“Emergency situation. Might help. Won’t hurt. Worth pursuing.” In a pandemic, it’s the right logic

A medical staff member talks to a patient at the covid-19 ICU of United Memorial Medical Center in Houston on Nov. 8, 2020. MUST CREDIT: Bloomberg photo by Go Nakamura

“Famotidine? Isn’t that used for acid reflux?” I nodded. “Then why are we giving it to this patient?” The medical student asked that question with a puzzled face as our patient gasped for breath.

It was a fair question. Our patient was not suffering from a disease of the stomach but of her airway: She had suffered an anaphylactic allergic reaction, and her throat was beginning to close. “You’re right,” I explained, “famotidine blocks histamine receptors in the stomach. The thought, though, is that if it works against histamine receptors there, it might just work against other histamine receptors causing our patient’s allergic reaction. I don’t think it’s the silver bullet that’s going to fix her, but her problem is severe enough that any little bit that might help is worth pursuing. Basically, it might help, and it certainly won’t hurt, so we give it in situations that are life-threatening.”

My medical student’s puzzled look evaporated: “Emergency situation. Might help. Won’t hurt. Worth pursuing.” She accepted the logic as sound.

This is not, of course, only my personal logic. It’s standard thinking in the treatment of medical emergencies. It is logic that the Centers for Disease Control and Prevention follows, as well. Despite citing literature that admits that “systematic reviews have not identified any randomized-controlled trials that support the use of these agents,” the CDC nevertheless advises physicians in published recommendations to “consider giving famotidine” to patients suffering from anaphylactic reactions.

But while the CDC is happy to accept such logic in that scenario, for some reason, it seems unable to apply the same thinking in others. And that’s continuing to hurt the U.S. response to the ongoing coronavirus pandemic.

Early on, the CDC advised the public against general mask usage. “If you are not sick,” the agency said in the spring of 2020, “you do not need to wear a face mask unless you are caring for someone who is sick.” Then-Surgeon General Jerome M. Adams followed this guidance in late February 2020, tweeting: “Seriously people – STOP BUYING MASKS! They are NOT effective in preventing [the] general public from catching #Coronavirus.” One month later, CDC Director Robert Redfield backtracked, stating that in light of new data, guidance on the general public’s use of masks was being “critically re-reviewed.” By then, the new virus had already spread beyond anyone’s ability to control.

Of course, there was never much harm associated with the idea of asking Americans to cover their mouths and noses with a piece of cloth. At worst, a bunch of people would have looked a little funny for no good reason. At best, it could have blunted the pandemic early, when a useful intervention would have had the most effect. Had the CDC pursued a strategy of “Emergency situation. Might help. Won’t hurt. Worth pursuing,” the early stages of the pandemic could have looked very different.

Similarly, it was not until May 2021, over a year into the pandemic, that the CDC admitted that the coronavirus behind the disease did indeed spread through the air via aerosolization rather than by droplet particles that fall quickly to the ground. Droplet diseases can be evaded by staying six feet apart from our peers and employing the use of simple surgical masks, while airborne diseases are best controlled by emphasizing good ventilation and the use of aerosol-protective N95 masks. Of course, no school or office building would have been injured by a recommendation that they open their windows in addition to spacing their desks apart, and no nurse or doctor would have been seriously harmed by utilizing an N95 mask before it was proved that they were absolutely needed. At worst, some people would have worn sweaters indoors for no good reason, and an extra layer of protective masks would have been worn when they weren’t absolutely necessary. At best, however, the pandemic would have been better contained, and many of the 3,600-plus health care workers who died in the first 12 months of the pandemic would still be alive today. Here again, “Emergency situation. Might help. Won’t hurt. Worth pursuing,” would have been a wise mantra to follow. (Because of ongoing misinformation, it is important to note here that the politicized treatments of hydroxychloroquine and ivermectin do not meet the criteria of this mantra. These treatments can better be described as “Won’t help, might hurt, don’t pursue.”)

Despite all this, the CDC and other federal agencies leading the pandemic response do not appear to have learned the lesson. Even as the Food and Drug Administration admits that coronavirus booster vaccines don’t carry any significant safety risk and that they appear to be effective, they have gone on to reject recommending them for most people, instead endorsing them only for the elderly and people at high risk of severe covid. The CDC appears to be on the verge of making the same mistake. The explanations given for this decision have varied. Some scientists claim that we lack evidence that boosters are needed to protect against severe infection and death. Of course, should that evidence ever become available, it would, by definition, be too late for some patients who might have benefited from a third dose. Others say booster shots should not be recommended because we should instead use those doses to vaccinate the unvaccinated at home and abroad. Seemingly lost in that argument is the idea that we could do both. Accepting false limitations has never been part of the fabric of our country. Certainly, should we decide that it is the right thing to do, we could figure out a way to increase production of a vaccine that is already being mass produced. And so, as nations such as Israel have gone ahead and recommended booster shots for all citizens over the age of 12, our country seems intent on waiting for a complete data set that will never come, leaving us once again failing to act decisively in the face of an emergency that is still ongoing.

Booster shots alone will not be a panacea. It is true that vaccinating the unvaccinated, rather than boosting the already vaccinated, is likely to be our best bet going forward. But it is also true that we are in an emergency situation, that booster vaccines are unlikely to cause harm, and that they might just help – maybe just a little, maybe quite a bit.

More important than any specifics, however, is that the current issue, like the ones before it, serves to highlight a fundamental logic gap that seems to be going repeatedly unaddressed at the highest levels of our government. In an emergency situation, we often don’t have the luxury of a complete data set before we decide to do what is right. As with a patient struggling to breathe as the result of an allergic reaction, we cannot wait for the worst to happen before we finally decide to take action. We don’t need to think our plan is a silver bullet for it to still make sense to pursue it.

Our current pandemic will have more stages to come, and the future will present us with new pandemics, each with their own challenges and difficult decisions. If we are to do a better job going forward than we have done looking back, “Emergency situation. Might help. Won’t hurt. Worth pursuing,” is a mantra our most senior officials would be wise to adopt.

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Farzon A. Nahvi is an emergency medicine physician and the author of the upcoming book “Code Gray: Death, Life, and Uncertainty in the Emergency Room.”

 

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