In early March, Vic Gara came down with severe muscle aches, headaches and a rising blood pressure, indicators of COVID-19 that weren’t well understood early on in the pandemic.
“Taking a shower, just the water hurt my body,” he said. “I couldn’t sleep. I slowly became hypoxic. I just couldn’t breathe.”
Eventually, he was admitted to Hartford Hospital, where he was quarantined immediately and separated from his wife, Laura.
“My wife was walking in from after parking the car, and I saw her from maybe 15, 20 feet away and I just barely raised my hand and said goodbye to her,” Gara recalled. “And I was there for a month.”
The 57-year-old was intubated and spent 11 days on a ventilator, which helped him breathe, before he regained consciousness. Like so many others who required intensive care, Gara was first transferred to a rehabilitation hospital for a short time before he could return to his home in West Granby.
He thought the worst was behind him. But by midsummer, Gara struggled with exhaustion, his headaches returned, he had poor balance and trouble speaking and “brain fog” had set in. Then he joined an online support group for COVID-19 survivors.
“Not until I was contacted did I find out, ‘Oh my god, there’s other people like me that are suffering almost identical situations,’” he said.
There is an untold number of COVID-19 survivors worldwide who struggle with long-term symptoms and complications from the virus. Scientists don’t yet know how common this occurs, but what they do know is symptoms can be both physical and mental in nature, and they can delay people from making a full recovery.
As the phenomenon becomes more well-known and researched, health organizations across Connecticut and the country are creating and expanding dedicated COVID-19 recovery programs to help survivors.
“We’re now seeing patients that have had some of those symptoms for eight, nine months,” said Dr. Jerry Kaplan, outpatient medical director at Gaylord Hospital in Wallingford. He runs the organization’s new COVID-19 recovery and rehabilitation program.
The hospital created an online support group over the summer for former COVID-19 rehab patients like Gara. Kaplan said that’s when patients came forward with a wide range of lingering health issues.
Gaylord opened its specialized outpatient program in early fall, and it provides COVID-19 survivors with occupational and physical therapies, nutrition education, psychological treatment and other services.
“Even if you can’t do everything you were doing before, we can get you to the highest possible functional level,” Kaplan said, “and that’s really what the program is designed to do.”
The program has picked up in the last several months as long-term complications from COVID-19 illness become more well-known.
“As we see more patients hospitalized with COVID now, we will continue to see the need for COVID recovery programs in the future,” Kaplan said.
The Post-COVID-19 Recovery Program at Yale Medicine opened several months ago as a Friday clinic with a small patient roster. Dr. Denyse Lutchmansingh said it has now expanded to three days a week as more patients and medical clinicians discover the program.
“I think early on, people would say, give it a couple of weeks and you should feel better,” she said. “And now we’re well past that give-it-a-couple-of-weeks period and people are still having symptoms.”
Lutchmansingh, a pulmonary and critical care physician who leads the Yale recovery program, said she and her colleagues initially expected that patients who had had moderate to severe COVID-19 illness, like Gara, would be the ones needing long-term recovery services the most.
That’s only been partly true.
“Patients who were classified as mild disease have also had persistent symptoms almost as severe as a patient who was hospitalized in an intensive care unit, and that has been quite eye-opening,” she said.
Lutchmansingh said the clinic is also seeing a surprisingly young population. She has patients in their 30s and 40s who were runners, athletically inclined, or generally in good health prior to getting a mild case of COVID-19 “who now struggle to walk up a flight of stairs.”
It’s some of these patients that Lutchmansingh has seen struggle the most mentally with their persistent symptoms.
“Because they expected to recover very quickly and move on,” she said.
Dr. Serena Spudich is the division chief of neurological infections and global neurology at Yale School of Medicine and leads a designated neuro-COVID clinic, which opened in October.
Her team collaborates with Lutchmansingh and other clinicians in the greater community to get referrals for COVID-19 survivors suffering with tingling and numbness, loss or impaired senses of smell, taste and hearing, headaches, cognitive impairment and other complications.
Many of these patients were never hospitalized or never required intensive care for COVID-19.
This is where more research can help make sense of the trends that health providers are seeing in their COVID-19 “long hauler” patients, Spudich said.
“I think it’s really important to try to understand why some people get these neurologic issues, and many people don’t seem to,” she said. “I know lots of people who’ve recovered from COVID who seem completely fine.”
Scientists are still trying to estimate exactly how many people in the world ever had COVID-19, including those who never got tested or people who got false negative results — cases that have not been recorded.
Only then might health experts know how common or rare long-term complications are among survivors, Spudich said.
“I think it’s important to be aware of them, to understand them and of course provide treatment for them,” she said. “But I worry that it’s sort of a fire that can take off where all the social media, all the press attention will suddenly make a lot of people think, ‘Oh, I’m having post-COVID problems.’”
“What is really, really important is getting patients who are having symptoms to a provider who can really critically take care of them and try to understand clinically what’s happening with them.”
What patients often want to know is, when will their health get back to what it was prior to COVID-19? And health experts don’t yet have a good answer to that as scientists continue to follow survivors in their recovery.
“We always make it clear to the patients that we don’t have all the answers. We are looking for answers,” Lutchmansingh said. “We remain hopeful, we have seen patients improve and build back to baseline, but it is a long pathway and it is not necessarily an easy pathway.”
For Gara, he continues recovery treatment at Gaylord on an outpatient basis. He tries to get outside more and build up his endurance with walks. For the most part, he takes it one day at a time.
“I went into it with an open mind and trying to stay positive,” he said. “I learned how to be more positive and look for the good rather than the bad. It helps.”
When Ashley Antonio contracted covid-19 in late March, the Canadian criminal lawyer fought against the common symptoms that come with most cases: fever, body aches, fatigue, headaches.
She would manage her symptoms at home and eventually overcome them, she assured herself. After all, she was a healthy 35-year-old with no underlying conditions who boxed and did strength training four times a week.
Except the symptoms never really went away — they intensified.
Now, 259 days later, Antonio is still suffering the repercussions of a virus that has upended almost every aspect of her life.
