Happy National Doctors' Day!
March 30th was chosen for National Doctors' Day because it is the anniversary of the first use of general anesthesia (ether) for a surgical operation (tumor excision from the neck), performed in 1842. Normally these days come and go without much fanfare, but with all that is happening in the world, I do appreciate the recognition. Although I haven't personally taken advantage of it, I have heard of many businesses doing what they can to help health care workers and emergency responders, and I find that so admirable, especially in light of the economic downturn. We are a community. We see and support each other. My friends, also, have been amazing in reaching out, setting up video chats, and offering to help, and that too, makes a difference.
Speaking of anniversaries, it's not quite a full century, but can you believe Alexander Fleming postulated the existence of penicillin only in 1928? It's been less than a century that we've known about antibiotics, and we didn't even have a therapeutic medication until 1942 (penicillin G). But in those intervening 80 years or so, antibiotic resistance and pandemics like COVID have changed the landscape of medicine. We may have new tools, but we face new challenges.
There is no question that health care workers are a vulnerable population during pandemics. A Lancet editorial published about a week ago noted that over 3300 health care workers in China and 20% of health care workers in Italy have been infected. The stories of hospitalizations and deaths of these colleagues spread like wildfire among our group texts. As we struggle with increasing shortages of personal protective equipment (a topic for a separate blog), we face a staggering reality: that nurses, respiratory therapists, staff, technicians, and physicians responding to this global crisis will die in the course of caring for others.
The other day in the intensive care unit, as I saw our critical care nurses arrive for sign-out on our COVID patients, I pictured Molly Weasley's clock with all the golden hands spinning to point to "mortal peril." I no longer think this is an exaggeration. We are seeing young, healthy people hospitalized, mechanically ventilated, and dying from COVID. At the same time we tell the rest of the world to circumscribe six feet about themselves, we ask our caregivers to enter the rooms of the infected without the gear to protect themselves.
This is not to say working in medicine is always safe. I've had my share of needlestick accidents, tuberculosis exposures, and even violent patients. But I think what is happening now is asking even more of our health care workers. That everyone is still showing up to work with grim resolve is not tacit approval but a sense of duty to something greater than our own well-being.
In an Atlantic article, emergency physician Thomas Kirsch says, "I've been to disasters all over the world, and I have always seen health-care providers pour in to help...No one has to ask; they just show up...But that sort of bravery, that work ethic, is not boundless. No one is so fearless or stupid as to discount all risks."
Even beyond fearing for our health and our lives, we worry about bringing infection home to our families. Some providers live in a hotel room to protect their spouse and kids. We forego meals, we work through the night, we suffer emotional strain. We don't complain when we work seventy, eighty, ninety hours. We aren't thanked, either.
Today, we show up to work. We wear a mask that we're reusing even though we shouldn't. We walk into a room with an invisible life-threatening pathogen which may be hovering in the air and clinging to each surface. We turn our attention away from our own deep-set anxieties and towards the person across from us asking for help.
In an Atlantic article, emergency physician Thomas Kirsch says, "I've been to disasters all over the world, and I have always seen health-care providers pour in to help...No one has to ask; they just show up...But that sort of bravery, that work ethic, is not boundless. No one is so fearless or stupid as to discount all risks."
Even beyond fearing for our health and our lives, we worry about bringing infection home to our families. Some providers live in a hotel room to protect their spouse and kids. We forego meals, we work through the night, we suffer emotional strain. We don't complain when we work seventy, eighty, ninety hours. We aren't thanked, either.
Today, we show up to work. We wear a mask that we're reusing even though we shouldn't. We walk into a room with an invisible life-threatening pathogen which may be hovering in the air and clinging to each surface. We turn our attention away from our own deep-set anxieties and towards the person across from us asking for help.
"...we had everything before us, we had nothing before us...in short, the period was so far like the present period, that some of its noisiest authorities insisted on being received, for good or for evil, in the superlative degree of comparison only."
You know, I enjoy Charles Dickens far more now than I did in high school. Another two stories for comparison - just stories, not meant for scientific conclusions. Early in the U.S. course of infection, we applied for "compassionate use" of remdesivir, an antiviral, for two of our severely infected patients. (Since then, due to overwhelming demand, the drug is no longer available for "compassionate use," though there are now clinical trials open to enrollment.) We do not know whether remdesivir is helpful in coronavirus, but now that there are trials, we wait to see whether, how, and when it should be given.
