I'm starting to understand more about the psychology of care in COVID. Although the news reports of ICU bed crises, staffing shortages, and burnout might sound like deja vu, I think the psychology is fundamentally different this time around. Some of what we're feeling as medical professionals struggling with the tide of critically ill COVID patients is that this surge could have been mitigated. That much of the death, disability, suffering, and turmoil was not predetermined. We could have done better, and we should have. With more vaccinations, more masking, more distancing, we could have prevented unnecessary infections, hospitalizations, deaths. We also would have buffered our health care system from the undue stress it's facing.

When someone is diagnosed with lung cancer, should it matter if he smoked a pack a day for fifty years or if he was a lifelong nonsmoker? I don't know. As medical professionals, we strive to be nonjudgmental, to rein in bias, to treat each individual with the dignity he or she deserves. But the truth is, I am more emotionally affected by the nonsmoker. This, perhaps, is a very human reaction.

I have read articles that we are losing our empathy for unvaccinated people dying of COVID. The numbing, the depersonalization, the emotional exhaustion are all hallmarks for burnout. And though I try very hard not to consciously behave differently toward an unvaccinated versus a vaccinated individual with COVID, I am certain there is some unconscious bias. Deep down, I feel that it did not have to be this way. 

I've worked in intensive care for six years now, and it has not gotten much easier to watch people die. These past few weeks, however, it has gotten much harder, knowing that if they had gotten a shot, or if those in their communities had gotten a shot, I would not be here bearing witness. I used to think I had nothing but love, compassion, empathy, and sympathy for my dying patients and their families. But the truth is, along with those feelings, I am also sad, upset, angry, lonely, frustrated, and exhausted.

I have met unvaccinated patients with COVID who did not trust the vaccine. Once they had the diagnosis, they tried a panoply of remedies, almost all of which have less evidence and more harm than the vaccine. They get admitted to the ICU and ask for any therapy I can offer, though these are generally less beneficial and more harmful than the vaccine. They want everything done. I do not blame them; they are sick, scared, and suffering.

We do not offer liver transplants to patients with alcoholic cirrhosis who continue to drink. Should society offer lung transplants to those who were eligible and encouraged to get the vaccine but refused?

I don't like that I feel this way. And I still truly experience and express a great deal of sympathy, compassion, and care for the patients who are admitted to my intensive care unit. But I felt it important to write a blog about how this phase of the pandemic is changing the psychology of health care workers. Thankfully, there are resources for us to build resilience and cope with these feelings. But ideally our families, friends, neighbors, and communities will make the right choices to help reduce preventable COVID infections.

The demographics of this "fourth surge," at least at my hospital, are striking. Several weeks ago, we began seeing a rise in unvaccinated people hospitalized with moderate to severe COVID. Talking to those patients and their families was quite compelling; we heard over and over again that people regretted not getting the vaccine (though there was a minority who remained in denial). These testimonies were powerful, and I hope they get amplified in news articles and interviews to encourage continued vaccinations. At the time, about a month ago, no fully vaccinated people needed intensive care. 

Unfortunately, that has changed. We have seen an uptick in fully vaccinated people admitted to the ICU with coronavirus. Noticeably, so far these patients all have suppressed immune systems from cancer, chemotherapy, or transplants. Medically, this is devastating because these patients have worse clinical outcomes with COVID pneumonia. But it's also emotionally devastating because these patients often did everything they could to avoid illness: getting vaccinated when it was immediately available, sheltering in place far longer than everyone else, reading and educating themselves about COVID and their other medical conditions. I think the new recommendation for people with immunosuppressed states to get a vaccine booster is very timely.

I know we are tired, and this "fourth surge" feels like a big step back after several months reprieve. But what we're seeing at the front lines is undeniable and alarming. We must increase our vaccination rates, protect those who are immunosuppressed, and reinstate behavioral measures to tamp down infections.

Obviously, my posts have become more sparse in the last few months, reflecting the reprieve we have had with COVID-19 in the spring and early summer. For a while, I contemplated closing this blog down in hopes that the worst had past. But I think I knew we were not out of the woods yet, and the Delta variant is confirming that unfortunate reality. After significant time without any hospitalized COVID-19 patients, our hospital has started to see an influx and has brought back status updates and contingency planning. 

I do not think most of us who have been seeing and treating patients during the pandemic are that surprised. I view this pandemic akin to an arms race. While we are administering vaccines, stockpiling PPE, and developing treatments, the virus itself is replicating, mutating, and adapting. Evolutionary pressure is extraordinarily strong and as I have alluded to in previous posts, the sheer number of viral particles out there means mutations will arise that increase infectivity, worsen severity, and evade our vaccines and therapies.

Furthermore, there's been a lapse in the social behaviors that protected our communities for so long. Indeed, simply being out in everyday life, I have seen a dramatic difference in our social distancing, indoor densities, and geographic mobility. I'm not sure if this was necessarily wrong, per se, because at the time, we weighed the risks and benefits to determine guidelines. But it seems we have run out of borrowed time. We need to adopt those risk-reduction behaviors again.

The crux of the issue is this. In medicine, we weigh each clinical decision by assessing its risks and benefits. The calculus changed significantly with vaccination, reducing individual and societal risk, allowing us to do more safely. But the Delta variant has reframed that risk-benefit analysis. The infectivity (R-naught) of this mutation is significantly higher, and comparisons have been made with chickenpox.

I believe we may be able to take a lesson from chickenpox. Like nearly everyone else my generation, I got the chickenpox in elementary school where it spread like wildfire. However, medical students today hardly see chickenpox at all because of a very effective vaccine developed in the 1990s. Even if a virus has a highly contagious R-naught value, we can tamp down outbreaks with widespread community immunity. 

There's a lot to say about the Delta variant. But what we know is that the vaccine is effective in reducing severe disease, hospitalization, and death, and we need to take advantage of that now. 97% of hospitalized COVID-19 patients are unvaccinated. The higher infectivity is ravaging unprotected communities. This wave is already here, and we need to act now. The best long-term tool we have is vaccination, but that will take time; we're already behind the ball because infections, hospitalizations, and deaths lag weeks behind exposures, and full immunity takes weeks to a month after a shot. Meanwhile, we need to mitigate spread with behavioral interventions.

The CDC has gotten criticism over these recent changes. Some say they liberalized their mask recommendations too early; others think this step back is premature; news reports find it confusing. From my perspective, it makes sense and feels necessary. At each point in time, we are weighing risks and benefits of each guideline, and they will change as the virus changes. If anything, the ups and downs of the past sixteen months argue that this may be the norm. So disappointing as it is, it's time to mask up and hunker down again to weather the storm.