Last month as my colleagues and I took care of Mrs. Smith (not her real name), a middle-aged woman hospitalized with Covid-19, every day felt like an education in learned helplessness.
No matter what our team did, her infection kept getting worse. At first she was breathing just room air. Then she needed extra oxygen delivered by a small tube sitting below her nostrils. After that she needed more oxygen delivered through a facemask.
We gave her the drug remdesivir, but she didn’t get better. We gave her high-dose steroids, but she didn’t get better. We even gave her the antibody cocktail that President Trump and many of his high-profile allies received, but she didn’t get better.
Mrs. Smith’s fever climbed, her breathing worsened, and her spirits sunk. Every time I called her husband, I searched for a silver lining, but all I could share was one decrement after another.
Despite our best efforts, she was transferred to the intensive care unit and connected to a mechanical ventilator to breathe for her. Not long after that she had a heart attack and, within a matter of days, she died.
Physicians crave agency, a power they can use to turn around the course of an ailing patient’s life. Yet for me and countless physicians, nurses, and other clinicians, Covid-19 has been a grim lesson in humility. While we have learned so much about this illness in such a short time, we still have almost no ability to change the fate of patients with severe Covid-19 infections.
Like many other viral infections, Covid-19 has turned into a graveyard for therapeutic interventions. Research my team performed showed that over a two-month span earlier this year, American doctors wrote half a million prescriptions for hydroxychloroquine and the Food and Drug Administration, despite having no real evidence for its benefit in Covid-19, prematurely issued an emergency use authorization for the drug — which it later revoked due to concerns about cardiac complications. Remdesivir, an antiviral drug, was approved by the FDA for treating Covid-19 in October 2020, even though the data supporting its use were marginal at best. Less than a month later, the World Health Organization recommending against using it.
Plasma collected from individuals who recovered from Covid-19, another widely hyped treatment, turned out to be useless in patients with moderate or severe infections. Even the antibody cocktails, often touted as a cure for Covid-19, haven’t yielded favorable results: Clinical trials testing antibodies developed by both Regeneron and Eli Lilly among patients hospitalized with Covid-19 have been halted due to the treatment being ineffective.
To date, the only drug therapy that appears to clearly help critically ill Covid-19 patients is steroids.
There is now concern that some of the drugs we were giving to Covid-19 patients were more than just useless — they might, in fact, have been harmful.
Early in the pandemic, clinicians noted that patients with Covid-19 had a propensity to form clots inside blood vessels that could have life-altering consequences, such as causing strokes or pulmonary embolisms. Doctors around the world began giving blood thinners to Covid-19 patients, and some medical societies offered guidelines for aggressive use of these medications. In an online poll, a majority of doctors indicated they would prescribe high-dose blood thinners to Covid-19 patients thought to be at high risk for blood clot formation.
Yet when the NIH studied blood thinners in a randomized trial, not only was the treatment futile but it may have been harmful for patients with severe Covid-19 infection by increasing bleeding. The trial was recently paused in that group because a “potential for harm in this sub-group could not be excluded.” Another major international trial of blood thinners also halted enrollment of critically ill patients, though enrollment of Covid-19 patients with less-severe disease continues as a risk of harm has not been identified in those groups.
Blood thinners are far from the only treatments that doctors have given Covid-19 patients that may have made matters worse. Early on, many doctors aggressively put Covid-19 patients with low oxygen levels, but who otherwise weren’t critically ill, on breathing machines, an approach that carries both short-term and long-term risks.
All these negative results make me wonder if an important reason why death rates from Covid-19 are dropping may not be because we have expanded testing or are doing more to fight the disease, but because clinicians are doing less for patients with it. A year into the pandemic, maybe we now know more about what not to do. Perhaps fewer people are dying because clinicians are being forced to be introspective and careful. An old adage is that a good surgeon may be wrong, but never in doubt. Perhaps after 2020 we will bury that one for good.
One of my aunts in Pakistan recently fell ill with Covid-19 and was admitted to a small hospital. My phone quickly filled with pictures of CT scans and prescriptions written in Urdu, along with videos of her breathing into an oxygen mask while sitting on a makeshift bed wearing her shalwar kameez. From the other side of the world, other than recommend steroids all I could do was leave hopeful voicemails.
It was eerily similar to how I felt looking through the glass door in the hospital at my latest patient struggling to breathe just a few feet away.
Looking back, we should have made it easier for clinicians to enroll patients in trials so we could learn more quickly about the impact of our actions. While academic physicians in the U.S. have published thousands of Covid-19-related papers, their contributions to randomized clinical trials, the gold standard of clinical evidence, has been limited. The United Kingdom has done a far better job of enrolling patients in trials even though it, too, is being hard hit by the pandemic.