The first patient had been struggling with COVID for a week when his profound oxygen failure required him to be put on a ventilator. At the time, China had just started a clinical trial for remdesivir, and a patient in Washington State had just received it. With great hope, we gave him the drug, but unfortunately, it made no difference. He continued to require escalating amounts of life support. As an intensive care physician, I often experience this feeling, hovering at the limits of medicine, offering a final potential therapy, and finding it wanting. It's a hard conversation to have with family; bringing up a last-ditch effort offers hope, though we really don't know what will happen. We temper our expectations, but still, we are almost always let down.
The second patient, also severely ill with COVID, flirted each day with the need to be intubated and put on a mechanical ventilator. He was younger, and around this time, we began hearing scattered reports of life-threatening organ failure in young patients. Although we know age correlates strongly with mortality, there are still patients in their twenties and thirties dying from this disease. We applied for and gave him the remdesivir. Within twelve hours, he had a dramatic improvement. He went from bedbound and continuously short of breath to sitting in a chair, texting on his cell phone. We were shocked. I can't think of many other situations that turn around so fast.
Remember Milo from Norton Juster's The Phantom Tollbooth whose assumptions carry him, the Humbug, and Tock to the Island of Conclusions? How easy it is to hear these two stories, or to see these two patients, and to desire so blazingly for this drug to work. Or to feel that we have crossed some threshold with this disease so rapid and terrifying that we can justify unproven last resorts. After all, if someone is that ill, what harm can come of just trying something - in case it works?
Though I understand that feeling, I don't think it is a rational or appropriate way to practice medicine. We have a history riddled with examples of interventions that seemed sound and had anecdotal benefit that later proved to be nonbeneficial after controlled clinical trials (hormone replacement therapy comes to mind). Individual case reports are too subject to irrational conclusions. As a recent JAMA viewpoint states, "a common interpretation...is that if the patient died, they died from the disease, but if the patient survived, they survived because of the given drug. This is not true" (Kalil, 2020).
Furthermore, in a disease that threatens to overwhelm our health care system and its resources, we need to focus on those things that we know will save someone's life without being distracted or bogged down by things that might or might not. It's easy to ascribe medications miracle properties, but without controlled trials, we don't know why one patient improves and another does not. There's a lot out there, especially on social media, on hydroxychloroquine, antivirals, interferon, and other possible therapies. All of these medications have side effects, and many of these side effects are life threatening, especially for the critically ill patient. COVID-19 can cause cardiac failure, liver injury, and bone marrow suppression, and many of these drugs can worsen those effects. Are we helping or are we causing harm?
Clinical trials, despite being cumbersome, time-consuming, and laden with disclaimers, do offer us a measure of hope. Without them, we cannot know who benefits and who is harmed, or even what those benefits or harms may be. In a pandemic like this, anxiety and urgency may send us flying to the Island of Conclusions, and I am grateful for those scientists and researchers who ground us, reminding me that there is an established method for us explorers forging past the boundaries of the known as we tackle a novel and scary disease.
You know, I enjoy Charles Dickens far more now than I did in high school. Another two stories for comparison - just stories, not meant for scientific conclusions. Early in the U.S. course of infection, we applied for "compassionate use" of remdesivir, an antiviral, for two of our severely infected patients. (Since then, due to overwhelming demand, the drug is no longer available for "compassionate use," though there are now clinical trials open to enrollment.) We do not know whether remdesivir is helpful in coronavirus, but now that there are trials, we wait to see whether, how, and when it should be given.
The first patient had been struggling with COVID for a week when his profound oxygen failure required him to be put on a ventilator. At the time, China had just started a clinical trial for remdesivir, and a patient in Washington State had just received it. With great hope, we gave him the drug, but unfortunately, it made no difference. He continued to require escalating amounts of life support. As an intensive care physician, I often experience this feeling, hovering at the limits of medicine, offering a final potential therapy, and finding it wanting. It's a hard conversation to have with family; bringing up a last-ditch effort offers hope, though we really don't know what will happen. We temper our expectations, but still, we are almost always let down.
The second patient, also severely ill with COVID, flirted each day with the need to be intubated and put on a mechanical ventilator. He was younger, and around this time, we began hearing scattered reports of life-threatening organ failure in young patients. Although we know age correlates strongly with mortality, there are still patients in their twenties and thirties dying from this disease. We applied for and gave him the remdesivir. Within twelve hours, he had a dramatic improvement. He went from bedbound and continuously short of breath to sitting in a chair, texting on his cell phone. We were shocked. I can't think of many other situations that turn around so fast.
