Ventilators are the go-to way physicians treat serious cases of COVID-19, but some patients at Wellington Regional Medical Center in Florida started refusing breathing tubes a couple weeks ago.
Some would "initially refuse and then beg us for it just before they tap out," said Dr. Rob Harrell, a cardiac surgeon who is medical director of the hospital's intensive care unit.
Physicians from the Palm Beach suburb of Wellington, in Salt Lake City, Boston and elsewhere were stumped and frustrated by a medical journal report last month that 88% of COVID-19 patients placed on ventilators died in a New York hospital system. Their own death rates were more like 20% and nearly always involved people older than 80, especially those with severe chronic health conditions.
The Journal of the American Medical Association study, published April 22 by researchers at Northwell Health, was followed by a little-noticed correction two days later. A more recent report from Massachusetts General Hospital researchers matches the lower rates, which doctors cite to fight what they say is dangerous anti-ventilator sentiment.
Outside experts started to recommend against ventilators because they were "synonymous with death," said Harrell. Says Dr. Sean Jorgenson Callahan, a pulmonologist at University of Utah Health: "The big sentiment floating around is that being put on a ventilator is a death sentence."
In the JAMA study, the mortality rate for 18 to 65 year olds on ventilators was more than 76%, while more than 97% of patients older than 65 on ventilators died. That's where the combined death rate of 88% came from. Death rates for those in these age categories who weren't intubated and place on ventilators were nearly 20% and nearly 27% respectively.
In the correction, Northwell said only 24.5% of the coronavirus patients on ventilators died or been discharged. The lower percentage adjusts the death rate to exclude everyone on ventilators who were still alive and battling the virus at the time the study ended.
"The 88% statistic is deceptive because patients developing severe respiratory failure from COVID can be sick for a long time," said Callahan. "If you report data in the midst of a pandemic - on an illness that can persist for a long time- the data can be incomplete. Patients haven't had the time or opportunity to recover."
Karina Davidson, Northwell's vice president of research, said the numbers were correct but it was 88% of the 323 patients put on ventilators for whom Northwell had an "outcome." These people had either been discharged, as in the case of 38 patients, or died.
"People are somehow hearing this very small percentage people for whom we knew an outcome and assuming it was the ventilator that was the problem," said Davidson. "That was not the case."
The study out a week later found less than 17% of COVID-19 patients on ventilators at Massachusetts General Hospital died. This newer report in the American Journal of Respiratory and Critical Care Medicine concluded continued use of ventilators for COVID-19 patients with "acute respiratory distress syndrome" was justified.
"We saw all the discussion and people were reporting the very high number, which made us more motived to publish our study," said Dr. Jehan Alladina, who was co-lead author on the paper. "We had a minimum 30-day followup and everyone was off ventilators."
"The big problem with the JAMA study is people were still on ventilators," said Alladina, a Mass General pulmonary and critical care physician. "You're not sure how they would do, but the (death rate) would probably be a lot lower."
Davidson acknowledges Northwell is learning from its ventilator experience. It was one of the first hospital systems to get COVID-19 patients and Davidson said many of its patients were considerably older - so more high risk. At the pandemic's beginning, the hospital waited many more days than it does now to intubate patients because "we did not understand how fast patients could be in serious respiratory distress."
Now, Davidson said she wants to "get the accurate information out that when patients arrive in a coma or not breathing, a mechanical ventilator Is a life saving technigique that has the possibility of prolonging their survival."
When patients stop breathing on ventilators, the ventilator "did not force them to stop breathing earlier," she said.
Harrell said New York hospitals, including Northwell, have been overrun with patients and "being overwhelmed is obviously bad for patient care." And he acknowledges his own hospital now has a 30 to 35% mortality rate of patients on ventilators as more people with multiple chronic health conditions come in
The key to caring for patients on ventilators, who often have to remain intubated and connected to them for two weeks, is "profoundily simplistic," said Harrell. They need the right mix of blood and oxygen or "the organs will not survive," he said. So by keeping the patient's blood moving, "our hope is eventually the patient will have enough reserve to rid themselves of the virus."
Still, Harrell doesn't want intubation to sound too easy, lest more people like the former students on spring break start minimizing the risks again.
"You do not want to be that guy in a chemical coma on a breathing tube for 30 days," said Harrell.
O'Donnell can be found on social media as @jayneodonnell or by email at email@example.com