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reassures me. As a compromise, we scan her for a pulmonary
embolism. No clot. “She looks the same today. We wait.”
Day 6. It’s 6:43 am and I am walking around the unit,
catching night nurses and their pearls before they head
home to sleep. I peer through the glass of K440, and see
Emelia. She looks terrible. Like always. No, wait. She looks
worse than terrible. I stare at her, subtle, subconscious clues
coalescing in my mind. Mike walks over, tells me today is
the day, which is the same thing he told me yesterday, and
the day before. But this time he is right; I know so because
she knows so, too. She told her nurse she wanted to be
intubated even before her blood gases came back from the
lab showing oxygen levels as low as they have ever been,
low enough that I wonder how much oxygen is getting to
the placenta and baby.
I ask myself what I would do if K440 were occupied by
Heather. I reach for my phone and call for help.
Two doctors, two nurses, a respiratory therapist. That is
what it takes to intubate a COVID patient. We slowly dress
for war, plastic gowns that act as droplet armour, helmets
with fans to make us bullet-proof to the airborne shrapnel
spewing from infected lungs.
Next comes the highest-stake thing doctors like me
do at work. We inject a paralytic agent, depriving Emelia
of a normally automatic, yet essential, bodily function:
Patient perspectives
Young person with long COVID after mild disease
Shannon (name has been changed) is a nurse in her 20s
who works at a busy hospital in Dublin, Ireland. When
the COVID-19 pandemic struck in March, 2020, Ireland
was one of the countries that went into a relatively early
lockdown. But still, the patients began to mount. At work,
Shannon was told her ward would be made a COVID ward
and she was scared. “It was so much to take in. We basically
learned as we went along. All the policy changes, the
changes to personal protective equipment (PPE). And all
this combined with the constant worry we ourselves could
be infected and take the virus home to our families”, she
explains.
Nothing could really prepare Shannon or her colleagues
for what followed in late March and into April. “The ward
became like a war zone. All the doctors and nurses were
scared. We just didn’t know what we were dealing with, or
how to treat these patients. It seemed like on every shift,
we’d have to move one or more patients to the intensive
care unit (ICU), and also at least one would die”, she
explains. “We were dealing with the stress and grief of the
families. Normally when a patient dies, their family is there
with them. As this can’t happen during the pandemic, we
had to ring their families. It was heart-breaking every time.”
www.thelancet.com/respiratory Vol 9 May 2021 453
Spotlight
diaphragm movement. I’ve entered a moral contract to
replace the air-flowing role of her diaphragm with some
artificial means instead. If I fail, she will asphyxiate.
The squeaky beep-beep-beep of the saturation monitor
descends into a dull bomp-bomp-bomp, the cockpit
equivalent of “PULL UP—TERRAIN”. I struggle to navigate
the endotracheal tube through her small oropharynx and
before I can even use my own larynx to issue a command
for assistance to my colleague, a bougie is thrust in front of
my foggy helmet.
I see Heather’s epiglottis. Emelia’s arytenoids. Ubiquitous
anatomical waypoints. I wiggle my blade into the back of
her vallecula and lift, revealing my prized target. I stare into
the abyss between the two vocal chords, pass the bougie,
thinking only of little LJ anticipating a sibling as the tactile
sensation of heavenly tracheal rings reminds me to breathe.
Emelia was extubated after being on a ventilator for 7 days.
She was eventually weaned off oxygen and discharged from
hospital with a normal obstetrical ultrasound.
I declare no competing interests.
