Clinical Conversations: Recent Episodes
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A VIDEO RECORDING OF THIS INTERVIEW WILL BE AVAILABLE WITHIN A FEW DAYS. [display podcast] In treating most exacerbations of chronic obstructive pulmonary disease (COPD) the usual regimen consists of prednisone plus 5- to 7-days of antibiotics. But what if a shorter course of antibiotic therapy would do? That would be both convenient for patients and less […]
The post Podcast 298: COPD exacerbations — 7 days of antibiotics versus 2 first appeared on Clinical Conversations.
A VIDEO RECORDING OF THIS INTERVIEW IS AVAILABLE HERE. This time, we look to New York for guidance on recognizing and treating monkeypox. Dr. Eric Meyerowitz of Montefiore and Dr. Stephen Baum of Einstein will lead you through the monkeypox thicket in a 17-minute chat. Included below is information for patients as well as links to some key […]
The post Podcast 301: Monkeypox — what to look for, how to treat first appeared on Clinical Conversations.
A VIDEO RECORDING OF THIS INTERVIEW IS AVAILABLE HERE. We’re back with another interview from this year’s IASLC conference. This time, Christine Sadlowski and Dr. Julia Rotow interview Dr. Mariano Provencio about the survival outcomes from the NADIM II trial. In that trial, patients with resectable stage III AB non-small cell lung cancer received nivolumab plus chemotherapy […]
The post Podcast 300: NADIM II trial offers “quite exciting” results in lung cancer first appeared on Clinical Conversations.
A VIDEO RECORDING OF THIS INTERVIEW IS AVAILABLE HERE. Interim results on overall survival in phase 3 of the IMpower010 trial were presented at this year’s meeting of the International Assosciation for the Study of Lung Cancer (IASLC). As part of the NEJM Group’s coverage of the conference, Christine Sadlowski interviewed the presenter, Dr. Enriqueta Felip. […]
The post Podcast 299: Lung cancer and atezolizumab — results from the IMpower010 trial first appeared on Clinical Conversations.
A VIDEO RECORDING OF THIS INTERVIEW WILL BE AVAILABLE HERE SHORTLY. THE USUAL AUDIO FILE IS AVAILABLE BELOW Steven Cummings has co-written a take-no-prisoners editorial in the New England Journal of Medicine. The topic? Vitamin D supplements. The conclusion? “…providers should stop screening for 25-hydroxyvitamin D levels or recommending vitamin D supplements, and people should stop taking […]
The post Podcast 297: Forget about all that vitamin D testing! first appeared on Clinical Conversations.
A VIDEO RECORDING OF THIS ROUNDTABLE IS AVAILABLE CLICK HERE. THE USUAL AUDIO FILE IS AVAILABLE BELOW Your host is old enough to remember when hospital corridors featured physicians with little black bags, scurrying around to see their patients. That’s no longer true, of course. Most of the physicians seen in those corridors these days are white-coated employees. The […]
The post Podcast 296: A roundtable on the question, Why are young internists flocking to the hospitalist practice style? first appeared on Clinical Conversations.
CREST-2’s results are probably more than a year away. In the meantime, what to do about diagnosed severe (but asymptomatic) carotid stenosis? Recent results suggest that medical management compares favorably with the surgical approach. In this edition, we address the question with a conversation between Dr. Allan Brett, NEJM Journal Watch‘s editor-in-chief, and Dr. Seemant Chaturvedi, […]
The post Podcast 295: How should clinicians manage severe (but asymptomatic) carotid artery stenosis while awaiting CREST-2’s results? first appeared on Clinical Conversations.
Locally advanced rectal cancer usually receives a three-part treatment: chemotherapy followed by radiotherapy and then surgery. In a small-cohort study presented at this year’s ASCO conference researchers used a PD-1 inhibitor — dostarlimab — every three weeks for 6 months against the disease. All patients had mismatch repair deficient tumors. No other treatments were needed however, […]
The post Podcast 294: PD-1 blockade in locally advanced rectal cancer first appeared on Clinical Conversations.
Patients with metastatic breast cancer whose tumors express low levels of HER2 are generally classified and treated as having HER2-negative disease. However, Dr. Shanu Modi of the Memorial Sloan Kettering Cancer Center and a group of international collaborators explored the use of a monoclonal antibody–drug conjugate (trastuzumab–deruxtecan) in patients with disease they classify as HER2-“low.” Compared […]
The post Podcast 293: HER2-“low” breast cancer and its reponse to an antibody-drug conjugate first appeared on Clinical Conversations.
Apnea testing is part of the protocol used to determine whether a patient is dead according to neurologic criteria. The question is, do clinicians need to obtain consent to proceed? In a fascinating 15-minute chat, two intensivists, Drs. Patricia Kritek and Robert Truog, discuss that question and another, larger one: what is death, anyway? Their back-and-forth […]
The post Podcast 292: Informed consent and apnea testing for death — or — What is death, anyway? first appeared on Clinical Conversations.
In the early waves of the Covid-19 pandemic why did patients in unionized nursing homes, have a roughly 10% lower rate of mortality than those in non-unionized ones? A report in Health Affairs tries to sort out the possible reasons. Listen to our 13-minute interview, which raises the question: Should you send your patients to non-unionized facilities? […]
The post Podcast 291: Unionized nursing homes had lower mortality during Covid-19 first appeared on Clinical Conversations.
The U.S. Preventive Services Task Force recently issued its sixth set of guidelines on using daily aspirin to prevent cardiovascular disease. The guidelines appeared in JAMA — whose editors asked our guest, Dr. Allan Brett, to write an editorial evaluation. This edition carries Brett’s advice on using the new guidelines in daily clinical practice. Brett’s JAMA editorial USPSTF […]
The post Podcast 290: USPSTF’s new take on aspirin and primary prevention of CVD first appeared on Clinical Conversations.
Saline or balanced crystalloids? The question of which resuscitation fluid to use in clinical practice seems to have been settled by recent research findings — or at least settled in favor of balanced crystalloids. But wait, our guests see slight differences that may affect your choice. Patricia Kritek practices critical care medicine at the University of […]
The post Podcast 289: Saline versus balanced crystalloids — what to choose first appeared on Clinical Conversations.
Spend 15 minutes with Dr. Natalia Shevchuk, whom we interviewed by candlelight last month. She is sheltering in the Odessa region now, having left the Donetsk area. This time, she relates how she lost a colleague in Russia’s attack on the Kramatorsk railway station and found another she’d feared lost in Mariupol. She told us that […]
The post Podcast 288: Following up with a Ukrainian narcologist first appeared on Clinical Conversations.
During the American Academy of Neurology’s 2022 meeting in Seattle, Dr. Richard Lipton of Albert Einstein College of Medicine took questions from Dr. Teshamae Monteith (U. Miami) and Joe Elia. Lipton’s group sought to characterize the impact of patients’ monthly headache days on their quality of life, especially the role of depression, allodynia, and anxiety. (Read […]
The post Podcast 287: Thinking about quality-of-life in migraine first appeared on Clinical Conversations.
