As coronavirus COVID-19 patients began to stream into southeast Michigan emergency departments last month, it wasn’t just the numbers that stunned doctors and nurses.
It also was the challenge of treating a novel virus — and in particular, one that seems to defy some of the standard treatments used for respiratory illnesses.
Six weeks into Michigan’s coronavirus crisis, the disease has resulted in numerous medical mysteries: What markers show a patient is about to take a turn for the worst? Under what circumstances should a ventilator be used? Why is it so difficult to keep some COVID patients on ventilators under sedation? Why do some patients seem fine even as their oxygen level plummets? Why does COVID-19 seem such more lethal for people with diabetes vs. those with asthma?
It’s an unprecedented challenge for doctors, who are having to change their treatment protocols “on an almost daily basis,” said Dr. Anne Messman, an emergency department doctor for Detroit Medical Center.
“It’s a different disease than we’ve ever seen before,” Messman said. “We don’t have years worth of data or randomized controlled trials to guide our management. We’re just going off to the experience of whatever country where COVID presented previously that can give us information. I’m not saying it wasn’t reliable, but the recommendations they were making don’t seem to be holding true over here.”
Dr. Teena Chopra, a Detroit infectious disease specialist, echoed that frustration.
“There’s a lot of unknowingness in this disease,” she said, “and applying the principles that people learned in China and Italy and France and elsewhere in the U.S. is challenging” because Detroit’s population has higher rates of risk factors such as obesity and diabetes, which complicate treatment of coronavirus.
“As we speak, we are designing protocols and processes so we can provide timely care in the form of drugs and other therapies,” Chopra said.
But the struggle to develop best practices on the fly with a new disease has been a formidable task.
Among the challenges:
Patients can deteriorate very quickly.
“It feels like they’re getting very unstable out of nowhere,” Messman said. “We’re still figuring out what are we looking for, exactly, to indicate that somebody’s getting sicker. We still don’t know how to tell that bad things are imminent.”
Chopra said she’s also been struck by the “very dramatic life cycle of this virus.”
“At one moment the patient is breathing fine and in another hour they are crashing on us,” she said. The virus can “invade various organs in our body and it can cause a downstream effect of damage in the form of what is called a cytokine storm,” an overreaction of the immune system in which the body starts attacking its own cells and tissues.
Those cytokine storms can be fatal, but doctors are still struggling to understand how to prevent them, they say.
Patients can have unusually low oxygen levels without other signs of deterioration.
“The markers are different in these patients,” Messman said. “Their oxygen level can go down, and they still say they feel fine. It’s unusual in any disease where that’s not an indicator of someone getting more sick.”
The standard practice with most illnesses is to maintain a high oxygen level, agreed Dr. Dennis Cunningham, an infectious disease specialist for McLaren Health System.
“It turns out with COVID patients, patients are tolerating lower blood levels of oxygen,” he said. “This may be the virus is actually altering hemoglobin, which is the protein that actually carries oxygen molecules.”
“So patients can be awake and talking, and there’s no sign that other organs are being impacted by the low oxygen,” he said. “They’re doing fine. So this is really something that’s very different from our usual management, and I think it’s taken some time for everyone to realize that.”
Diabetics seems at higher risk of complications than asthmatics.
Yet another mystery, Cunningham said, is that diabetes turns out to be much more of a risk factor for COVID-19 complications than asthma — which is odd, because COVID-19 attacks the lungs.
“Even if your diabetes seems to be well controlled, it’s still a risk and I don’t have any plausible explanation for that,” Cunningham said.
Nor can he explain why asthma seems to be less problematic.
“You would think asthmatics would be at a really high risk because usually viruses make asthma go out of whack,” he said. “I’m happy that’s not being a problem in the way we expected, but it really makes us question how well we understand the mechanism of infection that is causing symptoms.”
The struggle over timing ventilator use
The initial inclination was to put COVID patients on ventilators fairly early in the treatment process.
“We found the hard way that doesn’t seem to help. It actually seems to make things worse,” Messman said. “So now, we’re holding off as long we can. It’s been a complete 180.”
