This report is regarding my older sister, 81 years of age, a former moderate smoker (15cigarettes per day) since 60 years, living in Denver, USA. She quitted smoking 2016, after having inserted two ”stents” in stenotic coronary arteries.
On Friday March 6 , 2020 due to a newly developed 95% coronary artery stenosis my sister had an additional stent installed. It should be noted, however, that she never previously presented signs of heart infarction on electrocardiograms (ECGs) or angina – her heart contractility was considered good. On Saturday and Sunday, March 7th and 8th, my sister complained about severe postoperative fatigue, a never previously experienced loss of strength and extreme throat pain (later diagnosed as a COVID-19 infection). Based on my sister’s schedule, it was considered that she had probably been infected with the virus 7 days earlier, before the coronary artery procedure, when she and her husband were in close contact with many people at a well-attended jazz musical event in San Diego, California. On Tuesday, March 10th, my sister was intubated and connected to a respirator set to maximal oxygen concentration (100%) and +10 in PEEP (Post-end Expiratory Pressure*). She presented symptoms of septic shock**, that developed into ARDS, Acute Respiratory Distress Syndrome***.
Ventilation in the Supine Position – worsening of the pulmonary function
High respirator settings (100% oxygen and +10 PEEP) are not unusual during the first hours of treatment. In my sister’s case, however, these high settings had to be maintained constantly for 9 days. This must be extremely rare and I can not recall seeing this used during my 40 year long career as an intensive care doctor. Unfortunately, my sister’s lung function deteriorated and during the next five days it became necessary to raise the PEEP level stepwise from +10 to +18 to adequately oxygenate the blood. A PEEP higher than +18 was carefully avoided due to the risk of pressure injuries to the lungs and reduction in venous blood flow return to the right atrium and concomitant arterial blood pressure drops. As previously noted, oxygen at the highest possible concentration (90-100%) continued to be administered. Given the rapid worsening of my sister’s pulmonary function in the supine position it was necessary to try to increase blood oxygenation by other means.
Need for Ventilation in the Prone Position – worsening of the pulmonary function
On Saturday, March 14th, in an attempt to improve blood oxygenation my sister was placed in the prone position since this position facilitates better ”matching” between blood flow and airflow. It has long been known that normally there is a ”mismatch” between blood flow and air flow in the lung. This ”mismatch” is exaggerated when lying in the supine position but can be reduced in the prone position, which results in a much improved exchange of gases in the lungs. When my sister was placed in the prone position, it became possible initially to reduce both oxygen concentration (to 60%) and PEEP (to +10). Unfortunately, this effect was temporary and when after 8 hours in the prone position my sister was again placed in the supine position her respiratorsettings had to be increased back again to 90-100% oxygen and a PEEP of +14 to +16. In addition, during the period from March 14th to 19th, the number of hours in the prone position instead of the supine position had to be increased each day from 8 to 12 and then from 16 to 20 hours. On Tuesday March 17th, it was reported that my sister tolerated less than 4 hours ventilation in the supine position due to the poor oxygen uptake in the blood. And even when ventilated in the prone position, settings to 80% oxygen and +12 PEEP was necessary that day. The next day, Wednesday, March 18th, it was again necessary to increase oxygen to 90% and PEEP to+16 while in the the prone position. After March 18th the further deterioration of my sister’s the lung function continued and her doctors had limited options as respirator settings approached the maximum possible, 100% oxygen and +18 in PEEP.
Decision Not to Use Extra Corporeal Membrane Oxygenation
My sister’s family had previously been told that the doctors had decided not to place her in the ”heart-and-lung” machine (Extra Corporeal Membrane Oxygenation, ECMO), which is a machine capable of oxygenating the blood outside of the lung – a device that has directly saved the lives of many patients with severe pulmonary diseases. The decision not to use ECMO in my sister’s case was based on her heavy need for anticoagulants which made her an unsuitable candidate for ECMO. The decision not to use ECMO also was apparently based on the availability of trained personal and needed equipment during a period of extreme stress on hospital resources. However, APRV (Airway Pressure Release Ventilation), and other beneficial and milder ventilatory modalities, which have been proven to save patients’ lives, were attempted by hospital staff. Unfortunately, my sister did not tolerate these alternate procedures.
