Early in pandemic, frantic doctors traded tips across oceans

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Amid the chaos of the pandemic´s early days, doctors who faced the first coronavirus onslaught reached across oceans and language barriers in an unprecedented effort to advise colleagues trying to save lives in the dark.

With no playbook to follow and no time to wait for research, YouTube videos describing autopsy findings and X-rays swapped on Twitter and WhatsApp spontaneously filled the gap. When Stephen Donelson arrived at the University of Texas Southwestern Medical Center in mid-March, Dr. Kristina Goff was among those who turned to what she called “the stories out of other places that were hit before.”

Donelson´s family hadn´t left the house in two weeks after COVID-19 started spreading in Texas, hoping to shield the organ transplant recipient. Yet one night, his wife found him barely breathing, his skin turning blue, and called 911.

In New York or Italy, where hospitals were overflowing, Goff thinks Donelson wouldn´t even have qualified for a then-precious ventilator. But in Dallas, “we pretty much threw everything we could at him,” she said.

Like doctors everywhere, Goff was at the beginning of a huge and daunting learning curve.

“It´s a tsunami. Something that if you don´t experience it directly, you can´t understand,” Italian Dr. Pier Giorgio Villani said in a series of webinars on six straight Tuesday evenings to alert other intensive care units what to expect. They started just two weeks after Italy´s first hospitalized patient arrived in his ICU, and 10 days before Donelson fell ill in Texas.

Villani, who works in the northern city of Lodi, described a battle to accommodate the constant flow of people needing breathing tubes. “We had 10, 12, 15 patients to intubate and an ICU with seven patients already intubated,” he said.

The video sessions, organized by an Italian association of ICUs, GiViTI, and the non-profit Mario Negri Institute and later posted on YouTube, constitute an oral history of Italy´s outbreak as it unfolded, narrated by the first doctors in Europe to fight the coronavirus.

Italian friends spread the word to doctors abroad and translations began for colleagues in Spain, France, Russia and the US, all bracing their own ICUs for a flood of patients.

They offered “a privileged window into the future,” said Dr. Diego Casali of Cedars-Sinai Medical Center in Los Angeles, who is from northern Italy and was directed to the webinars when he sought advice from a front-line friend about how to prepare.

Dr. Jane Muret of the French Society of Anesthesia-Resuscitation also heard by word-of-mouth and, impressed by the breathing-tube lessons, posted a translation when France had only a handful of diagnosed COVID-19 cases.

“Now we can recognize our COVID patients” when they start showing up, she said.

Every tidbit about the newest baffling symptom, every trick to try, served as clues as the virus bore down on the next city, the next country. By the time Donelson arrived, Goff´s hospital was adjusting ventilator care based on that early advice.

But while grateful for the global swirl of information, Goff also struggled to make sense of conflicting experiences.

“You have no idea how to interpret what went right or what went wrong,” she said, “or was it just the native course of the disease?”

Even now, months into a pandemic first wave that´s more like constantly shifting tides, Goff is humbled at how difficult it remains to predict who will live and who will die. She can´t explain why Donelson, finally home after a 90-day ordeal, was ultimately one of the lucky ones.

Doctors in Italy were confused: Reports from China were suggesting a death rate of about 3% among those infected. But for the first 18 days, only the dead left the ICU at Bergamo´s large Pope John XXIII Hospital.

While the toll eventually dropped, 30% of the hospital´s initial 510 COVID-19 patients died.

After decades in practice, ICU chief Dr. Luca Lorini thought he knew how to treat the dangerous kind of respiratory failure — called ARDS, or acute respiratory distress syndrome — first thought to be the main threat.

“Every night, I would go home and I had the doubt that I had gotten something wrong,” Lorini said. “Try to imagine: I am all alone and I can´t compare it with France because the virus wasn´t there, or Spain or the U.K. or America, or with anyone who is closer to me than China.”

Only later would it become clear that for patients sick enough to need the ICU, death rates were indeed staggeringly high.

By February, China had filed only a limited number of medical journal reports on how patients were faring. Lorini´s hospital tried to fill the data gap by dividing patients into small groups to receive different forms of supportive care and comparing them every three or four days — not a scientific study, but some real-time information to share.

The first lessons: The coronavirus wasn´t causing typical ARDS, and patients consequently needed gentler ventilation than normal. They also needed to stay on those ventilators far longer than usual.

“We made big errors,” Villani said, weaning patients off machines too soon. Then mid-March brought another startling surprise: In a training video for US cardiologists, Chinese doctors warned that the virus causes dangerous blood clots, and not just in the lungs.

Dr. Bin Cao of the China-Japan Friendship Hospital in Beijing explained that as the virus sneaks past the lungs into the bloodstream, it damages the lining of blood vessels, forming clots in the heart, kidneys, “all over the body.” He urged American doctors to use blood thinners protectively in the severely ill.

In Italy´s epicenter, doctors were making the same discovery. Lorini described a scramble to get the word out via Skype and email. “This is a vascular sickness more than a pulmonary one and we didn´t know that,” he said. In the US, the finding about blood thinners made biological sense to Dr. Tiffany Osborn, a critical care physician at Washington University School of Medicine in St. Louis. “It means at least you´re not shooting in the dark.