COVID-19 fallout: Alarming trend of severe liver disease

‘We are now in the upswing of the curve,’ says Dr. Lee

This is another in a series of conversations between Dr. Jarone Lee, a frontline critical care and emergency physician at Massachusetts General Hospital and associate professor at Harvard Medical School, and Dr. Paul Hattis, a retired associate professor at the Tufts University Medical School who participates in CommonWealth’s Health or Consequences Codcast. Find links for past conversations at the end of the story.

PAUL HATTIS: As of Wednesday, state numbers show 1,576 hospitalized COVID patients statewide, with 308 in the ICU. That’s 60 and 47 percent increases, respectively, over the last two weeks. Where are things at Massachusetts General Hospital, and what do the demographics of COVID patients look like now in the hospital and in ICUs?

JARONE LEE: COVID is definitely back. Steadily increasing, seeing more and more COVID patients in the ED and in the ICU. Some days in the emergency department, it feels like how it was during the spring surge. At MGH right now, we have 318 COVID confirmed patients across the Massachusetts General Brigham system, with 104 at MGH; representing a 75 percent increase across the system and 40 percent at MGH when compared to two weeks ago. On the ICU side, we now have 60 COVID-confirmed patients across the system with 32 of these at MGH. That’s a 40 percent increase across the system and 45 percent at MGH. We are now in the upswing of the curve. Gov. Charlie Baker recently established a statewide hospital capacity reporting system by region and has moved the entire state up to the 2nd highest tier this past Monday—denoting a high risk of capacity constraints. He is also mandating that hospitals reduce elective surgeries requiring an inpatient hospital bed by this Friday.

As for COVID patients occupying beds in our system, anecdotally the age distribution seems slightly younger than last spring, with many hospitalized and also critically-ill and admitted to ICUs. A number of people are in their 30 and 40s, and many are requiring mechanical ventilation and long hospital stays. Overall, still predominantly male and the older population continues to have higher death rates.

Another alarming trend we are seeing is that many young patients come in with severe liver disease from alcohol use. While not COVID-19 infected, their stories of why they either relapsed or started drinking is related to the pandemic, as they note recent job loss or pandemic related depression and anxiety. In just the last few weeks, I can personally name at least five patients that passed away in their 30s and 40s because of alcohol-related liver disease in our ICUs. Overall, it’s a true public health crisis of immense proportions. What we are seeing is the tip of the iceberg with many long-term health and economic effects to come.

HATTIS: Within Massachusetts General Brigham are you dealing with the flow of COVID patients in a similar way as last spring, or different?

LEE: Unlike last spring, we are now actively spreading out COVID patients across our system, specifically between MGH and Brigham and Women’s Hospital. By monitoring the census at both academic centers, we can make an assessment of where to best accept a COVID patient from the community. We have also transferred patients between the two hospitals as well. This way no hospital will be overwhelmed. Of course, all patient transfers require patient or health care proxy approval.  While most of our COVID transfers right now are from hospitals within the Mass General Brigham system, we continue to receive transfers from across the region, especially for patients that might need extracorporeal membrane oxygenation, or ECMO.

HATTIS: How is your care changing from last spring?

LEE: On the inpatient side, we have learned a fair amount about what works and does not work. Besides standard supportive medical care, hospitalized patients generally receive dexamethasone and remdesivir. We are also finding that some patients who need oxygen support can get by with devices that can give a high concentration of oxygen without a mechanical ventilator via a high-flow nasal cannula. However, we also have learned that it can be detrimental if patients stay on these devices too long, as the high flow could worsen their lung injury and cause further damage. As such, we monitor our patients with COVID closely on high-flow oxygen, and if they do not improve quickly, we put them on a ventilator.

Across our system, we have also acquired additional dialysis machines given that many COVID patients that get admitted to an ICU require dialysis. During the spring, we had to share dialysis machines between patients, which worked but was not ideal and technically very difficult. At Massachusetts General Brigham, convalescent plasma is something we offer as part of a research protocol. The most recently published data showed no benefit of convalescent plasma; so we remain cautious about its use.

