This week will be my 21st Christmas at Brigham and Women’s Hospital. Before the COVID-19 pandemic, the holiday season was, on average, relatively light. Last week on the general medicine service, as has been the case for many weeks in 2021, the caseload of our team (and every other medicine team) had been pushed past our pre-pandemic limits. Each additional patient meant less time to spend with each patient and their family.
Almost half of my patients were there for COVID-19. This is up from one patient per team just a few weeks ago. We’re now in the third wave of COVID in Massachusetts, a combination of winter, waning immunity from vaccines, and the Omicron variant. But unlike last winter, this wave was largely preventable. All but one of my patients hospitalized with COVID-19 were unvaccinated (the one vaccinated patient had received the Johnson & Johnson vaccine nine months earlier). Unvaccinated people make up less than 17 percent of Massachusetts adults but 70 percent of those sick enough from COVID-19 to require hospitalization. Unvaccinated patients are 10 times more likely to be hospitalized and 13 times as likely to die from the disease. Early evidence suggests that the Pfizer and Moderna vaccines are still protective against serious disease from Omicron, especially after a booster shot.
Some of my patients with COVID-19 had been there for weeks, recovering from the devastating effects of their illness. One had developed kidney failure and was now on dialysis, and one still had a tracheostomy to help him breathe. Neither could walk on their own, but at least they were recovering. Three other patients were not so lucky. Before the pandemic, a patient with pneumonia would typically receive supplemental oxygen through the nose at a rate of 2-4 liters per minute. But with COVID-19, evidence has shown us that we should avoid mechanical ventilation at all costs, so instead we give ever-increasing amounts of oxygen through the nose: 10 liters per minute, 20, 30. These three patients had been on 70 liters per minute. It’s like taking in oxygen through a fire hose. And even that wasn’t enough for two of them, who are now mechanically ventilated in the intensive care unit. The medical ICU is now full.
The residents I supervise are tired. COVID-19 has consumed their residency training, and they are all caring for more patients than is optimal for patient care or good for the residents’ education. One resident had just finished working a two-week shift in the ICU. She was bitter: One of her patients was fully vaccinated but immunocompromised from an organ transplant, and the resident had watched her die of COVID-19. The resident attributed her patient’s death to those who were unvaccinated around her, and it was hard not to blame her. Each decision not to get vaccinated, not to wear a mask in indoor public spaces, not to get a booster, not to vaccinate one’s children, not to get tested before holiday gatherings, had increased the number of people in the community with COVID-19 and this woman’s risk of getting it. She had essentially been killed by the behavior of those around her.
I share my resident’s frustration. I conceptually understand the various reasons why many Americans remain unvaccinated, but those reasons ring hollow once you’ve had to tell a patient they might have to go on a breathing machine and you see the fear in their eyes that they might not make it, as I had to do last Monday. And Wednesday. And Thursday. I have spent much of the pandemic working with hospitalists from around the country, trying to figure out how to care for patients hospitalized with COVID-19: how to train and deploy staff, respond to new evidence, communicate with families, teach our residents, care for each other. Each wave brings a new level of desperation in the voices of my colleagues. We’ve learned a lot about this disease, but when will it end?
On Thursday, we discharged one of my patients lucky enough to fully recover from his illness without any major adverse events, a previously healthy man in his 30s. Upon discharge, I began a speech I had prepared for every patient like him. Can you please convince five of your unvaccinated friends and family to get vaccinated? They are not listening to me, but maybe they will listen to you, now that they understand how sick you can get. “Oh,” he replied. “Everyone I know is vaccinated.” Why hadn’t he been vaccinated? “The vaccine is still new,” he said. Had any of his vaccinated friends and family ever been sick enough with COVID-19 to be in the hospital? None of them had. That thought hadn’t occurred to him.
Dr. Jeffrey L. Schnipper is a hospitalist at Brigham and Women’s Hospital, where he is research director of the Division of General Internal Medicine and Primary Care, and a professor of medicine at Harvard Medical School.