San Antonio is just down the road from Austin. While this report on COVID in San Antonio is encouraging in terms of what doctors are learning, the virus remains tricky.
Emilio and I ran an errand in Austin this morning. The streets were quite empty, even eerily so. It all feels like a surreal, sci-fi movie that we're all in. The pandemic is so unnerving, making me wonder when the next "shoe is going to drop," so to speak, especially with Hurricane season in front of us. May we all be spared.
Even if it's making many folks go stir crazy, myself included, I'm glad that they're mostly staying at home around here. We should take reports like these seriously. In Express-News' writer, Lauren Caruba's, words, "tough summer ahead."
-Angela Valenzuela
By Lauren Caruba | San Antonio Express-News |
As the pandemic progressed, San Antonio’s health care workers overcame a steep learning curve with COVID-19. They treated hundreds of patients, including many who became critically ill. Along the way, they have become familiar with how the disease progresses and affects the human body. More treatments emerged, and preliminary data from studies has clarified their efficacy against an unpredictable disease.
On ExpressNews.com: 18 hours inside a COVID-19 ICU
Months after San Antonio identified its first coronavirus case, the approach to treating COVID-19 has evolved. Doctors and respiratory therapists have changed how they are deploying ventilators and other supportive breathing approaches. They have a better idea of what medications to use. After starting with few options, they now have more knowledge and tools at their disposal.
But there is no magic bullet or one-size-fits-all approach to COVID-19. Doctors still have many questions about the disease, and what works for one patient won’t necessarily do the same for another.
“I don’t think we’re ever going to be comfortable around COVID, but I do think we have a lot more confidence taking care of the patients now,” said Dr. Jeff Jones, an infectious disease physician with Methodist Healthcare.
A shifting approach to ventilators
When the coronavirus began spreading in the U.S., many health experts were concerned about the potential for hospitals to run out of mechanical ventilators for the sickest coronavirus patients.
While the breathing machines are still playing an important role in the care of people who become critically ill from COVID-19, doctors are no longer rushing to intubate their patients.
Part of that shift has to do with a greater understanding of the virus’ risk to health care workers.
Initially, doctors in San Antonio worried about reports from China and New York of high rates of infections among hospital staff, especially with breathing supports that could aerosolize the virus. It was unclear how the virus was spreading and how it would behave in a hospital environment.
In those early weeks, doctors would intubate patients more quickly, in the hopes that ventilators could help control the spread of infection by containing the virus in a closed circuit.
“We would lower our threshold for placing a patient like this on a ventilator, where in other diseases we would challenge the patients or see if they would tolerate less aggressive forms of oxygen support,” said Dr. Omar Enriquez, medical director of the intensive care unit at University Hospital.
But under this approach, doctors found that some patients weren’t doing well on ventilators. Mortality rates were high.
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Once patients were hooked up to ventilators, they often stayed on them for long periods of time, raising the risk of ventilator-related complications, said Michael Jones, University’s executive director of respiratory therapy.
“With positive pressure ventilation, it can weaken the body’s respiratory muscles,” he said. “It can cause different lung injury, because you’re blowing pressure and air into the lungs, as opposed to sucking in using the diaphragm.”
Nurse Olivia Rocha, left, administers the antiviral drug remdesivir to COVID-19 patient Betty Talton at University Hospital.
Photo: Bob Owen /San Antonio Express-News
Over time, as medical workers grew more comfortable using protective equipment to protect themselves, they began utilizing other types of breathing support for COVID-19.
Rather than rushing to intubate patients with dropping oxygen levels, they would give patients regular or high-flow oxygen. They have also deployed BiPAP machines, which are used for people with sleep apnea.
Some of the most critically ill COVID-19 patients will still need ventilators, but it’s not the only option.
“We’ve learned that perhaps it is better for the patient to not jump the gun so quickly and not put them on respiratory life support so early on,” Enriquez said.
The rise of proning
In the most severe cases, the coronavirus causes acute respiratory distress syndrome, where fluid accumulates in the tiny air sacs of the lungs.
For years, hospitals have used a technique called proning with ARDS patients, flipping them onto their stomachs to help open up their lungs. As a surge of people with COVID-19 filled hospitals in New York, doctors there found that proning helped improve breathing in those patients.
University implemented proning early on, Jones said, after observing its successes elsewhere.
“We learned from other places,” he said. “We could build our strategies, before we saw COVID patients.”
The idea behind proning is to capitalize on the anatomy of the human body.
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The lungs are narrower at the front of the body, while on the back they widen at the base. Enriquez likened them to the peak and base of a pyramid. When a person is lying on their back in bed, it can exacerbate the breathing problems they are already experiencing.
“Gravity works, and all the fluid and everything settles in the lungs,” Jones said.
But when they lay on their stomach, the widest part of the lungs is less restricted by the chest wall and the person’s weight, especially if the patient is obese.
Jones said the hospital has been able to keep some patients off of ventilators by giving them oxygen and having them alternate between lying on their stomachs and their backs. They also use proning for patients who are already on ventilators but are still doing poorly.
