Is the monoclonal antibody bamlanivimab a miracle drug?

The feeling I get is usually a mix of despair, anger, and foreboding. It typically starts with a conversation, email, or social media post by someone that is to the far extreme of asinine. These statements, at any other time in history, would make much chuckle and shake my head but this is not any other time in history. This is a time where misunderstanding and misinformation leads to ever more annoyance, suffering, and death as it fuels the fire of the pandemic. This is a time where such statements make me feel ill physically and emotionally. That was my headspace when I recently learned that some families with a child sick with COVID were intentionally getting the entire household infected to decrease their quarantine times. If that was not enough I was blamed for this behavior because I have advocated that schools follow expert guidelines on safe practices.

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Does the vaccine cause cancer?

He had smoked a pack a day for over 50 years and had no thoughts of quitting. He was a confident and defiant gentleman who did not take anyone else’s word for it and he knew his body better than any doctor. He didn’t want to get his flu vaccine but his wife talked him into it. Prior to the shot he had been losing weight but he had been eating less and didn’t think much of it. His primary care doctor was concerned, however, and at the same visit where he got his flu vaccine, he was sent for a CT scan of his chest. The scan was done a week later and showed a large mass which turned out to be lung cancer. He was furious, convinced that flu shot had given him cancer. This is a true story.

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Why I got the vaccine (and why you should too)

This post will attempt to answer the following questions:

  1. Should you get vaccinated?
  2. Why?
  3. How do you evaluate the risk of the vaccine?

The pandemic roller coaster of emotion can be jarring at times. The past week was more illustrative of this than any thus far. It was a whiplash of the best and worst moments of the pandemic. I should have known it would be a difficult week when a grieving family member was carried out of the ICU shouting expletives at our team for failing to save her mother. She was just one of the eight COVID deaths (plus two non COVID deaths) we had over the course of the week. I had never lost that many patients in one week before and, while none of the deaths were a surprise, the sheer number was more than unsettling. There was a pall over the entire unit.

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The Pfizer vaccine data explained

This post will attempt to answer the following questions:

  1. What is an emergency use authorization (EUA)?
  2. What are the official efficacy results for the Pfizer vaccine?
  3. What’s the difference between efficacy and effectiveness? Does it matter?
  4. Were there any safety issues?
  5. What were the major side effects of the vaccine and how should we treat them?

I typically try to make these posts more personal for people by describing my own experience with COVID-19. I know many people feel distant from the pandemic and many have told me it really helps them to get a frontline point of view. Today I was just too excited.  The reason for my elation is that I read the briefing document from the EUA analysis of the Pfizer vaccine put out by the FDA. I figured I’d summarize the report in laymen’s terms.  It is a 58 page document (and that’s just the summary) and may be too much for people on the go.

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Are the new quarantine guidelines a good idea?

There was a sense of foreboding outside room 527 that night at shift change. The unfortunate soul in that room had been in the hospital over a week with COVID-19 and had followed the pattern we had seen countless times. She had a severe case and was on a lot of oxygen but was holding her own without a lot of symptoms as long as she kept her oxygen on. Then, without warning, her blood work showed signs of rapidly increasing markers of inflammation and she started to look worse. She had escalating requirements for oxygen and was put on CPAP. The thing that was so scary to me as I started the shift that night was how she looked. She just looked so tired. She could not open her eyes or say even a few words. Her breathing was rapid and shallow and it didn’t appear she could last much longer. I adjusted her CPAP but over the next couple of hours, her oxygen levels started to drop. I had no choice but to put her on a ventilator.

The unspoken foreboding was palpable in the room. We all knew that when patients go on the ventilator things usually don’t turn out well. Most will not survive, many will have prolonged hospital courses with severe disabilities, few walk out of the hospital, and nobody is ever the same.

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What’s the deal with antibody tests?

Up until two weeks ago we had just a few COVID patients in total in my hospital and none in the ICU. For a few months we had quietly slipped back to our usual routine. We were caring for those sick with heart attacks, severe infections, drug overdoses, and other sundry calamities that can befall the human body and land someone in the ICU.

