Playing the odds

There was good reason to have faith in ventilators. They help doctors treat pneumonia, and pneumonia is one of the worst conditions associated with this virus. The ventilator count was a main concerns in March: would we have enough to accommodate all of the people who were bound to develop critical symptoms? Did we have a stockpile that might save lives?

We now know that most of the people put on ventilators because of the coronavirus won’t come off alive. This was dispiriting news to me — I’d hoped, as I’m sure that many did, that the ventilator would prove to be a reliable line of last resort. Enough patients do recover that the ventilator isn’t going anywhere; they’re going to be part of the medical arsenal as long as the virus is with us. But it’s clear that the standard medical protocol is shifting along with the facts, and it’s going to need to shift more before we reach any kind of stability or predictability.

When we go to the doctor, we want a treatment that aligns with our specific physiology and our particular complaint. We’re looking for something bespoke. What I’ve learned the hard way is that medicine doesn’t work like that. Public medicine will not treat me as a unique animal with a singular set of problems. Instead, the doctor thinks about thresholds, benchmarks, and percentages. If seventy five per cent of male humans in my age group respond well to a particular pill, I’m going to get that pill. If the doctor is good, she’ll examine me for signs that might suggest I belong to the other twenty-five per cent. But chances are, the doctors won’t know why the pill doesn’t work for everybody, and given their caseload, they’re not going to take the time to make a pharmaceutical experiment out of me. They’re going to hope that I’m somewhere in the majority and send me home with a prescription.

The call for ventilators is, in part, based on an established benchmark. When blood oxygen drops below a certain level, patients require medical intervention. When that initial intervention doesn’t work, doctors turn to the ventilator. One of the devilish things about the coronavirus is its tendency to depress oxygen to levels that doctors and nurses rarely see — levels that, according to protocol, suggest that intubation is necessary. Yet many of those those patients are still ambulatory, and this may be because their lungs are still capable of processing carbon dioxide. Intubation, I’ve learned, is a serious thing — a patient on a ventilator is essentially knocked out, sometimes for weeks, so that the machine can do his breathing for him. Even in optimal conditions, disconnecting from the device isn’t easy. If some coronavirus patients could be treated with CPAPs or BiPAPs instead, it might not just save time. It could save lives, too.

Because this pathogen is new, doctors have been forced to revise their protocols on the fly. This isn’t something that doctors are good at. For understandable reasons, they like to stick to things that have worked in the past. Learning from precedent and applying those lessons to new cases: that’s how the doctor moves, deliberately and carefully, with a suspicious eye on departures from orthodoxy. Even during desperate hours, they’re unlikely to chuck random medications at patients on a “what have you got to lose” basis — that’s just not how they think. The reason that chloroquine is even part of the conversation is because it was used to treat SARS, which was also caused by a coronavirus. Remdesivir, which is actually an antiviral medication (it was tried, unsuccessfully, against Ebola and Marburg), may appeal to skeptical doctors a little more than plaquenil does. Expect to hear that name a lot in coming days, and avoid the ventilators if you can. I promise to try to stay off of them if you do.