Another surge in the ICU: the Delta variant “hunts” the unvaccinated population
Medical staff work on a patient suffering from COVID-19 at Providence Little Company of Mary Medical Center. Photo by Alex D. Hakim M.D.
by Mark McDermott
When the wall came down in the ICU at Providence Little Company of Mary Medical Center, a small group of nurses, doctors, and technicians danced in jubilation. It was May 21, and to this exhausted crew of health care workers, it felt like the pandemic’s end was finally in sight.
“We are open,” one nurse exclaimed, her hands in the air. “We are open!”
This wall was more than symbolic. It was a metal wall installed so the Intensive Care Unit could better handle surges of COVID-19 patients. It went up during the first surge in the spring of 2020, and was steadily expanded as the number of Covid patients increased. During the biggest surges, last fall and winter, the wall came down, but for a different reason — because the ICU was completely full, with over 200 Covid patients, and a temporary ICU had been opened for non-Covid patients in the hospital recovery unit. The wall went back up as the winter surge receded, and then, finally, by the end of May, the ICU was Covid-free (save a single, chronic patient awaiting placement in a long-term healthcare facility) and the wall was taken down for what everyone believed was the last time.
“For the most part, we were hearing most people were getting vaccinated, and it felt good,” said registered nurse Lindsey Burrell. “It felt really good.”
The crew who’d worked inside the wall were different people than who they’d been 14 months earlier. They’d essentially gone through a war together. They’d worked seemingly unending weeks of 18 hour days. One doctor had worked 155 days straight. Some had not been able to see their parents and other close relatives for close to a year. Many had established protocols in their homes that meant they couldn’t hug their children when coming home from work. In a year’s time, all had witnessed suffering and death with an intensity they’d not experienced in the rest of their careers, even though they were accustomed to the tragedies and traumas for which ICUs exist.
“Here is the primary difference,” said Burrell. “In normal times, in the Intensive Care Unit, you were dealing with the sickest of the sick patients. I say to people, ‘If you meet me in intensive care, you are at your most vulnerable and possibly most terrible part of your life, because we are doing everything we can to save you. That is why you are in intensive care. So of course, we see heartache. We see tragedy. The difference when Covid hit is that normally you’d have family at the bedside crowding around and watching this person. Covid has taken out the humanity of this entire process. Now you are dying alone. Now you are dying without family.”
Several times, Burrell has held a phone above a dying patient, trying to lessen the fear he or she is experiencing by FaceTiming in family members.
“So you’re dealing with a family who’s grieving on the other end of the phone, and you are dealing with a patient who is passing and suffering with just you, who you otherwise just spent five minutes with before they were intubated,” Burrell said. “It’s very difficult for a nurse to be able to have that short term memory and walk out of the hospital and say, ‘Okay, I can leave it behind.’ Because you don’t. It haunts you every single time you close your eyes. You think of that person who is suffering in that bed and sobbing and pleading, begging not to be intubated.”
“You can’t shut that off. I don’t care who you are or how long you have been doing this. I truly believe that is why nurses are really suffering. We carry with us a tremendous, huge bag behind us of all the lives lost, all of their stories, and images of their families crying outside of our hospital, sobbing and begging to come in. That is the difference.”
Doctors have likewise been overwhelmed with a sense of loss. Dr. Anita Sircar, an infectious disease specialist who had previously fought outbreaks of malaria in South Sudan, cholera in Haiti, and Ebola in Guinea, experienced an awful realization during the early stages of the holiday surge.
“I have seen more deaths in the last eight months of this pandemic than I have in my entire career as a physician,” she wrote in an essay for the Easy Reader in December. “Young deaths. Devastating, never-saw-it-coming, ‘they were fine just yesterday,’ ‘how could this have happened?’ ‘they had no risk factors,’ ‘they were so young,’ ‘they just went to a birthday/retirement/Halloween /wedding party and they were fine,’ violent, catastrophic, heartbreaking deaths.
“Deaths where husbands and wives die hours apart in the same room. Mothers and sons, one day apart without saying goodbye. Fathers and sons one room down, neither knowing the other was next door. And these are not just here-and-there, random, one-off, anomalies of deaths, but daily, persistent, consistent, unpredictable and unrelenting deaths that never end.”
So on that day in May, Burrell punched the wall in the ICU, and was almost surprised when it gave way.
“Suddenly, the wall opens,” Burrell recalled.
“There was a lot of hope,” said Dr. Caleb Hsieh, a pulmonary and critical care physician who works in the ICU. “And a lot of release.”
