By Marc J. Sicklick, M.D.
What treatment modalities are available now? Why is COVID less likely to kill and cause hospitalization today than it was in March and April? Why am I a semi-optimistic pessimist?
This is not about masks, social distancing, shut downs, lockdowns, zoom, quarantine, isolation, personal choice, government mandates, or anything else that has been talked to death and that we are all tired of hearing. Everyone knows what should be done and either chooses to do what’s appropriate or chooses not to.
This is a brief review of treatments at a time when our LOCAL area is having an increase in cases and the projections show a very significant increase through the fall.
For respiratory distress, this was treatment No. 1 for sick COVID victims early in the epidemic. Our knowledge of this new disease’s pathophysiology was relatively primitive six to eight months ago, New York State was approaching 1,000 deaths per day by early April, hospitals were overwhelmed, morgues were overwhelmed, the governor was screaming for tens of thousands of ventilators, and between the desire to keep people alive and the extreme mental pressure placed on doctors by the daily press conferences demanding more ventilators, these were used almost universally for breathing difficulties or low oxygen readings. This was, to a degree, reflex rather than reflection.
Another problem was that many of those who were managing patients on ventilators were doctors from other fields who, after a brief period of instruction, had to become the experts. They had no choice and volunteered to step into the breach. They were not all anesthesiologists and pulmonologists with expert knowledge of the disease and the machines. Although their intentions were the best, the outcomes weren’t always. There were just too many patients for the number of available experts. The hospitals were overwhelmed. Talk to medical personnel who were there on the front lines. This is happening today in other states.
As the pandemic grows because people have increased COVID fatigue, anger, and indoor life, the hospitals will again become overwhelmed. There aren’t enough experts to manage cases so we will revert to having suboptimal care with doctors, nurses, and other medical personnel thrown into the breach because there isn’t another option. This will lead to more aggressive care modalities because it takes an expert to NOT do something. It takes a lot of knowledge and self-assurance to NOT place a patient with respiratory distress on a ventilator with indications that can lead the decision either way. It takes years of experience.
We know that not all respiratory disease needs this modality, and many are better off without artificial ventilation. Ventilators can damage the lung tissue, do not always address the real pathophysiology (the active disease process), and extubating patients (removing them from ventilators) is not always easy.
There are other ways to give oxygen that are less invasive and less dangerous. Flow oxygen, CPAP and other modalities are used much more readily now. Also, low oxygen readings are not all due to a primary lung problem.
Ventilators do and will continue to save lives. Many patients really need them and have no option, but having alternative treatments when medically indicated will also save lives.
2. Blood thinners
Not all organ involvement is because of the virus directly attacking the organ. Sometimes blood clots form and damage the organs. Blood thinners are now used, when indicated, to try to decrease damage from clots. This, too, lowers the morbidity and mortality rates.
3. Anti-white blood cell medications
We’ve all heard of the term “cytokine storm”. This is an over response of the immune system that clogs blood vessels and can damage organs and cause respiratory distress. The use of anti-white blood cell medications has also cut mortality and morbidity.
4. Anti-viral medications
These attack the ability of the virus to take over.
5. Anti-viral antibodies
There are two ways to make antibodies. One is called “active immunity”. Someone encounters an infection or gets a vaccine and their immune system responds. The other response is “passive immunity”. Antibodies against the infection are either taken from someone who already had the infection or are produced synthetically, and these can be administered to fight the infection. This form of immunity is short lived but helps during the acute phase. In a simplistic way, these can be thought of as a sponge that sops up virus.
Not all anti-COVID antibodies (noting that there are many different antibodies made in response to the infection) are equally beneficial and protective. As we learn which are the most critical and as we are able to use them, outcomes will improve.
The hope is that one of the many types of vaccines will provide immunity, or at least weaken the disease in the immunized. This is what attracts all the headlines. This seems to drive the Dow Jones up and down on a daily basis. Vaccines are not here now, may be here in a few months (I hope for the mid-spring. Others whom I respect have told me that I am overly optimistic and that they expect mid-summer), or may never be here. After release, it will take time (six months to a year) until enough people are vaccinated for it to create sufficient herd immunity to have a significant impact.
The recent news of a few people getting COVID for a second time could point to vaccine problems. On the other hand, perhaps natural disease may not be as protective as a good vaccine. Perhaps vaccines will elicit the more important antibodies. Time will tell.
Closing schools and putting children on the streets or in friends’ houses as opposed to keeping them in a controlled school setting, following health rules, makes little sense to me.
Shutting businesses and stores and causing tremendous financial and emotional damage while social gatherings continue to be the largest source of spread also makes little sense to me.
Hopefully, lockdowns will be reserved for cases that are absolutely necessary, which should mean places not adhering to CDC and Board of Health rules and with critical numbers of cases in that area.
The overall fatality rate currently seems to be well under where it was in the spring. This is due to these newer and fine-tuned approaches, a shift in the age of those being infected towards a younger and presumably otherwise healthier population, and the deaths in the spring of those who were most vulnerable (the elderly, the very infirm, and the unfortunate people who were exposed in nursing homes rather than being protected from exposure.). This does not mean that the symptoms won’t be severe in some younger people. Some may be left with chronic debilitation and damage. Some may die. We need to minimize this to the best of our ability.
The models still project New York State to peak at about 200 deaths/day in the mid to late fall. We have about 10/day now and we had close to 1000 in April.
As we saw from newspaper articles about President Trump’s illness, he was given oxygen as needed without a ventilator, steroids for the anti-cytokine storm effect, anti-viral medication, and antibodies. His course seems to have been much better than I would have expected for a 74 year old, overweight patient. I do not think he would have had the same recovery six months ago.
Hopefully, even without a vaccine, the improved care will help reduce the damage. A vaccine, if successful, will be a bonus on top of the new and developing care modalities.
My last statement is that people should not neglect other medical problems. Screening for colon disease, heart disease, blood pressure issues, getting usual immunizations, and a good physical exam are necessary and if not done will cause deaths from non-COVID reasons.
Dr. Marc J. Sicklick is an allergist-immunologist in Cedarhurst and practicing for more than 20 years. He is affiliated with Long Island Jewish Medical Center, North Shore University Hospital, Montefiore Medical Center, and Mount Sinai South Nassau.