Fortunately, I received the COVID-19 vaccine. For most of us eligible for the vaccine right now - healthcare workers seeing coronavirus patients day in and day out - I believe this decision is easy. The benefits far outweigh the risks. I trust the scientists who developed the vaccines and the independent experts who reviewed the data. I trust the colleagues I've talked to, physicians and pharmacists, who agree that the vaccine appears both effective and safe. I am grateful that it is here, and that I was able to receive it.

American health care doesn't prioritize preventive medicine, but preventive medicine is probably the most important thing we can do. Our health depends on a balanced diet, regular exercise, avoidance of smoking, drinking, and drugs, and, indeed, appropriate immunizations. If we prevent ourselves from getting sick, we save ourselves so much grief, pain, disability, and complication. We save the system money and resources. Although our healthcare is designed around treating things when they go wrong, we should put more emphasis on preventing things from going wrong in the first place.

I know we may have stubborn attitudes towards getting vaccinated, but this is important. It is preventive medicine. It is effective at protecting us from coronavirus, and these days, all of us are at risk for getting COVID. With over a hundred thousand Americans hospitalized with it right now and thousands dying daily, avoiding this disease is no small thing. It is certainly worth the mild discomforts associated with the vaccine (and so far, I have not experienced any problems). And though long-term outcomes are unknown, I believe the clear direct benefit outweighs any nebulous concerns that haven't yet come to light. As with everything, there are exceptions, and so those with severe allergies, history of vaccine reactions, pregnancy, or complicated medical histories should discuss with their physician.

I feel relieved after being vaccinated. Working long hours in an intensive care unit filled with COVID patients is stressful. Seeing its devastating effects on young patients is scary. I worry about bringing the virus home or transmitting it to others (though currently, we do not know whether a vaccinated individual can be an asymptomatic carrier). Seeing our communities struggle amid this pandemic is heartbreaking. But after receiving my first dose of the COVID-19 vaccine, I am beginning to see a bit of hope that these stresses, worries, and concerns will not last forever.

What a strange dichotomy, the arrival of a promising vaccine and the deepening crisis of the pandemic. So much hope juxtaposed with so much grief. At the same time health care providers are receiving the first dose of immunity, we are breaking records with the numbers of people infected, hospitalized, and dying. But I think this may signal the turning point of this global disaster.

It will take a lot of time. The rise in cases is still meteoric from Thanksgiving gatherings. Even with shutdown measures, it will take weeks to level off and plateau. And unfortunately, I believe we aren't as adherent to these shelter-at-home directives as we should be. As a result, we're not close to containing this virus, and measures like contact tracing have limited effectiveness. This skyrocketing number of infections has downstream effects on the number of people requiring hospitalization and intensive care, taxing our resources and leading to excess deaths. 

Unfortunately, the effects of the vaccine will take time. Two doses several weeks apart are required, so there will be a delay there, though there is partial immunity after a first dose. Logistically, it will take many months to vaccinate everyone who wants to receive it. Unfortunately, vaccine skeptics, false information, and distrust of the system will hamper our outreach efforts. Even those who may not disbelieve vaccines may be slow to sign up due to worry about side effects or feeling that they don't need it.

While on an individual level, someone may weigh the risks and benefits and elect not to get immunized, at a population level, we need as many people to receive it as soon as possible. The effectiveness of a vaccine at a population level depends on herd immunity, the point at which there are enough vaccinated individuals that it protects non-vaccinated individuals. This requires the majority of a population to have immunity. This also protects individuals who may not be able to get vaccinated for whatever reason. However, herd immunity may be challenging to maintain once our global community opens up. There will inevitably be cross-over between well-immunized populations and poorly-immunized populations which will dilute out the herd immunity effect.

All of this is to say that although I think we are at a turning point, we are not at the peak of the crisis. Things will still get worse before they get better. We will start turning things back, but the momentum of this pandemic is tremendous. As reiterated by our public health agencies, we need to continue masking, distancing, and avoiding risk even as the vaccine rolls out. We cannot get complacent. There is still a long way to go.

Over the past nine months in the Bay Area, we've bounced back and forth between stricter and looser regulations, trying and unable to find an equilibrium. We locked everything down in the spring, watching the East Coast in trepidation. Then in the summer, we navigated changing restrictions when the Midwest became overwhelmed. Up until recently, the Bay Area has avoided disaster. Unfortunately now, disaster is here.

It might feel like the boy who cried wolf. Before this, whenever we got scared, we shut things down, and went more or less unscathed. Now, we cry alarm, but our communities are exhausted, our businesses flailing, and our holiday hopes dashed. We are reluctant to listen to these cries, and now the wolf is real.

I don't think the analogy reflects what exactly happened. We avoided a surge in the spring and summer because we cried wolf. Our shutdown measures made a difference. We weren't giving false alarm. But I worry that with time and repeated calls for caution, fewer take heed.

Now, like the rest of the nation, California and the Bay Area are in a crisis. We reinstituted severe lockdown measures, to criticism from small business owners and struggling communities. I can't imagine how hard it must be to try to run a restaurant, or to worry about when unemployment benefits expire, or to feel trapped in one's home for nine months. There are devastating hardships and consequences from shutting things down. And the benefits may not be immediately appreciated from afar.

