding out loud.” Each of these is unique and idiotypic in its own way and something that we had…I mean, no one ever was anticipating this dynamic in labor and delivery, so the obvious question is how do you handle a woman who refuses to be tested, and how do you protect the healthcare personnel? This is a dynamic we had never considered before.

Joe Elia:     Andre, you’ve spent time in Rwanda setting up medical education facilities and other places, too. Do developing countries have lessons for the first world about how to behave during a pandemic?

Dr. Andre Sofair:     I’m sure that they do. You know, they have different pandemics. For instance, I was recently in Rwanda and they had an outbreak of dengue, the first significant outbreak that they’ve had in years, and so they’re able to mobilize things and do things in the hospital much faster than we’re able to, I think, because the hospitals tend to be smaller and the bureaucracy tends to be not as robust as ours, so I saw them mobilize the units and set up bed nets at the hospital very, very quickly for in-patients to try and prevent nosocomial transmission of dengue, for instance. They also have a lot of experience with the use of personal protective equipment that we don’t have as much, and as especially masking. For instance, they have a lot of tuberculosis and other infectious diseases that we don’t have here, so there are certainly things that they teach us that we can learn from them.

Joe Elia:     Now, in both places, Connecticut and Michigan, are visitors allowed into the hospital? I’m reading reports that for instance at Mass. General everybody’s got to be wearing a mask when they go into the hospital, whether you’re a visitor, or patient, physician. Is that true now, pretty generally?

Dr. Andre Sofair:     At our hospital, everybody is to wear a mask, healthcare providers, when they come into the hospital and wear it throughout the day. Those are typically surgical masks, the N95 masks are reserved really for people that are taking care of COVID-positive patients, or patients that are being evaluated for the possibility of COVID. We have a very strict visitor restriction policy at our hospital where visitors are only allowed to visit if people are dying or on hospice.

Dr. William Chavey:     And we’ve had the same, and we also see this in the ambulatory setting. We’re not allowing people to accompany patients when they are physically seen in the office unless it’s a young child or someone needing assistance in a wheelchair. Something of that sort.

Joe Elia:     Okay.

Dr. Andre Sofair:     I can say, Joe, just to add to that, it has made the stay for the patients very difficult, as you can imagine. They’re communicating with family and loved ones over the telephone. Physicians are doing the same, and it’s also very difficult to the family because of the fact that they don’t have the daily updates in person with their loved ones in the hospital, so it’s made the care of patients very challenging, I would say.

Joe Elia:     So, questions for the both of you. What do you fear will happen as a result of COVID-19.

Dr. William Chavey:     I think right now here is a great deal of uncertainty and health systems, private medical offices and clinicians about what the future holds, and I think one thing that is clear as we emerge is that the post-pandemic world will not resemble the pre-COVID world, and I think…and if it is I think that’s a shame. I think we need…I think one fear or concern I would have is that we pretend all of this is going to go away and things are going to operate the way they used to, and I hope and think that’s probably not going to be the case, but none of us really know, and I think we’ve had to realize that we’re not in control. None of us really know what that post-pandemic world is going to look like. There are health systems that are beginning to lay off staff and faculty and are cutting salaries. There’s concern that we will never have the same volume of patients, or in the same nature that we had before, and I think a lot of people are struggling to figure out what their role is going to be in this post-pandemic world.

Dr. Andre Sofair:     Yeah, I would agree with what Rusty said. I think there are too many unknowns at this point, in terms of how long it will last, what kind of immunity, and what kind of herd immunity, if any, we’ll have. What kind of vaccines, if any, will be available, and whether or not they’re effective in terms of preventing [spread in] the population, so I think there are a lot of unknowns.

But I do think that there will be some changes in the way medicine is practiced. I think that there will probably be more telemedicine than there was before. I think that our rounding procedures will probably be different. I think that our use of personal protective equipment will be different. I think that our attending of medical conferences, whether locally, nationally, or internationally will be different. I think there will be a lot of reliance on communication that is at a distance, as opposed to in-person. I do also share the question and concern about what will happen with out-patient practices because a lot of out-patient practices now have had to close because of lack of patients, and will they be able to reopen in the future because of staff having been laid off and maybe going to other types of work, so I think it’s still very unknown, but those are the changes that, at least, I see in the future.

Dr. William Chavey:     So, Joe, in response to what Andre said there was a…there’s a policy arm of the American Academy of Family Physicians, the Graham Center, and they published data that by June 60,000 family medicine offices would be either closed or would significantly cut back, and this would impact 800,000 employees of these offices, so this could be an existential threat to private practice in that regard, and as Andre said, will they come back online, will they be able to? If they don’t what will happen with the patients who have been going to those practices and can the hospital-based practices, absorb those patients when all of this is said and done.

Joe Elia:     It must be different to prepare yourself for the clinical day in these times. Is there something that…has your routine changed as you get up in the morning and you’re about to go in? Do you recall something that a favorite professor of medicine told you as a young resident, or is there anything different about it?

Dr. Andre Sofair:     I would say for me the major change is how I have led my life at home, so for instance for the past month I’ve been living in the basement and on a different floor from my family, and I’m eating my meals separately. I’m always, or at least try to be, six feet away, and the most notable thing for me is where I have my clothes, how I put them on in the morning, and then when I come back home how I take them off and how I try to make myself as clean as possible so I don’t run the risk of bringing anything home to my family, so that’s been a major change for me.

Dr. William Chavey:     I guess one report from the ambulatory setting yesterday, I think my first four patients were all done in different ways, and we have…we’re doing some drive-by or drive-thru testing so we’re seeing some patients. We walk out to the car…we put our personal protective equipment on and go to the car, and we’ll do sampling there, check blood pressures, do what we need to do with them in the car, and one of my patients was done via that approach. We have divided the clinic into two halves, one clean side, if you will, and one where patients who might have some sort of infectious symptoms come, and so I had to go on one side to see one of the other patients. Another patient was just via phone call and another patient was telemedicine, and so instead of getting into a groove I’m seeing patients in all of these different manners and having to adjust, and take off one coat and put on another coat and go into one office where I have a computer to do the telemedicine, and you don’t…the comfort level that you had, that you developed over the years gets lost because you’re in very unusual situations.

