Dr. Lee says COVID-19 patient counts down

Says he remains worried about a second peak

This is the eighth conversation 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, an 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: Last week we spoke during what we thought was the surge week in Massachusetts. Now it’s a bit unclear.

JARONE LEE: This week I am happy to report that the COVID-19 patient numbers continue to decline. We are down from around 450 COVID-19 confirmed and suspected patients to around 420 Thursday morning; similarly, our ICU numbers are down from a high of about 180 to about 140. A similar trend could be found throughout our system, and to my knowledge in the Boston hospitals. There may well be some hotspots, like in Brockton, where their numbers of COVID-19 patients continue to grow.

HATTIS: Does that mean we can all breathe a sigh of relief.

LEE: We might be past the peak. What we are worried about is a second peak. Governor Baker is right to extend the stay-at-home advisory until at least mid-May. Even though this feels like a victory, we are still in a very dangerous period.  Everyone, not just us healthcare workers and essential personnel, but everyone has done a great job social distancing and adhering to principles that will fight and beat this virus. Frankly, if we relax the public health measures too quickly, there could be a resurgence that could look worse than how it is now. This could be the toughest time for all of us during this pandemic since things are looking better, we all are feeling cabin fever, and the economy continues to downtrend. Also the weather is not helping as it is getting nicer and nicer outside. I urge folks to continue staying safe and socially distance aggressively so that all of the work we have collectively done does not get reversed.

HATTIS: Since last week, there was a JAMA article summarizing some of the clinical outcome experience in the New York City area, including a finding of an 88 percent death rate for those who were on ventilators. What’s your opinion of that article and the relevance of its numbers to the MGH experience?

LEE: We have to be careful with any mortality rates and numbers, especially this early with this disease.  The rush to publish and get numbers out is admirable and much needed for our scientific community, but this leads to both over-estimation and under-estimation of mortality rates and statistics.  In this example, the 88 percent death rate grossly over-estimates the mortality of COVID-19 patients requiring mechanical ventilation.  The authors only reported mortality for patients that either died or were discharged. They excluded over 830 patients that were still alive and on mechanical ventilation at the end of their study. Adding these patients back in, and assuming they all survive, the mortality rate drops to around 24 percent.  Unfortunately, this is probably an under-estimate of the mortality as we do not expect all these patients still on ventilators to survive. So reality will be somewhere between 24 percent and 88 percent, most likely closer to the 24 percent range. What we know from treating acute respiratory distress syndrome, or ARDS, before COVID-19 is that it has an extremely high mortality – around 30-40 percent.  As such, I believe the final mortality figures for COVID-19 patients once this is all over will probably be around those percentages.

HATTIS: There have been media articles suggesting that COVID-19 patients should avoid being placed on ventilators as much as possible—including when they are having severe breathing challenges. What do you think?

LEE: This is concerning to me because I do not believe it is the ventilator that is killing our COVID-19 patients. When a patient needs a ventilator to get enough oxygen, then they are already in a group of patients that is sicker than others.  If they do not get put on a ventilator, then they will die. This should not be circular like a chicken or egg debate. Instead, it is an issue of the chicken and we are seeing if the chicken gets better or dies. In other words, we need to learn who needs to be put on a ventilator because of low levels of oxygen in their blood and not focus on if the ventilator is killing the patient.  Mortality should be interpreted with a grain of salt. We can only know the true mortality once all of our COVID-19 patients have either recovered or passed—a number of weeks or months into the future.

HATTIS: Beyond ventilators, there have been media stories about patients at MGH being placed on ECMO. What can you say about its use and efficacy for patients with COVID-19 so far?

LEE: Yes, ECMO is a treatment that we should offer to our COVID-19 patients. Many of them have pure lung failure that is beyond survival using just our mechanical ventilators. As such they would need ECMO, an external way of providing oxygen to a patient without needing the lungs. So if we put a patient on ECMO, then their lungs can rest and recover. Our very first COVID-19 patient who required ECMO – Mr. Bello – is doing well. We have had a good number of COVID-19 patients on ECMO now at MGH. I am happy to report that around half of them were able to come off ECMO and are doing well.  Besides us, there are other ECMO centers in Boston, including Brigham and Women’s Hospital.

HATTIS: A new study seems to affirm the often observed clinical observation that men tend to get sicker with COVID-19 as compared to women. I wrote an article on this topic, and why Massachusetts appears to be an outlier but over time probably won’t be. What are you experiencing clinically along gender lines with your seriously ill patients?

LEE: At MGH, men do seem to get admitted more often to the hospital and also to our ICUs. My best guess is men comprise around 60-70 percent of the COVID total in the ICU. By gender, it seems like the number of men and women coming off ventilators is no different. Regardless of gender, once a COVID-19 patient enters the ICU their chance of death goes up drastically. Since men appear to have more severe disease than women, there are more deaths. This story of men being disproportionately affected is reflected in the data from other states and countries with significant numbers of cases. Men comprise a higher proportion of deaths despite the fact that women have a higher total number of reported infections.

Interestingly, as you said in your article, our state reports that overall COVID-19 mortality is evenly split between men and women. Is this because our nursing homes, which have a higher proportion of older women, are being hit harder in this first phase of the pandemic? Or could it be that there are men dying at home from COVID-19 who haven’t been virus tested. As a result, they remain outside of the COVID-19 death statistics? In either case, both are tragic.

