I recently listened to a talk on viral biology and COVID, and I learned so much. This is illuminating for several reasons. Although I see, treat, and think about COVID a lot, there are always opportunities for ongoing learning. I'm quite comfortable with the clinical aspects of treating hospitalized and critically ill COVID patients. But understanding viral biology - its structure, where mutations happen, how it compares to other coronaviruses, the enzymes it uses - gave me insight on why clinical COVID behaves the way it does. For example, now I have a better sense of why the incubation period can be several days, how the Delta variant mechanistically increases transmissibility, and where the evidence that vaccinated patients who get infected shed less virus comes from. None of these may change my day-to-day clinical practice per se, but I still think they are valuable to know.

It also reminds me of how much burnout affects clinicians. Early in the pandemic, I was able to find the time, energy, and focus to keep up with the plethora of COVID-related articles, lectures, and updates. But one of the consequences of extended burnout is that this becomes harder and harder. We keep up with what's necessary to take care of our patients, but burnout makes it harder to follow information that is not directly relevant. Of course, at the same time, the amount of COVID research has exploded so it may be impossible for anyone to keep up with everything. I greatly appreciate those who are able to curate the research, data, and relevant articles for me to study.

Lastly, this talk showed me how much incredible work has gone into understanding COVID. Researchers and scientists from institutions around the world have done an incredible amount of work in a compressed time. The money, effort, time, and brilliant minds dedicated to this have been fruitful. But we also see how much more we have yet to learn about this pathogen that did not exist two years ago. Many questions still remain that may help us develop novel therapeutics and plan for future epidemics.

I fear we have failed in understanding human psychology, motivation, and decision-making. The science of the COVID-19 vaccines is clear; vaccination is safe, effective, and our current best strategy against this pandemic. Yet nearly half of the United States still has not been fully vaccinated.  

How do we improve these numbers? We have tried many different methods including making vaccination free, bringing vaccines to people's homes, education, outreach from community leaders, incentives, and mandates. Even private businesses have tried to encourage vaccinations with free rideshares to vaccination sites, incentives, discounts, and requiring proof of immunization. Finally, the vaccine received full FDA approval instead of emergency use authorization.

Yet we are still far from widespread vaccination. Finally, the federal government announced the most encompassing mandate yet, potentially requiring millions of Americans to be vaccinated and holding large companies responsible for vaccinating their employees.

Is this the right decision? I don't know. Absolutely we need more people vaccinated. But we also need cohesion rather than division. During this pandemic, other mandates involving masks, businesses, and travel have not come across very well. I worry this new mandate will further polarize the country. Nobody, including myself, wants to be told what to do, even if it is clearly the right decision. I believe although more people will get vaccinated, the minority that has pushed back against rules during this pandemic will become more adamant.

Have we exhausted all our options? What else can we do? I don't know. We need to tap into expertise in human psychology and behavior. How do we help people make informed decisions based on fact and science, hopefully leading to vaccination? How do we lower barriers to getting a dose? How do we connect with those of different social or cultural backgrounds? What kind of incentives work best? Is there an alternative to forcing people to do something they have not yet accepted? Can we divorce policy decisions in the pandemic from politics?

Unfortunately, the severity of the Delta wave happened because we failed at widespread vaccination despite various carrots and sticks. This mandate feels like a last desperate attempt to tamp down numbers that have gotten out of control. But it is not without consequence, and I think we must also employ other ways of helping people understand the remarkable benefits of immunization to themselves, their families, and their communities.

Is Delta variant COVID clinically different from the "original" strain? This is not so easy of a question for me to answer. As a bedside physician, I see each patient as an individual microcosm with his or her own risk factors, physiology, and clinical course. It's hard to get a big picture of how COVID now compares with COVID before. Nevertheless, looking at news reports and nationwide statistics, I suspect that the Delta strain acts differently than the original coronavirus. Never before have we worried about pediatric intensive care units filling up. And though some of it may be explained by more infections from schools and daycares compared to last year, I worry that COVID has adapted to infect younger patients. This is frightening, especially since we are not yet vaccinating children, and we've already seen outbreaks originating in classrooms.

Similarly, I think the increase in younger adults hospitalized with COVID suggests this Delta variant really is more severe. Although locally, we haven't seen a significant increase in deaths, this is most likely related to our own improvements in hospital protocols, treatment regimens, and clinical care. While we scramble to improve our medical therapies and systems, the virus is mutating to increase its virulence and lethality. Unfortunately, I suspect this parallel escalation will continue.

This is worrisome. There aren't that many diseases which have gotten dramatically worse over time, especially in the short time frame of a year and a half. It makes me think of HIV and its rapidly developing resistance to antiviral medications or maybe the obesity epidemic which has escalated in the last few decades. But there are few comparisons, and this suggests to me that we need new frameworks to think of this disease's danger, not only in the current moment, but also in its unknown potential in the near and far future.

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.

