Time to Vaccinate

After many months of discouraging trends, news reports and heartache, the approval of two vaccines is like a ray of sunshine breaking through the clouds on a stormy day. Yesterday, I was excited to receive the first dose of the Pfizer vaccine. Many of my patients are anxiously waiting their turn. Many others are unsure and just anxious. To allay fears, I wanted to share what I have learned about these vaccines. 

How the vaccines work: 

Messenger RNA Both the Pfizer and the Moderna vaccines are "messenger RNA" vaccines (mRNA). Normally, mRNA is made in the nucleus of our cells from DNA and acts as a code of instructions to make proteins. Proteins are used as enzymes, structural building blocks, receptors, antibodies and many other purposes. This happens on the ribosome. Think of it as a 3D printer for proteins. The mRNA interacts with the ribosome which deciphers the code. The mRNA from the vaccine codes for the Corona Virus spike protein. This is the part of the virus that allows it entry into the cells and cause infection. The mRNA goes right to the ribosome where spike proteins are produced. They are then released into the body where our immune system recognizes them as foreign material and mounts an immune response by making antibodies that attach to the spikes. 

Activating the Immune Response 

Once a person becomes infected, his/her immune system recognizes the spike and can mount an immediate response. This differs from a person who has not been vaccinated. Their immune system also recognizes the spike protein but are not able to immediately make antibodies as that process can take several weeks. One of the reasons that patients give me for not being vaccinated as that they "have a good immune system" and don't want to put foreign material into their body. To me this is like saying that a runner wants to enter a marathon without doing any training runs. Exposure to the vaccine gives our immune system a head start. Primed and ready to go, it can be prepared on race day to act right away. 

Cell Delivery 

Many vaccines in the past used altered organisms that were not as deadly. This made an individual sick to some degree. Obviously, this is not an ideal situation. No one wants to get sick to prevent illness. The beauty of the mRNA vaccine is there are no infectious particles being injected. We have never had this technology before because mRNA is quickly degraded outside of cells and would be destroyed before reaching its target. Scientists have discovered how to pack the mRNA in lipid membrane vesicles (think of tiny little soap bubbles). This membrane is similar to our cell's membrane allowing for delivery of the vaccine right into the cell. The lipid membrane in the Pfizer vaccine is unstable at warmer temperatures which is why it must be stored in special low temperature freezers. 

Foreign Material 

One of the fears that I have heard from others is that the vaccine is injecting animal DNA into our cells. This is incorrect. Animals may be involved in making the mRNA strand but it does not enter the cell nucleus and does not interact with our DNA. In addition, there is no biochemical difference in the nucleosides (mRNA building blocks) from an animal source versus our own. In reality, unless we are strict vegans, we come in contact with animal particles every day. There is no concern for these vaccines. 

Side Effects 

The side effects stem from our immune response. The first shot will likely just give an individual a sore arm. The second shot may give more symptoms related to a larger immune activation on repeat exposure. This may consist of a headache, fever, and muscle aches. For individuals who are already prone to severe immune reactions that require them to carry injectable medicine (EpiPen) with them at all times, they are more likely to have a severe reaction to the vaccine. Such patients should consult with their physician.

Safety 

I am quite impressed that we were able to get data on clinical trials with over 50,000 patients in so short period of time. Frankly, if our country did not have such rampant spread of the virus, this would not have been possible. With so many being infected, it was easier to tell how effective these vaccines worked. We have safety data from these trial participants, but obviously it is short-term data. While, no one can say with absolute certainty that there will not be long-term issues, there is no indication so far to justify this concern. We will continue to learn and make recommendations, as more data is available.

Bottom Line 

My colleagues and I are not hesitant to receive or recommend these vaccines. We know with certainty what COVID can do. Not only is it currently killing more people each day than died at Pearl Harbor or the 911 attacks, it has also surpassed heart disease and cancer as the most common cause of death. The pandemic has wreaked havoc on our society, our economy, and our families. It is time to make this all end. Personally, I have received the vaccine and am grateful to put on this protective armor as I go to work each day. As a society, we need about 75% of our population to receive the vaccine so that the virus has nowhere to spread (herd immunity). This is the message that needs to go "viral." Pass the word, get your shot. Let's put an end to this virus now.

Staring Death in the Face

Like a dreaded tsunami, the current COVID surge has flowed over our protective barriers and is flooding our hospitals with sick, debilitated patients who are literally struggling to take each and every breath. The emergency sirens have sounded, the call for help has been heard and it is all hands on deck in the hospital.  Last spring, I and a dozen of my colleagues agreed to help staff an expanded ICU to care for the expected demand.  We did some training shifts but the numbers receded and our services were not required-until now.  My hospital usually has capacity for 30 ICU patients.  We have now expanded to take 57 such patients.  Last week I did my first over night shifts in 25 years.  This week I am finishing three 12 hour day shifts. 

