So what now?
Thankfully, case numbers are plummeting throughout the country. As we emerge from the holiday surge, we find ourselves in a similar situation as last spring, grateful for a reprieve. Hospitalizations and deaths are still pretty high, but those numbers lag, and I expect they will come down too.
How do we de-escalate? This is a real challenge in medicine; we're better at adding interventions than taking them away. But now's the time to figure out how to do this rationally and safely. Unfortunately, the issues are entangled with politics as mask mandates expire and vaccine efforts flag. How do we think about this? What should we be doing now?
I acknowledge that I live in a very COVID-careful part of the country and work in a COVID-cautious industry. As I've written and rewritten this blog, I've come to the conclusion that one question we have to ask ourselves is whether the role of public health is to protect the community at large or the most vulnerable individuals in our community.
For the average person, as prevalence of disease declines, it may be reasonable to shift from broad mandates to community, local, or individual decision-making. I'd prefer to wait until absolute numbers sink below pre-Delta levels, but I recognize the political capital for that is waning. Here, we weigh fatigue for rules, the importance of creating movement towards normalcy, and recognition that immunity protects healthy people significantly. We also recognize the counterarguments against mandates that we've heard time and again: personal choice, freedoms, overreach of government. I understand the many countries, states, and geographies letting restrictions lapse.
But for the vulnerable individual, the unvaccinated, the immunocompromised, the transplant patients, the very young children, COVID still poses a genuine risk. If the goal of public health is to protect those who need protection the most, then the answer is clear: we need to continue wearing masks, vaccinating more people, and developing advanced treatments.
The role of government and public health depends on one's political philosophy, and I don't make any pronouncements on what it should be. But I think we now live in two worlds: one in which immunized, healthy people can treat COVID as an endemic disease, and one in which the vulnerable still need to take precautions. The pandemic has worsened many societal inequalities, from wealth to race to jobs where we can or cannot work from home. This is a new inequality, and I worry it will persist and fracture our communities.
Ultimately, we cannot pretend the pandemic will never end in the same way we cannot pretend that there is no pandemic. It is definitely a good thing that the latest surge is waning and our society is opening up once more. We can talk about things that may have been taboo for many of us for the last two years: travel, concerts, celebrations, Disneyland, dancing. But our decisions must be nuanced and sensitive to those who are unlike ourselves. We must chart a path to a new normal, which may be different than pre-pandemic life.
So what is it like in the ICU these days?
In general, our ICU this month reflects the overall trends across the country. We are operating pretty much at capacity for our ICU and hospital, and some of the constraints result from nursing shortages as staff are out due to COVID. Nearly half of our ICU beds are occupied with COVID patients, though most of them do not in fact require ICU level care, reflecting the lower severity of Omicron. However, since our hospital has limited isolation beds on the general wards, when we have a surge of hospitalized COVID patients, they overflow into the ICU. Fortunately, few of our COVID patients are currently intubated and mechanically ventilated. Even fewer are dying, but this does not discount the gravity of each passing. There may be fewer deaths, but each one still exacts a deep emotional toll.
Does it matter if a patient is hospitalized due to COVID or hospitalized for another reason but turn out to be COVID positive? I don't think it makes a huge difference. Staffed isolation beds appear to be the main bottleneck, so any hospitalized COVID positive patient strains our system.
As we use up ICU rooms for non-ICU patients, our capacity to care for sicker patients becomes limited. We can't take transfers from smaller hospitals, and we have to be more discerning about whether to bring borderline cases into the ICU (as any hospital doctor knows, there's a gray area where a patient does not definitely need intensive care, but may benefit from it). When I was on service last week, we had periods of time when we didn't have a "code bed" to immediately accommodate a cardiac arrest if one happened in the hospital. We worried each day whether we could continue cardiac surgeries since they all require post-operative ICU. These concerns are not a normal state of affairs.
Although Omicron has peaked in the Bay Area and is starting to recede, hospitalizations lag behind cases, so things are still tight for the time being. Like other hospitals in the area, we have finally started reducing elective surgeries that require overnight stays. We're doing our best to handle the dynamic situation of staff getting sick, recovering, needing to quarantine, and being cleared to return to work. There are a lot of extra logistics happening behind the scenes.
I said this early on in the pandemic, and I feel it again: I am very grateful and proud of all the hospital staff, health care workers, and day-to-day operations specialists who keep things going. We are all feeling a great deal of physical exhaustion, emotional strain, and burnout these days, but we're in it together. We've weathered it so far, and it will get better.
I read a word of advice once: "Our job isn't to change local culture." I've been thinking about this recently with an influx of unvaccinated ICU COVID admissions. In several of these cases, the hospitalized patient comes from an entire household that is unvaccinated, where everyone contracted COVID. What strikes me most in this all-too-common situation is talking with the family and finding that they remain adamant against vaccination. Now, it is true that infection generates immunity and someone who had COVID must wait some time before they can get the vaccine. But vaccination (at least one dose) is still recommended because it generates even stronger protection. Nevertheless, many of these family members (and even patients who recover) refuse the vaccine. Some of it is misinformation still circulating on social media, talk shows, and the internet. Some of it is stubbornness without good justification. I spend a lot of time talking to families about this, because I think it could be an opportunity to show how serious COVID is and how beneficial vaccination could be.
But our job isn't to change local culture. We do our best to present the strongest case for vaccination, to justify science, and to protect our community, but at the end of the day, people will make their own decisions based on their beliefs. This is a really hard realization as someone who has seen the worst of COVID in the past year and a half. Sometimes the most difficult parts of my job don't relate to diagnosis or treatment decisions, but rather to the emotional challenges we may not have anticipated.
I recently read The Great Influenza by John M. Barry. I was impressed how relevant and prescient this book was to our current situation, and I wish I had read it earlier. Written by a historian in 2004, it is a thoroughly researched treatise on the 1918 influenza, the worst pandemic in modern history. Its approach is multidisciplinary and multifaceted, and its scope is ambitious. It's a long book, and I skimmed over sections with which I was familiar - those on medicine and epidemiology. Its biographical lens was also not my primary interest. But I was enthralled by its detailed historical account of how the pandemic unfolded in the United States in the midst of World War I. The descriptions of local, state, and federal response, overwhelmed hospital capacity, measures to mitigate spread, impact of the media, concerns over the loss of individual rights, and the mobilization of public health, medical research, and organized medicine are relevant today. The pandemic touched every aspect of life: political, cultural, economic, familial, military, scientific, religious, educational, societal, and more. I was shocked to see many parallels and dismayed that despite having this resource, we were inadequately prepared for the challenges of a global pandemic a century later. It also gives insight on the lasting, possibly years-long impact with resurgent waves that may still come. Ultimately, I think the past provides a wealth of experience in many different lenses, and this book is a well-researched, worthwhile read for anyone.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.