In reflecting on what we could have done better, we cannot overlook the impact of frankly inaccurate information propagated by both officials and the Internet last year. Of course, retrospect is 20/20 (or 2021), and a big challenge is that with a new disease, early on, medical knowledge is limited, circumstantial, and necessary all at once. 

I remember the spring of last year when COVID surged in Italy and then New York. I attended conference calls and web seminars where the presenter began with, "Well, in our limited experience..." We took the advice and suggestions with a grain of salt. Unfortunately, at the start of an outbreak, there isn't time to evaluate things methodically, systemically, and scientifically. That comes later.

So early on, clinicians were trying all sorts of things. Some of those interventions turned out to be efficacious, and we continue them today, like non-invasive positive pressure ventilation and prone positioning. Others ended up being soundly disproven and are no longer used, like hydroxychloroquine. 

The debacle with hydroxychloroquine disappoints me even today. At the beginning of the pandemic, based on limited evidence, Chinese, South Korean, and Italian health authorities suggested the use of chloroquine (and hydroxychloroquine) for COVID-19. Recognizing that data were limited, the WHO proposed studying it through a multinational large clinical trial. These were appropriate steps at this time.

Nevertheless, in mid-March, the President of the United States, arguably the person with the largest megaphone and biggest impact, started touting hydroxychloroquine without a strong scientific basis for doing so. This caused massive shortages of the medication, leading to problems for those with diseases that are actually treated by the drug. This problem worsened when he advocated using hydroxychloroquine as a prophylactic, for which there was even less evidence. The medication has many side effects, and without doubt, harm was caused to some of those who took it.

Furthermore, these statements confused clinicians and health authorities. I remember wondering whether there was something I was missing since hydroxychloroquine's poor evidence could not justify the daily news articles about it. The CDC gave it Emergency Use Authorization. At the same time, the Internet saw a surge of reports, videos, anecdotes, and stories championing the drug. The mass confusion that resulted, I believe, caused significant fallout in the loss of trust in governmental health agencies, media reports, the health care system, and clinicians.

Most of this happened in late March and early April, at which time a VA study showed that patients receiving hydroxychloroquine were more likely to die. By early June, a larger UK trial showed that it did not help, and subsequently, its emergency authorization was revoked. A trial in Brazil in July corroborated this data. Yet, the U.S. President still continued to promote the drug, and viral posts on the Internet propagated beliefs that it was beneficial. (There is further scandal with potentially inaccurate data in a WHO trial involving a company called Surgisphere). The harm of the whole to-do lasted far longer than it should have.

All this to say that hydroxychloroquine began as a reasonable hypothesis that quickly escalated into a Pandora's box opened by a President, media, and Internet that amplified a message unsupported by science. When appropriate scientific study debunked the utility of the drug, it was too late. I believe this caused real and material harm to patients, physicians, and our healthcare system.

I'm dismayed we aren't talking about it anymore. I'm not interested in assigning responsibility or blame. As we liked to say at the time, this was an "unprecedented crisis." Information was limited, people were scared, and we wished desperately for a solution. But I recall these events because we could have done better. We need to learn from what happened. 

And this is not an isolated incident. There are actually many wrong and harmful messages that got propagated this past year. I think of all the controversy over masks (that children can't wear masks or carbon dioxide will accumulate, etc.), and I lament the loss of lives that occurred because of spread which could have been curtailed. Even now, there is confusion over the need and utility of masks in the face of the Delta variant, which is causing spikes in parts of the country rivaling the winter surge. We need less spread of inaccurate, harmful, and wrong messages, and more propagation of appropriate, measured, and scientific responses. (And in that respect, I think of the tremendous good done by Dr. Fauci and his unflagging efforts and messages). Viral spread of messages can have as big of a public health impact as the virus itself. 

Thankfully, the COVID-19 situation in the United States is improved. It's easy for us to be grateful and move on. However, I think it is important to reflect on what went wrong and study how we can improve our response. I am certain another pandemic or international disaster will happen again, and we need to learn constructively from this crisis. The year went by in a blur and it would be so easy to strike it from memory. Nevertheless, I believe many things went awry and caused serious harm to individuals and our society.

This is not my expertise. Crisis management, infectious disease epidemiology, and public policy are complex disciplines. But I am sharing my voice as someone who cared for the sickest of coronavirus patients from the beginning when we knew so little, as someone who struggled when the health care system got overwhelmed, and as someone who held the hands of dying patients and called their grieving families.

One challenge is identifying the start to a potential pandemic. Pandemics spread exponentially, and time is crucial in containment. The difficulty, unfortunately, is that threats are constantly arising. Most of us do not know this. But new pathogens and mutations in old microbes are appearing all the time, and scientists have to determine how much of a threat they could become. Thus, surveillance is tricky. If we are too cautious and shut things down at every potential outbreak, we will have disruptions all the time. But if we miss the "next big one" we might have a situation like COVID-19.