The fifth surge
June passed with a sense of renewed normalcy. By July, a trickle of new COVID-19 cases began to arrive back in the ICU. By the end of the month, the trickle had become a flow. The wall went back up in the ICU. By the end of last week, the ICU once again was in full-pandemic mode, caring for more than three dozen Covid patients. The fifth surge had arrived.
Sircar saw it coming. In July, she took her first extended time off in 18 months, but it wasn’t really a vacation so much as preparation for what was to come.
“LA County withdrew the mask mandate June 15,” she said at the time. “By June 30 we were already seeing rumblings of this, with an increase of cases almost entirely comprised of unvaccinated cases. I predict the winter will be another surge in cases — not as bad as last year — and that we will start to see it in younger people more and more. The ´vulnerable’ at this level of the pandemic will be the unvaccinated and children.”
“We had a bit of a clearing, but we’re not out of the woods yet. The only way out is through, and the only way through is to keep vaccinating.”
Vaccination rates in LA County are slightly above the national average, with 5.5 million out of the 8.8 million fully eligible residents vaccinated (1.2 million children under the age of 12 are not yet eligible), compared to a national average just above 50 percent. What has caused the surge has been the extreme contagiousness of the new Delta variant of the novel coronavirus. The original virus had a basic reproduction number, known as R0, of 2 to 3, meaning that each infected person on average spread the virus to two to three other people. The Center for Disease Control estimates the Delta variant R0 is between 5 and 9, meaning each infected person gives the virus to between five and nine other people.
“It is a hunter,” said Dr. William Kim, chief medical officer for the Beach Cities Health District, referring to the Delta variant. “It is much more adept at finding an unvaccinated individual and affecting them, and then that individual almost exponentially can give it to others, including the vaccinated population — you know, there are a few breakthrough cases. But the good news is vaccines, particularly the messenger RNA vaccines, are pretty good at preventing serious disease with the Delta variant.”
But beyond the virus, something else has changed. Among health care workers, it has been called “compassion fatigue,” but it is also physical, emotional, and even spiritual fatigue.
“When you are going through this whole time, you have to draw strength from somewhere,” said Hsieh. “At some point, the well runs dry, and it’s hard to know where to go to fill it back up again.”
This is the optional surge. If more people had chosen to be vaccinated, it would not have happened.
“Personally, I have not seen one person who has come into our ICU who has stated that they have been vaccinated,” Burrell said. “They are all unvaccinated patients.”
And though this does not change the level of care doctors and nurses provide patients, it exacerbates an already overpowering sense of weariness. Hospitals were already in an exhausted state, both physically and economically. All the optional and outpatient surgeries that were delayed due to the pandemic were also the most profitable, which caused layoffs to non-essential staff in the midst of the pandemic. Meanwhile, a study conducted by the research firm Vivian in April found that 48 percent of ICU workers were considering leaving the profession. This has not occurred within the Providence Little Company of Mary ICU, but six nurses have indeed left, and those who remained are thus left with even larger burdens during this surge.
Lindsey Burrell at work in the Providence Little Company of Mary ICU. Photo courtesy Lindsey Burrell
The pandemic has been awash with tragedy since its arrival. But over the past month, health care workers have entered an even greater sense of tragedy. The patients are younger. Older people’s vaccination rates are much higher, and so Covid patients now tend to be in their 30s, 40s, and 50s. One of the patients Burrell cannot get out of her mind was a 38 year old man with a wife and children who did not survive. He was beyond being able to speak by the time she cared for him, but she sensed terrible regret in him. He was not vaccinated.
“The words that he did get out were just all sobbing and begging,” she said. “He just did not want to die. You know, this was coming from a very physically tough looking person — so, I mean, COVID has the ability to break down even the toughest. And I think that he was very regretful. For whatever reasons, and I don’t ask why, but most of the families volunteer, ‘We just didn’t get around to getting vaccinated.’ Or, ‘He just didn’t trust it.’
Outside of the hospital, Burrell has several times encountered people who tell her they don’t believe in the data surrounding the pandemic and don’t trust the safety of the vaccine. Her answer is simple.
“Look at the people who have gotten vaccinated,” she tells them. “They’re not being hospitalized. And if they are, it’s for a day or two, and they’re bouncing back, I mean, fine, don’t believe our data. I don’t know why you don’t. But the proof is in the pudding.”