Joe Elia:     Yeah. What advice would you give to a young clinician just starting out in the middle of all of this?

Dr. Andre Sofair:     When I was in medical school, I went to medical school in the Bronx at Albert Einstein, and that was the very beginning of the HIV epidemic, and so people were very unsure about how it was transmitted, what you had to wear to go into the room, and I think that there are a lot of analogies to the way that we responded then and the way that we respond now. And I really think that medicine is still a wonderful profession, whether you’re starting now where there’s a lot of insecurity about where we’ll be in the future, but I think that the calling is still the same. We’re there to collaborate with one another, to do our best together, to take care of suffering patients and families that are afraid, and so I still think it’s a very exciting time to be in medicine, and it’s interesting that some of the house officers that are on our unit said that they’ve spoken with some of their young colleagues who are not in medicine now and wish that they were.

Dr. William Chavey:     I think if you buy someone a gift you can either buy them something you would like or you can buy something they would like, and certainly the latter would be the preferred. Medicine is still, at its core, a vocation of service. And I think the advice I would give is, don’t go into it with your own perspective, your own sense of what it ought to be. If this has taught us anything it’s that we have to be flexible, and if you’re going to be giving the gift of service to a patient it has to be what they need in that environment, and that environment may change, and you may have to put aside your own sense of how you might want to do it in order to be prepared to serve.

Dr. Andre Sofair:     You know, the one thing that has struck me about…at least at our hospital, the way things have gone, and it’s been very comforting to me, is just the preparation on the part of the medical school and also of the hospital. Our hospital had a lot of foresight and started the preparations a couple of weeks before we started seeing our first cases, and we’ve been going at this now for about six weeks, and we have daily calls with our chief of our department of medicine and lots of leaders in the department to brainstorm, to get information out. Nursing has the same thing. The hospital leadership has the same thing, and I think that that planning processes has given people a lot of comfort and has allowed us not only to take care of each other but also to take the best care that we can of our patients. We have teams of physicians and researchers that are working on protocols to make sure that we’re delivering the best medicine that we can, given the lack of evidence.

We have teams that are working on recycling the PPE to make sure that we have adequate PPE that’s safe for us to use, and all of that gets disseminated on a daily basis out to the hospital and to the workers, and so I think that it has been the best situation possible given the circumstances.

The other thing that I just wanted to say — that has really touched me — is the bravery of all of the staff. We have residents that are in pathology, that are in psychiatry, that are in dermatology, that are in neurology that have volunteered to help out on the medical service to take care of patients, and we’ve had attending physicians from all of those levels that have also pitched in to help out. The anesthesiologists have been very helpful, for instance, in our ICUs to helping out the critical care attendings that have been strapped because of all of the patients that have needed care, and there’s been just an extraordinary amount of collaboration between the physician staff, the nursing staff. And the nursing staff have also stepped up. We have nurses that have not worked in an ICU for years that are now working in an intensive care unit, taking care of very sick patients, COVID-positive patients and non-COVID positive patients just to pitch in, so that has been the greatest memory and experience that I’ve had through this whole epidemic.

Joe Elia:     I want to thank you, Dr. William Chavey and Dr. Andre Sofair, for spending time with us today and sharing the wisdom of your experience with COVID-19.

Dr. Andre Sofair:     Thank you, Joe.

Dr. William Chavey:     Thank you, Joe. Thanks, Andre.

Dr. Andre Sofair:     Thanks, Rusty.

Joe Elia:     That was our 263rd episode. All of the previous episodes are searchable and available free at podcasts.jwatch.org. We come to you from the NEJM group. The executive producer is Kristin Kelly. I’m Joe Elia. Thanks for listening.

Apr 15 2020

20mins

Play

Podcast 257: Here comes the summer after COVID-19

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Four weeks ago — in early March — I interviewed Dr. Renee Salas about climate change and clinical medicine.

Back in those halcyon days, COVID-19 was very much a gathering storm, but it had not yet slammed into the United States.

Here we are, over 10,000 U.S. deaths later in early April, not having heard of much else but the disease.

I thought to use this interview now, both to give listeners a small break from “The Virus” — as President Donald Trump refers to it — and to remind us how quickly things can change on the planet.

We make mention during the course of the interview of the need to take the lessons from unanticipated disasters. We can only hope that the lessons the present crisis affords us won’t be lost.

Links:

Dr. Salas’ Perspective article in NEJM

Dr. Salas’ earlier NEJM editorial, written with Drs. Malina and Solomon, on “Prioritizing Health in a Changing Climate”

Harvard’s Global Health Institute

Running time: 18 minutes

TRANSCRIPT OF THE INTERVIEW WITH DR. SALAS

Joe Elia: This is Joe Elia. We’ve just turned the clocks forward here in the US and so summer is looming after a warm winter for Boston. If the past serves as a guide, we’ll have a warm summer, warmer than usual. Sleeping will get tougher, ticks will show up on our ankles, water will beckon us. Clinicians will work in comfortably air-conditioned suites, but their patients will often not be as lucky. Rene Salas reminds you all in a recent NEJM Perspective that hyperthermia is just around the seasonal corner. Our friends in the Southern Hemisphere have just had a horrible summer. Australia’s was unprecedented with an average temperature exceeding 30 Celsius or 86 Fahrenheit. We’ll talk about such things with Dr. Salas, who is a fellow at the Center for Climate Health and the Global Environment at the Harvard School of Public Health. She’s also in the Department of Emergency Medicine at Mass General Hospital and Harvard Medical School.

Welcome to Clinical Conversations, Dr. Salas.

Dr. Salas: Thank you so much for having me. I’m excited to be here.

Joe Elia: It used to be that summer was the time for bug spray and sunscreen. Everything’s changed, hasn’t it?

Dr. Salas: Yes. I think that there has been this growing recognition that climate change is not only happening in the world around us but it’s also impacting us as humans and it’s impacting our health. As this recognition has grown, there has been a goal to increasingly connect it to what we do every day to our clinical practice.