She has been in and out of the hospital four times in almost nine months. Her doctors have diagnosed Antonio with arthritis and a condition that causes her heartbeat to dramatically increase when she stands up. Both are long-term effects of the virus, they told her. They also don’t know if, and when, those symptoms will go away.
“Everyone is just told you either recover or you die,” Antonio told The Washington Post on Tuesday. “There’s never talk of all the people that are trapped somewhere in the middle with all of these long-term effects. We’re not recovered. We’re just not covid-positive anymore.”
Antonio is not alone. Doctors still aren’t sure why “long-haulers” continue to suffer the consequences of the disease months later or whether the symptoms will stay with them for the rest of their lives. But public health experts say it’s increasingly clear that many thousands of patients face long-term effects from the virus.
Long-haulers “are in every country, in every language,” Igor J. Koralnik, who started a program for covid-19 neurocognitive problems at Northwestern Memorial Hospital in Chicago, told The Post in October. “It’s going to be a big problem. It’s not going to go away.”
So far, clinicians have learned the long-term effects can impact both the old and the young, regardless of whether the case was mild or required hospitalization. Many long-haulers have turned to social media groups to share their experiences and advice.
Antonio, who lives in Edmonton and whose story was first reported by the CBC, said she had been taking precautions and working from home for a month before she got sick. Her best guess is that she caught the virus on a run to the grocery store. She began feeling symptoms around March 25.
But because she did not have a cough, which doctors and health experts then said was one of covid-19′s main symptoms, Antonio thought she only had a stomach flu.
She stayed home and started to feel like herself again days later. But every time she thought she was recovering, symptoms would return. In the next three months, old symptoms and new, graver ones left Antonio tied to her couch. The fatigue was so bad she could shower only a couple of times a week. Her blood oxygen levels would drop dangerously low whenever she took short steps. One day, her brain was so foggy that she could not remember how to hold a glass.
It wasn’t until mid-May when she was taken to the emergency room for the first time. Alone in her bedroom and fighting a high fever, Antonio began hallucinating. Then, she could not feel half of her body or her face. The hospital tested her for the coronavirus, but her results came back negative so she was sent home. About a week later, she was back. She would return two more times in the following months.
“I had every test you could imagine,” she said. But her doctors could still not figure out what exactly was wrong with her. An emergency room doctor suggested she might have long-term covid-19 effects and referred her to a special clinic.
In June, she tested positive for coronavirus antibodies. In July, doctors at a clinic for coronavirus survivors diagnosed her with arthritis and a condition that causes her heartbeat to raise significantly when standing. “But doctors couldn’t explain why my oxygen was still dropping every time I walked or any other symptoms,” she said.
Antonio turned to other long-haulers for more information, joining a Facebook group where she learned, for example, that she wasn’t alone in smelling cigarettes when no one was smoking near her. Other people experienced random smells too, they told her.
“I had a lot of questions and the doctors didn’t have a lot of answers. It was all so new to everyone,” Antonio said. “I just wanted to see if what I was experiencing was ‘normal.’ It was very comforting to know that I wasn’t alone.”
Although her symptoms persisted, in August, Antonio voluntarily returned to the law firm where she works as a criminal lawyer. Some days, she feels okay. But the increased heart rate, shortness of breath, joint pain and headaches are usually daily ailments. She also still suffers from blurry vision and gets skin rashes. Her doctors have now told her it’s possible that her long-term symptoms will come and go for the rest of her life. For now, Antonio said she is taking it one day at a time.
“I’m definitely worried it will be permanent,” she said. “It’s very overwhelming if I think that this is how the rest of my life is going to be.”
Antonio added: “When I have a good day, I no longer think that it will be over. I know I’ll have bad days again. It makes you feel hopeless.”
They have been at this for almost a year. While politicians argued about masks, superspreader weddings made the news, a presidential election came and went, and at least 281,000 Americans died, nurses reported for work. The Post asked seven ICU nurses what it’s been like to care for the sickest covid patients. This is what they want you to know.
As of Dec. 7, Idaho has seen 110,510 total confirmed cases, 1,035 deaths, and 477 people are currently hospitalized with the virus.
Kori Albi, 31
Covid unit intensive care nurse and unit supervisor, Saint Alphonsus Regional Medical Center
Our staff are getting sick. Our physicians are getting sick. And they’re not getting it from the hospital. They’re getting it from the community. We are almost lucky to care for the covid patients because we know who they are. Anytime we go into these rooms, we know exactly what we need to do. We have all the PPE we need. And as long as we are diligent and follow all the processes that are in place, we can keep ourselves safe. That’s not what worries me at all. Going out into the community is scarier than coming into work every day. Because you don’t know who has it.
This virus has caused this feeling, this sense of isolation. The covid unit is an isolated desert. Every door is shut. Every room has negative airflow. By the time you put your N95 mask on and then your surgical mask over the top of that, then you put your isolation gown on and your face shield on top of that, you can’t tell who is who. So much of health care is about that personal touch — now, our patients can’t even see our name badges because they are on under our gowns. All they see are our eyes through our face mask.
A lot of families are hesitant to have Zoom calls with patients because it can be uncomfortable and awkward. Especially if these patients are sedated and intubated. There’s always that awkwardness of: Can they hear you? Can they not hear you? Even as nurses, we feel like we’re talking to the wall. But we talk to them just as if they were awake. Allowing families to play their music that they like or pray with them or just talk to them can absolutely help. You see vital signs change.
One patient, all she wanted to do was have her son sing her a song. I think I spent over an hour in the room listening to him play the guitar and sing her a song. He sang her mostly hymns.
Death is a very intimate event that normally involves a lot of family members that help bring closure and that helps everyone process. In normal circumstances, health care providers form these relationships with the family at the bedside. All of that has been removed. And we now have to try to form those relationships over the telephone. It’s a traumatic experience. And it’s a long drawn-out process. A lot of people don’t make it out of here. It’s a slow, lonely death.