“We were all begging for a solution and then we got it. Now people are like, ‘No, I am not interested. I don’t trust what’s in it. I don’t believe the data.’ It became politicized and it didn’t need to be… Just time after time, people will tell me, ‘Well, I don’t know what’s in it, there’s not enough out there about it.’ I say to them, ‘But when you come into the intensive care, did you do your research about all the medications I will put into your bloodstream to keep you alive? Because I can tell you that’s a hell of a lot more deadly than what you put into your body in the vaccine.’ We’ve been here before with polio. Look where we are. Come on, there is a solution. It’s here.”
A strange thing often occurs when an unvaccinated person arrives at the ICU with Covid. They ask for a vaccination.
“It’s like, ‘It’s too late. You’ve got Covid. You are infected,’” Burrell said. “And they say, ‘But there’s got to be something you can do to save my life.’ And we are going to do everything we can to save your life. But you might not be one of the lucky ones.”
Hsieh likens the experience of medical professionals faced with a population that is reluctant to vaccinate with firefighters encountering people who refuse to leave their homes, even as a raging wildfire approaches.
“I am sure the firefighters get tired of just constantly battling these California wildfires,” he said. “It’s probably even more frustrating if you are telling people that there’s a forest fire coming, please evacuate, please get out of your house. And then hours later, you have to go and rescue families that have chosen not to heed your warnings despite the fire bearing down on them. You have been giving these warnings and asking people to take safety precautions. But because they don’t, you have to step in and but yourself and your family at risk.”
“We know that patients aren’t always going to make the right choices, and we’re prepared for that,” Hsieh said. “We take care of alcoholics, we take care of people that smoke, and we do so gladly. We don’t hold any of that against them. I think it’s hard to pinpoint the difference here. Part of it, I think, is that the decisions some people make are also putting others at risk. So it’s not just themselves. They are harming other people, as well.”
Unconsidered costs
A game of roulette is occurring among part of the unvaccinated population. Because they tend to be younger and often don’t have obvious underlying health issues, their risk calculation is that even if they become infected with novel coronavirus, they will survive. Maybe they’ve had a friend or family member who contracted Covid and suffered only minor symptoms, or perhaps their favorite baseball player had Covid and was back on the playing field within 10 days. Whatever the calculation, the belief is that they are safe from the worst impacts of Covid.
The rough calculus carries some sort of scary logic. So far, 37 million Americans have contracted COVID-19 while 623,000 have died. What health care professionals are focused on, however, are not just mortality rates, but longer-term health outcomes for those who survive Covid. This concern has increased as the aggressiveness of the Delta variant is better understood.
“This is a whole new ballgame,” Burrell said. “They get sicker, they’re getting sicker faster, and they’re circling the drain much quicker than they were before. I’m really interested to see the outcomes. I think people have a tendency to just focus on mortality rates, which I get. But then describe surviving versus living — what does that mean to you? Because many of these patients are going out to nursing facilities, a breathing tube in their throat and feeding tubes in their stomach. I don’t know about you, but that’s not living for me. I define living as getting up, going surfing, being active, running, working out, like living my life and feeding myself. Living in a nursing facility is not living. That should scare people.”
Dr. Hsieh, as a pulmonary specialist, throughout the pandemic has been called in to treat Covid patients both before, during, and in some cases after they are in the ICU.
“We will often see patients before they reach the ICU. We work along with the infectious disease [specialists] to see if there’s anything else that we can do to curb the progression of hypoxia — the lack of oxygen,” Hsieh said.
Hypoxia means oxygen is not getting into your blood at sufficient levels. It is also known as oxygen starvation. Blood carries oxygen to the cells throughout your body to keep them healthy, so hypoxia can cause myriad problems, some minor and others severely damaging — anything from headaches and shortness of breath to heart failure and brain damage.
Hsieh said that even among patients who survive, oxygen often remains an issue. If you are in need of oxygen supplementation then you can visit medical gas outlets for available tanks.
“I had a couple of patients who had prolonged hospital stays and made it out, thankfully,” he said. “And in those patients, unfortunately, my guess is that they will probably require long-term oxygen. COVID-19 can cause long term damage to the lung resulting in pulmonary fibrosis, in which basically your lungs scar. And those scarred lungs are no longer able to exchange oxygen and carbon dioxide. So, often supplemental oxygen is used to increase the percentage of oxygen in the air that you breath, that will allow the body to function.”
Not every patient with this outcome is unable to resume a somewhat normal life. But most must endure reduced abilities to breathe normally.
“I had a patient who, before the pandemic, was able to run every day, and do long-distance running,” Hsieh said. “Now, that patient is still able to run, but notices that they get fatigued easily and can’t keep up any more with their running partners.”
Other long-term impacts include loss of the ability to taste food, insomnia, chronic fatigue, and headaches.