Once scientists determine that a rapidly spreading pathogen is causing an epidemic, public health agencies and governments need to act swiftly. As we saw in COVID-19, geographies that contained spread early did remarkably better than places that dragged their feet. The Bay Area was one of the earliest places in the United States to initiate a dramatic lockdown, and we avoided the spring surges seen in other parts of the country. There is no doubt in my mind that this saved significant lives, not only in reducing the number of people who contracted COVID, but also in giving hospitals time and bandwidth to prepare. Early decisive decision-making can change the long-term course of an outbreak.

This decision is so difficult because of limited information. At the start of a potential epidemic, data isn't streamlined and expertise isn't shared. So we need to set up systems such that key players and decision makers can collaborate. Federal and state governments, local public health agencies, academic research centers, and on-the-ground surveyors have different skill sets and collect different data, but each perspective only has a limited lens on the actual problem. Only with communication between these players can we identify patterns in a timely fashion.

Furthermore, data needs to be reliable. At the beginning of the pandemic last year, we were hamstringed by the scarcity and limitations of diagnostic tests. For frontline providers like myself, I depend so much on reliable, accurate, and precise tests. In a new disease whose full clinical manifestations aren't completely known but whose symptoms overlap with many other common conditions, physical exam and history can only take us so far. So when the next pandemic happens, we need our health care system, research scientists, and industry partners to draw on resources to develop, validate, manufacture, and distribute tests as quickly as possible. It is a daunting but crucial task because diagnosis is absolutely necessary not only to treat individual patients but also to isolate the infected, limit spread, and characterize the course of the outbreak.

How do we look at the new CDC guidelines that have dramatically relaxed requirements for vaccinated people? These new changes have invited quite a bit of criticism, and I think this highlights the immense challenges of public health guidelines. I certainly don't envy their job.

Overall, the pandemic in the United States is dramatically better. With widespread vaccination, the spread of virus is dropping significantly. This is seen on a macroscopic scale with the lowest levels of new infections and deaths in a long time. But I have also seen it at a more granular level; in the winter, we faced a surge of patients from nursing homes. We even had a list of nursing homes with COVID-19 outbreaks so that we could appropriately prepare ourselves. After vaccinations rolled out, our nursing home COVID positivity plummeted. We really stopped seeing elderly patients come in with COVID. Anecdotal experience doesn't carry much scientific rigor, but it matches the studies from the U.K. and Israel; vaccinations dramatically reduce spread.

So I support the CDC's recommendation to loosen restrictions for vaccinated individuals. Although variants pose unknowns, the science reinforces the safety of otherwise healthy vaccinated people trying to resume their pre-pandemic lives.

But here is the CDC's conundrum. Risk is and should be an individualized matter. Different people have different risk tolerances. This depends not just on our physical health; of course those with obesity, diabetes, cancer, or other medical conditions will want to be particularly careful. But also, our personalities are different. Some people gamble. Others buy extra disability insurance. A few buy meme stocks. We cannot expect the CDC's guidelines or even our doctor's advice to take into account every nuance of risk.

And yet, we desperately want guidelines. Schools and businesses trying to open need to plan. A lack of uniformity among different geographies or states creates confusion and skepticism. The average person who doesn't have time to delve into details wants to know what to do.

How then does the CDC calibrate its guidelines? If it sets its standard too liberally, then those with medical conditions, persistent pandemic anxiety, and unvaccinated children panic at the masses of unmasked people milling about. But if it sets its standard too conservatively, then school education suffers, businesses struggle, and people complain about curtailed freedoms when they can't have their July 4 barbeque.

All this to say that taking into account the CDC's unenviable position and its bold stance, I am supportive of them. But I am also tailoring my personal decisions to my own risk calculation. Since I've worked in a hospital for over ten years, wearing a mask has minimal inconvenience; I simply don't mind. So I will likely continue to wear one even in settings where I don't have to. On the other hand, the CDC guidelines reassure me that I can attend a writing conference this summer set outdoors. I incorporate the CDC's guidelines with all the other data I'm weighing - my personal experience caring for COVID patients, my political and cultural milieu living in the Bay Area, my own anxieties and fears, my rational data-crunching mind, and my gut instinct. This is how we move forward with our lives.

I would be remiss to write about COVID in the intensive care unit without mentioning ECMO (extracorporeal membrane oxygenation) and lung transplant. These are extraordinary measures we might consider as a last-ditch effort in life-threatening COVID. They have been used successfully, but involve significant risk and potential harm to patients. I do not work in a center that provides ECMO or lung transplant, so we have to refer patients who may be candidates to other hospitals. I won't write a long blog because my experience is limited to the process of candidate selection and referral. But overall, I believe unfortunately, these are not miracle interventions that we can depend on. Resources and capacity are very limited, and although I have referred many patients for these possibilities, far more of our referral requests are declined than accepted. Realistically, we cannot count on them as a solution to life-threatening COVID.

