Daniel A. Gerardi, MD, FCCP, chief of pulmonary, critical care, and sleep medicine at St. Francis Hospital in Hartford, CT talks about an investigational drug that has been used to treat some COVID-19 patients.
You had mentioned you’re almost at the high watermark of this pandemic in terms of patients coming in. And just for a little background, for our viewers, can you give me some context that you and your colleagues have been doing to treat the critically ill, the ARDs patients who have been coming in?
GERARDI: So, we’ve been taking care of COVID patients like everyone else for over a year now. But late April, one year ago was really the high watermark in terms of the volume of patients when we had that initial massive surge of COVID patients. And so, we essentially closed our outpatient office except for emergencies and had every available pulmonologist in the ICU. We extended our ICU coverage from one large ICU to three. So, the cardiac ICU and the recovery room, the operating theater all became intensive care units. And it’s essentially an all-hands-on deck effort to take care of over 50 ventilated patients with COVID and almost 200 patients in the hospital with COVID.
Can you run me through a list, a laundry list of the kinds of treatments and devices and therapies that you and your colleagues have used and have tried and kept and discarded over the last year in learning how best to deal with these patients?
GERARDI: So, we’ve used a lot of things over the course of the past year, like many other hospitals and institutions, looking for, you know, best therapy and the wisest therapy. And what it comes down to is good general ICU care of these ARDS patients. But initially there was a surge using things like hydroxychloroquine or azithromycin which is an antibiotic. There was some information to suggest that might be beneficial. We later moved on to things like plasma, when we had that available. It was difficult to get initially until we had patients that had infection survived and recovered and could donate. We used IL-6 antagonists or rheumatologic agents to suppress the inflammation. And I’m sure you’re aware of that was an essential, difficult problem with these patients, with ARDS is it’s this rampant inflammation through the body, in particular the lungs and the kidneys. We’ve tried some maneuvers with patients in the hospital, such as proning patients and flipping them on to their stomach and ventilating them this way. And I think that got a lot of press, a lot of information. People understood that. The IL-6 antagonists, which we thought weren’t working and probably were hurting patients by giving infections because they do suppress the immune system in a way that patients can get infections, we saw some unusual infections in patients who had been sick for some time because these patients, remember, are hospitalized sometimes for a month or two months at a time. A lot can happen when you’re in the ICU or in the hospital in that period of time. And the data’s come back now that those medications, in fact, might be useful. And, of course, we were using steroid medications and different types of steroids, solumedrol, prednisone and, of course, dexamethasone, which got the most press because of a favorable study. And so that’s the standard of care of steroid in these patients with acute disease and the pneumonitis. So we’ve come a long way in using patients’ medicines in unusual, but the good general care, ICU care of an ARDS patient, I think that’s become what we already knew was the right thing to do, become the standard despite medicines coming and going, you know, taking care of patients to prevent pressure ulcers, infections, turning them frequently, excellent nursing care and respiratory care. These are the things that those patients need, careful observation, and let the body heal, as long as we don’t hurt the patient, we’re giving them medications or devices that might hurt them. And so that fundamental principle still holds true.
Are you able to speak a little bit to Michael DiDonato’s case?
GERARDI: So, he was very, very sick, about as sick as you can get with ARDS and COVID pneumonitis and in fact we were worried about his potential recovery. We thought he might not recover. A matter of fact, our best estimate was that he would not recover from the COVID pneumonitis. It was that severe. He was sick for at least six weeks before we would try a different medication on him with respiratory failure that wasn’t recovering in a patient who had very little health problems to start with. That’s another sort of surprising thing with these patients is we saw a number of patients very, very sick from COVID who had almost no health issues to begin with. Why would that happen? Why would that occur? What triggers that inflammatory cascade that these patients would become so sick? But he was very sick, really, not showing signs of recovery such that we were even talking with his family about what to do in the future. You know, should we limit life-sustaining therapy? What would the patient want in these circumstances? What would the family want? It really was that critical.
So, when you get to that point, what do you do? Someone had called it a Hail Mary. I don’t know if as a doctor you use that term. But what do you do at that point?
GERARDI: We don’t use that term. But you’re looking for, you know, anything, any small opportunity, small window. The patient, as sick as he was, the positive sign in there is that he hadn’t had died, actually. And so, he can get to the brink of illness and really showing either no recovery or maybe even most marginal recovery of his lung function, a little bit less oxygen that we were giving. We were giving him almost pure oxygen at the time and forcing it in on the ventilator. But he hadn’t died. He had survived that serious window. And so, we knew by that time we had taken care of enough patients along the way that some patients do recover even after extended illness four, six or even eight weeks. And so, you’re hopeful always that the patient can somehow recover either on their own or maybe you can give them medication or a leg up that might help them get the extra weight and pull through.