Blair Bigham
bigham@stanford.edu
Stanford University School of Medicine, Palo Alto, CA 94301, USA
Shannon decided to move out of the home she shared
with her parents as soon as she knew she would be working
on a COVID ward, and moved in with her partner, so that
her middle-aged parents would be less likely to be exposed
Tim Vernon/Science Photo Library
to the virus. It was at the end of April, when she had done
two long shifts over two consecutive days, that Shannon
started to feel unwell. “I had a few aches and pains in my
legs, but as I had increased the distance I was running that
week, I thought it was related to that. I also had a headache,
but when you wear PPE a lot, headaches are common”, she
explains. “But the next day I was very short of breath and Published Online
exhausted, and later that evening I had a slight dry cough, March 3, 2021
https://doi.org/10.1016/
followed by the loss of taste and smell. I knew that it could S2213-2600(21)00123-5
only be COVID-19.” For the blog post see https://
Shannon went to be tested and her positive result was blogs.bmj.com/
no surprise, “It turns out there had been something of bmj/2020/05/05/paul-garner-
people-who-have-a-more-
an outbreak at work among colleagues”, she says. “But protracted-illness-need-help-to-
looking back, it was unavoidable, we were all working understand-and-cope-with-the-
closely together, sharing break rooms and had to remove constantly-shifting-bizarre-
symptoms/
our PPE to eat. There wasn’t proper ventilation. And for
nurses, we had so much close contact with the patients.”
Shannon also became aware of another colleague, also
in his 20s, who ended up in intensive care with COVID-19.
 Spotlight
For the study on long COVID see
PLoS ONE 2020; published online
Nov 9. DOI:10.1371/journal.
pone.0240784
454 www.thelancet.com/respiratory Vol 9 May 2021
“I thought could this happen to me too? Could I end up in
ICU? I was really worried.” Shannon infected her partner,
but thankfully he recovered after just 2 days of illness.
However, Shannon’s symptoms continued, and for a
month she felt like she had a bad case of influenza, with a
blocked nose, sore throat, fatigue, and feeling breathless
without moving. The doctors were worried about her
breathlessness so they sent her a pulse oximeter to monitor
her blood oxygen. “My partner and I even discussed at what
point we might need to call an ambulance for me, just to
have a plan in place”, she explains.
From the time of her positive test, Shannon isolated for
around 3 weeks, worried that because her symptoms were
not going away, she was still infectious. “I did what I could—
rested, took vitamins, went on short walks in the back garden
and lay in the prone position, because we’d been told that
was helping patients with their breathing”, she remembers.
The fatigue continued, and Shannon also suffered chest
tightness and muscle aches and pains on a regular basis.
Her heart rate was also regularly much higher than normal
and she experienced palpitations. Attempting to go up the
stairs left her exhausted. She also experienced night sweats
and weight loss, and became prone to other infections—she
had one fever, two urinary tract infections, and three skin
infections. In addition to these physical symptoms, what she
has been going through was and still is mentally tough.
Throughout this time, which was still relatively early
in the pandemic, she had not heard anything about
so-called long COVID, a much more familiar term now
that collectively describes all people with long-term COVID
symptoms. “When I was still experiencing symptoms,
I started to wonder if I was losing my mind or if there was
possibly something more sinister going on. Finally, in June,
I saw a blog post in the BMJ by Paul Garner, an infectious
diseases expert from Liverpool, UK, discussing this. All
the things he was talking about, I’d been experiencing”,
she says. “In addition to the physical symptoms, I have
also been suffering a brain fog, difficulty concentrating;
sometimes having trouble speaking correctly.” One place
she found support and empathy is on Facebook, where she
has joined a group of fellow long COVID patients who can
all speak frankly about their experiences.  in a study by Dr Liam Townsend of Trinity College Dublin,
Shannon could see that, for most colleagues who she
knew had been infected, they had eventually returned
to work, mostly quite quickly. But as the weeks rolled by,
4, 6, and 8 weeks later, she still was feeling very unwell
and could not go back to nursing. “It’s not just for fear of
my own health and my really limited energy, it’s more
that I worry about making a critical mistake in patient care
when I can’t rely on myself and my skills as I could before.”
She also worries that she could end up with chronic
fatigue syndrome (CFS), limiting her work and personal
life forever. To avoid having complete energy slumps, she
follows advice for patients with CFS: prioritise, plan, and
pace. “I plan my tasks one by one, and my day based on
energy levels. I can’t plan the day before because I never
know how I’ll feel until I wake up”, she explains, adding
“I feel cold all the time, and have muscle twitches and reflux
and am now taking various medications that I never used
when fit and healthy”. 
