What Doctors on the Front Lines Wish They’d Known a Month Ago
Ironclad emergency medical practices — about when to use ventilators, for example — have dissolved almost overnight.
Doctors say the coronavirus is challenging core tenets of medicine, leading some to abandon long-established ventilator protocols for certain patients. But other doctors warn this could be dangerous.CreditCredit...
The New York Times
By Jim Dwyer
Just about a month ago, people stricken with the new coronavirus started to arrive in unending ranks at hospitals in the New York metropolitan area, forming the white-hot center of the pandemic in the United States.
Now, doctors in the region have started sharing on medical grapevines what it has been like to re-engineer, on the fly, their health care systems, their practice of medicine, their personal lives.
Doctors, if you could go back in time, what would you tell yourselves in early March?
“What we thought we knew, we don’t know,” said Dr. Nile Cemalovic, an intensive care physician at Lincoln Medical Center in the Bronx.
Medicine routinely remakes itself, generation by generation. For the disease that drives this pandemic, certain ironclad emergency medical practices have dissolved almost overnight.
The biggest change: Instead of quickly sedating people who had shockingly low levels of oxygen and then putting them on mechanical ventilators, many doctors are now keeping patients conscious, having them roll over in bed, recline in chairs and continue to breathe on their own — with additional oxygen — for as long as possible.
The idea is to get them off their backs and thereby make more lung available. A number of doctors are even trying patients on a special massage mattress designed for pregnant women because it has cutouts that ease the load on the belly and chest.
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Some doctors have placed Covid-19 patients on special massage mattresses made for pregnant women.
Credit...Ken Sutin
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Some patients, by taking oxygen and rolling onto their sides or on their bellies, have quickly returned to normal levels. The tactic is called proning.
Doctors at Montefiore Medical Center in the Bronx and Mount Sinai Medical Center in Manhattan have described it on Twitter; a flier is posted next to beds at Elmhurst Hospital Center in Queens as a guide for patients on how often to turn themselves.
At Lincoln Hospital in the Bronx, Dr. Nicholas Caputo followed 50 patients who arrived with low oxygen levels between 69 and 85 percent (95 is normal). After five minutes of proning, they had improved to a mean of 94 percent. Over the next 24 hours, nearly three-quarters were able to avoid intubation; 13 needed ventilators. Proning does not seem to work as well in older patients, a number of doctors said.
No one knows yet if this will be a lasting remedy, Dr. Caputo said, but if he could go back to early March, he would advise himself and others: “Don’t jump to intubation.”
The total number of people who are intubated is now increasing by 21 per day, down from about 300 at the end of March. The need for mechanical ventilators, while still urgent, has been less than the medical community anticipated a month ago.
One reason is that contrary to expectations, a number of doctors at New York hospitals believe intubation is helping fewer people with Covid-19 than other respiratory illnesses and that longer stays on the mechanical ventilators lead to other serious complications. The matter is far from settled.
“Intubated patients with Covid lung disease are doing very poorly, and while this may be the disease and not the mechanical ventilation, most of us believe that intubation is to be avoided until unequivocally required,” Dr. Strayer said.
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