Physicians are a sturdy lot. They come in all shapes and sizes, yet they all have a common goal; to find means to heal and comfort the sick. Ask any doctor, in an Emergency Room filled with patients; where some are crying in agony, others are gasping for air and still, others are infirmed into total silence. These physicians never let the trauma of life and living alter their sense of being. One by one, each is given the remedy he or she seeks and while most withdraw to their homes in comfort, some remain under the vigil of others within the walls of the hospitals till recovery. It is not only the ER doctors but most, in all different specialties who carry the same burden. Ask a bleary-eyed surgeon awakened in the middle of darkness, with adrenaline coursing through his veins, while he rushes to suture a gaping wound, an aorta, or a ruptured viscus all without a peep of self-doubt or self-pity. Or ask a family physician who sees a patient in the fit of a coughing spell calmly administer relief without a pat on the back. No, physicians by their very nature are destined to quietly move through society and life, bearing the burdens without calling attention to the burden itself or to themselves.
If further proof was needed, look at the 136 physicians who have quietly given up their lives in the wake of this Coronavirus pandemic. Called to arms, they, the physicians, have gathered up their collective selves and hurled into the maelstrom with both feet. Like wilted twigs of winter turning into the stout blossoms of spring, physicians are by their very nature blossoms of humanity for all seasons. Quick on the learning, even quicker on the healing.
Their wisdom is derived from past leaders in medicine. When their science is carefully cogitated with their experiential references, voila a bouquet of therapeutic offerings emerges! Looking back at history, several notables took their cue from the human interaction with nature itself. Look for instance at Edward Jenner, after observing the benefit of cowpox stemming the risk of smallpox, he ventured into a trial vaccination of an 8-year-old boy delivering immunity to the child in Gloucester in 1757. He might have been vilified in this day and age for not doing a randomized controlled trial, but he manifestly saved millions of lives from the disabling and deadly disease. Another stalwart who lived in the same venous tributary of a thinker and doer named Barry Marshall. After many attempts to educate his fellow experts about the cause of peptic ulcers as not emanating from too much acid in the stomach but from a bacterium named Helicobacter Pylori, he failed to gain their support. He was ignored, then laughed at and finally given the gravity of his findings he had to drink a glass full of the H Pylori and develop an ulcer to prove his findings when organized medical science was forced to take notice of the causal nature of the disease. He did receive the Nobel Prize for his findings eventually.
Deep in our most convincing organ called intuition, there are many valves and levers of balance. The valves open to input from nature, from observations and the levers of balance, are the risks and benefits of using those observations as therapy. Doctors have long deployed this intuitive-complex, in their armamentarium to ascertain the best possible therapy for their patients. But over time a steady stream of complexity has overshadowed this modus operandi. The complexity craves for unending and at times valueless research that does little to advance the hypothesis but only to prove at the outset what was envisioned. We have come to a time where even large meta-studies are filled with the bias of the offering author. In the field of Oncology alone, for instance, data from one meta-analytic study revealed that only 11% of the “Landmark” studies were reproducible, verifiable or could be validated. That in itself is a damnable smudge on the progress of scientific evidence. But having said that, not all scientific data is reproachable. There are valid reasons to conduct studies in an organized manner so as to prove the benefit and lack of harm to the patient. That rigor, however, takes time.
In the time of such panic when lives are being lost as now while facing a pandemic, the automatic response of RCT (Randomized Control Trial) as the only form of control to the use of potentially life-saving medication must need to withdraw. Even Anecdotal data that may reduce illness or thwart the disease from gaining a foothold and claiming more lives should be considered as an intuitive reason to forgo the strict complexity and delay of published “evidence.” If physicians in the battlefield against the pandemic are seeing the benefit and perhaps even through the colored lenses of their viewpoint, it is imperative that hurdles not be placed in their decisions. They are the frontline soldiers, not the commanders in a tent 100 miles behind. They see the ugliness of the fight; lives won and lost daily, while the commanders plot in the distant background. The wars are never won if the soldiers and their battalion leaders are forced to take a course of action that negates their intuition of the ebb and flow of the nature of the incoming fire.
Hydroxychloroquine is a classic example of this new(old) potential armor against the current COVID19 pandemic. Several small “anecdotal” studies seem to validate the findings of this drug in conjunction with Azithromycin and possibly Zinc as having an influence on attenuating the course of this COVID19 induced illness within a human body. The data is mostly gathered in observational form and lacks the RCT of this vs. that to fit the Kaplan Meier curves. But this limited data even when viewed through rose-colored glasses suggest a potential benefit to some. When one adds the past common literature, which is found in abundance, that these drugs by themselves have few side effects, the common-sense test would be to use it in the earlier cases where the pulmonary cytokine storm has not yet overwhelmed the patient. Using it in late stages where the body’s immune surveillance has been overwhelmed, would be counterproductive and again looking to confirm biased belief. If Hydroxychloroquine (HCQ) can thwart the entry of the virus into the cell and within the cytoplasm, reduce the pH and prevent entry into the endoplasmic reticulum to prevent the replication of the virus based on basic scientific data, then it must be given the go-ahead as a treatment choice, especially when nothing else is available. Waiting for Godot is a fool’s paradise as is waiting for the results of a placebo-controlled trial. Waiting is not a wartime battlefield strategy given the urgency of the need. That these drugs are effective against COVID-19 has been proven in laboratory experiments. And now evidence is mounting that these drugs are working to decrease viral load in patients . Decreased viral loads mean patients not only avoid the hospital but are less infectious to others. This will decrease the burden on the healthcare system and upon the doctors and nurses that bear the ultimate responsibility of the patient’s care. In fact, India is officially considering health care professionals and family members of sick patients prophylactically take HCQ. The New York Times reports of a recent study: “Cough, fever, and pneumonia went away faster, and the disease seemed less likely to turn severe in people who received hydroxychloroquine than in a comparison group not given the drug.” More recently a Randomized Trial shows similar benefits as well.
Certain State Officials in various States have been misled into thinking that using HCQ + Azithromycin is removing the HCQ from the stockpiles needed to treat Malaria, Lupus or Rheumatoid Arthritis. For one, Malaria does not exist in the US, for another, the numbers of RA and Lupus patients do not require millions of doses that are already stockpiled. Officials should understand the urgent need of the patient and not the fancy of the stockpiled biases that exist when considering policies. For instance, the New Jersey Governor has placed a restriction on the use of HCQ, which is unfortunate. It bears on the thinking that perhaps using these relatively non-toxic medications by the physicians, nurses and first responders as a precaution just might prevent the loss of these front-line soldiers also. Empty virtue signaling of “for the public good,” while placing unnecessary constraints leads to harm and loss of life for both patients, their physicians, and nurses. As mentioned above, early treatment is crucial for keeping patients out of the hospital and off ventilators. Delaying treatment results in the opposite, more sick patients ending up in overburdened facilities. Besides, other State Governors of Nevada and Michigan, who formulated similar mechanisms of restrictions to the use of Hydroxychloroquine quickly reversed course, when seeing the burgeoning loss of life. If the restriction is to prevent hoarding of the medication, then perhaps using the Texas model of limiting the drug dosing for 10 days might be more appropriate. It prevents harm to our vulnerable, sick and infirmed patients and potential loss of life.
In keeping with the oath of Hippocrates and in keeping with the welfare of our patients foremost, we physicians must not have arbitrary and capricious hurdles placed in front of us while treating and managing the patients who are struggling to gain a foothold on their lives against the Coronavirus. It is time to unshackle the constraints and allow physicians to heal the sick as they are trained to do.
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