Drugs and Medications Used
Within two days of my sister’s arrival at the hospital Intensive Care Unit (ICU), on Thursday March 12, her doctors put her on the medication Hydroxychloroquine, which after a full dose was then changed to Remdesivir. Both drugs are well-recognized medications used against COVID-19. My sister was later put on the combination of Hydroxychloroquine + Azithromycin after a scientific report was released that showed that the drug combination had cured 100% of the patients studied who had COVID-19. It must be noted that my sister’s ICU doctors were quick to offer ”state of the art” medication. Unfortunately, none of these medications appeared to have any effect on her life-threatening clinical situation and the deterioration of her lung function continued. Without better curative alternatives there was the risk that she would soon reach a ”point of no return”.
First Contact via Telephone
Through one of my nieces I was connected to the ICU-doctor on call on Sunday, March 15th, to whom I expressed our wish to give her high doses of Vitamin C intravenously (I.V.) as a viable alternative. The doctor on call responded that he was familiar with Dr. Paul Marik’s papers on the combination of Vitamin C + Thiamin (Vitamin B1) + Hydrocortisone in septic shock cases. However, since my sister was not in septic shock the ICU did not believe that this treatment was indicated by her conditions at that time. At this point on March 15th I realised how challenging it would be for me in Sweden and also for her closest relatives in Colorado to discuss medical matters with my sister’s healthcare providers over the phone.
Becoming My Sister’s Medical Advocate
Around Sunday, March 15th my niece now emphasized that she wanted me to be my sister’s medical advocate. My niece believed that since her mother was now sedated and could not speak for herself that the family needed me to review medical information and advocate on her mother’s behalf. In view of this I decided to write detailed letters about what the family’s thoughts and wishes were and send them to the responsible ICU-doctor.
Intravenous Vitamin C – a Safe Treatment
In my first letter to the ICU-doctor, who was in charge for 4 days from Monday March 16 to Thursday 19, I presented my background as an Intensive Care Doctor since 1980 and my insights into the problems faced in my sister’s case. In my correspondence I discussed the previously noted difficulties and the lack of remaining options; namely that the use of ECMO was not tried and that APRV and the medications prescribed did not appear to be improving my sister’s condition. In fact, I wrote that, from my professional standpoint, her prognosis seemed to be deteriorating and her pulmonary function getting worse despite the best efforts of healthcare providers. I indicated that it seemed to the family that it was now absolutely critical to try something new. My suggestion was to use high doses of Vitamin C intravenously. As an Intensive Care Doctor I had had very encouraging clinical experiences when using Vitamin C during the past three years. I addition, I did an extensive literature review during those 3 years of the available scientific research done on Vitamin C. Furthermore, it was apparent to me that based on these studies IV. Vitamin C was absolutely harmless, even when given in high doses such as 50-60 grams infusions a fact which I had both theoretical knowledge of as well as clinical experiences. The next day I attached an extensive summary which I had written about the use of Vitamin C for cases of septic shock and ARDS. I also included a report detailing a severe Swine-flu case in New Zealand in 2009, in which a patient, Alan Smith, had his life saved by 25 grams times two (x2) of Vitamin C IV. despite significant resistance against the use of Vitamin C by Mr. Smith’s doctors. This case seemed particularly relevant to my sister’s case. Since my sister ’s condition deteriorated even further between March 17th and 18th we received a message on Wednesday, March 18, that the attending doctor was willing to try IV. Vitamin C (1,5 grams times 4). My view was that this was a start but that higher doses of IV. Vitamin C (i.e. 25 grams x 2) were needed just as had been employed in the dramatic, 2009 Alan Smith Swine-flu case.