Then everything changed in just a few days.

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Vaccine joy and winter sorrow

He was a lonely older man without any living family. He came into the hospital with severe COVID but, after several days, stabilized. He wasn’t getting better and he wasn’t getting worse. We had given him all the standard treatments and were hopeful that he would improve. Then, as is often the case with COVID-19, he rapidly deteriorated over the course of a day and ended up on life support.

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The burning embers

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She was only in her 30s. She only had mild diabetes. She developed a cough, aches and fever about a week prior to when I saw her. Many of her coworkers had recently tested positive for COVID-19 and she tested positive as well. Gradually she noticed difficulty breathing prompting her to come to the hospital where she had low oxygen levels and was promptly admitted. She was not in long when she worsened further and was transferred to the ICU. When I saw here she was requiring a lot of oxygen and her lab work did not look good. We gave her all the standard treatments – decadron, remdesevir, convalescent plasma, and lovenox – and she stabilized for several days. She was still requiring high levels of oxygen and using CPAP at night but she was not getting worse. In fact there were some signs of improvement.

I have a clear memory of kneeling down next to her as she sat in the chair in her room. She was calm but I could see the fear behind her eyes. She was struggling to maintain control in the face of her situation. I had to nearly scream to be heard over the buzz of the negative pressure generator and my PAPR, “You’re stable and you’ll start getting better soon,” I told her. The minute I said it I could see the tension ease on her face and feel it ease in myself as well.

That was the last thing I said to her.

That night she stood up to use the commode and her oxygen dropped precipitously. This had happened before but she had always recovered in a few moments. This time she didn’t. She lost consciousness, her pulse slowed, and then her heart stopped beating. CPR was started and fortunately the team was able to resuscitate her quickly and placed her on a ventilator. Things got much more difficult from there. We induced a medical coma and paralyzed her to reduce her oxygen usage. We put her in a special bed that rotates her to keep her face down and improve blood flow in the lungs. We did everything possible with the ventilator to keep her oxygen up. She stabilized somewhat but if she was manipulated or turned on her back her oxygen would quickly drop to life threatening levels. We had nothing more we can do for her. Our only option was to transport her to a special center to hook her up to a heart lung bypass machine called ECMO.

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Why COVID-19 is political (IMHO)

What would you say is strongest single predictor of behavior and attitudes towards COVID-19? What factor makes it most likely that someone will follow masking and social distancing guideline?

You would be considered reasonable if you answered that those with the greatest risk of dying would be the most cautious. You would be wrong. You would be considered a rational thinker if you answered that healthcare workers that are confronted with the sick and dying from COVID-19 would have the strongest emotional response motivating them to extra caution. You’d be wrong. You would not be thought crazy if you answered that those with more education would be more careful because they have more of an understanding of the complicated factors at play. Again, you’d be wrong.

Race? Wrong. Gender? Wrong. Employment status? Wrong.

The single strongest predictor of behaviors and attitudes towards COVID-19 is political affiliation.

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What Should I Do With My Test Results?

When I was growing up watching sports there used to be a segment on Monday Night Football entitled “You Make the Call”. The audience would be shown a specific play that required referee intervention. We would then be asked to play pretend referee and decide if it was a touchdown, a penalty, or some other point of rules contention concluding with the phrase “You make the call”. The game would cut to commercial and a lively debate would usually ensue. When the commercials were over they would show the play in slow motion and give you the correct call. I thought it would be a good idea to do a COVID-19 version of “You Make the Call”. I’ll give you the scenario and you can decide how you would respond if you were the doctor.

He woke up in the morning with a bit of a headache. It was not that bad and he hadn’t slept much so he attributed the headache to sleep deprivation. His throat was a bit scratchy but he had allergies every fall and this was typical for him. He decided to get tested to be safe. His rapid antigen test was positive and he is calling to ask you what he should do. What would you tell him to do?

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