On April 8, David Williams got a standing ovation as he was wheeled out of the John L. McClellan Memorial Veteran's Hospital in Little Rock, Ark.
Williams, 54, a Marine Corps veteran, had survived eight perilous days on a ventilator with COVID-19, and the hospital staff had lined up to give him a joyous, fist-bumping send-off.
Today, Williams is back at home with his wife, D'Anna. But a full recovery remains a distant prospect.
"I still have to wear oxygen," he says. "I have like a hundred-foot cord. And so I wear my oxygen in my nose, and I'm still able to travel all over the house."
Williams can take a few steps on his own, but still uses a walker.
"I need it like when I have to wake up in the middle of the night or something and need to go to the bathroom," he says. "Because trying to get the feet going again is a little rough."
Williams has improved a lot since leaving the hospital. And he says he might be doing better if he hadn't been out of shape and overweight when he got sick.
When Williams first woke up with a breathing tube in his throat, he had almost no control of his arms or legs. And, like most patients on a ventilator, he felt parched pretty much all the time. He couldn't drink, so one day a nurse left him a damp swab to suck on.
"It took me like five or six minutes to just pick that thing up, to get my fingers actually on it and my brain telling my hand to lift it up and you know to put it in my mouth," he says.
Williams can feed himself now. But he's still having problems with memory and thinking.
Computer passwords he's used for years are now hard to recall, and he is sometimes unable to complete sentences. "It takes me awhile to think about the words I need to say," he says.
Williams hopes he can work around these limitations and resume his job as veteran's service coordinator at the University of Central Arkansas.
If Williams makes a full recovery, he can count himself among the fortunate, says Dr. Amy Bellinghausen, a pulmonary and critical care fellow at the University of California, San Diego.
Some COVID-19 survivors will never recover completely from a condition known as post-intensive-care-unit syndrome, she says. It can produce long-term disabilities from muscle wasting, organ damage, brain damage, and PTSD.
"Unfortunately, oftentimes when they're coming off the ventilator, it's not the same person who went on the ventilator," Bellinghausen says.
One of the most common problems among ICU survivors is weakness and fatigue, Bellinghausen says. "That whole time in the ICU, they're losing muscle mass. People lose 20,30,40 pounds over a week or two."
As a result, "things like walking the dog, going up a flight of stairs, doing your laundry are really, really difficult to do," she says.
And many COVID-19 patients will also have organ damage, which can be caused by the virus itself, or the extreme measures used to keep them alive.
"People can have scarring in their lungs, sometimes kidneys are impacted, but really any organ can suffer injury in the ICU," Bellinghausen says.
The brain is especially vulnerable.
In part, that's because the drugs used to sedate patients while they're on a ventilator can have lasting effects on memory and thinking. Also, COVID-19 patients whose lungs are badly impaired in the ICU "often have times when their oxygen level is very low. And that also causes damage to the brain," Bellinghausen says.
Then there's the emotional impact.
Bellinghausen says patients who may be delirious from fever or sedation can feel trapped in a scary, noisy place where they are connected to machines that have taken control of their bodily functions. And if they move too much or try to remove a tube, they may be forcibly restrained.
All that can contribute to paranoia, she says. "They really think that all these efforts that we're doing in the ICU to try to save their life may be [us] trying to harm them. And so people come out of the ICU with pretty profound symptoms of PTSD sometimes."
Patients with life-threatening COVID-19 seem to be especially vulnerable to post-ICU syndrome, says Dr. Negin Hajizadeh, a pulmonary critical care doctor at the Donald and Barbara Zucker School of Medicine at Hofstra-Northwell in New York.
One reason is that the infection is often so severe that patients spend weeks on a ventilator, not just days. "The longer you are on the breathing machine, the steeper the road to recovery," Hajizadeh says.
As a result, many COVID-19 survivors will need months or years of rehabilitation. But a few have been able to bounce back quickly.
Matthew Robertson, 28, a tech worker who lives near Seattle, was one of the country's first COVID-19 patients, and nearly became one of the first fatalities.
"I got to the hospital on Feb. 29," Roberts says. "When I woke up I was looking at the date on my chart that was on the window and it already said, like, March 7."
Robertson spent a week on a ventilator and nearly two weeks in the hospital. Today, though, he's pretty much back to normal.
"I think the only thing that still hasn't properly recovered is the vocal range of my voice," says Robertson, who likes to sing. That's a common problem caused by breathing tubes that pass through the vocal cords.
So Robertson says he's not ready to go back to the karaoke clubs yet. But at the moment, they're all closed anyway.