As an intensive care physician, I focus primarily on acute COVID pneumonia. My world involves monoclonal antibodies, antivirals, steroids, CT scans, oxygen delivery modalities, intubation, ventilator modes, sedatives and paralytics, life support, and end-of-life conversations. But this is a small sliver of the health impact of COVID-19. I am humbled by how little I know about the myriad manifestations of the disease, and I wanted to write and acknowledge the chronic forms.

In particular, we are seeing patients who had COVID weeks to months ago who now present with life-threatening scarring of the lungs, the so-called fibrotic stage of COVID-19. These patients recovered from their initial acute illness, but they come in with recurrent shortness of breath. Imaging and pathology remind us of pulmonary fibrosis, a rare and devastating condition with few treatments. These patients don't have any active virus and they don't test positive for COVID. Their body has fought off the disease, but at the expense of residual collateral tissue destruction and organ injury. I have seen several patients die from this, including some who were young. To me, this fibrotic stage is very scary and we know very little about it. I am grateful for those scientists and physicians beginning to study it.

Similarly, we don't know enough about "long-haul" COVID, the systemic, functional, and mental debility that some people endure for months after their acute illness. I don't tend to see these patients in my practice, but I believe the impact on their lives to be enormous. Given the number of infections our country has faced in the last few months, I think these chronic COVID symptoms will become another epidemic, the kind our health care system fares poorly at addressing. I really don't know much about it, but I worry "long-haul" COVID will be lumped into a category of diseases physicians find frustrating, baffling, and easy to discount, like fibromyalgia or chronic Lyme disease. I am glad for those patients who have spoken up to describe the brain fog, fatigue, and weakness they experience months after they've recovered from the initial COVID infection. It reminds us how much we don't know and how much we have to learn. We need to bolster our providers, resources, and expertise to address this new chronic condition.

I am cautiously optimistic. Looking at numbers nationwide and within the state, we are seeing improvement in the daily new cases, hospitalizations, and even deaths (which lag behind the other statistics). Within my own hospital, we have felt a reprieve; we are no longer boarding intensive care patients outside the ICU, and we are resuming elective surgeries (which were held due to limited hospital beds). The ICU itself remains busy, but part of that is related to the long convalescence that COVID-19 patients suffer. Overall, I believe we are through the surge from holiday gatherings. It has been a long three months, and we are grateful for a little breathing room. I also want to believe it marks the worst of the pandemic, and we are on the long journey to recovery. There is a palpable sense of optimism, hope, and relief at work and in daily life.

However, I provide a cautionary thought. Though things are improving, many people are still getting ill and dying. The worst may be over, but it doesn't mean things are good yet. Our absolute numbers are still as high as they were in the fall. Which means that we must remain vigilant. We must act to prevent further surges, especially as variants circulate in the community. We cannot abandon our precautions; that things are getting better only validates that our behavioral interventions work. This pandemic has an unbelievable mass and momentum; we've slowed it down and started to turn it around, but we still need a lot more work and force to get it under control.

Can we do it? I think so. I recently read an article that described the remarkable achievement of the NBA to stage playoffs last fall without any COVID-19 infections. Of course, this bubble required an exorbitant sum of money, but it demonstrated that detailed protocols, adherence, and resources can allow us to resume even close-contact team sports safely. Perhaps with the vaccine, the need for "bubbles" will decline, but there's a lot we can learn from the NBA experience: how to get buy-in from stakeholders, the mental health impact of months-long "bubbling," and the real gains in reducing infections in a high risk environment. I know some schools and workplaces have implemented or are considering protocols to minimize the health impact of resuming business as usual. Many are doing it successfully, with lower test positivity rates than the broader community. We look toward these examples as we reimagine how to structure our businesses, social lives, and communities.

In medicine we often see an attitude of invincibility among younger people. Early in this pandemic, this message was reinforced; the biggest risk factor is age, and young people aren't at high risk for dying. Statistically, this is true; only a small percentage of COVID positive people under 60 require hospitalization and only a minority of them go on to require intensive care or a ventilator. 

Unfortunately, when the number of infections is astronomical, there will be young people who die from this disease. They are the ones who affect us emotionally the most. We don't see many diseases that will incapacitate and kill 30 and 40 year olds. Sometimes trauma, acetaminophen overdose, or drug related complications can do it. But by and large, I don't see many infections that cause the severity and extent of damage seen in COVID.

The youngest patient I've admitted to the ICU with COVID was in his early 20s. The youngest I put on a ventilator was in her late 20s. We have 30 and 40 year olds who have been on a breathing machine for nearly a month. The maneuvers we do for life-threatening respiratory failure - paralysis and prone-positioning - aren't meant to be done for weeks on end, and there are complications. After patients pull through with these heroic interventions, they deal with tracheostomies, loss of muscle mass, cognitive impairment, bed sores, and debilitating weakness. They have to work with therapists to learn to walk again. Their lives will be changed forever, but they have their lives, and we count that as a meager win.

Because other patients who on paper look similar don't make it. Despite all our therapies - dexamethasone, remdesivir, monoclonal antibodies - their lungs get worse and worse. I remember meeting someone who was texting a twin because both tested positive for COVID. He was in the emergency department then, and we were using BIPAP to support his oxygen needs. Over the following weeks, his twin got better and was discharged from another hospital, while this patient needed escalating oxygen modalities. Gasping for air, he finally needed a breathing tube, a mechanical ventilator, and paralysis. He died from COVID, and he was in his 40s. I really cannot think of any other disease this devastating.

I'm curious and worried about the coronavirus mutations and variants. Viral mutations are common, and with the sheer number of infected individuals in the world right now, they're inevitable. The vast majority of mutations do very little, but the few strains we're seeing could pose a significant danger. I'm most worried about strains like the UK and South African strains (N501Y and B.1.351) which may have increased infectivity. Increased spread translates into a much higher mortality than one would assume. One might think a mutation causing 50% increased lethality is worse than one causing 50% increased infectivity, but modeling studies show that increased infectivity and the exponential spread of virus translates into a much higher death rate at the population level. Furthermore, increased spread means control of the virus and herd immunity will be more elusive. 

This is echoed by reports that the Brazilian strain B.1.1.248 may evade neutralizing antibodies. Since our vaccine targets the unique spike protein of COVID-19, mutations in this spike protein may mean our immune systems may not recognize the pathogen. If this happens to be the case, our ~95% vaccine effectiveness may be attenuated. But I think a lot remains to be studied and understood.

Although these mutations and variants are disappointing in the outlook for the pandemic, I think it will be the new reality. Pandemics are not static entities, and we must adapt as the virus adapts. I have so much gratitude and appreciation for those tireless scientists working to understand and predict the course of this pandemic. As a clinician, I realize the importance and the challenge of understanding the basic virology going on here. It's not my area of expertise, and I depend so much on the researchers studying it.

We're seeing a lot less influenza this year. Usually the winter months in the ICU are marked by at least a couple patients with severe pneumonia from the flu, but this year is very different. I don't think I've seen even a single patient with flu needing a ventilator these last few months. I think this shows masking, distancing, washing hands, and other behavioral changes make a significant difference in the transmission of flu. It also shows that comparatively, COVID is more contagious and more resistant to our social interventions. In the end, it is a relief that our hospitals are not inundated with both influenza and COVID-19 at the same time. We were worried that a dual surge in viral pneumonias may worsen our capacity crisis and confound diagnosis and treatment.