“There’s all sorts of these impacts that you don’t see,” Hsieh said. “Endpoints in most of the literature are morality, death, ICU length of stay. But outside of those, there are all these other long-term impacts, as well.”
Many long-term costs of the pandemic are beyond measure. For health care workers, even those who remain devoted to the profession, those losses include more than a year of diminished and often fraught family life.
Burrell is one of those people who is all in with whatever she does. For her, nursing is less a job than a calling. Her mother, Julie Baker, has been a nurse for 48 years and works alongside Burrell at LCM.
“My mom is still working,” she said. “I thought this was going to break her and force her to retire. But I think I get a lot of my personality from her, and she said, ‘How can I turn my back on the community during such a terrible time?’”
Burrell is taking a break. She will return, but as a mother of a three-year-old and a five-year-old, she finally had to take some time away. The arrival of the new surge made it painfully apparent to her that this battle is a long way from over, and so she is recharging for the long winter ahead.
“I don’t have a full tank,” Burrell said. “Because I think to come back and fully mentally, emotionally, and spiritually heal from what we just encountered in the last year, that doesn’t happen overnight. And it certainly doesn’t happen in a couple of months. I’ll speak for myself. I didn’t have the opportunity to refuel myself and give myself what I needed. We were just kind of thrown in the thick of it again, without that chance to reboot that you need. You need a whole new mental strategy when you go into a war like this. And when you hear states around the U.S. saying, ‘Screw it, we’re not getting vaccinated, yet I want you to pull out every heroic measure known to man to save my life when I do become sick…’ It’s morally defeating.”
“I love what I do. My work is my life, and I would never turn my back on it. But this time around, I’m not mentally in the game. And I knew that I needed to take a pause.”
A concern for health care workers is not only their own mental and physical health but that of their families. Hsieh has had the unusual experience of becoming a father right as the pandemic began.
“My wife and I, we had our first daughter at the very beginning of the pandemic,” he said. “She was born the day all the hospitals shut down in March. So I was lucky in that I was the last father allowed into the labor delivery ward before they just closed it off completely to all fathers. And I count my blessings. I was able to be there for my daughter’s delivery.”
But this also means that all his daughter has thus far known in life are the altered conditions of a pandemic. And perhaps even worse, when Hsieh held his daughter in his arms after returning from work, a terrible, nagging thought often visited him.
“There was just always this constant fear of, ‘Am I going to potentially transmit this to her?’” he said.
Burrell had a touching conversation with her five-year-old son this week.
“Mommy, what do you have to go back to work?” he asked.
“Baby, I´m off right now,” she said. “I’m home. I’m here with you.”
“I really miss you,” her son said.
This conversation replaced another that had become sadly routine.
“Are you going to go in Covid today?” the boy would ask her. “If you are going to Covid today, I can’t touch you.”
“No baby,” she’d reply. “You can’t touch me.”
Lindsey Burrell, enjoying a break from work with her children. Photo courtesy Lindsey Burrell
A week off has left Burrell feeling like a new person.
“I had no idea how much I was mentally struggling until I stepped away and just kind of let myself crumble a bit, because I just needed that, and just being with my husband and kids,” she said. “I am a nurse, but the first thing I am is a wife and a mom, and those are the two most important jobs I have in my life.”
Burrell knows that her kids have experienced a different kind of mother over the last 18 months.
“I was very short-tempered, very distant, physically there but not emotionally,” she said. “My husband would notice my mood swings, like, ‘I can tell you’ve got to work today because you are so anxious and so worked up.’ But now I’ve had a chance to step away and just kind of clear my head and not be involved in the numbers and death for the first time in a year and a half.”
“I haven’t seen a person die in the last week, and that is amazing,” Burrell said. “I feel like I’m seeing nothing but great things around me. I’m very thankful for my life, and I’m very thankful to be alive.”
Burrell said she is often asked if she will allow her children to be vaccinated when vaccines are approved for children under 12. The answer is an emphatic yes.
“I have said, time and again, if there’s a .00001 that there’ll be a long-lasting effect [from Covid] on my children, I would never take it. I want no chance,” Burrell said. “And if that vaccine becomes available to my children, yes, absolutely I will vaccinate them. I want nothing more than to protect them. I need to give them that chance to fight off Covid like we have. I think it’s a matter of time, especially now that we’re seeing a rise in pediatric cases and a rise in the side effects from Covid for pediatric cases. Meanwhile, we all live in fear. And that’s what most of us nurses are going through, is that people forget that we’re humans and we have families too. We devote our lives to our work, and our patients, but we have families at home to worry about.”