Dr. Natalia Shevchuk (pictured above) treats substance use disorders in Ukraine’s Donetsk region. Her face is candlelit because her town is under curfew, and people aren’t allowed to put on their room lights (if they have electricity) in the hours of darkness, lest Russian bombardments use the lights as guides. She talked with Dr. Ali Raja […]
The post Podcast 286: Talking about addiction treatment by candlelight from Ukraine’s Donetsk region first appeared on Clinical Conversations.
Gastroesophageal reflux, or GERD, was the focus of a revised set of guidelines issued in January in the American Journal of Gastroenterology. Given the frequency of that condition in primary care clinics, internist and NEJM Journal Watch editor-in-chief Allan Brett proposed a discussion about the practical application of these guidelines with David Bjorkman. Dr. Bjorkman, […]
The post Podcast 285: GERD’s revised guidelines — an internist and a gastroenterologist discuss them. first appeared on Clinical Conversations.
Some 85 years ago Guernica was bombed, and after that came Dresden, Coventry, Hiroshima, Bach Mai, and the rest. This episode of Clinical Conversations asks how it might be possible to help clinicians under bombardment in Ukraine. As you will hear, one hospital in Chernihiv keeps all but essential staff away from its buildings when […]
The post Podcast 284: The clinical situation in Ukraine first appeared on Clinical Conversations.
You want more evidence that post-recovery vaccination against Covid-19 reinfection helps? Here is a careful study from the U.K. that followed some 35,000 health care workers — initially without symptoms — in over 100 institutions there. Starting in June 2020 the SIREN study tested these people regularly, with blood sampling every month and nasal swabs […]
The post Podcast 283: More data — this time from the U.K. — about post-Covid vaccination first appeared on Clinical Conversations.
Governments’ directives about how and when to vaccinate people who’ve recovered from Covid-19 vary widely. But, according to this episode’s guest, Dr. Ronen Arbel, they all say they don’t have enough evidence to set firm policy. So, Arbel and his colleagues set out to collect evidence from some 150,000 patients’ records in Israel who’d recovered […]
The post Podcast 282: Vaccination after Covid-19 recovery prolongs natural immunity to reinfection first appeared on Clinical Conversations.
Why can’t the U.S. control prescription drug pricing as they do in the U.K., where per-capita spending is less than half our level? In a capitalist democracy, many parties — the drug companies, medical associations, consumer groups — get to lobby their points of view. Is the problem intractable, or just an exercise in chaos? Our three […]
The post Podcast 281: Drug Costs — What’s “The Right Price” for prescription pharmaceuticals? first appeared on Clinical Conversations.
Multisystem inflammatory syndrome in children (or MIS-C) is a serious complication of Covid-19 infection, usually showing up about a month after infection. CDC worked with several hospitals around the U.S. to discern whether vaccination in adolescents would lessen the likelihood of this outcome. A vaccine hadn’t yet been approved, as it now is, for kids between […]
The post Podcast 280: MIS-C after Covid-19 in adolescents — can vaccination prevent it? first appeared on Clinical Conversations.
Kiarri Kershaw has written a simple letter in JACC — the Journal of the American College of Cardiology. The letter conveys a strong message: health inequities don’t act uniformly across one’s lifetime. Her examination of Black versus white mortality from all causes and from cardiovascular causes with the use of age-specific data shows places in […]
The post Podcast 279: Age-specific data do better than age-adjusted data in revealing health inequities first appeared on Clinical Conversations.
An internist at Massachusetts General Hospital, Dr. Joseph Betancourt also runs their program on equity and community health. In this, the final entry in our four-interview exploration of race and clinical equity, Betancourt talks about the need for medical institutions to pay attention to what’s happening in their patients’ communities. To that end, MGH has a […]
The post Podcast 278: Where equity and community health intersect — a conversation with Joseph Betancourt first appeared on Clinical Conversations.
Dr. Sheares talks about her experience with inequities. She believes that clinicians should aspire to be students of their patients as well as of the pathophysiology of the diseases their patients present with. Listen in. Running time: 20 minutes
The post Podcast 277: Race and clinical equity — know your patients — a conversation with Karen Dorsey Sheares first appeared on Clinical Conversations.
In this, our second conversation on race and clinical equity, Dr. Karol Watson of UCLA offers her observations on what she’s observed as a cardiologist trying to deal with treatment plans for patients who’ve lost their health insurance or have had to go to a plan that doesn’t cover what’s needed. She reminds us that tagging […]
The post Podcast 276: Pay attention to the structural barriers that contribute to clinical inequity — Karol Watson first appeared on Clinical Conversations.
We’ve conducted a set of four interviews with physicians on the topic of race and clinical equity. The conversations center not so much on their published research, but on the roles that these physicians take in their organizations and, in addition, the stories they tell about their own experiences. Our first is with Dr. Kimberly Manning, who’s […]
The post Podcast 275: Race and Clinical Equity — a Conversation with Dr. Kimberly Manning first appeared on Clinical Conversations.
Apologies for the long silence. We have been off doing other things — one of which has been figuring out how to cover conferences. Last month, after much preparation, we covered the American Society of Hematology (ASH) annual conference; our second foray consists of brief coverage of the American Society of Clinical Oncology (ASCO) gastrointestinal […]
The post Podcast 274: Preliminary Thoughts on the 2021 ASCO Gastrointestinal Cancer Conference first appeared on Clinical Conversations.
Eric Rubin is editor-in-chief of the New England Journal of Medicine. I asked him how COVID-19 has affected that journal, which has been around since the War of 1812 and seen its share of pandemics. Listen in — it’s the first in a planned series of interviews with the editors of the principal clinical journals. Running time: 19 minutes […]
The post Podcast 273: The journals and the pandemic — NEJM first appeared on Clinical Conversations.
Dr. Paul Sax writes the closest thing that the NEJM Group has to humor. He’s serious, of course, since his blog “HIV and ID Observations” concerns all things infectious . But he sprinkles in the odd cartoon or links to … dog videos, fer cryin’ out loud. He scours the ID literature (and we must include […]
The post Podcast 272: And now for something completely different… almost first appeared on Clinical Conversations.
Back in late March (people often tell me that, these days, 4 months ago might as well be 4 years ago) we talked with emergency physician Julian Flores, who was working out of Broward County. Covid-19 cases were modest in number but threatening to get worse, and indeed they did. The county’s cases jumped 100-fold, from […]
The post Podcast 271: Checking back in with Florida — 4 months later first appeared on Clinical Conversations.
Don’t expect HIPAA regulations to protect your “digital health footprint” from prying eyes. Every time you swipe your card to buy goodies at the supermarket (are you risking diabetes with all that ice cream?), or binge-watch that kinky series (how’s your mental health these days, really?), or let your step-tracker show you’ve fallen off the pace […]
The post Podcast 270: Is healthcare privacy possible if “all data are health data”? first appeared on Clinical Conversations.
