Doctors rapidly changing tactics, but are they saving more lives?
In battle against virus, difficult to determine success of treatment
Since the coronavirus pandemic descended on Connecticut and the nation more than six months ago, physicians and medical researchers have worked to fill the void of information on COVID-19.
And while drug companies are racing to formulate a safe and effective vaccine, coronavirus remains a deadly virus. Nearly seven months after the first confirmed case in Connecticut, COVID-19 is still a disease without a cure. It has so far claimed more than 4,500 lives in Connecticut.
But even in the absence of a definitive treatment, medical professionals now at least have a game plan to follow when a patient walks through the hospital doors. Even with a host of questions still left unanswered, clinicians say they are better prepared to treat COVID-19 patients now than they were at the beginning of the pandemic, which was a time of unprecedented uncertainty and worry.
“There was a helplessness, that you’d be watching these patients decompensate in front of you and there was nothing you could do,” said Dr. Ulysses Wu, the system director of infectious disease at Hartford HealthCare.
Recent months have at least brought greater consensus on how to give coronavirus patients their best possible shot at surviving. Whether that consensus has actually brought down the virus’ mortality rate is, however, difficult to determine.
In July, science magazine New Scientist reported that the mortality rate in both the U.S. and the U.K. appeared to be dropping, either from improved treatment regimens or more widespread testing that catches less severe coronavirus cases. But a Stat News report found that most of the change in fatality rate can be explained simply by the increased testing. That is, the evolving treatment process itself doesn’t appear to be reducing the number of people who die from COVID-19, according to Stat News.
In Connecticut, some clinicians say they believe the improved treatments play at least some role
in a declining mortality rate. Wu and Yale New Haven Health’s medical director of infection prevention, Dr. Richard Martinello, said the changes in treatment seem to be bolstering patient survival at least a bit.
But Dr. Tom Balcezak, the chief clinical officer of Yale New Haven, said that the hospital system has seen a “pretty consistent” mortality rate of about 13% among hospitalized patients.
“There are no truly effective treatments that have been shown to reduce mortality of COVID-19, still, to this day,” he said.
At first, ‘a sense of desperation’
When COVID-19 first made its appearance in Connecticut hospitals, physicians scrambled to treat their patients with anything that might be available — including drugs that experts now know are unhelpful at best and fatal at worst.
“We have never really encountered a time in medicine like this, where on a worldwide scale unproven treatments were being given without any evidence,” Wu said.
The most significant example of that, and the example that medical experts brought up time and again, was hydroxychloroquine, the anti-malaria drug that President Donald J. Trump has continually touted as a miracle treatment for coronavirus.
“There’s a lot of political pressure to suggest and use certain types of drugs,” Wu said. “And because of that I think we were using therapies that were possibly dangerous in the beginning. And we tried to use them as minimal as possible.”
Hospitals across Connecticut used hydroxychloroquine — sometimes alongside the antibiotic azithromycin — in the early months of the pandemic, the Courant reported in April. Even at the time, physicians acknowl
edged that they were using the treatment out of desperation. There simply wasn’t any other drug that might help patients fight off COVID-19.
“At this point, early on in March, people were latching onto anything that they could to really treat some of these very critically ill individuals,” Martinello said. “We’re human, too, and we get a sense of desperation.”
As time went on and researchers studied both hydroxychloroquine and azithromycin in the dosages that were being used for COVID-19, it became clear that the drugs could trigger an irregular heartbeat in some patients. And sometimes, that could be fatal.
Early in the pandemic, there was also some discussion among medical experts that steroids might also help coronavirus patients. But that decision, like all treatment decisions, was left in the hands of individual physicians.
Beyond that, patients were mostly treated with what physicians call “supportive care” — that is, treatments that may alleviate symptoms or complications of the disease, but don’t actually treat the disease itself.
For early pandemic coronavirus patients, that supportive care took the form of Tylenol to reduce fevers, IV fluids to keep the kidneys running smoothly,
anti-coagulants to prevent clotting and oxygen, possibly through intubation. Physicians also knew that, for intubated patients, placing them on their bellies instead of their backs would help their lungs function better.
But “we really didn’t have any particular medications that would be novel coronavirus-specific,” said Dr. Syed Hussain, the chief clinical officer for Trinity Health of New England.
Rapid changes
As the pandemic progressed and researchers dropped everything else to focus on COVID-19, the changes in treatment recommendations came in so quickly that hospital systems sometimes revised treatment guidelines multiple times a month.
Hartford HealthCare has updated its guidelines 10 times since mid-March, said senior director of pharmacy Eric Arlia. Yale New Haven Health hit one dozen iterations in early September. And Trinity Health Care released the 19th version of its treatment plan earlier this month, according to Hussain.
Dr. Jessica Abrantes-Figueiredo, the chief of infectious disease at Hartford’s St. Francis Hospital, said the rapid changes underscore how little was known about the
virus at first, and how much was being learned every day.
“Things will change,” Abrantes-Figueiredo said. “Especially with something so novel, you really can’t get it right the absolute first time.”
Some of the changes were intuitive. Arlia said the Hartford HealthCare staff initially thought the pandemic would require widespread use of nebulizers, which emit a medicated mist that patients can breathe into their lungs. But they quickly realized that delivery method would also pose a massive risk for spreading coronavirus particles throughout the hospitals.
“We thought we were going to use a lot of nebs,” Arlia said. “We had to make an abrupt change.”
Other treatment changes took more research — such as removing hydroxychloroquine from the treatment rotation after studies showed limited effectiveness and significant risks.
But while each new iteration of guidance reflected the most up-to-date information at the time, hospital officials said they still gave their physicians the final call.
“Ultimately it was really the individual physicians who made decisions about what to use,” Martinello said. “Our individual physicians have a lot of flexibility.”