Joe Elia: Your recent perspective article in the New England Journal of Medicine gives a useful table for various healthcare demands, starting with EMTs who are bringing overheated patients to the ER, all the way out to the management types who need to prepare for what they can’t predict yet. Can you talk a bit about that?

Dr. Salas: So we know that there are associations across a broad range of climate exposure. So that ranges from heat to rising pollen levels, wildfire smoke, infectious diseases as you noted in the introduction, changes in water quality, and the intensification of extreme weather, but I think that the recognition is that all of these have very practical implications no matter what your role is in the healthcare system. So there’s a case that I outline about a man who was brought into the hospital because he was confused, but we were in the middle of a record-breaking heatwave, and his wife had called 911 and the EMT said that when they opened the door that it was like they were being hit by the Sahara Desert heat.

They lived on the top floor of lower-income housing and they had no air conditioner. They only had one window that was partially cracked, and so I think that that shows that EMTs are on the front lines, and I think as medicine is increasingly embracing and trying to expand community paramedicine, recognizing that they are my extensions from the emergency department out in the community and so how can we use them to educate patients about the risk of heat, counsel patients on what to do if they lose power, even if they normally have air conditioning.

The National Climate Assessment put out by the federal government has shown that they anticipate that the intensification of extreme weather and extreme heat are going to amplify and intensify the power outages. We actually had one right down the street, in fact, a power outage at Mount Auburn Hospital. That actually caused them to have to bring patients down from the top floor of the hospital because it was getting so warm because the backup generators don’t actually supply cooling to all areas. Even when the power was restored actually a lot of the equipment was so hot that it couldn’t function so they had delayed ability to be able to resume their normal functions because they had to wait for technology to cool down and this was in Greater Boston in 2019.

Joe Elia: Pretty interesting. So, as we were saying before, there were things that administrators must prepare for that they can’t imagine yet. I guess the only way to imagine it is to experience it and say, “Oh, damn, we should have done it this other way!” I mean of course we could be jocular about it now but when it happens — boy, oh, boy. For instance (and I guess you can’t talk about anything including candy bars without mentioning coronavirus these days). What do you think? Do you see any connection at all between global warming, climate change, and this kind of spread of infection? Is that at all on your radar, or is it a strong signal?

Dr. Salas: Yeah. It’s a great question. I mean we know that vector-borne diseases, so diseases transmitted by mosquitoes and ticks, that those have been on the rise. So not only longer seasons but moving to new geographic regions, which makes it hard for clinicians because now suddenly they’re facing patients who come in potentially with infectious diseases that they haven’t been used to seeing. Lyme disease can present in a multitude of areas and one that has really been expanding, here in the Northeast. So every rash to me in the emergency department has to potentially be Lyme, but I think that that shows that we really need to have a dynamic education curriculum and work closely with our public health colleagues in order to ensure that we can stay up to date on emerging infections and also make sure that we can educate our clinicians on those signs and symptoms of diseases that they aren’t used to seeing.

There’s always this issue, right, that we face these situations and research, because of the sound scientific practice it has to go through is delayed. I have to admit, I feel that climate change is truly that meta-problem and that threat-multiplier. So I believe it connects to everything in some way, whether directly, indirectly or even if it’s minimal effects. So my concern is that climate crisis may be fueling coronavirus in some way, but we don’t know yet. It’s too early. I think that it just shows that there’s so much research that needs to be done because we can’t prepare for what we don’t understand.

Joe Elia: Yeah. So back to those poor administrators who are going to be held to account when things go wrong: Is it really possible, do you think, to have drills about power failure? I’ve noted before that the [Boston] Marathon bombings were made a bit less chaotic because Boston hospitals had practiced, and many cities do practice now for mass casualty events. How does an institution practice for a calamity like power failure?

Dr. Salas: Yeah. So this is interesting and I think I really want to promote that that table [in the NEJM Perspective] was more of a thought exercise, where I was hoping to take the reader with me in thinking through different things that we can potentially implement to help prepare us as clinicians for what the climate crisis has brought and will bring. I think we always are better served if we are as prepared as we can be for situations. I think recognizing that power outages create a limited-resource environment in a normally well-resourced hospital. Again, everything from cooling not being in every area and maybe perhaps limited imaging and all of these unintended and unforeseen consequences that if a hospital has already gone through that and knows exactly what to do when a power outage occurs then inevitably I’d like to believe that we would then be better prepared when we actually face that.

You always have to weigh kind of the number of drills versus the benefits and so kind of rely on my disaster preparedness expert colleagues to end up making that decision but it is something to think about.

Joe Elia: Speaking of that, if that happened at Mount Auburn — and it did — how efficiently are the lessons of that disseminated to the other hospitals in the region? Are you aware of any formal way that a hospital having undergone such a calamity is able to share that?

Dr. Salas: Yeah. It’s a great question, and I think one that I know myself and my colleagues and others are thinking about is how can we share these best practices? Even when you think about heat, for example, and the fact that certain areas of the country and even the world have been facing extreme temperatures that are extreme for areas like here in the Northeast but have been facing hotter temperatures and know how to operate in that environment so we can learn from them. But you bring up a good point that when something like this happens like the power failure at Mount Auburn that that isn’t currently disseminated. In fact, when I talk about it even to people in Boston, many people didn’t know that it happened.

Leadership, again, may be aware but again just creating this sense of dissemination of experience is enormously powerful so we can learn from one another. I always come back to my emergency medicine roots and think about when a patient is crashing in front of us and we save them that it’s not saved by one person — it’s a collective team that saves that patient. Everything from environmental services that cleaned the room to the pharmacist to the nurse to the doctor to everyone. I think I recognize that this climate crisis needs to collectively bring the medical community together, across all sectors and disciplines to learn from one another. I think we’re stronger together and that’s part of why we are building this climate crisis in clinical practice initiative where we’re actually going to have symposiums similar to the one that we actually held in Boston on February 13 in different regions around the US at flagship sites and even internationally.

We currently are going to hold one in Australia. The goal of that is to come up with a group of us that have different geographic experiences, are exposed to different climate change exposure pathways, and to build an initiative where we can get some expert consensus and ways to share best practices.