Her general practitioner (GP) has been very supportive,
helping her onto medications where needed and also
referring her for specialist care. Thankfully, Shannon also
has private health insurance that is enabling her to see
specialists she needs, including recently having a cardiac
MRI scan to help work out the issues she is having with
her heart. “While lying for 45 min in the confined space
of the MRI scanner, it hit me how much I’ve had to do
because of getting the virus; the consultant appointments,
tests, physiotherapy, and GP visits. I have had to be my
own advocate throughout this process and that’s been
hard. When I first requested an MRI 6 months ago, I had
been denied, so I had to go privately. I thought of how my
life has completely changed and I don’t know when or if I
will fully recover.” She adds: “I have been lucky having
this insurance—I’m not sure what people do who need
this specialist care and don’t have any private insurance”.
Following her MRI, Shannon was diagnosed with pericarditis
and a pericardial effusion, requiring more medication.
Day to day, Shannon can become quite lonely. She tries to
exercise every other day, but a slow-paced 30-min walk is
the most she can do. She is looking forward to returning to
work, but realistically believes she is at least 3 months away
from a phased return. To deal with the mental struggle of
COVID, she has had multiple sessions of counselling, which
helped immensely, and also meditates daily. 
She wishes that the Irish health-care system had more long
COVID clinics to help manage cases like hers, but says these
are only available in the cities of Dublin and Cork. She was able
to attend two of these clinics herself. She pays tribute to the
first-class care she has received in the post-COVID clinic at St
Vincent’s Hospital. “Here in Ireland, we are not as far along
with treating long COVID as they are in places like France and
the UK”, she explains. She has kept herself informed about the
latest research on long COVID, and was particularly interested
Ireland, which showed that persistent fatigue occurs in more
than half of patients recovered from COVID-19, regardless
of the seriousness of their infection. The results of this study
were presented at a European Coronavirus Conference in
September, 2020, and received media coverage worldwide.
“It was a real relief to me to see that people who did not
need hospitalisation, like me, were just as likely to have long-
term fatigue as those who were in intensive care”, explains
Shannon. “It just made me realise there must be so many
people out there going through something similar to me.”
Shannon is looking forward to something like normal
life returning for her. “I just want my quality of life back,

I want to be back at work, and feel like myself again. But
for now, I’m having to deal with a whole load of physical
symptoms and also my brain not working properly. Even
for this interview, I had to write myself a list of key things
so I didn’t forget them. Just to be able to climb stairs and
not be out of breath, that would be wonderful. But for
COVID-19 vaccination in athletes: ready, set, go…
In the fight against the COVID-19 global pandemic, the focus
in 2021 has fortunately turned to vaccination strategies. The
successful development of several vaccines, and their proven
efficacy and short-term safety in large scale multinational
trials against severe acute respiratory syndrome coronavirus
2 (SARS-CoV2), offers promise in controlling the pandemic.
Many countries are now operationalising their vaccination
programmes, and prioritising health-care workers and the
most vulnerable individuals within the population—eg, the
elderly and those with chronic health conditions.
In the sporting world, COVID-19 has curtailed normal
activities considerably and led to the postponement and
cancellation of a vast number of national and international
events. Several studies within the past year detail COVID-19
transmission occurring in sport, and while the delivery of
rigorous infection control procedures is central in preventing
SARS-CoV2 transmission, the issue of COVID-19 vaccination
in elite and competitive, recreational athletes is fast
becoming a pressing issue for individual athletes, sporting
teams, and organisations. Sport clinicians are now facing
several important considerations, including the impact of
exercise on efficacy of vaccines, the potential side effects, the
best type of vaccine for a given athlete or group of athletes
(if choice becomes relevant), advice regarding the timing of
vaccination, and finally whether vaccination prevents SARS-
COV-2 transmission.
