Dr. Jamie Nadler spends much of his work shift dressed head to toe in personal protective equipment, treating some of the sickest Covid-19 patients in the region.
The Buffalo General Medical Center critical care physician gets to step out every now and then for a short break, or worse, to share the latest news about the conditions of his patients with their anxious loved ones. That news almost always comes by phone or computer during this global pandemic. The medical intensive care unit waiting room is empty because coronavirus precautions prohibit almost all visitors, even here.
“It looks like a war zone when you walk into our unit,” Nadler said.
He and his colleagues aren’t exactly sure what they will experience in the days ahead, but a growing arsenal of experimental treatments gives them greater hope that they can start doing more for new patients.
“I don’t want to jinx it” by making predictions, said Nadler, medical director of quality and patient safety for Buffalo General and Gates Vascular Institute next door.
Kaleida Health and Erie County Medical Center have two treatments in hand for Covid-19 patients and are closing in on two others.
Medical providers in China and elsewhere report all of them changed the course of treatment for a fairly high percentage of novel coronavirus patients, though Nadler and others caution that their availability was limited, the number of patients relatively small and the power of the new virus is still very lethal to millions.
Those who are elderly, immunocompromised, or already struggle with chronic heart and lung conditions are particularly vulnerable, he said, based on global reports and what he sees in the Buffalo General ICU.
That’s why social distancing, frequent hand-washing and staying away from others if you are sick remain so important.
Nadler and others say it will take weeks, at least, to collect and examine enough data to see which experimental treatments are most effective, as well as for the drug companies that make them to ramp up production. A vaccine is likely a year or more away.
Meanwhile, here is a closer look at the most immediate treatments.
The anti-malarial drug was also used for years to treat autoimmune diseases that include lupus and rheumatoid arthritis. It’s being used on patients at most regional hospitals with Covid-19 symptoms, including at facilities run by Kaleida and Catholic Health. Catholic Health hopes to start other experimental treatments soon, spokeswoman JoAnn Cavanaugh said.
Small studies suggest rapid improvement in some patients with mild forms of the disease.
Potential side-effects include fever, trouble breathing, cardiac challenges, hallucinations and gastrointestinal distress, so doctors won’t prescribe this and other experimental treatments if they deem the risks outweigh potential benefits.
Other experimental treatments will start with critically ill patients until doctors know more about their effectiveness.
“If we’re finding them successful, then we want to start rolling them out to more moderately ill patients to prevent their decline sooner,” said Nadler, who is also a clinical assistant professor in the University at Buffalo Jacobs School of Medicine and Biomedical Sciences.
Some of the most critically ill patients at Buffalo General, Erie County Medical Center, Millard Fillmore Suburban and Roswell Park Comprehensive Cancer Center are receiving sarilumab (pronounced Sirilia-mab), an injectable antibody treatment for those with rheumatoid arthritis.
“It works by shutting down the inflammatory cascade, which is a consequence of getting the Covid-19 infection,” said Nadler, principal investigator at Buffalo General and Millard Fillmore Suburban for the clinical trial, which is being led by researchers at Roswell Park and UB. “Once that inflammatory cascade is suppressed, it gives the body the opportunity to heal, so we don't see an immediate improvement.”
Buffalo General enrolled its first trial patient on Saturday. The hope is that the patient and others who might otherwise be on a ventilator for two weeks can get off in a few days.
Health providers and researchers hope this and a similar drug made by Genentech, tocilizumab, will block pathways that supercharge the immune system in some Covid-19 patients, bringing on and worsening pneumonia or acute respiratory distress syndrome, the condition that claims the lives of many who die from the new coronavirus.
The treatment weakens your immune system, so it predisposes eligible patients to secondary infections including bacterial pneumonia.
Described as an Ebola-turned-Covid-19 drug, remdesivir is designed to kill a virus directly, which reduces the “viral load” – or disease burden – before it can trigger an inflammatory cascade and respiratory failure. Kaleida Health has ordered it from the drug-maker, Gilead, and hopes to receive its first dosages in the next week or two.
“Our hope is that this will probably have the biggest impact of all the medications we're using,” Nadler said.
Plasma from Covid-19 patients
The state and Erie County health departments are working with hospitals across the region to design a process that will allow those who tested positive with Covid-19 and recovered to donate their plasma to help treat patients seriously sickened by the disease.