I am covering a unit with 10 patients.  Most of them have COVID and are on high flow oxygen delivery systems.  In the beginning of the pandemic all of such patients were put on ventilators.  It was feared that such oxygen systems would enhance the propagation of the virus.  We have since learned that it can safely be used if appropriate precautions are taken. This has greatly improved our ability to treat such patients as well as to safeguard the limited supply of ventilators.  Now if a patient has gotten severe enough to warrant mechanical ventilation, they are much more ill. Either their condition is too severe or they have lingered on these oxygen therapies for weeks and have now started to deteriorate. The grim reality is that if they require ventilation and survive they face an almost certainty of needing to be on it long term which requires a tracheostomy (a surgical hole in the neck to insert the breathing tube). They also will likely need to be in a ventilator specific nursing home till they can be weaned off of the machine. 

This last week, I have spent most of my hours having conversations with the patients and their families about this difficult reality.  Some have chosen to push forward with all we have to offer.  Others, often who are elderly or otherwise compromised, have decided that if their condition gets that bad, they would prefer that we focus on making them comfortable at the end of their life and to withhold life support.  Staring your mortality square in the face is hard. It is hard for the patient, it is hard for their families and it has been exhausting as their doctor.  The patients are tired.  They have been breathing thirty times a minute for weeks, as if they had just finished a sprint that never recovers.  The thought of being on life support for months is daunting.  Many families have a hard time grasping how ill their loved one is.  They see others in the community who are sick for a few days and recover just fine.  They are not allowed in the ICU and must gain all their knowledge from our phone calls. It is hard for them to truly see how sick their loved ones are. 

I have a passion for making sure that patients and families truly understand the ramifications of whatever decision is made.  There is a reason why almost all physicians chose to not be resuscitated and put on life support if the condition arises. We know that it is a horribly uncomfortable experience for the patient. Hollywood makes life support seem as if a simple tube is taped by the nose while the patient is able to talk, eat and carry on with life.  That is far from the truth.  Over the 72 hour span of working this week, I had the "death talk" over 10 times.  There were 3 individuals who chose to withhold life support that we made comfortable in their last hours, making sure that family was by their side. I had the heart wrenching experience of helping the family of one of my own patients to whom I had cared for over twenty years, make the decision to withdraw the ventilator as there was a certainty that he would never recover. In every case, the family was so gracious and kind.  As emotionally exhausting as it is to have these conversations, it is immensely rewarding as well.  I truly could not do it without my belief and faith in God and that they will live on in spirit. 

News of an effective vaccine is like a break in the clouds, the sun shining over our flooded land.  It provides hope that this kind of suffering and these kind of difficult conversations may not be needed, at least for this dreaded virus.  It will take time for the population to get sufficiently vaccinated to provide herd immunity.  May we heed the call of the sirens to head for safety, to continue to watch out for each other as we get vaccinated, mask up, stay apart and keep safe.

The Breath of Life

 For nine months this precious baby grew and developed in her mother's womb receiving all her nutrients and oxygen through the placental "feeding tube."  All that she needed to grow came from her mother.  After hours of being jammed into the bony birth canal and somehow flipped "sunny side up," she exited the warm comfortable fluid of the uterus, entering the cold stark outside world.  As fluid drained out of her lungs and she opened to the surrounding air, her whole circulatory system immediately changed. Oxygen rushed into her lungs causing resistance to blood flow to decrease in the lungs but to increase in the rest of the body. Her skin, at first a bit blue and dusky immediately pinked up.  To me the whole process is a miracle of biology, orchestrated by a loving Heavenly Father.  In the scriptures, the initiation of respiration is referred to as God's "breath of life." 

The idea of life giving breath can be found in the ancient Hawaiian practice of the expression of "ha."  This is a face-to-face greeting, the expelling of one's breath for the other to feel.  It denotes a deep sense of brotherly love and caring. It is ironic that what has at one time been viewed as an expression of good will would now be considered as rude and reckless in today's mask wearing society.  Such action could spread disease and death rather than love and life. COVID has changed everything.  

On the very night that I was able to visit my daughter and her adorable baby at the hospital, I was on my way to the floor above hers to care for patients over night in the ICU. One patient in particular kept our attention for most of the night. His breath was coming fast and shallow, breathing 35-45 times per minute (normal is about 18 breaths per minute). His oxgyen levels were drifting lower but just barely holding steady.  The worry was how long he could keep breathing at that pace. We were doing all we could to keep him off of a ventilator since nearly half of all those with COVID who are put on ventilators never come off. This is due to both the severity of their disease but also results from cascading deleterious affects from the whole process. The patient was transitioned to the highest level critical care unit where he indeed required mechanical ventilation.  The critical care doctor expertly placed the tube and his breath of life was sustained once again.  The whole process is terrifying to the patient and anxiety ridden for the health care team. 

The juxtaposition of new breath and declining breath was a stark reminder to me of the world we now live in.  I am grateful to have a daughter and son-in-law who are willing to start a family in such a world.  Their faith, love and devotion will be a blessing to my granddaughter that she won't learn to appreciate for many years to come.  I am equally grateful for a team of nurses here at the hospital who with faith, love and devotion as they watch over the patients to make sure their current breath is not their last one.  They are being spread thin and can only do so much.  As such, I am even more thankful to all of you who are willing for the time being to cover their mouths with masks, keep their distance from others even when their heart aches to do otherwise.  The pandemic will not last forever. The day will come when we will once again embrace those we love, face-to-face sharing their breath with ours.