Cunningham agreed that figuring out best use of ventilators for COVID patients “has been a big challenge” and McLaren’s current strategy is “avoid the ventilator for as long as possible.”
“Theoretically we know a lot about how to manage ventilators,” he said. “But this disease has some quirks to it. It’s a unique virus we have not seen before, and it’s hard to figure out the best way to do things.”
Related to the ventilator issue, nurses have reported it’s hard to keep COVID patients calm and sedated while on the ventilators, sometimes forcing use of drug combinations that can bring down a patient’s blood pressure and make them more unstable.
Cunningham confirmed that’s true. “And it doesn’t make it easier there are some drug shortages, so we’re not necessarily able to use our preferred sedatives that we have the most experience with,” he said.
Debate over effective medications.
“One week, we’re recommending steroids and the next week we’re recommending against it, and treating with hydroxychloroquine,” Messman said. “I think the answer is, we just don’t know.”
“All we have is anecdotal evidence instead of real data,” she said, adding different doctors have “completely opposite opinions” on medications such as hydroxychloroquine, which has been repeatedly touted by President Donald Trump as a possible “game-changer” in the fight against coronavirus
“I’m agnostic on its use,” Messman said about hydroxychloroquine. “Some people feel very strongly that it helps. Some people feel very strongly that it’s harmful.”
But that opinion often results from each doctor’s experience with a few patients — and it’s hard to tease out the drug’s impact when “there are a million different variables” at work, she said.
Chopra said she’s been prescribing hydroxychloroquine. “If used early on, it seems to be helping,” she said. She’s also been trying steroids, as well as blood thinners because of the number of patients she’s seen with clots in the lungs.
Cunningham said he’s also using steroids for people whose lungs are severely impacted, “and that seems to be helpful.”
“I’m not impressed by the data” for hydroxychloroquine, Cunningham said. “I don’t think that’s going to do the trick. The one that’s most promising is remdesivir; I think that’s the one that going to wind up being the best, but we’re still waiting for the clinical trials.”
New ways to intubate patients.
The fact COVID-19 is so contagious has further complicated treatment plans, and led to doctors and nurses developing new protocols around intubation, which is part of the process of putting someone on a ventilator.
A routine procedure in normal circumstances, intubation is one of the riskiest maneuvers for health-care practitioners caring for coronavirus patients because it requires getting right into the patient’s face and inserting a tube that results in a expulsion of breath likely laden with the virus.
Because of the risk, Derek Rouse, certified registered nurse anesthetist for Kalamazoo Anesthesiology, said he and a co-worker developed a new protocol for intubation at Borgess Medical Center in Kalamazoo.
That protocol involves having everyone else leaving the room while the intubation is being done, while the person during the intubation is double-gloved and completely covered.
Instead of visually assessing the patient’s airway, he said, a miniature camera is used, and he uses a process called Rapid Sequence Induction and Intubation to get the breathing tube inserted within 60 seconds.
“It’s a shorter timeframe” than the normal procedure, he said.
Dr. Matt Longjohn, a public-health physician on the faculty of the Western Michigan University medical school, said he been amazed and impressed at how health-care practitioners are rising to the challenge of dealing with COVID-19.
“It’s amazing how quickly we’re learning,” he said, and yet there is still much that’s unknown.
“When you’re operating in a crisis environment, studying what you’re doing is a lower priority than keeping the patient in front of you breathing,” Longjohn said. “You can’t wait for the best data available.”
“This mountain of evidence has to build” before best-practices can truly be developed, he said. “As amazing as it is, as quickly as it is that we’re developing our information base, we still are so far behind. We’ll have to continue to be flying this plane as we’re building it for awhile.”
In addition to washing hands regularly and not touching your face, officials recommend practicing social distancing, assuming anyone may be carrying the virus.
Health officials say you should be staying at least 6 feet away from others and working from home, if possible.
Carry hand sanitizer with you, and use disinfecting wipes or disinfecting spray cleaners on frequently-touched surfaces in your home (door handles, faucets, countertops) and when you go into places like stores.
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