Those who have recovered must wait at least two weeks before they can be considered as donors. The health departments are tracking positive cases and will be able to reach out to eligible patients when treatments can begin.
Such “convalescing serum infusions” were used to help treat severe acute respiratory syndrome, or SARS, in 2003 and Middle East respiratory syndrome, MERS, in 2012.
“There have been small trials and small attempts around the world that seem to have had some degree of success," Nadler said, "so it's worth trying as long as it's done correctly.”
Nadler said one or a combination of these or other treatments could be used going forward, depending on study findings.
Meanwhile, he underlined that more than 80% of those who contract the new coronavirus can fight it at home and that most people who come to the hospital emergency room with symptoms can be helped without being admitted.
Those hospitalized are the most seriously compromised, the critical care doctor said. All are started on hydroxychloroquine, a series of blood tests are given and patients are treated with supportive measures given to all patients with the flu or other respiratory conditions. Patients who fall into respiratory distress are moved to the ICU.
Early data at Buffalo General shows that about half of patients will end up in the ICU, Nadler said
Loved ones of all patients with Covid-19 – including those doctors believe will recover – are understandably anxious about the fate of those sickened. Many think it’s “the end game” when someone is placed on a ventilator, Nadler said. That isn’t the case.
“We don't want to oversell the experimental treatments either,” he said, “so we're explaining what they are at this point and telling them we don't know if they're going to work. They've been met with varying degrees of success around the world but at the moment they’re our only option."
Clinical trials, including those in the region, will continue to provide a growing sense of which treatments work best for which types of patients. Nadler and others hope drug companies will be able to quickly boost manufacturing to save lives.
Even in best-case scenarios, that won’t mean a quick end to Covid-19.
“That cumulative effect of having patients on ventilators for so long will continue to fill up our ICU for weeks to come,” Nadler said. “So even if we've hit our peak, this is going to be weeks if not months of recovery, even after the peak is gone.”
Amid tragic losses, Nadler marvels with what he's seen.
“It's not all doom and gloom in ICU,” he said. “We've had some very good success stories.”
The first two patients admitted to the Buffalo General medical ICU and placed on ventilators have recovered and gone home, he said. Several others have been transferred to regular beds in medical-surgical units set up to treat Covid-19 patients.
Still, the growing number of patients raises fears.
"This has taken on a feeling of not knowing what's going to happen, not only to the patients but to our community, and how many patients we're going to expect," Nadler said.
Buffalo General has 82 ICU beds. More can be added if needed.
All 34 beds in the sixth-floor medical ICU are full with patients who tested positive with Covid-19 or are suspected to have it, Nadler said. Other suspected novel coronavirus patients have spilled into the surgical ICU and can fill beds in the neuroscience and cardiothoracic ICUs if needed. The latter two now serve only non-coronavirus patients.
Nadler marvels at the Buffalo General staff. He singled out Kathy Papia, the family liaison in the medical ICU, but said many are heroes.
“Our staff has been nothing but phenomenal,” he said. “Our nurses and respiratory therapists who are going in and out of the rooms every day have not thought twice about doing it and taking care of the patients. Same with our physicians. Same with our pharmacists. Our colleagues in surgery and in cardiology without hesitation have all offered their services should we get overwhelmed. Everybody's really stepped up to the plate.”
Personal realities further complicate things. Some hospital workers have gotten sick at Buffalo General, though not enough to impact patient care, Nadler said.
He generally works daily shifts of at least 12 hours for a full week, though he is on call 24 hours each of those days, which can stretch to 16 hours on days when ICU emergencies and patient numbers climb. Typically, he then has a full week to recover. Now he often spends at least a few hours working almost every day.
Before Covid-19, Nadler, who is from Toronto, and his wife, Megan, a clinical pharmacist at Buffalo General who grew up in Syracuse, faced the typical challenges of a working couple raising young children in communities far from other family members.
They’ve needed to juggle their schedules in recent weeks so they can take turns caring for the kids, who are home from day care.
“The anxiety of not knowing what's happening, not just medically but with the economy, with everything else, it’s definitely a stressful time,” Jamie Nadler said.
The couple hope the science will soon catch up to their hopes, and that Dr. Nadler can smile at more patients, as well as loved ones up to hundreds of miles away who see him on even the smallest of smartphone screens.
“That doesn’t mean we can relax with what we're doing right now,” he said, “because we don't know where we are on this coronavirus curve. If the peak is coming in two weeks and and we relax ourselves today, we're in big trouble.”