The COVID public health emergency is officially drawing to a close. Although COVID still lurks in our communities and still causes harm and death, its impact is dramatically less than before.
I will look back on COVID as a time when clinicians -- myself included -- felt blindfolded. From very early on, most of us had little knowledge of the "novel" virus, SARS-CoV-2. We tried our hardest, sometimes did the wrong thing, but pressed on the best we could.
I recently attended a continuing education course and was not at all surprised to learn that most of the antivirals we gave early on had little to no impact on outcomes. Even our best wasn't as good as we hoped.
During the pandemic I worked in a rural Appalachian emergency department (ED). What stood out the most to me was that COVID became as much an issue of resources as of pathology. My small hospital frequently had used all of its ventilators, BiPAP devices, and high-flow nasal cannula systems. At one point, oxygen itself was in short supply. But the biggest issues were nursing and beds. The two are, of course, tied together. No nurses to staff a bed means no bed.
Our 25 inpatient beds too often became 20, and our four-bed intensive care unit was frequently a zero-bed unit as we didn't have critical care nurses to manage it. Sometimes our hospitalists felt too overwhelmed by 25 beds and capped our admissions at 18 inpatients.
Then came the transfers. We had patients dying with COVID who needed to go to higher levels of care. Patients with non-ST segment elevation myocardial infarction, sepsis from obstructing kidney stones, seizure, or vascular occlusion all became problematic as we faced the fact that hospitals were full and the best we could hope for was to be put on the nebulous "waiting list." Even calls for consultation were sometimes declined.
Sick patients might require 70 phone calls before a glimmer of hope for a transfer. Even when accepted, we would learn that EMS crews were exhausted and unavailable until the next morning, 12 hours later. Paramedics, ambulances, and helicopters became precious, limited resources.
All of this led to hospitals like mine, with few resources, holding patients in the ED for days or weeks. Nurse to patient ratios were wildly dangerous and physicians were left managing patients for longer than normal, with complex issues, which in larger centers, would have had multiple specialists in consultation.
When I reflect back on COVID, I believe I will always be most stricken by the hard reality that our first world nation, our modern civilization, simply had far less medical capacity than we had ever imagined. Not that we didn't suspect this. In fact, many of us had pointed out the danger for years. But systems, particularly profit-driven systems, don't typically invest money in what "might" happen. Prevention is not our strong-suit. We learned a hard lesson over the past few years.
There were other hard lessons too. One of the bitterest was that patients and physicians alike can be pulled into the black hole of cultural and political strife. So much of the discord that happened during the pandemic was clearly demarcated by politics. Yes, it revolved around vaccines, masks, and lock-downs; around information and disinformation, and all the rest. Still, all of that was tied to ideology and tribe. And the result was a politicized public health response and a politicized reaction by the populace.
Both sides became far too toxic and we may never know how much injury and death, how many lives wrecked and jobs lost, grew out of that Balkanization. Sadly, it will take years to reestablish proper trust on all sides.
Fortunately, every disaster that humans face offers lessons, if only we'll pay attention. Everyone alive today is testament to the fact that their ancestors either learned from struggle or benefited from what others learned from it. We stand at the tip of human life. Those who came before us may have faced far worse than COVID.
What did I learn? I learned that if our patients don't trust us, if we dismiss their concerns and talk down to them, then they won't listen to the recommendations we make for their well-being. Connection and compassion are essential.
I learned that every public health measure, and every bedside measure, has a greater consequence. Closures that cost people their livelihoods were harmful in some cases. Isolation of the dying was cruel. It's all too easy for us to be reductionists, to frame medicine in terms of disease rates or deaths only, and to ignore larger impacts beyond our metrics and weekly statistics.
I also learned that nobody has a monopoly on the truth. Although there will always be people on the fringe, we would do well to pay attention to voices outside of our own echo chambers. We should remember that physicians were threatened with firing, or fired, or reported to medical boards, for suggesting heterodox views on pandemic response.
Now we have learned that the way we used masks may or may not have helped as much as we thought, that the pandemic "lab leak" theory wasn't necessarily wrong, and that extended school lockdowns did cause harm to many children in the form of learning lost and mental health consequences. These were all views that for a while were best kept quiet. Now we see the importance of weighing the pros and cons in open discussions.
We will face another pandemic; rest assured. Who knows what it will involve? My bet is that it will be something neurological or gastrointestinal -- if only because we'll be planning for a respiratory illness and won't have enough of what we need when it arrives.
But when it happens, maybe the most important thing will be for us to strive for compassion and unity, and for a broader perspective on what constitutes health and wellness in our patients, many of whom live already in poverty and vulnerability.
Someone recently asked me how to have a successful career in emergency medicine. I never answered. Now I will: I think it's kindness. And that would have gone a long way towards a better pandemic response all around.
Edwin Leap, MD, is an emergency physician who blogs at edwinleap.com, and is the author of The Practice Test and Life in Emergistan. You can read more of his writing on his Substack column, Life and Limb.