The first two COVID-19 patients to reach the emergency room at Banner University Medical Center Phoenix were a young mother and her adolescent son.
They had been airlifted from Whiteriver, the largest settlement in the sprawling Fort Apache Indian Reservation 180 miles east of Phoenix. By the time they finally arrived, the mother was in severe respiratory distress, and the son was dead. This was mid-March and though the staff suspected they had COVID-19, it was still so new they weren't quite sure how to treat it.
"The mother was sick for a week, then went to a local clinic and within about two hours, she deteriorated and required a respirator," recalls Dr. Marilyn Glassberg, division chief of Pulmonary Medicine, Critical Care and Sleep Medicine, for the 800-bed hospital. "Because we didn't know what we know now, we didn't manage them the way we would manage them now."
If those first two patients had been among the current wave of patients flooding into Banner Health from around the state of Arizona today, the mother at least might have had a fighting chance. Even just a few weeks later, the doctors would have known about the devastating micro-clots found throughout the bodies of autopsy patients and put her on blood thinners. They would have understood that her own immune system was killing her, and they could have blasted her system with a powerful dose of steroids to try to get it under control. In fact, if that first patient and her son had gotten sick today, state and federal officials almost certainly would have identified them sooner, diagnosed them quicker and sent them on to Phoenix for critical care far earlier. If that mother and son had gotten sick today, in other words, they both might have made it.
As the nation is hit with a devastating self-inflected second COVID-19 surge, brought on by a combination of hubris, the bizarre politicization of protective mask wearing and that apparently irrepressible human urge to finally just live a little again, consequences be damned, there is at least one silver lining. Six months into the crisis, medical clinicians know far more than they did when the pandemic first struck. As a result, the quality of care for many of those entering top hospitals in places like Phoenix, Jacksonville and Houston today is likely to be far better than it was for patients in Wuhan, Northern Italy, New York City and other early hotspots.
"We've benefited, unfortunately, from what happened in China, then Northern Italy and then definitely New York," says Keith Frey, Chief Medical Officer for Dignity Health, which has six hospitals in the Phoenix metropolitan area. "We did have some time to prepare."
"Probably a day doesn't go by where we don't at least pick up one idea from somewhere else in the world that helps us do a better job," says Roberta Schwartz, executive vice president, chief innovation officer and COVID-19 "incident commander" at Houston Methodist Hospital, which, like Phoenix, is at the center of the current surge.
There's a good chance that the sickest COVID-19 patients in Arizona, Florida, Texas, California and other states now experiencing a steep rise in new cases will have a much better chance of surviving their illness than ever before—if these states succeed in flattening their curves. That's a big "if." Hospitals that are overwhelmed with patients will almost certainly see lower survival rates.
Anecdotal evidence
So far, the numbers suggest that there's already been some improvement in survival rates. In the United States, the percentage of deaths attributed to pneumonia, influenza or COVID-19 decreased in mid-June from 9.5 percent to 6.9 percent, the ninth week of a decline, according to statistics released in July from the U.S. Centers for Disease Control (CDC).
Epidemiologists say that it's too early to know to what extent those numbers are attributable to actual improvements and how much of them are statistical artifacts. As the availability of testing increases, it drives down mortality rates because more healthy people are tested in the community than in the hospitals. Many of the patients driving the recent spike in COVID-19 case numbers are younger adults, who are at lower risk of complications. And there is a time delay of several weeks between when people are first diagnosed with the disease and when they die from it. Death rates will surely rise in the weeks ahead.
Still, hospital administrators in both current and former hotspots believe, based mainly on anecdotal information, that public health officials have identified more tools to effectively fight the disease. "There's no question we're getting better at managing patients who are seriously ill," says Peter Jay Hotez, a prominent virologist and the dean of the Baylor College of Medicine's National School of Tropical Medicine in Houston, Texas. "And I think that is beginning to save a lot of lives."
At NYU Langone Health, which has now seen more 24,000 COVID-19 patients and was on the frontlines of the last surge, the mortality rate for those admitted has been trending steadily downward and has fallen from about 18-to-20 percent at the beginning of March to 10-to-12 percent for the last week statistics are available, says Dr. Fritz Francois, the massive hospital system's Chief Medical Officer and Chief Quality Officer. Those improvements have been mirrored in big-city hospitals in the new hotspots. At Houston Methodist Hospital, for instance, Schwartz estimates the number of patients who end up in the ICU has fallen from 50 percent to 30 percent, a change she attributes to innovations in care. Hospital death rates have fallen from 10 percent to 6 percent.