The amount of death with covid is profound. As nurses, we have learned to process death, but the amount of death has happened in such a short span of time — that’s what’s been overwhelming. I had a patient that we did a Zoom call with. His four-year-old granddaughter lived with him. And she brought tears to the room. The naivete of a four-year-old. Her grandfather was intubated so he couldn’t talk. But he could kind of look around the room. But the innocence of her, saying, “Come home, Pa. I miss you, Pa. I love you Pa,” all through a video screen. The 14-year-old that also lived with them couldn’t formulate words to say anything, and he didn’t know what to do or say in that video. But the four-year-old was telling Pa to come home.
As of Dec. 7, Mississippi has seen 166,194 total confirmed cases, 3,961 deaths, and 1,157 people are currently hospitalized with the virus.
Catie Carrigan, 28
ICU, University of Mississippi Medical Center
There are some patients who have been in their younger 20s and their younger 30s, and I think maybe those are the hardest cases. They have families and they have kids just like I do, and it’s hard coming into work and taking care of them. Knowing they’re supposed to be going to college, they’re supposed to be getting married, they’re supposed to be having kids and, instead, they’re laying in a hospital bed on a ventilator fighting for their life.
They have their whole entire lives ahead of them, and then they get hit with this disease that everybody thinks is a hoax and then they die.
I worked in the ER a month ago, so I know exactly what’s going on down there, and now I work in the ICU, so I know exactly what’s going on on both sides of it. There are no ICU beds in the hospital. None. When there are no ICU beds, we hold them in the ER, or we hold them in the PACU (post-anesthesia care unit). The ER still has to treat our trauma patients, our car accidents, our gunshot victims. So when we have those ICU holds in the ER, it obviously makes the jobs of nurses and doctors in the ER way more difficult than it needs to be. We are treating patients in the hallway. They’re just trying to do the best they can with the resources that we have.
There is no room left, essentially, and I think that’s really what people don’t seem to understand. And I get it, when you’re not in health care you don’t really see our side of it, but we’re seeing the worst of it. It’s hard for us to convey that to the public because they don’t seem to want to take our word for it — but take our word for it. Take our word for it.
As of Dec. 7, Iowa has seen 244,844 total confirmed cases, 2,717 deaths, and 898 people are currently hospitalized with the virus.
Allison Wynes, 39
Medical intensive care unit, University of Iowa Hospitals and Clinics
I cry every day when I walk in to work, and I cry every day when I walk to my car after work.
You get it out of your system before you show up and you do your job and you’re fine. Then, you go home and you cry before you get home. And then you go home and be mom.
My 9-year-old daughter asks frequently, “Mommy, how many patients were there today? Mommy, how many sick ones were there today? Were you safe? Was everything okay? Do you have to go to work again? How many patients?” She gets it.
I think one thing that people do not appreciate is it’s not only the number or volume of patients that comes through — it’s the level of care that they require, which is so much greater than a standard patient in the ICU or a standard patient in the floor, because they can get very, very sick very quickly.
We were walking a patient who was on ECMO, which is extracorporeal membrane oxygenation, and it took five people to walk her. That’s not normal.
I work in the MICU, so it’s never like a party up in here, but it used to at least be, nine times out of ten, calm and controlled and tidy and clean. Occasionally stuff would go bad and we would all run and help, and then we would all go about our days. Now it just feels like, especially of late, there is equipment everywhere. There are gowns everywhere. There are gloves everywhere, there are people everywhere, and there are fires everywhere.
I’m actually scared, and I’ve never been scared at work before. I am scared that we will lose control.
It’s the human resources we are running low on. We can make a bed, we can find a ventilator, we have PPE. But it’s the human cost of caring for these patients that has been keeping me up at night the past couple of weeks and really making me nauseous every day.
I didn’t think it would be over by now, but I didn’t think we’d be getting hit this hard this late. I thought we’d still just be smoldering. I didn’t know that we would just be a raging fire at this point in time. We’re not prepared for that, but here we are.
After this, I’m going to take my kids to a beach or somewhere.
As of Dec. 7, Illinois has seen 796,264 total confirmed cases, 14,216 deaths, and 5,190 people are currently hospitalized with the virus.
Luisa Alog Penepacker, 51
ICU, Glenbrook Hospital
I’ve taken care of a lot of husband-wife patients, unfortunately. One of the cases was one in which the husband had tested positive for covid first, but he was a mild case. She was a little bit more serious. She ended up on our unit.
The husband ended up in the hospital the next day, but he was on the step-down unit. When I admitted her, she was terrified, especially knowing that her husband was upstairs in another unit. She was having a hard time breathing, and she grabbed onto my hand and looked at me. She goes, “Am I gonna die?” I mean, I didn’t know what to say. And I just told her, “Not on my watch.” So we just kept on going. But unfortunately, she got intubated the next day.
Then I was sent to work upstairs on the step-down unit. I had her husband that next day, and he was actually quite happy that I saw her. He goes, “You took care of my wife, how is she? I heard that she’s not doing well.” I didn’t know what to say to him, either. I just said, “You know, she’s in the best of care. We’ll take really good care of her.” And he looked really relieved. He goes, “I’m just so glad that someone who had seen her is here now to talk to me.” And my heart broke with that.
She ended up passing. A few days after, he went home, and I didn’t see him, so I don’t know how he took it. He wasn’t able to see her before she passed.
We wear personal air purification respirators on our heads — these big white domes over our heads with a respirator hose going to a machine strapped around our waist, and we look like astronauts walking through the unit, going in and out of patients’ rooms with our plastic gowns and gloves.
It can be frightening to family members if they’re allowed to come to visit and definitely for patients because we’re kind of scary-looking. It can be frantic at times. You walk through the hall, and you see a lot of patients on ventilators. You hear a lot of beeping. People are rounding constantly to check on patients. It’s a busy place.
You don’t know what to tell family members when you see them. What can you say? You just say, “I’m sorry.” You can’t even hug them. I used to be able to hug family members, but you can’t with all the gear.
