Making the Rounds: ICU Discoveries to Become Part of National Study

Making the Rounds

May 12, 2020 Issue 242

Thanks to a more plentiful supply of tests, UNLV Medicine is making appointments for all individuals who would like to be tested for COVID-19. Patients no longer need to be exhibiting symptoms. There is no out of pocket cost. For appointments, call (702) 583-4408 between 8:30-4:30 p.m. M-F. Since March 23rd, UNLV Medicine has tested more than 7,600 Southern Nevadans.

Friends and Colleagues,

COVID-19. It’s a new virus that’s unfolded quickly, requiring the entire medical community to work together to come up with ways to treat a disease for which there is limited data to go by. Infections with the virus have multiple presentations from asymptomatic, to mild, to patients who are horribly sick. Should doctors quickly sedate COVID patients and put them on ventilators, or should they roll patients onto their abdomens and have them continue to breathe on their own -- with supplemental oxygen -- for as long as possible? Which antiviral drugs used and developed for other viral infections seem to help? What is the right answer?

In today’s newsletter, we feature Dr. Rajany Dy, a UNLV School of Medicine pulmonologist whose work, along with that of her colleagues in the UMC ICU, will be part of national studies seeking to find which treatments work, and which do not.

Marc J. Kahn, M.D.

Dean, UNLV School of Medicine

Coronavirus Crisis

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ICU Discoveries to Become Part of National Study

In one of the earliest formal COVID-19 studies, UNLV School of Medicine Dr. Rajany Dy and her colleagues in the ICU are collecting data on severely ill COVID-19 patients and sharing it with Harvard and Mayo Clinic researchers to learn more about comorbidities and other factors.

Dr. Rajany Dy is a UNLV School of Medicine Assistant Professor of Internal Medicine who’s seen COVID-19 patients die in the UMC intensive care unit that she was sure would live. She’s seen others live she just knew wouldn’t make it. To Dr. Rajany Dy, who’s right far more often than she’s wrong, COVID-19 is a coronavirus so novel that the only thing purely predictable about it is its utter unpredictability.

Yes, Dr. Dy, who was the valedictorian of her medical school class and completed her internal medicine residency through the Yale School of Medicine, admits there is no playbook for treatment of the virus -- what’s needed are clinicians with an insatiable curiosity, medical professionals devoted to finding a weakness in a virulent infection sapping the last bit of strength out of thousands of Americans.

“You may come home tired but you have to stay up and read the literature to find out if someone is doing something that is really helping patients more -- you have to keep studying,” says Dr. Dy, a UNLV attending physician in the UMC ICU who’s had several COVID patients. She’s also the UNLV School of Medicine Associate Program Director of the Critical Care Fellowship.

Her love for science and biology in high school pointed her to a career in medicine that began at De La Salle University College of Medicine in the Philippines. “Watching doctors at work when my youngest cousin had leukemia reinforced that,” says the native Filipino who completed a fellowship in pulmonary and critical care medicine through the State University of New York.

What has particularly impressed her about the medical teams attending to COVID-19 patients is the matter-of-fact courage they display as they attend to patients infected with a virus for which there is no cure. “The entire ICU staff is so brave,” she says. “They’re with the patients more than anybody and they just do all they can for them without ever hesitating. It’s who they are.”

She says antiviral treatments used to fight off other viruses may or may not work on COVID-19. Ditto for hydroxchloroquine, the anti-malarial drug President Trump promoted for awhile as a “game changer.”

“It’s really hit or miss,” says Dr. Dy, whose research has been published in several medical/scientific journals, including the American Journal of Respiratory Critical Care Medicine and the Journal of Pulmonary & Respiratory Medicine.

She remembers that her “first COVID patient was very sick with ARDS (acute respiratory distress syndrome) when she was admitted to the ICU. She stayed on the ventilator for more than a month, underwent a tracheostomy and was eventually weaned off the ventilator. I’m happy to say that she was discharged from the hospital to a rehabilitation facility.”

Another of her patients, a retired doctor, was talkative, matter of fact about having the disease. He just wanted the medical team to make sure to update his family regularly on his status. He was far more concerned, Dr. Dy says, about how his family would handle his time in the hospital than he was about his own welfare. He died. “It’s very hard to predict how patients are going to do in the ICU,” Dr. Dy says, and she says it’s “especially hard” if they’re COVID patients, for whom there is no tried and true standard of care treatment. ”It’s very disheartening to see someone die who seemed to be doing well at first.”

She says patients are well aware from news accounts that the virus is taking lives. “We’ve had patients who ask if they are going to die right before intubation and there really is no right response since it’s very hard to predict their clinical course. We reassure them that we will do the best we can to help them get better and that we will give daily updates to their family.”

“We’d like to find out more about the risk factors in the United States as well as what treatments seem to be working better than others. Treatments now are largely based on anecdotal evidence. Doctors want to do better than that for our patients.” --

Dr. Rajany Dy

Before they’re intubated/placed on ventilators, patients with worsening oxygenation are typically placed on a high flow oxygen nasal cannula and proning is generally used, where a patient is positioned on his stomach so the lungs are less compressed. While as many as 80 percent of patients who ended up on ventilators reportedly died in other areas of the country, Dr. Dy said less than a third of ventilated patients have died at UMC. “Our COVID patients typically require the ventilator for an average of 20 days or more and they stay for three weeks to a month in the hospital on average,” Dr. Dy says. “Our numbers seem better than the national average.”

Dr. Dy’s COVID-19 patients have varied in age from their early 30s to late 80s. They typically have very high fever and shortness of breath that worsens in 24 to 48 hours in severe cases. She says some patients also present with gastrointestinal symptoms such as diarrhea and vomiting. “I guess the most remarkable difference in caring for them is that they have severely low oxygen levels that take a long time to improve despite doing interventions such as proning and paralzying them (patients receiving breathing assistance frequently are pharmacologically paralyzed so they can’t take very large breaths and cause damage to the lungs.) A patient with pneumonia that is not COVID related may improve after antibiotics and ventilation after a few days.”

Fear of contracting the virus in the hospital is less of a concern four months into the pandemic, the pulmonologist says. ”There’s always been worry about contracting the virus, but honestly, being directly involved in the care of these patients and seeing the majority of them improve allays fears and anxiety. Our PPE (personal protective equipment) has not been an issue.”

The experiences of COVID-19 patients in the UMC ICU are now part of studies underway though the Mayo Clinic and Brigham and Women’s Hospital, a teaching hospital of Harvard Medical School. Up to now, she points out that studies have largely come from foreign exposure to the virus, including patient experiences in China and Italy.

“We've been finding out in China, for instance, that the patient population is often older, but we’ve been finding younger people with it too in the U.S.,” she says. “We’d like to find out more about the risk factors in the United States as well as what treatments seem to be working better than others. Treatments now are largely based on anecdotal evidence. Doctors want to do better than that for our patients.”

Dr. Dy is a member of the Gold Humanism Honor Society which recognizes excellence in clinical care, leadership, compassion and dedication to service. She has received an Abstract Scholarship Award from the American Thoracic Society Critical Care Assembly for her work in fluid responsiveness in the ICU.