Most of my posts discuss the pandemic in the United States, and I think this is a shortsighted view. Watching the news on countries like India, I am shocked, dismayed, and heartbroken. My thoughts and prayers go out to the people and healthcare workers in India grappling with this truly dire situation. The surge right now shows how superspreader events can transform a relatively controlled situation into an unbearable tragedy. It reminds us that our healthcare resources are finite, and when that capacity is overwhelmed, the unnecessary loss of lives can be tremendous. It warns us how we cannot let our guard down until vaccines are widespread, and how responsibility must be shared by individuals and governments for keeping the pandemic tamped down. Much of this we know from the surges over the past year in the United States, but the importance of these lessons cannot be overstated.

Currently in my community hospital in the Bay Area, most of our sickest critical care patients with COVID-19 are travelers from India. They require so much nursing, respiratory therapy, and physician attention. I cannot imagine the situation in India where even basic interventions like supplemental oxygen are scarce. Seeing the influx of these patients reminds me of the international and interconnected nature of our society; what happens in a faraway country will immediately impact us at home. We must help other countries. Even beyond the immediate and imperative humanitarian reasons, it is necessary for global health. We will not have ended this pandemic until we have all ended this pandemic.

One of the biggest lessons we must learn from this pandemic is that public health depends on trust and clear messaging. This is not an easy task. At the beginning of the pandemic, a lot was unknown, and unknowns cause panic. Many were dying, and we knew little of the virus. Medical experts and the government had limited information yet had to issue messages and guidance. The mixed messaging on distancing, masking, asymptomatic carriers, testing, hydroxychloroquine, and other related issues muddied the waters a lot. Some of this is understandable; we used the word "unprecedented" a lot a year ago because it was all new territory. We balanced the goal of getting information out against the rigors of the scientific method. We struggled with the politicization of public health recommendations. We had to revise mistaken information as we learned more. We struggled with conspiracy theories, misinformation, and the Internet. These are no small challenges. Unfortunately, this process cost us public trust.

Science is rarely straightforward. New evidence can change longstanding practices; hormone-replacement therapy comes to mind as an example. Those of us in medicine understand this, and our training teaches us to evaluate trials and data, maintain skepticism, and continually improve our practices. However, public health messaging suffers with uncertainty and retractions. Especially in our current society and the way we consume media, we cannot expect most people to spend hours deep-diving into nuances of data. We want the headline, the quick summary, the TikTok sized newsbite. That is a problem, but not one we will solve today. So we need to guide our messaging to consumers who expect quick soundbites.

Eroding trust hurt us during the winter surge. I believe there were significant excess infections and deaths resulting from too much travel and too many gatherings. I believe this could have been mitigated with earlier, more consistent, and stronger messaging. People will make their own choices, of course, but the government and public health system could have been more effective had it preserved more trust.

I think on this again with the recent pause in the Johnson and Johnson vaccine. I applaud many things including that it is another vaccine helping us fight this pandemic, and that scientists have detected these adverse events. We must investigate further so that we do not cause significant harm with our vaccinations. Transparency, too, is important. However, in a climate of hesitancy, vaccine-skepticism, and soundbites, a headline of vaccine stopped due to serious side effects may cause more harm than good. It will certainly erode trust and consistent messaging about the vaccine (though, of course, a dearth of transparency would do that too). 

COVID-19 is still killing hundreds of Americans every day, and pausing a highly effective vaccine for a handful of adverse events involves a challenging risk-benefit calculation. However, as I have written before, we don't know when an infection is prevented or life saved from a vaccine. But we do know when someone has a complication. That creates a bias for weighing adverse events more than prevented deaths.

But even more than those whose vaccines have been delayed, we must now acknowledge those who were on the fence, and now don't want the vaccine. Those who have lost the tenuous trust in our public health messaging and vaccine science. It will take significant work now to convince them that the benefits of immunization outweigh the risks. As a bedside physician, I understand the value of trust, a strong patient-doctor relationship, and consistent clear messaging. This is the same at the macroscopic scale. I hope going forward, and in the next crisis, we improve these intangible yet critical foundations of public health.

The idea of "vaccine passports" is a controversial topic for which I don't have a clear answer. The concept is that businesses, events, or travel guidelines may treat people differently based on their vaccination status. For example, imagine a cruise requiring all passengers have proof of immunity or concerts with different sections, one with social distancing and one without. Depending on whether someone is immune or has a recent negative test, he or she may be able to get better benefits.

There are certainly pros and cons to this setup. From a purely epidemiological standpoint, I think it is reasonable to consider vaccinated and unvaccinated individuals differently. The risks of infection, asymptomatic carrier status, and spreading the virus are significantly reduced when one has immunity. Ideally, we weigh public health against the curtailing of social freedoms, and this balance changes with the vaccine. Additionally, as we discuss how to approach economic recovery responsibly, I think there is a strong argument for letting businesses do more if it is safe. 

On the other hand, "vaccine passports" risk significantly worsening societal inequalities. Vaccine supply remains limited, and distribution has been unequal; racial minorities and low-income populations lag behind in immunizations. Vaccination status might actually be a proxy for demographic factors and minority populations. Treating people differently based on that will worsen societal divides.

