A 22 year old who tested positive for COVID several weeks earlier presents to the hospital with severe shortness of breath. When he was initially diagnosed, he had mild symptoms and quarantined at home. So it was strange for him to come in a month later with severe symptoms. In the emergency department, he was assumed to have COVID and started on standard treatment. But when I examined him, I felt that I was missing something. He looked to me to be in heart failure, the type of presentation we see in someone with multiple heart attacks. His X-ray didn't look like typical COVID but rather pulmonary edema, fluid accumulation as a result of an ineffective heart. I looked at his heart with an ultrasound and it was not beating as strongly as I expected. I also noted a rash and abdominal symptoms.

I had a suspicion, though I had never seen this disease before. I called our infectious disease consultants, and we agreed, this was the pediatric manifestation of COVID-19, called multisystem inflammatory syndrome (MIS-A for adults). At the time (this was many months ago), there were fewer than a hundred adult cases published in the literature.

Fortunately he recovered. But his course was prolonged; we even referred him for possible heart transplant. It turns out, his shortness of breath was entirely due to pulmonary edema and not COVID at all. COVID seemed to be targeting all his other organs instead.

At the beginning of the pandemic, we thought children were spared severe disease from coronavirus. It seems that though they get sick less frequently, manifestations like MIS-C can be devastating. It was a fascinating experience seeing an adult present with a predominantly pediatric disease; other than some genetic disorders I don't think of pediatric medicine much at all. It engaged a lot of diagnostic skills I haven't used in this pandemic and reminded me to stay sharp when patients present in unusual ways. I am glad I keep up with new findings, reports, and studies of this unbelievably strange, multifaceted, and deadly disease.

One final post on a hodgepodge of vaccine topics.

The current most common COVID-19 vaccines, made by Pfizer and Moderna, require two doses. The booster shot occurs about 3-4 weeks after the initial dose and is necessary to achieve ~95% protection to the virus. Initially, the plan was to distribute half the doses and to keep the other half for the second shot about a month later. Now, several governments and prominent scientists have suggested releasing all the available vaccine immediately so that more people can receive a shot.

I greatly trust and respect some of the voices advocating this second approach. Normally, I would be a stickler for the rules and give the vaccine as it was studied in the trials. Notably, the second method - releasing all the doses - doesn't preclude that; if manufacturing and procurement keep up, we could be able to supply everyone with the second dose by the time a month rolls by.

Although we only have good study data for two doses several weeks apart, in a crisis, we need to think creatively about whether other approaches can achieve better outcomes faster. I don't think answers are clear. We don't know how much partial immunity one gets from just one dose. And we worry that if someone doesn't receive the booster shot, the effectiveness of the vaccine will wane. But I do think a current priority needs to be vaccinating more people faster. Viral spread is exponential, and its prevalence is incredibly high in some communities right now. We need to engage all our tools to slow its spread. If modeling studies show releasing all the doses will tamp down viral spread, then it's worthwhile to entertain. But we still must attempt to get everyone their booster at the appropriate time.

I worry about the ability for developing countries to vaccinate populations at scale. Health care systems need to ensure follow-up for those who need two doses. Robust infrastructure is required to manage the storage conditions of mRNA vaccines. Fortunately, there are some vaccine candidates in the pipeline that may not have such challenging requirements; thus we need to keep pursuing COVID-19 vaccine research. We must not leave developing nations behind.

Lastly, I am pleased to see that the guidelines for vaccine prioritization cover all staff who work with patients and infectious materials. In this blog, I talk a lot about physicians, nurses, and respiratory therapists, but I would be remiss if I did not acknowledge all the other team members who make the delivery of care possible. I worry about the technicians who take X-rays of our COVID patients, the therapist who assesses how they swallow, our housekeeping staff that sanitizes the rooms, and the laboratory technicians who process COVID specimens. They are essential members. They absolutely need to be protected. 

Widespread vaccination will be a huge undertaking that will take a while. Until then, we must remember that even if we are vaccinated, we need to continue all the social distancing, masking, hand-washing, and other interventions that help us reduce transmission. 95% effectiveness is wonderful, but not perfect. We also have many unanswered questions like whether vaccinated individuals can be asymptomatic carriers. We cannot let our guard down until this pandemic is fully under control. I worry whether we can reach herd immunity with significant numbers of people declining the vaccine, but I believe that education and time can help improve our numbers. I think that reaching herd immunity will be the most effective way of reducing COVID-19 deaths long term and resuming our pre-pandemic lifestyles.

