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By Susan Dominus
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Mangala Narasimhan, a doctor in the intensive care unit, began to feel impatient shortly after the start of an assembly she attended at Long Island Jewish Medical Center on May 13. She tried to return to the unit, but instead was sitting at a conference. room with a dozen colleagues. At that time, the outbreak of Covid-19 cases, the waves of suffering that had been collapsing in his hospital for months, were beginning to miraculously recede. The multitude of out-of-town fitness personnel who had come to New York to help was also declining, returning the house to the spaces where the times would go. Narasimhan and her team now had fewer hands to monitor the arrival of new patients and those who had long suffered with fans and still needed meticulous attention. Long Island Jewish, Queens, had treated more Covid-19 patients at the time than any other hospital in the country; doctors were still tired, beaten, their power and their time needed a curly ration.
Narasimhan, who had a rate of more than 20 ICU in Northwell’s health care system, knew beforehand that the assembly could be tense. Adey Tsegaye, a remotely called lung intensive care physician, shared some of Narasimhan’s concerns. The assembly timeline included time for statements through Alex Spyropoulos, a principal investigator at the Feinstein Institutes of Medical Research, Northwell’s study arm, who ran a clinical trial. Research was looking for whether a popular dose of an anticoagulant or a higher dose was higher for patients with Covid-19 who were already oxygen or respirators and had a major threat of organ failure and clotting.
A doctor in Narasimhan’s unit had recently disagreed with a member of Spyropoulos’ study team. Stella Hahn, a lung intensive care physician, arrived at the charts the day before the assembly to locate that a Covid-19 patient had suffered cardiac arrest. She knew that the patient was inscribed in the clinical trial and had been randomly assigned to obtain the popular dose of the anticoagulant or the highest dose. As in the trials of maximum thoroughness, neither the patient nor Hahn were intended to know which organization this woman belonged to. Double-blind randomized controlled trials (R.C.T.s) are considered the reference point for studies because they do not blur the effects through a doctor’s biases or assumptions. But Hahn believed that the patient’s condition now required a higher dose, which could eventually require the patient to be removed from the trial.
The news returned to a doctor working with Spyropoulos, and that doctor called Hahn to urge him to reconsider, or at least get additional tests before acting. They exchanged passionate words, while the colleague begged him to follow the course. Hahn rejected it: he had to rely on his clinical judgment and felt it was unethical to expect more information. How can researchers dictate care to a doctor by the patient’s bedside, especially when the patient’s condition is so severe?
The point of discord will be discussed at the may 13 meeting. Dozens of Northwell doctors held videotapes, adding Spyropoulos, who was sitting at his home in Westchester. Hahn’s colleagues, a tight-knit unit that had been very close to each other, sat in combination in the convention hall, sometimes checking their phones or exchanging glances during the meeting. As Spyropoulos publishes, he spoke with the organization about the importance of high-quality randomized trials to achieve clinical progress and the dangers of seeking experimental remedies without them. “I am under pressure for the organization that we deserve not to abandon this principle, even in the very stressful environment of a pandemic that was overwhelming our hospitals in Northwell,” he said. Trusting their instincts rather than evidence, he told them, was necessarily “witchcraft.”
For Tsegaye, the word landed like a blow. “There’s a bloodless one in the air,” said Tsegaye, who recorded it even by videoconference. “Followed through an immediate setback.” Spyropoulos temporarily explained that he had a lot of respect for what these doctors had done: he hadn’t been to intensive care units in the emergency room, which he knew didn’t look like anyone else he’d ever met. “But it’s like a retraction sent to the paper the next day, ” said Tsegaye. “The name says it all. Retraction the next day? It doesn’t have the same impact.”
In the days that followed, every time Tsegaye had any idea what Spyropoulos had said at that meeting, she was distraught again. He knew he had never been prolonged on behalf of his patients as he had since March. He continued to return to a day when he told him that a ventilated patient’s endotracheal tube had fallen, a scenario that can be fatal to the patient and also harmful to the doctor: his replacement requires the doctor to approach him. the patient. patient’s breathing. Tsegaye dressed in his N95 mask to enter the patient’s room when his elastic split in half. There is no time to move to the source domain to get a new mask. What’s the right thing to do? With a sense of terror, he recovered and headed to the patient’s room. When she was ready to enter, one of her comrades, whose mask was intact, told her to leave; maybe he could go through on his own.
Looking back, Tsegaye felt that the agony of making such decisions all day had aggravated the pain he felt in treating so many patients that it might not just help. “These are the decisions we’ve had to face,” Tsegaye said. “For someone like me, who had been in this situation, for someone to tell you that you practiced witchcraft is not to give any price to the sacrifice I made, that’s what my colleagues did.
While doctors face new spikes in Covid-19 instances across the country, they also face a harsh reality: the fatal secrets of the virus remain largely intact. The medical network now has some research-backed drug remedies: remdesivir, an antiviral drug that shortens hospital stays, and dexamethasone, a reasonable and easy-to-obtain steroid that appears to decrease deaths in respirator patients by a third. But six months after the first patient tested positive on the West Coast, there is still no remedy that reliably slows disease progression, let alone a cure. In July, the number of patients who died in the country exceeded 1,000 five days in a row, according to the Covid Tracking Project.
During those first few months, doctors faced two unknowns that sought to combat the devastation. The first is the virus itself: deadly, contagious and completely new. The popularity of care for maximum refractory diseases develops over the years, as doctors build a framework of studies that tests various theories, compares and contrasts doses, measures the potency of one drug over another. Here, doctors start from scratch: any treatment protocol beyond supportive care (oxygen, hydration, antibiotics and ventilation) was a guess. The second, equally new challenge was the scale of the epidemic. Few doctors in this country have faced the large volume of patients, the feeling of helplessness, exhaustion and despair to save lives. Hospital directors have been fully immersed in difficult decision-making in the absence of strong, unifying federal directives. Most have done so without the advantages of perfectly parallel case studies or private jolgorio in hospitals so hit by suffering.
When there is no precedent, when there is a data gap, decisions are inevitably open to the challenge. In an already heated environment, some of the worst tensions occurred between study-oriented doctors and those who considered themselves mainly medical. Many patients who dealt with the box thought as axiomatic that, with so many deaths so temporary and so little to do, they trusted their delight in making judgments about the options of remedy. They would try using drugs that had been approved for other diseases, but not yet for this disease, which the medical network calls unsupported uses, if they felt they had a smart explanation for why. They would take into account all available data: the observations of doctors in Milan and China, the conversations between doctors in the texts of the WhatsApp organization and in the Facebook teams of the doctors of Covid-19, excerpts from studies that still had a medical significance. had not yet been companions. Revised.
Other physicians, namely the doctors most interested in the studies, were frustrated that many of their colleagues were not interested enough in the importance of empirical studies to determine which remedies worked most productively and were the safest. Kevin Tracey, president of the Feinstein Institutes, tried to point out to doctors affiliated with the Northwell Hospital System that if they wanted to try non-MMA drugs, they deserve to continue to do so as a component of a clinical trial: the drug can help some patients but it can further harm. If this were the case, it was better to know than to work with an addition of hope and conviction. He understood, he said, the urge of doctors to check for compassion the drugs that do not meet the standards, and “the pure emotion of humans seeking to help each other without knowing what to do.” But he didn’t approve. “Emotions can’t prevail,” he says. “You want evidence-based medicine and you want clinical trials. You don’t make any exceptions in the middle of a pandemic.”
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