HATTIS: Any updates on drug trials with any of these: remdesivir; hydroxychloroquine, drugs treating cytokine storm, and recovered plasma infusions?

LEE: We continue to enroll in the remdesivir trial and continue to use hydroxycholoroquine cautiously. I think it is important to add that Dr. Fauci’s news about remdesivir is hopeful.

There are a lot of details missing, including why mortality was not an end-point. I’m sure we will learn more in this coming week. We have to remember that drugs like hydroxycholoroquine have a lot of side effects and interactions with other drugs.  Unfortunately, we have also seen patients that have overdosed on hydroxycholoquine trying to self-treat.  We are planning to participate in a convalescent plasma study soon. It is still too early to tell if this treatment will be helpful.  Similar to the other trials, we need more and better research.

HATTIS: Last week you said you have sufficient numbers of ventilator machines, but worry about adequate tubing to connect patients to the ventilators. Where does that stand?

LEE: We continue to have issues getting new tubing for some of our ventilators, but with fewer ICU patients needing mechanical ventilation it is less of an acute issue. However, if there is another surge or peak, we could be in a bad situation. Many of our ventilators use proprietary tubing from the manufacturer and typically can only be sourced from the company itself. During a crisis like this, with increased demand and not enough production, every hospital that is using ventilators is at risk of running out of tubing. The ventilator becomes an expensive paper weight.

Looking forward, we would like to get additional tubing for our ventilators, not just for COVID-19 patients in case of a second surge, but also for any patient that could need a mechanical ventilator in the future. Speaking as a clinician wanting to have the resources to take care of our patients, there should be a way for some form of public-private collaboration so that ventilator tubing is completely interchangeable regardless of the ventilator. Definitely something to consider for the next pandemic.

We received a few ventilators from the national stockpile, but we have not been able to get additional tubing. The reason is three-fold.  First, the tubing is proprietary as we talked about before. Second, there is a short supply of the components to put together the tubing. We tried to buy the separate components, but they are also in short supply. Lastly, all orders for additional tubing are being diverted for the federal response and so we cannot get additional supplies directly from the company. While I understand the reasons and also appreciate the need for our federal government to coordinate supplies, this leaves us with minimal options.

HATTIS: Last week there was a lot of discussion about patients with serious illnesses who were not coming in to hospitals because of fear of COVID-19. Is that starting to change?

LEE: Thank you for asking as I believe this is an important issue. For some reason, we are seeing less heart attacks and strokes unrelated to COVID-19. I doubt that these diseases have gone away, but instead my worry is that people are staying home and getting sicker and sicker. At some point it could be too late for us to help. Having deployed as a medical officer during disaster situations, my team and I have gone into places where medical infrastructure is destroyed and suspended. Initially, we see patients that have delayed care because of infrastructure. Some are sicker than others, but, overall, we get them the treatment they need. Later on in the deployment, we start hearing of patients who never made it to us and ended up dying at home. This is what I am worried about as people delay medical care. I imagine there are a lot of people with chronic conditions isolated at home alone, too scared to come to the hospital. My personal feeling is that COVID-19 could cause many more deaths above and beyond just infection. My message to everyone is to please come in if you need to see a doctor. The hospitals are safe, especially ours. Many of my ICU nurses have told me that they actually feel less at risk of contracting the virus while working at the hospital than at home in the community.

HATTIS: Last week we talked about how MGH is using more interpreters because of an increase in Spanish-speaking patients.  Any updates on this?

LEE: We continue to use interpreters as this disease continues to significantly affect our Hispanic communities at greater rates than other communities. What has been hard on us are the emergent moments with these non-English speaking patients, when we do not have time to use an interpreter. It could be a situation where the patient is so tired from breathing heavily because of their COVID-19 lung injury that they cannot support their own breathing any more.  Medically, the next step would be to put them on a mechanical ventilator. The challenging part is that these patients are scared, and as clinicians we know that this might be the last time they can talk to their families. Even if we can get an interpreter to the bedside quickly, it’s a very difficult situation. Furthermore, these patients are now alone because we need to minimize visitors in the hospital. If possible, we are trying to have our patients talk to families before putting them on mechanical ventilation, even if it is only for a few seconds. And if we cannot contact the family, we try to record a short video of them speaking to their families as if they were in the room or on the phone, with the possibility that it will be shared later with their family,

HATTIS: Any updates about the family?

LEE: Having our son always at home is especially difficult with both of us working. Our primary source of childcare before COVID-19 was my parents who live a few blocks away. With me working in the hospital, we decided to fully quarantine ourselves away from them. What we have discovered is that video chatting between the grandparents and our son works. Even if it is only for a short time, the grandparents keep him entertained enough so that we can get work and housework done. Also, he regularly has play dates with a cousin around his age on the west coast. They are very close now, whereas before this they only knew a bit about each other. Their favorite game to play is to make faces at each other while changing their faces to animal faces on the video chat app.

 

Previous conversations with Dr. Lee:

The Codcast: A report from the frontlines at MGH

&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

Meet the Author

Paul A. Hattis

Associate professor, Tufts University Medical School
Surge still manageable for Dr. Lee

Dr. Lee: We’re busy but in good shape