Joe Elia: Here’s a question, what do you say to people who are skeptical about the role of climate change in clinical medicine?

Dr. Salas: It is enormously hard to scroll through your newsfeed, since most of us nowadays digest our news through a phone or some tablet of sorts without seeing that there are new things that people are experiencing in the environment around us. I think personally the science is very clear that the climate change is happening, that it’s human caused, and we have solutions. Nothing is harder for me than having a patient in front of me where I don’t have a treatment. Thankfully, here we have the ultimate treatment and the ultimate prevention, which is a decrease in our production of greenhouse gases. But I think recognizing that if we want to try to minimize the human suffering that is already happening, especially for vulnerable populations, but recognizing that we also have to simultaneously adapt not only our public health infrastructure but our clinical practice. While some of the implications of the climate crisis are clearer than others now, I think there are these insidious changes that we have to recognize. If we want to put the health of patients first in order to deliver the best patient care that we can, we have to add a climate lens to it because historically we’ve always been able to look backwards and try to predict the future based off the past, but that’s no longer possible.

The climate crisis is creating this uncharted future, and we have to prepare and prepare now and work together to do that.

Joe Elia: I wanted to ask you how you got interested in this whole question of the clinical implications of climate change and global warming.

Dr. Salas: I learned about climate change and its impact on health about six-and-a-half years ago, and it was fascinating because I had not heard about it at all during medical school or residency. For me, it was really an epiphany moment where I recognized that I could not imagine focusing my career on anything else because I couldn’t imagine anything else impacting my ability as a doctor to protect the health of my patients and to do my job than climate change. So it really started me on a path that has put me on the course that I’m currently on. For me, you can call it a job hazard of spending all of my time outside of the emergency department focusing on climate change, but I increasingly began to see that it was harming my patients, again sometimes in small ways, sometimes in larger ways, but I quickly saw that there was a need to add a climate lens to what I did in my practice, and I think increasingly as I had more conversations with others recognized that we needed to have a larger conversation to really adapt our clinical practice in the era of climate change, which has led to the initiative that I spoke about.

Joe Elia: As a result of your efforts, Dr. Salas, what do you hope will happen?

Dr. Salas: I think first and foremost we need to recognize that the health sector and the voices of health professionals is the most trusted messenger to connect climate change and health. I think one thing that at least I personally believe is why we haven’t had as much action on climate change and engagement up to this point is that it hasn’t been personal. We have had visions of icebergs and polar bears. Trust me, I love polar bears but it’s really about our children. It’s about our aging parents, who are enormously vulnerable, our less fortunate neighbors, and if that’s not enough to motivate you then it’s about yourself because climate change is harming your health in some way, again, however small, however large.

So the recognition of making these connections and talking about climate change as a public health threat — and I would argue as something that is changing our clinical practice — is first and foremost what we need to do as a medical community. So the ultimate end goal of that, as we engage in this conversation is that we need to talk about the fact that climate action is actually action to improve health. I would say that the Paris Agreement is the world’s greatest public health pact. So recognizing and connecting these things:

That not only are there short-term benefits of reducing particulate matter from the combustion of fossil fuels (which we know will improve health, but also the driver of climate change and thus will decrease, again, the human suffering that we will experience both now and in the future) is really important and encouraging our transfer to renewable energy sources.

Then I think the second half of that is adapting. So ensuring that we can adapt our public health practice and our clinical practice to continue to provide the best care to our patients and our communities when they need it most.

Joe Elia: All right. Well, I want to thank you very much for talking with me today, Dr. Salas.

Dr. Salas: Oh, it was a pleasure. Thank you so much for having me and for lighting this topic.

Joe Elia: That as our 257th episode. The whole collection is searchable and available free at Podcasts.JWatch.org. Clinical Conversations is a production of the NEJM Group and we come to you from NEJM Journal Watch. The executive producer is Kristin Kelly. I’m Joe Elia. Thanks for listening.

Apr 06 2020

17mins

Play

Podcast 262: COVID-19’s larger lessons

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We talk with Colleen Farrell who’s doing her third year of an internal medicine residency in New York City.

Fortunately, we caught her during a one-week vacation (she was supposed to be taking two), and she chatted with us about how she and her colleagues are coping.

We asked her what she thought COVID-19’s larger lessons would be, and she gave an interesting, impassioned answer.

Running time: 12 minutes

Other interviews in this series on COVID-19:

  1. Dr. Anthony Fauci
  2. Dr. Susan Sadoughi
  3. Dr. Matthew Young
  4. Dr. Julian Flores
  5. Dr. Kristi Koenig

Joe Elia:

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

We’ve come to New York City this time, at least electronically, to talk with Colleen Farrell.

Dr. Farrell is a third-year resident in internal medicine at NYU in Bellevue Hospital. This July, she starts a pulmonary and critical care fellowship at New York Presbyterian-Cornell. I became aware of Dr. Farrell when a classmate of hers sent along a posting she’d made on social media. It read, in part, “I feel grateful that I am able to put my training to public service. I don’t do well being cooped up at home. I became a doctor to do this work, but I would be lying if I said I wasn’t scared. I am calm and committed but also deeply, deeply terrified.”

Welcome to Clinical Conversations, Dr. Farrell.

Dr. Farrell:

Thank you. Thank you for having me, Joe.

Joe Elia:

So there you are in New York City. How are you and your colleagues doing? Are you getting enough time away from the clinic to get sleep and get food?

Dr. Farrell:

Yeah. So I would say that the experience varies widely from week to week. So in this situation right now in the midst of the COVID pandemic it seems — like for everyone — you’re either fully on or totally off at home. So you’re catching me in one of those off periods. About two weeks ago, I started taking care of coronavirus patients at Bellevue. When you’re doing that work, the shifts are long and really tiring. Our whole residency schedule has been kind of recreated to meet the staffing needs of this crisis but built into that is some time off.

So right now, I was still due for a two-week vacation towards the end of this year, and so right now I’m getting one week of that. So I’m in this weird place of getting rest right now and knowing that I’m jumping back into it in just a few days.

Joe Elia:

Well you mentioned in that posting that I quoted from, you mentioned a patient. I wonder how that patient fared. Do you know?

