We failed to learn from Covid-19
Critical Care Medicine learned nothing from its gravest times
Critical Care Medicine learned nothing from its gravest times
For a brief moment, during the COVID pandemic, I felt Critical Care Medicine was alive and vibrating. We were thrown into the battle of our lifetimes, and we were prepared. We had decades of experience with acute severe lung disease, and we had the right gear.
And we had authoritative treatment guidelines from our academic leaders.
The pandemic turned out to be notorious for the social media armchair “specialists” promoting all sorts of nonsense to the public. For a large swath of the population, treating viruses with antiparasitic drugs became acceptable overnight, simply because someone in their political bubble said it. I remember an old doctor, recording from Copacabana beach, fearmongering about masks. He pontificated that masks don't allow for carbon dioxide molecules, resulting in accumulation and re-inhalation, which would cause respiratory acidosis, and acidosis would worsen COVID because viruses thrive in acidosis while immune cells fail. All-out nonsense by someone who can't imagine the size of a carbon dioxide molecule, to begin with. The logical conclusion: those defending masks of course knew this acidosis thing, and their final objective was to reduce Earth's human population. That was the kind of absurd claim we got used to hearing during the pandemic.
In Brazil, the president himself opposed us. He stated that hospitals were not full of COVID patients and that we were lying about it to receive more money. His supporters invaded a few hospitals. At some point, his political bubble started shouting that physicians were being paid for each COVID death certificate. This accusation was particularly offensive.1 Society became engaged and misled by the influence of social media instantaneous virologists and political villains. We intensivists, once calm and discreet, were in the vortex.
It was hard work in those ICUs fighting an unknown disease with unseen mortality. Don't forget we were also the people at the highest risk of acquiring COVID, many of us died, and we could see on social media those hydroxychloroquine gurus making money with online prescriptions of “early treatment” protocols without ever facing an infected patient in person.
Those were harsh times, but the critical care establishment covered our backs.2
Every major critical care society launched comprehensive COVID guidelines in early 2020. The zeitgeist was for early intubation to decrease P-SILI (patient self-induced lung injury) during spontaneous laborious breathing, as proposed by Gattinoni's group. The Italian giant was publicly opposed by nobody less than the giant among giants Martin Tobin. Wow. A clash of giants! I was 100% Tobin's team.
Anyway, P-SILI shaped the earlier guidelines in combination with the fear of aerosol contamination. Physicians were instructed to perform intubation always with neuromuscular blockade, a non-trivial procedure in rural and under-accomplished urban settings. Moreover, we were advised to avoid pre-oxygenation with the usual facial devices, to avoid bagging the patient before intubation, and to avoid non-invasive ventilation and high-flux nasal oxygen.
These suggestions delineated a call for very early intubation. On top of that, many of us were scared to be exposed directly to the virus, and we were supposed to intubate from inside a deep diver suit and/or behind a face shield, if not a helmet. I'd love to read about your experience with COVID intubations. Drop it in the comments.
After performing the intimidating intubation protocol, the patient would be in our hands for what we do much better than everyone else. For the original purpose of our specialty. For what defines us.
Yes, a long period of complicated mechanical ventilation.
COVID fell under the ARDS umbrella definition. Hence, we had the full set of ARDS protocol measures including protective low-volume ventilation, driving pressure, higher breath rate for respiratory acidosis, escalating PEEP/FiO2 tables for hypoxia, prone positioning for lower PaO2/FiO2, etc.
And then it happened. Reports of patients not responding to the ARDS protocol surfaced everywhere. Protective ventilation produced acidosis in many patients, PEEP was ineffective in others, and so on. Those patients were the outliers. We had to go off-protocol to save them. Their lives hung on the skills of the bedside intensivist, not on the authorities’ advice.
Thanks to the internet, we started sharing real-time information about going off protocol to save the patients. Soon, a genuine bottom-up approach upended the world of critical care. Liberated from the “protocol droid” mentality, we started learning about the new respiratory disease. Every item of the ARDS protocol was reappraised and subverted. Mortality started dropping everywhere. We have learned to ventilate COVID, and to the dismay of the establishment, it was not “baby-lung” ARDS.
It was obvious that the ARDS definition was in check. The idea to lump all patients with chest infiltrates and low P/F for a one-size-fits-all “treatment” was dying in front of the public. If you are a reader of this publication, you know what I am talking about: it was the end of the 60-year-old Petty mistake.
Except it wasn't.
The Task Force Class soon overtook the narrative. Initially, they argued there were phenotypes, etc. Then someone invented COVID-ARDS and non-COVID-ARDS. These are outstanding examples of the erroneous inductivist argument my paid subscribers are acquainted.
When the Task Force Class weighed in, the debate became so irrelevant that I didn't follow closely. Now they are splitting hairs over their invented phenotypes in their signature theory-free style.
The initial intubation recommendations were easily abandoned because they were not part of a dogma. In contrast, the ARDS status quo stands.
We missed the opportunity to abandon the ARDS clinical construct.
Five years later, we still cling to failure.
Thank you for reading The Thoughtful Intensivist.
I associated with Dr. Lawrence Lynn to tell the story of the battle for the outliers in our book “The Physician's War”. There, we firmly frame the Petty and Bone mistake and discuss its roots and how it perpetuates. We present the manifest causes of such perpetuation, namely intellectual colonization and the Leviathan.
If you still live in the Petty and Bone matrix you are either a colonized or a part of the Leviathan.
Meanwhile, many of his supporters died in regret for following his “hydroxychloroquine instead of masks” exhortation. A subsequent epidemiological study revealed that the areas with more COVID deaths had more Bolsonaro voters countrywide.
If you are not new to The Thoughtful Intensivist, you know I am a harsh detractor of our “thought leaders” bad reasoning. However, we were on the same side of the COVID war in early 2020. We are all intensivists, for God's sake!