It is impossible to write about the pandemic without commenting on our government response, but I try to avoid overtly political matters. I think they are important, but that's not what this blog is about. I also live in a very liberal, and in many ways, privileged segment of this country, and my perspective is shaded by those influences. Nevertheless, seeing the shocking events unfold at the Capitol on January 6, I felt that our democracy was under attack. There is no justification for such domestic terrorism.

I have been meaning to write a blog about how political views, "false news," "alternative facts," conspiracy theories, social media, and misinformation have worsened this pandemic. In the last five years, I have noticed a crescendo in the fervor, vitriol, and extremism in the political views of our society. There has also been a breakdown in healthy dialogue between competing opinions. 

I was a philosophy major in college, and I spent a lot of my time learning about logic, arguments, and rhetoric. I really do believe healthy debate can and should happen. It moderates our views, gives us insight on our own beliefs, and persuades others. It is also an important part of democracy. 

I have watched arguments about coronavirus and the vaccine play out over social media, and it has been eye-opening. It seems like we cannot agree on the facts or premises of the arguments. Conspiracy theories, "alternative facts," and "fake news" undermine our ability to agree on the simplest things: what sources we can trust and how to determine what is actually real. 

Furthermore, social media has acted as an echo chamber so that conspiracy theories, "alternative facts," and "fake news" become amplified. Those who subscribe to this hear it repeated on their feeds and become more entrenched in those beliefs. As our society diverges on what can be accepted as truth, we become more polarized with diminishing hopes of finding common ground. This is a problem politically as shown by the events several days ago, but also affects our ability to talk about and respond to the pandemic.

How can we address coronavirus if some people believe it is a hoax or even that it is caused by 5G wireless networks? Where do we start if misinformation has become so prevalent that basic scientific and medical facts are ignored? For example, a simple understanding of biology refutes the idea that an mRNA vaccine could alter DNA. A first year medical student understands what vaccines can infect someone with live virus and why. The COVID vaccines out there do neither. But I hear this echoed repeatedly. We must be able to accept some basic premises to start a conversation.

And we ought to have a conversation. Different political persuasions have differing opinions on how to balance businesses and public health, the pros and cons of drawing debt to provide economic relief, and the types of restrictions we can enact to reduce spread of disease. These are important and meaty topics that ensure our response to the pandemic is democratic and incorporates the voices of diverse stakeholders.

All this to say our fractured systems of belief concern me. It's hard to imagine a functioning society if we cannot have rational discourse. In an uneventful world, we may not notice that we exist in a bubble. But in times of political or public health stress, these divisions in our society become evident and hamstring our ability to work things out.

I've been thinking about vaccine distribution lately. In a worldwide pandemic with multiple competing interests, the best way to vaccinate isn't entirely obvious. What we're seeing now in the United States with a haphazard and slow rollout is a failure of planning. We spent so many resources on developing this vaccine yet little on distribution and actualizing the immunizations. 

At the most basic level, vaccines need to be given. We may debate about who gets priority and how to do it, but more doses need to be given, and soon. The pandemic is a raging fire, and we need to sap the fuel. Those logistics are not easy. In our fractured health care system with many providers, insurers, and systems, capturing everyone is going to be a nightmare. We need strong leadership and foresight to tackle that problem.

But even from a more theoretical standpoint, we should define our goals for vaccination. I think three important but competing goals are: (1) preventing unnecessary deaths, (2) getting the pandemic under control, and (3) maintaining our health care system. Strangely enough, these goals can be at odds with each other.

In the short term, to prevent unnecessary deaths, we ought to vaccinate those for whom contracting the disease could be fatal. Here we would immunize high-risk people, the elderly, those living in nursing homes, and those with medical comorbidities. Each person vaccinated could be a potential life saved.

Yet, to prevent deaths in the long term, we need to get the crisis under control faster. To stop spread effectively, we could immunize those who are likely superspreaders. One of my friends suggested that we stand outside bars and vaccinate everyone who comes out. Although this was said in jest, it's not a bad idea. There are modeling studies that show if you immunize the most likely spreaders in a population, you can get herd immunity quicker. In one such model, researchers asked college students who their most popular friend was and gave that person a flu shot. They found less community spread of flu with that plan compared to vaccinating a random sample of students.