We interview Dr. Michael Gonzalez, a Houston-based emergency physician, who describes the situation there as “an ongoing, slow-rolling, level 6 hurricane that just isn’t gonna go away and, more importantly, isn’t gonna tell us when landfall is coming and when it’s gonna be over.” How are his patients reacting to this surge? What does he do […]
The post Podcast 269: The pandemic in Texas is like a “slow-rolling level 6 hurricane” first appeared on Clinical Conversations.
This time Dr. Ali Raja and Joe Elia talk with two authors of a study that found disparate effects on traffic deaths from the legalization of recreational cannabis. The two states under study, Colorado and Washington, were compared, not with each other, but with a composite of states that most closely resembled what Colorado and […]
The post Podcast 268: Cannabis and road accidents — is there an association? first appeared on Clinical Conversations.
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 […]
The post Podcast 267: Acute kidney injury in COVID-19 — how one New York system dealt with it first appeared on Clinical Conversations.
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 […]
The post Podcast 266: Interferon and early treatment in COVID-19 bring good outcomes first appeared on Clinical Conversations.
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 […]
The post Podcast 265: COVID-19 in skilled nursing facilities first appeared on Clinical Conversations.
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 […]
The post Podcast 264: Is COVID-19 pushing MIs out of emergency departments? first appeared on Clinical Conversations.
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 […]
The post Podcast 263: Checking in with Connecticut and Michigan on medicine after COVID-19 first appeared on Clinical Conversations.
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 […]
The post Podcast 257: Here comes the summer after COVID-19 first appeared on Clinical Conversations.
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 […]
The post Podcast 262: COVID-19’s larger lessons first appeared on Clinical Conversations.
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:
- Dr. Anthony Fauci
- Dr. Susan Sadoughi
- Dr. Matthew Young
- 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.
The post Podcast 261: COVID-19 as a medical disaster first appeared on Clinical Conversations.
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.
The post Podcast 260: Interview with a Broward County, Florida, emergency room physician first appeared on Clinical Conversations.
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.
The post Podcast 259: A first-year resident tells us what he sees in the Covid-19 pandemic first appeared on Clinical Conversations.
We talk with Susan Sadoughi, an internist at Brigham & Women’s Hospital in Boston, about how quickly things have changed over the past week.
Last week, I introduced the Fauci interview by saying that I’d heard a clinician complain that she’d spent half her time answering questions about COVID-19. This week, she’s our guest, and she’s looking back from the vantage point of a completely changed health system. She describes that change as “enormous.”
She’s doing lots of telephone consultations with her patients, talking about sending her kids to be with relatives at the other end of the country, and being wistful about the sound of a cello in her hospital’s corridors.
She’s learning to live with uncertainty, she tells us.
Listen in, clinicians, and see whether these observations resonate with you.
LINKS:
Last week’s interview with Anthony Fauci
Running time: 18 minutes
TRANSCRIPT OF THE CONVERSATION WITH DR. SUSAN SADOUGHI
(Please remember, this is a conversation and not an essay. As such, it can seem incoherent when presented as prose, but perfectly understandable when heard. We present it essentially as spoken in order to get it to you quickly.)
Joe Elia:
You’re listening to Clinical Conversations. I’m your host, Joe Elia.
While many of us work from home, some of us — such as first responders, mail carriers, supermarket clerks, and cooks — continue working during the uncertain course of the COVID-19 epidemic. Clinicians, of course, also continue their services, and we have with us today Susan Sadoughi an internist in the division of General Medicine at Brigham and Women’s Hospital in Boston, where she teaches residents and medical students. Dr. Sadoughi is a deputy editor of the daily Physician’s First Watch and has a been a colleague of mine there for many years.
The other day, during one of her phone calls with the First Watch newsroom she expressed some frustration with the problems the COVID-19 epidemic has created, and I thought it would be useful for other clinicians to hear about those problems or to know at least they were not suffering alone. She’s kindly agreed to talk with us. Welcome to Clinical Conversations, Susan.
Susan Sadoughi:
Thanks for inviting me.
Joe Elia:
It’s my pleasure. Tell us a little bit about your experience these days. Last week, as I said, you said you were spending about half your time answering patients and possibly clinicians’ questions about COVID-19, and I’m guessing you’re probably spending much more time this week.
Susan Sadoughi:
I have to say a week’s span of time has been an enormous difference from last week to this week. A week ago, I would say my clinical experience, in a lot of ways, was similar to the week prior in that I still had scheduled patients. I was seeing patients in the office, and I was seeing 15 patients a day. And last week I was frustrated, I remember, primarily because added to the usual business of seeing patients and filling in regular questions there was all of the discussion around, “Doc, what do you think this is? Can you tell me more about it? How do I protect myself?” It blows my mind how much things are different this week compared to last week.
Suffice it to say, if I were to just highlight the fact that this week I had zero patients that I saw in the office for routine visits. So beginning on Sunday night we actually screened all of our patients for the next two weeks and contacted all of our patients to let them know that almost all patient visits will take place on telephone. So we sort of divided our patients into three categories. If you’re just here to get your physical and you have no complaints or no problems that have to be followed, we will reschedule you for a month from now.
And then there was this category of patients that had problems, that were going to see me for routine follow-up, and we converted it to phone calls. Now, we have been advocating for phone visits forever and we’ve been told about all the barriers of phone visit. Lo and behold, in the middle of crisis, today I had six visits that were phone visits out of the 12 that I was supposed to see in the morning. So six of the visits were completely rescheduled. Six of them were converted to phone visits. And then I had the third category of patients, which are the patients who are symptomatic and need to physically be seen.
We divided those patients into patients with respiratory symptoms, which go to a completely separate wing of our clinic for whom I have to completely use preventive protection. And then symptomatic patients who, say, if they had a headache or other things that are non-respiratory. So our clinic, in the span of one week, has been utterly transformed.
So last week, it was absolutely overwhelming because there was the routine stuff and then the added counseling of the patients around COVID concerns as well as 100 questions on the emails that I was getting via our gateway messages. Ninety percent of those questions are now being triaged by a separate group of clinicians and nurses. There’s a whole hotline that has been developed who basically screen all my messages and if they’re COVID-related questions they’ll triage those questions.
So I think the structure of the clinic is utterly different. The feeling around the hospital is absolutely eerie. You walk around and there are not many people around. All of us are on this standby. The residents have all been pulled off the clinic. No routine visits. Waiting in case they’re needed, and then all the attendings who don’t have urgent care responsibility…so for example, I had urgent care responsibility today so I physically came to the hospital but tomorrow all of my patients are going to be phone visits. So I don’t have to come to the hospital. So they’re not…it’s just absolutely surreal. There’s no other way to describe it.
Joe Elia:
So what do you do to protect yourself? I mean in the absence of readily available testing for the presence of the virus.
