The memory of the patient in her fifties still haunts Dr. Cameron Kyle-Sidell. She was one of the first with Covid-19 he treated at an emergency Covid-19 ICU he established at Maimonides Medical Center in Brooklyn on March 23, just as coronavirus cases began to overrun the city. Her blood oxygen level had dropped into the 80s despite receiving high levels of oxygen support. This was concerning and indicative of hypoxia — a healthy oxygen level is in the mid-90s.
The hospital’s protocols called for placing her on a ventilator except she didn’t seem ill enough to warrant it. She should have been gasping for breath and possibly comatose, yet she was fully cognizant, talking to Kyle-Sidell and other caregivers, with no complaints of shortness of breath. Kyle-Sidell wondered if Covid-19 was somehow causing a false blood oxygen reading, but additional tests revealed the reading was accurate. Doctors would soon start calling patients like this — who they had never seen so frequently before — “happy hypoxics.”
When Kyle-Sidell told the patient that they wanted to place her on a ventilator she was terrified. “Is this going to save my life?” she asked.
He didn’t know what to say.
The 39-year-old ICU- and ER-trained doctor was beginning to have serious doubts about the manner in which caregivers were intubating people with Covid-19. Reports he’d seen from Italy were indicating as many as 80% of people placed on ventilators had died. Ventilators at his hospital didn’t seem to help his patients as much as he expected. Often, people would get worse after being placed on the machines.
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“As a physician, you know that bad things might happen to people and you may make the wrong decisions,” Kyle-Sidell says. “You take the 60% chance and it turns out they do worse, but you usually know that you did the right thing in the time that you did it.”
With Covid-19, there were no established rules, and some assumptions the medical community had made about the disease seem flawed to him. “Really in my heart, I didn’t know what was right,” he says.
In accordance with the wishes of the patient in her fifties, and his own thinking, he delayed putting her on the ventilator until her condition worsened to the point at which there really was no other option. She never came off the device. Like many other people with Covid-19 at that time, her ventilator was set to a high-pressure setting, and like others, she got worse after being intubated and ultimately died (today lower pressure settings are more common in the management of people with Covid on ventilators). While Kyle-Sidell believes he made the right decisions at the time, he wondered if patients like her should be managed with lower pressure ventilation settings, and in some cases, whether other patients should be placed on the ventilator at all.
In March, staff at hospitals across the U.S. were prepared to treat people with Covid-19 who developed acute respiratory distress syndrome (ARDS), caused by pneumonia from the virus. Most hospitals, including Kyle-Sidell’s, established Covid-19 protocols that would require intubating people earlier in the progression of the disease than they would traditionally. This was based on reports from China that patients who seemed critical but okay could deteriorate rapidly. It was also to protect hospital staff from the virus. Many feared infection dangers from emergency intubation procedures as well as the potential aerosolization of the virus from oxygen-support therapies such as high-flow nasal cannulas, which when on a high setting, might blow the virus around the room, a particularly unsettling prospect when matched with PPE shortages. (Doctors at several hospitals where these types of oxygen support therapies were used told me later on that they did not notice a corresponding uptick in infections among staff.)
But Kyle-Sidell started to wonder if the assumptions about the likelihood of emergency intubations and threat from oxygen support therapies were wrong. Although many of his patients were deteriorating, it was a slow deterioration over at least half a day, frequently more, not the hour or half-hour rapid deterioration that would necessitate the emergency intubations hospital staff across the country were hoping to prevent with earlier intubations. The threat of aerosolization from oxygen support therapies was also unproven. “I wasn’t sure that it was safe, but I knew that there was no consensus, and I felt if there’s no consensus then it’s incumbent upon us to give the patient that treatment if we felt it was the best for the patient,” he says. “Even were it to be proven that there was some aerosolization that’s why we’re wearing PPE — and we had PPE. Even if there is some increased risk that’s our job.”
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In addition, many patients he was seeing didn’t seem to have classical ARDS and he thought a less-aggressive-than-usual, not a more-aggressive-than-usual, ventilator strategy was warranted. He worried that the lungs of those with Covid-19 were particularly vulnerable to the risks associated with intubation — including ventilator-induced lung injury and kidney failure. “They didn’t seem to go into multi-organ failure until we put them on a ventilator,” he says. “Something about the ventilators seemed to really exacerbate their condition.”
In late March, he went public with these concerns on Twitter, which led to a guest appearance on a podcast for ThinkingCriticalCare.com, a popular resource for critical care physicians. He also started trying to keep more of his patients off ventilators for as long as possible and urge fellow physicians to rethink the protocols. “I was stopping anesthesiologists from intubating some patients,” he says. “I was taking doctors all over the hospital through the ICU. I was really trying to convince everyone at the hospital to take a closer look at this disease.”
