An elderly man who has lived his entire life in the Bay Area, taught engineering at a local community college, served in the army, been married, divorced, and remarried, who does woodworking and reads biographies in his free time presents with severe shortness of breath, fever, chills, and a cough. He has coronavirus, and his oxygen levels are precipitously low. He has a POLST - a prepared document that outlines his wishes at the end of life, and he does not want heroic life-saving interventions. When I talk to him, he confirms that he would not want to be intubated and mechanically ventilated. He expresses his wish clearly and consistently, understanding that he may die from this disease. (Patient details have been changed).

Coronavirus has changed how we approach the end of life for our patients. This is a topic of particular importance to me as I have written and revised a chapter on end of life care and withdrawal of mechanical ventilation for an ICU textbook. We can and ought to provide patient-centered, comfort-focused, compassionate care to every single person we treat. With a disease like this, there will be patients, and probably many patients, who will die despite our best efforts. We also may have so many patients we feel that we cannot take care of all of them. Despite this, we must still attend to the dying - afraid, lonely, isolated, frail, confused, and suffering - with compassion. We may not be able to provide the full panoply of comfort-focused measures, but there are things we can do, and we must.

Palliation, of course, exists on a spectrum and can be deployed in conjunction with curative-intent therapy, but here, I speak primarily of the end of life. The medical side - the morphine and palliative drugs - are less concerning to me than the social aspects. Policies have changed in most hospitals to limit visitors, even for those who are actively dying. To protect our staff from exposure and to conserve protective equipment, we may limit in-room visits by social workers, chaplains, and palliative care practitioners. At the end of life, when many fear dying alone, we stay at bedside, but the mask, gown, gloves, and other protective gear we wear acts as a barrier. To this end, we have been rapidly adapting and innovating to what we can safely offer.

It's a fluid situation and what we are able to do changes from week to week, day to day, but for the patient at the beginning of the post, whose mental status remained engaged, I invited his daughter to visit (we allow one family member at the end of life). The patient's oxygen saturations on high flow nasal cannula were in the 70s. I did not think he had long. When she arrived, at around midnight, we suited her up in personal protective equipment and let her sit at her father's bedside. They talked for over an hour. We used teleconference technology on a tablet to let them visit other family members at home. That's how I learned bits of his life, like flashes of light. He passed away several hours later, around sunrise.

At the beginning of the coronavirus outbreak, we saw a lot of hysteria, panic, and alarm. The unknown and its uncertainty are terrifying. I heard stories of the chaos in airports in Europe when the travel ban was issued. Aisles at grocery and warehouse stores were emptied. The stock market plummeted. Our social media blew up. The confused and uncoordinated responses by different governmental bodies, local workplaces and schools, and public health agencies put us all on edge. Of course, in the moment, we do the best we can with limited information, and in hindsight, we are able to piece together what made sense and what did not. But there's no doubt that the world had reached a level of anxiety I had never seen before.

Anesthesiologists think a lot about emotional reactions to stressful situations. One description of our job is hours of boredom punctuated by moments of sheer terror, and it's not that much of an exaggeration. Some of our training focuses on how we react under pressure because when a surgery or anesthetic plan goes awry, there may only be seconds to minutes to determine and execute the best course of action. We quickly learn how panic becomes debilitating, how terror causes us to lose control. In residency, we learn this through simulation, originally modeled after flight scenarios that put pilots in crisis situations. But we also see this in real life; although rare, we've all encountered massive bleeding, allergic reaction, cardiac instability, anesthetic machine failure. Our crisis management training gives us resources to face situations like this.

In the microcosm of the hospital, we anticipate and plan for a surge of patients, modify our environment to take care of them, designate leadership and a system for additional help, establish role clarity, distribute the workload, communicate, and mobilize resources. It's a long checklist of stuff, but as anesthesiologists and critical care physicians, we know that building this infrastructure helps allay alarm, chaos, and hysteria if (when) things get bad. By trying to maintain control over the situation and minimizing panic, we optimize the cognitive, emotional, and technical bandwidth to handle what comes.

I think this translates to the macro scale as well. As a society and community, the more we can transform our anxieties to controlled caution, rational decision making, and focused attention to problems, the less collateral damage we will see from this pandemic. One example is the idea of universal masking. Partial masking (in a society like ours where masking is unusual - as opposed to Asian countries where it is more commonplace) may engender anxiety and fear. Our culture distrusts people who cover their face. Are they ill? Should I worry? Why are they outside? But if we mandate universal masking, then perhaps we take away that uncertainty. Obviously, masking is a complex issue, but haphazard masking presents hazards we may not anticipate.

Fortunately, I think the emotional turmoil at the beginning of the pandemic has subsided into a steady-state. We saw a lot of fear-mongering in social media and the news early on, and its contribution to hysteria, terror, and panic set us back. However, with calm, measured, rational approaches to public health, we can takes steps forward in quelling this crisis.