When patients are scared, I will hold their hand even though I’m wearing gloves. I look them in the eyes as much as I can because really, that’s all you can see. You can’t see our faces. You can barely even hear past the mask. So I’ll make sure to look at them. I try to make an effort to smile with my eyes and to just hold their hand if they need it.
As of Dec. 7, Utah has seen 215,407 total confirmed cases and 939 deaths.
Tammy Kocherhans, 41
Respiratory ICU, Intermountain Healthcare
These patients are different than the typical patient. They’re very complex. They can change in the blink of an eye. And it’s very hard as a nurse when you wrap your heart and soul into taking care of these patients. I started noticing that I was emotionally tired. I was physically completely exhausted. And I was beginning to question whether or not I could continue forward being a nurse at all. I was past my physical capacity.
I happened to be working a day where another health care worker who was a veteran said that this was like a combat zone, and for some reason in my head, that validated the way that I was feeling. So I reached out to one of my best friends who is a veteran, a flight medic, and he said, “I meditate and do yoga.”
Once I started doing that, I was able to handle the emotional crises, the physical pain of working so, so many long, hard hours. We do something called proning, where you take patients and flip them over onto their bellies. And that sounds really easy, but it takes a team of a minimum of five people. It is extremely taxing on your body. It hurts. And I lift weights! The meditation and yoga really has saved my life, my mental capacity, my spiritual capacity, my physical capacity, everything that is required to give to these patients.
Hopefully by 8 p.m., I’m out in the parking lot and spend a minute in my car to unload from my day. It’s all about taking a moment to breathe for myself and then going through whatever came up that day that I need to let go of. It depends on how complicated my patient was that day, whether I can let my whole day go or if I have to spend time to go through each piece and work it down to: What did I do right? Did I miss something? Sometimes I just can’t let some details go quickly, and I have to work them down to allow myself to say I did everything that I possibly could for this individual this day, in this time, in this situation. And whatever the outcome was or is, I followed protocol. I did everything that I knew how to do. And it’s going to be OK.
I find it very frustrating when I go out and about on my days off and I see people very blatantly not wearing masks or trying to tell me how come they don’t work or telling me that this pandemic isn’t real. I find it completely disrespectful to the work we do to save people’s lives, to have people think that this pandemic isn’t real, to show utter disregard for people around them, not trying to do their part.
And I really wish that I could take people on a day with me so that they can see what I see. So that they can feel your feet ache so bad that you wish they’d just fall off, because you’re on that concrete for so many hours. Your back aches because you’re wearing equipment to save your life — so that you can save somebody else’s life. And your head hurts. I’ve never had so many headaches in my life because part of the equipment sits on your head, and after 12 hours, it starts to exert so much pressure that you start to have a headache, and you’re dehydrated.
Early in the pandemic, I remember walking into this room, and this young patient was crying and asked me if they were going to die. And I’m a mom of teenagers. For me, that was awful because this patient was all alone, and we as staff were minimizing contact because we didn’t want to get the virus.
This patient started physically trembling in the bed. I couldn’t take it anymore, and I went over and just held this patient because that’s what I’d want somebody to do for my children. That was my first patient that I held like that. And there have been many since.
As of Dec. 7, Utah has seen 215,407 total confirmed cases and 939 deaths.
Nate Smithson, 28
Respiratory ICU, IntermountainHealthcare
A few weeks ago, my wife and I were on a date at a restaurant. And in the middle of nowhere, I had this panic attack and went and hid in the bathroom stall for half an hour. I have no idea what brought it on. I just couldn’t handle being there right then, which was weird for me. That’s the first time anything like that has happened. But since then, it’s happened multiple times, where the anxiety and stress is overwhelming, and I can’t handle it. So I have to go and excuse myself for a little bit.
Balancing work and life is something that used to seem possible. Now it doesn’t seem like there is any difference between the two. I fall asleep and I dream about my patients.
When we got our first covid patient in February in the hospital, in the ICU, we all kind of thought it was a little bit of a joke, to be honest. I had this patient, and he was sitting there with minimal amounts of oxygen in the room just watching TV. He’s like, “I’m fine. I don’t know why everyone’s freaking out about this.” And I thought the same thing. And then a few hours later, he stands to go pee, and I’m looking at his monitor. And it drops down to the low 90s. Ninety-two is about as low as you want to go. And then it starts dropping down lower, to about the 70s. Then it gets down into the 60s and 50s. And that’s dangerous territory. That’s where brain cells start dying and you start having some serious problems.
I run into the room. We get him back into bed and throw all the oxygen that we have in the room on him, crank everything up, and he’s not recovering from it. We had to intubate right then and there. And about an hour later, he finally starts recovering a little bit. But at this point, he’s sedated, he’s on the ventilator. Everything is worse. And that’s the first time where it’s like: Oh, crap, this is serious. This is something else. I’ve never seen anything like that before.
If a patient’s heart stops or if they stop breathing, we call a code blue, and that’s when the doctor, respiratory therapist, nurses, everybody comes into the room. We start chest compressions or CPR or that kind of stuff. This one patient’s heart is not working. So I call the code blue. We all get in there. We start doing the chest compressions. Five minutes later, we get the patient back. We all go back about our work. Twenty minutes later, same thing happens again. We start doing the chest compressions. We start pushing medications as fast as we can to get the patient back again.
The spouse comes into the hospital. I explain: “Just so you know, this is what happened before. It could possibly happen again. If it does, I’m going to need you to step outside of the room.” And as I’m explaining this, sure enough, it happens again. We lose the pulse. We lose the heartbeat. So I ask her to leave the room. Everyone gets in there, and we start going for it. We went for almost two hours: chest compressions, pushing medications, shocking the patient’s heart.
The doctor is ultimately the one who makes the decision about when we stop, and they call time of death. But typically in situations like that, where it’s unexpected and sudden, they want to make sure that everybody can go home that night feeling OK about what they did, knowing that they did everything. And after an hour, he stops, turns to the room and asks: Does anyone have a problem with us stopping?
I didn’t have a problem, but then as he’s saying that, I look out the window, and the patient’s wife is just watching us. She’s been sitting out there watching us for an hour, and no one’s saying anything.
