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Feature: ISSUES IN NURSING

The fog of war in the battle against COVID-19

Chen, Leon L. DNP, AGACNP-BC, FCCP, FAANP, FNYAM

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doi: 10.1097/01.NURSE.0000718036.20227.01
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IN 2003, THE DOCUMENTARY The Fog of War was released to critical acclaim. It focused on the life and times of former US Secretary of Defense Robert McNamara through major conflicts such as the Cuban missile crisis and the Vietnam War. The film demonstrated that in the thick of war, decisions are made by leaders without absolute certainty about facts or circumstances, resulting in confusion and often poor outcomes. When the fog is lifted, complex problems may be apparent in hindsight. The fog of war is a major obstacle to a fighting force trying to accomplish a goal, and it has been a significant barrier to success in the fight against COVID-19.1

Mysterious illness

In late December 2019, those who paid attention to world news began to see brief mentions of a mysterious new respiratory illness without identifiable cause emerging in Wuhan, China. Due to an initial lack of transparency, key disease characteristics essential to early disease control such as likely person-to-person transmission were not made public. When the facts began to emerge, the horse had left the barn and we were on our way to a pandemic.

In those early days, the disease later named COVID-19 devastated Wuhan, China, as well as Lombardy, Italy, and most of Spain. Through the efforts and bravery of those early healthcare providers, we gained much-needed understanding of the disease, including clinical characteristics, case fatalities, possible treatment modalities, and the impending disruption to the supply chain.

From the first case in the US in Washington state to the eventual havoc COVID-19 caused in New York, our medical system seemed to be one step behind the disease in every way.2 This included shortages of personal protective equipment, certain commonly used critical care drugs, testing capacity, and mechanical ventilator availability. Additionally, misinformation flooded social media, inducing uncertainty for both healthcare workers and the public. These factors compounded a sense of confusion and created chaos in an already stressed healthcare system.3

Rush to judgment

In an attempt to quickly generate data and evidence that could be proven beneficial for this novel coronavirus, scientists and healthcare providers looked to both conventional and unconventional therapies to make progress. The need for answers became so urgent that prominent medical journals, seemingly overwhelmed by the barrage of manuscripts they received, fell short of their usually high level of due diligence in peer review prior to publication. This created additional confusion about untested interventions, leading to a loss of confidence in traditionally trusted publications.4

Prestigious medical journals that usually have a rigorous peer review process instantly transitioned to platforms for poorly designed preliminary data.2 Studies initially published in The Lancet and The New England Journal of Medicine related to COVID-19 therapies were later retracted due to data error.5 Many more manuscripts that had not been peer-reviewed were nevertheless published on websites accessible to all.

However, this confusion was not limited to academic journals. Government health agencies such as the CDC also lost credibility. The incident that immediately comes to mind is the 180-degree about-face on the universal wearing of face masks, a practice that is routine in many Asian countries that have lived through other pandemic respiratory illnesses such as SARS and H1N1 influenza. Following CDC recommendations, the US Surgeon General initially sent a strong message through social and news media informing the public that masks should be reserved for healthcare workers only. But a short few weeks later he reversed his stance and recommended strongly that everyone wear some form of facial covering.6 While it is true that scientific evidence and recommendations rapidly evolve in unprecedented times of uncertainty, the quick reversal in recommendation from the CDC created a whiplash in public sentiment and likely eroded the public's trust in the agency.

Hypotheses about pulmonary physiology that in previous times would have been an interesting debate among academics suddenly became standard of care—with very little supporting evidence. Some of these hypotheses included the concept of two distinct types of acute respiratory distress syndrome (ARDS) that differ in lung compliance, so ventilator strategy should be different. Eventually this was found to be pure conjecture.7

There were also different thoughts on the degree of aerosolization of viral particles made by high-flow nasal cannula, and many patients were endotracheally intubated once they could no longer tolerate 6 L/minute, risking all the associated complications that come with mechanical ventilation. Prominent emergency medicine physicians posited that awake prone positioning may help patients delay and even prevent intubation. More rigorous studies later showed that proning may delay intubation by a few days; however, many patients with rapidly deteriorating lung function due to injury incurred while breathing spontaneously ultimately still require intubation.8

Drug trials generated similar confusion, with the use of drugs such as hydroxychloroquine, either used alone or in combination with azithromycin, receiving initial popularity based on small, flawed trials in other countries. As a result, many seriously ill patients received hydroxychloroquine until larger studies showed no efficacy and possible harm.

