April 27, 2020 Update
Dear All,
Some thoughts from last weekend in the hospital.
The Good:
The number of total patients in the hospital with COVID-19 has come down. Still in the hundreds but no longer the entire hospital. I even had some (albeit few) COVID-19 negative patients on my service.
We also changed our visitor policy so that patients who were actively dying would be allowed to have 1-2 visitors come to the bedside after they went through a brief health screening so that fewer patients were dying alone. I was able to do this for 1 patient who did not want to be intubated yet their lungs were failing them on maximum oxygen support. Because they were actively dying, we were able to get their loved ones into the hospital to the bedside before the patient ultimately passed away. The family reiterated over and over how meaningful it was that they were able to be at the bedside with their loved one before they passed.
The Bad:
From the above, you can surmise that deaths are still happening on a daily basis. The number of people dying each day is still FAR greater than ‘normal’ times. Further, the number of patients in the ICU and those on ventilators is not dropping nearly as fast as the number of hospitalized patients. This means that many of patients left in the hospital with COVID-19 are those who are requiring ICU level care and/or ventilators. Whereas we’ve been able to close some of the wings we created for floor patients, we have not been able to close the makeshift ICUs as the demand for those beds remains high.
This is consistent with national data that folks put on the ventilator are staying on the vent for a prolonged period of time. Many of the intensivists I’ve spoken with have commiserated on how challenging its been to wean patients off the vent. Which leads to the last thing many of us physicians are commiserating about…
We still have no good way to treat this virus either on the floors or in the ICU.
2 weeks ago when I was on service our protocol was to give hydroxychloroquine, azithromycin, and zinc. This was based on consensus expert opinion of our top infectious disease, pulmonary, and critical care physicians. 2 weeks later all three meds have now been taken off the protocol. None of three are ‘recommended’ but physicians can still give hydroxychloroquine and zinc (no one is using azithro) if they so choose.
2 weeks ago, the general consensus of the same expert group was to avoid steroids. Now, several intensivists I’ve spoken with are starting to use steroids at day 7 or later, especially for patients with significant oxygen requirements. The basis for this recommendation is not based on hard data, but based on their anectodal experience that it seems to be helping their patients. My hunch is that part of what’s driving this ‘kitchen sink’ approach is a helpless feeling on behalf of us physicians on watching someone deteriorate without trying SOMETHING to stop it even if we have no data to support it will work.
And finally, 2 weeks ago, very few patients were getting prophylactic (preventative) blood thinning with anti-coagulants (blood thinners). Now, we’re putting patients on full-dose blood thinners based on lab markers alone without evidence of clots. Blood thinners come with risk, most notably, severe bleeding. This can be particularly dangerous if a patient has a fall in the hospital, hits their head, or has a spontaneous bleed all of which are possible in a hospitalized patient.
In ‘normal’ times we make calculated decisions on whether someone should be on a blood thinner based on data that would enable us to calculate the benefit (treating/preventing a clot) versus the risk of bleeding. However, in COVID-19 we’re having to weigh these treatment decisions with no data or science as to whether we’re helping or hurting a patient’s chance of survival.
In summary, there are no rigorous trials or studies to support or refute any of the interventions we’re taking above. And, all of these interventions such as steroids and blood thinners may end up over time proving to be more harmful than helpful.
We just don’t know.
Never in my career have we had to fly blind like this before. Never in my career have entire treatment guidelines changed in 2 weeks time. And never in my career have we had to rely on anecdotal evidence alone to make major clinical decisions. But, that’s the world we’re living in treating COVID-19.
So, I gave steroids to a few folks who were maxed out on oxygen and on the cusp of crashing. One responded really well, another did not. I started some patients with really high d-dimers (lab value that can be elevated when someone has a blood clot but not specific) on full-dose blood thinners. Why? Because the protocol created by our experts who’ve seen as much COVID-19 in the last month as anyone recommended it.
These anecdotal protocols and recommendations are coming from the same doctors at NYU that I would want treating me if I needed hospital care. They are really smart, have seen a ton of COVID-19, and are widely published experts at the top of their field. Yet, they’ve been rendered to making educated guesses that need frequent revising week-to-week. We’re rigorously tracking outcomes in a pre/post fashion as we iterate our protocols and treatment guidelines to look for trends, but we all know none of this is as strong as traditional randomized trials we typically use to generate data.
My hope is that we’ll get more concrete answers to some of these questions in the near future because practicing medicine flying blind is as harrowing as it sounds. We can’t take the blindfold off soon enough.