This is how bad the health care system has and will become. We are seeing a steep rise in cases. Before Thanksgiving, our COVID patients occupied less than a third of the intensive care unit, nicely sequestered in our COVID-specific "pod." The following week, the numbers surged and we didn't have enough room in our COVID-designated areas. Our engineers scrambled to convert rooms to accommodate COVID patients. A few days ago they made up two thirds of our intensive care patients, and most recently, 80% of them. Our ICU still needs to care for strokes, heart attacks, sepsis, cardiac arrests, overdoses, and all the other life-threatening illnesses that come to our door. We have opened up additional intensive care availability in our post-anesthesia recovery area. We have boarded patients on ventilators in the emergency department as they wait for beds. Every day we are discussing mitigation strategies to make it through that day.

However, beyond beds, our biggest shortage will be staffing. Nearly every shift I have in the intensive care unit, I see the clerk calling nurses at home, seeing if anyone can come in on short notice. When that fails, we ask nurses that are working 12 hour shifts if they can extend to 16 hours. Our intensive care doctors are stretched thin. At the busiest, I am responsible for intensive care patients in three areas of the hospital on three different floors. 

We are experiencing burnout. The physical and emotional stresses of caring for these patients are enormous. Many of them are young. Many of them are dying. Many require heroic interventions and efforts to save them. And working longer hours, more shifts, with busier services, we don't have the bandwidth to process these emotions or even to eat or drink water. This is not sustainable, and yet, we anticipate this surge to last for weeks to months.

Does intensive care make a difference? I think this is an important question, else we are scrambling and stressing for little benefit. It does. We have patients who arrive in extremis, requiring complex coordinated intensive care and life-support who survive when we weren't sure they would. The hospital stays are long and they face an arduous recovery, but we can save lives. Each critically ill coronavirus patient requires weeks of intensive care, dozens of doctors, nurses, and therapists, and a lot of love, care, and support. We have love, care, and support in abundance, but hospital beds and providers will get scarce.

I don't think it is easy to weigh the benefits and consequences of a lockdown. In the spring, a lockdown made sense; businesses did not have the masks, sanitizer, gloves, barriers, guidelines, and education necessary to run safely. I know that a lockdown now, when there is no federal support for businesses, will have drastic and long-lasting consequences. Asking people to isolate during the holidays is not a small thing. Our communities are weary and battered. And a complete shutdown isn't ideal; it's a blunt instrument when perhaps selective restrictions may strike a better balance between protecting the health care system and preserving parts of our lives we can conduct safely. But here we are, and we need to do something.

Because from the ground, from the intensive care unit where I reside, we need all the help we can get, and I'm appreciative of all the sacrifices made to make that happen.

A pregnant woman at term with severe pre-eclampsia presents in labor. She tests positive for COVID during standard screening. She is asymptomatic and does not need any oxygen. However, her pre-eclampsia is concerning; she requires several medications to control her blood pressure, and the fetal heart strip is flat, abnormal. The obstetricians worry that she may eventually need a C-section, though one is not emergently required now. They ask what the optimal plan should be.

How much should a COVID diagnosis change care?

One important goal in any pregnancy is to avoid an emergent "crash" C-section - the kind that involves running to the operating room, inducing anesthesia as quickly as possible, splashing iodine onto the belly, and getting the baby out immediately. These scenarios are uncontrolled, stressful, and chaotic. Occasionally they cannot be avoided, but with early identification, prevention, and planning, they can be kept to a minimum.

In any pre-eclamptic with a concerning fetal heart strip, we need to mitigate risk. But how do we take into account asymptomatic COVID positivity? There are several possible decisions we can make. The most extreme would be scheduling a C-section so we could deliver the baby in a controlled, planned fashion. It would avoid pushing, which may aerosolize the virus. A more moderate approach might be placing an early epidural which can be used for anesthesia in the case of an urgent C-section (though there still may be a small risk of needing general anesthesia).

We know from early COVID studies from China that general anesthesia in a patient with COVID has significant mortality. Intubating a patient with COVID, even if she is young and healthy, puts her at real risk. In addition, emergency COVID surgeries place staff at risk. Although we would ideally be wearing all the necessary protective gear, in the real world, such things don't always happen. I've been in "crash" C sections (pre-COVID) where surgeons didn't have time to put on a surgical cap, a mask, or (once) even shoes (they were asleep when the C-section was called). Expecting perfect PPE adherence in an emergency is unrealistic.

So how much does COVID change things? If the patient were COVID negative, I would recommend an early epidural, but if she declined, I would be amenable. But here, I felt a stronger imperative to explain why an epidural could be life-saving. And if the obstetricians scheduled a C-section, it wouldn't be unreasonable. Like all aspects of medicine, decision-making is a shared responsibility between patients and their providers. I'm learning how to incorporate what we know about COVID into that discussion. Medical decisions should not be unilateral, but the invested parties should think of all the ramifications of this disease including protecting the staff from unnecessary exposure, reducing harm, and keeping the health care system sustainable through this pandemic.