Emergency physicians have all encountered that situation where—in just minutes—a patient will likely die if you don't do something. Even so, we do not shock patients in asystole, give thrombolytics in codes, or stab ballpoint pens into tracheas. We are not even doing blind pericardial sticks or giving high-dose epi or IV calcium. Heck, we don't even do precordial thumps anymore.
There is also a suggestion that the “standard” epinephrine we give could be causing higher mortality. (J Am Coll Cardiol. 2014;64:2360.) Why in these most dire and immediately critical circumstances aren't we willing to try something? The answer is because we have data, some clinical and some historical, that these things on the whole don't work. Or, as in the case of epinephrine, they may cause more harm.
If we are capable of being mostly rational in MacGyver emergency situations, shouldn't it be easier for less critical patients and for sure with outpatients? The harms that result from the need to do something outweigh any potential benefit (e.g., antibiotics for the probable viral illness causing Clostridium difficile, anaphylaxis, diarrhea, vaginal yeast infections, etc.). Regardless of illness severity, it appears that we struggle to maintain scientific reason. Why?
Because we are treating fear. This is no crime. Fear is real. Fear is common among us and our patients, families, friends, and staff. Fear is powerful, and it is fueled by many sources. I am not against admitting and addressing those fears. But if we treat them with unproven therapies, the harm and cost can be catastrophic. What if we treated this fear like we treat our codes, with information, with data, with “data” from history?
Look at COVID-19 and the history of infectious disease, including our very recent history of virology. The epidemics and pandemics of the world (with some exceptions like Yersinia, cholera, typhus, and tuberculosis) have largely been viral (smallpox, polio, influenza, yellow fever, dengue, chickenpox, measles, mumps, rubella, hepatitis, rabies, HIV, Ebola, and Zika). With the exception of HIV and hepatitis C, the solution in essentially every one of those viral epidemics and pandemics was not a medication.
The medications for HIV and hepatitis C took 10 to 25 years from the time the virus was identified until we had a curative treatment. The solution in every one of these illnesses was a combination of public health measures, behavior change, and an effective vaccine. That is not my opinion; it is the data that history, even very recent history, gives us.
It is not reasonable to think that we are going to invent an antiviral medication six months after we discover a novel coronavirus, and it is magical thinking to hope and believe that a medication already out there for some other disease just might work. Even if we find there is some statistical significance in a relatively small controlled trial; it will take time to validate the findings, and they will likely be marginal at best (like Tamiflu).
Some people say that we have experimental reasons or even animal data that show it could help. You could fill pharmaceutical graveyards with the drugs that met that standard and never made it to market. We have heard about the immunomodulatory effects of azithromycin for 35 years with no proven clinical outcome data to support it. There was a five- to 10-year span where people wanted to use it for coronary artery disease and acute myocardial infarction because of its anti-inflammatory properties. This idea was appropriately killed in the WIZARD study. (JAMA. 2003;290:1459; https://bit.ly/3ddzwVD.)
Now, here we are again with a drug so overused it barely treats anything effectively anymore, and we are throwing it at COVID-19 for its mystical anti-inflammatory properties. (Let's toss in a statin while we are at it.)
Some people say, “What can it hurt? You don't want these people to die!” The answer is, despite good intentions, drugs like chloroquine have a very narrow margin of therapeutic safety, and drugs like hydroxychloroquine and azithromycin can prolong the QT and cause life-threatening rhythms, especially in conjunction with ondansetron and whatever else the patient is on (antipsychotics) that may prolong the QT. I don't want them to die. That is why I would not use an unproven drug that could kill them. And I would include antiviral medications, anti-cytokines, protease-inhibitors, convalescent plasma, eye of newt, and whatever else is added to the line-up if we keep falling behind. The history of medicine is filled with harmful therapies employed because trying something somehow felt better than doing no harm.
The Infectious Diseases Society of America released guidelines on treating and managing patients with COVID-19. (Clin Infect Dis. 2020 Apr 27; https://bit.ly/3dfTHlS.) Infectious disease experts, who are just as prone to want to do something as you and I (maybe more because it is their specialty), have said not to empirically throw unproven medications like hydroxychloroquine, azithromycin, remdesivir, or anything else at COVID-19 unless the patient is enrolled in a randomized controlled trial or part of a local or collaborative registry. This is completely consistent with what Anthony Fauci, MD, the director of the National Institute of Allergy and Infectious Diseases, and all the other public health and infectious disease specialists have been saying from day one.
Maybe history's data will be wrong this time. I hope so. But we are not doing nothing by withholding unproven therapies. We medically support the patient without good medications like we do for a lot of diseases. We advocate for public health measures of physical distancing, masks, and handwashing for 20 seconds while we wait for a vaccine. This has been our history of what works.
The first patient of 45 healthy volunteers was given a COVID-19 vaccine in April. Maybe next summer, we will find out it works. While we are waiting, we will educate Americans better than we have with the influenza vaccine, that if a vaccine has only 50 percent efficacy, its effectiveness could be 90 percent or more if everyone takes it. The information of medical history and our expertise in science and statistical reasoning must be kept in our white coat pocket. We must run this code of COVID-19 with our heads and not let our fear harm the patient
Dr. Mosleyis an emergency physician in Wichita, KS.