What Medicine Is Learning from the COVID-19 Pandemic

With every great health care challenge, there is knowledge to be gained.  We are only months into this pandemic, and we have been forced to recognize once again how humbling it is to try to fight nature.  We have managed to dampen the lethal potential of viruses, primarily through vaccines, only in the past few lifetimes.  Great scourges of the past such as smallpox and polio have been reduced to only a historical footnote.  Yet we are shut down. 

The Spanish Flu of 1918 prompted some of the greatest medical advances in human history.  It was associated with the advent of bacteriology, virology, and the nascent field of antibiotic pharmacology.  We think we have learned so much since then, but viruses are a dispassionate teacher, reminding us of how much we still do not know.

We believe we have learned several things from this particular iteration of viral illness and the treatment options we have provided:

1. Initial survival after intubation for respiratory failure from COVID-19 in many reputable hospitals was 20–30%.  Only weeks later, it is 70–80%.  This is due to a multiplicity of reasons, but one is the use of prone ventilation, essentially breathing for them through a tube while flat on their stomachs rather than lying on their backs.

2. Use of oxygen-assisted CPAP and BiPAP machines for patients with very low oxygen levels in their bloodstream has proven desirable when intervention is done in time.  Opting for this instead of intubation has resulted in greater survival.  These machines are the standard of care in obstructive sleep apnea all over the world and are readily available.

3. COVID-19 can cause advanced clotting disorders in the blood vessels and the heart.  Hearts filled with a large thrombus (clot) are inefficient at pumping, and lungs filled with clotted blood vessels oxygenate poorly.  Vasculitis (inflammation of blood vessels) causing this abnormality is a known possibility in viral disease, and COVID turns out to be particularly nasty.  We have learned to begin anti-clotting medications early, when possible, and this has already proven to help survival significantly.

4. Many of the stricken are pre-diabetic, diabetic, or morbidly obese.  Aggressive management of blood sugar levels is proving to be important in acute care.

5. Myocarditis, an inflammation of the heart muscle, is common with COVID-19.  Unfortunately, this has proven to be a real problem in our endeavor to intervene pharmaceutically.  Both the hyped anti-malarial drug hydroxychloroquine and the antibiotic azithromycin endanger lives by causing arrhythmias, electrical abnormalities in the electrical system, in some people with heart muscle inflammation.  Many of the deaths from COVID-19 are from heart attacks, and we do not know how many of these are pharmacologically induced.  These medicines have helped a great many people, but this issue may prove significant enough to make many doctors choose not to use these as a treatment option.

6. Use of hydroxychloroquine prophylactically in uninfected health care professionals may have caused sudden cardiac deaths in people with previously undiagnosed cardiomyopathies or arrhythmias.  This is a reminder that even "safe" drugs are potentially lethal.

7. Remdesivir, an antiviral medication, was being studied in a double-blind study and was judged effective a lot sooner than most scientists would have liked.  To those familiar with statistics, medicine considers a p-value of >0.05 significant.  Once Remdisivir hit 0.059, it was judged to be effective enough to no longer give trial patients a placebo medication.  While a small percentage of lives are being saved with this decision, it will interfere with future testing of treatment options, as testing will no longer be done without using this medication as well.  Many research pharmacologists think we are missing a great opportunity for more rigorous study with more statistically significant numbers.

8. Steroids, an anti-inflammatory medication, are proving a lot more effective in battling COVID-19 than doctors might expect.  Steroids are a non-specific treatment, meaning we don't exactly know what type of inflammation we are fighting and what organ we are targeting.  Steroids also raise blood sugar levels and predispose patients to candidiasis — a yeast infection.  That said, doctors are seeing a real benefit.

9. COVID-19 is reminding doctors just how random viral illness can be.  Sudden loss of the sense of smell is very common with this virus, even with few other symptoms.  Other cranial nerves can be affected as well.  These range from sudden hoarseness due to a paralyzed vocal cord to sudden hearing loss, blindness, and swallowing difficulties.  Aggressive and early treatment with steroids is crucial to having a chance for recovery of function.

This list is incomplete, and hopefully many more lessons will be learned.  Many health care professionals are wincing when asked about the economic shutdown.  We are concerned about all the hopes and dreams being delayed or lost from the economic fallout and the health consequences that result.  But the identifiable benefits of managing these hospitalized COVID patients may help many acutely ill people in the years to come.

