Do You Remember COVID?

Welcome back!

Today I want to talk to you about COVID. Do you still remember COVID? Probably some of the people who will read this post in the future will not even understand what exactly I am talking about. COVID emerged as a pandemic at the end of 2019 and the beginning of 2020. Anyone curious enough to look up the general facts is free to do so. I have no intention of giving you theoretical lectures. Nor do I intend to count myself among those of you who never believed in COVID, those who only heard about COVID on television. I want to show you the reality of COVID as I experienced it myself.

COVID is caused by a virus that uses the Spike protein on its surface to bind to ACE2, angiotensin-converting enzyme 2, which is present on the surface of cells. ACE2 is found in different tissues such as the lungs, heart, brain, intestine, kidneys and blood vessels. This partly explains why the pathology can range from a mild headache to thrombosis, lung injury and myocarditis.

Besides this variability in location, ACE2 expression also varies considerably from one individual to another. This can partly explain medically why the symptoms varied so much that they became the basis for so many conspiracy theories. If there had been only one type of symptom, it would have been easier for the population to accept it. But when every patient presented with something different, many people had difficulty accepting both the pandemic and the need for vaccination. Even more so because vaccination did not guarantee a mild course in every case. That is about enough general information about COVID. Now I want to tell you what it was like for me personally.

COVID caught me professionally at the University Hospital in Minden, Germany, at what was probably the peak of my training and career as an anesthesiologist. At the end of 2019 I was 33 years old, approaching 34. I remember that when I first heard the news about this new virus coming from China, I dismissed it as if it had nothing to do with me. Oh boy, I had no idea just how much it was going to have to do with me over the following years. Not long after that, the first cases appeared in northern Italy. That did not impress me either.

Before the pandemic broke out, I had already been spending more and more time in intensive care. Germany, like most European countries, has a system of anesthesiology and intensive care medicine in which the training and work of an anesthesiologist involves several different areas of the hospital. In Germany specifically, an anesthesiologist works in the operating room providing anesthesia for surgical cases, has mandatory experience in the ICU, and many anesthesiologists continue rotating through intensive care throughout their careers. They also play a role in emergency departments, where every critically unstable patient arriving in the ER is received by a resuscitation team that includes an anesthesiologist. That role in emergency medicine continues outside the hospital as well, where many emergency physicians working in the prehospital setting are again anesthesiologists. Inside the hospital, pain medicine services, both acute and chronic, are also commonly led and delivered by anesthesiologists. In a way, an anesthesiologist trained in Germany ends up with experience across a very broad spectrum of medical disciplines. I am not saying this to brag about my own experience. I am saying it because it helps explain why, once you acquire this kind of expertise, it becomes very easy to be arrogant.

And boy, what an arrogant prick I was. At the peak of my professional training, after spending the previous two years predominantly in intensive care and wanting a career exclusively in ICU medicine, it is easy to understand why I looked down on my Italian colleagues when the pandemic hit Italy. In my mind, they had to be doing something wrong. We had so many treatment options. Modern medicine could keep people alive almost indefinitely. So why were so many people dying in Italy? For the first few weeks, that was my line: “It is just the flu. The Italians are treating it wrong.” But what do you do when that supposedly harmless flu keeps moving north and slowly reaches Germany? When the COVID ICU was created, I was asked whether I wanted to be part of the team, and I accepted without hesitation. After all, I actually wanted to take care of those patients and do a better job than my Italian colleagues, right?

Minden had an Intensive Care Medicine center with almost 90 adult ICU beds, plus neonatal intensive care. Initially, 30 beds were isolated specifically for COVID. In the end, those beds turned out to be enough, but only because the entire hospital had the ability to provide oxygen on almost every ward. Our internal triage system became relatively simple. Patients would first be admitted to a regular ward and receive treatment and oxygen there. Admission to ICU generally followed certain criteria, one of them being oxygen saturation below 90% or an oxygen requirement of more than 6 liters per minute. All these details are almost useless by themselves, but they explain why, at any given time, a hospital with around 1,000 beds could be treating between 200 and 300 COVID patients. Just from those numbers alone, it was obvious that this was not just another viral infection.

I remember that my bravado ended when one of the nurses working in ICU became infected with COVID and had to isolate at home. At that point we did not even have a single hospitalized COVID patient yet, but that was the first moment when I genuinely became uneasy. It felt as if the tsunami was now directly in front of us, and it suddenly did not look like the small storm I had imagined. Not long afterwards, we had our first admission: a 72-year-old woman with ARDS, but otherwise biologically healthy. The media constantly portrayed severe COVID cases as multimorbid patients suffering from multiple cardiorespiratory conditions and taking endless medications. Well, this woman had nothing. Not even a single blood pressure pill.

