Although most of this blog is written from my experiences as an intensive care physician, my other professional hat is that of an anesthesiologist. A young, perfectly healthy man comes in for an orthopedic procedure. The only remarkable medical history is that he had COVID two months previously. He was minimally symptomatic with just a few days of fever, cough, and weakness. He never required any medical attention.

We delayed his orthopedic procedure for several weeks and then deemed it safe to proceed according to public health guidelines. When I met him he hadn't had any symptoms for over a month. His particular surgery required general anesthesia (that is, it could not be done with regional nerve blocks or other techniques). Under anesthesia, I noted that his oxygen levels were safe but lower than expected.

Specifically, even on 100% pure oxygen and a little extra pressure ("PEEP"), I couldn't get his saturation to read higher than 94% on a finger probe. While 94% is perfectly safe, this is highly unexpected. A healthy adult should easily have 100% oxygen saturation in this situation. (Of course, those of us who work with medical monitors know the limitations of our devices; ideally, I would have gotten an arterial blood gas, but I did not).

Nevertheless, this case raised some questions for me. Can even minor COVID infection cause lasting pulmonary injury or susceptibility? Perhaps the impact wouldn't be noticed on a day-to-day basis, but it might become apparent when someone undergoes the stress of surgery and general anesthesia where physiological parameters are measured constantly. About a year ago at the beginning of the pandemic, a case series out of China alerted us that general anesthesia in patients with active COVID had a substantial mortality. I am unaware of any findings for general anesthesia in patients with recovered COVID, but perhaps this should be an area of research and might shine a light on chronic complications of this strange disease.

We spent most of the last year yearning for when life can return to normal. Now that it's within reach, we struggle with our own levels of comfort. In the last post, I speculated about opening up businesses and communities, but it's also interesting to think about opening ourselves up to a post-vaccine world. We've become so accustomed to keeping our distance, avoiding crowds, and curtailing our social activities that it's not so psychologically simple to return to our old lives. Although it is now permitted and reasonable to invite vaccinated friends over, I feel a little anxiety and weirdness about it even as I'm experiencing an overwhelming need to reclaim more social interaction.

Such ambivalence is human nature. Our emotional responses and our rational judgment rarely align perfectly. After recalibrating ourselves for a year, I'm certain it will take us time to decide individually what our comfort levels and boundaries will be. I read an article that this past year of pandemic is an experience of trauma. We have all been affected by this disease. Even if we and our closest circles have not been infected by COVID, our emotional, social, familial, cultural, professional and economic selves have certainly been impacted. Our cultural memory is both long and short, but right now, as we are still grieving, despairing, hoping, and anticipating, the trauma is fresh in our minds and our hearts.

So I acknowledge how I feel. I am grateful for the vaccine, I believe in immunology, and I know that suddenly the risk calculus of social engagement has changed. At the same time, I recognize that coronavirus still scares me, that my feelings of apprehension around strangers are okay, and that I'm not ready to get on a plane or attend anything more than a modest gathering. I know some of my worries are irrational. I give them space, then give them science. I believe things will continue to get better and I will at the same time recalibrate myself and my boundaries. And I will support my friends, family, and community as we all heal from this immense trauma, acknowledging that we will open ourselves up to a post-vaccine world at different rates and in different ways. 

How do we open our society, economy, and businesses up again? I think I wrote a similar post in the summer of last year. Currently we are seeing various counties and states loosening restrictions at different paces, so it's an important question to consider. We need a slow, deliberate, and individualized approach. I worry that a scattershot, uncoordinated, or rapid reopening will cause harm in the long term.

All the same considerations as before apply. We need to protect our health care resources from being overwhelmed. Our public health departments need to be able to contact trace effectively. Our businesses must operate responsibly. And we need to prevent superspreader events. This is all balanced against the importance of protecting jobs, giving our emotional and mental selves a break, addressing the educational needs of our children, and finding a new normal.

