Weekly coronavirus-related chat, questions, and minor updates - week of January 10

My bile rises as I’m asked to move my dying cancer patient out of ICU to make room for an unvaccinated man with Covid

“I don’t know how you do your job,” is a common sentiment oncologists hear from those who assume that treating cancer must be uniformly depressing. But this is not the whole truth. The real gratification comes from accompanying patients on a tough journey and staying the course.

Which is why I rush to intensive care when I hear that one of my long-term patients has been admitted overnight.

While I was away, her disease progressed. She had begun aggressive chemotherapy and days later, she fell ill. Expecting a conversation about a temporary setback, I encounter a gravely ill woman who is intubated, with failing organs, on maximal life support.

Her family has been allowed in for a glimpse. Our long association makes the exchange hard. I tell them that the next 24 hours will be critical and even if she survives, there is difficulty ahead.

A few hours later, the intensive care doctor calls.

She’s very unwell, he says before getting to the real point.

“I am asking you if we can make an early call to palliate and discharge her from ICU.”

“When?”

“Now.”

My disbelief must be open because it prompts the rueful explanation that a Covid patient needs an intensive care bed.

The pieces fall together instantly. With intensive care at capacity, I am being asked to move my patient to make room for another. “After all, your patient does have incurable cancer.”

My bile rises. And even as I know it’s a petty question, I can’t help asking: “Is the Covid patient vaccinated?”

“No,” he says wearily. “That’s why he is so sick.”

Recriminations flood my mind, but this is no time for argument. I have deep regard for an old colleague who feels ethically conflicted and is asking for my help. I am torn between respecting his predicament and honouring my patient.

He agrees that absent a pandemic, if I had suggested withdrawing care, he would have counselled hanging on a little longer. And he concedes that while many of my patients die prematurely, it is important for the family to know that we did all we could. To change course merely hours after our bedside conversation would multiply this family’s grief. In turn, I understand that for a chance at survival, the Covid patient needs a ventilator.

By nature, I seek consensus and I’d like nothing more than to relieve my colleague’s obvious stress. But in a career filled with ethical dilemmas, this one really tugs at me. Only my word stands between the trajectory of a patient’s life and how her family will forever recall the experience. I am staggered by a power that I never sought, and it makes me queasy.

Keeping my voice steady, I say: “If you are asking for my permission to withdraw care tonight, I can’t give it. My patient may have cancer, but she deserves a chance.”

As I worry about alienating him, his voice breaks.

“I hope that if asked, my parent’s oncologist would make the exact same decision.”

The revelation leaves me speechless but with patients to see, there will have to be another time to ask after him.

My patient died quickly in intensive care. When we spoke, her family was grateful for our compassion and care and could not fault the system.

We don’t know what happened to the other patient. If he endured a prolonged wait, his family might feel let down by the delay, though his certain extended stay in intensive care will impact the next patient.

I doubt this will be any consolation to anyone, least of all those who must actually make the difficult decisions.

"Hospitals Are in Serious Trouble: Omicron is inundating a health-care system that was already buckling under the cumulative toll of every previous surge."

In this surge, COVID-19 hospitalizations rose slowly at first, from about 40,000 nationally in early November to 65,000 on Christmas. But with the super-transmissible Delta variant joined by the even-more-transmissible Omicron, the hospitalization count has shot up to 110,000 in the two weeks since then. “The volume of people presenting to our emergency rooms is unlike anything I’ve ever seen before,” Kit Delgado, an emergency physician in Pennsylvania, told me. Health-care workers in 11 different states echoed what he said: Already, this surge is pushing their hospitals to the edge. And this is just the beginning. Hospitalizations always lag behind cases by about two weeks, so we’re only starting to see the effects of daily case counts that have tripled in the past 14 days (and are almost certainly underestimates). By the end of the month, according to the CDC’s forecasts, COVID will be sending at least 24,700 and up to 53,700 Americans to the hospital every single day.

[...]

Every part of the health-care system has been affected, diminishing the quality of care for all patients. A lack of pharmacists and outpatient clinicians makes it harder for people to get tests, vaccines, and even medications; as a result, more patients are ending up in the hospital with chronic-disease flare-ups. There aren’t enough paramedics, making it more difficult for people to get to the hospital at all. Lab technicians are falling ill, which means that COVID-test results (and medical-test results in general) are taking longer to come back. Respiratory therapists are in short supply, making it harder to ventilate patients who need oxygen. Facilities that provide post-acute care are being hammered, which means that many groups of patients—those who need long-term care, dialysis, or care for addiction or mental-health problems—cannot be discharged from hospitals, because there’s nowhere to send them.

[...]

To be clear, these problems are not affecting just COVID patients, but all patients. When Swaminathan’s friends asked what they should be doing about Omicron, he advised them about boosters and masks, but also about wearing a seat belt and avoiding ladders. “You don’t want to be injured now,” he told me. “Any need to go to the emergency department is going to be a problem.” This is the bind that Americans, including vaccinated ones, now face. Even if they’re unconcerned about COVID or at low personal risk from it, they can still spread a variant that could ultimately affect them should they need medical care for anything.