Other drugs and therapies were trialed, including remdesivir, methylprednisolone, tocilizumab, and convalescent plasma. Most of these were given to patients before large datasets were available to show benefits in mortality.9 It was as if under the fog of war, the scientific and medical community tossed up their hands at evidence-based practice and threw whatever drugs they had at patients, all with the good intention of saving lives. Scientific process is the unfortunate collateral damage when we succumb to the urgent desire for a magic bullet.

The aftermath

Recognizing the highly variable treatment practices performed by clinicians treating patients with COVID-19, the Infectious Diseases Society of America produced a guideline for all drugs commonly used to treat patients with COVID-19. It emphasized that not all of the available therapies have shown clinical benefits and should be used only in the context of a clinical trial. The guideline also acknowledged that frontline providers will have to ultimately make a decision for treatment with the knowledge that most COVID-19 therapies have a low level of evidence.9 The proposed two different types of ARDS did not stand up to scrutiny and it was discovered that standard ARDS management should be used for all patients with COVID-19 in acute respiratory failure.7 The awake prone positioning method, while eye-catching and innovative, resulted in improvement for only some patients; those with more severe infection ultimately required intubation.8

Nursing implications

In nursing education, we emphasize evidence-based practice. Of course, this is difficult in the setting of a novel disease without preexisting clinical data to rely on. Nurses caring for patients at the bedside should maintain diligence when scrutinizing the latest studies and take into consideration important factors, including how robust the sample size is and how rigorous the methodology. If the study lacks rigor, it would be prudent to maintain the current standard of care that has been validated by existing literature. We should also be selective in our information sources and rely on experts in the fields of public health, medicine, and nursing.

Overall, the course of COVID-19 has been similar to that of previous viral respiratory tract infections in many ways. Optimal ventilation management, supportive therapies, and use of our existing knowledge of physiology seems to be the best course of action. Other novel therapies should undergo an expedited but still rigorous peer review process. Being at war with this disease does not mean we must succumb to the fog of war and perform therapies blindly. With this attitude, we may cause more harm than good—and that goes against the tenets of our profession.

References

1. Holden S. Revisiting McNamara and the war he headed. The New York Times. 2003. www.nytimes.com/2003/10/11/movies/film-festival-review-revisiting-mcnamara-and-the-war-he-headed.html.
2. World Health Organization. WHO Timeline—COVID-19. 2020. www.who.int/news-room/detail/27-04-2020-who-timeline-covid-19.
3. Ranney ML, Griffeth V, Jha AK. Critical supply shortages—the need for ventilators and personal protective equipment during the Covid-19 pandemic. N Engl J Med. 2020;382(18):e41.
4. Kurian OC. Fog of war: the politics and economics undermining scientific debate on HCQ. Observer Researcher Foundation. 2020. www.orfonline.org/expert-speak/fog-of-war-the-politics-and-economics-undermining-scientific-debate-on-hcq-67334.
5. Joseph A. Lancet, New England Journal retract Covid-19 studies, including one that raised safety concerns about malaria drugs. STAT. 2020. www.statnews.com/2020/06/04/lancet-retracts-major-covid-19-paper-that-raised-safety-concerns-about-malaria-drugs.
6. Dwyer C, Aubrey A. CDC now recommends Americans consider wearing cloth face coverings in public. NPR. 2020. www.npr.org/sections/coronavirus-live-updates/2020/04/03/826219824/president-trump-says-cdc-now-recommendsamericans-wear-cloth-masks-in-public.
7. Bhatraju PK, Ghassemieh BJ, Nichols M, et al. Covid-19 in critically ill patients in the Seattle region—case series. N Engl J Med. 2020;382(21):2012–2022.
8. Elharrar X, Trigui Y, Dols A-M, et al. Use of prone positioning in nonintubated patients with COVID-19 and hypoxemic acute respiratory failure. JAMA. 2020;323(22):2336–2338.
9. Bhimraj A, Morgan RL, Shumaker AH, et al. Infectious Diseases Society of America guidelines on the treatment and management of patients with COVID-19. Clin Infect Dis. [e-pub April 27, 2020].
Keywords:

CDC; COVID-19; misinformation; pandemic; personal protective equipment; PPE

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