This commentary is by Marvin Malek, M.D., who also holds a master’s degree in public health and is an internist/hospitalist at Springfield (Vt.) Hospital.
This week brought two milestones in the Covid pandemic:The Covid death toll in the U.S. reached 688,000.
675,000 is the best estimate of the number of U.S. deaths that occurred in the great influenza pandemic of 1918-20. A century later, we have electron microscopes allowing us to see the virus. We have had 100 more years to organize a public health sector, including the Centers for Disease Control and Prevention, which until 2017 was universally regarded as the lead public health organization in the entire world.
We have DNA amplification technology and PCR that allowed us to delineate the virus’ entire genetic code within a month of the onset of the pandemic, and mRNA vaccine technology, which led to the development of highly effective and remarkably safe vaccines within a few months of the pandemic’s onset
But we broke through 675,000 deaths anyway.
And the bad news here in Vermont is that, for the last week, we’ve been setting daily records of new cases and hospitalizations — disturbingly now among a younger group than the deaths that occurred earlier in the pandemic.
With tripartisan support from the Legislature, the Phil Scott of 2020 through April 2021 adopted a proactive approach to protecting Vermonters from the orgy of death and illness that swept the country. This included indoor occupancy restrictions, an intensive testing strategy, limitations on large gatherings, mask mandates, and a well-organized vaccine rollout.
His sober, firm approach with clear explanations about how to remain safe was reassuring and garnered support for the basic measures that mitigate spread of this highly infectious respiratory virus. And it worked. Vermonters were protected, consistently ranking among the states with the lowest per capita case, hospitalization and death rates.
But now? Not so much.
The governor tells us that we needn’t take the preventive actions we took last year because the case counts will fall very soon. And he’s been telling us that same thing week after week for a month now.
Of course, he’s right: The Covid case counts will come down — it’s a pandemic, and pandemics don’t last forever. But in the interim, Vermonters are dying. The question is: How many more severe cases and deaths will occur before Vermont will succeed in controlling this latest surge?
No one knows, including the governor. If we’ve learned anything during the pandemic, it’s that we can’t predict the next move the virus will make.
Prudent political leaders — like the Phil Scott of 2020 — used the motto: Hope for the best, but be ready for the worst. But not the Phil Scott of summer-autumn 2021.
To many of us who have been working on the front line of inpatient care, we are at a loss to understand this gubernatorial torpor. We thought we had an ally.
Completely out of touch
With the governor lifting the indoor mask mandate, the majority of people I see in grocery stores — even the elderly — now seem comfortable without protective masks. Why not? No one in a position of authority is telling them in clear terms that this is a really bad idea.
The governor and his team appear to be completely out of touch with the health care workers of Vermont. His team typically reports on cases, hospitalizations and deaths. But they never present data on closed ICUs, critically ill patients who aren’t being cared for in ICUs, transfer refusals, the number of short-staffed wards, the number of traveler and other substitute health care workers.
Just as is happening across the nation, here in Vermont, those of us on the front lines are tired and we are burned out.We spend our days repeatedly putting on and removing gowns, gloves, face shields, N95 masks — knowing that an error removing the PPE may bring the virus home and infect our families. Covid contracted at work is the leading cause of health worker absences.
And there is a powerlessness in treating Covid, as current treatments are far less effective compared to available medications for bacterial pneumonia.
And it doesn’t help morale to know that almost all the current cases didn’t have to happen had our patients received the Covid vaccine, practiced social distancing, masked up when indoors, and avoided risky indoor activity. But nonetheless, watching helplessly is painful to all of us on the treatment team, as chest X-rays become ever more worrisome, and lonely patients become increasingly short of breath.
Where can they go?
Last week, within an hour of arriving at work, yet another Covid-infected patient was literally drowning in the secretions of infected lungs — a virtual whiteout on chest X-ray. We were obliged to intubate her and place her on a ventilator.
