How the medical community adapted treatments to save COVID-19 patients
As an emergency doctor, I was both an active participant and witness to the medical community's journey to improve outcomes for those who were admitted to hospitals with COVID-19. Since the start of the pandemic, the mortality rate of those admitted has dropped significantly. This wasn't due to laboratory driven research but because of doctors and nurses applying real life learnings from active practice. This benefits everyone as fewer patients need hospital treatment which will hopefully lead to improved recovery times.
As SARS-CoV-2 made its inexorable journey from Wuhan to Italy, New York and other hubs around the world, COVID-19 cases came hurtling into the United States and our acute care departments. Before we knew it, the entire system was strained treating COVID-19 patients. At my hospital, we had very sick patients, the most worrisome were those with low oxygen levels and pneumonia. But the symptoms varied massively: cough, fever, body aches, gastrointestinal issues, and the loss of taste and smell when the infection was mild. At a later stage, we would see respiratory collapse or septic shock, as multiple organs lose their functionality and become resistant to treatment. This led to high rates of mortality. In all my decades as an emergency physician, I have never seen so many people die in such a short time.
Testing new approaches in an evolving pandemic
Early on in the pandemic we had no understanding of the behavior of the disease, and we certainly lacked treatments. Physicians and researchers tackled this challenge by constantly sharing the latest updates online, and often texting with other physicians around the country for the latest updates and possible treatments.
None of us really knew what the best course of care was, and some early treatments soon proved to worsen COVID-19 outcomes. Initially, we ventilated patients early, as their blood oxygen fell, but we later determined that the early ventilation led to worse pulmonary outcomes than a delay in intubation. This was certainly a surprise to me, and not what I was used to since this was the standard treatment but resulted in worse outcomes. So, like everyone, I adapted. I turned to other approaches like high flow oxygen in a mask or tube, or other therapies such as ECMO – a dialysis-like machine for the lungs – and our results improved. We tried to take learnings from other conditions. We knew that steroid use was effective for asthma, so we assumed that it would help breathing early on – it seemed intuitive to me at the time. I shared our findings over a hurried lunch, during a quick coffee break or on social media, and was eager to hear what other approaches my colleagues had tried. It was a slow, day-by-day process, but we were making progress at last.
We soon realized that giving patients steroids early on was not as effective as it could have been, as it might have further stimulated an already dangerously high immune response, causing worse outcomes in our most vulnerable patients. In the summer, a study from the UK showed that dexamethasone, another steroid, had better results when given as a treatment later during an infection, greatly reducing mortality. I discovered that I had a cheap and plentiful drug to use on my most vulnerable patients – combined with our other lessons, we could finally treat the sickest patients.
Finding a new normal
After months of slow and difficult treatment, it goes without saying how happy I was when I heard of our collective progress: successful vaccine trials to protect the public, new antibody treatments to quickly fight off infection, and accurate diagnostic tests to find the asymptomatic cases. We even started to explore further, routinely giving anticoagulation drugs to hospitalised patients to reduce their risk of blood clots which could lead to stroke.
Soon, identifying a COVID-19 patient became as easy as looking for heart failure or listening to a croup patient. After six months of experimenting and refining our treatment protocols in the medical community, we could finally start treating COVID-19 more routinely. The nurses I worked with just said "COVID-19" and it was clear what had to be done. We knew who needed admission and who we could treat with IV fluids or inhalers and send home. We now had the confidence to make that call.
One great development was when we were able to offer monoclonal antibody infusions, which fight infection by blocking inflammatory processes, to elderly or high-risk patients who could then recover in the comfort of their own home. Like any new treatment, some people were resistant – I remember how I had to convince patients to try it when it was first released and put their fears to rest. But word of its effectiveness spread quickly and within a few weeks, people were asking for it. For us physicians, this subtle but notable shift in acceptance of the new therapy suggested that we were not just pulling ahead in the diagnostic and therapeutic race but also in the information race.
Lessons learned that help doctors and insurers
Our improved understanding of which treatments work best is also beneficial to the insurance industry. While we still have a lot to understand about long-COVID, we know that lengthy stays in hospital or intensive care can mean that patients take longer to bounce back to a new normal of health or back to work. To avoid lengthy sick leave or death, we found out that we can use monoclonal antibodies and steroids which are likely to speed up patient recovery and prevent disabilities.
The past year has taught me many lessons that I believe we can apply for future pandemics. I know as physicians we must be flexible when we look at treatment protocols and cautiously open to new approaches. I also believe that there must be public trust around social distancing and new treatments.
The World Health Organization developed an R&D blueprint plan to explore, research and accelerate therapeutics, vaccines and diagnostics globally in response to the pandemic. The treatment advances I saw were directly related to these global science teams and their research efforts. The results are vaccine and medication successes and adapted treatments that are bringing about improved outcomes. I believe the world is more resilient now with this new “superpower” of knowledge and better able to adjust to future challenges.