The Covid Drug Wars That Pitted Doctor vs. Doctor - The New York Times How much freedom should front-line clinicians have in treating Covid-19 patients with unproven drugs? The question opened up a...

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The Covid Drug Wars That Pitted Doctor vs. Doctor - The New York Times
How much freedom should front-line clinicians have in treating Covid-19 patients with unproven
drugs? The question opened up a civil war in some hospitals.
By Susan Dominus
Aug. 5, 2020
To hear more audio stories from publishers like The New York Times, download Audm for iPhone o
Mangala Narasimhan, an intensive-care-unit doctor, started feeling impatient soon after the start of a
meeting she attended at Long Island Jewish Medical Center on May 13. She wanted to get back to the
unit, but instead she was sitting in a conference room with about a dozen colleagues. By then, the surge
of Covid-19 cases, the waves of suffering that had crashed down on her hospital for months, was
eginning, miraculously, to recede. The throngs of out-of-town health care workers who had come to
New York City to help were also diminishing, heading home to regions whose own times would come.
Narasimhan and her team now had fewer hands to oversee new patients coming in and the long-
suffering ones on ventilators who were still in need of meticulous care. Long Island Jewish, in Queens,
had, at the time, treated more Covid-19 patients than any other hospital in the country; the doctors
there were still weary, still battered, their energy and time in need of careful rationing.
Narasimhan, who was in charge of more than 20 I.C.U.s across the Northwell Health system, knew
heading into the meeting that it might be tense. Adey Tsegaye, a pulmonary-critical-care doctor who
was calling in remotely, shared some of Narasimhan’s concerns. The meeting’s agenda included time
for remarks from Alex Spyropoulos, a lead researcher at the Feinstein Institutes for Medical Research
— the research arm of Northwell — who was running a clinical trial. The research was trying to
determine whether a standard dose of an anticoagulant or a higher dose yielded better outcomes fo
Covid-19 patients who were already on oxygen or a ventilator and were at high risk of organ failure and
A doctor on Narasimhan’s unit had recently been at odds with a member of Spyropoulos’s research
team. Stella Hahn, a pulmonary-critical-care doctor, a
ived at work the day before the meeting to find
that a Covid-19 patient had gone into cardiac a
est. She knew that the patient was enrolled in the
clinical trial and had been randomly assigned to receive either the standard dose of the anticoagulant o
the higher one. As is always the case in the most rigorous trials, neither the patient nor Hahn was
supposed to know to which group this woman belonged. Double-blind, randomized, controlled trials —
R.C.T.s — are considered the gold standard in research because they do not allow findings to be
muddied by any individual doctor’s biases or assumptions. But Hahn believed that the patient’s
condition now called for the higher dose, which could potentially require the patient’s removal from the
The Covid Drug Wars That Pitted Doctor vs. Docto
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Word made it back to a doctor working with Spyropoulos, and that doctor called Hahn to urge her to
econsider, or at least to get more tests before acting. They exchanged heated words, as the colleague
implored her to stay the course. Hahn pushed back: She had to rely on her clinical judgment and
elieved that it was unethical to wait for more information. How could researchers dictate care to a
doctor right there at the bedside, especially when a patient’s condition was so dire?
The point of contention would be discussed at the May 13 meeting. Dozens of doctors from the
Northwell system videoconferenced in, including Spyropoulos, who was seated in his home in
Westchester. Hahn’s colleagues, a tightknit unit who had seen one another through so much, sat
together in the conference room, occasionally checking their phones or exchanging glances as the
meeting went on. As Spyropoulos recalls, he talked to the group about the importance of high-quality,
andomized trials in making scientific progress, and the risks of trying experimental treatments
without them. “I stressed to the group that we should not abandon this principle, even in the very
stressful environment of a pandemic that was overwhelming our hospitals at Northwell,” he said.
Alex Spyropoulos, a lead researcher at the Feinstein Institutes for Medical
Research. Adam Ferguson for The New York Times
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Relying on gut instinct rather than evidence, he told them, was essentially “witchcraft.”
For Tsegaye, the word landed like a blow. “There was a chill in the air,” said Tsegaye, who registered it
even by videoconference. “Followed by rapid backpedaling.” Spyropoulos quickly explained that he had
so much respect for what those doctors had done — he had not been in those critical-care units, in the
emergency room, which he knew were unlike any other he had ever experienced. “But it was like a
etraction sent to the newspaper the next day,” Tsegaye said. “The headline says it all. The retraction
the next day? It doesn’t have the same impact.”