"We're not the only city in the United States seeing that switch and there are a lot of reasons," she says. "Sure, it's [due in part to] changing demographics—some of these patients skew younger. But it's also early recognition, earlier testing and better drug cocktails." That is what one would expect to see based on other public health emergencies seen in recent years, such as cholera outbreaks in Bangladesh and Africa, says Justin Lessler, a professor of epidemiology at the Johns Hopkins Bloomberg School of Public Health. "We generally see a high case fatality rate early on, but it drops significantly," he says. "And one of the reasons is that treatment gets better because the doctors learn how to treat better. Some of it is having the right tools available, but even more of it is knowing how to use them."
Coming together in the emergency room
One of the most disturbing elements of the current surge is the reckless disregard some young people have shown to protecting the health of older Americans. But the collaborative efforts of leaders in medicine offer some solace. In cities across the nation, hospital administrators say that institutional rivalries have often melted away and personnel have worked together to share up to the minute advice and insights.
This spirit of cooperation yielded insights from the beginning. In those tense first weeks when the first COVID-19 cases hit the U.S. and began to surge to their first peak, hospital policymakers and staffers in New York City participated in phone calls and video conferences with colleagues overseas and out west, who warned them of the crippling toll the disease had taken on healthcare workers, and urged them to take precautions.
At NYU, as the number of cases ramped up at the main Manhattan campus, administrators created a dedicated area in the emergency room sealed off from the rest of the hospital and limited access to a select group of staffers clad in personal protective equipment and masks. That staff evaluated the severity of each case and decided whether to immediately begin ventilation, a procedure that required doctors place the patient in a medically-induced coma.
The dedicated area and other protocols made it safer for the medical staff to rely on less invasive forms of respiratory assistance thought to pose a greater risk for contaminating others, such as CPAP machines, which can sometimes "aerosolize" the virus. As the epidemic went on, staffers got better both at keeping patients off of ventilators for longer—sometimes avoiding the need to place the patient in a medically-induced coma all together—and at safely-repurposing less invasive breathing machines, improving outcomes.
Similarly, as it became clear that efforts to keep healthcare workers safe were working at Columbia University Medical Center, doctors there became more aggressive in performing tracheotomies, a procedure that allows doctors to remove a patient from a medically induced coma and begin physical therapy sooner. Tracheotomies often help patients recover quickly, since the tubes are easier to clean and the patient can begin working on regaining the strength to recover. But they can pose a potential hazard to medical personnel by aerosolizing the virus.
"We didn't do them super early. For these patients, we waited sometimes three, four weeks on the ventilator. There were a lot of concerns around keeping everybody safe, because of concerns for aerosolization of the virus," says Susannah Hills, Pediatric Otolaryngologist-Head and Neck surgeon and Assistant Professor at the Columbia University Medical Center. "But as time went on, we were able to do them earlier."
By most accounts those warnings and precautions made a big difference. In mid-May, Governor Andrew Cuomo announced that in New York City, 20 percent of the general public had antibodies, compared to about 12 percent of healthcare workers—suggesting that efforts to protect hospital staff were working. (In Spain, nearly 14 percent of the first 40,000 confirmed cases were healthcare workers.)
Meanwhile, clinicians elsewhere in the country were watching closely. At Houston Methodist Hospital, administers sought advice on the best PPE to order from colleagues in Florida, who had already tried them out. A clinician brought in a picture sent to him from a friend in China that detailed how to make a protective "intubation box" that would allow doctors to perform risky procedures in a way that protected them from dangerous viral particles.
Beyond that, these clinicians also learned important clinical tips and insights about the disease itself that had been discovered in the overwhelmed hospitals of Manhattan.
For Banner Health's Glassberg, a key turning point came in a conference call with frontline clinicians in New York City. On the April 5 call, part of a weekly series organized by the American Thoracic Society (ATS), she listened as Charles Powell, her counterpart at New York City's Mount Sinai Hospital, presented autopsy data that suggested many patients were suffering from tiny blood clots that were wreaking havoc on their bodies—and often killing them. His staff had begun to treat them with anti-coagulation drugs like Heparin. which was making a big difference.