Remember Milo from Norton Juster's The Phantom Tollbooth whose assumptions carry him, the Humbug, and Tock to the Island of Conclusions? How easy it is to hear these two stories, or to see these two patients, and to desire so blazingly for this drug to work. Or to feel that we have crossed some threshold with this disease so rapid and terrifying that we can justify unproven last resorts. After all, if someone is that ill, what harm can come of just trying something - in case it works?
Though I understand that feeling, I don't think it is a rational or appropriate way to practice medicine. We have a history riddled with examples of interventions that seemed sound and had anecdotal benefit that later proved to be nonbeneficial after controlled clinical trials (hormone replacement therapy comes to mind). Individual case reports are too subject to irrational conclusions. As a recent JAMA viewpoint states, "a common interpretation...is that if the patient died, they died from the disease, but if the patient survived, they survived because of the given drug. This is not true" (Kalil, 2020).
Furthermore, in a disease that threatens to overwhelm our health care system and its resources, we need to focus on those things that we know will save someone's life without being distracted or bogged down by things that might or might not. It's easy to ascribe medications miracle properties, but without controlled trials, we don't know why one patient improves and another does not. There's a lot out there, especially on social media, on hydroxychloroquine, antivirals, interferon, and other possible therapies. All of these medications have side effects, and many of these side effects are life threatening, especially for the critically ill patient. COVID-19 can cause cardiac failure, liver injury, and bone marrow suppression, and many of these drugs can worsen those effects. Are we helping or are we causing harm?
Clinical trials, despite being cumbersome, time-consuming, and laden with disclaimers, do offer us a measure of hope. Without them, we cannot know who benefits and who is harmed, or even what those benefits or harms may be. In a pandemic like this, anxiety and urgency may send us flying to the Island of Conclusions, and I am grateful for those scientists and researchers who ground us, reminding me that there is an established method for us explorers forging past the boundaries of the known as we tackle a novel and scary disease.
"...it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the season of light, it was the season of darkness, it was the spring of hope, it was the winter of despair."
A couple stories of what COVID-19 coronavirus has looked like for me (with clinical details changed). I saw two separate patients who were both "COVID rule-outs." Our tests have been taking a while to come back (another topic of great angst), so we have many patients who are in isolation, awaiting the results of their test.
The first, an elderly gentleman with a longstanding cardiac history, is sent by his primary care physician with low-grade fever and shortness of breath. In the emergency department, his oxygen levels are low, and I am called in consultation. When I looked at his clinical picture, my first gestalt is that he does not have coronavirus - he has two separate processes, a urinary tract infection and congestive heart failure. The coronavirus testing - while necessary given the degree of community prevalence - created a lot of angst for the patient, his family, and our staff. Even transporting him from the emergency department to the intensive care unit required a parade lead by security who cleared the path, followed by a fully attired (bunny suit) nurse, respiratory therapist, and transporter, caboosed by our environmental services staff to clean the route. But when I told him I thought coronavirus was unlikely, the tension in his face melted. Fortunately, my clinical gestalt was correct, his test came back negative, he improved with antibiotics and diuretics, and he left intensive care two days later.
The second, a young gentleman, immunocompromised from melanoma treatment, had traveled three weeks earlier. Since then, he has been fighting malaise, fever, chills, and a persistent dry cough. His chest X-ray suggested the "ground-glass" worrisome for coronavirus. (Radiologists love similes with unfamiliar objects. What's ground-glass? What's crazy-paving? What's a snowstorm? How being Californian has sheltered me). Even before we learned the results of his test, his lungs were failing. Because our suspicion was so high, we were prepared when he began to decompensate.
What do these stories suggest to me? Despite our inability to test widely and the delays in receiving results of the tests, clinical judgment still has a role. In pediatrics, we learn the mantra "not all wheezing is asthma," and here, not all fever and shortness of breath is coronavirus. Although we treat all our rule-outs with caution, isolation, and personal protection, their probabilities can differ widely, and we have to remain vigilant for other processes that we may overlook in our anxiety about COVID. On the other hand, some presentations are so concerning for coronavirus that the test is only confirmation. In these situations, what can we do but face this disease head-on, with courage and resolve.
A couple stories of what COVID-19 coronavirus has looked like for me (with clinical details changed). I saw two separate patients who were both "COVID rule-outs." Our tests have been taking a while to come back (another topic of great angst), so we have many patients who are in isolation, awaiting the results of their test.