Especially in light of this last year, the medical system must be more proactive against racism. Even if the intent behind a "vaccine passport" is in the right place, we cannot discount the profound consequences it may have on dividing our society if vaccine status reflects a richer, better-educated, or whiter population. We must take steps to improve vaccination outreach and availability. This is important for many reasons. What will hamper our recovery from the pandemic is the residual pockets of society that remain unvaccinated. Uneven coverage will lead to a patchwork of vulnerable sectors where COVID will continue to circulate. We must reach out to minorities, rural areas, and even anti-vaccine groups to educate and encourage immunization. 

In the end, I do not know what the right answer is. I think there is significant risk that "vaccine passports" will worsen societal inequities. But the underlying problem may not be with "vaccine passports" themselves, but with the bigger problem of uneven vaccinations. Our current governments, federal, state, and local, have made headway into this problem, but there is still significant room for improvement.

We should not be alarmed when people who are fully vaccinated come down with COVID. None of our current vaccines are completely protective, though they come close. The Pfizer and Moderna vaccines are around 95% effective. So among vaccinated individuals who are exposed to coronavirus, for every 20 people who would have gotten COVID, 19 would be protected, but 1 would still be infected. This is why we must continue to wear masks, distance, and live our lives responsibly. While numbers and exposures remain high, vaccines will significantly reduce cases but not eliminate them. 

More importantly, vaccine studies show that they reduce the incidence of severe disease requiring hospitalization. All of the vaccines appear to be highly protective against life-threatening disease. After watching our health care system buckle under the weight and complexity of cases last year, I think this is paramount. I can envision a world in which we (collectively) have enough antibody protection that although we won't eliminate COVID, it will become a disease similar to (dare I say it?) influenza. That is, coronarvirus may become an endemic disease for which we get regular vaccination to hopefully keep us out of the hospital. 

The protective effect of vaccines is evident. We are seeing fewer older people hospitalized and fewer admissions from nursing homes. Instead, the sicker COVID patients now are younger, who have not had the opportunity to get vaccinated but may have jobs or living situations that put them at risk of exposure. Our scope and rate of vaccinations are directly influencing who gets admitted to the hospital with this disease.

One last thing about vaccination. Like any preventive health measure, its benefits can be difficult to discern at the individual level. We do not notice when we avoid illness. We proceed happily with our day and our lives blissfully unaware that our immune system has fended off an attacker. But we remember when someone who has been vaccinated gets sick or if someone gets side effects from the vaccine. This recall bias makes us think vaccines are less effective than they actually are. So it is important to analyze data at a macroscopic level to see the effect of our interventions.

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.

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.

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.

Fortunately, I received the COVID-19 vaccine. For most of us eligible for the vaccine right now - healthcare workers seeing coronavirus patients day in and day out - I believe this decision is easy. The benefits far outweigh the risks. I trust the scientists who developed the vaccines and the independent experts who reviewed the data. I trust the colleagues I've talked to, physicians and pharmacists, who agree that the vaccine appears both effective and safe. I am grateful that it is here, and that I was able to receive it.

American health care doesn't prioritize preventive medicine, but preventive medicine is probably the most important thing we can do. Our health depends on a balanced diet, regular exercise, avoidance of smoking, drinking, and drugs, and, indeed, appropriate immunizations. If we prevent ourselves from getting sick, we save ourselves so much grief, pain, disability, and complication. We save the system money and resources. Although our healthcare is designed around treating things when they go wrong, we should put more emphasis on preventing things from going wrong in the first place.

I know we may have stubborn attitudes towards getting vaccinated, but this is important. It is preventive medicine. It is effective at protecting us from coronavirus, and these days, all of us are at risk for getting COVID. With over a hundred thousand Americans hospitalized with it right now and thousands dying daily, avoiding this disease is no small thing. It is certainly worth the mild discomforts associated with the vaccine (and so far, I have not experienced any problems). And though long-term outcomes are unknown, I believe the clear direct benefit outweighs any nebulous concerns that haven't yet come to light. As with everything, there are exceptions, and so those with severe allergies, history of vaccine reactions, pregnancy, or complicated medical histories should discuss with their physician.

I feel relieved after being vaccinated. Working long hours in an intensive care unit filled with COVID patients is stressful. Seeing its devastating effects on young patients is scary. I worry about bringing the virus home or transmitting it to others (though currently, we do not know whether a vaccinated individual can be an asymptomatic carrier). Seeing our communities struggle amid this pandemic is heartbreaking. But after receiving my first dose of the COVID-19 vaccine, I am beginning to see a bit of hope that these stresses, worries, and concerns will not last forever.

What a strange dichotomy, the arrival of a promising vaccine and the deepening crisis of the pandemic. So much hope juxtaposed with so much grief. At the same time health care providers are receiving the first dose of immunity, we are breaking records with the numbers of people infected, hospitalized, and dying. But I think this may signal the turning point of this global disaster.