“I felt if there’s no consensus then it’s incumbent upon us to give the patient that treatment if we felt it was the best for the patient.”
These actions ruffled feathers. Administrators sent him home for a few days and ultimately transferred him from critical care to the ER, a decision he understands to a certain extent. “This was a time of chaos and everything was in war mode,” he says. “You can’t have one doctor running around trying to create their own protocol.”
But even so, Kyle-Sidell was not done getting the word out. Prior to working with people with Covid-19, he sent his three-year-old son to live exclusively with his mother — from whom Kyle-Sidell is divorced — so as not to risk infection and because Kyle-Sidell had limited time away from the hospital. Alone in his Brooklyn apartment, he began to reflect on the virus. A native of Los Angeles, he went to medical school at Ben-Gurion University of the Negev in Israel and completed his residency in Detroit. He trained emergency medicine residents for a year in Haiti. Still, the conditions he’d witnessed in New York City had been the worst he’d ever seen at a U.S. hospital.
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“People were dying,” he says. “Young and old.” He talked to the wives, husbands, parents, and even children of the patients he lost. They were awful conversations to have. “You don’t know what to say,” he says. “I would always just repeat, ‘These are terrible times.’”
Temporarily benched from that chaos, he envisioned the virus spreading outward from New York and with it the flawed ventilator protocols. “There was just an absolute focus on getting people onto ventilators. That was the only thing on the news. It was what was being talked about in hospital meetings,” he says. “I was imagining people being put on ventilators left and right all over the country. And at the same time, I was sensing that wasn’t necessarily the best thing for them.”
Hoping to help prevent this, he made a six-minute video and posted it to YouTube and Vimeo on March 31. In the video, which was shot in his kitchen, Kyle-Sidell is wearing his scrubs. His curly black hair is slightly unkempt and you can see the exhaustion in his eyes and hear an almost desperate pleading in his voice. “I believe we are treating the wrong disease, and I fear that this misguided treatment will lead to a tremendous amount of harm to a great number of people in a very short time,” he says while staring directly into the camera. “As New York City appears to be about 10 days ahead of the country, I feel compelled to get this information out. Covid-19 lung disease, as far as I can see, is not pneumonia and should not be treated as one. Rather it appears as if it is some kind of viral-induced disease most resembling high altitude sickness.”
“I don’t know the final answer of this disease,” he adds, “but I’m quite sure that a ventilator is not it.”
As the virus spread throughout New York and other parts of the country, other physicians were beginning to make similar connections, and the topic of whether ventilation was being used properly in Covid-19 became a widespread discussion among critical care health workers within weeks. He was featured in the New York Times with other frontline doctors and made more podcast appearances aimed at the medical community. He believes the discussions he and other medical professionals engaged in online served a similar function as a traditional peer review.
However, it wasn’t just doctors who watched the video. It went viral and began to resonate with conspiracy theorists. To date, it has been viewed more than 900,000 times on Kyle-Sidell’s accounts. There were aspects of the video — he talks about challenging “long-held dogmatic beliefs within the medical community,” for instance — that resonated with conspiracy theorists. And though his intended audience was other physicians working with Covid-19 patients in the ICU, overnight he became an unwilling hero of the alt-right, anti-vaccine advocates, and conspiracy theorists of all kinds. A clip from the video was featured in the viral fake news-peddling documentary Plandemic. And to Kyle-Sidell’s regret, his video was used to help fuel a conspiracy theory that hospitals were putting patients on ventilators for more money, a charge he has repeatedly pointed out as false.
“You wouldn’t believe the emails I’ve gotten,” he says. He told the communications staff at his hospital, “Listen, if there’s 5G anywhere in the email I don’t need to see it.”
But he believes the viral attention the video got, even the kind he could do without, helped publicize his concerns. “I feel that the only reason it got picked up by other people was because it was sort of a loud video,” he says. “If I made some calm video, I don’t know if it would have been seen by the people I wanted to see it.”
On April 22, Kyle-Sidell and several other critical care physicians posted a preprint paper called “Re-thinking the early intubation paradigm of COVID-19: time to change gears?” on the Thinking Critical Care blog. The authors forwent the traditional publishing process, noting that while the topic was “highly relevant and somewhat controversial 10 days ago, it is now almost already accepted!” It wasn’t until June that the paper was published in the CEEM journal, the member journal of the Korean Society of Emergency Medicine.
