COVID Isn’t Over, And Why That Will Impact Everyone

Much of the United States is at Medium to High Risk of COVID
Compare the risk of COVID infection (map above) to the statewide rate of COVID vaccinations

We didn’t vaccinate enough people. Unfortunately, that means that everyone will suffer the consequences of that problem.

“But I’m vaccinated.” You think. “Why should I suffer?”

Let me explain. This is gonna be a long journey. Let’s go.

First, I want to make explicitly clear that vaccines are safe and effective, and are our best hope of getting to the finish line. Currently available vaccines stand up against all the current variants, including Delta.

Remember when this started and we leaned into the idea of preventative measures such as masks and social distancing to “flatten the curve” because we didn’t have any other options and we needed to prevent the health care system from becoming overwhelmed? https://twitter.com/tnicholsmd/status/1241095073967661058?s=20

Well, we aren’t doing that any more — the public has given up on that idea and hospitals aren’t taking adequate measures to prepare.

But why not?

Patient numbers plummeted during the early part of the pandemic as patients stayed out of the hospital.

In a sick twist of capitalism, this sharp decrease in patient volumes through the emergency department and occupying hospital beds, while non-emergency operations were put on hold, lead to decreased revenue for hospitals and physician groups.

With a lack of revenue and a lack of foresight for the possibility of further surges and the arcane and length process of applying for hospital credentials, that lead to hospitals cutting staff including nurses and physician groups cutting hours and pay or even firing physicians.

That fact also doesn’t account for the burnout and despair that has nurses and physicians leaving medicine altogether. There is only so much we can take before we reach our breaking point. I cannot tell you how devastating this all has been for us. When you experience one reality in the hospital and then leave to be faced by people denying that reality even exists, to be attacked and called liars by the former President, to have our collective pleas all but ignored by so many hurts in a way that is hard to put into words.

Taken together, those factors have led us to our current position in health care in which we are facing one of the most dire staffing shortages at one of the absolute worst times.

“But there are still enough beds, right?”

Short answer, maybe. Just look at Missouri. But even then, this mantra still holds true: Beds can’t staff themselves. Nurses are hard to replace. Great nurses are irreplaceable.

“Ok, so staffing is short, that seems like a problem, but why is it at the worst time?” Let’s dive in.

Those of us on the front lines of caring for COVID patients had a collective yet cautious sigh of relief with the rapid development of highly effective and safe vaccines. The finish line was in sight! Or was it?

To reach that finish line of herd immunity, we knew that a significant percentage of the country would need to be vaccinated. With approx 25% of the US under age 18, and initial estimates to reach herd immunity of around 70%, nearly every adult in the US needed to be vaccinated. Before people start saying “but what about disease-derived immunity” keep in mind only around 10% of the US population has actually had COVID, and that many of those will — and should — be vaccinated so that amount cannot just be directly added onto vaccination estimates. Also, our estimates of the number needed to reach herd immunity now have to increase as the transmissibility increases with new variants, as Delta significantly more transmissible than the original COVID-19 virus and about 50% more transmissible than the Alpha variant that hit us with the worst surge during the fall and winter. What does that mean if you’re vaccinated? That means so long as other people don’t get vaccinated, COVID will continue to circulate and people will get sick.

All the while, non-elective operations are continuing through a backlog of cases to catch up on, and the number of patients back in the emergency department are back to pre-COVID levels for non-COVID related injuries and illness. Which brings me back to: https://twitter.com/tnicholsmd/status/1238488640868601857?s=20

Of course, we’re also now seeing significant increases in volumes of patients who are coming in to the emergency department not just with COVID infections, but sick with COVID. With multi-focal pneumonia from COVID. Requiring intubation due to COVID. And those patients who are becoming sick from COVID may end up with fairly long hospital stays, taking up beds for longer periods of time. Particularly as patients getting ill and requiring intubation and ICU stays are younger, and families struggling with the potential end of life decisions, particularly without any sort of living will or advance directive. While COVID ICUs are filling back up in pockets across the country, hospitals are full from patients from non-emergency operations and general non-COVID-related illness and injury.

Despite those rising numbers of COVID patients and the potential for a surge, many hospitals are already dealing with “boarding” of patients who require hospitalization remaining in the emergency department for long delays until a hospital bed becomes available. What happens with lots of “boarding” patients and high volumes of patients coming into the ED?

Turns out, the short answer is “nothing good.” In short, more “waiting room medicine,” longer delays, more potential for medical errors, higher morbidity and mortality, and ironically, longer hospitalizations. This paper provides an excellent summary: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6774012/

Emergency departments already face the downward pressure from hospital systems driving to optimize productivity and upward pressure from increasing complex medical and social needs driving more patients to the emergency departments. We’re about to get squeezed even more. That impacts everyone, regardless of your vaccination status.

So, if you’re vaccinated, thank you! But don’t let your guard down now. Keep social distancing, wearing masks, and please encourage everyone you know to get vaccinated. If you aren’t yet vaccinated, please, please, please get vaccinated. We need your help.

Original tweet thread: https://twitter.com/tnicholsmd/status/1416921153617100803?s=20

Humanist. Emergency Medicine Physician. Health policy enthusiast. Views are my own. (He/Him)