Dr. Hugh Cassiere is the director of critical care services at Northwell Health’s North Shore University Hospital (NSUH) in Manhasset, N.Y. He’s been a doctor for 24 years and says he’s used to treating “the sickest of sick patients.”
But nothing prepared him for what he calls the “tsunami of [COVID-19] patients” that hit the hospital this spring, when New York quickly became the epicenter of the global coronavirus pandemic.
“This was surreal … in terms of the sheer number of critically ill patients, and every single patient was sick beyond belief,” Cassiere told Yahoo News.
The experience, he said, “pushed me to my limits and skills.” It also taught him valuable lessons, and that knowledge is now being passed on to other physicians currently battling the disease in other areas of the country.
From a medical perspective, Cassiere said, learning that the use of steroids — specifically dexamethasone — early on in patients with low oxygen levels is of paramount importance.
“If I could go into a time machine and go back, I would tell myself to start using steroids freely, dexamethasone on all critically unstable COVID-19 patients. I did use steroids in the beginning, but I had a lot of trepidations for it. I didn’t use it on all patients because of the concerns about harm. Those fears are gone,” Cassiere said.
Severe COVID-19 illness can result in excessive inflammation throughout the body, including the lungs, heart and brain. This inflammatory response to the virus has been shown to be equally if not more damaging than the virus itself.
Since steroids have been used for decades to reduce inflammation in a range of conditions, including cancers, dexamethasone – a corticosteroid that’s used specifically to treat inflammation – was one of Cassiere’s go-to therapies early on.
“It’s the only therapy that’s been shown to date to save lives,” Cassiere said.
Results from a University of Oxford clinical trial released last month show that dexamethasone can indeed reduce mortality. According to Oxford’s report, “for patients on ventilators, the treatment was shown to reduce mortality by about one third, and for patients requiring only oxygen, mortality was cut by about one fifth.”
The drug, which has been on the World Health Organization’s essential drugs list since the 1970s, is “affordably available in most countries,” according to the agency.
Another treatment currently being used by physicians to treat COVID-19 patients is the antiviral drug remdesivir. Cassiere said there’s not enough data yet supporting that it can save lives. However, if administered early on, it may help shorten the duration of symptoms. “I don’t want to minimize that at all. It’s just not the blockbuster that we thought it was going to be,” he said.
When asked about the antimalarial drug hydroxychloroquine, which President Trump has touted for months as an effective treatment, Cassiere issued a warning: “Hydroxychloroquine just doesn’t work for patients with severe COVID-19 disease. That’s just a science fact. I don’t use or would not recommend it for treatment.”
Another complication from severe COVID-19 infections that is playing a major role in mortality is excessive blood clotting. Many patients in the ICU develop blood clots in small and large vessels, as well as in the lungs, legs and even the brain. These can lead to more serious issues such as strokes, pulmonary embolism, kidney failure and heart inflammation. In some patients, the lack of blood flow to the extremities is so severe that amputations have been necessary to save their lives.
To treat this “hypercoagulable state,” anticoagulants, or blood thinners, are being administered by doctors in some hospitals, and they seem to be helping patients in many of the country’s ICUs.
Unfortunately, some doctors have also reported that this COVID-19-related clotting does not always respond to standard blood-thinning treatments.
“I’ve had many patients who – I’ve gotten them through their lung injury and hyperinflammatory response, just to die from blood clots,” Cassiere said.
When it comes to treating low oxygen levels in patients, pulmonologists like Cassiere were relieved to learn that high-flow nasal oxygen therapy is effective and safe.
The method, which is a traditional technique used to provide high levels of oxygen through the nose, was avoided at the beginning of the pandemic for fear that the virus would spread in the ICU and infect health care workers. But Cassiere says they now know that is not the case, and urges doctors to not shy away from using this approach.
“You’ll probably prevent not everyone from being intubated or being put on ventilators, but maybe 10 to 20 percent of patients,” he said.
Many patients across the country with severe COVID-19 will unfortunately still need to be put on a ventilator. Luckily, doctors are now equipped with better methods to improve patient-ventilator interaction. Using blood thinners to prevent blood clots, flipping patients on their belly to improve oxygenation and keeping fluid levels low are a few methods Cassiere highlighted for the treatment of intubated patients.
Aside from the medical lessons, Mikaela Wolf, a critical nurse practitioner at NSUH who worked hand in hand with Cassiere during New York’s surge, told Yahoo News that the value of teamwork is one of the most important takeaways from this experience.
“It takes every – all of the hands you can get. All the support you can get … it doesn’t matter what your title is because you all have the same goal, and that’s to save patients.”
Both Wolf and Cassiere believe that when dealing with a crisis like the one presented by COVID-19, leaning on colleagues, family and friends is crucial.
“Communicate your feelings and what you’re going through with your colleagues. They’re feeling the same things you are. You can decrease the stress and the burden by doing that,” Cassiere said.
“Be resilient. There is light at the end of the tunnel,” Wolf added.
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