The step-by-step protocols that doctors learn in medical school just were not stopping the new coronavirus from killing people.
There is a classic process for treating respiratory problems: First, give the patient an oxygen mask, or slide a small tube into the nose to provide an extra jolt of oxygen. If that is not enough, use a “Bi-Pap” machine, which pushes air into the lungs more forcefully. If that fails, move to a ventilator, which takes over the patient’s breathing.
However, these procedures tend to fail with COVID-19 patients. Physicians found that by the time they reached that last step, it was often too late; the patient was already dying.
Illustration: Tania Chou
In past pandemics like the 2003 global SARS outbreak, doctors sought answers to such mysteries from colleagues in hospital lounges or maybe penned articles for medical journals. It could take weeks or months for news of a breakthrough to reach the broader community.
For COVID-19, a kind of medical hive mind is on the case. By the tens of thousands, doctors are joining specialized social media groups to develop answers in real time. One of them, a Facebook group called the PMG COVID19 Subgroup, has 30,000 members worldwide.
“If you had someone in resp[iratory] failure and you didn’t have help, what would you want to know?” a critical-care doctor wrote in a March 12 posting to the group.
Comments poured in. Italian pulmonary specialists gave video lectures viewed by thousands. Others shared experiences and data from China and other countries already ravaged by the virus. They learned that the best chance of saving a COVID-19 patient is to turn almost immediately to ventilators after intubating the patient.
That was a breakthrough, said Hala Sabry, 41, who manages the online group.
“If someone has respiratory failure, you skip oxygen and go straight to intubation,” Sabry said.
In what may be the first pandemic of the social media age, doctors face a highly contagious virus that, as of yesterday, has already infected 536,640 people and killed 24,117 worldwide amid a shortage of needed supplies, including masks and ventilators. Governments and established groups, including the US Centers for Disease Control and Prevention and the WHO have struggled to keep up.
Doctors are trying to fill an information void online. Sabry, an emergency-room doctor in two hospitals outside Los Angeles, found that the 70,000-strong Physician Moms Group she started five years ago on Facebook was so overwhelmed by coronavirus threads that she created the COVID-19 offshoot. So many doctors tried to join the new subgroup that Facebook’s click-to-join code broke. About 10,000 doctors waited in line as the social media company’s engineers devised a fix.
She is not alone. The topic also consumed two Facebook groups started by Nisha Mehta, a 38-year-old radiologist from Charlotte, North Carolina. The 54,000-member Physician Side Gigs, intended for business discussions, and an 11,000-person group called Physician Community for more general topics, are also all coronavirus, all the time, with thousands waiting to join.
“We have already saved a large number of lives just by sharing information about social distancing, propagating stories from the front lines, helping with diagnosis and treatment, and connecting physicians to other sources,” Mehta said.
On Twitter, Brief19, a group formed by three emergency-room doctors, posts a daily roundup of information and policy on the pandemic. Created on Friday last week, the group already has 2,500 followers. Its Twitter bio, for location, lists: “Everywhere, unfortunately.”
One of the Brief19 doctors, Jeremy Faust of Brigham and Women’s Hospital in Boston, also cohosts a six-year-old podcast that focuses on “what’s hot” in emergency medicine. Last week, he and cohost Lauren Westafer, an assistant professor of emergency medicine at University of Massachusetts Medical School Baystate, moved to a daily analysis of the flood of nascent data that is coming online in so-called “pre-print,” or rough-draft, articles from researchers and medical journals about COVID-19 and related topics. Thousands of doctors are tuning in, greeted by this warning:
“We are going to try to bring you daily updates on COVID-19. There is a firehose of information and most of us are too busy to read and digest it all. Note: If you are listening to these more than a few days in the future, please beware that information may have changed and check subsequent episodes.”
“Some of the things that we are talking about, some of the ideas that are being spread, are really smart, but aren’t necessarily part of our usual approach to critically ill patients,” Faust said in an interview. “It’s not intuitive or obvious, but it makes sense once you hear it.”
