COVID-19 vaccines: medical concerns and recommendations

[Nephrology]

That’s what worries me. The thought of no biking, no hiking, or not even being able to walk the dogs seems awfully bleak.

To be honest when I am outside breathing freely circulating air I never worry about COVID at all, don't wear masks outdoors for this reason. I am sure there is some % chance of getting COVID from someone I am sharing a hiking trail with but after 3 vaccines and with quasi-infinite dilutional volume for their expired air, it is surely fairly low.

Sharing indoors spaces is a different calculus, but I don't think COVID should make you feel as if you cannot bike/hike/walk the dogs.

[4RNR]

My whole family (aunts, uncles, cousins, grandparents on both sides. Ages 20 - 85) just went through covid. Almost no one vaccinated. Symptoms from mild cold to flu to WTF but nothing terrible. Some people were done in a few days others took about 2 weeks to completely get over it.

Some older people without vaccines did better than younger people with vaccines

There was one death of an elderly relative

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[4RNR]

To be honest when I am outside breathing freely circulating air I never worry about COVID at all, don't wear masks outdoors for this reason. I am sure there is some % chance of getting COVID from someone I am sharing a hiking trail with but after 3 vaccines and with quasi-infinite dilutional volume for their expired air, it is surely fairly low.

Sharing indoors spaces is a different calculus, but I don't think COVID should make you feel as if you cannot bike/hike/walk the dogs.

I think he meant after getting sick. Like in your example of 40 year olds walking around with oxygen

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[Nephrology]

I think he meant after getting sick. Like in your example of 40 year olds walking around with oxygen

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Oh, my bad. I must be missing context or not have read carefully enough...

re: the persistent breathlessness in many COVID patients after infection, it does seem like most do experience some degree of improvement over time. There isn't a lot of literature on it out there but what I have read suggested most people experience measurable improvement at 6 and 12 months after infection, but to be honest the studies I have seen have been relatively small and not many in number. Still something we are just beginning to understand.

[peterb]

I think he meant after getting sick. Like in your example of 40 year olds walking around with oxygen.

Exactly. Doing active stuff outdoors is *important* to me. Having my lungs not work properly would be a huge decline in my quality of life.

[HeavyDuty]

Oh, my bad. I must be missing context or not have read carefully enough...

re: the persistent breathlessness in many COVID patients after infection, it does seem like most do experience some degree of improvement over time. There isn't a lot of literature on it out there but what I have read suggested most people experience measurable improvement at 6 and 12 months after infection, but to be honest the studies I have seen have been relatively small and not many in number. Still something we are just beginning to understand.

Does religious use of an incentive spirometer seem to matter?

[45dotACP]

I saw lots of COVID on 2 months of hospital medicine, now at rapid access clinic at local VA and seeing lots of pts for follow-up visits after d/c from admission for covid pneumonia. Really striking number of people with no significant past medical history, now have new oxygen requirement and the telltale sign of post-COVID pulmonary fibrosis (patchy peripheral ground glass opacities in read of CT/XR). A lot of 40 year olds who now are walking around with an O2 tank and can't go more than a couple blocks without stopping. I can only imagine the degree of disability his will create in the future as this population ages with this significant baseline impairment in functional capacity... it is going to be a huge problem.



No traveling service for MD residents unfortunately

Dang, you guys need to be paid way more IMO. FWIW the hospital I work for has a few different IM groups and they rotate who gets the "COVID floors" like mine to try to avoid burnout. I think there used to be hazard pay, but that kinda fell off because the CEO of the hospital didn't get his 11 million dollar bonus in 2020, the poor thing.

A colleague of mine had a spouse who was hospitalized on our unit and required high flow oxygen for some months. According to my colleague, said 40ish year old spouse only just now got off of oxygen after being sick in July of 2020.

