As a surgeon I am a bit removed from the front line of COVID-19 that my colleagues face in emergency rooms, intensive care units, urgent care centers, and primary care offices. I am on call this Christmas and am covering three hospitals for partners who are out of town so I had the chance to ask around about the situation. It seems for the most part that although large numbers of patients are hitting the ER and testing positive, the vast majority of them in our area are being sent home. They are coming in with flu-like symptoms and are largely being told to quarantine at home.

This is in stark contrast to March 2020, where an overwhelming number of patients were coming in with severe COVID-19 pneumonia and dying in large numbers. To clarify, pneumonia is a condition where the lung tissue is infected and is often associated with severe illness requiring oxygen support. If it progresses, it can lead to sepsis where the body starts to become overwhelmed by the infection and ultimately other organs such as the kidneys or heart can sustain damage and result in death.

I’m not quite sure what to make of the current situation. I think the following factors are at play:

  1. A high community vaccination rate mean that there is significant immunity which may not totally prevent breakthrough infections but is preventing serious illness requiring hospitalization
  2. Multiple waves of COVID-19 have left some amount of immunity as well, also keeping people out of the hospital
  3. A lot of vulnerable people such as the elderly or people with underlying medical conditions have already died in previous waves and most of the ones who remain are already vaccinated
  4. COVID-19 produces a flu-like illness before progressing to pneumonia. It may take more time before pneumonia cases hit the ER

It seems that the most pressing issues in our area are twofold. First, we are close to running out of tests, even at the hospital level. It seems absurd at this point, but the Omicron variant exploded out of nowhere and the supply chain is catching up. I see in the news that President Biden has ordered more tests but those take time to manufacture. In a way it is a good problem to have because it means people are seeking out tests and presumably quarantining when they come back positive. The second problem is that a lot of staff such as doctors and nurses are being quarantined with COVID-19. I know some of these people had COVID-19 in the spring of 2020 and are fully vaccinated although I am not sure if they have had the booster. So far the ones who I know have mild symptoms. That tells me that this thing is very contagious, with significant breakthrough infections. The CDC recently shortened the quarantine period for medical workers to 7 days from 10 in order to try to alleviate the shortage.

Is the Omicron variant less severe? I always hesitate to say that it is because saying it may be less severe provides a false sense of security. If the hospitalization rate is half that of Delta but it infects 10 times as many people, 5 times as many will end up in the hospital as during the Delta wave which will cause a disaster. But yes, for whatever reason, whether it due to the intrinsic biology of the Omicron variant or to the immunity in the population, the disease we are seeing is less severe.

My concern at this point is that the number of cases is still rising exponentially so it is not clear when we will hit a plateau. If enough people get infected, eventually vulnerable people will get infected and start showing up with COVID pneumonia and need hospitalization. If enough people show up that the hospitals run out of beds, then the whole system will become overwhelmed and stop functioning. Another concern is that many children aged 5-11 are not yet vaccinated and children under 5 cannot yet be vaccinated. Normally children do not need large numbers of hospital beds, especially ICU beds. There are not enough pediatricians and pediatric nurses to care for a major disaster amongst children. Although children have a lower rate of complications, if the virus continues unchecked, some proportion of children will end up in the ICU and those units can be easily overwhelmed. It has been reported that pediatric ICU beds are already running short which is a bad sign.

I think we still have to be in “flatten the curve” mode. I know that this prolongs the pandemic, but time is the most precious thing there is and we need to buy some. If we can spread things out, it will result in less infection and death, and most critically, prevent hospitals from being overwhelmed. If hospitals break down, all hell will break loose and it will be like March 2020 again.

One thing we don’t have answers for yet is whether the Omicron variant is just as likely to cause “long COVID.” This is a condition where chronic inflammation remains in the body after the virus is cleared and the patient experiences chronic pain and fatigue which can be disabling. I’ve seen young people in their 30’s and 40’s who were completely healthy before COVID but now can barely walk a few steps, much less take care of their kids. We may get hit with a pandemic of long COVID even after the virus becomes endemic so this is another reason to vaccinate, boost, and wear a high filtration mask this winter.