Thread by @ChecchiaPaul

1/46 I’ve spent some time being thoughtful and esoteric; today is about data, evidence, and perspective.

Let’s examine the pediatric situation in the country. It’s bad. No question. We, and others, are seeing a record number of admissions.

2/46 Most data sites haven’t been updated yet for this week, so I expect them to be staggering when they update on Friday. But, as always, let’s move beyond the clickable headlines and dive deep.

The percentage of ICU admissions is significantly lower, by half.

3/46 The length of stay is significantly shorter. The overwhelming majority of children admitted are those unvaccinated, and not in the ineligible age groups, but rather in those that have access to them. Furthermore, this is not a child-seeking variant.

4/46 Children once again reflect the adult population. Hospitalization percentage of children infected has remain consistent. (nbcboston.com/news/local/kid…) Of course, if the denominator is larger, the number is larger, but this is not a different virus.

5/46 In fact, based on ICU proportion, it is in fact less severe…but NOT mild. This is a balancing act that we must face.

6/46 I have no doubt that when the data is updated this week, the overall percentage of hospitalization will not change from the 0.8-0.9% found previously (downloads.aap.org/AAP/PDF/AAP%20…).

7/46 I specifically bring this up because I am completely and unequivocally supporting in person school for all age groups. We have done this before. We know the data thanks to our experience in the fall. It cannot be clearer; children must be in school.

This wave will decline.

8/46 We will get through this. Omicron did not change as it crossed boarders. There was not an increase in the percentage of pediatric admissions in South Africa (nicd.ac.za/diseases-a-z-i…) .

9/46 There has been similar data from the UK as they have shown flat admission curves for all ages and no indication of increased severity in the pediatric population. (ons.gov.uk/peoplepopulati…)

More helpful data. We are not in the same situation as earlier waves.

10/46 RSV and Flu are not raging. The overall census of pediatric hospitals is lower and therefore more manageable. Not pleasant, but manageable. Staffing issues are more pronounced than previously (more below).

11/46 This isn’t what any of us wanted, but this is where we are right now. We will get through this. The biggest continued take away is that vaccines are protective for children. Even a single dose of anything in this age group is protective.

12/46 Furthermore, I will continue to support the idea that even one dose provides benefit.

Let’s talk about boosters for children for a second. These vaccines are safe. They are effective. They are available.

13/46 I have no doubts, questions, or hesitation whatsoever in stating that every child eligible should be vaccinated. I also have no doubts, no questions, no hesitation whatsoever in stating that a booster dose in these ages is safe and effective.

14/46 However, I have a slightly different view on their need. I have been very clear that I support the idea that more protection is afforded to more people by advocating for more people to be vaccinated.

15/46 I stand by my earlier statements that I would rather see 100% of children receive at least 1 dose than see 30% of them receive 3.

16/46 We are currently at a dismal 15% of 5–11-year-olds, and 53% of 12–17-year-olds fully vaccinated. (mayoclinic.org/coronavirus-co…)

17/46 Again, let me be crystal clear: As a pediatrician I would love to see all children fully vaccinated, all vaccines are safe for these ages, all doses are safe for all ages. NO QUESTION, NO DOUBTS.

18/46 However, I think we are unnecessarily confusing the goal when we discuss boosters in this age group. We have more important work to do.

19/46 For example, why don’t we concentrate on the message that 75% (!) of 5–11-year-olds are still without even the protection of a single dose.

20/46 I am a pediatric intensive care physician and thus that makes me an optimistic realist. Let me explain my thoughts about the current wave, the need for vaccination as I outlined, and my optimism.

21/46 On any given night in any given ICU, there are critically ill patients where you, as the caregiver, are along for the ride. This usually happens in the overwhelming inflammatory response of septic shock. We don’t have a tool to fix that situation.

22/46 Antibiotics are given to stop the inciting event. Medications are given to keep the blood pressure up. Ventilators provide oxygen. You spend hours playing pathophysiologic whack-a-mole.

23/46 Yet, in the end, the body will do what the body does and we just hope we can keep up on the ride. There are hundreds of thousands of investigators, clinicians, and scientists trying to find that magic bullet to stop that cascade; but we don’t have it yet.