California Issues New Guidance on Quarantine and Isolation for Healthcare Workers

Healthcare workers who are exposed to COVID-19 and are asymptomatic may return to work immediately without quarantining and testing, and those who test positive and are asymptomatic may return to work immediately without isolation and without testing.

Australia has reached a benchmark: 95% of people aged 16 and over have received their first dose of a COVID vaccine.

https://covidlive.com.au/australia

And we're rapidly vaccinating the 12-15 years (commenced Sep 2021) and 5-11 years (commenced Jan 2022) age groups as well.

Vaccinating 95% of a population is referred to as "full vaccination". We're on track to achieve that.

Just wanted to share some positive news.

(We're also in the midst of a significant outbreak of the Omicron variant, which is dwarfing all previous outbreaks we've had, and we're going through this outbreak without any significant restrictions, relying only on vaccines & masks.)

State of Affairs: Jan 10 (Your Local Epidemiologist)

A good US-centric overview of current stats. If you're interested in following this you should probably just subscribe. (Substack supports email and RSS subscriptions.)

Pfizer plans to manufacture up to 100 million doses of omicron-specific vaccine by spring

Pfizer is racing ahead with plans to manufacture 50 million to 100 million doses of a new omicron-specific version of its coronavirus vaccine, a reflection of rising concerns that current vaccine formulations may need to be tweaked for the new threat.

Pfizer also is testing hybrid combinations of vaccine to target multiple coronavirus forms, as well as larger doses.

The omicron-specific doses will be created “at risk,” CEO Albert Bourla said Monday, meaning that if they are not needed, Pfizer will absorb the costs. The company has climbed to the lead in global vaccine production with 3 billion doses in 2021 and is planning to produce up to 4 billion doses in 2022.

[...]

Bourla disclosed the manufacturing plans at an annual health-care conference sponsored by JPMorgan Chase but did not provide a number for doses involved. A Pfizer spokesman, Steven Danehy, said in an email Tuesday that “we hope to have 50-100 million doses of the omicron specific vaccine available by late March/early April.”

U.S. reports 1.35 million COVID-19 cases in a day, shattering global record

The United States reported 1.35 million new coronavirus infections on Monday, according to a Reuters tally, the highest daily total for any country in the world as the spread of the highly contagious Omicron variant showed no signs of slowing.

The previous record was 1.03 million cases on Jan. 3. A large number of cases are reported each Monday due to many states not reporting over the weekend. The seven-day average for new cases has tripled in two weeks to over 700,000 new infections a day.

The record in new cases came the same day as the nation saw the number of hospitalized COVID-19 patients also hit an all-time high, having doubled in three weeks, according to a Reuters tally.

There were more than 136,604 people hospitalized with COVID-19, surpassing the record of 132,051 set in January last year.

United Airlines says 3,000 employees have tested positive for the coronavirus

Kirby cited the impact of the virus on the airline’s Newark hub, noting that on a single recent day nearly one-third of employees called out sick. The New York region was among the first spots in the United States to see a sharp uptick in coronavirus cases, largely driven by omicron.

As a result, Kirby said United will reduce its near-term schedule to better balance staffing with flights. In doing so, United joins other carriers, including JetBlue and Alaska Airlines, which in recent days also have announced schedule reductions.

[...]

United has drawn fire from critics for requiring that employees be fully vaccinated and firing workers who did not comply with its policy. In his letter, Kirby defended the mandate, saying it spared employees from the worst effects of the coronavirus.

He said none of the 3,000 employees who have tested positive and are vaccinated are hospitalized. Since the policy went into effect, the hospitalization rate among fully vaccinated employees has been a hundredth of that of the general population of the United States, Kirby said. In addition, United has gone eight weeks without a coronavirus-related death among vaccinated employees.

Supreme Court blocks Biden Covid vaccine mandate for businesses, allows health-care worker rule

"Although Congress has indisputably given OSHA the power to regulate occupational dangers, it has not given that agency the power to regulate public health more broadly," the court wrote in an unsigned opinion.

"Requiring the vaccination of 84 million Americans, selected simply because they work for employers with more than 100 employees, certainly falls in the latter category," the court wrote.

1 million expired COVID tests sitting in Florida warehouse OK to use after FDA grants extension

Earlier this month, Gov. Ron DeSantis' administration revealed between 800,000 and 1 million Abbott BinaxNOW COVID-19 tests had sat idle in a warehouse and expired in December.

Federal regulators, however, approved a three-month extension, meaning the tests can be used through March.

[…]

The Florida Department of Health clarified in a statement that the tests are "produced for testing sites and require trained professionals to administer them."

Meanwhile, the expiration date for at-home Binax tests has been extended to 15 months.

I'm not really feeling it, but for the record:

We're very lucky - It could be far, far worse (Erik Topol)

Has omicron crested in the Bay Area? Sewage samples seem to suggest so