Susan Sadoughi:
So essentially, I would say 80 percent of the patient visits have been converted into future visits or phone visits. The people who are being seen are the people who have acute respiratory symptoms. Those people, we pretend as if they do have COVID, and we have universal precautions for them. Other patients who are being seen in urgent care, which are very few…very few patients that are being seen in urgent care are not absolutely necessarily respiratory-type symptoms. Those people we stay away six feet. We wash our hands constantly. We have a ton of Purell and are wiping surfaces constantly. These are completely low-risk to no-risk for possible respiratory process.
And then all the other respiratory symptoms, be it that you have sore throat, be it you have some nasal congestion, be it you have some ear pain, we get dressed as if it could be COVID. So it’s so different this week.
Joe Elia:
So you’re kind of waiting around for the other shoe to drop, aren’t you?
Susan Sadoughi:
Yeah. I have to say, even my residents are like I can’t believe…because I see the same residents from last week to this week, and we were all saying I just can’t believe where we are in one week. Where we all are doing our phone visits and we’re sort of on this standby. Today, as I was going to a different section of the hospital, Brigham has this music-therapist cello player. They only usually come once every week or so. She’s been playing every day, it seems like, all day. And you walk around and I had ran into another colleague who was upstairs. You know, you vacillate between, oh, my God, this is so profoundly sad. Look at what is happening to our hospital.
Then you look around and there will be a message that makes you feel like, okay, I’m a soldier. I’m here. If something happens, I’m going to step up and I have to tell you, at times, I get so teary-eyed listening to that cellist playing because — I don’t know — there’s something incredibly patriotic about it. It’s so crazy because the whole atmosphere has changed.
Joe Elia:
You have a family at home.
Susan Sadoughi:
Yes.
Joe Elia:
And youngish children.
Susan Sadoughi:
Yes.
Joe Elia:
So how are you protecting yourself? Tell me a little bit, if you would, what that’s like.
Susan Sadoughi:
I’m in a little bit of a unique position, knowing that they have three weeks off and I have family in Florida we’re actually contemplating sending the rest of the family to Florida because there is very good chance I will be among the few urgent care doctors who will be assigned to see all the respiratory patients, meaning like every day I will be testing symptomatic people. I think that is high-risk enough that it might mean they’re better off distant from me. If they were home, I would probably, in addition to frequenthandwashing, etcetera, I’m in favor of keeping that six foot distance because what if I am one of those asymptomatic people who will contract it?
Luckily, the data around the young people are pretty encouraging every day, but I probably would be in favor of just keep a safe distance from me and in addition to the usual handwashing, the usual wiping off a surface. I’ve been really good about reminding the residents and also reminding the staff that we should consider ourselves as one of the scarce resources and we don’t want us to be quarantined or furloughed, never mind anything else.
Joe Elia:
The New Yorker has a daily newsletter. Benjamin Wallace Wells, in The New Yorker (who, by the way, lives in Boston) was talking with ethicists about some of the decisions that people might have to make about the use of respirators if things became as bad as they are, say, in Italy. I know that you’ve probably thought about that. Have you had conversations with your residents about that?
Susan Sadoughi:
Yeah. You know, to be honest with you, we’re in a different phase right now in the sense that we are commenting about how we’ve been able to reduce census in the hospital. The hospital feels empty because we really have been so proactive to divert patients who could be managed at home or elsewhere and also I think patients have been really good about trying to avoid the ER and keeping the staff available. So I think at this point, we’re just shocked by, “my God, we’re in this prep mode and we don’t know what to expect.” I think we haven’t prepared ourselves for the other side of the equation where we were totally overwhelmed. I don’t think we’re there yet. So I don’t think we played that scenario as much.
I’ll tell you one thing about my experience with these phone calls, which has been so unique. We’ve been asking to try and have phone visits for years, especially in primary care because so much of it can take place on the phone. Number one, the patients are so incredibly appreciative — Joe, I cannot even tell you — that they don’t have to come in. But also, just how much we can get done on the phone. Literally 90 percent of what we need to get done could get done on the phone for various patients. Then I was struck by every conversation at the end comes to a COVID discussion and the level of the discussion has changed, and it’s really interesting because last week the general public was uninformed. So a lot of the questions were very basic questions. What should I do?
Now, it’s so much different and it’s so unique to their own situation. I spoke to my 75-year-old who has to babysit for the grandchildren and what should he says to his daughter about limiting the little kids’ playdates. Then I had one other patient today, this woman who’s working from home, but she has some mental health struggles and she usually runs outside and exercises, and the gym has closed. And in talking to her about what you could do instead, “You could do this, you could do that, I want you to still do your exercise etcetera, it’s just a completely different discussion from last week. It’s much more advanced around how to protect themselves.
I think people…my own sense of it right now, the mindset is different. I think people have a mindset of what can I do instead? How can I protect myself? What can I do instead? I think there’s basic knowledge and then they’ve come to acceptance. It’s almost this is acceptance. If they’re worried, like I’ve been really trying to emphasize maybe you can do A, B, and C but you can do X, Y, and Z and you should feel good you’re being flexible. You’re being resilient. You’re still trying to find your way to do the things you need to do.
People have been so incredibly appreciative. I think it makes me much stronger and in a much better mindset this week compared to last week.
Joe Elia:
But for the clinicians who haven’t yet seen their first case or their first presumptive case yet, what’s the best advice that you could offer them?
Susan Sadoughi:
You know, I think the very first few times that I was seeing patients and trying to make decisions, should I send this person for COVID testing, should I not test them? It was so unsettling because it seemed like every two hours the guideline was changing. I would reach out to our infectious disease expert and after about the second or the third time where I heard them say, you know what, there is no clear-cut answer right now. Here’s what we need to deal with and there’s no easy answer, I finally realized as physicians we want certainty and in these times you have to understand the guidelines are changing. We don’t have the availability of testing all the people we want, and we have to be comfortable with some uncertainty. I’m better at that now because if the infectious disease person didn’t know the answer and says to me, “This is my best advice I can give you, and these are all hard decisions and we just have to live with that,” I think there’s something calming about that.
Whereas, last week I was terrified that I was making the wrong decision and now I realize this is such a fluid decision that there’s not a black and white answer and there is some comfort in knowing that we have to make decisions with some level of uncertainty, and it just feels different.
Joe Elia:
All right. Well, I want to thank you very much, Susan, for talking with me today about all this.
Susan Sadoughi:
Sure. Sure. There’s a lot to be learned over the next week or so.
Joe Elia:
Or maybe the next several months.
Susan Sadoughi:
Yes.
Joe Elia:
I wish you and your family well.
That was our 258th episode, all of which are searchable and available free at Podcasts.JWatch.org. We come to you from the NEJM Group. Our executive producer is Kristin Kelley, and I’m Joe Elia. Thanks for listening.
The post Podcast 258 — One clinician’s experience of the early days of the COVID-19 epidemic in the U.S. first appeared on Clinical Conversations.
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 keep informed about it?
Listen in.
Link:
The new federal website
Running time: 13 minutes
TRANSCRIPT OF THE INTERVIEW
Joe Elia:
This is Joe Elia.
