When fighting a brand-new disease, medical workers are starting from scratch and learning on the job.
Unlike treating ailments that have been around for decades, with volumes of study and tried-and-tested interventions, when COVID-19 entered Indiana in March, the novel coronavirus was unlike anything doctors dealt with before.
But over time, collective knowledge about how the disease attacks the body and how to treat it have grown and measures to keep the virus in check are helping improve medical outcomes for the most serious cases that end up in hospitals.
“It’s the collective knowledge we have and sharing, we can put this stuff together relatively quickly and come together with some best practices,” Cameron Memorial Community Hospital Chief Medical Office Dr. Todd Rumsey said. “This respiratory disease is atypical, meaning things don’t make sense in the conventional way.”
To start, Dr. Hariom Joshi, medical intensive care unit director for Parkview Regional Medical Center, said COVID-19 presents with some unusual quirks not typical of other respiratory ailments.
One of the unique aspects that Joshi said doctors are seeing is a term he dubbed “happy hypoxia.” Patients will come in showing signs of hypoxia — reduced oxygen levels in the body — but not show breathing distress that would normally be seen with such significant drops in oxygen levels.
Normally if someone has significantly reduced oxygen, they might come in with severe wheezing and breathing trouble or display other signs of discomfort. In COVID-19 patients, however, many will still be functioning normal until oxygen levels drop to levels that begin to affect organ function.
“They won’t be in that much discomfort and they won’t notice it,” Joshi said. “In COVID patients, their oxygen will just be a number. If you look at them they are playing game on mobile. They don’t realize it.”
Because of this phenomenon, people with heart conditions tend to end up having more serious cases, Joshi said. In healthy people, good blood flow may be able to compensate for the reduced oxygen, but people with circulatory problems or heart disease may find themselves in more trouble when combined with the oxygen-reduced effects of COVID-19.
For a community hospital like Cameron that doesn’t have an intensive care unit and isn’t equipped to handle critical patients, Rumsey said identifying which patients will need more care than the hospital can provide is a key first step of the local health system’s role.
While Indiana’s average stay for COVID-19 patients is at about 22 days, Cameron reported that their average stay for is just a few days. That, Rumsey said, is because Cameron is only taking care of patients who may need some minor oxygen assistance or care and then can be sent home.
More serious cases are shipped down to Fort Wayne hospitals that are equipped for more critical care.
Parkview reported that most hospital stays range from 4 to 20 days, although some stays can be longer than 20 days. Patients in the ICU requiring ventilation typically are the ones who have those longer stays.
One thing doctors have learned about COVID-19 is that people who get seriously ill do so quickly, so rapid response and treatment is critical.
“When these people get sick they get sick very quickly,” Rumsey said. “What we’ve learned to expect is that when these people get sick they get sick very quickly.
“Those triggers are not a checklist but a mental checklist of what does this person need and what can we provide and what are the chances of them needing more in the next 72 hours?” Rumsey said.
For Joshi, who does look after those critical patients, he said COVID-19 patients typically have longer stays in hospitals compared to things like influenza or pneumonia in part because of the type of care they require but also because of hospital precautions.
A patient with serious respiratory distress from other illnesses may spend a week or two in intensive care. For COVID-19, and for patients who require mechanical ventilators to help them breath, that stay is going to run a little longer.
And part of the equation is that, after languishing in critical care for a week or two, most patients will experience reduced muscle function and require rehab, but Joshi said that rehab centers want to see two negative COVID-19 tests before accepting patients to their programs. So that adds time to the hospital stay due to the virulent nature of the pandemic.
That being said, one lesson learned by health care providers throughout the pandemic is that ventilators may not always be the best course of action.
Early on, Joshi said, patients in active respiratory distress would be vented early. But through months of treatment and tracking of patient outcomes, doctors have discovered that may not always be the best course of action, he said.
“The threshold for putting them on a ventilator was very low,” Joshi said, which is not the case any longer.
Comorbidities — other underlying conditions such as high blood pressure, diabetes or other chronic conditions — greatly increase the chance a patient may have serious complications with COVID-19.
As described above, since COVID-19 can cause greatly reduced oxygen capacity in the body, that oxygen loss can put stress on organ systems and people who already have decreased health from chronic conditions are more likely to have COVID-19 cause more serious complications.
While some have pushed back against COVID-19 numbers by stating that the disease is simply killing off patients who were already dying of something else, Joshi disagreed strongly with that sentiment.
Having high blood pressure of diabetes or even heart disease and cancer isn’t necessarily a death sentence on its own. But, when a body that’s weakened by a disease like that is then also hit with a severe respiratory illness, the combination can become deadly.
COVID-19 is being attributed with the deaths because those patients wouldn’t be dying except for being ill with the virus.
“The most common comorbodity is hypertension. You don’t see the person with hypertension getting the flu and dying just because they have hypertension,” Joshi said as an example, going on to add that national analysis of deaths from March-June show that more overall people are dying than in previous years, which is another sign that COVID-19 is playing a role beyond just people dying of end-of-life condition. “More people have died, more than last year and that is directly attributed to the COVID deaths.”
The battle against COVID-19 is ongoing and it’s still relatively new, which means the medical community is still learning as time goes on.
While knowledge about how COVID-19 attacks the body and how to treat it have improved, big open questions still remain like what, if any, long-term damage the virus might cause to the body or how long does immunity to the virus last?
People shouldn’t simply dismiss medical advice because it’s different than what it was three months ago, Rumsey said. What seemed like a best practice months ago may not be any more, because new data and experience can cause that to change.
That’s one of the biggest challenges of fighting a new disease, is that doctors don’t have years and years of knowledge, treatments and medicines to fall back on for support.
“What seems right the first day is very different the next. You see that with leadership in the medical community and the government, what we thought was the right answer at first is not the right answer right now,” Rumsey said. “This is a moving target and everyone learns at different speeds.”
For Joshi, the one aspect he really wanted to impress upon the community is how important it is to control the spread of the virus and not overwhelm health care capacity.
If health care providers have to expand out of their normal means — Joshi gave as an example, having to host critical-care patients on a medical floor not typically tasked with handling that type of patient — outcomes are not going to be as good.
“If, as a physician, if you give me 15 patients with COVID, I can take care of them and have a good outcome,” Joshi said. “But as a physician, as a hospital system, if you give me 30 patients, I’m sure that the outcome is not going to be better for them.”
For Parkview, the local system hasn’t seen numbers threatening to overwhelm their capacity, but with cases numbers on the rise across the state, it’s a concern, Joshi said.
“Make sure that you don’t overrun your hospital system, that is the main message,” Joshi said. “If you come five patients at a time, we can handle it. Just don’t overrun your healthcare system.”