Realistically, that type of plan wouldn't pan out. These days, we struggle to enforce mask wearing and social distancing. If we started vaccinating those who didn't follow the rules, there would be backlash. Even worse, people might stop following guidelines in order to get immunized.

But ultimately, our current vaccination scheme prioritizes one other important goal: the preservation of our health care system. First responders, nurses, respiratory therapists, physicians, hospital workers, and nursing home staff are at high risk for exposure. As our health care system reaches and exceeds capacity, risks to health care workers increase. This makes us vulnerable to a catastrophic spiral: our health care workers fall ill and can no longer work, our hospital system becomes even more strained, remaining staff are exposed to more risk, and more workers contract COVID. If our health care falls apart, we will have unnecessary deaths both from COVID and non-COVID causes.

Of course, as an intensive care physician, I am biased regarding vaccine prioritization. In general, health care workers are not at the highest risk for dying if they get COVID. Vaccinating me may not prevent me from dying. But if it prevents me from falling ill and quarantining for two weeks, that may translate into lives saved. I think the initial goal of protecting health care workers and nursing home residents makes a lot of sense.

Who do we vaccinate next? I don't know. I turn to the experts who can outline our objectives and weigh the risks and benefits. I see arguments for vaccinating other front-line workers, the elderly, those with comorbidities, and pockets of society with rapid spread. I'm not sure about the best approach. But I do think we should not let other factors, namely wealth, affect our vaccinations. In the last few months, I've had several instances of wealthy families trying to use their resources to get specific care. This is ethically indefensible. COVID vaccinations are in short supply. Taking them away from those who need it may mean the difference between life and death or another outbreak or a hospital forced to ration care. I hope our government and health policy experts are working on improving our vaccination plan.

Never in modern history has there been so much hope, fear, optimism, and sorrow tied to the turning of the year. This global pandemic, which began over a year ago and since visited every continent, has upturned our society to an unimaginable degree. It has taken an unimaginable number of lives. It will leave scars in our personal lives, our communities, and our collective histories. This New Year's I take a moment in memory of those who have died from this pandemic. 

When September 11 happened nearly twenty years ago, I struggled to put into words the enormity of such tragedy. I actually wrote every year about it for a decade. Disaster leaves deep impressions. Right now, we are losing more people each day than died on September 11. The numbers, statistics, and scope of what is happening - what has been happening - far exceeds my capacity to comprehend and make sense of it. For me, writing and reflection are ways of trying to, of coping.

Right now, working in the intensive care unit in the Bay Area, I am seeing a situation I have never before witnessed. Even though it is less severe than Italy, New York, or Southern California, and even though I had prepared myself for it, it is unbelievable. Never have I seen such immense strain on our medical system, and never have I seen such true heroism, sacrifice, compassion, and dedication from the caregivers I work with. 

There are so many aspects to this disease, the pandemic, and how our lives have changed, and I strive to capture them in this blog. This New Year's, I spend a little time contemplating the medical complexity of the disease, the miracle of such speedy vaccine development, and the humility of how much we still don't know. I think of the individual patients I have cared for, the stress and anxieties of the procedures I've had to do, the heartbreak in the families I've had to call. I think of our successes, the patients who have survived despite all odds. I think of our losses, the death certificates I've had to sign. I think of the comraderie I have with our critical care team, the nurses and respiratory therapists who work side-by-side with me every day, and the extended support team that make my job manageable. I think of our public health system, of those policies that have helped and hindered, of the work yet to be done at a local, national, and global level. I think of the sacrifices made by our families, communities, and businesses for this pandemic, of the postponed hopes and dreams, of the irrevocably changed way of life. I think of the Before Times.

In some ways, today is a day like any other in this pandemic. But I do think, for me at least, there is some value in recognizing even arbitrary occasions. 2020 is over. We look ahead to 2021. Without doubt, the first few months will remain a crisis. But I want it to be the beginning of a new hope, that equipped with a vaccine and renewed resolve, we will again flatten the curve, find a plateau, and rein this disease in. Our communities will adapt, remain creative, and thrive in ways we did not anticipate. We will mourn and cope and nurture and grow. We are facing a global challenge unlike any other in modern history. We did not get it under control in 2020. But I am optimistic that this year we can and will do better, finding humanity, hope, and a new future emerging from the darkest of times.