Quebec doctors have made strides treating COVID-19, they say -- but don't be complacent

Six months after Quebec's first wave of COVID-19 came crashing down on the health care system, local doctors say they now have a better handle on how to treat it -- but their confidence is not enough to warrant taking any risks or overtaxing the health system.

For example, they still don't understand why the disease is a death sentence for some, and benign for others. That's one mystery they're racing to try to grasp before any worst-case second-wave scenarios come to pass. 

"We are on alert," said McGill University's Dr. Donald Vinh.

"Right now, I'd say we're like a rock being thrown into a puddle. We're starting to see a ripple effect. But what's the magnitude of that ripple effect? That's what we have to be careful about."

On Monday, the province reported 276 new infections over a 24-hour period. There were no additional deaths or hospitalizations reported, though hospitalizations have increased slightly over the last five days.

But experts say it's not the time to become complacent. The more community infections there are, the greater the risk the disease will spread from younger, healthier groups to vulnerable people around them, leading to more hospitalizations.

"When they spread it to others, that can certainly be the start of a second wave," said Vinh, a microbiologist and infectious diseases specialist.

One critical-care physician at the MUHC suggested we'll get a better picture of Quebec's fate in four to six weeks, when children will have been back at school for longer.

A PAINFUL TRIAL AND ERROR

Doctors agreed they've made great strides in understanding how COVID-19 works, including those who got a crash course in Montreal hospitals.

Dr. Gordon Samoukovic described his experience in the ICU during the first wave as "humbling" and said he and his colleagues are certainly more prepared now to treat the sickest patients.

"It is extremely rare in medicine that in a very short period of time we learn so much," Samoukovic said.

For example, some medical approaches employed early on were found to hinder recovery rather than help. 

Initially, the management plan for patients included early intubation, sedation, paralysis and ventilators to help patients breathe.

Dr. Samoukovic explained they thought the intubation approach would facilitate "lung rest." But that turned out to be a problematic approach because doctors didn't yet understand the disease process, or specifically, how it progressed in a patient hooked up to a ventilator.

"Perhaps the time spent on a ventilator was the time period that allowed complications to happen, and subsequently, the patients would never get off the ventilator," he said.

"So somewhere midway, the first wave of the pandemic, we changed our strategy."

From then on, early ventilation was avoided. Now, as often as they can, doctors rely on non-invasive oxygen assistance to help patients breathe on their own.

Conversely, after initially deciding not to use another invasive therapy called ECMO during early stages of COVID-19, ICU teams now support patients with it. An acronym for "extracorporeal membrane oxygenation," the process uses tubes and a machine to add oxygen to the blood and pump it through the body, like a heart. 

Scientists here in Montreal and worldwide have also tested many medications on COVID patients, including antibiotics and anti-viral medications. 

"It appears that the use of steroids is supported the most by experimental and clinical studies," Sanoukavic said, for use early in the course of the illness. 

MYSTERIES REMAIN

Even though critical-care approaches have been refined, many questions about the SARS-CoV-2 virus and the disease it causes remain unanswered.

"What we really want to understand is why is there this variability," said Vinh, and why it is that some who are infected only have mild or flu-like symptoms while others go on to develop pneumonia, respiratory or organ failure.

"It's still the same virus, so it's not necessarily the virus that's the issue, it's how the body is fighting off the virus," he said. "And that's still what we don't understand."

Respiratory viruses are nothing new, but COVID-19 doesn't fit the mold.

It can also become a cardiovascular disease affecting the lungs and the circulatory system, causing all kinds of changes such as clotting, even in tiny blood vessels.

"I think we all learned that regardless of how advanced medicine is in 2020, the surprises and challenges we face every day can be of a very direct and challenging nature," said Samoukavic.

He said he remembers every one of his ICU patients from the first wave, including who lived and who died.

As the province tracks the number of cases day by day, he suggests now is a good time for everyone in Quebec to take stock and reboot their sense of discipline. With doctors still finding their way, following public health guidelines is the only safe way forward.

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