The first, an elderly gentleman with a longstanding cardiac history, is sent by his primary care physician with low-grade fever and shortness of breath. In the emergency department, his oxygen levels are low, and I am called in consultation. When I looked at his clinical picture, my first gestalt is that he does not have coronavirus - he has two separate processes, a urinary tract infection and congestive heart failure. The coronavirus testing - while necessary given the degree of community prevalence - created a lot of angst for the patient, his family, and our staff. Even transporting him from the emergency department to the intensive care unit required a parade lead by security who cleared the path, followed by a fully attired (bunny suit) nurse, respiratory therapist, and transporter, caboosed by our environmental services staff to clean the route. But when I told him I thought coronavirus was unlikely, the tension in his face melted. Fortunately, my clinical gestalt was correct, his test came back negative, he improved with antibiotics and diuretics, and he left intensive care two days later.
The second, a young gentleman, immunocompromised from melanoma treatment, had traveled three weeks earlier. Since then, he has been fighting malaise, fever, chills, and a persistent dry cough. His chest X-ray suggested the "ground-glass" worrisome for coronavirus. (Radiologists love similes with unfamiliar objects. What's ground-glass? What's crazy-paving? What's a snowstorm? How being Californian has sheltered me). Even before we learned the results of his test, his lungs were failing. Because our suspicion was so high, we were prepared when he began to decompensate.
What do these stories suggest to me? Despite our inability to test widely and the delays in receiving results of the tests, clinical judgment still has a role. In pediatrics, we learn the mantra "not all wheezing is asthma," and here, not all fever and shortness of breath is coronavirus. Although we treat all our rule-outs with caution, isolation, and personal protection, their probabilities can differ widely, and we have to remain vigilant for other processes that we may overlook in our anxiety about COVID. On the other hand, some presentations are so concerning for coronavirus that the test is only confirmation. In these situations, what can we do but face this disease head-on, with courage and resolve.
How do you learn crisis and disaster management? In residency and fellowship, we had lectures on specific illnesses (sarin poisoning, bioterrorism, radiation poisoning) or situations (airplane emergencies). Occasionally, we had simulation exercises (hospital-wide electricity failure, oxygen pipeline failure) to help us practice multitasking, communication, resource allocation, and thinking ahead. But nothing quite prepares you for this.
Back in 2013, I was a senior resident doing pain consultation rounds in the hospital when I heard a screech from my pager I had never heard before. It's like being jarred by an amber alert issuing from your phone. The page read: "Code Triage - Major. Mass Casualties. Plane crash at SFO."
I was one of the first residents to get to the operating room. We were getting information in bits and pieces, from lots of sources. Twitter told us more than official channels. A Youtube video showed the tail of the plane being ripped off, smoke billowing. I was assigned to the first patient from that airplane crash who needed emergency surgery. I remember feeling what I am feeling now - anticipation and anxiety in this calm before the storm. But when that patient arrived, a peculiar and keen focus set in, similar to what athletes (or surgeons) describe. The rest of the world receded, and for the next several hours, I was utterly engrossed in providing anesthesia in this emergency. Only after we finished did the world catch up to me. I expect that's what these next few weeks might feel like.
The other experience I had with disaster management was in 2015 during the Ebola epidemic. Although no patients ended up coming, we prepared extensively. I remember sitting in a handful of committees trying to figure out policies and procedures. Pandemic management involves many, many shareholders. Physician care is a small cog in this machine. We spent our time working with facilities management on restructuring waiting areas, cleaning services on disposing contaminated equipment, and transport services on how to get patients from the emergency department to the intensive care unit with minimal contamination. I got a sense of how this organic system we call a hospital must adapt to critical situations.
I remember going through training for putting on and taking off personal protective gear (for Ebola). There are 38 steps to putting everything on and 27 steps to taking everything off, and it is all carefully observed by a safety officer each time. We wore three layers of gloves, three layers of footwear, and an impermeable suit under an impervious surgical gown. You work up a sweat really quick in there. It also takes a while to get into all that gear. Thankfully, we never saw a patient with Ebola, and Ebola precautions are more draconian than COVID-19, but these smaller disaster scenarios come to mind as I think about what's happening and what lies ahead.