It will take a lot of time. The rise in cases is still meteoric from Thanksgiving gatherings. Even with shutdown measures, it will take weeks to level off and plateau. And unfortunately, I believe we aren't as adherent to these shelter-at-home directives as we should be. As a result, we're not close to containing this virus, and measures like contact tracing have limited effectiveness. This skyrocketing number of infections has downstream effects on the number of people requiring hospitalization and intensive care, taxing our resources and leading to excess deaths. 

Unfortunately, the effects of the vaccine will take time. Two doses several weeks apart are required, so there will be a delay there, though there is partial immunity after a first dose. Logistically, it will take many months to vaccinate everyone who wants to receive it. Unfortunately, vaccine skeptics, false information, and distrust of the system will hamper our outreach efforts. Even those who may not disbelieve vaccines may be slow to sign up due to worry about side effects or feeling that they don't need it.

While on an individual level, someone may weigh the risks and benefits and elect not to get immunized, at a population level, we need as many people to receive it as soon as possible. The effectiveness of a vaccine at a population level depends on herd immunity, the point at which there are enough vaccinated individuals that it protects non-vaccinated individuals. This requires the majority of a population to have immunity. This also protects individuals who may not be able to get vaccinated for whatever reason. However, herd immunity may be challenging to maintain once our global community opens up. There will inevitably be cross-over between well-immunized populations and poorly-immunized populations which will dilute out the herd immunity effect.

All of this is to say that although I think we are at a turning point, we are not at the peak of the crisis. Things will still get worse before they get better. We will start turning things back, but the momentum of this pandemic is tremendous. As reiterated by our public health agencies, we need to continue masking, distancing, and avoiding risk even as the vaccine rolls out. We cannot get complacent. There is still a long way to go.

Over the past nine months in the Bay Area, we've bounced back and forth between stricter and looser regulations, trying and unable to find an equilibrium. We locked everything down in the spring, watching the East Coast in trepidation. Then in the summer, we navigated changing restrictions when the Midwest became overwhelmed. Up until recently, the Bay Area has avoided disaster. Unfortunately now, disaster is here.

It might feel like the boy who cried wolf. Before this, whenever we got scared, we shut things down, and went more or less unscathed. Now, we cry alarm, but our communities are exhausted, our businesses flailing, and our holiday hopes dashed. We are reluctant to listen to these cries, and now the wolf is real.

I don't think the analogy reflects what exactly happened. We avoided a surge in the spring and summer because we cried wolf. Our shutdown measures made a difference. We weren't giving false alarm. But I worry that with time and repeated calls for caution, fewer take heed.

Now, like the rest of the nation, California and the Bay Area are in a crisis. We reinstituted severe lockdown measures, to criticism from small business owners and struggling communities. I can't imagine how hard it must be to try to run a restaurant, or to worry about when unemployment benefits expire, or to feel trapped in one's home for nine months. There are devastating hardships and consequences from shutting things down. And the benefits may not be immediately appreciated from afar.

This is how bad the health care system has and will become. We are seeing a steep rise in cases. Before Thanksgiving, our COVID patients occupied less than a third of the intensive care unit, nicely sequestered in our COVID-specific "pod." The following week, the numbers surged and we didn't have enough room in our COVID-designated areas. Our engineers scrambled to convert rooms to accommodate COVID patients. A few days ago they made up two thirds of our intensive care patients, and most recently, 80% of them. Our ICU still needs to care for strokes, heart attacks, sepsis, cardiac arrests, overdoses, and all the other life-threatening illnesses that come to our door. We have opened up additional intensive care availability in our post-anesthesia recovery area. We have boarded patients on ventilators in the emergency department as they wait for beds. Every day we are discussing mitigation strategies to make it through that day.

However, beyond beds, our biggest shortage will be staffing. Nearly every shift I have in the intensive care unit, I see the clerk calling nurses at home, seeing if anyone can come in on short notice. When that fails, we ask nurses that are working 12 hour shifts if they can extend to 16 hours. Our intensive care doctors are stretched thin. At the busiest, I am responsible for intensive care patients in three areas of the hospital on three different floors. 

We are experiencing burnout. The physical and emotional stresses of caring for these patients are enormous. Many of them are young. Many of them are dying. Many require heroic interventions and efforts to save them. And working longer hours, more shifts, with busier services, we don't have the bandwidth to process these emotions or even to eat or drink water. This is not sustainable, and yet, we anticipate this surge to last for weeks to months.

Does intensive care make a difference? I think this is an important question, else we are scrambling and stressing for little benefit. It does. We have patients who arrive in extremis, requiring complex coordinated intensive care and life-support who survive when we weren't sure they would. The hospital stays are long and they face an arduous recovery, but we can save lives. Each critically ill coronavirus patient requires weeks of intensive care, dozens of doctors, nurses, and therapists, and a lot of love, care, and support. We have love, care, and support in abundance, but hospital beds and providers will get scarce.