And yet, though we have made little progress finding a “cure” for Covid-19, we have made exceptional progress in finding ways to prevent the spread of the infection. From public health measures like wearing masks and physical distancing to the development of two stunningly effective vaccines now approved for use — and likely more to come — our ability to prevent this infection will surely be the way we make it out of this pandemic.
Unlike Mrs. Smith, I have had many patients who recovered from Covid-19. One of them developed such severe heart failure that we listed him for a heart transplant and yet, after months of struggling, he turned the corner. Another who was admitted to the hospital the same day as Mrs. Smith left a few days later without any symptoms to speak of. My aunt in Pakistan also is back home and doing well.
I wish I had the audacity to take credit for wins like these. But the truth is that when it comes to Covid-19, prevention has handily trumped our failed quest for a cure. The need to control the spread of the virus has now grown even more crucial as we attempt to build a bridge to widespread vaccination.
Haider Warraich is a cardiologist and researcher at Brigham and Women’s Hospital, associate director of the heart failure program at the VA Boston Healthcare System, and an instructor in medicine at Harvard Medical School. The views presented here are his and don’t necessarily reflect those of his employers. Patient details have been withheld or changed to preserve confidentiality.
As a rugged hippie who has eschewed medical care for a decade after my stroke and walks 8 to 10 miles a week, I am thrilled the obese privileged of our nation are getting a richly deserved comeuppance. Your unaffordable heath care system won’t save you when you have excluded so many for so long. Oo one s afe untilevery homeless kid is fully vaccinated.
We are starting good treatments too late in the disease, usually when they are so sick that they are hospitalized
Early treatment for bacterial or viral disease is a must, just as we did for Trump and his cronies.
Prevention is infinitely better than cure. The only reason why we scamper around for a cure in the first place is because we did not prevent the illness otherwise why will anyone cure a disease that has been prevented. My problem with vaccine however is that we honestly do not know if it will truly prevent this disease- covid 19. We also are not sure of the long term effects. That’s why indiscriminate roll out of vaccinations is not only stupid and idiotic, it may ultimately prove to be self destructive. Let every individual assess his individual needs and consent to vaccination. This individual needs will surely be based on age, comorbid conditions and general state of well being. Let no man think he has the mandate to decide for another human being.
Last line of defense…
Maybe try testing
(((Smoke crystal meth)))
While the details are accurate, I find the title and tone of the article disturbing.
Several treatment options instituted at the beginning of the pandemic were abandoned once they were found to not be helpful and in some cases harmful. The biggest one was the timing of intubation. Because people developed severe respiratory failure with remarkably rapid deterioration, physicians tried to establish control of ventilation early hoping they could better manage the catastrophic failures they were observing.
I think the physicians that were in the trenches for the early management of this disease did remarkably well and deserve a lot of credit. Without any road map to follow they tried everything they thought might help (except bleach and light) and then modified their treatments as information and experience grew.
The author’s comment:
“Perhaps fewer people are dying because clinicians are being forced to be introspective and careful. An old adage is that a good surgeon may be wrong, but never in doubt. Perhaps after 2020 we will bury that one for good.”
I find condescending, arrogant and insulting.
The truth hurts.
JAMA, July 26, 2000—Vol 284, No. 4
“…with the release of the Institute of Medicine
(IOM) report “To Err Is Human,”2 millions of Americans
learned, for the first time, that an estimated 44000 to 98000
among them die each year as a result of medical errors.
The fact is that the US population does not have anywhere near the best health in the world. Of 13 countries in
a recent comparison,3 the United States ranks an average of
12th (second from the bottom) for 16 available health indicators…”
“These total to 225000 deaths per year from iatrogenic
causes…most of the data are derived from studies in hospitalized patients. Second, these estimates are for deaths only and do not include adverse effects that are associated with disability or discomfort. Third, the estimates of death due to error are lower than those in the IOM report. If the higher estimates are used, the deaths due to iatrogenic causes would range from 230000 to 284000. In any case, 225000 deaths per year constitutes the third leading cause of death in the United States, after deaths from heart disease and cancer”
https://www.jhsph.edu/research/centers-and-institutes/johns-hopkins-primary-care-policy-center/Publications_PDFs/A154.pdf
This is a brave and thoughtful opinion, that sometimes fate will take Natures course. The early high death rates certainly appear to be the result of unnecessary intubation, and now the later stage lower death rates reveal that leaving the body to fight on its own, no matter how hard that may seem, is almost all we can do for those who get it. I agree that the key is keeping the spread down. I also wish more real research would be done on the effects of Vitamin D deficiency on the serious progress of the worst cases. Vitamin D is cheap, easy and readily available, but it’s not being seriously discussed by the press or medical establishment. At a minimum, people should be checking with their doctors and if they’re deficient, taking some supplementation. Better safe than sorry when all the medicine in the hospital only results in higher fatalities. Here is a great deep dive in the role of Vitamin D from Medcram: https://www.youtube.com/watch?v=ha2mLz-Xdpg