If you’re like the clinician I heard from last week who said she’s spending half her time counseling patients about COVID-19, you’re probably wondering how best to discuss the problem with your patients.
This time my co-host, Dr Ali Raja, and I are talking with Dr Anthony Fauci, Director of the National Institute of Allergy and Infectious Diseases about how clinicians might approach these conversations and about how both parties — clinician and patient — can best inform themselves about the developing details of this widespread illness.
Dr Raja is helping to direct the Mass. General Hospital’s emergency department’s response. He’s Executive Vice Chairman of the Department of Emergency Medicine and he edits the NEJM Journal Watch Emergency Medicine newsletter.
Dr Fauci has directed NIAID for some 25 years, arriving in the early years of the HIV/AIDS epidemic. He has advised six US Presidents on health issues. Most recently we’ve all noticed that he’s become the principal clinical voice in this country’s response to the threat of COVID-19 as a member of the White House Coronavirus Task Force.
Dr Anthony Fauci:
Well, first of all I’ve directed the Institute for 36 years, not 25 years.
Joe Elia:
I’m sorry, Dr Fauci.
Dr Anthony Fauci:
You’re making me younger than I am!
Joe Elia:
Time flies when you’re having fun, right?
Well, so welcome to Clinical Conversations, and we’ll try to get other facts right as we talk to you! We’re going to keep this simple and frontline-clinical to respect your time and preserve your voice. I’ll have Dr Raja ask the first question.
Dr Ali Raja:
Thanks, Joe. Welcome, Dr Fauci.
Dr Anthony Fauci:
Good to be with you.
Dr Ali Raja:
You can imagine that we’ve been getting a lot of patients coming into emergency departments around the country, I’ve seen them here at MGH, with questions and with concerns. Honestly, I’ve struggled with the best way to advise them, so let me ask you. Beyond good hand hygiene and common sense regarding reducing transmission, what can we tell our patients about COVID-19 both to make them aware of the potential risks but also to hopefully calm them and help with the sense of panic that we’re feeling?
Dr Anthony Fauci:
Yeah. I mean, obviously a pivotal and great question that every one of us are facing.
So I think to give them the broad picture without unnecessarily sugar-coating because we’re in a really serious situation here.
But for the individual patient I try to explain that they should not take upon themselves the burden of the broader global health issue. So if you look at the situation of what it means to get infected, in the United States as a country in general the risk of getting infected is clearly very low.
However, the situation is changing, it’s evolving, and the difference of sitting in a place where there are either no cases or two or three easily documented cases. Like a travel case: Someone comes in from Iran to New York, they nail it, they isolate them, it isn’t in the community yet. You have a cluster there.
But for somebody who walks into an ER in an area where there isn’t community spread, the risk of getting infected is low. However, if you do get infected we need to look at the data that we have now and the data predominantly are from China, South Korea, northern Italy, and Japan, and that is about 80 percent of the people who get infected do well. I mean, they’re not asymptomatic, they have a flu-like illness but they recover spontaneously without any specific medical intervention, so to give them a feel.
However if you are an individual who has an underlying condition of which you’re all familiar with — chronic obstructive pulmonary disease, cardiovascular disease, congestive failure, diabetes, anything that could compromise your immune system — if you get infected then you have a much higher chance of having a complication, and then if you look at the serious disease and death it’s totally weighted to that group with the occasional one-off outlier that we even see with flu: A 35-year-old person who’s perfectly well gets the flu and then gets really sick and might die. That can happen, but different from flu, children and young people do really, really well with this.
So you give them the broad picture, that should take like two minutes in the office to tell them that. Then you tell them what do you need to do. Right now in places like Seattle, LA, New York, and Florida there’s clear community spread so what you need to do is start already what we call social distancing which some people don’t understand what that means. It just means separating yourself as best you can. No crowds, don’t get on crowded planes if you’re a senior citizen, particularly with an underlying condition. Don’t get on a cruise ship for sure. Wash your hands as much as you possibly can, and if you have a person in your own home who is immunocompromised or falls into that compromised group, you almost have to act like you yourself are infected.
So if you’re a 35-year-old person who feels healthy and you have someone in your home that’s on cancer chemotherapy, you’ve got to protect them. You’ve got to physically distance yourself from them. Now that’s now in Massachusetts.
If you happen to be in Seattle you’ve got to do more than that. You yourself have to do a lot of social distancing because when you have community spread then you just don’t know the penetration in the community unless you do a massive screening in the community, and that’s where we really need to catch up because what I’d like to see is just flooding the system with testing to see what percentage of people who come into any emergency room actually have COVID-19. If that’s 0.1 percent, okay. If that’s four percent, time out, we really have a problem.
Anyway, I was a little bit more long-winded than my usual answer but…
Dr Ali Raja:
That was exactly what we needed. Thank you.
Joe Elia:
Thank you, and Ali, what’s the situation at Mass General?
Dr Ali Raja:
Well, Joe, as an example let me tell you about the kinds of things that we’ve done in anticipation of a more widespread impact of this virus. As Dr Fauci mentioned we aren’t Seattle yet but we’ve already converted our ambulance bay to a large sealed-off treatment area that allows us to screen and test for patients separate from the rest of the emergency department when they meet the current CDC criteria.
And I want to emphasize that last part because the target seems to constantly be evolving and changing and so in addition we’re having daily meetings with all of our clinicians and our clinical leadership but also our supply chain leaders, our hospital administrators to make sure that the hospital keeps transforming based on the information that seems to be changing every day.
Dr Anthony Fauci:
That’s a really good point. This is not a static situation. It literally changes every day and that’s so difficult to do when you’re trying to put into place the kind of things that Ali just mentioned. You got to, as you say, meet every day and figure, Do we have to turn the knob one way or the other? That’s really important message.
Joe Elia:
I’d like to ask you, Dr Fauci, what do you consider the best sources of information for clinicians and the public who want to keep abreast of that changing information? Is it the CDC site or is it MMWR? What would you recommend?
Dr Anthony Fauci:
You know, the CDC has put up a site, the Federal government, it’s an all-of-government site. It’s called Coronavirus.gov. They just put it up. I mean, we said at the press conference yesterday “Just dial coronavirus.gov,” and I did and it wasn’t where I needed it to be. But it should be there today. The other thing is that what we’re putting up on the website is something that we literally put together yesterday and it is what to do at home, what to do at the workplace, what to do in the hospital, what to do here, and really simple talk that not only physicians can benefit from but the general public.
So I would do CDC.gov and coronavirus.gov.
Dr Ali Raja:
Perfect. I’ll go there today actually. Dr Fauci, what about our listeners? The public isn’t typically going to listen to our podcast but a lot of clinicians do. What do the clinicians themselves do? What should they be doing given the conflicting ongoing need to be able to continue to screen and treat patients who are potentially affected, but also avoiding getting ill themselves? We know the basics of wearing the masks and the gowns, but what else can we be doing or what should we be doing as a system to protect our clinicians?
