Josh Marshall and his team at Talking Points Memo have been doing an incredible job on the pandemic. They picked up early on the problem with not all coronavirus deaths being reported which is skewing the numbers, and they’ve been trying to run down what’s been going on with the Federal government seizing critical medical supplies and the way they are being portioned out.
One of the big issues has been ventilators — the mechanical assistance given to patients who are having trouble breathing on their own. As the virus seems to attack lung tissue in particular, patients begin to lose function as their lungs begin to fill with fluids; breathing becomes difficult and patients may not be able to get enough oxygen into their blood. They have to be put into a coma to tolerate having tubes put down their throat. Between the drugs, the mechanical stresses from the ventilator, and the damage to tissues from the virus, there can be long term consequences.
Where it gets interesting is that there is apparently a debate going on in the medical community over the best way to use a ventilator on a patient with coronavirus. It’s not just a matter of connecting a patient to the machine; some of the variables include how much pressure to use, how much oxygen to use, what levels of oxygen in the blood are tolerable, how soon to resort to it, and so on. There are trade offs, and some doctors are finding out that coronavirus may call for different protocols than other conditions.
Josh Marshall has been following up on this with communications from different doctors. Possible Developments in the Treatment of Acute COVID-19 is his first go round; his second is Possible Developments in the Treatment of Critical COVID-19 #2. Here’s what got Marshall’s attention:
This appears potentially quite important. Since it has to do with technical clinical details and treatment protocols I’ll try to be both as precise and general as possible. Yesterday I noticed this grainy youtube video posted on March 31st by a New York City emergency and critical care physician, Cameron Kyle-Sidell. Kyle-Sidell said that he thought the treatment protocol and basic understanding of acute COVID-19-induced respiratory distress were both wrong. He said that what he is seeing in his ICU does not look like pneumonia but rather oxygen deprivation (hypoxia). Thus the treatment shouldn’t be focused on high pressure for someone whose lungs aren’t able to function but rather more effective ways of delivering additional oxygen. Critically, he argued that the high pressure ventilation might be damaging the lungs. He also said his impressions were based both on his ICU work over the previous two weeks and conversations with other clinicians around the country.
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Now before everyone gets too excited about this, Marshall has been looking at how the discussion is going on about this in the medical community. He has some cautions.
Let me emphasize a basic editorial point. TPM is not the place to litigate emerging clinical protocols for novel diseases. And we’re not trying to. See this more as a window into emerging discussions among clinicians around the country wrestling with a novel disease. This isn’t unexpected. It is a truism of modern medical history that wars often see major advances in medicine. Doctors are overwhelmed with large numbers of novel or seldom seen injuries and through a grim process of trial and error they develop new insights into treatment…
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It’s a matter of more than a little interest in the International medical community to determine what is the most effective way to treat people in severe cases.
...at least some critical COVID-19 cases are significantly different from standard Acute Respiratory Distress Syndrome (ARDS) and require a different treatment protocol. Since posting that piece I’ve found more evidence that this is a rapidly emerging discussion among critical care doctors and perhaps even some emerging consensus about how critical COVID-19 cases are different from ARDS.
What I found interesting was this incidental comment from one of the doctors who has been in communication with Marshall.
I am a physician and actively treating a number of COVID patients. Something you may not be fully aware of is that MDs nationwide have formed large (tens of thousands strong), private communities on social media to facilitate exchange of information on PPE best practices and PPE shortages, telehealth best practices, and most importantly information on what works and what doesn’t in COVID patients. We have been fortunate to have input from physicians in Italy in particular who have shared their experiences just as our first wave of patients was hitting the ICUs. I would go so far as to say that these groups have supplanted many traditional sources of information for front-line physicians. There is a broad lack of trust in our national leadership so we are relying on the only ones we can believe in ~ one another.
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Read both articles (the first and the second) to get the full picture if this is something you want to follow up. Marshall also includes links to a number of places he has found are providing solid information on coronavirus.
There are three things that occur to me just off the top of my head.
- Expertise on how to use a ventilator and having the judgement to change its settings as indicated by how a patient is doing is important — and evolving.
- A more effective treatment regime with ventilators will affect survival rates.
- If ventilator treatment can be modified to be more effective, it can get people off ventilators sooner, and reduce the number of ventilators that are needed.
Kyle-Siddell’s observations on the best way to use a ventilator came up during Governor Andrew Cuomo's briefing today, so there is attention being given to this by the media and elsewhere. What Marshall concluded in his first look at this is that his work is getting misinterpreted.
The responses to his videos on social media, both pro and con, suggested he was saying that the COVID-19 virus wasn’t the cause of the sickness or that ventilators weren’t necessary. I listened closely. That was clearly not what he was saying. He was saying that the disease model most doctors are working with – pneumonia/ARDS – is not what these patients are presenting with and the treatment protocol is not suited to their disease.
Two more stories at TPM point up how important this discussion is. From just a few hours ago, Some Doctors Fear Ventilators Could Be Harming Certain Patients.
The evolving treatments highlight the fact that doctors are still learning the best way to manage a virus that emerged only months ago. They are relying on anecdotal, real-time data amid a crush of patients and shortages of basic supplies.
...Generally speaking, 40% to 50% of patients with severe respiratory distress die while on ventilators, experts say. But 80% or more of coronavirus patients placed on the machines in New York City have died, state and city officials say.
...Similar reports have emerged from China and the United Kingdom. One U.K. report put the figure at 66%. A very small study in Wuhan, the Chinese city where the disease first emerged, said 86% died.
From April 6: ‘Nothing Works’: Hospitals Race To Train More Docs To Operate Ventilators.
A fixture in intensive care units, a ventilator requires near-perpetual management. Pulmonologists work with respiratory therapists and nurses to diagnose, intubate, drug, and manage patients hooked up to the devices.
“That’s why it’s the ICU,” said Joshua Denson, an assistant professor and associate director of pulmonology at Tulane University School of Medicine. “It’s all very intensive, between the nurse, the doctor who is looking at the bloodwork, making changes to the patient’s meds, and doing procedures on the patient.”
...But the devil comes down to the details: The machines can be difficult to operate, requiring a mixture of training combined with diagnostic intuition that comes with having spent years treating patients on them. Some doctors – like critical care surgeons – are familiar with operating mechanical ventilators, but many are not.
Needless to say (but I will anyway), NOT getting the virus is still the best course. Social distancing and other isolation methods seem to be having an effect. Abandoning them too soon — as Trump is eager to do — could cause the situation to deteriorate.
The best long term measure for controlling the pandemic and other health issues is, of course, to stop voting for Republicans.
Talking Points Memo is providing free access to coronavirus stories for the duration. Normally, a subscription is needed to get full access; they’ve been trying to shift from relying on ads for income to relying on subscribers (I’m one), but with the economic impacts from the pandemic, it isn’t enough for them to support the staff TPM could use. Subscription information is here: highly recommended.
UPDATE: Here are resources Josh Marshall recommends:
Key Coronavirus Crisis Links