Jelic was among the doctors treating COVID-19 patients in New York in the spring, when hundreds of people were turning up at the city’s hospitals everyday unable to breath. Patients were crammed into hallways; doctors were overworked. Normally, Jelic says, she might have seen eight or 10 patients in a day. In April, she and two fellows were responsible for 60, any of whom might crash and need to be intubated.
Lack of knowledge about the virus constrained what doctors did. Hospitals initially favored ventilation in part because doctors feared that high-flow therapy oxygen could aerosolize the virus and spread it to staff who didn’t have adequate supplies of personal protective equipment. (Now, of course, we know that the virus can be spread through aerosols generated from just normal talking and exhaling.) In some cases, aggressive intubation might have done more harm than good in patients who didn’t need it. Doctors stopped putting every patient on a ventilator once they realized the benefits of less invasive oxygen therapy and even turning patients onto their bellies, also known as proning.
Because COVID-19 can, like many conditions, manifest so differently from person to person, knowing which patients might benefit—or be hurt—by a treatment is a key part of the learning curve. “There isn’t a one-size-fits-all treatment,” says Nicholas Caputo, a doctor at Lincoln Hospital in the Bronx, who was one early advocate of proning. Ventilation is one example of a treatment that can help or hurt depending on the patient. Another is dexamethasone, a steroid that suppresses the immune system. The drug has been shown to reduce mortality in patients with severe COVID-19, whose immune systems have become hyperactive, but might harm patients with milder cases whose immune systems are still trying to clear the virus.
Doctors have also learned to watch out for COVID-19’s more unusual symptoms. The disease has been linked to kidney failure; those patients might need dialysis. It’s also linked to blood clots; patients who show warning signs might need blood thinners. Seeing more cases of COVID-19 has also allowed doctors to refine details like the size of tubing used with ECMO, an artificial-lung technology for the sickest patients who aren’t doing well on ventilators.
A lot of this experience has been shared in real time and informally. J. Eduardo Rame, a cardiologist at Thomas Jefferson University Hospitals, helps convene a regular Zoom forum where doctors discuss the latest, such as how to use ECMO. “Experiential learning,” as Rame puts it, has been vital for sharing information about a new disease. But doctors are also trained to rely on data and randomized, controlled trials, not anecdotes. “We’re nowhere near the inflection point where we can have medical care dictated by evidence,” Rame says, which puts doctors in a strange position. For now, they have experience to go on, which is better than nothing. But it’s not data.