When all else fails
In some of the most severe cases, when those options and even ventilators fail, some hospitals are falling back on a last-ditch effort — extracorporeal membrane oxygenation, or ECMO.
This type of life support, which replaces lung and sometimes heart function, adds oxygen directly to a patient’s blood, giving damaged organs an opportunity to rest and recover.
ECMO comes with its own risk of serious complications, so it’s most often used in younger patients and those without significant underlying health problems who would likely die otherwise.
The large ECMO program at Methodist Hospital has treated close to 30 coronavirus patients since early April. That number includes people in their 30s and 60s, but the majority have been in their 40s and 50s, said Dr. Jeff DellaVolpe, co-medical director of Methodist’s ECMO program.
Photo: Bob Owen /San Antonio Express-News
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As of Friday, eight coronavirus patients were on ECMO at the hospital.
Methodist’s ECMO patients have fallen into two main groups, DellaVolpe said. The first includes people who improve after about a week on the machine. The second is comprised of people who may stay on ECMO for more than a month, in some cases eight or nine weeks.
Because these patients are so sick, DellaVolpe said, outcomes have been mixed. Doctors have found “the earlier the better,” he said. In some cases, they have placed people on ECMO instead of intubating them, an approach that spares patients from the damaging effects of ventilators.
Over the past few months, the program has refined its process for selecting people who will do well on ECMO.
“It’s a limited resource and we’re trying to leverage the resource so it’s doing the most good for the most people,” DellaVolpe said.
From anti-malaria to antiviral
From the start of the pandemic, hospitals were hampered by the lack of effective medications against the virus.
Early on, many doctors were treating coronavirus patients with hydroxychloroquine and chloroquine.
The cocktail of anti-malaria drugs was unproven for COVID-19. But in March, the Food and Drug Administration granted their off-label use during the pandemic, after they were found to prevent the growth of the virus in a laboratory environment. President Trump touted hydroxychloroquine as a solution to a growing public health crisis and, without evidence, said he was taking it to prevent becoming infected.
The medications quickly became politicized, and a prominent study claimed they were associated with higher mortality rates. That study was retracted earlier this month at the request of its authors, who expressed concerns about the data, which they had not collected themselves.
Still, on Monday, the FDA revoked its emergency authorization for the drugs, citing a different randomized study of hospitalized patients that found no improvements to mortality rates or recovery times.
“That squares with our experience with it,” said Jones, of Methodist. “We were giving it and really weren’t seeing anything with it.”
Other experimental but promising treatments have risen to take its place.
One, the antiviral remdesivir, was tested on COVID-19 patients in San Antonio as part of a national study.
Doctors are now also administering convalescent plasma collected from those who have recovered from COVID-19 to some of their sickest patients. Transfusions of blood plasma have long been used for diseases without a cure to equip the ill with disease-fighting antibodies.
On ExpressNews.com: His COVID-19 patient got better after a plasma transfusion. To know if it worked, a San Antonio doctor is encouraging more donations.
The use of both therapies are supported by data from strong clinical trials, said Dr. Marc Chalaby, a pulmonologist and chief of intensive care medicine at Christus Santa Rosa Hospital in the Medical Center.
Preliminary data from remdesivir studies determined it shortened hospital stays and reduced mortality rates. A small trial of Houston Methodist patients found most improved after receiving plasma. A larger study found convalescent plasma was safe and associated with lower mortality rates, but there was no comparison group.
While the supply of plasma is growing as more people recover and become donors, remdesivir remains scarce, as do guidelines for how and when to administer it. Hospitals in San Antonio are receiving distributions of the drug from the state, but the short supply has forced them to ration it to their patients.
Additionally, physicians now know to prescribe blood thinners, after many coronavirus patients demonstrated a propensity for developing blood clots.
And while they originally thought that prescribing steroids might be detrimental, doctors have found they can help reduce inflammation in some patients, Chalaby said.
Tough summer ahead
Even with the familiarity hospitals have gained with COVID-19 over the past few months, the pandemic still poses an enormous challenge for health care systems.
San Antonio’s hospitals are now contending with a new surge of coronavirus cases that began earlier this month, alongside other patients who are receiving routine medical care. The city’s hospitalizations for COVID-19 have nearly tripled since the beginning of June, and DellaVolpe said his hospital was “exceptionally busy.”
“Our cases just keep going up,” he said. “We’re doing what we can to keep up.”
There still remain many unanswered questions about COVID-19, Chalaby said.
“This illness has many facets. It’s tricky,” he said. “Some people can have it and have no symptoms and go around their regular life and maybe infect other people, who get really sick.”
Jones, the Methodist infectious disease specialist, said it could be a difficult summer for hospitals caring for the acutely ill and for other health care providers that are supporting people’s recovery from a debilitating illness.
“We don’t know what the long-term effects are going to be,” he said. “It’s not something to take lightly.”
Lauren Caruba covers health care and medicine in the San Antonio and Bexar County area. To read more from Lauren, become a subscriber. lcaruba@express-news.net | Twitter: @LaurenCaruba
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