Approval of High-dose IV. Vitamin C
Late on Thursday evening, March 19, the attending doctor sent a very sincere, kind, compassionate and articulate letter to me in which she laid out her worries and very pessimistic view about my sister’s difficult clinical situation. She discussed that she would be transferring my sister’s care to another doctor in charge on Friday morning, March 20. In a positive development the doctor told our family that she now was willing to give whatever dose of IV. Vitamin C my sister’s family would like to try and she indicated she was aware that high-dose Vitamin C would be ”harmless” to try, but she did not want for us to raise our expectations too high. My sister’s doctor also stressed that the only measure known to increase survival rate in patients with ARDS is ventilation with ”low tidal volume”( i.e. 6 cc per kilogram bodyweight), which was my sister’s present respirator setting, 350 cc/breath. Given that my sister’s pulmonary function was not improving but appeared to be deteriorating despite this treatment modality, the family was indeed aware that my sister’s prognosis looked bleak. The doctor wanted us to reflect on my sister’s potential fate. What would happen if my sister survived against all odds? All surviving patients with severe ARDS , to her knowledge, had come back to life on a much lower functional level, even after several months of rehabilitative efforts. And she said that this might very likely be the outcome in my sister’s case, although admittedly the hospital had not been able to perform a neurologic assessment, and they could not confirm this would be the case. The doctor questioned whether my sister would accept this loss of function and the future life it might entail. Only the family members may know, she wrote. My family understood what that meant and this was a sad moment, but we decided not to talk about it further until high dose IV. Vitamin C had been tried for at least four days.
Vitamin C 1,5 grams times 4, IV.
On Thursday, March 19, my sister was given an IV. infusion of Vitamin C 1,5 grams times 4. The day after, on Friday morning, the oxygen demand in the prone position had been reduced from 90% to only 50% and the PEEP from +16 to +10, a first improvement. The new doctor was very happy but puzzled – what had really happened? Simultaneously, it was possible to assess this change by objective measures, P/F-ratio, which went from around 70, at its worst, to 120 and then 128. This was a very clear improvement from severe ARDS (=70) to moderate ARDS (=128)**.
Vitamin C 25 grams twice a day IV. for two days
My sister’s family and I received a promise from the new doctor to raise the dose of IV. Vitamin C to 25 grams twice daily, which unfortunately could not be implemented immediately, however, due to the lack of IV. Vitamin C at the hospital pharmacy and throughout Denver at that time. Six days later, on Wednesday, March 25, the Vitamin C solutions arrived and my sister was immediately given 25 grams IV. (x2) the same day. The next day she was off the respirator and could breath by herself for 3 hours. After another day of treatment with the same dose Vitamin C she was off the respirator and breathed by herself for 6 hours. The rapid clinical improvement by my sister (after administration of high-dose Vitamin C) was a huge surprise to the attending nurse, who also acted as her ”respiratory therapist”, why she asked the permission to read all the reviews I had written about Vitamin C, septic shock and ARDS and that I had communicated to the doctors. On Friday, March 27, the pulmonary X-ray displayed a huge improvement (as in the Alan Smith case, who had suffered from very severe Swine flu in 2009). Concomitantly, the P/F-ratio had increased to 148 after one day of very high dose treatment and to 196 after two days treatment – which all corroborated her improvements. Unfortunately, this progress stopped over the weekend when apparently due to a miscommunication treatments with Vitamin C were inadvertently discontinued. My sister’s condition deteriorated again, both clinically and on pulmonary X-ray and she displayed a lower P/F-ratio of 158 as well.
Vitamin C 25 grams twice a day IV. for five days
On Monday, March 30, the chief ICU doctor was back on duty and he corrected the discontinuation of Vitamin C treatments that had occurred over the weekend – he was, in fact, enthusiastic about continuing this treatment modality. Again my sister was put on IV. Vitamin C 25 grams twice daily for another five days. On Friday, April 3, she also received a tracheostomy***** plus a PEG****** after having remained intubated orally for 24 days. Vitamin C intravenously was then discontinued and replaced by liposomal******* Vitamin C 24 grams/day through the gastric tube, a dose that was reduced to 12 grams a day after 9 days. After April 3rd my sister’s recovery proceeded rapidly. Despite having had severe life-threatening conditions, she did not suffer further complications, i.e. no heart infarction, no kidney or liver insufficiency, no neuromuscular injuries or swallowing or vocal cord paralyses. Also, she is mentally absolutely alert and talks daily with her family members and friends through FaceTime on her iPad. She has now been tested negative twice for COVID-19 but only after 7 weeks, since April 27.