Dr. Farrell:

Last I checked he was still in the ICU. He was intubated and requiring dialysis. Yeah. So this is actually the first coronavirus patient I met, and when I met him I was really worried about him. He was still breathing on his own but requiring a lot of oxygen. So it was the middle of the night. I called one of our ICU doctors and he was moved to the ICU where he still is. We’re seeing that with a lot of our patients, that when they get to the ICU it looks like it’s a pretty long course for a lot of them. It’s not needing to be intubated for a few days and quickly extubated, but it’s a long course with a lot of uncertainty. So I keep kind of checking in, hoping that he’ll get better, but it’s going to take time, I think, to see.

Joe Elia:

Yes. Let’s hope that he does get better. How are you keeping up with policy? Have you joined any of the private chat groups like the one described by Dr. Julian Flores during his interview here?

Dr. Farrell:

Yes. Right now, we’re dealing with so much information. So I’m getting information from several places. First of all, I think — especially in my role as a resident physician — decisions I make are about the patients I’m directly caring for, or managing my own team, and so it’s hyperlocal. So first I have to pay attention to the policies from my institution. We get multiple emails a day and like a lot of residents I’m not employed by just one. Well, I’m employed by an academic medical center, but I rotate at NYU Langone, Bellevue Hospital, and the VA. So those are three completely different hospital systems. They’re three different hospitals, for one, but they’re also a private hospital, a public hospital, and a federal hospital.

So just to do your job you have to keep track of those policies. So we have a lot of internal communication with documents: “This is the latest of the PPE standard. This is how long you have to be out of work if you have symptoms. This is when a patient is allowed to move to this place or that place.” Those are the policies I pay the closest attention to. Then I would say while I’ve been home this week on my “vacation” I’ve been tuning into New York Governor Cuomo’s updates and those actually help me understand kind of even what I’m seeing sometimes at the hospital.

He’s been talking about [transferring] patients from some hospitals in New York City to others to even-out the load, and that helps me understand [that] when I’m at work I might be getting transfers from other hospitals and understanding why that is. Then in terms of more informal mechanisms, I’m pretty active on Twitter. I get a lot of updates there from people on the frontlines and then I’ve also been reconnecting with colleagues from medical school that I haven’t been in touch with for years. My Harvard Medical School class Facebook group — I don’t think anyone touched it for three or four years but all of a sudden people are connecting on there, talking about what’s going on in their hospitals and just sending support to each other. We’re all thinking of each other and kind of reading what’s going on in different parts of the country.

Joe Elia:

Tell us a bit about your social media posts. Are you looking at maybe a career as a writer?

Dr. Farrell:

Yeah. I’ve loved writing at least since college and have been writing about social and ethical aspects of medicine since I was an undergrad 10 years ago and I was writing about the early years of the AIDS epidemic in the US. At that time, I was reading Atul Gawande and found his books captivating as so many do. I kind of even realized at that time that I wanted to do the kind of writing in medicine that spoke to audiences beyond the doctors and scientists in a hospital.

So then in medical school I was really closely mentored by Dr. Suzanne Covin, who’s the writer-in-residence at Mass. General Hospital, and she’s been a tremendous role model to me. I use writing as a way of both processing my own experiences and kind of sharing with a broader medical community — and more society at large — some of the social and cultural aspects of medicine. So sometimes that’s through essays that I publish but I actually really like using Twitter and sometimes Facebook as a way to send off little missives. I like that they’re informal. They feel real and authentic. They’re not filtered through an editor or someone else. It can be a really cool way to connect with people and it’s writing. Any time you’re using words you’re learning how to write.

Joe Elia:

Yes. I know those editors do get in the way…

Dr. Farrell:

I’m grateful for editors but sometimes it’s paralyzing knowing that you’re going to be scrutinized.

Joe Elia:

Sometimes they help… So you’re on vacation this week. Are you reading or binge-watching?

Dr. Farrell:

I mean it’s a very weird vacation. I’m just staying inside my apartment. My husband is home. He is a third-year NYU law student and is doing law school remotely this week. We’re watching movies. We take turns who picks the movie each night. So we watched Alien. We watched How to Survive a Plague, a really great documentary about the early years of AIDS and then we watched Indiana Jones. So we’ll see what we pick tonight.

Joe Elia:

Those are all consonant with your current experience…

Dr. Farrell:

And writing. That’s the other thing. Right now, it’s nice to have some time. I’m doing some writing about my experience in the ICU last week and also doing some writing reflecting on…I mentioned I wrote my senior thesis in college on the early years of the AIDS epidemic. I’ve been thinking about what I learned doing that historical research then and what lessons I might be able to take from it now. So it’s nice to have some time to think and marinate a little bit before I jump back in.

Joe Elia:

I want you to project yourself forward in time a bit. When this pandemic ends and you’re training other young clinicians, say 20 years from now, what will you tell them was COVID-19’s most important lesson?

Dr. Farrell:

Well, I think it’s a lesson about health inequities and existing injustices in healthcare. I think that we are seeing right now that the health of one person affects the health of the entire society and that health cannot be treated as a commodity only available to those who can afford it. It needs to be treated as a human right. Right now we’re hearing politicians say no one should be denied a COVID test or COVID treatment because of their ability to pay, well I agree with that, but why shouldn’t that be the case for cancer or diabetes or anything else? I think we’re going to see more that this pandemic doesn’t affect all communities — even within the US — equally. It is ravaging Rikers Island right now, where we have mass incarceration.

When I call families and update them on their sick family member it’s totally different if they have a big apartment where they can separate within the apartment from those who have symptoms and those who don’t. But when you talk to a big family in crowded city housing they don’t have those possibilities. When government support doesn’t include undocumented immigrants you have a huge health justice issue on your hands. So I think that one of the biggest lessons from this time is to say that the social safety net and healthcare for all is not optional. It’s not a luxury. It’s a foundation of a functional society that has any degree of concern for the people within it. I think that we have been existing in a healthcare structure that is grossly unequal and oftentimes prioritizes profits over people, and I think that this pandemic is going to lay that bare for our whole society to see.

