The coronavirus pandemic has revealed how different critical care doctors are from the rest of us—and how similar. Different: They log heroic hours in the ICU, putting their own health and well-being at risk, to save as many lives as they can. Similar: Some of them pay too much attention to Twitter.
Those two facts go a long way toward explaining the mission of the authors of the “Fast Literature Assessment Review” (FLARE) newsletter at Massachusetts General Hospital. When they’re not treating Covid-19 patients in the intensive care unit, the eight doctors on the FLARE team work a second job: updating fellow physicians on the latest novel coronavirus research and debunking the freshest unproven theories floating around on social media. The free email list is still small but growing fast: It grew from around 1,000 to nearly 2,000 subscribers over the past week.
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It started informally, in early March. A team of doctors at the hospital, led by pulmonologist Charles Corey Hardin, wanted to develop internal guidelines for Covid-19 treatment. Realizing that the state of knowledge was changing by the day, they decided to take turns summarizing the most up-to-date information in a daily email.
“A few of us who are interested in some combination of basic science and medical education had been sending, as we often do, informal emails to our colleagues about papers we’d read,” recalls Raghu Chivukula, a pulmonary critical care doctor and biochemist who’s part of the newsletter team. “Things were evolving very fast, and there was no centralized place of knowledge that we could all trust.” Over the course of a week or so, those informal emails developed into the FLARE newsletter. In one of them, they debunked the idea that Covid-19 is similar to altitude sickness. In another, Chivukula poured cold water on the hype around hydroxychloroquine, the antimalarial drug that some people—most notably Donald Trump—had begun breathlessly touting as an effective treatment for Covid-19. “Corey, myself, and some of the others that self-organized into this group, do have a little bent of myth-busting about us, and I think all of us wanted to push back on this overexuberant, not really data-driven, enthusiasm,” Chivukula says. An expert on the biochemistry underlying chloroquine, he was well positioned to explain both why the drug could theoretically work to treat Covid-19 and why there was still insufficient real-world evidence to support using it.
Here’s where I’d normally quote from Chivukula’s piece. But it wouldn’t be much use unless you can parse sentences like “In the ensuing years, basic virology studies established that SARS-Cov depends on endosomal escape, that it buds from the Golgi apparatus, and that its receptor (ACE2) is itself glycosylated in the Golgi.” FLARE is very much by doctors, for doctors. For the trained specialists who know their way around pulmonary jargon, however, the newsletters are concise, to the point, and meticulously footnoted. They begin with “The FLARE Four,” an Axios-style list of key takeaways, in large font, for the TL;DR crowd. And while the layout is unlikely to win any design awards, there’s just enough formatting to help a tired ICU doctor’s eyes navigate through the densely packed material.
Sign-ups spread quickly throughout Mass General and then beyond. Delivered via MailChimp, it now reaches doctors as far away as South Africa and India. Başak Çoruh, the program director for the pulmonary and critical care fellowship at the University of Washington, says she reads every issue and encourages her 19 fellows to do the same. “It’s a curated, easily digestible resource, and it’s based on scientific evidence,” she says. “Nearly all of them have been incredibly helpful, because they’re really targeting common questions that come up in critical care.” The archived emails are all freely available on Mass General’s website.
The FLARE team meets every day for a 4 pm Zoom meeting, at which they discuss a first draft written by a team member or, occasionally, an outside contributor. Later, they’ll group-edit a Google Doc. Camille Petri, a pulmonary and critical care fellow, is in charge of formatting and hitting Send—which often doesn’t happen until late at night. Considering these are all doctors who treat Covid-19 patients in critical care, the tone of the meetings is surprisingly goofy. Inside jokes abound. Some of the doctors set scenes from favorite movies as their Zoom backgrounds; meetings begin with a brief round of trying to guess one another’s movies.
The goal isn’t always myth-busting. Many issues of FLARE are explainers (“SARS-CoV-2 Affects Children Differently Than Adults”). But the topics gravitate toward whatever questionable theory is being discussed on medical Twitter. “I’m only being a little facetious here: Some of it is what pisses me off during the day,” Hardin says. “There’s a lot of stuff that’s floating around that I would characterize as nonsense.”
One recent example: the credulous reaction to a New England Journal of Medicine article on the promise of the antiviral drug remdesivir, produced by drugmaker Gilead Sciences. As the April 16 FLARE pointed out, that paper lacked a control group (in fact, Gilead chose the patients), included no information on how the drug affected viral load, and was funded by Gilead and written and edited in part by Gilead employees. As a result, the team concluded, “the study results cannot be used to guide clinical decisionmaking.” (That doesn’t mean remdesivir won’t work, only that it hasn’t been proven yet. Gilead’s CEO has released an open letter acknowledging the paper’s data collection limitations but defending “compassionate use” investigations, in which an unapproved drug can be used as a last-chance treatment for critically ill people.)
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During a recent Zoom meeting, the thing pissing Hardin off was a theory going around that hospitals are being too quick to place Covid-19 ICU patients on ventilators. The medical publication STAT had recently published an article that quoted a handful of doctors making the claim, based on anecdotal observations of patients who had dangerously low blood oxygen levels but didn’t seem to be doing too badly otherwise. This fell into a broader argument that runs through many issues of the newsletter: whether Covid-19 patients in critical care are different from normal pulmonary critical care patients and require new, innovative treatments. Hardin and his colleagues argue that the answer is no. While the virus is new, it’s causing a familiar condition known as acute respiratory distress syndrome, or ARDS. Even seemingly “normal” patients with low blood oxygen can fall within the diagnostic criteria for ARDS. The best thing to do for those patients, the FLARE team argues, is to apply the ventilation protocols developed from decades of rigorous ARDS research—not try out a different approach that may have worked in a non-controlled setting on a handful of patients.
Other pulmonologists who are not part of FLARE have echoed that argument. “What I’m seeing as I care for patients with Covid-19, who by definition have ARDS, is that we should continue to practice best ARDS management because we are confident that these principles keep patients safe on the ventilator and improve outcomes,” says William G. Carlos, a pulmonary critical care doctor and chief of internal medicine at Eskinazi Hospital in Indianapolis. “It’s dangerous to make blanket statements that Covid-19 is not ARDS because it jeopardizes best standard practice and may lead to inappropriate or potentially harmful ventilator management.”
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To Hardin and his team, the counterargument—that Covid-19 critical care patients require a departure from the ARDS literature—reflects a natural, but perilous, human impulse to extrapolate from limited data in an unfamiliar and daunting situation. The underlying message of most FLARE issues is to avoid the temptation of anecdote, the allure of the silver bullet that will make the pandemic go away. “In the ICU in particular, you just can’t rely on information that’s been derived from 20, 30, 40 patients in a single center,” says Hardin. “You can’t rely on things that seem to make sense.” What works for one patient, he says, might make things worse for another. “I told all my fellows: Here’s what I want you to do. I want you to look at your patient, and I want you to close your eyes and imagine it’s last July, before SARS-CoV-2 existed. What would you do for this patient? Do that. Just do that, and you’ll be OK.”
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