Last month as my colleagues and I took care of Mrs. Smith (not her real name), a middle-aged woman hospitalized with Covid-19, every day felt like an education in learned helplessness.
No matter what our team did, her infection kept getting worse. At first she was breathing just room air. Then she needed extra oxygen delivered by a small tube sitting below her nostrils. After that she needed more oxygen delivered through a facemask.
We gave her the drug remdesivir, but she didn’t get better. We gave her high-dose steroids, but she didn’t get better. We even gave her the antibody cocktail that President Trump and many of his high-profile allies received, but she didn’t get better.
Mrs. Smith’s fever climbed, her breathing worsened, and her spirits sunk. Every time I called her husband, I searched for a silver lining, but all I could share was one decrement after another.
Despite our best efforts, she was transferred to the intensive care unit and connected to a mechanical ventilator to breathe for her. Not long after that she had a heart attack and, within a matter of days, she died.
Physicians crave agency, a power they can use to turn around the course of an ailing patient’s life. Yet for me and countless physicians, nurses, and other clinicians, Covid-19 has been a grim lesson in humility. While we have learned so much about this illness in such a short time, we still have almost no ability to change the fate of patients with severe Covid-19 infections.
Like many other viral infections, Covid-19 has turned into a graveyard for therapeutic interventions. Research my team performed showed that over a two-month span earlier this year, American doctors wrote half a million prescriptions for hydroxychloroquine and the Food and Drug Administration, despite having no real evidence for its benefit in Covid-19, prematurely issued an emergency use authorization for the drug — which it later revoked due to concerns about cardiac complications. Remdesivir, an antiviral drug, was approved by the FDA for treating Covid-19 in October 2020, even though the data supporting its use were marginal at best. Less than a month later, the World Health Organization recommending against using it.
Plasma collected from individuals who recovered from Covid-19, another widely hyped treatment, turned out to be useless in patients with moderate or severe infections. Even the antibody cocktails, often touted as a cure for Covid-19, haven’t yielded favorable results: Clinical trials testing antibodies developed by both Regeneron and Eli Lilly among patients hospitalized with Covid-19 have been halted due to the treatment being ineffective.
To date, the only drug therapy that appears to clearly help critically ill Covid-19 patients is steroids.
There is now concern that some of the drugs we were giving to Covid-19 patients were more than just useless — they might, in fact, have been harmful.
Early in the pandemic, clinicians noted that patients with Covid-19 had a propensity to form clots inside blood vessels that could have life-altering consequences, such as causing strokes or pulmonary embolisms. Doctors around the world began giving blood thinners to Covid-19 patients, and some medical societies offered guidelines for aggressive use of these medications. In an online poll, a majority of doctors indicated they would prescribe high-dose blood thinners to Covid-19 patients thought to be at high risk for blood clot formation.
Yet when the NIH studied blood thinners in a randomized trial, not only was the treatment futile but it may have been harmful for patients with severe Covid-19 infection by increasing bleeding. The trial was recently paused in that group because a “potential for harm in this sub-group could not be excluded.” Another major international trial of blood thinners also halted enrollment of critically ill patients, though enrollment of Covid-19 patients with less-severe disease continues as a risk of harm has not been identified in those groups.
Blood thinners are far from the only treatments that doctors have given Covid-19 patients that may have made matters worse. Early on, many doctors aggressively put Covid-19 patients with low oxygen levels, but who otherwise weren’t critically ill, on breathing machines, an approach that carries both short-term and long-term risks.
All these negative results make me wonder if an important reason why death rates from Covid-19 are dropping may not be because we have expanded testing or are doing more to fight the disease, but because clinicians are doing less for patients with it. A year into the pandemic, maybe we now know more about what not to do. Perhaps fewer people are dying because clinicians are being forced to be introspective and careful. An old adage is that a good surgeon may be wrong, but never in doubt. Perhaps after 2020 we will bury that one for good.
One of my aunts in Pakistan recently fell ill with Covid-19 and was admitted to a small hospital. My phone quickly filled with pictures of CT scans and prescriptions written in Urdu, along with videos of her breathing into an oxygen mask while sitting on a makeshift bed wearing her shalwar kameez. From the other side of the world, other than recommend steroids all I could do was leave hopeful voicemails.
It was eerily similar to how I felt looking through the glass door in the hospital at my latest patient struggling to breathe just a few feet away.
Looking back, we should have made it easier for clinicians to enroll patients in trials so we could learn more quickly about the impact of our actions. While academic physicians in the U.S. have published thousands of Covid-19-related papers, their contributions to randomized clinical trials, the gold standard of clinical evidence, has been limited. The United Kingdom has done a far better job of enrolling patients in trials even though it, too, is being hard hit by the pandemic.
And yet, though we have made little progress finding a “cure” for Covid-19, we have made exceptional progress in finding ways to prevent the spread of the infection. From public health measures like wearing masks and physical distancing to the development of two stunningly effective vaccines now approved for use — and likely more to come — our ability to prevent this infection will surely be the way we make it out of this pandemic.
Unlike Mrs. Smith, I have had many patients who recovered from Covid-19. One of them developed such severe heart failure that we listed him for a heart transplant and yet, after months of struggling, he turned the corner. Another who was admitted to the hospital the same day as Mrs. Smith left a few days later without any symptoms to speak of. My aunt in Pakistan also is back home and doing well.
I wish I had the audacity to take credit for wins like these. But the truth is that when it comes to Covid-19, prevention has handily trumped our failed quest for a cure. The need to control the spread of the virus has now grown even more crucial as we attempt to build a bridge to widespread vaccination.
Haider Warraich is a cardiologist and researcher at Brigham and Women’s Hospital, associate director of the heart failure program at the VA Boston Healthcare System, and an instructor in medicine at Harvard Medical School. The views presented here are his and don’t necessarily reflect those of his employers. Patient details have been withheld or changed to preserve confidentiality.