I hope that in 20 years I will be able to say maybe this is the last straw that helped our society change and provide healthcare to everyone. I hope that’s the story rather than we continue on or we return to the status quo after this ends.

Joe Elia:

Well, Dr. Farrell, I want to thank you for speaking with me today and I hope you’ll come back in 20 years and we’ll review that together.

Dr. Farrell:

That would be lovely. Thank you so much.

Joe Elia:

That was our 262nd episode. All the others live at Podcasts.JWatch.org. We come to you from Physician’s First Watch and NEJM Journal Watch — members of the NEJM Group. The executive producer here is Kristin Kelley, and I’m Joe Elia. Thank you for listening — and wear your masks and wash your hands.

Apr 01 2020

12mins

Play

Podcast 261: COVID-19 as a medical disaster

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San Diego County has Dr. Kristi Koenig as medical director of its emergency medical services. That’s fortunate for the county, because she’s co-edited a definitive textbook, “Koenig and Schultz’s Disaster Medicine: Comprehensive principles and practices.”

We’re fortunate to have her as our guest. She’s full of sound advice on organizing a community’s response (for example, setting up “incident command” structures) and evaluating patients as new threats emerge (the well-known “three-I’s” approach — Identify, Isolate, and Inform).

With the number of COVID-19 cases rising quickly there in San Diego, she’s been busy (as have all of you).

Running time: 19 minutes

Links:

Interview from 2016 with Koenig and Schultz on the second edition of their “Disaster Medicine”

Koenig, Bey, and McDonald’s article on applying the 3-i tool to novel coronavirus in Western Journal of Emergency Medicine (Jan 31 online)

Other interviews in this series on COVID-19:

  1. Dr. Anthony Fauci
  2. Dr. Susan Sadoughi
  3. Dr. Matthew Young
  4. Dr. Julian Flores

TRANSCRIPT OF THE CONVERSATION WITH DR. KRISTI KOENIG:

Joe Elia:

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

Dr. Kristi Koenig is Medical Director for Emergency Medical Services in the county of San Diego, which as of this afternoon, Saturday March 28, had about 420 confirmed COVID-19 cases with six deaths.

The county is lucky to have her, if I may say so, because she’s co-edited a definitive textbook on disaster medicine, and arguably the novel coronavirus epidemic qualifies for entry into that club.

Dr. Koenig is Professor Emeritus of Emergency Medicine and Public Health at the University of California Irvine, School of Medicine, and she was also, I should say, a long-time contributor to NEJM Journal Watch Emergency Medicine.

Welcome to Clinical Conversations, Dr. Koenig.

Dr. Kristi Koenig:

Thank you very much for having me.

Joe Elia:

What are you seeing there in San Diego?

Dr. Kristi Koenig:

Well, we are very concerned in San Diego, as is the rest of the country, and we’re taking a three-pronged approach on the ground in San Diego. Number one is to flatten the epidemic curve. Number two is to increase surge capacity for our healthcare system, and number three is to focus on using an incident command system to coordinate all of our needs and resources, and I can explain each of those in more detail if you’d like.

Joe Elia:

I recognize that, from having looked at your textbook a few years back, so go ahead.

Dr. Kristi Koenig:

In San Diego, we were very early to implement what’s called NPI, non-pharmaceutical interventions, to try to spread out the diseases over time so that we don’t have as a great a chance of hitting a peak number of diseases early on, which could exceed our healthcare capacity.

This so-called flattening of the epi curve, I’m sure people have seen. Even on the news people are getting educated in epidemiology these days.

The idea with that is we won’t necessarily decrease the total number of patients but if we can spread patients out over time we can potentially continue to care for everybody in our healthcare system. This is not only the COVID patients. This is also our regular emergencies.

We know that emergency departments are crowded on a day to day basis. So by using these interventions, which are called things like social distancing (although it’s not really social distancing it’s more physical distancing) we still can keep in contact with people. Other types of interventions to try to prevent the rapid spread of the disease, we can make a huge difference. It’s complicated because we may not see the effects for a week, two weeks, or even more because there are already people in our communities who are incubating the disease that have not had symptoms yet or not. Some people never have symptoms but who have not presented yet to our healthcare system.

The second thing would be for surge capacity, and we’ve developed a concept about 20 years ago along with my colleague, Major General Donna Barbish, for the 3-S concept of surge capacity, which is stuff, staff, and structure. We find it very helpful to organize everything around stuff, staff, and structure, and I can explain that in more detail if you’d like.

Joe Elia:

Yes. I would guess that the “stuff” is going to include things like masks.

Dr. Kristi Koenig:

Absolutely and ventilators and N95 respirators and surgical masks and other types of PPE (personal protective equipment) are very important in an epidemic of this nature. One of the challenges is that the news media and the politicians love to count stuff. You can see it. You can show it on TV. You can touch it. You can count it but one of my famous lines is “Ventilators don’t take care of patients.” Stuff is important but it’s not sufficient. While we do need, certainly, to protect our healthcare workers on the front lines and to have things like ventilators to care for patients in this setting, the stuff component of the 3-S is not enough.

So we also need the staff, which is all of us, the people, and we do know that some people unfortunately will get sick and even die and some people will not be able to come to work because they may be caring for a relative or other reasons. So we have to account for probably maybe perhaps 30 percent of people will not be able to come to work or not be willing to come to work. We also need specialists in the staff. So it’s not just the total number but we need people with specialized expertise. For example, infectious disease specialists, critical care specialists.

Then the third component is the structure and that is the physical location where we care for patients. What we’re seeing now is we’re being very innovative and I think actually this is going to help us after we get through all of this to have better capacity in our healthcare system. We’re seeing alternate care sites develop. We’re seeing field hospitals. We’re seeing the military, for example the Mercy just arrived in Los Angeles today I believe. We’re seeing things like tents being put up outside hospitals to do screening.

In San Diego, we’re also looking at behavioral healthcare centers outside hospitals. We’re seeing telemedicine, telehealth popping up. So lots of things for the structure piece as well where we care for patients. So again, stuff, staff, and structure is very helpful to organize all the components we need to increase the surge capacity of the system.