And I ask them to keep going.
So we did. We went almost for another hour after that, and we didn’t get the patient back. He ended up dying.
But I think for me, that was important — to keep going. Not because we thought we would get them back, but so that his wife would know that we did everything we could.
I still go to bed with her face kind of burned into my mind, of just seeing her sitting out there watching us, and that’s what kills me.
As of Dec. 7, Ohio has seen 475,024 total confirmed cases and 6,959 deaths.
Kahlia Anderson, 32
ICU, Ohio State University Wexner Medical Center
I graduated from nursing school in May 2019. I started here at the Wexner in August. Our orientation is a 20-week program, and so I came out on my own Jan. 12, 2020. The pandemic hit us at the end of February.
In nursing school, I think your biggest fears are making med errors, or harming your patient in some way, or just not knowing how to do everything. Did I check my patient’s blood pressure before I gave this blood pressure medication, or did I give the correct dose of a specific medication? I had heard stories about that on the unit, like make sure you’re careful with the needle stick, or make sure you’re careful with this medication. And I don’t even think about those kinds of things anymore.
Now it’s the fear of the unknown. It’s the fear that anything could happen because of this virus and my patient could die regardless of what I do.
When I got my first covid-positive patient, I remember thinking: Somebody did the assignment wrong because there’s no way that they believe that I should be taking care of this patient. I can remember the feeling. I can remember the day. It was a weekend. I was on a day shift. And I was thinking to myself: Who trusted me, the new nurse to take care of a covid-positive patient? How am I going to do this? How am I going to keep this patient safe? How am I going to keep myself safe? Am I safe? Wait, who cares about me? Let’s get back to the patient. What do they need?
At the time, I didn’t even understand some of the ventilator settings because I was still that new, and it was still that fresh to me. And I thought: This machine is doing that much work for them, and I don’t know enough about it, but I’m going to make sure that I get it done and I’m going to figure it out today to make sure that this patient gets everything that they need. And I’m going to call their family and double check with them and check in with them and call them.
That patient is alive. That patient is no longer in the hospital. As far as I know, that patient is home and safe with family.
I would feel like: There’s someone more experienced. There’s someone more adequate to deal with this. And I was like — oh, it’s me. This is me, I’m doing this, and I’ve been doing it ever since.
I saw new nurses come out of orientation, and I saw the type of assignments that they would get. So my mind fixated on like: I’m going to get patients that are ready to transfer out. They can talk, they can eat. They’re just waiting for a bed on another unit. Or maybe it’s a patient who needs long-term care. So they’re waiting to go to a facility to be discharged. And so I was thinking to myself: I’m going to get my feet wet. It’s going to be great. I’m going to build up this experience, and then I’m going to start getting sicker patients, and I’m going to be ready.
Once covid hit, there was no room for those types of patients anymore. Everyone had covid, everyone was sick, everyone was intubated or approaching intubation.
And for me, I just wanted my first experience. I wanted to have the simple experience of building and getting better. But that’s not what was in store. And I can’t say that I’m upset about it today. I’m grateful for this experience. I don’t wish this pandemic on anyone. I wish it was not here. I wish that it was different. But as a nurse, as a new nurse, these experiences are unique to me. It’s making me a better nurse. It’s made me a better person, and I can only continue to just be.
We did cry in the beginning, and now not so much. I think we all struggled when we had a young death. Someone in their 20s was very difficult for us. Because you think: That was a young life. What a young life that was, and they’re not here anymore. Because of a virus. That’s hard. It’s very hard.
AstraZeneca on Monday became the third pharmaceutical company to announce remarkable results from late-stage trials of a coronavirus vaccine, saying that its candidate, developed by Oxford University, is up to 90 percent effective.
This is the third straight week to begin with buoyant scientific news that suggests, even as coronavirus cases surge to devastating levels in many countries, an end to the pandemic is in sight.
Pfizer and its German partner BioNTech and Moderna have each reported vaccines that are 95 percent effective in clinical trials. A direct comparison to the Oxford-AstraZeneca vaccine is complicated, due to the trial design, but the vaccine may be a more realistic option for much of the world, as it is likely to be cheaper and does not need to be stored at subzero temperatures.
Peter Piot, director of the London School of Hygiene & Tropical Medicine, who was instrumental in the battle against AIDS, said the positive results from three vaccine candidates cannot be overestimated.
“2020 will be remembered for the many lives lost from covid-19, lockdowns and the U.S. election. Science should now be added to this list,” said Piot, adding, “the only way to stop covid-19 in its tracks is having multiple effective and safe vaccines that can be deployed all around the world and in vast quantities.”
“I’m totally delighted,” said Hildegund C.J. Ertl, a vaccine expert at the Wistar Institute in Philadelphia. Adding to the results from Pfizer and Moderna, “what it tells me is this virus can be beaten quite easily: 90 to 95 percent efficacy is something we’d dream about for influenza virus, and we’d never get it.”
The Oxford-AstraZeneca team said in a video conference with journalists that its candidate offered 90 percent protection against the virus when a subject received a half-dose, followed with a full dose one month later. Efficacy was lower — 62 percent — when subjects received two full doses a month apart. The interim results, therefore, averaged to 70 percent efficacy.
Andrew Pollard, chief investigator of the Oxford trial, said the findings showed the vaccine would save many lives.
“Excitingly, we’ve found that one of our dosing regimens may be around 90 percent effective, and if this dosing regimen is used, more people could be vaccinated with planned vaccine supply,” he said.
Britain has preordered 100 million doses — which at a dose and a half per person would cover most of its population. The United States has ordered 300 million.
The results have yet to be peer-reviewed or published, and will be scrutinized by regulators. Many questions remain, including whether the vaccine can reduce transmission of the virus by people without symptoms, which would have repercussions for how soon people could stop wearing masks. It is also unclear how long the immunity from the vaccine lasts — a crucial question.
Sarah Gilbert, a lead Oxford researcher, cautioned that the dose-and-a-half regimen would have to be more closely studied to be fully understood. But she said the first half-dose might be priming a person’s immune system just enough, and that the second booster then encourages the body to produce a robust defense against sickness and infection.