Posted on March 13/ 2021:
Below is a video of my sister which is displayed here with her permission. It was produced on July 5 – 2020, two months after her discharge from the hospital in gratitude to all the doctors and nurses at the ICU for all their heroic efforts to keep her alive – against all odds. They never gave up. If someone wonders why she speaks so slowly she told that it’s on purpose. Since English is not her native language she tried to avoid stumbling.
July 5 2020
Sture Blomberg, M.D., Ph.D.Anesthesia & Intensive Care, Gothenburg, Sweden stureblomberg@gmail.com
Explanations:
* PEEP (Post End Expiratory Pressure) is a pressure generated from the respirator, which keeps the pressure constantly positive in the lungs after the expiration. The benefit is that the alveoli do not collapse between breaths and the transport of oxygen from the alveoli to the blood capillaries is facilitated at the same time. The drawback is that the blood pressure decreases and the lungs might be injured by longstanding high positive pressure. The PEEP is often measured in centimeters of water. The expression +10 PEEP therefore means the equivalent of 10 centimeters of water column in PEEP. In addition to this constant pressure there is a ”top pressure” generated by the very insufflation of new air during inspiration which results in a higher total pressure, but this total pressure is not displaýed here.
** Septic shock is defined as mental confusion, high respiratory rate, low blood pressure and sometimes but not always high temperature.
*** ARDS, Adult Respiratory Distress Syndrome, is a somewhat obscure, mainly inflammatory condition in the lungs which makes it more difficult for oxygen to diffuse from the alveoli to the pulmonary capillaries. The concept was originally framed in contrast to IRDS (Infant Respiratory Distress Syndrome), which affected premature infants. Nowadays the term ”Acute Respiratory Distress Syndrome” (from 1994) is more commonly used. However, it is the same condition that is denoted.
****P/F-ratio is a measure on how much oxygen can be absorbed by the blood and which oxygen fraction of the air is needed to achieve this. P stands for Pressure and is a measure of the partial pressure of oxygen in the blood. This is normally 100 mmHg. F stands for fraction of oxygen in the air given from the respirator. If 50% oxygen is given this is expressed as the fraction 0,5. Thus, a young, healthy person should have a P/F-ration of 100/0,21 ≈ 400-500. A person with a value of <300 has mild ARDS, <200 moderate ARDS and <100 severe ARDS. .
*****Tracheostomy is a hole in the trachea, which is given to patients who have been intubated more than 7-10 days will have. This simplifies the care, avoids injuries to the vocal cords. When the patient has improved, there is in no need af the tracheostomy any longer, and the tube is withdrawn the wound will heal spontaneously in just a couple of days..
****** PEG, Percutaneous Endoscopic Gastrostomy, means a hole in the skin just above the stomach that involves introducing a feeding tube directly into the stomach through this hole. This was performed in my sister’s case since there was uncertainty whether or not her swallowing reflexes were normal (they were). The tube will be withdrawn later and the holes sutured for healing.
******* Liposomal Vitamin C. The water soluble Vitamin C is surrounded by microscopic fat soluble ”soap bubbles”, whose walls consist of the same lipids as the normal cell wall. This form of administration means that Vitamin C is resorbed in a much higher amount than ordinary water soluble tablets that can be bought in the pharmacy and which are absorbed by the by the body at a quantitative limit of approximately 350 mg/day irregardless of how much an individual drinks or eats. The liposomes pass straight through the cells walls where they then empty their content of Vitamin C directly into the interior of the cells.