With every great health care challenge, there is knowledge to be gained.  We are only months into this pandemic, and we have been forced to recognize once again how humbling it is to try to fight nature.  We have managed to dampen the lethal potential of viruses, primarily through vaccines, only in the past few lifetimes.  Great scourges of the past such as smallpox and polio have been reduced to only a historical footnote.  Yet we are shut down. 

The Spanish Flu of 1918 prompted some of the greatest medical advances in human history.  It was associated with the advent of bacteriology, virology, and the nascent field of antibiotic pharmacology.  We think we have learned so much since then, but viruses are a dispassionate teacher, reminding us of how much we still do not know.

We believe we have learned several things from this particular iteration of viral illness and the treatment options we have provided:

1. Initial survival after intubation for respiratory failure from COVID-19 in many reputable hospitals was 20–30%.  Only weeks later, it is 70–80%.  This is due to a multiplicity of reasons, but one is the use of prone ventilation, essentially breathing for them through a tube while flat on their stomachs rather than lying on their backs.

2. Use of oxygen-assisted CPAP and BiPAP machines for patients with very low oxygen levels in their bloodstream has proven desirable when intervention is done in time.  Opting for this instead of intubation has resulted in greater survival.  These machines are the standard of care in obstructive sleep apnea all over the world and are readily available.

3. COVID-19 can cause advanced clotting disorders in the blood vessels and the heart.  Hearts filled with a large thrombus (clot) are inefficient at pumping, and lungs filled with clotted blood vessels oxygenate poorly.  Vasculitis (inflammation of blood vessels) causing this abnormality is a known possibility in viral disease, and COVID turns out to be particularly nasty.  We have learned to begin anti-clotting medications early, when possible, and this has already proven to help survival significantly.

4. Many of the stricken are pre-diabetic, diabetic, or morbidly obese.  Aggressive management of blood sugar levels is proving to be important in acute care.

5. Myocarditis, an inflammation of the heart muscle, is common with COVID-19.  Unfortunately, this has proven to be a real problem in our endeavor to intervene pharmaceutically.  Both the hyped anti-malarial drug hydroxychloroquine and the antibiotic azithromycin endanger lives by causing arrhythmias, electrical abnormalities in the electrical system, in some people with heart muscle inflammation.  Many of the deaths from COVID-19 are from heart attacks, and we do not know how many of these are pharmacologically induced.  These medicines have helped a great many people, but this issue may prove significant enough to make many doctors choose not to use these as a treatment option.

6. Use of hydroxychloroquine prophylactically in uninfected health care professionals may have caused sudden cardiac deaths in people with previously undiagnosed cardiomyopathies or arrhythmias.  This is a reminder that even "safe" drugs are potentially lethal.

7. Remdesivir, an antiviral medication, was being studied in a double-blind study and was judged effective a lot sooner than most scientists would have liked.  To those familiar with statistics, medicine considers a p-value of >0.05 significant.  Once Remdisivir hit 0.059, it was judged to be effective enough to no longer give trial patients a placebo medication.  While a small percentage of lives are being saved with this decision, it will interfere with future testing of treatment options, as testing will no longer be done without using this medication as well.  Many research pharmacologists think we are missing a great opportunity for more rigorous study with more statistically significant numbers.

8. Steroids, an anti-inflammatory medication, are proving a lot more effective in battling COVID-19 than doctors might expect.  Steroids are a non-specific treatment, meaning we don't exactly know what type of inflammation we are fighting and what organ we are targeting.  Steroids also raise blood sugar levels and predispose patients to candidiasis — a yeast infection.  That said, doctors are seeing a real benefit.

9. COVID-19 is reminding doctors just how random viral illness can be.  Sudden loss of the sense of smell is very common with this virus, even with few other symptoms.  Other cranial nerves can be affected as well.  These range from sudden hoarseness due to a paralyzed vocal cord to sudden hearing loss, blindness, and swallowing difficulties.  Aggressive and early treatment with steroids is crucial to having a chance for recovery of function.

This list is incomplete, and hopefully many more lessons will be learned.  Many health care professionals are wincing when asked about the economic shutdown.  We are concerned about all the hopes and dreams being delayed or lost from the economic fallout and the health consequences that result.  But the identifiable benefits of managing these hospitalized COVID patients may help many acutely ill people in the years to come.