The issue of vaccination in the sporting community is not
new. On an annual basis, many thousands of athletes receive
influenza vaccination, and discussion regarding the risks and
benefits of vaccination, in this specialist community, has
long been debated. Studies in the general population have
shown heightened rates of vaccine efficacy, with an increased
antibody titre, in individuals who undertook moderate
intensity exercise before vaccination. However, the evidence
is not conclusive, with other studies showing no appreciable
impact of exercise on vaccine response.
A study analysing the effects of regular physical training
by a group of elite athletes on vaccine-induced cellular and
humoral immunity showed that although both groups
had a marked increase in vaccine-reactive CD4 T-cell levels,
which peaked 1 week after vaccination, this increase was
more pronounced in athletes when compared with healthy
controls. Similarly, the increase in neutralising antibodies was
stronger in athletes, suggesting that regular high frequency
www.thelancet.com/respiratory Vol 9 May 2021 455
Spotlight
now, my partner, who has been so supportive, is helping
me do pretty much everything. When I’m completely out
of energy, he’s even carried me up the stairs to bed!”
Tony Kirby
and intensity of training might enhance vaccine response.
Another study in athletes, analysing the impact of the timing
Sigrid Gombert/SPL
of influenza vaccination on antigen-specific T cell responses,
showed no appreciable difference between administration 2
and 24 h post training. Overall, the historical data does not
appear to indicate that physical training undertaken around Published Online
the time of vaccination will reduce efficacy, and could in February 5, 2021
https://doi.org/10.1016/
fact improve vaccination response. Studies will be needed S2213-2600(21)00082-5
to evaluate these outcomes in the context of the novel For more on COVID-19 and
formulations of COVID-19 vaccination. athletes see Spotlight in
A logical concern in the context of COVID-19 vaccination Lancet Respir Med 2020;
8: 557–58
relates to the impact of vaccine-related side effects. Detail on
For more on vaccination in elite
COVID-19 vaccination tolerability in the general population athletes see Sports Med 2014;
is still emerging (ie, the post-licensing data is still awaited) 44: 1361–76
and will likely differ based on type and formulation of For more on the effects of
vaccine. In the meantime, preliminary trial data provides exercise on vaccination
responses see
reassurance regarding an overall low serious adverse event Brain Behav Immun 2014;
rate, and that severe systemic effects were reported in only 39: 33–41
1–3% of individuals. For a study on acute exercise
A broad range of local and systemic side effects following and immune response to HPV
vaccination see
COVID-19 vaccination have, however, been reported in late-
Papillomavirus Res 2019;
phase trial data. Although these side effects are generally 8: 100178
mild (ie, they do not typically impact routine activities), they For more on elite athletes and
are more prevalent in younger individuals (ie, those younger vaccine-specific T cells see
Brain Behav Immun 2020;
than 55 years) and more pronounced following the second
83: 135–45
dose with some vaccines, within sequential staged vaccine
For study on timing of
administration. Specifically, in one of the most widely used vaccination after training see
COVID-19 vaccines to date, the Pfizer/BioNTech vaccine Med Sci Sports Exerc 2020;
(BNT162b2 mRNA Covid-19), local reactogenicity was 52: 1603–09
encountered in 83% of younger individuals and systemic For more on the safety of the
Oxford–AstraZeneca vaccine
reactogenicity, with fatigue and headache, was reported (ChAdOx1 nCoV-19) see
in about 50% of all individuals, with around 25% requiring Articles Lancet 2020
anti-pyretic or analgesic medication. Pertinent to athletes, 396: 467–78
myalgia was reported in 21% of younger individuals For more on the safety of the
Pfizer–BioNTech vaccine
following the first vaccine, rising to 37% following the (BNT162b2 mRNA Covid-19)
second vaccine. Notably, there are no published data on the see N Engl J Med
duration (days) of side effects and their impact on ability to 2020; 383: 2603–15
perform physical activity; clearly this information will be an
important consideration.
Safety analysis from the other main class and widely
available vaccine, the Oxford–AstraZeneca vaccine (ChAdOx1
nCoV-19), revealed that around 50% of recipients had
localised pain and tenderness at the vaccination site,
of mild to moderate severity, which on occasion lasted