I don't think it is easy to weigh the benefits and consequences of a lockdown. In the spring, a lockdown made sense; businesses did not have the masks, sanitizer, gloves, barriers, guidelines, and education necessary to run safely. I know that a lockdown now, when there is no federal support for businesses, will have drastic and long-lasting consequences. Asking people to isolate during the holidays is not a small thing. Our communities are weary and battered. And a complete shutdown isn't ideal; it's a blunt instrument when perhaps selective restrictions may strike a better balance between protecting the health care system and preserving parts of our lives we can conduct safely. But here we are, and we need to do something.

Because from the ground, from the intensive care unit where I reside, we need all the help we can get, and I'm appreciative of all the sacrifices made to make that happen.

A pregnant woman at term with severe pre-eclampsia presents in labor. She tests positive for COVID during standard screening. She is asymptomatic and does not need any oxygen. However, her pre-eclampsia is concerning; she requires several medications to control her blood pressure, and the fetal heart strip is flat, abnormal. The obstetricians worry that she may eventually need a C-section, though one is not emergently required now. They ask what the optimal plan should be.

How much should a COVID diagnosis change care?

One important goal in any pregnancy is to avoid an emergent "crash" C-section - the kind that involves running to the operating room, inducing anesthesia as quickly as possible, splashing iodine onto the belly, and getting the baby out immediately. These scenarios are uncontrolled, stressful, and chaotic. Occasionally they cannot be avoided, but with early identification, prevention, and planning, they can be kept to a minimum.

In any pre-eclamptic with a concerning fetal heart strip, we need to mitigate risk. But how do we take into account asymptomatic COVID positivity? There are several possible decisions we can make. The most extreme would be scheduling a C-section so we could deliver the baby in a controlled, planned fashion. It would avoid pushing, which may aerosolize the virus. A more moderate approach might be placing an early epidural which can be used for anesthesia in the case of an urgent C-section (though there still may be a small risk of needing general anesthesia).

We know from early COVID studies from China that general anesthesia in a patient with COVID has significant mortality. Intubating a patient with COVID, even if she is young and healthy, puts her at real risk. In addition, emergency COVID surgeries place staff at risk. Although we would ideally be wearing all the necessary protective gear, in the real world, such things don't always happen. I've been in "crash" C sections (pre-COVID) where surgeons didn't have time to put on a surgical cap, a mask, or (once) even shoes (they were asleep when the C-section was called). Expecting perfect PPE adherence in an emergency is unrealistic.

So how much does COVID change things? If the patient were COVID negative, I would recommend an early epidural, but if she declined, I would be amenable. But here, I felt a stronger imperative to explain why an epidural could be life-saving. And if the obstetricians scheduled a C-section, it wouldn't be unreasonable. Like all aspects of medicine, decision-making is a shared responsibility between patients and their providers. I'm learning how to incorporate what we know about COVID into that discussion. Medical decisions should not be unilateral, but the invested parties should think of all the ramifications of this disease including protecting the staff from unnecessary exposure, reducing harm, and keeping the health care system sustainable through this pandemic.

For those in the United States, wishing you a safe, healthy Thanksgiving. This year is unlike any other, and most of us are feeling upset, pain, sorrow, anger, and disappointment. I can certainly commiserate with that. But I also hope that we can identify a few things to be grateful for. 

I am thankful for the hard work, dedication, sacrifice, and persistence of the health care community that has stepped up during this pandemic. The team I work with in the intensive care unit is incredible. I could not ask for better nurses, respiratory therapists, consultants, and colleagues. Day and night we work shoulder-to-shoulder (figuratively - we distance when we can) taking care of the sickest patients, talking to their families, and performing high-risk procedures. Our infectious disease specialists have been a great boon, sifting through literature and helping us navigate this new illness. Our department and hospital leaders are aware of the mental, emotional, and physical toll this prolonged pandemic has taken, and are doing the best they can to alleviate the burnout. Our care of COVID patients also depends on an army of seldom-recognized co-workers, from those who source the PPE to those who dispose of it when we are done using it. We have so many people behind the scenes helping us in a myriad of ways so that we clinicians can focus on bedside patient care. Thank you.

In our larger communities, I am grateful for those tireless scientists who make my work possible, who give us hope, and who equip us with the knowledge and tools to tackle this disease. I appreciate those leaders in our communities and governments that have taken this threat seriously and done what they can to enact policies to protect public health. I am grateful for those in our community that have changed their lives and made sacrifices in order to social distance, avoid gatherings, and reduce transmission.

Most importantly, I appreciate my family, friends, and support network during this difficult and trying year. I think back to the beginning of 2020 and can't believe things have changed so much, but my friends and family have held steadfast through all these months. We will get through this together. Thank you.