Dr Anthony Fauci:
Yeah. I mean, obviously that is so critical because if you look at what happened in China, the healthcare providers, I mean, there was like 1700 of them in just in the city of Wuhan who got infected. I would do as strict precautions as you possibly can. I would clearly wear an N95 mask, absolutely. I would wash your hands until it starts getting chaffed. I mean, we do that anyway with universal precautions but I would clearly do that.
The other thing, if you start and you will, guys. You’re going to start seeing cases come in. I mean, it’s inevitable.
Yeah, I would just…when people call in, and I know you’re doing that, you got to tell them and you said you have a system that’s segregated, that if you feel sick don’t just come into the emergency room. Stay at home for now and if you’re going to come in, figure out a way that they don’t come in and essentially infect five other people when they come in. That I think the clinicians need to know.
First instinct is that if this person has it I want to take care of them. You can take care of them but you got to be careful about essentially making the matter worse.
Joe Elia:
Dr Fauci, I wanted to ask you, what is the one thing you hope that people listening to this podcast will do differently in response to COVID-19?
Dr Anthony Fauci:
You know, it’s a binary thing. I want them not to panic because panic gets people to do unreasonable things that are even counterproductive to what you’re trying to do from a public health standpoint. You might overwhelm systems when you don’t need to overwhelm systems. But on the other hand without panicking and without making it dominate your life, pay attention to the fact that you have to act differently like you’ve never acted before. You’ve really got to be socially distant.
You know, it’s very interesting that my deputy was one of the two Americans who went to China as part of the WHO umbrella group that visited and in China now, they got hit badly, they had a few missteps in the beginning but they’re getting it right now. I mean, they’re really being super, super careful. They don’t allow anyone to eat at a common table. They have these little tables that are separated from each other in the hospital and other places where people don’t mingle. I mean, we’re all social beings but for the next few months, and I hope it does go down, it might not, but I hope it does the way flu does, we just got to hunker down. It’s part of what we need to do, we need to hunker down.
Joe Elia:
All right. I want to thank you, Dr Fauci, for talking with us today.
Dr Anthony Fauci:
It’s my pleasure.
Joe Elia:
Best of luck to you and to you, Ali, in the coming months. Thank you again.
Dr Anthony Fauci:
Thank you both. Thank you, Ali. It’s a pleasure to meet you.
Dr Ali Raja:
You as well. Thank you.
Dr Anthony Fauci:
Take care.
Joe Elia:
That was our 256th 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 Kelley. I’m Joe Elia.
Dr Ali Raja:
And I’m Ali Raja. Thanks for listening.
The post Podcast 256 — Anthony Fauci: Talking with patients about COVID-19 first appeared on Clinical Conversations.
Here we have an interview with Prof. Feng He, whose English is much better than my Mandarin. Thus, I’ve attached a transcript to make her ideas on salt intake (no level is too low) and blood pressure (there’s a dose-response relation with salt) more immediately available than it might be to your ears alone.
She’s coauthor of an article in The BMJ — a meta-analysis — that finds the effect of salt is greater with age, and in non-white populations and those with hypertension.
Links to articles mentioned and apps:
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The BMJ meta-analysis discussed
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Salt reduction in England from 2003 to 2011: its relationship to blood pressure, stroke and ischaemic heart disease mortality https://bmjopen.bmj.com/content/4/4/e004549
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Formulas to Estimate Dietary Sodium Intake From Spot Urine Alter Sodium-Mortality Relationship https://www.ahajournals.org/doi/full/10.1161/HYPERTENSIONAHA.119.13117
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Role of salt intake in prevention of cardiovascular disease: controversies and challenges https://www.researchgate.net/publication/324874931_Role_of_salt_intake_in_prevention_of_cardiovascular_disease_controversies_and_challenges
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Salt Reduction to Prevent Hypertension and Cardiovascular Disease, JACC State-of-the-Art Review http://www.onlinejacc.org/content/75/6/632
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Salt reduction lowers cardiovascular risk: meta-analysis of outcome trials https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)61174-4/fulltext
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Foodswitch app: http://www.foodswitch.co.uk/
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SaltSwitch app: https://www.ncbi.nlm.nih.gov/pubmed/28631933
Running time: 28 minutes
Here is a transcript of the interview:
TRANSCRIPT OF INTERVIEW WITH PROF. FENG HE WHO HAS REVIEWED AND CORRECTED IT
Joe Elia:
Salt and sodium intake have challenged medical researchers for generations. What seems indisputable is that too much salt is not good, especially in hypertension. After that things get fuzzier. National advice on restricting salt intake has been challenged by findings that restricting salt too much can increase cardiovascular risk.
Professor Feng He and her colleagues looked at the question of whether existing studies showed a relation between reductions in dietary sodium and changes in blood pressure. They performed a meta analysis of 133 studies comprising some 12 thousand 200 participants. Those studies all randomly allocated participants to either reduced sodium intake or usual (and thus higher) intake. All studies collected 24-hour urine sodium data to estimate those intakes. In short, they found a dose – response relationship between intake and blood pressure change.
Professor He works at the Wolfson Institute of Preventive Medicine at Barts and the London School of Medicine and Dentistry, Queen Mary University of London. Welcome to Clinical Conversations, Dr. He.
Dr Feng He:
Thank you. Thank you for having me.
Joe Elia:
You have been researching salt for about 25 years. What have you observed about the research over that time? Have you changed your mind about the effect of dietary salt and health and blood pressure?
Dr Feng He:
No, I haven’t changed my mind, because when you look at salt reduction as a public health strategy, you need to look at the totality of evidence. You need to look at all different types of studies, including epidemiological studies, population-based intervention studies, randomized trials in humans, animal studies, and also physiological studies.
So all of these different types of studies have consistently shown that a high salt intake is a major cause of raised blood pressure. Salt intake is also an important determinant of the increase in blood pressure with age. I remember when I was in medical school, we were taught that systolic blood pressure increases with age — that this is a normal physiological phenomenon. But later scientific evidence has clearly shown that this is not normal, and that high salt intake is an important contributor for the increase in blood pressure with age.
If you look at the societies now, you know, there are still some societies isolated to tribes. They don’t have added salt in their diet, and that’s like our human ancestors, And their blood pressure, their average blood pressure for the adult population is only 90/60 mm Hg, and their blood pressures do not increase with age and these populations do not have cardiovascular disease at all. You may say, “No, people in isolated tribes die at a much younger age.” However, if you compare those isolated tribes with Western populations of the same age group, in Western societies so many people suffer or die from cardiovascular disease.
Joe Elia:
Yeah. The fact that the research is ongoing tells us that not everyone believes that the results are final yet. Would you agree with that?
Dr Feng He:
No. Actually you know, you never get a final result because you know what? For any dietary factors, it is extremely difficult to do randomized outcome trials. Remember, for salt reduction you have to randomize many thousand individuals to the high-salt or the low-salt diet and keep these two groups for many, many years to see whether there’s a difference in cardiovascular outcome.
