Cruelty Won’t End This COVID Groundhog Day

When I was in residency, Dave Park, MD, an intensivist who I greatly admired, observed that “the trauma ICU is filled by man’s cruelty to man, and the medical intensive care unit (MICU) by man’s cruelty to himself.” Without the use of tobacco, alcohol, and opioids, there would be less chronic obstructive pulmonary disease, cirrhosis, and endocarditis. Without dietary indiscretions, there would be fewer complications of diabetes. Without medication “noncompliance” we would not see as many exacerbations of chronic illness. The MICU could lead one to wonder how so many patients “did this to themselves,” but the other crucial lesson I learned from Park was about compassion. He was never judgmental of patients for their illness. Even if bad choices had led to a worse illness, our responsibility to provide care remained unchanged. Serious illness may be a consequence of bad decisions, but it’s not punishment for them.

My COVID Groundhog Day

I’ve been on the front lines of the pandemic since early 2020, when the coronavirus first appeared in Washington state. Recently, I was reminded of Park’s lesson as I cared for people suffering from the latest Delta wave. As in the prior year, I saw the grim specter of ICU wards filled by COVID-19, patients kept alive on ventilators, sedated on intravenous drips, placed prone to improve their oxygenation. Again, I watched the inexorable progression of illness over hours to days as patients required more and more oxygen. We eventually face a difficult choice: to intubate or not? Some choose not, but most people, facing death, decide to be intubated.

I’ve learned to always offer patients the opportunity to speak to loved ones by phone before placing the tube; it may be their last chance. Once patients are intubated, some will remain on ventilators for days, but for most it will be weeks or months. Some will eventually recover and breathe on their own. Others, despite our best efforts and proven treatments, will die. The survivors will face a long recovery. Many will have permanent disability. Many will never live independently again, unable to return to their pets, homes, and families.

In some cases, I’ve seen multiple members of the same family admitted to the hospital. The electronic health record bolds their last names and pops up the warning “Name Alert” to avoid potential confusion. But not all the suffering is experienced in the hospital. I’ve seen family members with mild COVID-19 wracked with guilt about their loved ones in the ICU. Family members at home grieve and may feel powerless to help. The fact that they are unable to visit worsens their plight.

And, just like in the early days of the pandemic, many hospitals are overwhelmed; while moonlighting in eastern Washington, I accepted a transfer from a small community hospital in a neighboring state after they ran out of oxygen. On a recent shift, I cared for an ICU full of COVID-19 patients. They had little in common, ages ranging from 20s to 80s, some with many comorbidities, others with few.

But they all had one thing in common: they were unvaccinated.

The last year has been marked by a periodic déjà vu: a bizarre Groundhog Day where we seem to be making progress, COVID-19 recedes from our ICUs, and then a few months later, a new wave hits and we’re back where we started. The last 18 months have taught us what to expect in these surges. The Delta variant is more infectious than prior strains, but the critical illness it causes is similar. If so much about the Delta surge is familiar, why does it feel so different?

This Time Is Different

I can think of three reasons why this wave feels different.

First, the suffering this time is almost completely preventable. In initial testing, the mRNA vaccines were more than 94% effective at preventing severe disease and death. Even against the Delta variant, the vaccines remain highly effective at preventing hospitalization and death. It is estimated that vaccination in the U.S. had already saved 279,000 lives by the end of June. My colleagues in the ICU and I were eager to receive the first doses last December, but in the U.S., there is a sharp divide between doctors, over 96% of whom are fully vaccinated, and the general public, of whom less than 60% are (and about 13% of U.S. adults say they will definitely not get the vaccine).

Second, prevention is relatively easy. It should be much easier to receive a free vaccine at a walk-in clinic than to quit an addictive behavior.

And finally, the negative externalities around vaccine refusal are enormous. Not only are the unvaccinated risking their own health, they are potentially endangering others, including the immunocompromised and children not old enough to receive the vaccine. Moreover, low vaccination rates delay society’s “return to normalcy,” leading to incalculable harm to every segment of the population.

In the early waves, people were “victims” of the coronavirus. But as the pandemic and the emotional toll on healthcare workers wears on, this feels less true. I’m reminded of Park’s lesson to care for all patients in the MICU, even those who “did this to themselves.” But I still feel dissonance in caring for vaccine refusers. No one chooses to have COVID-19, just as no one chooses to have cirrhosis. Instead of seeing this wave as a choice, I see it as a consequence of a comorbidity: misinformation. Just as addiction is a disease that causes other disease; so too is misinformation.

The impetus for this article started as a Tweet:

I considered this a heartfelt, though innocuous statement. Still, the vitriol I saw among some commenters, dismissing the veracity of my claim and promoting anti-vaccine sentiments, shows that we are dealing with a cognitive virus in addition to the coronavirus. This syndemic of COVID-19 and misinformation has led to unnecessary suffering.

What Can We Do About This?

I was fortunate to be one of the first to get vaccinated, and since then millions more have followed suite. Initially, vaccines were scarce, and few sites could administer them. Now vaccines are plentiful in the U.S., but we must lower barriers to vaccination.

We should view every interaction with the healthcare system as an opportunity for someone to make a good decision and accept vaccination. Pharmacists should inquire about vaccine status when filling prescriptions and offer immediate vaccination. Before the pandemic, when I took my kids to their pediatrician I would get my flu shot there in front of them. The pediatrician’s office did this to lower access barriers and reassure kids that getting a shot is no big deal (that last part didn’t work as well as hoped). Patients admitted to the hospital for non-COVID reasons should be offered vaccination before discharge, as should their loved ones who are picking them up. Often in family meetings, a patient’s family members will ask “what can we do?” In this case the answer is simple: get vaccinated to protect yourself and others. In my experience, one person saying yes in a group setting can convince others still on the fence. As ICU doctors we’re not used to taking on this unfamiliar public health role of offering vaccines in family meetings, but it behooves us to use these teachable moments.

Despite our best efforts, people will continue to decline vaccination. As a pulmonologist I learned the key to helping people quit smoking was to persist non-judgmentally. Quitting smoking is hard, and most who successfully quit require multiple attempts. In contrast, vaccination generally only requires one attempt in order to be protected (or ideally twice, 21 or 28 days apart). However, there’s an important difference between the smoking example and vaccine hesitancy. Almost everyone knows that cigarettes are bad for you but many — perhaps 5% of the U.S. — don’t believe the pandemic is real. The cure for ignorance is education, and every critically ill patient is an opportunity to educate their loved ones about the virus and the benefits of vaccination.

Park died several years ago, but his observation — that the MICU is filled with self-inflicted cruelty — is, tragically, even more true today. In confronting the latest wave of the pandemic, we need to remember that the cure for self-inflicted cruelty isn’t more cruelty. If we view misinformation as an illness, it’s much easier to empathize with the afflicted and help them recover.

Nick Mark, MD, is an attending ICU physician at Swedish Medical Center in Seattle and is also the founder of OnePager ICU.