‘No two cases are the same:” Yakima hospital tailors treatment for each COVID-19 patient | Coronavirus

TAMMY AYER Yakima Herald-Republic

Seven days a week, Virginia Mason Memorial Hospital staffers who are caring for patients with COVID-19 meet in the morning to go over cases.

They gather in the auditorium so there’s room for people to sit and stand 6 feet apart from each other. The hospital maintains a list of every current patient who has tested positive and is under investigation for COVID-19, the respiratory illness caused by the novel coronavirus, said Dr. Marty Brueggemann, chief medical officer of the hospital. The 8:45 a.m. daily COVID rounds deal with the clinical management of COVID patients but also involve discussions about broader treatment strategies and issues such as community trends, new testing strategies and personal protective equipment.

“We go literally case by case. We discuss the latest treatments, try and tailor our approach to each. We started that really early, pretty much the minute we started to get patients,” Brueggemann said in an interview Thursday, when the hospital had 32 COVID-19 patients.

“Every day it gets a little bit bigger. … It’s almost like having a daily medical conference. It’s great for learning. … You really get good at the nuances of this; no two cases are the same. You really tailor your treatment to the specific intricacies of each patient.”

In the process they’ve learned what works, such as prone positioning for those with COVID-19, meaning patients are placed on their stomachs. When patients are on their backs, the bottom portion of their lungs gets pressure from tissue on their chest. “If you flip them over onto their stomach, you’re changing what part of the lung you’re using. Sometimes you can flip them back and forth,” Brueggemann said. Sometimes it means doctors can hold off on intubating them.

They’re also learning more about risk factors. “The biggest risk factor we’re seeing right now is obesity. We’ve had these young people who died or got really sick (and) what we’re finding is a huge proportion of those are morbidly obese,” he said.

Discussion also turns to continued efforts to slow the spread of COVID-19 and protect others. They have “flattened the curve” but people are getting fed up with being isolated and are starting to get complacent, Brueggemann said.

“We expect that will prolong this and we will see a spike” after Gov. Jay Inslee lifts stay-at-home order, which will take place in phases. “I would anticipate a few weeks after that we’re going to see a little bit of a spike. It’s still here, it’s not gone. (But the novel coronavirus) doesn’t have the fear factor (it did),” he said.

Brueggemann answered other questions related to care of COVID-19 patients. Responses to the following questions have been edited for clarity.

• What do you want the public to know about some of the new COVID-19 symptoms outlined by the Centers for Disease Control? What about how the symptoms present in older adults vs. younger adults?

We’ve seen so many different ways this presents … everything from asymptomatic all the way to sudden cardiac death. The classic we think about is fever, body aches, cough. One of the things that’s really difficult about COVID, there are some really insidious symptoms that people don’t recognize for what it is.

This is one of the challenges we face. … People submit case reports to scientific journals because those cases are interesting and different. As you take something like a COVID phenomenon, what do the majority of people present like? That becomes old news. Then this one person presented with they couldn’t smell; we should report that. It becomes an interesting thing to talk about on TV, but you’re talking about a kind of rare exception case. … All that does is just create anxiety and questions. It’s so remote and not mainstream.

If you talk about the symptoms, the newer issue is the realization of how many asymptomatic people are out there. There’s this kind of sense developing nationwide … people are starting to let their guard down. What actually has happened is we’re victims of our own success. We have successfully flattened the curve. We’re seeing pretty stable numbers.

With the flattening of the curve, it gets spread way out. … The cases are still coming in. We’re seeing this very prolonged peak. What that means is this going to take us a lot longer to come out of.

We’re probably going to see cases for months and we actually expect this to rebound in the fall. We can’t go back to what we’re doing now to slow the spread; the economy and society won’t tolerate it. Hopefully we’ll have better infrastructure in place for testing. … the Holy Grail is the vaccine.

• How is Virginia Mason Memorial treating patients with COVID-19? What medications are you using? Are hydroxychloroquine and remdesivir among them?

This is highly evolving. Here’s the other thing you see with something like COVID. Generally when we get a new drug for treatment, it has been through robust trials and FDA scrutiny. By the time it rolls out, we have a really good idea of if it’s effective. … By and large these things have been really well studied before they release to us.

Here you have a brand new disease process that did not exist six months ago. Then it becomes a race, who can develop the treatment. There’s an actual public crisis where you need these treatments.

Remdesivir shows some promise. Hydroxychloroquine is an old drug; we use it to treat malaria. We do use it in certain COVID-19 cases, hospitalized patients who are sick and declining. We have seen some of those patients improve.

… We try and tailor our treatment. The remdesivir is investigation only. It’s not approved. It’s kind of a last resort. The FDA allows trials to give it. We’re not approved to give it. Virginia Mason, our partner agency does have that option. We do have patients transferred to Virginia Mason in Seattle. You have to be on a ventilator. We go through all the different criteria concerning the potential to benefit from it, then patients get transferred over.

• What about intubation for COVID-19 patients? Have approaches on that changed locally?

That is one of those areas that’s evolving a little bit. The team that meets every morning discusses each one of these cases. When someone needs to be intubated — put on a ventilator — it usually doesn’t happen precipitously.

What’s the appropriate timing for intubation? When do we need to do that? You’re usually ventilating for a long time.

You intubate them as early as you think you need to, to limit injuries to the lungs. Once you put them on a ventilator, you put them on a closed system so there’s not as much virus being spread through the air. Every time they cough, they’re blowing virus all over the place. If you think someone’s going to need it, do it sooner rather than later to protect your staff.

As I understand it, we’re starting to rethink this a little bit. Let’s wait a little bit. Let’s give them a little bit longer to declare themselves. Maybe they turn around.

As it turns out, the process of intubating someone is really dangerous for the person doing it. … When you’re putting a breathing tube in, you are right in that person’s face for several minutes. It’s a really high-risk thing to do. When we do it, we err on the side of doing it early, allow more time to set it up and ensure safety for staff rather than wait until patient is on the verge of dying and have to do it quickly.

• Do we have ECMO (extracorporeal membrane oxygenation) capability here? Has it been used?

No, that’s something you’re only going to see at a tertiary care center. That’s not something you’re going to find in a community like Yakima. It requires a lot of resources. You’re not going to find that in a community hospital. That’s pretty high-level stuff.

• What about the latest information involving blood clots? Are you doing anything differently in that regard?

Last I heard, there wasn’t any specific change in treatment. But actually any patient coming into an ICU setting, even without something like COVID, you’re at risk of a blood clot because you’re sedentary.

Blood clots have not been a common recurring medical problem with COVID-19 patients here.

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