COVID Surge

It is unusual to talk about the straw before the camel’s back, but since it is still so fresh in our minds, let’s deal with COVID before we do the dive into what preceded it. If you would like a quick review of COVID, my friend Dan and I wrote a book about it that you can find here.

There were family doctors burning out before COVID; all COVID did was grease the skids.

While COVID is not the only reason you can’t find a family doctor, it is integral as to how we find ourselves where we are now and not five or ten years from now. COVID contributed two things to the Family Doctor situation; exhaustion and defeat.

Billions of people got COVID. The numbers put a significant strain on existing infrastructure. The healthcare business is used to surges; a surge is where a circumstance causes a marked increase in the need for care: during snowstorms, it isn’t unusual see an increase in slip and falls, as well as middle aged men having their first heart attack from shovelling snow. Outbreaks of diarrhea on cruise ships. Influenza season.

COVID made surges like that seem trivial, in terms of volume, duration and intensity. Even mass casualty events have limits in terms of volume and duration. If a bus full of students crashes, there are only so many students on the bus, it takes so long to deal with them, but they are treated. The wave washes over the providers but part of the reason it doesn’t take them with it is that they know the patients will eventually stop coming in the door and that they will, eventually, be able to catch a breath, pun unintended.

COVID had none of that. Once they started coming, they just kept on coming. Everywhere filled up; Emergency, ICU, OR recovery, areas of the hospital were repurposed to deal with COVID. From the front line on back; delivering healthcare to the population was disrupted. The ripple went through the system. Outside of something life threatening, care became virtual only. Governments that had resisted paying for virtual care before COVID were forced to because the lockdowns allowed nothing else.

That the system responded as effectively as it did in as little time as there was to pivot is a testament to the people in the system you rely on for care. All of them, not just the doctors, every person, including the person on the desk that takes your name and your problem to the person who got the floor clean for the next patient who would require it to be so.

It wasn’t just the numbers of people sick, it was the effort that went into the care they required. The closer you were to the front lines (somehow a wartime analogy seems not an exaggeration in this context), the more you had to gear up to provide care, all the while trying to minimize your risk of needing to be the one to be cared for. All that protective gear that had to be worn to just be in the environment of care – the weight of it, the seclusion, the heat. People in the community complained about having to wear a mask; the people trying to keep their relatives, friends and community alive wore layers, when it could be found. When it couldn’t, they improvised, and put their own lives at risk. Some lost their lives, serving others.

Surges can be survived by practitioners as long as the light at the end of the tunnel can be seen. This tunnel, in the early days of the pandemic, had no end, no light. It appeared, or at least felt, to not be so much a surge as a surrender.

Lot’s of people died.

Death is a part of taking care of the health needs of others. Depending on whom you provide care for, the likelihood of death varies; if you are a trauma surgeon, especially in the United States, with it’s oversupply of guns, you are going to lose more patients than if you are a paediatrician. What portion of your patients you lose is a function of what area of medicine you practice, but every aspect of providing care is done under the shadow of the possibility the patient may not survive. Many factor the amount of time they will be dealing with death into their decision of what medicine they will practice; would you rather deliver babies or provide palliative care? What keeps most of us going is how infrequently one must deal with the death of a patient.

During the early days of COVID in particular, the death toll was high and the toll it took on practitioners was too. Those of us who remember the early days of AIDS recognized the phenomenon; a new, unknown disease. Science in realtime, with the public watching with keen interest. “Science in realtime” is messy and most of the public are unfamiliar with it. When a new drug comes to market with the instructions, “Take 10 milligrams three times daily,” most people don’t wonder why not 20 milligrams instead of 10. Why not 30 milligrams once daily? They don’t see that those and many other doses and frequencies were tried and this was the recommendation that was shown to be most effective and least toxic.

With COVID, science started from scratch and was done in the full glare of the press and public. Health professionals are not comfortable with not having an answer to the questions, “So, what do we do now?” And yet, just like AIDS, in the early days of COVID , we didn’t know what to do next, except follow basic infections disease principles. Hence, masks, social distancing, cloister. We started with what we know about other viruses and worked as quickly as we could. We made mistakes, learned from them and then pivoted based on what was learned.

All of which made the number of people dying even more difficult to accept. We are used to knowing what to do with the sickness in front of us, what to expect from our treatment and how many people might succumb. With COVID, all we had were lines of stretchers with sick people who had a disease we didn’t know how to treat but many – most? – were dying. People moved from the line of stretchers to the lines of body bags, despite the best efforts of dedicated people who were putting their own lives on the line to provide what care they could.

Yet, they kept on dying. The psychological toll was enormous. Long hours, difficult conditions both physically and emotionally, professional apprehension over how to get ahead of the sickness and dying. A toxic cocktail for an already burning (burnt?) out workforce. This combination would have been enough to get some people to raise a hand and mutter, “Give.”

Unfortunately, there was one more twist, one that continues to push weary family doctors out the door.