Photo by Tony Valainis
The pandemic professor
Dr. Aaron Carroll—a pediatrician at Indiana University Health, educator, and IU’s chief health officer—has been a regular contributor to The New York Times and The Atlantic throughout the current healthcare crisis. Here, he previews the stories he selected for this year’s feature.
THE COVID-19 PANDEMIC has dominated all of our lives, but little has been more affected than the healthcare system. Hospitals, emergency rooms, and clinics have been stressed for well over a year, and it’s fitting that this year’s Top Doctors issue focuses on the disease. We’re lucky to have the area’s best physicians explaining its ongoing effects in their own words.
Although vaccines have been plentiful for some time, too many people have yet to accept them, leading to repeated surges of infections and the severe cases that accompany them. One story in this issue focuses on the evolving treatment of COVID-19. How are we treating this disease now, and why does it remain challenging?
COVID-19 affects more than just those who contract the virus, though. As it fills hospitals and clinics, patients in need of other types of care get bumped or delayed in receiving treatments. Another story here focuses on the pandemic’s effect on other services. What other treatments have been most affected by the pandemic, and what is the fallout?
Although most patients recover from the acute consequences of the disease, some do not. These patients continue to have symptoms for months, sometimes longer, and don’t truly get better. While the proportion is small, the effects are not for those afflicted with what’s come to be known as “Long COVID.” A third piece focuses on patients who suffer from this mysterious condition.
As I write this, the FDA appears to be close to authorizing the vaccine for children ages 5–11, but they remain a large, vulnerable group. Parents obviously are concerned, and it’s not clear that most of them will rush to get their kids vaccinated. A fourth article in this feature focuses on children and the vaccine. Will parents get them inoculated, and what are the consequences of that decision?
Finally, doctors are burning out at an alarming rate. The continual stress of caring for patients in an emergency is taking its toll. A final story focuses on that, asking what effect the pandemic has had on local health workers and what that might mean for healthcare going forward.
It’s always worth celebrating excellence in our physician workforce, and I’m pleased to see Indianapolis Monthly do so once again. This issue provides much-needed updates on how the pandemic has affected them and more. I won’t lie, though. I hope next year’s edition can focus on something else.
The following articles are written by Indianapolis Monthly contributing editor Alicia Garceau.
Trials and errors
Dr. Imad Shawa, a pulmonary critical care physician at Franciscan Health, describes the evolving treatment of COVID-19—and its continued limitations.
WE HAVE a huge ICU, and in early 2020, we were busy taking care of the usual sepsis, infection, overdoses, strokes, and heart attacks. We got our first COVID patient that winter, and shortly after, we started getting flooded with them. The vast majority of the people who got admitted had respiratory failure, and we treated them the way we treated anybody with ARDS (acute respiratory distress syndrome). There was no COVID-specific therapy—just supportive care.
Quickly, everybody recognized that many of the people who were dying were dying because of blood clots in the lungs, brain, extremities, and even the skin. It became the standard of care to prevent clotting, and that made a difference in the management of the disease.
Decadron (a steroid) has mortality benefits and became a standard of care. Remdesivir (an antiviral) is now part of the standard of care. There were a lot of therapies that we implemented at the beginning that did not lead to any meaningful improvement—the hydroxychloroquine, the convalescent plasma—so we changed course.
Unfortunately, in the last few months, with the Delta variant’s arrival to the U.S., we started getting another tsunami. There has been a shift in the age of the patients we’re seeing with severe COVID. More younger people—those in their 40s and 50s—and pregnant women are now in the hospital. We did a good job as a society in getting a lot of the elderly population vaccinated. That’s why we’re not seeing as many new COVID cases in that group while the other age ranges surge.
Before Delta, young people were getting infected, but they were not needing as many hospitalizations as we are seeing right now. The new COVID cases are more severe, more destructive to the lungs, so younger people are dying. The disease remains difficult to treat. We are using the ECMO (extracorporeal membrane oxygenation) machine. Practically speaking, it’s an iron heart and lungs. It’s a very invasive, very expensive model of therapy. Before COVID, we used it only occasionally on heart patients. Now we use it on a daily basis.
Then there are the monoclonal antibodies. I was one of the principal investigators for one of those. They help to prevent the progression of the disease, but they require infusion in a hospital and they’re not authorized for everyone. The initial authorization was only for those above the age of 65, or above 55 with hypertension or a chronic disease. Going forward, more access to those infusions will make a difference. There are studies looking into making the monoclonal antibodies in the form of a simple subcutaneous injection, and if that’s the case, the ease of administration will make a difference. I hope it will put a dent in the way we’re dealing with this.