The problem with this is, firstly, there’s overwhelming evidence that shows that a high salt intake is harmful to human health. It’s unethical to put a group of people on a high-salt diet for so many years.
Secondly, you know, on the lower-salt group in the current food environment, it is extremely difficult for individuals to keep to the lower-salt diet for many, many years. That’s almost impossible in the current food environment.
And thirdly, many countries have started salt reduction initiatives — governments and NGOs have programs as do health professionals. Even in the media — in the control group if you want them to be on the high-salt diet, they’ll receive all these messages from the media — from the radio, from television, from newspapers. They [high-salt controls] will lower their salt intake, too. So in the end you wouldn’t see a difference in salt intake between the two groups and then there’s a severe contamination between the two groups.
So it’s difficult to do such outcome trials you know, to keep two groups on the low and the high salt there for many, many years.
Joe Elia:
I see. Is it possible to lower salt intake too much?
Dr Feng He:
No, if you look at those isolated tribes, they don’t have added salt to their diet. You know, there’s lots of food, and some of the food naturally already has sufficient salt, like meat. Our ancestors, they did not have added salt, but they lived healthily. Now in the isolated tribes, they are still living in the lifestyle of hunter-gatherers. They don’t have added salt. Their salt intake as measured by 24-hour urinary sodium excretion is less than 1 g a day. It’s much lower. You know, they live perfectly well. They don’t have cardiovascular disease.
So, you know, in our current food environment in Western societies there’s no way you could reduce salt intake to such a level. Currently in most countries the average salt intake is about 10 g per day and the WHO recommended level is 5 g per day. And for the US it’s 6 g per day and for the UK it’s also 6 g per day for the general population.
However, for the US, in almost half the population, the target actually is much lower. It’s 4 g per day for individuals with high blood pressure, people of African origin, and people with kidney disease, because they are at increased risk. So their target should be even lower — to 4 g per day.
Joe Elia:
Well, what prompted you and your colleagues to undertake this meta-analysis?
Dr Feng He:
This actually is an updated meta-analysis. I don’t know whether you know, we have published a meta analysis in 2013 in the same journal, The BMJ. At that time what we looked at was a modest reduction in salt intake and over a longer duration as the current public health accommodation. For example, from 10 g per day to 5 g per day to see whether that had significant effects on blood pressure. What we showed was that a modest reduction in salt intake for a longer term, like for a duration over a month or longer, there’s a significant effect on blood pressure in both hypertensives and normotensives.
So for the new meta-analysis, not only did we update it to include many more trials but also there’s a focus on the dose-response relationship with salt reduction and blood pressure. And we also looked at duration, whether the duration [of reduction] has any effect on the effect of the salt on blood pressure.
So this time the inclusion criteria were different. We basically included almost all of the salt reduction trials with 24-hour urinary sodium measurement. So with these many studies we have shown a clear dose-response relationship; so the greater the reduction in salt intake, the greater the fall in blood pressure.
The current public health recommendation is from the current level of approximately 10 g per day to the WHO-recommended level of 5 g per day. That will have a significant effect on lowering blood pressure. However, if you lower salt intake further, down to 3 to 4 g per day, the effects on blood pressure would be bigger. So there’s a clear dose-response relationship: the greater the reduction in salt intake, the greater the fall in blood pressure.
Joe Elia:
So you found that lowering salt intake is good for blood pressure, even among people without hypertension. But you were careful to limit your findings to blood pressure and not cardiovascular disease or other things, and…
Dr Feng He:
This is very good question. Because as I mentioned earlier, it’s extremely difficult to do a randomized trial for cardiovascular outcomes. Hardly any trials have looked at the longer-term salt reduction on cardiovascular outcome. And having said that, I don’t know if you have seen our previous meta-analysis published in the Lancet. Basically because there’s an insufficient number of studies looking at long-term salt reduction on cardiovascular outcome, what we looked at in that meta-analysis was the trials whose aim was to look at the blood pressure.
However after the trials completed, the researchers followed this population up for many years after the trial, so even that type of study you know, wasn’t exactly a long-term outcome trial; but still, that type of study has indicated that a reduction in salt intake has a significant effect on reducing cardiovascular events.
Joe Elia:
But the question that you asked was a simpler one and in addition to lowering blood pressure across the board, you found that studies that were of a short duration, for instance two weeks or less, didn’t show the effect as much as those studies that were longer-term. Is that right?
Dr Feng He:
That’s right. That’s right. Basically these studies show that the dose-response relationship is much stronger in the longer-term trials compared to short-term trials. So it’s likely that the shorter-term studies have underestimated the impact of salt reduction. The problem with looking at the duration and looking at the effect of duration on the effect of salt reduction is quite difficult, because at the moment not many longer-term salt-reduction trials, only a few trials have had a duration lasting six months or longer.
The problem with this type of trial is, initially, people achieve their reduction of salt intake, but with time you know, with the current food environment it’s impossible for individuals to keep the lower-salt diet for long term. So by the end of, say, a few years their salt level has already gone back to the higher level, so that’s why longer-term studies cannot see a greater effect. Because over the longer term they have not achieved a greater reduction of salt intake.
So if you really want to look at the long-term effect, the duration, the effect of duration on blood pressure, we should have longer-term trials, with the individuals kept on the low-salt diets throughout with multiple measurements of blood pressure throughout. The only study that can show this is the DASH Sodium study. I do not know whether you have heard of the DASH Sodium study. In this DASH-Na study the compliance is perfect because it’s a feeding study. All of the food and the drinks are provided to the participants. So the individual can keep the lower salt diet over the whole study duration. That study has shown that, with a longer duration the effect of salt reduction on blood pressure is bigger, compared to short-term study.
A footnote: Dr. He wanted to add this observation after her comments on DASH: “Countries that have achieved a reduction in salt intake for several years, for example, Finland and the UK, have demonstrated a much greater impact of salt reduction on population blood pressure”.
Joe Elia:
The effects seemed especially stronger in older people, non-white populations, and those with higher baseline systolic pressures.
Dr Feng He:
That’s right.
Joe Elia:
Okay. And so I guess that’s the population it would seem that would have been exposed, especially older people, to this kind of food environment as you describe it, that is going to have loaded their bodies up with salt over many years, isn’t it.
Dr Feng He:
That’s one of the reasons but there are other reasons. In our human body we have these hormonal systems like the renin-angiotensin system, and this system is actually maintaining our blood pressure. And because for individuals with older age and people of African origin and also people with high blood pressure, their renin-angiotensin system is suppressed. And so usually, like in young people, if you reduce your salt intake, the renin-angiotensin system would react and then there’s an increase in plasma renin activity and increase in angiotensin II.
This is like a compensatory mechanism to maintain our blood pressure. So for elderly and for people of African origin and also for those with high blood pressure, this system is not as active as in young people or compared to their counterpart in the white population or people with normal blood pressure. That’s one of the mechanisms for those subgroups to have a greater fall in blood pressure for a given reduction in salt intake.