I've been fascinated by the language used around the coronavirus pandemic. From "front-line" to "hot zones" to "triage," there's a lot of war diction. The imagery evokes us "fighting" to "defeat" an "unseen enemy." Even the photographs around the pandemic look a little bit war-like with masks and gowns and body bags. What effect does this have on our perception of the current events? How can language be used to direct our focus or amplify our message?

Certainly, the use of war diction in public health is not new. We've had a "war on cancer" and "war on drugs." What does it mean to use that language in public health? It certainly makes me uneasy. It's almost like a mixed metaphor, trying to mesh figuration of violence with healing. It's one reason I've avoided using the phrase "front-line" in this blog. But I think the effect does achieve the intended result, drawing our attention to the unseemliness of the current event, how out of place it feels. Instead of doctors and nurses caring for patients and healing them, we hear stories of how they are fighting this killer. The story is no longer just about narrative; now it has drama.

War imagery also shifts our lens on this pandemic. It makes us feel less uneasy with authoritarianism, with spending, with Machiavellian ethics. Wars give the president special authority; they ask society of certain sacrifices; they help achieve an agenda. The war rhetoric paints the world in more of a black and white. It heightens senses of paranoia, hysteria, and fear. Could war-time language exacerbate racial discrimination in this pandemic? Could they be worsening intolerance?

Rhetoric, figuration, language, and imagery are powerful, pervasive influences ("weapons") on the subconscious. We learn about them in high school English, but unless we spend our time writing or marketing or in public relations, we stop thinking about them. This pandemic is a serious public health and socioeconomic crisis. Millions are infected and probably hundreds of thousands will die. Our resources are strained, industries have shut down, and the government has pumped trillions of dollars into the economy. But to me, the narrative is still one of seeing patients and caring for them. Although occasionally, I picture myself gearing up for battle, most days, I go to work with hope, optimism, empathy, and compassion. I don't feel like a soldier, and I don't want to be one. I shy away from war-time language because it doesn't capture what I do and how I feel about the current pandemic.

Never did I imagine that I would see a brand new disease. It's really quite a remarkable thing. I do encounter rare diseases from time to time, but even the most uncommon entities can be looked up or found in a footnote of a lecture in medical school (I realize we don't know what we don't know, so perhaps we encounter unknowns more often than we think). But to see a novel illness, this widespread, with such an impact, the mind boggles. The closest comparison I can make is the HIV/AIDS epidemic in the 1980s. It is a humbling experience.

I do believe this is a brand new disease. While initially, we tried to categorize it as a pneumonia progressing to acute respiratory distress syndrome, it doesn't quite behave in the same way. COVID doesn't fit nicely into any kind of box. The body of knowledge is building rapidly; we know far more now than we did two weeks ago, but we still have many more questions than we have answers. I blogged about this before, but I am constantly reminded that there are no experts in this disease. There are opinions I trust, but there aren't data specific to the management of COVID. We start with first principles, physiologic data, and the goal to do no harm.

The majority of my blogs aren't focused on the medical aspect of this disease, but I thought here I'd mention a few baffling observations. I see mostly COVID that is severe enough to warrant intensive care unit admission. Compared to other infections that cause respiratory failure, it seems that COVID doesn't make the lungs stiff. Usually, after I place someone on a mechanical ventilator, I have to use high driving pressures to inflate the lungs (imagine a stiff balloon), but some coronavirus patients have very elastic lungs. Why is that? (Others have the expected stiff lungs - how do I account for the difference?). In addition, coronavirus patients are prone to forming clots. We have an unusual number of patients with clots in the vessels of their lungs (pulmonary embolism), a life-threatening condition, even if they were on prophylactic doses of anticoagulant. Why is this the case, how do we risk-stratify, and how do we treat? Lastly, patients with coronavirus seem to die, not from respiratory insufficiency, but from multiorgan system failure. We don't usually see acute heart failure from a pneumonia, but here, many patients seem to die from cardiac complications. We've also seen kidney failure and liver injury concurrently with COVID infections. How does coronavirus do this? How does this change our approach to management and treatment?

These uncertainties about the medicine regarding coronavirus compounds the challenges we face day to day dealing with the disease. It is hard to manage resources, discuss prognosis with family, and weigh risks and benefits of interventions when we are still scratching our heads on what the illness entails. But I am hopeful that we are pouring our resources and smartest minds to tackling this disease. Part of controlling this pandemic is caring for patients one at a time.

More importantly, what are the medical and psychological consequences of coronavirus and prolonged sheltering? I imagine in retrospect we will have a better sense of how humans behave and function under such stressors, but here are some initial observations.