Soon after admission we went through the usual diagnostic process. In intensive care you often repeat investigations again and again simply to make sure you have not missed something. The recommendations from the European intensive care societies advised against routine bronchoscopy in COVID patients because there generally was no airway pathology that could be meaningfully addressed through bronchoscopy. Of course I did not believe them. In my mind, those recommendations came from the same colleagues who apparently were not doing such a great job with these patients anyway, so I decided to take a look myself. I personally bronchoscoped the first ten or so COVID patients admitted to our unit. I found nothing, exactly as the guidelines had said.

Around three weeks after admission, that first patient died. She deteriorated constantly despite everything we did. No matter what treatment we tried today, tomorrow she was worse. We never had a chance. Not even a small one. Not even enough to create the illusion that we were helping her, if not for her sake then at least for ours, for the team, just so we could feel that we were doing something meaningful. Nothing. Three weeks wasted. Then came the second patient, then the third, and it continued. They all followed almost the same trajectory: admission, maximal treatment, and death roughly three weeks later. I would estimate that during those first months, mortality among the patients we admitted to our ICU was around 90%. While everybody else watched television and saw stories about people who had COVID and barely had symptoms, I only saw the ones who were dying. I had never seen anyone with COVID who had absolutely nothing. Actually, no. That is not true.

Once we had an 18-year-old patient. He was COVID-positive but had no COVID-related symptoms at all. He had been involved in a motorcycle accident and arrived at the hospital as a polytrauma patient. Because he had to be isolated, he could only be treated on the COVID ICU even though COVID itself was not his medical problem. What he had was the classic polytrauma package: hemorrhage followed by coagulopathy, pneumothorax and diffuse axonal injury. I still remember his pneumothorax very clearly because I had to decompress it. It was a summer morning and I was dressed in a COVID isolation suit with gloves, protective glasses, a face shield and head covering, and then another sterile gown over all of that with a second pair of sterile gloves. Subjectively, the air conditioning in the room was useless. On top of that, the combination of protective glasses and face shield meant that my own breath kept fogging up the visor and making it harder to see. Some colleagues say they could perform a thoracotomy blind. I can probably say the same.

When I look back at the COVID years, I honestly do not know where the time went. All I did was work and sleep. At one point I managed 100 hours in a single week, with five weekends in a row working both Saturday and Sunday. Being rotated away from the COVID ICU simply meant being rotated onto the surgical ICU. In other words, I was taking a break from work by working somewhere else. It was nothing personal. We simply did not have enough qualified staff. Intensive care requires not only a very particular skill set, one that takes years to develop, but also a particular mentality that many doctors simply do not have. ICU mentality cannot really be trained. Either you have it or you do not. It means being able to resuscitate a pediatric patient and, once the immediate crisis is over, being able to calm yourself down again. You have to be able to detach, drink a coffee with your team, have a normal conversation, because there is a good chance the next patient will create another crisis. ICU cases are like waves for surfers: ride each wave individually.

Broadly speaking, we had three major waves of COVID. In the first wave, during the first winter, we mainly saw older patients. Younger people were not affected in the same way yet. In that first wave, around 90% of the patients who reached our ICU died. One reason was simply that we did not yet know how to treat them. We had not accumulated enough experience. And yet that first wave was also characterized by an incredible sense of team spirit and sportsmanship.

I still remember my first shift on the COVID ICU. I looked at the team of nurses around me and they were all young. At 33, I was the oldest one there. Somehow, we all felt indestructible. We had already worked together for a long time, professionally we were all among the strongest people in our respective roles, and we were motivated. Maybe we were motivated precisely because we were so young. We were naive and wanted the ultimate glory of having fought COVID itself. I remember taking a selfie with the helipad behind me, laughing. And I remember that at that exact moment a stupid thought crossed my mind: when this pandemic is over, will all of us still be here? Could one of us die, just as had already happened to other healthcare workers elsewhere? I did not know. I pushed the thought away immediately because I felt that otherwise it would paralyze me with fear. I needed to think logically and coldly, almost like a machine.

My wife was extremely worried and kept telling me to be careful. I kept telling her that I would never catch COVID from the hospital. My argument was simple: if I was properly trained and did not make mistakes with isolation procedures, then I had no reason to become infected. I always joked with her that if I ever got COVID, I would catch it somewhere else, not in the hospital. And that is exactly what happened. I was right. I eventually got COVID only after I had left the ICU rotation, roughly three years later. My training and the protective measures had been enough to keep me safe.