Joe Elia:

We’ve chatted before when the second edition of your textbook came out. You (or maybe it was Dr. Schultz) mentioned that the third edition should include a chapter on how to prepare oneself to participate in responding. Do you have any advice for clinicians now about to face the challenge of a surge in demand?

Dr. Kristi Koenig:

Yes. We definitely need clinicians. One of the most challenging things about this event is the psychological piece of it. People who are working on the front lines are seeing their colleagues get sick and unfortunately likely even die and it’s very difficult. Or they may have a situation where they don’t have enough resources, and we’re used to taking care of everybody. So keep focused on what we’re doing to take care of patients and take care of your own mental health. There’s lots of resources online for mindfulness and other types of techniques you can use. Make sure that even though we’re physically distancing that we’re still connecting socially with others.

Joe Elia:

When I was going through your textbook again, I noticed the mention of the incident command system. Talk a little bit about that if you would.

Dr. Kristi Koenig:

An incident command system is necessary to coordinate all of the resources that we need. What happens is, people want to help, and they have good ideas, and they try to work outside the established system. And we’re seeing it everywhere. It takes up people’s time to respond to well-meaning requests, spontaneous volunteers, spontaneous donations as opposed to if everything can be funneled into the incident command system it can be coordinated as needed to help manage the disaster.

These are systems that are practiced both in hospitals (we usually use something called the Hospital Incident Command System). In the prehospital setting in all levels of government and there are liaisons between the various incident command systems so that you can coordinate and do something that’s on a regional, statewide, and even national basis that otherwise would be overwhelming to try to manage.

Joe Elia:

At the beginning of an incident like this, what would you do typically with the incident command system, would you put out something immediately saying “We understand you’d like to volunteer” or “If you want to volunteer if you want to bring food, masks, or whatever…”

Dr. Kristi Koenig:

One of the portions of the incident command system would be the logistics section. So the incident commander could refer a volunteer idea to that section who could decide how to best integrate it into the overall response.

Joe Elia:

The US is in mitigation mode right now — as opposed to trying to prevent the entry of the virus into the country…

Dr. Kristi Koenig:

Actually, I wouldn’t agree with that.

Joe Elia:

Tell me how I’m wrong there.

Dr. Kristi Koenig:

The US has different phases right now of the disease. So for example, in New York and some other emerging areas at the time we’re making this recording such as New Orleans and Chicago and Los Angeles, they’re a little bit farther along that epidemiological curve in terms of the rise in cases. But there are some parts of the United States where there are very few cases — or at least few that we know of. So they’re probably earlier on in time. I would say in San Diego, for example, we’re not quite on the same upslope as they are in some other parts of the country like New York.

In places where there’s widespread community transmission, certainly we need to do mitigations and that’s probably most places, to be honest, because we see this disease being spread in asymptomatic or minimally symptomatic people and that’s why this stay-at-home message. This social distancing is so important to flatten that curve, but we also still need to isolate people that are sick. We need to identify them and isolate them so that we can prevent rapid spread by known people who are sick. So we’re doing more than just mitigation.

I’ll just say we’re doing identification and contact tracing to prevent spread of disease from known cases in addition to the mitigation.

Joe Elia:

I mean you started the month with one case in San Diego and now we’re up to many more than that. What have you seen over that time, Dr. Koenig, that has changed your mind?

Dr. Kristi Koenig:

It’s been very interesting in San Diego because we’ve had several disasters within the disaster, if you will. Let me explain what I mean. We have the local military base, Miramar. You may have seen on the news that when we were repatriating people from Wuhan they came into a federal quarantine. So we’ve been closely collaborating and have a strong relationship with the federal entity such as the CDC and what’s called the ASPR, the assistant secretary for preparedness and response, which is located in HHS at the federal level and also the state. Because in the US, the way things are organized it’s local to state to federal in terms of how the resources work.

So we had people coming back from Wuhan that were on quarantine, and we helped support the quarantine on the base. I’ve actually been standing a little bit more than six feet away from a patient who ultimately turned out to be positive from that repatriation. We have systems in place where we have transported patients who became infected or became positive from the base to hospitals and potentially back. Then after we had that mission, which really helped us to get systems in place, we had people coming from the cruise ships. Same thing where we had positive cases in that cohort, and we were able to make sure that those cases did not spread out into the community and that those patients got care and ultimately once their 14-day quarantine was finished they were able to return to where they live.

So that gave us a lot of experience and we’re still actually having more cruise ships coming into San Diego and managing that along with our federal partners. So it’s incredibly complicated, but it’s given us a lot of experience of how to manage this. In addition, you mentioned at the beginning my role in EMS. We put in place screening so that when somebody calls 911, initially several weeks ago when it was more relevant to ask the travel history, we were asking about travel from China and some of the other hotspots, and we were identifying people potentially infected at the level of dispatch so that when our paramedics responded they were already wearing the appropriate personal protective equipment.

When they picked up the patient for transport, they were notifying the hospitals ahead of time, “Hey, we’re coming in with someone who might have COVID” and the hospitals were wearing PPE. Oftentimes, seeing them — if they were stable enough — outside of the emergency department first, to make sure that we weren’t transmitting infection to others.

Joe Elia:

So nothing that you’ve seen so far has changed your mind about the approach that should be taken. Would it be fair to say that it’s reinforced?

Dr. Kristi Koenig:

One of the most challenging things is that the recommendations are changing very frequently. That’s because this is a novel virus. It’s new and we are learning. I’ve actually been following this since December, believe it or not, and I can remember the first report was “It’s not transmitted from person to person,” which I didn’t believe. “Oh, it’s not transmitted to healthcare workers,” which I didn’t believe. But things have been evolving over time in terms of PPE recommendations.

Initially, it was very helpful to identify people traveling from certain international hotspots. Now there’s such widespread disease, that’s less useful at this point. So there is a challenge and there are things that are changing, but one thing that we worked with for all infectious diseases is the concept of the three “I”s. The identify, isolate, and inform. For people working in hospitals, we want to immediately identify patients who are potentially infected, and because this is a disease contagious from person to person we then would immediately isolate them. And the third “I” would be to inform both public health and your hospital infection prevention personnel.