AstraZeneca and Oxford have been conducting Phase 3 clinical trials worldwide, with the most recent data coming from an interim analysis based on 131 coronavirus infections in Britain and Brazil among 10,000 volunteers, with half getting the vaccine and half getting a placebo.
The company said it would present the results to Britain’s health-care products regulators immediately and would seek approval to fine-tune its clinical trials in the United States, to further assess the half-dose shot followed by a booster.
Because the vaccine is already in production, if approved, the first 4 million doses could be ready in December, and 40 million could be delivered in the first quarter of 2021, company executives said. By the spring, the company and its global partners in India, Brazil, Russia and the United States could be cranking out 100 million to 200 million doses a month.
British Health Secretary Matt Hancock said “should all that go well, the bulk of the rollout will be in the new year.”
In a statement to Parliament, Prime Minister Boris Johnson said that vaccines were “edging ever closer to liberating us from the virus, demonstrating emphatically that this is not a pandemic without end. We can take great heart from today’s news, which has the makings of a wonderful British scientific achievement.”
World markets have rallied on optimistic vaccine news, though shares in AstraZeneca were down Monday on the London stock exchange.
No participants who received the vaccine developed severe cases or required hospitalization, AstraZeneca said Monday. The drugmaker also said that no “serious safety events” were reported in connection with the vaccine, which was typically “well tolerated” by participants regardless of their dosing levels or ages.
The vaccine uses a harmless cold virus that typically infects chimpanzees to deliver to the body’s cells the genetic code of the spike protein that dots the outside of the coronavirus. That teaches the body’s immune system to recognize and block the real virus.
Although the reason the regimen with an initial half-dose worked better remains to be teased out, Ertl said that it could be related to the fact that the body’s immune system can develop a defense system to block the harmless virus that’s used to deliver the spike protein’s code. Giving a smaller initial dose may lessen those defenses, and make the vaccine more effective.
Several other vaccines in late-stage development use a similar technology, harnessing a harmless virus to deliver a payload that will teach the immune system how to fight off the real thing — including the Johnson & Johnson vaccine, the Russian vaccine being developed by the Gamaleya Research Institute and the vaccine made by CanSino Biologics in China.
While the results released by AstraZeneca indicate somewhat lower efficacy than Pfizer and Moderna, the vaccine can be stored and transported at normal refrigerated conditions for up to six months. That could make it significantly easier to roll out than Pfizer’s vaccine, which has to be stored at minus-70 degrees Celsius, or Moderna’s, which is stable in refrigerated conditions for only 30 days and must be frozen at minus-20 degrees Celsius after that.
The Oxford-AstraZeneca vaccine was first developed in a small laboratory running on a shoestring budget by Gilbert at Oxford and her team. The university kicked in 1 million pounds ($1.3 million) and then sought a manufacturing partner, before settling on AstraZeneca.
“We wanted to ensure there wouldn’t be any profiteering off the pandemic,” said Louise Richardson, the university’s vice chancellor, so that their vaccine would be widely distributed “and wouldn’t just be for the wealthy and the first world.”
The scientists said that although it appeared to be a race, or a competition, among the front-running vaccine developers, no one company could produce by itself the millions of doses needed to end the pandemic.
“We don’t have enough supply for the whole planet,” Pollard said, adding that the important message is that today there are at least three highly effective, safe vaccines, that also appear to work well among the elderly, and that they are produced using different technologies, ensuring the quickest route to manufacture the billions of doses that will be necessary.
Pollard said it is “unclear why” the different vaccines were producing different results, and he said he and the scientific community awaited full data sets from all the clinical trials to fully understand what is going on. He said different studies were also using different end points to describe efficacy.
“At this moment we can’t fully explain the differences,” Pollard said. “It’s critical to understand what everyone is measuring.”
As record numbers of coronavirus cases overwhelm hospitals across the United States, there is something strikingly different from the surge that inundated cities in the spring: No one is clamoring for ventilators.
The sophisticated breathing machines, used to sustain the most critically ill patients, are far more plentiful than they were eight months ago, when New York, New Jersey and other hard-hit states were desperate to obtain more of the devices, and hospitals were reviewing triage protocols for rationing care. Now, many hot spots face a different problem: They have enough ventilators, but not nearly enough respiratory therapists, pulmonologists and critical care doctors who have the training to operate the machines and provide round-the-clock care for patients who cannot breathe on their own.
Since the spring, American medical device makers have radically ramped up the country’s ventilator capacity by producing more than 200,000 critical care ventilators, with 155,000 of them going to the Strategic National Stockpile. At the same time, doctors have figured out other ways to deliver oxygen to some patients struggling to breathe — including using inexpensive sleep apnea machines or simple nasal cannulas that force air into the lungs through plastic tubes.
But with new cases approaching 200,000 per day and a flood of patients straining hospitals across the country, public health experts warn that the ample supply of available ventilators may not be enough to save many critically ill patients.
“We’re now at a dangerous precipice,” said Dr. Lewis Kaplan, president of the Society of Critical Care Medicine. Ventilators, he said, are exceptionally complex machines that require expertise and constant monitoring for the weeks or even months that patients are tethered to them. The explosion of cases in rural parts of Idaho, Ohio, South Dakota and other states has prompted local hospitals that lack such experts on staff to send patients to cities and regional medical centers, but those intensive care beds are quickly filling up.
Public health experts have long warned about a shortage of critical care doctors, known as intensivists, a specialty that generally requires an additional two years of medical training. There are 37,400 intensivists in the United States, according to the American Hospital Association, but nearly half of the country’s acute care hospitals do not have any on staff, and many of those hospitals are in rural areas increasingly overwhelmed by the coronavirus.
“We can’t manufacture doctors and nurses in the same way we can manufacture ventilators,” said Dr. Eric Toner, an emergency room doctor and senior scholar at the Johns Hopkins Center for Health Security. “And you can’t teach someone overnight the right settings and buttons to push on a ventilator for patients who have a disease they’ve never seen before. The most realistic thing we can do in the short run is to reduce the impact on hospitals, and that means wearing masks and avoiding crowded spaces so we can flatten the curve of new infections.”