In the days to come, whenever Tsegaye thought about what Spyropoulos said in that meeting, she felt
appalled all over again. She knew that she had never extended herself on behalf of her patients the way
she had since March. She kept flashing back to a day when she was told that a ventilated patient’s
endotracheal tube had fallen out, a situation that can be fatal for the patient and is also dangerous fo
the physician: Replacing it requires the doctor to come into close contact with the patient’s
Tsegaye was putting on her N95 mask to enter the patient’s room when its elastic snapped in two.
There was no time to go to the supply area to get a new mask. What was the right thing to do? With a
sense of dread, she found her feet and moved toward the patient’s room. As she prepared to enter, one
of her fellows, whose mask was intact, told her to leave — she could manage it on her own.
Looking back, Tsegaye felt that the agony of making those kinds of decisions all day long compounded
the grief she felt while treating so many patients she could not help. “These are the decisions we have
had to face,” Tsegaye said. “For someone like me, who had been in that situation, to have someone tell
you that you have been practicing witchcraft is kind of giving no value to the sacrifice that I have made
— that my colleagues have made.”
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Stella Hahn, a pulmonary-critical-care doctor at Long Island
Jewish Medical Center. Adam Ferguson for The New York Times
Mangala Narasimhan, a doctor who is in charge of intensive-
care units throughout the Northwell Health system. Adam
Ferguson for The New York Times
As doctors face new spikes of Covid-19 cases around the country, they are also confronting a harsh
eality: The virus’s deadly secrets remain largely intact. The medical community now has some
esearch-backed drug treatments — remdesivir, an antiviral drug found to shorten hospital stays, and
dexamethasone, a cheap, readily available steroid that seems to cut deaths of patients on ventilators by
a third. But six months after the first patient tested positive on the West Coast, there is still no
treatment that reliably slows progression of the illness, much less a cure. In July, the number of
patients dying in this country topped 1,000 five days in a row, according to the Covid Tracking Project.
In these early months, doctors have faced two unknowns in trying to fight the devastation. The first is
the virus itself: deadly, contagious and entirely novel. The standard of care for most intractable
illnesses develops over years, as doctors build a body of research that tests various theories, compares
and contrasts dosages, measures one drug’s power against another. Here doctors were starting from
scratch: Any treatment protocol beyond supportive care — oxygen, hydration, antibiotics and
ventilation — was conjecture. The second, equally novel challenge has been the sheer scale of the
eak. Few doctors in this country had encountered the overwhelming volume of patients, the sense
of helplessness, the exhaustion and the desperation to save lives. Hospital administrators found
themselves plunging headlong into making difficult decisions in the absence of strong, unifying federal
guidance. Most did so without the benefit of perfectly parallel case studies or personal experience in
hospitals so ove
un by suffering.
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When there is no precedent, when there is an information vacuum, decisions are inevitably subject to
challenge. In an already heated environment, some of the worst of the tensions played out between
esearch-oriented doctors and those who saw themselves primarily as clinicians. Many treating
patients on the floor considered it axiomatic that, with so many dying so fast and so little to go on, they
would rely on their experience to make judgment calls about treatment options. They would try using
medications that had been approved for other illnesses but not yet for this one — what the medical
community calls off-label uses — if they felt they had good reasons to do so. They would take into
consideration any information that was available: the observations of doctors in Milan and China,
conversations among doctors in WhatsApp group texts and in Covid-19 physician Facebook groups,
tidbits of research that made medical sense but had not yet been peer-reviewed.
Other clinicians, and especially doctors more heavily involved in research, were frustrated that many of
their colleagues were not sufficiently invested in the importance of empirical research to figure out
which treatments worked best and were safest. Kevin Tracey, president of the Feinstein Institutes, tried
Remdesivir, an antiviral drug found to shorten hospital stays. Adam Ferguson for The New
York Times
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to emphasize to the doctors affiliated with the Northwell hospital system that if they were going to try
drugs off-label, they should always be doing so in the context of a clinical research trial: The drug might
help some patients but could hurt even more of them. If that was the case, it was better to know than to
operate out of
Answered 1 days AfterJan 19, 2022

Answer To : The Covid Drug Wars That Pitted Doctor vs. Doctor - The New York Times How much freedom should...

Abhishek answered on Jan 21 2022
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