This severity of illness requires care in an intensive care unit. Dartmouth-Hitchcock in Lebanon is the closest hospital, and I called its transfer center. But as has been the case the majority of the time lately, it had no available beds for our patient.
A nurse from our emergency room told me that, the prior day, Dartmouth had refused to accept a heart attack patient who needed care within 90 minutes of arrival by current guideline. So it’s not just the Covid patients who are at risk from the pandemic.
I then called UVM Medical Center. Same response. And then the same response from Albany Medical Center.This frustrating activity of caring for critically ill patients on a regular medical floor, and having to present our cases to multiple tertiary care facilities, is time-consuming and gets in the way of caring for the other patients on the service. But this is what it’s been like lately.
But then two hours later, a Covid patient in Albany Med’s ICU died, so our patient got her bed. I fear that she will face that identical outcome.
Vermont has 145 or so ICU beds, but this figure is misleading, since some of them are specialty beds (for instance, for neonates, post-op, etc.). And you can install 1,000 beds, but if there are only enough nurses for 85 beds, then you have 85 beds. This forces hospitals to hire traveler nurses, who cost the hospital at least twice as much — sometimes much more — than staff nurses and are about half as effective, as they’re coming in unfamiliar with our facility, our procedures, and our software.
What Gov. Scott should do
Around the country and in Vermont, health care workers — especially nurses, who are absolutely on the front line of Covid — are becoming increasingly burned out, exiting nursing in record numbers. Others are on temporary leave — in quarantine or Covid-infected themselves, as happened to one of the doctors on our team a few weeks ago.
The governor should rouse himself and demonstrate his concern for the health of Vermont. He should:
- Implement an indoor mask mandate
- Limit the size of indoor gatherings, and place a maximum occupancy level for fitness centers, restaurants and other heavily used indoor public facilities.
- Close down bars — most all occupy small spaces, and inebriated people aren’t likely to practice any kind of precautions, especially against a threat that is microscopic in dimension. And it isn’t possible to drink with a mask on. The argument is made that we cannot continue to jeopardize the income of bar and restaurant owners. But last I checked, Vermont’s state government is awash in funds the federal government directed to the states for this very purpose.
- Scott’s entire Covid team needs to stop arguing that Covid is largely a problem for the elderly. This is misleading. Yes, death and hospitalization are far more likely among the elderly and chronically ill.
But while unlikely to die from Covid, a large portion of younger people feel terrible when infected — drenching sweats, aching everywhere, losing their sense of smell, often for weeks, coughing day and night, and being forced to abandon responsibilities they face due to periods of quarantine and isolation.
And typically every other person in the household catches the illness, leading to additional problems.
Furthermore, as many as 20% of Covid patients end up as “long haulers” with persistent symptoms — fatigue, cough, achiness that just never seem to resolve. And as of a few weeks ago, 21,785 Americans under age 45 had died of Covid, a total greater than all the deaths on 9/11, the war in Afghanistan and the war in Iraq combined.
So all ages stand to benefit from not becoming infected, not merely the elderly.
Winter will make things worse
The onset of colder weather will not help the situation. As the cold of the winter months forces us to spend more time indoors, we are at even higher risk. We need action now.
Perhaps the situation will improve in a month. But we don’t know that now, and in the interim we should behave with caution. If things improve, then we can lighten up restrictions when that becomes clear.
Last November, Vermonters went to the polls and overwhelmingly reelected Phil Scott. This was largely due to his consistent, life-affirming approach to the first eight months of the Covid pandemic. And this approach was quite successful in protecting us.
We expected that, when reelected, he would continue to prioritize the integrity of our health care facilities and workers, and the well-being of Vermonters. The Phil Scott who performed so well during the first year of the pandemic appears to be AWOL. We want that Phil Scott back.
Had we wished to install a clone of Ron DeSantis into the governorship here — which is what we seem to be getting currently from the governor — we could have elected such a figure.