The complications
Dr. Erica Huddleston, a family medicine physician with Community Health Network, describes the impact of the pandemic on patients with conditions other than COVID-19.
INITIALLY, PEOPLE were delaying care because the entire healthcare system shut down at the start of the pandemic in 2020. Things slowly started to get back on track this year, but patients were still scared. There was a lot of misinformation—and those fears weren’t being addressed because people weren’t able to follow up with their healthcare providers on a regular basis.
Now that we’re seeing patients again, people are worried about contracting COVID here. They have fears about going into the hospital and becoming ill, because the hospitals are full of COVID patients. I have patients tell me regularly, “I’m not going to get my mammogram,” or “I’m going to hold off on my colonoscopy.”
In regard to prevention—those mammograms and colonoscopies that may have been delayed for a year or more—we’ve noticed that patients are coming in with increased disease states and rates in their staging if it’s a cancer. Things have progressed unnecessarily. Some patients are just more afraid of contracting COVID than they are of anything else, but you wouldn’t know that your blood pressure is sky high until you start having stroke-like symptoms or chest pain. A lot of patients don’t have those symptoms until their blood pressures are extremely elevated. Same thing with diabetes. I have a lot of new patients who were diagnosed by going to the emergency room with symptoms like severe fatigue. They were going in thinking it was COVID, and it was an uncontrolled diabetes diagnosis.
In regard to patients with high blood pressure, they haven’t been seeing their primary-care doctors regularly. By the time we see them in the office 18 months later, their blood pressure is out of control, which can lead to other comorbidities like stroke. With chronic-disease management, just because your doctor put you on a medication a year and a half ago doesn’t mean you don’t need to see him or her anymore.
We’re also seeing worsening COPD due to patients smoking more because they’re working from home, so they don’t have to wait to take personal breaks. They can smoke all day long, but that’s going to really progress their COPD. Asthma conditions and lots of respiratory disorders have worsened since the pandemic started.
Patients should realize that, in all honesty, the doctor’s office is probably one of the safer environments given that the nurses are constantly cleaning. They’re sanitizing after every patient. Everyone is required to wear a mask at all times. Providers are sanitizing hands before and after visits, and throughout the day. If you have questions or concerns, call your doctor’s office to get more information. Whatever you do, don’t delay your care.
Looking further
Dr. Amy Beth Kressel, medical director of infection prevention and antimicrobial stewardship at Eskenazi Health, discusses the little understood phenomenon of Long COVID.
GENERALLY, IF you’ve had symptoms for more than four weeks, that could be considered Long COVID. There are two phases: four to 12 weeks after your initial infection, and then more than 12 weeks. And you can get Long COVID even if you’re not hospitalized. About 10 percent of COVID patients in one study had either shortness of breath, fatigue, or they still couldn’t smell more than 12 weeks out. About 30 percent of patients, even if they weren’t hospitalized, had one of those three symptoms after four weeks. We know people can have symptoms for months, but we’re only 18 months into this pandemic. Will some people just get better on their own after a year or two or three? How many people five years out will still have symptoms? Those are unknowns right now.
The National Institutes of Health are funding trials to look at people who are recovering from COVID and figure out what’s going on. Are there biochemical markers? Could you do a blood test on somebody and look for inflammatory markers and see who was going to get this syndrome? And what’s the mechanism? CT scans of people who are recovering from COVID sometimes show that their lungs are damaged. That might be why some people feel short of breath. It might be different things in different people.
NIH is studying this in a very structured way, so it may take some time. Which is very frustrating to people who are experiencing Long COVID now, but physicians are trying to work through this with their patients in the meantime. Some people will have abnormalities in X-rays or pulmonary function tests or postural hypotension that we can measure. But some people just say, “I feel short of breath,” “I feel fatigued,” “I still don’t have my sense of smell back,” or “I have chronic headaches.” Physicians, in general, like to know exactly what they’re treating, and they like some measure of getting better, so this presents challenges. If you can’t measure what’s getting better, how do you know what’s working? There is not a standard of care yet. It is symptom management.
I think you’re going to see more demand for these appointments, and then the question is: What is the best venue for the visits? I don’t think we know, but there will be continued demand for medical care for this, certainly.
