The Covid-19 Newsletter That’s by Doctors for Doctors

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.”

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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