As the holidays near, we try to navigate the complex interplay of risk and reward. On the one hand, we crave our families, miss our traditions, want to "live our life," feel that we can take precautions, and believe holidays can be an exception. But on the other hand, the virus is spreading exponentially, hospitals are at or beyond capacity, mass travel during this time compounds risk, and holiday get-togethers gather multiple households.

To me, the math is clear. Unfortunately, these should not and cannot be the holidays you remember from last year. They will probably not be the holidays you want. Frighteningly, the case trend even before Thanksgiving travel has gotten out of control. Our community prevalence is so high everywhere that you cannot eliminate risk even with a negative test and appropriate precautions. And without seeing signs of a peak or plateau, I think holiday gatherings will dig us into a deeper hole, something we cannot afford.

All that said, I do think it's a complex and hard call. Most public health recommendations say that we should only get together with those of our household. For traditional nuclear families, that might work pretty easily. But our country has a diverse mix of households. What about those living alone, those sharing custody of a child, a college student who has to go home for the end of the semester to a household with grandparents, or families with a newborn that need childcare assistance from relatives?

Ultimately, our country thrives on self-determination. We make our decisions, trying to weigh not only the risks and benefits to ourselves but also the risks and benefits to our communities. I really believe that if we have a well-informed citizenship that acts deliberately and with integrity, we can make it through together. The holidays have different types of significance for each of us, and a one-size-fits-all strategy isn't appropriate. But we cannot ignore that in this pandemic, our decisions will translate into life and death. Part of this blog is trying to arm ourselves with the information we need to do the right thing.

Scientists, public health officials, doctors, and news outlets are sounding the alarm. Each day this pandemic hits new records. Our health care system is facing incredible strain, and the death toll is rising. I have written in recent blogs about the responsibilities of our government and of individuals. But looking at this crisis, I think we need to be creative about who can help and how.

Should large, wealthy companies help? They have - at the beginning of the crisis, we received generous donations of N95 masks from local tech companies who stockpiled them for wildfire season. Other companies pivoted to learn to make ventilators. Many businesses offered discounts to front-line workers and first responders. Most companies transitioned to remote work. These actions make a difference.

But there is room for more. Companies have a lot of expertise and resources to contribute. For example, once the vaccine is available, distribution will not be easy. We can and should tap into companies that have figured out how to deliver nearly anything anywhere within a couple days. Vaccine storage may be a challenge because it requires incredibly cold temperatures; we should start identifying who can provide appropriate storage in our communities. Early in the pandemic, we faced serious PPE and ventilator shortages; manufacturing companies should consider if they can help maintain that supply. There are numerous roles for motivated volunteers to help with contact tracing, food banks, meal delivery to seniors. Companies should encourage their employees to help the community. I heard some companies paid volunteers to be poll workers; how incredible it would be if they decided to include pandemic volunteering.

Nobody wants a widespread shutdown. The economy is already teetering. One way to ameliorate the need for a complete lockdown is for wealthy businesses to give the health care system more buffer, more resources. I'm not calling on the small businesses that are struggling - they need all the help they can get, and I am advocating for another economic stimulus package - but on the companies that have the means. It may take a little creativity to figure out whether and how different industries can contribute, but since it looks like the federal and local governments and individual behaviors are insufficient to curb this crisis, we need to think outside the box.

Winter is coming. I think this may be one of the hardest winters this nation will face in recent history. The pandemic is out of control, and it will get worse. Tens of thousands of people will die. Hundreds of thousands will be infected. Many will have long-lasting health effects from the virus. Some of this death and disability will result from suboptimal care due to overwhelmed health facilities and health care providers. Some hospitals may even talk of rationing care. Non-coronavirus illnesses may be undertreated or neglected. The next few months will substantially change the health of our population. It is a terrible thing.

Unfortunately, this is on top of economic fallout, political divisiveness, social isolation, and industry upheaval. It occurs when we are fatigued and afraid and angry. Our mental, physical, social, and societal resources are being depleted. We have little reserve left. Our ability to meet outdoors is diminishing, and riskier indoor activities will rise. We face challenges in deciding how to celebrate the holidays; without doubt, they will cause a surge in cases, hospitalizations, and deaths.

There is some hope. Vaccine trial data is coming out and is promising. We may be able to begin developing a national immune system. A change in the White House may mean stronger leadership, closer adherence to expert recommendations, and more support to those who need it. Scientists are learning more about the virus, the disease, and the epidemiology. And our clinical experience in the last nine months have helped those of us on the ground take care of patients a little more effectively and efficiently.

I suppose I write posts like this every few months, and each time it feels just as pressing. Acting immediately and acting drastically will change the course of winter. We need to reduce viral spread now. Individuals need to take responsibility of masking and distancing, and governments need to take responsibility of educating, mandating, and enforcing. Health care systems need to look ahead, and governments need to provide resources to mitigate the oncoming deluge. We need to rethink our holiday and travel plans. We need to reimagine businesses. We need to reach out to each other in support. The more we do now and the fewer risks we take, the quicker we can make it through this pandemic.