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A medical worker at NYC Health Hospital is seen in front of the COVID-19 test site on April 22, 2020 in the Queens district of New York City. The United States, with nearly 45,000 deaths and more than 800,000 coronavirus infections, is the country hardest hit, and the health care infrastructure at major hot spots, such as New York City, has struggled to cope.
Image credit: AFP
New York: As the new coronavirus spread through New York City in late March, doctors at Mount Sinai Hospital noticed that something strange was happening to patients’ blood.
Doctors from different specialties detected signs of blood thickening and clotting in different organs. This would turn out to be one of the alarming ways the virus devastates the body, as doctors there and elsewhere began to notice.
At Mount Sinai, nephrologists noted that kidney dialysis catheters were clogged with clots. Pulmonologists who monitor COVID-19 patients on mechanical ventilators can see that parts of the lungs were strangely bloodless. Neurosurgeons faced an increase in their usual stroke load due to blood clots, the age of the victims became younger, with at least half of the tests positive for the virus.
“It is amazing how much this disease causes clots to form,” Dr. J. Mocco, a neurosurgeon at Mount Sinai, said in an interview, describing how some doctors think that the disease caused by the coronavirus is more than a lung disease.
In some cases, Mocco said, a stroke was the first symptom of COVID-19 in a young patient.
As colleagues from various specialties pooled their observations, they developed a new treatment protocol. Patients now receive high doses of an anticoagulant medication even before any evidence of coagulation appears.
“Maybe, just maybe, if you prevent clotting, you can make the disease less severe,” said Dr. David Reich, president of the hospital. The new protocol will not be used in certain high-risk patients because anticoagulants can cause bleeding in the brain and other organs.
Atypical cases
In the three weeks that began in mid-March, Mocco saw 32 stroke patients with large blood blocks in the brain, double the usual number for that period.
Five were unusually young, under the age of 49, with no obvious risk factors for strokes, “which is crazy,” he said. “Very, very atypical.” The youngest was only 31 years old.
At least half of the 32 patients would test positive for COVID-19, Mocco said.
Meanwhile, Dr. Hooman Poor, a lung specialist from Mount Sinai, found himself working a late shift with 14 ventilator patients. The fan readings were not what he expected.
The lungs did not appear stiff, as is common in pneumonia.
Instead, it seemed that blood was not circulating freely through the lungs to be aerated with each breath.
Poor met a kidney doctor that night, who commented that dialysis catheters were often blocked with clots.
“And I said, ‘It’s funny that you mentioned that because I feel like all these patients have blood clots in their lungs,'” Poor recalled.
Reich, the hospital president, told Pobre about the increase in strokes seen by Mocco and said the two doctors should team up, which would trigger days of discussions and meetings with the hospital’s department heads.
At 2:46 a.m. on Easter Sunday, Poor sent Mocco his first draft of what would become the new treatment protocol.
Doctors share findings
As their wards began to overflow with COVID-19 patients, Mount Sinai doctors read documents describing similar findings by doctors in China’s Hubei province and other affected areas, and discussed them with their peers in phone calls and seminars. Web.
Mocco called neurosurgeons he knows in other parts of the country. At the Thomas Jefferson University Hospital in Philadelphia, Dr. Pascal Jabbour had begun to see a similar increase in strokes among people with COVID-19. The way his patients’ blood froze reminded him of congenital conditions like lupus or certain types of cancer.
“I have never seen any other viruses that cause that,” Jabbour said.
In Boston, Beth Israel Deaconess Medical Center began a clinical trial earlier this month to see if tPA, a blood-thinning drug, could help seriously ill patients with COVID-19.
Clotting can develop in anyone who becomes seriously ill and spends long periods of time immobile on a ventilator, but doctors say the problem seemed to appear earlier in COVID-19 patients as a more direct consequence of the virus.
At Mount Sinai, intensive care patients often receive the anticoagulant agent heparin in weaker prophylactic doses. Under the new protocol, patients will be given higher doses of heparin than is normally used to dissolve clots before any clots are detected.
The treatment joins a growing toolbox at the hospital, where some patients receive antibody-rich plasma from patients recovered with COVID-19 or experimental antiviral medications.
The American Society of Hematology, which has also noted clotting, says in its guidance to physicians that the benefits of anticoagulant therapy for patients with COVID-19 who are not yet showing signs of clotting are “currently unknown.” “I certainly wouldn’t expect to play harps, angels to sing and that people would just pluck their IV lines out of the hospital,” Reich said. “It’s probably something where it only moderates the extent of the disease.”