There was data from the United Kingdom—and this was pre-Delta—that found only two out of 1,000 fully vaccinated people got COVID. If you got COVID after the vaccine, you were only half as likely to have Long COVID. And if you did get Long COVID after being vaccinated, your symptoms were milder. So the vaccine does make a difference with this disease as well. It helps prevent Long COVID.
COVID and kids
Dr. Eva Freeman, a pediatrician at Ascension St. Vincent, shares her concerns about the rising incidence of COVID-19 in children.
WHEN THE PANDEMIC began, my fellow pediatricians and I noticed we weren’t seeing a lot of sick kids. Part of that was because everybody was isolating, and most of them were at home. But now that the Delta variant is circulating and kids are back in school—some masked, some not—we’re definitely seeing an increased incidence in children. Because they’re not immunized, kids are completely unprotected around a much more contagious variant. Right now, the highest numbers of positive cases are happening in children. Our local children’s hospitals, Riley and Peyton Manning, are at or near capacity between COVID, RSV, and flu.
In order to really protect other kids in classrooms and daycares, we need people to test at the first sign of symptoms. If a child has a fever without being tested, we don’t know if it’s COVID or not, and that can affect a lot of people. So I encourage my patients to come in and get tested. Or, if they’re older, they can go to CVS, the health department, or do home testing, even though there’s still about a 20 percent chance of a false negative in those rapid tests.
If your kids are eligible, I definitely encourage having them vaccinated. If we can increase the level of immunity among children, it’s going to protect them. Every single physician I know has been vaccinated. All of us who have children able to get the vaccine have already vaccinated them. Children who develop Multisystem Inflammatory Syndrome (MIS-C) from having COVID are extremely sick. Many of those kids are hospitalized. Some are in the ICU on ventilators. There are completely healthy kids out there who have developed MIS-C. Unfortunately, for whatever reason, their bodies reacted to COVID in a way that made them very ill. The question is: What happens to those children in a year or two? I don’t know. We don’t have that answer yet.
If you extrapolate from adults, Long COVID, where symptoms persist after four weeks, is definitely a concern for kids. One of the things I tell parents when I’m encouraging them to have their children vaccinated is I don’t know what the long-term effects of COVID are going to be, but I’m very confident that there are no long-term side effects with vaccinations.
Also, the American Academy of Pediatrics has really emphasized the need to continue regular checkups for kids—the developmental screening, the regular vaccinations. Unfortunately, I think some of that has fallen behind in people who have been hesitant to go into offices. And I’ve always recommended that children 6 months and up get their annual flu vaccine. It’s even more important this year, and eligible children can get that and their COVID vaccine at the same visit.
Viral overload
Dr. Jon Jansen, a surgeon at Community Health Network, devotes some of his time to addressing a growing problem in the age of COVID-19: physician burnout.
IT HAS BEEN a very challenging year for the world, and certainly for medicine. I feel for the caregivers who are on the front lines—in the emergency rooms, on the COVID floors, in the ICUs. And I mean every caregiver, not just physicians. It’s also the nurse practitioners. It’s the physician assistants. It’s the incredible nursing staff, the medical assistants, and the techs. The pandemic has had a negative impact on all of them. As far as the physicians go, I speak from experience. I serve on our physician wellness committee, and I can tell you it has been very trying.
It’s busy. We have as many, if not more, COVID patients in the hospital right now than we had at the beginning of the pandemic, before the vaccine was available. The overwhelming majority of those patients—I’m talking 90 to 95 percent—are unvaccinated. That’s what is overwhelming the country’s hospital systems. These facilities were not built for an ongoing pandemic.
Despite that, our network has done a good job of supporting physicians and other caregivers the best it can, making sure they have the resources they need and enough time off to reset themselves to deal with these challenges so they can keep coming back in. Every day, they’re getting hit with more and more patients who are infected with this brutal virus.
Community has been very aggressive about physician wellness, and it started even before the pandemic. We created a committee to address the burnout we were seeing, and I’ve been happy to be a part of that. The signs we look for in doctors are continuous fatigue, loss of drive, change in appetite. Anything that you might see in someone with depression. The solution is to make sure those people are getting plenty of time off to improve their diet, exercise, or just unplug.
My message for the public is this: If you run into someone you know who is taking care of COVID patients on a daily basis, please take time to thank them. Our only other plea is for everyone out there who is not yet inoculated: Please speak with your physician and consider getting vaccinated.