I was quarantined weeks before the Bay Area rolled out the "shelter-in-place" order. My feelings on quarantine might have been more insightful then, before we were all doing it. The county public health department was aggressive in quarantining health care workers who might have been exposed because early in an epidemic, the most important intervention is identifying and isolating contacts. At the time, there were only a handful of patients in the U.S. hospitalized with coronavirus, and it made sense to aggressively close off those clusters. Unfortunately, since then, we have realized the much higher prevalence of disease in the community and the role of community spread in propagating COVID-19.
In any case, dozens of doctors, nurses, respiratory therapists, and staff were quarantined from this one patient. Fortunately, none of us developed symptoms, but it was nerve-racking. We were beginning to appreciate how severe this disease can be. One barrier to this - and the reason why for a while, we had claims that "this is like the flu" - is that coronaviruses are a general category, and the infections these viruses cause range from mild to life-threatening. The vast majority of (regular) coronavirus infections I see are mild, and it takes a real shift in perspective to see how much scarier COVID-19 is. Many of us have never seen Middle East respiratory syndrome (MERS) or SARS. I was still in college when the SARS epidemic happened. It was only during my quarantine period about a month ago that we began appreciating the data from China and realizing the severity of respiratory failure with COVID-19.
I don't usually ruminate, and I'm not a hypochondriac, but there's some degree of anxiety and guilt. Should we have isolated the patient earlier? Did I put my nurses and respiratory therapists at risk? Was there anything that could have clued me in earlier to this patient's diagnosis? When you're stuck in a 1000 sq ft apartment, these thoughts loom large. Time drags her feet.
And yet, for those two weeks, we didn't see any dramatic nationwide movement to prepare for this disease. It was already on U.S. soil, already putting patients in the intensive care unit and health care workers in quarantine, and most places were still doing business as usual. Hindsight is 20/20, and it's always easy to say we could have done more earlier, but I still stand by that sentiment.
By the end of my quarantine period, we were starting to see some mobilization, but the United States, and in particular, health care in this country, is a lumbering inertial beast. I spoke at a company-wide call with thousands of listeners about my experience with COVID and quarantine. Looking back on that just several weeks later, I wonder if I would have said something different knowing where we are now.
And yet, for those two weeks, we didn't see any dramatic nationwide movement to prepare for this disease. It was already on U.S. soil, already putting patients in the intensive care unit and health care workers in quarantine, and most places were still doing business as usual. Hindsight is 20/20, and it's always easy to say we could have done more earlier, but I still stand by that sentiment.
By the end of my quarantine period, we were starting to see some mobilization, but the United States, and in particular, health care in this country, is a lumbering inertial beast. I spoke at a company-wide call with thousands of listeners about my experience with COVID and quarantine. Looking back on that just several weeks later, I wonder if I would have said something different knowing where we are now.
These are truly extraordinary times. The COVID-19 pandemic will leave a permanent mark on our world and how we live our lives. In the Bay Area, we have seen dramatic upheaval within just the last ten days. Sitting here in the hospital on call, I decided to restart blogging just to capture a little of what it's been like for me. I think the point of this blog is to tell a story from my perspective. This blog isn't medical advice or public health information or updates on coronavirus - there are many better resources for that.
My first encounter with COVID-19 coronavirus was a month ago. It started off as a normal day attending in the intensive care unit. I rounded on my patients and dutifully began procrastinating on my notes, as is my wont. Early afternoon, I got a call from one of my pulmonology colleagues. He had just seen a patient on the floor who had respiratory distress and felt that the patient needed to transfer into my care in the intensive care unit.
To protect patient privacy, I won't go into detail about the clinical story, but it did not offer a simple or straightforward picture. Our differential diagnosis - the possible diseases we considered - was quite broad - though it did include viral pneumonia. An uncertain diagnosis is not uncommon in the intensive care unit where patients are complex and presentations rarely textbook. The public health department was contacted, but at that time - still early in the U.S. course of infections - COVID was felt to be unlikely.
The rest of the day - and in fact, the rest of my time as the ICU attending - passed uneventfully, and I signed the patient out to the next intensive care physician, indicating that broad therapies were instituted but the diagnosis had so far eluded me. The public health department was pursuing the possibility of coronavirus, but had not yet rendered an opinion.
Two days later, I was called that the patient came back positive with COVID. I was to immediately begin a two week quarantine by isolating myself from the world and monitoring for symptoms.
We (in the Bay Area) are all doing this now but at the time - almost a month ago - very few people had their world upended like this. It was a real shock. I went from a perfectly normal state of affairs and business as usual to having wards drawn on my property line like a pentagram about a demon.
More on this tomorrow.
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