There are downsides to this rapid information-sharing: The accelerated pace can lead to mistakes — and there is no time for the exhaustive study needed to assure new approaches are as safe as they can be. Medical journals like the New England Journal of Medicine are rushing out novel findings online before they have been fully reviewed. However, even the most deliberated change in medical thinking can later be debunked, and healthcare is constantly evolving.
“That’s how medicine works,” Sabry said. “You learn from other people to not make the same mistakes so people won’t die.”
These global doctor’s lounges have grappled with some thorny questions. In the second week of this month, Christina Lang, a 37-year-old internist who cares for hospital patients in Modesto, California, was alarmed by some physicians’ online chatter: Some patients appeared to get sicker when taking ibuprofen, a ubiquitous pain and fever-reducing pill taken by millions of people every day. Could patients be hurt just by taking a widely available pill when coronavirus’ fever began to set in?
A research letter published by the medical journal Lancet on March 11 suggested that ibuprofen, which is sold under brand names including Motrin and Advil, had the potential to increase the number of receptors the virus uses to hijack healthy human cells and spread.
That preliminary information, which normally is used to generate ideas for future studies, kick-started deep conversations among doctors on social media. French Minister of Health Olivier Veran tweeted that patients should eschew ibuprofen for acetaminophen, a different pain reliever and fever-reducer that is sold in the US as Tylenol.
“This grabbed our interest,” Lang said.
Normal arbiters of medical information were of little help. The WHO issued conflicting reports. The US Food and Drug Administration said it had no evidence that certain pain medicines could worsen an infection, but added that there are other options available.
An investigation is under way.
Doctors dug into the question online. Lang, who is on maternity leave from her hospital job, went to an online group of 1,000 doctors that she helps run and called in infectious-disease and public health specialists. As they evaluated the data, the site’s algorithm opened up the floor to hundreds of additional doctors, and their comments spread across other doctors’ groups online. One thread branched into another, and then another. Debate raged.
“It’s a little bit like the wild west,” Lang said. “We are turning to these groups to get the latest information. We want to make sure the science is evaluated and you can back it up.”
Groups have taken differing positions. By March 14, the specialists in Lang’s Openxmed group made up their minds: They concluded it was not worth the risk to keep coronavirus patients on ibuprofen. They could just switch to Tylenol. The larger COVID-19 group reached a similar conclusion.
However, the thousands of doctors in Mehta’s group were less convinced, deciding there was not enough evidence to change practice.
“You have to understand that medicine isn’t black or white,” Sabry said. “It’s a whole world of gray.”
On other topics, online discussions — like one at a “hub” for infectious diseases set up by the American College of Emergency Physicians (ACEP) — have had clear, potentially life-saving impacts on how patients are evaluated and treated.
At the Jack D. Weiler Hospital in Bronx, New York, a 70-year-old woman came in with a mild fever, nausea and vomiting that was causing low blood pressure. Doctors initially thought it might be a typical seasonal illness, said Deborah White, vice chair of emergency medicine at the facility.
Then doctors in Washington, where an outbreak in a nursing home led to the first US hot zone, noted on the ACEP hub that many older COVID-19 patients exhibited mainly gastrointestinal issues, such as nausea and diarrhea.
Back in the Bronx, the 70-year-old patient immediately hit doctors’ radar screen as a potential coronavirus case. The hospital — which helps care for patients of nearby nursing homes — started grouping all elderly patients with gastrointestinal symptoms and low blood pressure together as potential COVID-19 patients, a process called cohorting.
“That became a paramount piece of information for us,” White said, adding that previously such patients were often sent back home or returned to nursing homes with orders of bed rest and a simple diet.
Now, however, some of those patients are testing positive. Cohorting is not traditionally done in such cases, but instant information-sharing allowed a rapid, important change, she said.
“This is what we do, pivoting in the very moment,” White said. “It’s the bread and butter of emergency medicine.”
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