Joe Elia:
What do you think these findings mean for people who are skeptical about over-restricting salt intake? There have been some researchers in Europe — I know of one group — that have data saying that over-restriction of sodium leads to greater cardiovascular risk.
Dr Feng He:
Yes, I’m fully aware of these publications. We have published several papers and there’s lots of debate about this. The problem with their studies is that there are severe methodological problems. For example, their study measured salt intake using spot urine. Spot urine measured sodium concentration. For example, if I just have two glasses of water now, and two hours later I collect spot urine. If you measure my sodium concentration in that spot urine, it’s much lower because it’s diluted.
And also this spot urine, they converted spot urine sodium concentration to 24-hour urine sodium to estimate individuals’ daily salt intake.
Joe Elia:
I see.
Dr Feng He:
They used a formula to convert this spot urine sodium to 24-hour urine sodium. This formula included age, gender, sex, height, weight. We all know age is an important determinant of any health outcome and death, and that age is also associated with salt intake. And also the other factors — gender and body weight and a 24-hour urine creatinine — all of these factors are important confounding factors because they both related to salt intake, and also related to health outcome.
So in this study you know, they can’t control such confounding factors.
Joe Elia:
I see. Okay.
Dr Feng He:
So there’s a lot of methodological [errors]. We call it measurement errors. Using spot urine is one of the contributing factors for the J-shaped findings. We published a paper in the International Journal of Epidemiology and another one in Hypertension, and clearly showed that this formula — the variables like age and gender, height and weight, the creatinine concentration — they all are important contributors to the J-shaped findings.
That’s the only one of the factors. Another factor in lots of cohort studies is that they included people who are not well, who are sick. And this is called “reverse causation,” because we know that if you are not well you can’t eat, and then you have lower salt intake. And then because you’re not well, you have a chronic disease, you’re more likely to die, so the lower salt intake in these individuals is the consequence of their underlying disease and it’s [lower salt intake] not the cause. So there are lots of problems with the J-shaped findings. And so you see our recent paper [which] clearly shows that these different factors have contributed to the J-shaped findings.
If you use accurate measurements of salt consumption like we did, we analyzed the Trials of Hypertension and Prevention [TOHP] follow-up data. Actually that study was done in the US, and we collaborated with Professor Nancy Cook at Harvard University [Brigham and Women’s Hospital]. In the TOHP study, all the participants had multiple nonconsecutive 24-hour urine measurements and measured their salt intake, and so if you look at it, this salt intake, you can see there’s a clear linear association. So the lower the salt intake, the lower the risk of death, down to a salt level of actually 3 g per day. There’s no J-shaped or U-shaped relationship.
Joe Elia:
There is none. Okay. What do you hope will happen as a result of your continuing work on this and your current published analysis?
Dr Feng He:
I hope definitely there’s a clear message that salt reduction is extremely beneficial to the whole population, not only in those with high blood pressure but also in individuals with blood pressure in the normal range. So firstly, the general public need to be more salt-aware and also reduce their salt intake. And for the clinicians, they need to give their patients appropriate advice on how to reduce their salt intake, because in our clinic, sometimes the patient will say “Oh, my salt intake must be low because I never use salt in my cooking or at the table.”
But when we measure it, you know that salt intake is extremely high. The patients, they did not know that the food they usually eat — bread, breakfast cereal — are really high in salt. So in most of the Western countries like the US, UK, and in many other developed countries, about 80 percent of salt in our diet is added to our food by the food industry.
So for the food industry, they needed to make a gradual and sustained reduction in the amount of salt they add to all of their products. And the UK has been very successful in reducing the population salt intake. In 2000, 2003 we [the UK] started a salt reduction program in collaboration with the Food Standards Agency and also our group Action on Salt. What we did is to set incrementally lower salt targets for over 85 categories of food.
And the principle is a small reduction — a 10 to 20 percent reduction — and then you repeat it at two- to three-year intervals. And if you do it gradually, you know, small reductions, the general public wouldn’t notice any difference in their taste. And they can continue to buy the food that they usually buy and their salt intake will come down. The UK salt-reduction program has been really successful. From 2003 to 2011 salt intake in the population was reduced by 15%, from 9.5 g per day in 2003 to 8.1 g per day in 2011.
So this you know, 15% reduction in population salt intake has led to a significant reduction in population [systolic] blood pressure by 2.7 mm Hg, and this was associated with a significant reduction in population mortality from stroke and ischemic heart disease.
Joe Elia:
Oh. I think we should all be reading labels more carefully when we buy food.
Dr Feng He:
Definitely. For individuals in developed countries it’s important that when we do shopping, we choose the lower salt option, and actually now there’s an app available. You can use this app and scan the bar code and then it will give you the lower salt option and you know, there is a similar product that tells which ranks high in salt, which ranks low in salt.
Joe Elia:
What is the name of that app?
Dr Feng He:
It’s [Salt Switch]. Actually there’s a more comprehensive one, it’s called Food Switch.
Joe Elia:
Just a footnote here, Dr He contacted me after our interview and wanted to be clear that she had misspoken about the name of one of the apps. They are Salt Switch and Food Switch and I’ve included links to both on the website, podcasts.jwatch.org.
Dr Feng He:
And then in the UK, Australia, and in China, and in India, there’s an app, freely available for download and when you go shopping you just scan the bar code and it will give you the “traffic light” labelling. It tells you which one is healthier, and it gives you alternatives to buy.
Joe Elia:
Well, I want to thank you very much for talking with me today, Dr He.
Dr Feng He:
Thank you. Thank you very much. It’s so good to talk to you.
Joe Elia:
That was our 255th episode. All of them are available free at podcasts.jwatch.org. We come to you from NEJM Journal Watch and the NEJM group. The executive producer is Kristin Kelley, and I’m Joe Elia. Thank you for listening.
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The post Podcast 255: Salt talks — transcript included first appeared on Clinical Conversations.
JAMA recently published a review of some 40 papers examining the relation between malpractice liability strategies — tort reform, increased insurance premiums, etc. — and the quality of care. Apparently the efforts had no discernible effect on mortality rates, length of hospital stays, and the like.
An editorial accompanying the paper sketches out a vision of where future efforts should lead, especially given the shift in U.S. medicine from private to institutional practice.
The coauthor of that editorial — surgeon and law professor William Sage — is our guest.
Links:
Malpractice liability and health care quality article in JAMA
Sage and Underhill’s editorial in JAMA
Running time: 17 minutes
The post Podcast 254: Old malpractice liability strategies need rethinking first appeared on Clinical Conversations.
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.
Cancer article
Cancer editorial
An earlier (2015) podcast on the question of the number of vaccine doses needed to confer protection
Running time: 16 minutes
The post Podcast 253: Is a single-dose HPV vaccination effective? first appeared on Clinical Conversations.
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 offer that conversation again. We hope you’ll listen and vote — and if you do vote, please leave a comment as well.
URL for November’s original podcast
Running time: 19 minutes
The post Podcast 252: We revisit our chat about chatting about guns first appeared on Clinical Conversations.