Can you talk to me about this one particular drug that you used with this patient and two others?
GERARDI: Trying to think of what I want to say. So, this was a novel therapy that had some good data, preliminary data about its anti-inflammatory effect and the vasodilator effect where it might improve patient’s oxygenation. So, we were happy to use it. The family had done their own research, which in this day and age, the internet could be helpful. We don’t always like families looking all over the place for therapies. But I think it was a joint decision and uncovered a potential treatment option for the patient. When we gave it to him initially, it took some doing to get because we have to clear it. Any new medication, novel medication, has to be clear through an institutional review board. You can’t just bring a medication in. So, it actually takes more effort. And there was several people in the hospital that helped us behind the scenes to get the medication quickly, to get it approved. We had the pharmacy involved. You can’t go to the corner drugstore and get these kinds of things, as you understand. So, when we gave it to the patient, it was three doses over three days. You’re hoping to see either a side effect, which might suggest that the medication is working. He had none. Also, maybe an improvement in his oxygenation because if it’s a vasodilator, it might improve his oxygenation. It did not, which concerned me about its effect. But nonetheless, the patient did eventually recover.
You said it was three doses over three days?
GERARDI: Three doses over three days, an intravenous 12 hours each day.
And you also used the same drug on two other patients. And did they survive? Did they get better? Did you see anything with those two patients?
GERARDI: We used the drug on two other patients. One survived and one did not. But that doesn’t necessarily mean the medication wasn’t effective in a small group of patients.
How is this one particular patient doing now? Is it too loud? OK. How is this one particular patient doing?
GERARDI: He’s recovered. He had an extended stay in rehabilitation and is recovering at home with his family.
What would you say to the people that are going to see this about, first of all, about the options that are out there in terms of treatments and about what we’re still learning? I mean, this is not over by a long shot. And I would suspect that we’re still going to be learning a year from now, two years from now, you know, five years from now, we’re going to be learning. Yeah, boom, I’m done. What are we going to learn still? What do we still have yet to learn from this?
GERARDI: Well, we’ve learned that our fundamental principles of critical care medicine haven’t changed in how we take care of patients on a day-to-day basis. We’re better at taking care of these patients now. We’re more comfortable taking care of sicker patients for longer periods of time because we can have a better understanding of who has the ability to cover in how the disease progresses and how patients recover. We’re still learning about new medications, you know, because this illness and the extent of it produces novel therapy and treatment options, older medications that can be tried in this circumstance or more likely newer medications. So, I think even though we’ve come full circle on some medications like steroids in treatment of these patients, newer medications are coming available, particularly in the outpatient setting. So, when this pandemic is over, we’re going to be really good at treating COVID pneumonitis and, God forbid, if it ever occurs again.
And you had mentioned that you didn’t for this one particular drug, the data wasn’t there in your mind because the science hasn’t been done yet. But could we learn a year or two years from now, we’ll know more about what we’re doing now?
GERARDI: We’ll know much more in a year or two as we pool data from this patient and others. And this and other medications have, you know, excellent potential because of the anti-inflammatory effect in particular and as a vasodilator. So, I’m encouraged about this and other novel therapies. And medicine, you know, has progressed and everybody understands how medicine progresses. But with our study of the gene, the development of this vaccine, for instance, how quickly this can happen, are therapies and other illnesses such as cancers, immunotherapy that’s become medicine has progressed rapidly in a lot of fronts over the last decade. And I would expect that to continue, particularly as we deal with these difficult viruses and any future pandemic.
And you did say this is an anti-inflammatory and a vasodilator.
GERARDI: Yes.
And this did go through and was approved by the hospital IRB?
GERARDI: It was.
And is there anything I didn’t ask you, sir, that you would want to ask?
GERARDI: Not about this medication. I just think that taking care of these COVID patients, I’ve said it before, but taking care of these patients was a team effort in all effects, the family being involved, and it was very, very difficult for families who were unable to come to the hospital and see their loved one. We’d make exceptions when we could. We had computer visitation. But it was a team effort day to day with, you know, nurses doing things you can’t believe, you know, taking care of critically ill ICU patients, therapists, pharmacists, and even the people in the research department and pharmacy that backed us when we’re using this newer medication.
Interview conducted by Ivanhoe Broadcast News.
END OF INTERVIEW
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