Joe Elia:

Yes. I saw that you had written a paper on the application of the three Is to the epidemic. I’m going to put a link to that on the website.

Dr. Kristi Koenig:

Thank you. And the three-I concept actually developed during the Ebola outbreak in 2014. The idea is that we don’t necessarily think in our day-to-day work about the potential for a patient to be infectious to the point where we could contract the disease or other people in the waiting room to contract the disease, and we have to think about that immediately in something like this epidemic so that we can immediately isolate and protect the patient from exposing both healthcare workers and other patients.

Joe Elia:

As a country, what do you think we could be doing more of or less of at this juncture?

Dr. Kristi Koenig:

It’s important to know that every single person in this country is on the frontlines. For me, this epidemic and every single person’s actions are important to help us stomp out this disease. If you are a non-healthcare person just staying home and washing your hands, as simple as that sounds, can be incredibly helpful, as I talked about earlier, for flattening that epidemiologic curve. So everybody has an essential role in the entire country. As healthcare workers, I would encourage everyone to keep focused. Again, the approach we’re taking in San Diego is this three-pronged approach of the interventions to flatten the curve, coupled with increasing the surge capacity, and making sure we work within an incident command system structure.

Joe Elia:

I know it’s hard to look into the future. How do you think COVID-19 might change clinical practice? Do you see any indication that it might?

Dr. Kristi Koenig:

Absolutely. Once we get through this I think we’re going to have a much better healthcare system. It’s amazing the collaboration and the innovation we’ve had in such a short time. Things are happening you never would have thought could have happened. I mentioned earlier, telehealth as an example, increasing behavioral health resources, increasing resources for the homeless. There are incredible collaborations happening. We’ve had meetings with all the chief medical officers of our 20 hospitals including VA and military in our county. We’ve had meetings with all the CEOs of all our hospitals along with the board of supervisors and the chief medical officer of the county.

This kind of cooperation and collaboration would not have happened if it weren’t in the face of a crisis.

Joe Elia:

Is there one essential lesson that you want clinicians to take as they’re about to face this?

Dr. Kristi Koenig:

Keep focused. We will get through this if we organize our actions and our thinking. We can save lives. You are the heroes. You’re on the frontlines and we thank you for everything you’re doing every day.

Joe Elia:

I want to thank you for your time today, Dr. Koenig. I wish you good luck in the coming days.

Dr. Kristi Koenig:

Thank you very much. Stay safe.

Joe Elia:

Thank you. That was our 261st episode. Its predecessors are all searchable and available free at Podcasts.JWatch.org. We come to you from Physicians First Watch and NEJM Journal Watch — all part of the NEJM Group. My executive producer is Kristin Kelley and I’m Joe Elia. Thanks for listening and stay healthy.

Mar 29 2020

18mins

Play

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:

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.

Mar 27 2020

13mins

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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.

Mar 25 2020

12mins

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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 […]

Mar 19 2020

18mins

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Podcast 256 — Anthony Fauci: Talking with patients about COVID-19

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We have Dr. Anthony Fauci of NIAID to talk with us about COVID-19, the disease caused by the 2019 novel coronavirus (also known as SARS-CoV-2). He’s full of sound advice in the midst of a rapidly changing epidemic. We wanted to know, How do you talk with patients about this rapidly spreading infection? How do you […]

Mar 10 2020

13mins

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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 […]

Mar 06 2020

28mins

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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 […]

Feb 28 2020

16mins

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Podcast 253: Is a single-dose HPV vaccination effective?

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With human papillomavirus vaccine in short supply around, moving from a three- or two-dose regimen to one dose would immediately double or treble supplies, cut costs, and simplify logistics. A careful study in Cancer by this week’s guest, Ana Rodriguez, and her colleagues adds to the evidence that single-dosing is possible and protective against pre-cancerous cervical lesions. […]

Feb 21 2020

15mins

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Podcast 252: We revisit our chat about chatting about guns

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Back in November, Ali Raja and Joe Elia talked with Garen Wintemute about his Health Affairs paper regarding addressing the topic of guns with patients. Having encountered another of those weeks in which interviewees were either on vacation (richly deserved, we’re certain) or too busy to respond to Joe’s requests (get some sleep!), we’re going to […]

Feb 13 2020

18mins

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Podcast 251: Intermittent fasting

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Intermittent fasting has salutary effects. Listen how Dr. Mark P. Mattson, co-author of a recent NEJM review on the topic, assesses the practice — and how he’s managed to skip breakfast for the past 30 years or so. Dr. Ali Raja joins Joe as co-host again this time. Links: de Cabo and Mattson’s review in the New […]

Feb 07 2020

17mins

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Podcast 250: #MeToo in the OR

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It turns out that the disrespect starts even earlier — when women are questioned about their choice of a surgical specialty. Nor is the bad behavior the exclusive province of the “old guard.” We talk with Dr. Pringl Miller, a Chicago surgeon who’s compiled a collection of instructive stories from women surgeons who’ve had to dodge […]

Jan 30 2020

17mins

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Podcast 249: Quality time with your EHR — or just time?

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Why aren’t you able to navigate your electronic health record (EHR) as easily as you can find a recipe on, say, Google? And, what about those requirements for documenting everything? Listen to a chat with Julia Adler-Milstein, the author of an editorial that comments on a recent Annals of Internal Medicine study detailing the amount of time […]

Jan 24 2020

17mins

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Podcast 248: “Hotspotting” didn’t work in its home town — why?

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The process of identifying super-users of healthcare and reducing the frequency of their hospitalizations — so-called “hotspotting” — was subjected to a randomized, controlled trial in Camden, NJ, the birthplace of the idea. It failed there. Those in the intervention group had a readmission rate within 6 months that was statistically identical to those getting usual care. […]

Jan 17 2020

15mins

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iTunes Ratings

39 Ratings
Average Ratings
29
6
3
1
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Great news and interviews!

By MJH8 - Sep 11 2019
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This is a great way to get the week’s top medical news very succinctly, and Joe Elia’s conversations with researchers are highly educational and entertaining!

Is it coming back?

By nyhunter77 - Feb 13 2013
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This is an awesome podcast, is it coming back for 2013?