There will definitely be a significant amount of disability to patients who wind up in my unit, because we tend to transfer them once they can tolerate being on 6L NC and the whole time they're with me it's either OptiFlow, BiPap continuously and usually 20-40ppm of nitric. If they don't get intubated they'll be on my unit for weeks... sometimes months.

I'm a huge believer in pulmonary rehab and incentive spirometer definitely seems to help. I give one to every patient I get and lecture them about how important it is and it does seem to work, but I have no study data to back up what is likely just my instinct.

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[Nephrology]

Does religious use of an incentive spirometer seem to matter?

No, the IS is good for popping open lungs that have collapsed at the bases for whatever reason (often due to shallow respirations caused by pain, pain meds, whatever) but fundamentally the pulmonary fibrosis is a consequence of the peculiar hyper-inflammatory nature of the immune response to COVID infection in certain individuals. Recruiting your bases with the IS won't do anything to change that.

Dang, you guys need to be paid way more IMO. FWIW the hospital I work for has a few different IM groups and they rotate who gets the "COVID floors" like mine to try to avoid burnout. I think there used to be hazard pay, but that kinda fell off because the CEO of the hospital didn't get his 11 million dollar bonus in 2020, the poor thing.

Hah well I am still in training so my pay comes in the form of a bonus called "the gift of education." Will be that way for a while longer...

I'm a huge believer in pulmonary rehab and incentive spirometer definitely seems to help. I give one to every patient I get and lecture them about how important it is and it does seem to work, but I have no study data to back up what is likely just my instinct.

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It's super important in the inpatient context no doubt, atelectasis superimposed on baseline reduced pulmonary reserve is a bad situation and patients de-recruit easily when they're supine in a hospital bed most of the day. I just don't have any reason to think in the long term it will affect the pathophysiology of post-COVID fibrosis as fundamentally it is driven by the peculiar immune response to this virus specifically.

About 50-60% of my thesis was about fibroproliferative ARDS; my first author paper from this work was published online the week that COVID became headline news in USA (mid March 2020). At the time, the concept of post-ARDS fibrosis was fairly controversial and had received little attention in medical literature as it was subtle and equivocal. While many patients in post-ICU clinics were observed to have reduced lung function after ARDS, it was hard to say definitively whether that was a true new deficit or if there was some degree of baseline resp insufficiency that had evaded clinical attention, or if there was a component of MSK involvement affecting ventilation, or whatever. Fairly controversial whether or not it really existed.

It is really bizarre now, almost 2 years later, to see it commonly and in such a large % of the patients I am seeing in clinic. Of the ~120-150 patients I've seen in the last 4 weeks, probably 20 or so of those visits were post COVID PNA ED visit +/- admit, all of them with some degree of residual deficit, satting 92%ish @ check in, down to mid 80s when I ambulate them on the monitor, listen to them tell very similar stories while I put in order for Home O2 in CPRS... Pretty weird experience.

[ccmdfd]

Hah well I am still in training so my pay comes in the form of a bonus called "the gift of education." Will be that way for a while longer...

"If you are on call every other night, then you are missing 1/2 of the learning in this hospital!"-

Some of the old blowhard attendings would say this often back in my school days. Wonder how they would think about things now with all the limitations as to how much call a resident can take.

[ccmdfd]

I'm a huge believer in pulmonary rehab and incentive spirometer definitely seems to help. I give one to every patient I get and lecture them about how important it is and it does seem to work, but I have no study data to back up what is likely just my instinct.

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Can't say that I thought about using incentive spirometry. I might have to think about that one. However I am an absolute big fan of pulmonary rehab for this. I've asked how we had people to try to keep track of how many we have and maybe we can do a paper or something in the future.

At this point it's about all we have. Primary Care keeps sending patients over thinking we've got some miracle drug that's going to reverse their fibrosis. Maybe they'll come up with one in the future.

My personal experience mirrors what @Nephrology mentioned, many patients have Improvement but quite slow, especially compared to standard ARDS. Months and months of recovery. And then there is a subset of people who just will not get better at all.