Powell also discussed the use of steroids. For years, doctors had vigorously debated their use on patients suffering from Acute Respiratory Distress Syndrome (ARDS), the often-fatal lung condition that has forced so many COVID-19 patients onto ventilators. Steroids are one of the most extreme and risky interventions available to doctors. Those who pushed for them argued that in many cases the body's overwhelming immune reaction to the virus—the so-called "Cytokine Storm"—was responsible for killing many patients. But steroids often act like a circuit breaker on the immune system, essentially shutting it down. Those opposed to using them in COVID-19 treatments warned it was foolhardy to administer a drug to suppress the immune system just as an aggressive virus was attacking.
The day after Powell's presentation, however, Glassberg and her colleagues rewrote the hospital's COVID-19 protocols. They immediately began integrating the more aggressive use of blood thinners and steroids into patient care.
It was the right call. Following the initial mother and son case came a parade of Native Americans—including Navajos from Kayenta, 290 barren, cactus-studded miles to the north, and members of the Yuma tribe from protected lands far to the west. Native American reservations were emerging as COVID-19 hotspots. In the weeks that followed the implementation of the new protocol, Glassberg did not lose a single patient. (Sadly, that streak was broken when the current surge hit). Both the blood thinners and the steroids are likely one reason why.
In mid-June, researchers at the University of Oxford announced the preliminary results of a massive clinical trial that tested steroids on thousands of patients on ventilators. They claimed to have driven down mortality by 35 percent simply by administering a 10-day course of another powerful steroid, dexamethasone.
"The survival benefit is clear and large in those patients who are sick enough to require oxygen treatment," Peter Horby, Professor of Emerging Infectious Diseases in the Nuffield Department of Medicine at the University of Oxford and one of the chief investigators for the trial, said in a widely reported press release. The drug "should now become standard of care in these patients."
New patients in the largest hospitals in Texas, Arizona and Florida are now also benefiting from six months of clinical trial data. While the anti-malarial drug Hydroxychloroquine, hyped prematurely by Donald Trump, has been shown to be ineffective and dangerous, Gilead Sciences' antiviral drug Remdesivir has been shown to be effective when administered early. Convalescent plasma, available in a growing number of cities around the nation, is helping patients fight off the virus by providing neutralizing antibodies. Tocilizumab, an immune modulating medication presently being given to treat the Cytokine Storm, is undergoing clinical trials to confirm its effectiveness.
All of these lessons are being passed on to doctors and healthcare workers in other parts of the nation through professional networking organizations, email chains, Twitter and organized phone conferences between hospital leadership. In addition, the National Institute of Health regularly updates its website to help clinicians keep up with the latest treatment advances.
The big caveat
This good news comes with a caveat. If the number of patients overwhelm medical facilities and there aren't enough personnel and equipment to take care of them all, these improvements in care might not matter. Doctors will switch to "crisis standards of care," which means they'll have to make heart breaking decisions about whom to save and when. All the knowledge in the world won't be enough if patients die on gurneys in corridors or don't come to the hospital for fear of being turned away. "If our healthcare system gets overwhelmed and you have patients that need ventilators that are lining up in your [emergency department] because all your ICUs are filled up, that's probably going to have an impact on the outcomes," warns Dr. Mamta Jain, an infectious disease expert and physician at UT Southwestern. "I'm concerned that we will see increases in our death rate."
Unfortunately, the numbers tell a frightening tale familiar to anyone who lived through the crisis in New York City during March and April. With troubling spikes in case numbers in states like Arizona, California, Texas and Florida, the unwillingness of a growing number of Americans to wear masks and social distance, healthcare officials are warning of a potential calamity. Already some hospitals in California, Texas, Illinois and elsewhere are reportedly hitting capacity, raising the troubling possibility that some might run out of ventilators.
"What we learned is great," says Schwartz. "What we didn't learn is how not to do it again. The unfortunate part is, I don't see it slowing down. Which has me very worried."
Flattening the curve to avoid a crisis is currently the best and only strategy to mitigating the effects of COVID-19. That will likely remain the case until a vaccine is available, which likely won't arrive for months at the earliest, notes Lessler. "They're chipping away at it bit by bit, and those things will add up over time and eventually they can make a big difference," he notes "But none of them is the magic bullet that takes us from 'this is a deadly disease to this is not a problem." The difference between survival and death sometimes comes down to timing.
Correction: the spelling of Marilyn Glassberg's name was corrected. 8:16 pm EDT 7/9/20