A patient perforates a body cavity by accident and requires emergency surgery. When asked what happened, he genially says, "I was bored." There has been an uptick in requests for benzodiazepines because the daily news has exacerbated patients' anxieties. A surge in overdoses may represent correlation rather than causation, but it is certainly suspicious.

Since the beginning of sheltering, we have severely restricted visitors in the hospital, a necessary but difficult decision. This especially impacts our patients with dementia, delirium, or limited English language ability. Our patients with COVID face even more stringent isolation. Even as they grapple with having a novel, frightening, and life-threatening disease, they cannot lean on their usual avenues of social support. No visitors are allowed. The nurses and doctors who enter are dressed in spacesuits (we currently use powered air-purifying respirators). We avoid unnecessary contact. We don't linger in the room. What a real and devastating impression this must have. We try to ameliorate it by using video conferencing technologies to help patients visit with their loved ones remotely. We do our best to maintain a human connection. But we cannot fully mitigate the psychological consequences of being hospitalized or having this disease.

We should not discount the physical and psychological strain on our health care providers as well. It is no small thing to go into work knowing that there is a risk we could contract this life-threatening illness. No small thing to hear of other health care providers getting sick, testing positive, being admitted to the hospital. No small thing to be unsure whether there is virus on doorknobs, keyboards, infusion pumps, or even our badges, phones, and shoes. Most of us have developed a complex decontamination routine when we get home from work so as not to infect our family or bring the virus into our homes. We have trouble sleeping. We are worn down by stress. We feel an obligation without an end in sight.

COVID would be a frightening disease even without the baggage it carries as a pandemic. Now that we're nearing a month of sheltering, I remind myself that we must be kind to each other. We support each other. We are on the lookout for the physical and psychological illnesses, injuries, and stresses that come with isolation, with illness, and with trying to treat this disease.

What is the collateral damage of sheltering in place, quarantine measures, and isolation?

I have no doubt that this is the right public health decision and that social distancing is making a difference in the course of the pandemic. In the Bay Area where we instituted early social distancing and work-from-home measures for many tech companies, we are hopefully avoiding the steep surge of cases that have overwhelmed hospitals in other places. It's too early to say if the curve is flattening, but I think there's enough data to say it's helping. I am hopeful that these extreme public health measures will save a significant number of lives.

But what's the cost? As in medicine, necessary interventions are often accompanied by unavoidable side effects, risks, and harms. The most obvious, apparent, and devastating complication is the economy, which is far from my area of expertise. In writing this blog, I wanted to set aside the big-picture financial impact of the pandemic, leaving that to those who know more than I do. But there are small, tangible ways that this has entered my life, and I wanted to focus on my personal experience. After sensing the sincere gratitude of local restaurants when I get take-out, I've really tried to step-up my support for those small businesses struggling to keep afloat. All parts of this community are interlinked and the more we are able to help each other, the more resilience we have as a whole.

The other strange economical consequence of this pandemic is that although health care is in high demand, health care organizations are struggling financially. By and large, hospitals make money off procedural departments like surgery, interventional radiology, and cardiology. Although there are definitely exceptions, in general, emergency departments and inpatient medicine tend not to generate much income. I'm not going to tackle the controversies of these skewed incentives, but their implication in a pandemic is clear. As we postpone and cancel elective procedures, physician groups and hospitals lose their main stream of revenue. At the same time, hospitals are spending money to purchase more protective equipment, expand clinical capacity, and pay staff overtime. The severity of this imbalance between costs and revenue are recognized in the bills passed by Congress which set aside money for health care organizations. But it's frightening that in the midst of crisis, hospitals don't know if they will stay solvent or need to shut down once the dust clears. Doctors and nurses put themselves at greater risk for less pay. I am glad to have a job and to take care of patients, and I don't want to make this seem like a tragedy when other sectors face financial ruin and soaring unemployment. But as I write about my personal experience, I think we face the reality that first-line responders to this pandemic feel tangible financial uncertainty.

Where is the resource bottleneck in taking care of coronavirus patients? It is heartbreaking and tragic watching the situation unfold in Italy and New York City. The torrent of coronavirus patients have completely overwhelmed the health care systems there, leading to shortages of personal protective equipment, beds, ventilators, and personnel. Pretty early on, the Society of Critical Care Medicine published a document on resource availability in the United States for this outbreak. It put together the number of ventilators, board-certified critical care physicians, and types of beds in every hospital in the country. When I read it at the time, I wasn't quite sure how to interpret all the data. It discussed strategies to expand intensive care beds, modify anesthesia machines to act as long term ventilators, and access the Strategic National Stockpile. As the last few weeks have unfolded, we have seen these resources stressed and depleted.

