Dealing with Delta: Insights from ICUs Across the Country

MARIO NACINOVICH:
Coming to you from the ReachMD studios, this is COVID-19: On the Frontlines. I'm Mario Nacinovich, and joining me to talk about his experiences treating critical care patients across the United States amid the spread of the Delta variant is Dr. Randy Young, former Director of the Division of Pulmonary and Critical Care Medicine at the Milton S. Hershey Medical Center. Dr. Young, welcome back to the program.

DR. YOUNG:
Thank you. It's great to be with you today.

MARIO NACINOVICH:
Now, Dr. Young, we spoke with you back in May of 2020, when things were pretty dire towards the start of the COVID-19 pandemic, and now we're seeing another surge in cases caused by the Delta variant. So can you start by giving us an update on what you're currently experiencing in the ICUs and how it compares to what you were seeing the last time we spoke?

DR. YOUNG: 
Yes, I think in many ways, things are somewhat better, and at the same time, considerably worse. The gains we've made are largely in advancing our clinical experience with critically ill COVID patients. We know a little bit better about what works in terms of ventilatory strategy, we have come to a little bit of improved understanding about some of the medications, although we recognize we don't have anything that works really well at this point. And we've developed a lot of teamwork strategies and interdisciplinary approaches in the ICU that really make it much more standard and easier to take care of critically ill patients with respiratory failure especially.

What has been discouraging is that we really haven't made much progress. And as we've dealt with this surge of cases largely in unvaccinated, somewhat younger patients, we are confronting our inability to care for these people and seeing many of them succumb even though they're previously healthy and now have what we recognize as a largely preventable illness. It's been taking a real toll on the energy and morale of the healthcare teams.

MARIO NACINOVICH:
And in your travels across the country, does the severity or number of cases and the resulting impact on ICUs of course, vary depending on what part of the country you're in?

DR. YOUNG: 
It does. Here in the northeast, we've not seen such an uptick in case numbers and mortality, although there has been some, but if you look at places in the Midwest, and especially in the southeastern United States, areas of the country where people are much more likely to be unvaccinated, we discovered that the case numbers are severely taxing hospital and healthcare resources. And the numbers of hospitalized patients and the numbers of ICU patients have exceeded even the worst days of the early months of the pandemic.

MARIO NACINOVICH:  
Now, Dr. Young, we know a lot of the current hospitalizations are stemming from the unvaccinated. So, what are your experiences caring for these patients? And are there any main concerns you have regarding their care?

DR. YOUNG:
Well, the care of the patients is much the same as it's always been. We try to keep them as well oxygenated as we can using a variety of strategies I think more and more of our ICUs, even small ICUs and small hospitals, have become comfortable using prone ventilation and adhering to ventilatory guidelines to ventilate people as safely and effectively as possible.

But we have not developed or had access to drugs that are any more effective than they were at the beginning. We've achieved a small advance in our understanding of certain classes of drugs such as those things that target the cytokine storm features of the disease. But careful, well-controlled studies have shown that those are probably not terribly effective in the vast majority of patients, especially those who are severely ill.

And we continue to struggle with all of the same issues. The fact that patients’ families cannot be with them in the end, that patients are largely dying alone. And all of that is now overlay by this sense of futility that many healthcare workers are beginning to feel. That's been especially severe among our nursing colleagues who really bear the absolute brunt of caring for these patients. They're doing such with usually more adequate supplies of personal protective equipment but without the help that they need. They are working extra shifts, they're taking care of more patients than they probably should have to. And all of this is really setting the stage for taking a severe toll on the mental and emotional health of our healthcare teams.

MARIO NACINOVICH:
We've also seen outbreaks of Delta in vaccinated people, they are becoming infected. And certainly for many of these cases, this just really means mild infection for most. But for the unvaccinated, we're certainly seeing more of the rapid spread of the virus not only to the lungs, but other parts of the body. How does that become a challenge, for you and your colleagues in the ICU?

