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'Covid's back on the board,' and ER doctors like me are bracing for an awful fall

Even if the number of Covid hospital admissions and deaths stay on the lower end of estimates, the impact on our country's hospitals will be significant.
A shopper reaches for a box of Covid-19 tests in Dallas on Sept. 29, 2022.
A shopper reaches for a box of Covid tests in Dallas in 2022.Nitashia L. E. Johnson for The Washington Post via Getty Images file

“Covid’s back on the board,” a colleague said to me recently as he signed out at the end of his emergency room shift and I signed in at the beginning of mine. 

This summer, we saw the lowest estimated death rates attributable to Covid since we started regularly celebrating the presumed end of the pandemic. Those numbers fell to 6,300 hospitalizations and 500 deaths a week. But things didn’t stay there long. Throughout the past month, Covid cases have been ticking back up.

“Covid’s back on the board,” a colleague said to me recently as he signed out at the end of his emergency room shift and I signed in at the beginning of mine.

In the ER, Covid positive shows up on the tracking board: either in the column that lists the reason for a patient’s visit or in the column used to communicate critical information to staff. 

 So far, where I work, it’s just been a few patients here and there, sprinkled between the usual case mix. At the start of one of my shifts, an elderly woman was waiting for an inpatient bed after feeling weak for two days and then collapsing in the shower at home. A wide range of diagnostic tests were benign, but a positive Covid test explained her symptoms. Later that shift, I saw a patient who’d had a positive home test but came in because of symptom severity. He’d considered going back to work for the first time since long Covid sapped his energy capacity about a year ago, and he feared the new infection would knock him back to where he started.

Estimates for the surge this fall and winter range from 484,000 to 839,000 hospitalizations and 45,000 to 87,000 deaths. Even if the actual number of hospital admissions and deaths stay on the lower end of those estimates, they will still be hugely significant.

First, health system capacity has not returned to normal and, right now, hospitals are already under strain. The staff is stretched to its limits, waiting times are painfully long, and physical spaces are full to bursting. Of course, ER visits and hospitalizations only represent a small fraction of people with Covid. The estimates above translate to many millions of outpatient clinic visits for Covid, which will collide with visits for other respiratory illnesses expected this winter: Australia’s flu season, which is a bellwether for the U.S., has been particularly tough on children this year.

Further, due to the end of continuous Medicaid enrollment instituted at the onset of the pandemic, millions of Americans have already lost their Medicaid coverage this year and have less access to their primary care clinics. Add to that, the steady closure of rural hospitals and our underutilization of existing therapies against severe Covid, and you get an acute care system under strain. Again. 

The quality of care drops when hospitals are under such strain, which means that facilities already at the tipping point of chaos will not be able to deliver the same standard of care if they descend completely into chaos. Second, the inability to function well during strain contributes to what we call the “moral distress” of health care providers — when the right course of action is clear but institutional constraints prevent one from taking it. Moral distress leads to more personnel leaving front-line clinical work, which leads to reduced capacity, which leads to more distress. It’s a vicious cycle.

Further, long Covid is no joke. Every time I see a patient with long Covid, like the one I cared for the other day, I am struck by how it stubbornly challenges any comforting notions about the disease itself. We’d like to think, for example, that because acute Covid is often (though not universally) mild, it’s nothing to worry about. But long Covid most often occurs after mild disease.

Some people are convinced that Covid “only” matters if the person who gets it is elderly, immune compromised, chronically ill or disabled, and the eagerness of so many people to embrace this line of thinking exposes how quick we are to devalue the lives of people in those categories. But long Covid also appears in young, previously healthy and highly active people, including children.

Yes, many people recover from long Covid. And also, some don’t. The waiting list for my health system’s long-Covid clinic remains full, and those who are seen there have severe, debilitating illness, the defining feature of which is a disabling and devastating fatigue.

Every time I see a patient with long Covid, I am struck by how it stubbornly challenges any comforting notions about the disease itself.

As we publicly cheered the end of the pandemic, there have been few celebratory laps for those affected by long Covid. We still don’t understand the underpinnings of the disease, the timeline of symptoms or improvement for those with severe disease, or the impact of successive waves of acute Covid illness on those with chronic Covid illness.

The Office of Long Covid Research and Practice announced a year ago only launched last week. So too did the first trials of therapeutics to treat long Covid. Like post-viral myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) before it, the existence of long Covid is so inconvenient that it is standard to ignore and dismiss it. But our journey with long Covid is just beginning.

It remains to be seen what, exactly, Covid has in store for us this winter. But we’re likely to see some degree of health system oversaturation, struggling hospitals and clinics, reduced access to needed care and reduced functionality of the whole system. Some of this may feel wearily familiar. Unfortunately, in terms of long-term fixes for both the health system and long Covid, we are still waiting for meaningful breakthroughs.