1/n One of the most challenging things about the #COVID19 outbreak in NYC is having to act both fast and slow. What do I mean by this? On one hand, as an ID physician, I am in state of perpetual impatience. I want to do the best possible thing for the one patient under my care at
2/n any particular moment. I want the instant gratification of feeling I did something important and relevant for this particular human being. So my heart wants to tear open a package of hydroxychloroquine and offer a tablet, to set up the IV for an infusion of convalescent
3/n serum, to block cytokines that are elevated in a patient's serum, to provide medications to ease a cough. That's the fast. On the other hand, my mind knows that hydroxychloroquine has not shown antiviral activity against any human viral disease in the clinic (the jury is out
4/n on COVID). In fact, I spoke with a legend in the field of medicine today who has confirmed COVID. She/he took hydroxychloroquine and developed a cardiac arrhythmia that required hospitalization. My mind whispers that we need carefully designed trials to figure out if this
5/n drug (and many others) can help #COVID19 patients. In medical grand rounds this morning, I hear about many patient experiences in Italy and Singapore from exceptional physicians practicing there. A slide suggested that anakinra, a drug that counters a molecule called inter-
6/n leukin-1 may help severely ill #COVID19 patients. I wonder whether blocking a single cytokine can reverse the lung tissue damage seen at the end stage of COVID disease. After all, the inflammatory storm involves dozens of mediators. Will blocking one be decisive?
7/n That's the slow. The recognition that I have to step back from the individual and think about how to advance science. Receiving an investigational drug and seeing a clinical improvement does not imply causation. Though it's fantastic to see this in a presentation because
8/n it provides a jolt of energy, of hope, that, yes, perhaps it might work for my patient too. And I want something right now. So how do we merge the slow and the fast? We need to treat each patient to the best of our abilities, while acknowledging and filling the gaps in
9/n knowledge as rapidly as possible. We have to do the informative trials as quickly as we can (and there are so many happening in real time) to try to get in front of this pandemic. We also need to be thoughtful and (slow) in approaching each patient. Two weeks ago, I took some
10/n time to talk to a nurse taking care of one of the first #COVID19 patients admitted @sloan_kettering. I asked her about how the patient was doing. She told me that the patient had a severe cough and the primary provider sent in an order for a nebulized medication for relief.
11/n I asked if she had administered the medication yet. She said no, but that she would do it next. I told her to cancel the order and to ask the ordering physician whether giving an aerosolized medication was appropriate. I was concerned about the risk to her. #COVID19
12/n challenges us to think slow when taking care of patients too, to consider risks to HCWs, and to be thoughtful about balancing risks. Both in patient care and in scientific inquiry we have to balance these dueling impulses to forge ahead, to never let up, and do the best
13/13 possible job for patients under our care. What's hard is that the best possible job tomorrow will undoubtedly be different from the best possible job today.