There are a few lessons that we've learned the hard way. First, communities must move slowly. The time lag between viral exposure to intensive care admission can be significant. When rules are relaxed, we won't see the impact on hospitalizations and health care utilization for weeks. After making a change, we need to be patient to see where our case numbers end up before making the next change. As an anesthesiologist, I find this akin to managing a medication with a long half-life. For example, fentanyl patches and methadone cannot be titrated rapidly or we will overshoot the effect. Slow, measured changes are the way to go.

Secondly, we now have to consider variants. Variants that increase spread will make modeling and prediction a lot more difficult. I would caution us to err on the side of moving gingerly. We don't want to overextend and run out of hospital beds, nurses, oxygen, and resources again. Furthermore, variants arise more readily when more people are infected since they occur with viral replication. Keeping the numbers down may thus prevent even more dangerous, worrisome, or serious mutations from happening.

All this is balanced against our ability to vaccinate our population. From a purely pandemic management standpoint, we would ideally achieve herd immunity before reopening, though of course this is not practical. But I think it can guide our public health efforts. Should we vaccinate teachers before opening schools? I think so, though there are a lot of stakeholders in that question. It is near impossible to weigh public health against individual health considerations, educational quality, and jobs. But it is more the reason to vaccinate professions like these as soon as we can.

Finally, as we open up, we need to think specifically about minorities. The disproportionate impact on minorities is something we cannot ignore. Minority groups, especially African Americans and Hispanics (at least in California), have significantly higher infection rates and poorer outcomes from COVID. Minorities also make up many of the service industries that have shed jobs during the last year. They are also less likely to get vaccinated. The impact from health and economic standpoints is enormous, and as we look to open up our communities and economy, we need to mitigate these racial, ethnic, educational, and socioeconomic disparities.

On a related topic to the previous post, I think we need to address the simultaneous mental health epidemic happening as a consequence of COVID. Even at the start of the crisis a year ago, I saw worrisome increases in mental health and substance abuse problems. In the intensive care unit, we had a noticeable spike in patients with intentional overdoses, severe alcohol withdrawal, and methamphetamine-related complications. A former alcoholic told me that he had been sober for nearly two decades but fell of the wagon when sheltering-in-place happened. I remember talking to a patient who was quarantined in a hotel with COVID who was still able to get contactless drop-off of meth. I have talked to poison control more times last year than ever before for overdoses of different prescription medications. These stories stay with me. They remind me the pandemic has put intense stress and pressure on those struggling with their psychiatric illnesses.

I worry that we will also see new diagnoses of depression, anxiety, and other psychiatric conditions. After being stuck at home for the majority of the past year, most of us are feeling stir-crazy. When we go out, we may have unconscious anxiety about those around us who are getting too close or neglecting to wear a mask. Our sleep is disrupted. Our diets are affected. There is no question that all of us are at some risk for a mental health disorder. I think this will be a coming epidemic, one our understaffed and underresourced mental health system won't be able to manage. 

Lastly, I am worried about provider burnout. We have all felt it, working in the intensive care unit. During a crisis, we burn adrenaline, pushing ourselves through the exhausting hours and long weeks. But as this saga stretched out over months with surges and lulls, we find ourselves spent. For many of the nurses and staff, the work is physically exhausting. During the last three months, many providers averaged sixty to seventy hours a week. We have deferred our vacation and time off. And then there are the stresses in domestic life: home schooling, elderly parents, doomscrolling, political turmoil, isolation. Our emotional and mental reserves haven't had a break in a year. I know a few people who have retired or quit, and I know many, many more who are contemplating it. Burnout is a real phenomenon, and if we are not careful, we will see an exodus of providers, a wave of mental health consequences, and a loss of the satisfaction we find in our jobs.

All this to say that we should be proactive and bolster our public health and mental health safety nets now. We were caught off guard when the COVID-19 pandemic first hit, and we've been playing catch up since. But now we can anticipate the coming medical and psychiatric fallout from this past year, and preparing for it will pay off in the long run.