Kyle-Sidell’s belief that Covid-19 was not always causing ARDS remains a matter of debate requiring further research, but putting patients on ventilators later and relying instead on other oxygen-support strategies moved rapidly from fringe to mainstream Covid-19 treatment policy as critical care physicians across the country made similar observations.
Jonathan M. Siner, MD, an associate professor of medicine and medical director of the medical intensive care unit at Yale New Haven Hospital, says that early on in the pandemic there was a lot of concern about health care providers getting Covid-19 and that many hospitals were intubating people earlier than they might have usually. “But it became apparent that a lot of these patients could do fairly well with a lot of supplemental oxygen, and so our set point for initiating mechanical ventilation was delayed until patients were sicker,” he says. He adds that they also began to prone patients who weren’t on ventilators, turning them onto their stomachs to improve oxygenation. He believes such an evolution was fairly common in ICUs across the U.S.
Bhakti Patel, MD, a critical care physician and assistant professor of medicine at the University of Chicago Medicine, says her hospital followed a similar path from early to later ventilation strategies in the first weeks of the pandemic.
“We were recognizing that we were putting patients on ventilators much earlier than we normally would and they weren’t seeming to receive any additional benefit from that,” says Patel, an authority on less-invasive alternatives to ventilators. When it comes to less invasive methods, Patel’s research suggests an oxygen-support therapy called the helmet, a transparent hood patients wear over their heads to supply oxygen, is more effective for treating ARDS than traditional face mask hospitals often use for oxygen delivery. At the start of the pandemic, helmets were rare at U.S. hospitals, and Patel says hers was one of the only ones with firsthand experience with them.
An accurate ventilator fatality rate for people with Covid-19 is still hard to come by. In early April, New York Gov. Andrew Cuomo said that 80% of patients placed on ventilators in his state were dying. As the pandemic progressed, estimates were lower, ranging from 30 to 70%, depending on the hospital. Debate is ongoing about the causes of this variation, and whether it was overcrowded hospitals or early ventilation strategies that caused the poor initial rates. Some hospitals continued with their early intubation protocols, including the Harvard-associated Massachusetts General Hospital and Beth Israel Deaconess Medical Center, where doctors had good results. In a study of 66 patients at those hospitals, 70% survived ventilation.
As important as mortality is, it’s not the only factor driving treatment decisions. Patel believes there is wisdom in avoiding ventilating patients whenever possible. “If you check in with people six months after being on a ventilator, three-quarters of them will say they have some sort of disability,” she says. “A quarter of those will say it’s severe.”
As for whether Covid-19 was creating a different condition in some patients, Siner says Yale New Haven Health is studying that question, and is so far finding that over the course of about five to seven days, people who had very low oxygen levels but appeared better than expected tended to evolve more like the typical ARDS patients. “If you have pneumonia and you get ARDS, it’s mostly in the lungs. But Covid-19 seems to affect the blood vessels that go in through the lungs too,” he says. “That may be part of the explanation for people who have very low oxygen levels but look better than expected, because the problem may be in the blood vessels and not entirely in the lungs.”
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Siner and his colleagues plan to publish research on this question later this fall, but he says concluding it is a new condition prior to this type of research would be a mistake. “There are some differences there, but our assumption is: Treat them like they have ARDS,” says Siner. “Then maybe if there are additional therapies, such as aspirin or blood thinners, you add them on top. Don’t totally throw out the baby with the bathwater.”
Kyle-Sidell is glad these conversations are taking place both inside and outside traditional research arenas. For those patients who do need to be ventilated, he believes an alternative ventilator strategy called airway pressure release ventilation (APRV) should be studied. Lately, he’s been wondering if even oxygen support methods like high flow nasal cannula are too aggressive, as they can also harm the lungs, and believes this question deserves more attention from physicians and researchers. “If someone is doing well and they’re saturating at 80%, do we necessarily need to have them saturate above 90%?” he says. It is all about finding the correct balance between potential damage to a patient’s lungs from oxygen support versus working too hard to breathe without support, he adds.
He stresses that these questions likely have nuanced answers. He recently retweeted and endorsed a fellow clinician’s statement that despite misconceptions in the public, intubation does not always equal death and oxygen by other means does not equal survival.
At heart, Kyle-Sidell is a patient advocate who believes in the power of individualized care. Asked by a Twitter follower why the fatality rate has gone down for Covid-19 patients since the start of the pandemic, he replied that a variety of factors, including less early intubation and steroid-based treatments, probably play a role. However, he adds, perhaps most important is a “medical system not busting at the seams with better provider/patient ratios.”