So what is it like in the ICU these days?

In general, our ICU this month reflects the overall trends across the country. We are operating pretty much at capacity for our ICU and hospital, and some of the constraints result from nursing shortages as staff are out due to COVID. Nearly half of our ICU beds are occupied with COVID patients, though most of them do not in fact require ICU level care, reflecting the lower severity of Omicron. However, since our hospital has limited isolation beds on the general wards, when we have a surge of hospitalized COVID patients, they overflow into the ICU. Fortunately, few of our COVID patients are currently intubated and mechanically ventilated. Even fewer are dying, but this does not discount the gravity of each passing. There may be fewer deaths, but each one still exacts a deep emotional toll.

Does it matter if a patient is hospitalized due to COVID or hospitalized for another reason but turn out to be COVID positive? I don't think it makes a huge difference. Staffed isolation beds appear to be the main bottleneck, so any hospitalized COVID positive patient strains our system. 

As we use up ICU rooms for non-ICU patients, our capacity to care for sicker patients becomes limited. We can't take transfers from smaller hospitals, and we have to be more discerning about whether to bring borderline cases into the ICU (as any hospital doctor knows, there's a gray area where a patient does not definitely need intensive care, but may benefit from it). When I was on service last week, we had periods of time when we didn't have a "code bed" to immediately accommodate a cardiac arrest if one happened in the hospital. We worried each day whether we could continue cardiac surgeries since they all require post-operative ICU. These concerns are not a normal state of affairs. 

Although Omicron has peaked in the Bay Area and is starting to recede, hospitalizations lag behind cases, so things are still tight for the time being. Like other hospitals in the area, we have finally started reducing elective surgeries that require overnight stays. We're doing our best to handle the dynamic situation of staff getting sick, recovering, needing to quarantine, and being cleared to return to work. There are a lot of extra logistics happening behind the scenes. 

I said this early on in the pandemic, and I feel it again: I am very grateful and proud of all the hospital staff, health care workers, and day-to-day operations specialists who keep things going. We are all feeling a great deal of physical exhaustion, emotional strain, and burnout these days, but we're in it together. We've weathered it so far, and it will get better.

Well, just on the heels of the last post, this past Monday, the U.S. reported nearly 1.5 million cases of COVID (which again, may include delayed reporting from the weekend). Given that the total U.S. population is 330 million, this translates to almost 0.5% of the population testing positive in one day. Wow.

We talk a lot about the incidence of COVID, the rate of persons who get the disease in a certain time period, but we also have to consider the prevalence of disease, the proportion of persons who have it at a given time. If the incidence of COVID is 700,000 or more a day, the prevalence (how much COVID exists in America right now) is terrifying. It's everywhere. The risk of encountering someone with COVID in any public place is very real.

This problem is out of control. It will run its course, and our current attempts to tamp it down will feel like too little, too late. Right now, we're trying to minimize the damage any way we can. 

There may be many parallels to this disaster, but two spring to mind. In health care, prevention is an investment whose returns may be enormously worthwhile with regard to saving lives, preventing suffering, reducing long-term health effects, minimizing costs, and optimizing health care utilization. Our health care system which prioritizes treatment over prevention is costly, inefficient, and backwards. I believe this is true on an individual level and now, on a societal level. If we had vaccinated more people, encouraged more mask wearing, reduced travel, thought about our gatherings, and increased test availability, we might not be in this position.

The other comparison I think of, which is a complete tangent and not my expertise, is that global warming could follow this trajectory. We may have an opportunity to contain global warming and prevent disastrous consequences, but if we don't do enough early enough, the problem will get away from us, leading to a lot of potentially preventable harm.

The United States reported over 1 million positive COVID cases last Monday. Is this number important?

Well, first, is it accurate? Probably not, but the magnitude is still mindboggling. Because of all the at-home testing which isn't tallied, the number may be an underestimate. But with the holidays, test reporting gets bunched up, and this number likely reflects delayed reporting from the New Year weekend. Smoothing it out by taking the seven-day average is more important. But I like spending a moment on the absolute number just because it's so unbelievable. A million new cases of COVID in one day represents more than double the prior record for any country (India at 400,000) and over three times the previous U.S. peak last January (300,000). The rate of the rise in case numbers suggests we may hit astronomical numbers every day quite soon.

Fortunately, the thin silver lining is that hospitalizations and deaths are not rising at the same rate. Some people have been asking why follow case counts at all. With influenza, we don't meticulously track infections, but we still tally annual deaths. At this stage however, I think case counts still matter. For one, this is a dynamic process, and we don't know where the peak will land. Infections are not completely decoupled from hospitalizations and deaths, and we need to determine the new relationship between them. Even if a smaller percentage of COVID cases are severe, we still need to characterize that percentage. Furthermore, with the sheer numbers, the majority of hospitals are buckling under the strain.

Case numbers also reflect how much illness we may see in the health care workforce. These last two weeks, a staggering number of health care workers have called in sick. This will get worse. When the CDC shortened isolation times in order to allow front-line workers to return to their jobs faster, I understood this idea only on paper. But now, I am seeing it play out. There are bottlenecks in the emergency department and post-anesthesia care units because there aren't enough floor nurses. Wait times for lab collection and results have increased due to staffing shortages. Delays in breathing treatments and X-rays result from how tight our respiratory therapy and radiology technician staffing is. Stress, burnout, and departures from the workforce will get worse. In the earlier phases of the pandemic, we worried about shortages in ventilators or hospital beds; now it is a shortage in the highly skilled and irreplaceable bedside providers that limit our care.

The numbers matter. And they are (again) threatening the collapse of our healthcare system.