Medical association message boards in states like Iowa, Oklahoma and North Dakota are awash in desperate calls for intensivists and respiratory therapists willing to temporarily relocate and help out. When New York City and hospitals in the Northeast issued a similar call for help this past spring, specialists from the South and the Midwest rushed there. But because cases are now surging nationwide, hospital officials say that most of their pleas for help are going unanswered.
Dr. Thomas E. Dobbs, the top health official in Mississippi, said that more than half the state’s 1,048 ventilators were still available, but that he was more concerned with having enough staff members to take care of the sickest patients.
“If we want to make sure that someone who’s hospitalized in the I.C.U. with the coronavirus has the best chance to get well, they need to have highly trained personnel, and that cannot be flexed up rapidly,” he said in a news briefing on Tuesday.
Dr. Matthew Trump, a critical care specialist at UnityPoint Health in Des Moines, said that the health chain’s 21 hospitals had an adequate supply of ventilators for now, but that out-of-state staff reinforcements might be unlikely to materialize as colleagues fall ill and the hospital’s I.C.U. beds reach capacity.
“People here are exhausted and burned out from the past few months,” he said. “I’m really concerned.”
The domestic boom in ventilator production has been a rare bright spot in the country’s pandemic response, which has been marred by shortages of personal protective equipment, haphazard testing efforts and President Trump’s mixed messaging on the importance of masks, social distancing and other measures that can dent the spread of new infections.
Although the White House has sought to take credit for the increase in new ventilators, medical device executives say the accelerated production was largely a market-driven response turbocharged by the national sense of crisis. Mr. Trump invoked the wartime Defense Production Act in late March, but federal health officials have relied on government contracts rather than their authority under the act to compel companies to increase the production of ventilators.
Scott Whitaker, president of AdvaMed, a trade association that represents many of the country’s ventilator manufacturers, said the grave situation had prompted a “historic mobilization” by the industry. “We’re confident that our companies are well positioned to mobilize as needed to meet demand,” he said in an email.
Public health officials in Minnesota, Mississippi, Utah and other states with some of the highest per capita rates of infection and hospitalization have said they are comfortable with the number of ventilators currently in their hospitals and their stockpiles.
Mr. Whitaker said AdvaMed’s member companies were making roughly 700 ventilators a week before the pandemic; by the summer, weekly output had reached 10,000. The juggernaut was in part fueled by unconventional partnerships between ventilator companies and auto giants like Ford and General Motors.
Chris Brooks, chief strategy officer at Ventec Life Systems, which collaborated with G.M. to fill a $490 million contract for the Department of Health and Human Services, said the shared sense of urgency enabled both companies to overcome a thicket of supply-chain and logistical challenges to produce 30,000 ventilators over four months at an idled car parts plant in Indiana. Before the pandemic, Ventec’s average monthly output was 100 to 200 machines.
“When you’re focused with one team and one mission, you get things done in hours that would otherwise take months,” he said. “You just find a way to push through any and all obstacles.”
Despite an overall increase in the number of ventilators, some researchers say many of the new machines may be inadequate for the current crisis. Dr. Richard Branson, an expert on mechanical ventilation at the University of Cincinnati College of Medicine and an author of a recent study in the journal Chest, said that half of the new devices acquired by the Strategic National Stockpile were not sophisticated enough for Covid-19 patients in severe respiratory distress. He also expressed concern about the long-term viability of machines that require frequent maintenance.
“These devices were not built to be stockpiled,” he said.
The Department of Health and Human Services, which has acknowledged the limitations of its newly acquired ventilators, said the stockpile — nine times as large as it was in March — was well suited for most respiratory pandemics. “These stockpiled devices can be used as a short-term, stopgap buffer when the immediate commercial supply is not sufficient or available,” the agency said in a statement.
Projecting how many people will end up requiring mechanical breathing assistance is an inexact science, and many early assumptions about how the coronavirus affects respiratory function have evolved.
During the chaotic days of March and April, emergency room doctors were quick to intubate patients with dangerously low oxygen levels. They subsequently discovered other ways to improve outcomes, including placing patients on their stomachs, a protocol known as proning that helps improve lung function. The doctors also learned to embrace the use of pressurized oxygen delivered through the nose, or via BiPAP and CPAP machines, portable devices that force oxygen into a patient’s airways.
Many health care providers initially hesitated to use such interventions for fear the pressurized air would aerosolize the virus and endanger health care workers. The risks, it turned out, could be mitigated through the use of respirator masks and other personal protective gear, said Dr. Greg Martin, the chief of pulmonary and critical care at Grady Health Systems in Atlanta.
“The familiarity of taking care of so many Covid patients, combined with good data, has just made everything we do 100 times easier,” he said.
Some of the earliest data about the perils of intubating coronavirus patients turned out to be incomplete and misleading. Dr. Susan Wilcox, a critical care specialist at Massachusetts General Hospital, said many providers were spooked by data that suggested an 80 percent mortality rate among ventilated coronavirus patients, but the actual death rate turned out to be much lower. The mortality rate at her hospital, she said, was about 25 to 30 percent.
“Some people were saying that we should intubate almost immediately because we were worried patients would crash and have untoward consequences if we waited,” she said. “But we’ve learned to just go back to the principles of good critical care.”
Survival rates have increased significantly at many hospitals, a shift brought about by the introduction of therapeutics like dexamethasone, a powerful steroid that Mr. Trump took when he was hospitalized with the coronavirus. The changing demographics of the pandemic — a growing proportion of younger patients with fewer health risks — have also played a role in the improving survival rates.
Dr. Nikhil Jagan, a critical care pulmonologist at CHI Health, a hospital chain that serves Iowa, Kansas and Nebraska, said many of the coronavirus patients who were arriving at his emergency room now were less sick than the patients he treated in the spring.