On the outpatient side, the data with the monoclonal antibodies is encouraging. There are two that are now approved under an emergency use authorization. They are made by Eli Lilly and Regeneron. They should be available soon to institutions across the US. These antibodies are infused in an outpatient setting—like chemotherapy for cancer. As with any new drug and infusion, there are many risks and side effects associated with these new drugs. The benefit is still equivocal and unknown and requires further study.

HATTIS: What’s your reaction to the governor’s vaccine distribution plan?

LEE: We are excited about Baker’s announcement that we will be getting initial doses of vaccines during Phase 1 of his plan, along with long term care facility patients and staff, first responders, inmates and others in congregate settings, home-based health care workers, and other non-COVID facing health care workers. With limited doses, in the hospitals we will need to figure out which COVID-facing staff get the initial doses. For example, in my ICU, we would consider not only our doctors, nurses, and respiratory therapists but also our janitorial staff being vaccinated later this month.

Another important issue is that the vaccine could cause a low-grade fever even if you are not infected. Regardless of cause of the fever, our staff members will need to stay out of work until the fever and symptoms resolve. As such, we do not want to vaccinate an entire unit or team at once, or we might be left with a shortage of clinicians—so we will need to stagger the vaccine administration a bit within a unit.

Also, the Pfizer and Moderna vaccines require two doses for gaining optimal protection. While there is controversy among experts in terms of how to best move towards vaccine induced herd immunity, most believe that the best approach with these vaccines is for people to get both doses. All of this will likely present logistical challenges, especially in non-hospital settings.

HATTIS: A big issue being talked about nationally is the possible shortage and burnout of staff. Any thoughts?

LEE: Everyone associated with this pandemic is tired. It’s not just frontline clinicians, but also office staff. They have been incredibly burdened by all of the administrative support work needed to keep the health care system functioning in a smooth way.

On the clinical side, visiting nurses and respiratory therapists continue to be in high demand. During the first surge, we relied on many “traveling” nurses and respiratory therapists. During the spring surge, the rest of the country was not surging as well. This time, the entire country is scrambling to find additional clinical staff to maintain bed capacity and space for new patients.

With shortages of clinicians across the US, I know that our Disaster Medical Assistance Teams (DMATs), as well as many other federal assets from all the federal agencies, have deployed to all regions of the US to help with COVID-19 surges. Personally, the team I am with has been out constantly throughout this year and many of them just received a COVID-19 Civilian Response Medal issued by Health and Human Services for the extended missions this year.

HATTIS: Any news on the personal front to share right now?

LEE: As parents of a school age child during the pandemic, my wife and I are always thinking about school and COVID spread during this time. We know that this has been such a complex and challenging issue for families with school-age children, school staff, and policy makers. Although the data has not always been clear, we decided to send our child to a private school that was clearly wanting to maintain in-person education. To date, they have been able to maintain that form of learning; but we know that, in order to continue, COVID needs to be under control in the community. So as cases build here in Massachusetts, we, like all other parents, are worried what this will mean for school. We also wonder how schools can be closed, but in-person dining is allowed to continue. Clearly, we live in an interdependent world when it comes to COVID and truly depend on each other for best practices to avoid the spread of infection.

 

Earlier interviews with Dr. Lee:

The Codcast: A report from the frontlines at MGH

Q &A with MGH doc Jarone Lee: We’re seeing patients of all ages

Dr. Lee: Preparing for the surge

Dr. Lee: ICU units won’t beat this disease

Dr. Lee: At MGH patients don’t die alone

Surge still manageable for Dr. Lee

Dr. Lee: We’re busy but in good shape

Dr. Lee says COVID-19 patient counts down

I’m seeing promising ventilator death data

At MGH, they worry about a second surge

Fewer but sicker patients in the MGH ICUs

Meet the Author

Paul A. Hattis

Associate professor, Tufts University Medical School
The black swan of our time

With COVID surging again, Dr. Lee returns