In early March, most doctors in the United States had never seen a person who had COVID-19. Four months later, almost every emergency doctor and intensive care doctor in the country is very familiar with the disease. During this time, they learned a lot about the best way to treat patients. In some cases, however, they still take the same approach as in the spring.
"There is so much different and so much the same," says Megan Ranney, an emergency doctor and associate professor at the Brown University Department of Emergency Medicine.
"There is so much different and so much the same."
In the early months of the pandemic, recommendations for every incremental decision in a hospital changed faster than ever. "You almost couldn't keep up – from one day to the next, your practice would change and your protocols would change. It was really confusing for doctors and nurses," says Ranney.
Information shared between colleagues, through medical education blogs and podcasts, and on social media. The doctors talked about new research results on Twitter and exchanged new strategies in Facebook groups and on WhatsApp. If a suggestion posted by a doctor in a Facebook group is low risk and appears helpful, it can be put into practice immediately. "If it's a small change, they could start the next day," she says.
In this way, the practice common today to ask patients with COVID-19 to turn on the stomach: through word of mouth and on social media. When someone is lying on their back, their organs squeeze their lungs and make it difficult for the airways to expand completely. When someone lies on their stomach, their lungs have more space to fill with air. The advice spread to the medical community before there was a formal, published study of the practice.
Testing wouldn't have many drawbacks (it wasn't dangerous for patients) and it was easy to do. "There is a possibility that it could be positive and there have been many stories about it that have a positive effect," says Ranney. "So it spread much more organically and faster because it was something we could do, but we weren't afraid that it would harm the patient."
Physicians such as Seth Trueger, an assistant professor of emergency medicine at Northwestern University, saw the position in helping patients get enough oxygen to avoid the need for a ventilator. "I started jokingly calling it" tummy time, "he says. Studies are beginning to validate these observations and find that patients who have spent time in the stomach actually do better.
A team is helping to put a COVID-19 patient on his stomach.
Photo by John Moore / Getty Images
Since March, doctors have found other ways to help seriously ill patients avoid ventilation. "We know that this is probably not a great thing for these patients, and we have developed other methods to provide people with high oxygen levels," said James Hudspeth, director of COVID response for inpatients at the Boston Medical Center. For example, doctors turn to nasal cannulas in front of a ventilator, which are non-invasive tines that blow oxygen into the nose.
"We have developed other ways to give people a high oxygen content."
You now have better medicines for hospital patients. Since March, doctors have gone through several different options – like hydroxychloroquine, which has been found to be ineffective. Now they're mainly using Remdesivir and an antiviral drug that appears to help COVID-19 patients recover faster, and the steroid dexamethasone, which improves the survival rate of ventilator patients. “Many intensive care units and hospitals have created their own standard order sets or standard therapies for people with COVID-19,” says Ranney. These shift when new knowledge about different drugs is available.
It's not uncommon, says Ranney. Hospitals regularly change the medicines they use to treat conditions like flu and pneumonia as soon as new data are available. "What is unusual is changing practice so quickly," she says. "It's just the reality of a global pandemic with an illness we've never seen before."
Most changes in doctors' strategies in recent months have been made in critically ill patients. If someone is sick enough to be hospitalized with COVID-19 but doesn't need to be in the intensive care unit, doctors still can't do much for them. They are given fluids to make sure they stay hydrated and given oxygen when they need it. Doctors will try to keep their fever low and monitor them to see if they get sick, but that's about it.
"It's just these basic things," says Ranney. Doctors are now more alert to the blood clot threat that has occurred in many COVID-19 patients in the past few months. With more tests available in hospitals than earlier this year, they will also confirm that a moderately ill patient actually has COVID-19 – and avoid unnecessary treatments. However, active interventions for patients with less severe symptoms are still about as high as in March. "We are still waiting vigilantly," she says.
Active interventions for patients with less severe symptoms are still about as high as in March
One remaining question, says Hudspeth, is how to stop these moderately ill patients from becoming seriously ill. Steroids could be helpful earlier, as could artificial antibody treatments that block the virus, although these strategies are still under investigation. "Part of the challenge we are currently facing is that temperate patients are often where we want to intervene," he says.
Changes in treatment strategies for patients who are not seriously ill were more difficult to obtain – also because it is riskier to try something new in this group. Unless someone is dangerously ill, using experimental treatment that may be harmful can not do so much, so doctors take fewer risks. "We tend to try things with sick patients," says Ranney. "And their families tend to agree to a clinical trial."
Despite the unanswered questions about COVID-19 treatments, the rate of new information is slowing. Doctors don't change practices as quickly as in March and April, and Trueger believes the next few months may be relatively stable. Doctors may get new information about which drugs are more or less helpful, but other common best practices may be more entrenched. "I don't think things will change as quickly as the changes we had before we really flew half blind," he says.