24/46 All we can do at the patient’s bedside is react and fix what we can fix, control what we can control, aim for what is ultimately most important as we adjust expectations. (see where I am going with this).

25/46 So many nights, I would wish that the lactate would clear, the SVO2 would improve, the CO2 was lower, and the saturations were higher; but most times that was only hope for perfection. Every ICU practioner knows to adjust the bar at some point. Win where you can.

26/46 Any patient that makes it to the morning alive is a win.

Many times, the enemy of good is the striving for perfection. This is not the acceptance of mediocrity, it is aiming for what is truly important.

27/46 What’s important is a clear vaccination goal, keeping sick kids alive, and keeping healthy kids thriving.

28/46 “The best thing one can do when it is raining is to let it rain.”- Longfellow.That doesn’t mean to not put up an umbrella or at least try to get under shelter, but we are currently in the position that we are left to ride out the storm. Honestly, what choice do we have?

29/46 I promised a discussion about staffing. I will start with a quote: “Every system is perfectly designed to get the results it gets.” -- W. Edwards Deming

The current situation in most hospitals is that they have the physical space, but not the staffing.

30/46 Medicine likes to compare themselves to the airline industry. We like the approach to safety, quality, error prevention, and communication. Just like the cancellations seen in the airline industry, we now face staffing shortages.

31/46 This is because, like with pilots and crews, healthcare has adopted the “lean” mentality. Excess, whether in people or supply, produces cost. Reduce excess and you can at least control cost. Well, this is what we get.

32/46 It’s a delicate balance on an edge and anything pushes you over: a storm or a pandemic. For far too long in this country, we have not valued the people that deliver healthcare.

33/46 Just like teachers, we haven’t figured out how to value the bedside nurse whether they be young, idealistic, and starting their career or one who has more medical knowledge in her 20-year experienced pinky finger than most physicians have in their entire bodies.

34/46 We overwork primary care physicians to the point that they are forced to double book to make a living. We are constantly looking for the perfect staffing ratio to provide quality care with the least number of people.

35/46 We burn out ICU physicians at a rate that is unsustainable with the response of “resiliency”. I’m not blaming all administrators. To be fair, they must play in the same sandbox with their own set of pressures.

36/46 So many people in my institution and others are desperately trying to figure out how to do this right. They are drowning just like everyone else. However, let’s be clear that these issues were not caused by the pandemic; they were exposed by it.

37/46 Staffing issues pre-dated Omicron.

38/46 There are all sorts of reasons, but years of misplaced priorities, cultural attitudes that value overwork rather than quality work, and financial models with inappropriate reward systems (insurance CEOs I’m looking at you) comes to the surface.

39/46 We must figure out a way to provide care to those who provide care. We must find a way to value them. Also, to be clear, money is not the only answer. There are only so many moonlighting shifts that can be tolerated.

40/46 I don’t profess to know the answer, but I do know the problem.

Let me conclude on one positive and one interesting note.

41/46 Predictions in this pandemic have long served as a fool’s errand. However, many predictions are coming out about better days ahead. (covid19scenariomodelinghub.org ) (greekreporter.com/2022/01/04/omi…) I’m hopefully.

42/46 There is a freak-show of fear trying to be built up about another variant in France with 46 mutations. History has a lesson for us.

43/46 Here is an incredibly relevant history story that is some of the most important reading to do about the evolution of coronaviruses in humankind. It has to do with the so-called “Russian” flu pandemic of 1889 which killed an estimated 1 million people around the world.

44/46 Here is the interesting part: emerging evidence suggests that that pandemic wasn’t caused by an influenza virus but rather a novel coronavirus.

45/46 Yes, there potentially was a COVID-1889, HCoV-OC43, it came from cows, (jvi.asm.org/content/79/3/1… ) and it caused havoc around the world.( theguardian.com/world/2020/may… ) Furthermore, it might actually be that the novel coronavirus of 1889 has mutated over the years into what is…

46/46 …now referred to as the “common cold”. (ncbi.nlm.nih.gov/pmc/articles/P… )[Read this if you read anything!]

Again, perspective; we can manage this infection and even live with it. Viruses evolve, but so do we.