When I look back at some of my early actions, particularly bronchoscopy, I see them differently. The ventilators were pushing mixtures of oxygen and air directly into lungs full of virus, and I was temporarily opening the circuit to insert the bronchoscope. In some situations air would leak around the circuit and spread into the room. I could feel it around my face and I would wonder whether the mask had a perfect seal, whether the adhesive strips around my face and wrists were truly airtight. Everyone in medicine has heard of a code blue. Well, I was sometimes very close to a code brown.

In the second wave, the patients changed. They were no longer mostly elderly and compliant. By then, much of the older and high-risk population had already been vaccinated and we rarely saw vaccinated patients arriving in critical condition. While people outside the hospital complained that the vaccine did not work, from where I was standing it was obvious that it did. The ICU was now filling with younger patients, often between 30 and 40 years old, who either had not yet been vaccinated or did not believe in vaccination. The major difference was that many of them were non-compliant. They knew better what they had and what they did not have. And because COVID supposedly did not exist and was just something invented by the media, they obviously did not need our treatment either.

Fewer of these younger patients died because biologically they were stronger, but some developed impressive neurological sequelae. Six months after COVID they would return to the hospital for follow-up MRIs, and I would again be the anesthesiologist taking care of them. Calling them “O₂ filters” would almost be an understatement. These were people who, for one reason or another, had refused vaccination, had fought against our treatment, and now were living with major central neurological injuries, some remaining in states resembling awake coma. I often asked myself whether the system was fair. I respect every person’s right to refuse vaccination. But if someone chooses not to vaccinate and insists that they know better, should they also accept the consequences of that decision? Why should I destroy my own health and work 100-hour weeks because somebody else believes they know better than the medical system?

During the second wave, the first cracks also became visible among the staff. Many ICU nurses quit because they no longer wanted to care for patients who were ungrateful and openly non-compliant. One case that has never left my mind was that of an eight-year-old girl whom I cared for over three consecutive nights. She had been completely healthy, with no known disease, and her entire family had had COVID about four weeks earlier. She herself had apparently been unaffected, but she was admitted with hemodynamic instability and signs of acute heart failure. In short, she developed fulminant myocarditis associated with COVID, was resuscitated three times in the ICU, required pediatric ECMO and was even considered for the transplant list. Somehow, after two weeks of treatment, she recovered without visible neurological or functional deficits.

What stayed with me most was not only the medical severity of her case but the rupture between me and her parents. She had severe heart failure. Among the many tests we can use in these situations is serum NT-proBNP. In normal circumstances the values are usually in the range of a few hundred. In chronic heart failure caused by hypertension or other cardiac disease, you can see values in the thousands, and severe acute cardiac injury can push them into the tens of thousands. Her laboratory result came back above 70,000, beyond the measurable range of our laboratory. The machine simply did not report anything higher. Now take that number and imagine arguing on the phone with the girl’s father, who was himself unvaccinated, telling me that his daughter did not have COVID because she did not have respiratory problems. Everybody knows COVID is only about the lungs, right? So why would the heart be affected?

There were many cases like that during the second wave, and in a world where social media spreads false information at incredible speed, it becomes exhausting to argue with every idiot on Earth. Even the brilliant medical scientist Donald Trump was talking in the United States about COVID being some kind of hoax. I remember thinking, “America is fucked with him,” but I was so consumed by what we were doing in Europe that I barely had time to follow what was happening there.

In Europe, however, the medical response was incredible. As a member of the European Society of Intensive Care Medicine, I had access to weekly online meetings, either live or as recordings. Information was being exchanged faster than I had ever seen before. Reports came from Spain about early cases of myocarditis. British teams were experimenting with video calls and tablets to connect families with isolated patients. French teams were using the ROX index to identify patients at higher risk, while Italian colleagues in Milan were sharing what they were learning about assisted ventilatory support and the role of PEEP. We exchanged experiences about ECMO cannulas clotting and about experimental treatments that seemed promising but turned out to be insufficient.

Somehow, within Europe, borders disappeared overnight. We were all colleagues. We were sharing what we knew almost in real time. Everything suddenly came alive in the service of patients and of a population that needed us. I have never been prouder to practice medicine in Europe than I was during that period, especially on Thursday evenings when I would sit down and go through the latest updates from colleagues across the continent.

Those of you who went through something similar will understand exactly what I mean. To everybody else, to those who never came into direct contact with this side of the pandemic, all I can say is this: be proud of the healthcare workers who took care of you, often at enormous personal cost.

Deep down, I am proud of every colleague in Europe and beyond, of everyone who stepped forward during COVID, and of everyone who remains committed to serving a population that still needs us.