Our Next Crisis

https://www.nytimes.com/2020/06/04/opinion/covid-19-survivors-effects.html

Our Next Crisis Will Be Caring for Survivors of Covid-19

Many among the most ill may emerge with debilitating infirmities that will present major challenges in care  .By Robert Klitzman

Dr. Klitzman is professor of psychiatry at Columbia University Irving Medical Center.

June 4, 2020


The surge of Covid-19 patients is declining in New York and several other cities, but in its wake, another surge is underway. Many Covid-19 survivors are suffering serious medical problems that will continue to tax the resources of hospitals, rehab centers and other medical providers.

Over the next weeks and months, these patients will tell us what “survival” from Covid-19 really means. We have plenty of data on rates of death versus survival from the virus, but not much on the quality of survival. But what we do know from the limited data about survivors of Covid-19, and about how ventilated and critically ill patients fare after spending weeks in intensive-care units, raises significant concerns.

These patients often end up on ventilators, in which a tube is inserted into the mouth and down into the airway. Imagine a tongue depressor thrust down your mouth 24/7 for a week.

Patients are sedated on medications because of the discomfort and to stabilize their breathing. They can’t move or eat. Their muscles atrophy.

About 90 percent of Covid-19 patients on ventilators develop acute kidney injury, with about a quarter needing renal replacement therapy such as dialysis, according to early studies.

Making matters worse, patients who end up in I.C.U.s for extended periods often develop post-intensive-care syndrome, which can include cognitive, muscular and neurological problems, as well as PTSD. These problems can persist for months and even years. In Britain, as of mid-May, about a third of Covid-19 patients in I.C.U.s were still there after 20 days, putting them at high risk for these conditions.

And many of these patients will develop Acute Respiratory Distress Syndrome, in which fluid builds up in the tiny air sacs of
the lungs, reducing the oxygen that gets into the bloodstream and to the organs.

At discharge, almost all ARDS patients have significant neuro-cognitive deficits, including impaired memory, attention and concentration (the result, for instance, of low oxygen levels). These problems can still be found in up to 20 percent of these patients five years later, according to a 2016 article in the journal Intensive Care Medicine.

Depression and PTSD were also prevalent.

 It’s not a stretch to conclude, therefore, that many of these Covid-19 patients are likely to emerge with debilitating infirmities that will present major challenges in care, even as we brace for a possible resurgence of the coronavirus later this year in an economy that has been laid low by it.

In a recent article on the blog of the journal Health Affairs, three public health experts at Harvard estimated that assuming 40 percent of the country is infected over the course of the pandemic, more than 20 million Americans will be hospitalized and nearly 4.5 million will require intensive care.

How many will suffer from these chronic, disabling conditions that fall into what I call post-Covid-19 syndrome, requiring continued care and rehab in health care facilities or at home, is unknown.

One of the shortcomings of the nation’s public health response to the pandemic — on top of the lack of adequate testing and contact tracing — has been its failure to collect and synthesize sufficient data to help us prepare to care for these patients. But from what we do know, their number is likely to be significant.

How will we deal with them?

Usually, hospitals try to discharge them to longer-term rehabilitation centers, long-term acute-care hospitals or nursing homes, but these institutions have limited capacity and often don’t want to accept Covid-19 patients, who may still be infectious.

That’s why, increasingly, some of these patients remain in hospitals, using resources that could be used for other Covid-19 patients or those who have cancer, diabetes or other serious diseases but have had to postpone treatment because of the pandemic.

Others who are being sent home may have significant physical or cognitive impairments, preventing them from working or caring for themselves.

The needs of Covid-19 survivors have received little attention and must be addressed.

We are simply not prepared to handle them. Families are often unaware of the burdens they will face and will need assistance. Vulnerable populations who have had difficulty getting health care, including many African-Americans, as well as the uninsured, poor, homeless, undocumented and mentally ill, will face added obstacles. New federal funding to help hospitals and others cover the costs of treating Covid-19 may not be enough.

Many politicians and others delayed responding to the pandemic, hoping that it was a myth or that if we simply ignored it, it would go away.

We should not make that mistake again.

Robert Klitzman is a psychiatrist and the director of the Masters of Bioethics Program at Columbia University. He is the author, most recently, of “Designing Babies: How Technology Is Changing the Ways We Create Children.”