DR. YOUNG: 
We were seeing non-respiratory manifestations of the disease in an increasingly sizable number of patients. The Delta variant certainly can cause breakthrough infections in even fully vaccinated patients, but those infections tend to be almost universally milder and not associated with needs for critical care. It's in the 90-plus percent of hospitalized patients who are unvaccinated that we see the worst manifestations of things. We recognize now that that the risk of extrapulmonary disease myocarditis sepsis syndrome, so-called cytokine storm syndromes, remain a problem and we don't have a good way to deal with them right now. 

There was a recent report about the risk of myocarditis in Delta strain cases. That is something that can cause serious cardiac arrhythmias and even loss of cardiac function. So those are the kinds of disease manifestations that we're still struggling to come to grips with.

MARIO NACINOVICH:
For those just joining us, you're listening to COVID-19: On the Frontlines on ReachMD. I’m Mario Nacinovich, and I'm speaking with Dr. Randy Young about his experiences caring for critically ill patients in the ICUs across the country amid the rise in COVID-19 cases and the Delta variant.

Dr. Young, you just mentioned this and certainly want to get a little bit more focused on those healthcare professionals, both the doctors and nurses who are treating those specifically in the ICU. Tell us a little bit more about how these healthcare workers are feeling right now about the Delta variant and the steep rise in cases they're experiencing?

DR. YOUNG: 
I think many of the emerging emotions are, unfortunately, rather negative.  These people are consummate professionals, so they're always going to do what they need to to take care of the patient and put the patient's best interests at heart. But it's harder and harder to do that when you are dealing with people who up to the moment that they're being put on the ventilator continue to deny that the disease is real, continue to feel no remorse about having chosen not to be vaccinated.

MARIO NACINOVICH:  
And so with that being said, what can be done to help relieve some of the fatigue and frustrations the healthcare workers are experiencing right now?

DR. YOUNG: 
Well, that's a very good question. I think we have yet to really hit upon the optimal strategy for reaching out to people who have continued to decline vaccination. I think there are several components to what has to happen here. Certainly, getting full FDA approval for current and future vaccines is an important component of it. The fact that some of the vaccines are becoming fully FDA-approved instead of just being granted emergency use authorization will help to convince some people and some organizations that vaccine is as safe and effective as we're knowing it to be. I think that we still need to work in partnership with community leaders, clergy, private practice physicians, pediatricians as we move into more childhood groups and teenage groups. All of these people need to raise a common voice in an effective way to help people see the importance of what can be accomplished. So I think it's going to continue to take a concerted multi-pronged effort on the part of both healthcare professionals and others to help people take this seriously and realize that it's not a political issue. It's not an infringement upon their rights. It's merely sound public health strategy that's going to be necessary for us to conquer this.

I think that getting more people on the frontlines, especially our nursing colleagues who are so very strapped by this. Most hospitals unfortunately continue to pay their nurses the standard rate at the same time that they're paying traveling nurses who might just be from the next town over, two to three times what their own fully employed nurses are getting to work alongside and do the very same work. And I think that reflects at least two factors. One is this across-the-board undervaluing of what nurses accomplish and how essential they are to the process and the fact that we continue to make people work in stressful undermanned situations.

MARIO NACINOVICH: 
As we come to a close, Dr. Young, are there any final thoughts you want to leave with our listeners?

DR. YOUNG: 
Please go out and get vaccinated if you're not already. Please reevaluate the fact that we've considered these people to be heroes yet continue to make them work under vastly difficult conditions. Please take care of yourselves, encourage your family to take care of themselves, and continue to pray for the progress that we really need to see.

MARIO NACINOVICH: 
While considering the far-reaching impacts of the Delta variant on both our patients and fellow healthcare workers, I want to thank Dr. Randy Young for joining me once again, to provide this essential update and for continuing to care for patients during this critical time. Dr. Young, it was great having a chance to speak with you again.

DR. YOUNG: 
Thanks, Mario. Great to speak with you as well. Have a great day and stay safe.

MARIO NACINOVICH: 
For ReachMD, I’m Mario Nacinovich. To access this and other episodes in our series, visit ReachMD.com/COVID-19 where you can Be Part of the Knowledge. Thanks for listening.