This is an unacceptable problem, and yet a reality we face. We are unprepared for a pandemic of this magnitude. As a consequence, patients are dying and will continue to die as a result of inability to deliver best care. Fortunately, where I am in the Bay Area, the situation is so far still manageable. Yet I worry every day that we will have a shortage of personal protective equipment, beds, ventilators, physicians, nurses, or respiratory therapists. In critical care, we often hit the boundaries of what we can do for a patient because of limitations in medical knowledge or therapeutics, but rarely because of limitations in resources. How do we wrestle with those ethics, to be in a situation where we would offer something in normal circumstances but cannot in these exigencies?

One particular concern is personal protective equipment. This has obviously flooded the news lately, but I think it worth exploring. The majority of us who enter this field - my classmates in medical school, my coresidents and cofellows, my colleagues today - do so to serve others, often at our own expense. Some things are expected of us; we sacrifice our sleep, skip meals, even suffer overdistended bladders on a regular basis. For ten months of intern year, I worked thirty hour shifts every four days through weekends and holidays. Spending seventy to eighty hours a week in the hospital, seldom encountering sunlight, facing emotional strain and psychological burnout, we suffered real and undeniable health and mental consequences.

These other sacrifices make it easy for us to tolerate suboptimal personal protective equipment, but this shouldn't be the case. The stories of mask shortages and N95 rationing at overwhelmed hospitals are unimaginable. We must protect our providers. This responsibility, I believe, falls not only on the hospital, health care system, and government, but also onto the general public. There is a sense of dismay and anger when I hear about non health care workers buying up all the masks on the market, and then sometimes selling them at a premium. Universal masking is a separate issue, but certainly does not require N95 respirators that should go to our doctors and nurses who put themselves in exquisite risk. If we do not protect them, there will be no one to take care of the rest of us when we get ill.

There is also no end in sight to this pandemic. We are in for the long haul. And though ventilators don't need to sleep, our workforce does. We will get tired, sick, burned out. We will need a day off, a shoulder to cry on, a friend to confide in. We still have to negotiate the crowds at Costco or find an Instacart slot. We still need to arrange for childcare. To this end, I think our health care workers are eventually going to be the bottleneck to managing this pandemic. With time, we will make beds and source equipment. It may take a company months to start churning out ventilators, but it took five years after medical school for me to become a board certified intensive care physician. If we run out of doctors, filling the personnel gap will not be simple. This is why it is incumbent on the system to protect and support us.

There are no experts in this disease. It didn't exist four months ago. Although we are getting experience with it at an overwhelming pace, there is still a considerable amount we don't know. We have knowledge from prior epidemics, other coronaviruses, and experience with respiratory failure from pneumonia, but fundamental questions still remain unanswered. Does long-lasting immunity persist? What treatments work? Will there be seasonal variation? How effective might a vaccine be? After recovery from COVID, are there any persistent health consequences?

Even aside from the biology of the virus and the clinical course of disease, questions abound. We are seeing an unprecedented effect on the economy. We wonder how computer modeling, statistics, and epidemiology might help predict the future. We are co-opting other companies, factories, and facilities to make personal protective equipment. We depend on journalists to paint a picture of a world we cannot go outside and see. We use new apps to reinforce our social networks while sheltering at home.

I am deeply impressed and grateful for all those brilliant minds working on each facet of this problem. But I also see how silos limit our insights. For example, I talked to a company pivoting to provide telemedicine services, but the questions they ask make evident they don't know the workflow of a medical practice. I've talked to a computer scientist designing an app for tracing contacts, using technology I didn't know we had. It was a fascinating and engrossing conversation where I learned as much as I shared. To tackle the really complex problems generated by the pandemic, we need to collaborate. I think it is shortsighted for an individual to think himself an expert.

And yet I see that, a little. It's easy (myself included) to critique from our couches. How many of us sit at home criticizing the government's lack of preparedness or delay in social distancing? Two weeks ago, my social media forums were filled with doctors posting things like, "I haven't seen a COVID patient yet, but based on what I've read, my plan is..." In a situation like this, void of certainty, we want to believe we've figured it out, but I think we must remain humble. We are not experts. We remain open-minded, inquisitive, critical, and rational.

So where do you get your information? I've seen social media propagate out-of-date or inaccurate information. But I've also seen it reinforce social distancing. I've gotten institutional protocols from half a dozen places that all differ. I have read peer-reviewed papers that were obsolete a couple weeks later and news articles that span the gamut from hysterical panic to dismissive skepticism. The way I've been trained puts a lot of weight on publications and memos coming from ivory tower institutions, but in a landscape this dynamic and rapidly changing, I open myself to other sources. Indeed, technology has changed the way we learn. In particular, I really like webcast interviews with critical care physicians in Italy and New York. How vivid and memorable the descriptions of someone in the thick of it. How admirable that in the midst of crisis, they can find the time to share their experience with the rest of the world.