“There’s a lot more awareness about the symptoms of Covid-19,” he said. “The first go-around, when people came in, they were very sick right off the bat and in respiratory distress or at the point of respiratory failure and had to be intubated.”
But the promising new treatments and enhanced knowledge can go only so far should the current surge in cases continue unabated. The country passed 250,000 deaths from the coronavirus last week, a reminder that many critically ill patients do not survive. The daily death toll has been rising steadily and is approaching 2,000.
“Ventilators are important in critical care but they don’t save people’s lives,” said Dr. Branson of the University of Cincinnati. “They just keep people alive while the people caring for them can figure out what’s wrong and fix the problem. And at the moment, we just don’t have enough of those people.”
For now, he said there was only one way out the crisis: “It’s not that hard,” he said. “Wear a mask.”
Like a lot of people, I have really gotten into listening to podcasts over the last year. They’re such an immersive way to learn about the world, and I like how the format lets you dive as deep on a topic as you want. So, I was inspired to start one of my own—but I knew I couldn’t do it on my own.
I couldn’t ask for a better partner on this project than Rashida Jones. A mutual friend suggested that the two of us might have a lot to talk about, and it turned out he was right. I already knew she was a talented actor, but I was impressed by her thoughtful perspective on the world. So, we decided to start a podcast that lets us think through some of today’s most pressing problems together. In our first episode, Rashida and I explore a big question that is top of mind for many people: what will the world look like after COVID-19?
I know it’s hard to imagine right now while new cases are surging around the world, but there will come a time when the COVID-19 pandemic is behind us. I think it’s safe to assume that society will be changed forever, given how disruptive the virus has been to virtually every part of our lives.
Unfortunately, we still have a long way to go before life truly gets back to “normal.” Rashida and I were joined by Dr. Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases, to discuss what to expect in the months to come. I’ve had the opportunity to work with Dr. Fauci on a number of global health issues over the years, including the quest for an HIV vaccine and cure. He’s such a quiet and unassuming guy normally, so it’s been wild to watch him become a huge celebrity.
Dr. Fauci and I are both optimistic that a vaccine will bring an end to the pandemic at some point in the near future. But what the world looks like after that is a lot less clear. I suspect that some of the digitization trends we’ve seen—especially in the areas of online learning, telemedicine, and remote work—will become a regular part of our lives. I hope this episode leaves you hopeful about the future and curious about what comes next.
Hospitalized COVID-19 patients receiving SNG001, inhaled nebulized interferon beta-1a, were more likely to show clinical improvement than those receiving placebo, a small pilot study in the U.K. found.
Moreover, patients in the intervention group were more likely to revert to an OSCI score of 1, or no limitation of activities, on day 15 or 16 (HR 2.19, 95% CI 1.03-4.69, P=0.043), the authors wrote in the Lancet Respiratory Medicine.
Type 1 interferon is “one of the first cytokines induced by viral infection of a cell and is a primary driver of innate immune responses in the human lung,” the researchers noted. They explained that SNG001 is a formulation of recombinant interferon beta “for inhaled delivery by [nebulizer],” which has been well tolerated in clinical studies among patients with asthma or chronic obstructive pulmonary disease.
In addition to different composition of the two trials, the editorialists found another key difference: route of administration. SOLIDARITY used subcutaneous interferon beta-1a, whereas this trial used nebulized therapy that “delivers interferon beta-1a directly to the respiratory tract.”
“[Nebulized] therapy allows targeted delivery of interferon to the lungs, where it can induce the expression of interferon-stimulated genes that participate directly … or indirectly … in the antiviral response in the mucosa,” Peiffer-Smadja and Yazdanpanah wrote.
For the new study, Wilkinson and colleagues randomized adults hospitalized with COVID-19 symptoms, who tested positive for SARS-CoV-2 via reverse-transcriptase polymerase chain reaction or point-of-care test to receive either SNG001 or inhaled placebo for 14 days. Primary outcome was change in clinical condition on the WHO OSCI (a 9-point scale where 0 means no infection and 8 means death).
From March 30 to May 30, a total of 48 patients were randomized to SNG001 and 50 to placebo in an intent-to-treat analysis. Patients were a mean age of 57, 59% were men, and 80% were white. Baseline comorbidities included hypertension, cardiovascular disease, diabetes, chronic lung condition, and cancer.
Demographic characteristics between groups were similar, although the SNG001 group had more severe disease, with 77% of patients receiving oxygen therapy vs 58% in the placebo group. Mean duration of symptoms before treatment initiation was 10 days.
In the SNG001 group, the odds of improvement were more than three-fold greater on day 28 versus placebo (OR 3.15, 95% CI 1.39-7.14, P=0.046), the authors noted.
Five patients underwent intubation or died compared with three in the intervention group. Over the 14 days of treatment, patients in the intervention group were more than twice as likely to recover.
There was no difference in the odds of hospital discharge or time to hospital discharge between groups. By day 14, 73% of the placebo group and 69% of the intervention group had been discharged.
Regarding safety, 54% of patients in the intervention group and 60% in the placebo group reported treatment-emergent adverse events, the most common of which was headache (15% and 10%, respectively). Fewer patients in the intervention group had serious adverse events compared with placebo (15% vs 28%), and the most common were respiratory failure (6% vs 12%) and pneumonia (6% each).
One patient in the placebo group had multiple organ dysfunction syndrome and one had pulmonary embolism, which caused them to withdraw from the study. These patients later died, along with a third patient in the placebo group, who died of COVID-19 pneumonia.
In their editorial, Peiffer-Smadja and Yazdanpanah noted that the study was not powered to assess mortality outcomes, and called for large randomized trials to investigate the effectiveness of nebulized interferon beta-1a, speculating that it might benefit patients in an early stage of disease in the outpatient setting.
“In patients with severe COVID-19, an exacerbated inflammatory response has been identified as a cause of pulmonary complications, and interferon beta-1a — a pro-inflammatory cytokine — could increase the inflammatory response and be associated with safety issues,” the editorialists wrote.
They added that safety will also be a concern, as “[nebulization] of interferon has no marketing [authorization] for any indication yet.”