When the dust settles, what will be the new normal? I'm curious what everyone thinks. Will we still be wearing masks and crossing the street when we encounter someone from the other direction? What will daycares and schools and offices look like? Will middle seats be a thing on airplanes, and who will take public transportation? Will we give our friends hugs? What will dating be like? Will people dance at weddings? Can we host board game nights and dinner parties? Can we visit family members in the hospital? How many people can attend a birth or a funeral?

I have a million questions, and I'm not sure I like the answers. Coronavirus probably affects every single aspect of our lives. And it seems in most settings, it separates us. Social distancing may be manageable for several weeks, but now a couple months in, it's really trying. I sincerely hope it does not become the new norm. We are social creatures, and even among introverts like me, we draw some amount of energy, creativity, motivation, and desire from others. I'd as soon drop handshakes, but I do think the occasional pat on the back or hug makes a material difference. Masks protect us and those around us, but we draw so many social cues from facial expressions. How much our society has changed. As we adjust to working from home, videoconference fatigue settles in. How focused can we be in a home office? Can we achieve the same amount of collaboration and innovation outside a shared space?

I believe some things will improve as a result of this pandemic. We will fortify supply lines to avoid the global disruption we saw here. We will realize that we can indeed lower carbon emissions and see tangible results within weeks. We will prepare and stockpile better for disasters. We will use technology in new and effective ways.

But how long will it be before we go to a museum, an aquarium, an amusement park? When will we next attend a play, a musical, a concert, a sports game? What will restaurants look like? How will getting a haircut or a massage change? There's no doubt that every industry, field, and facet of life must adapt to a new world. I hope it's a world where we can connect, build, and thrive.

Are we all going to get infected anyway? Ever since the scale of the pandemic became apparent, I have wondered about this. We cannot contain this outbreak. Until we have some population immune protection - either by herd effect or by vaccine - the spread of virus will continue. Some communities and countries have floated the idea of trying to achieve herd immunity faster by allowing exposures. If most of the population is going to get it anyway and reaching that point will then build immunity and limit spread, why delay the inevitable, especially if there are dire economic consequences?

It's an interesting idea, but I don't think it has worked. We don't know how much immunity the body develops after exposure and how protective this immunity is. Unfortunately, there are concerns that reinfection can occur even if someone's immune system is sensitized to the virus. We believe herd immunity will kick in, but we don't know for certain. It's hard to decide on a strategy of exposure when we know the risks but it's unclear what the health benefits will be.

Of course, as we relax sheltering restrictions in different states, we are, in essence, allowing further exposures. I think especially for those of us in higher-risk situations - health care, nursing homes, extended families, essential businesses - we must accept that though we can mitigate the risks, we are likely to be exposed. Still, I believe the longer we can avoid the disease, the better. Even if we will eventually get it, more time gives scientists and physicians a greater chance at understanding the disease, anticipating its complications, and possibly developing a therapy. I have a lot more experience with COVID now than I did a month ago. And we hope eventually, a vaccine may be developed. The more we can flatten the curve of infections and draw it out, the greater the likelihood that when people get it, we'll be better equipped.

What's the on-the-ground view of it all? From my perspective, in Mountain View, it's been manageable. We don't have that many hospitalized or ICU level patients. We haven't needed to activate our many levels of backup staffing. Currently, I think our challenges involve nursing homes; I can't speak for them specifically since I don't attend there, but we do get regular ER visits from COVID positive patients from nearby facilities. I think it's important, looking ahead, for the health care system to focus its resources on those communities. Our testing capacity has expanded greatly. And although there's psychological stress, we have a sense of optimism. Some of us in medicine are superstitious and don't like to admit when things look promising, but the truth is the Bay Area did a phenomenal job flattening the curve, and we're riding the plateau.  

This is not the case elsewhere. As I talk to my colleagues, I realize how lucky I am. The impact of this pandemic varies so much geographically. Friends in New York and Massachusetts tell unimaginable stories: patients overflowing into non-clinical areas, conference rooms, calls rooms, and offices; physicians taking weary naps in sleeping bags on inflatable mattresses instead of going home; providers in roles they don't normally have; rationing of N95 masks which are turned in at the end of the day for resterilization and redistribution; entirely new "COVID ICU units" being constructed; the chaos of emergent medical procedures like chest tube placement, intubation, and CPR being conducted on COVID positive patients. But I also hear of a united front against this new disease, a sense of resolve, an indomitable courage in the face of personal risk. For these colleagues, I have but the greatest admiration and awe.

I am grateful that California's swift and widespread response gave us reprieve from these dire situations. In addition, we have been cautious in relaxing our restrictions, and officials remain vigilant for future waves of infections. But clearly, our experience is not that of other places. This suggests that no single response will work evenly for every local situation. But it also suggests there is much we can learn from each other.

How do we open the country back up again? I think of this question in two different parts. First, we must know the risks of lifting the shutdown. Public health experts, epidemiologists, and scientists may be able to model the spread of infection, the likelihood of further outbreaks, the strain on hospitals, and the number of projected deaths. This is not an easy task; there are so many variables and uncertainties. But it is paramount that we have predictions of what might happen when different sectors of society are slowly reopened. This is certainly out of my expertise, but there are a lot of brilliant and detail-oriented scientists trying to figure this out.

The other part is estimating the economic boon that comes from reopening the nation. This is even further from my area of expertise, but I imagine it might be easier to predict. What do we expect from a financial or business standpoint if we open different parts of the economy? How many jobs do we preserve? How many businesses will be able to survive? What effect will there be on consumer prices, supply chains, and the job market?

But the real decision-making falls to how to balance these two parts: public health and economics. How many lives are we willing to jeopardize to revive businesses? I don't mean this to be glib. I think this decision needs to be made, and we must be frank with ourselves that we are accepting that risk. Certainly keeping everything locked down may minimize deaths, but we cannot maintain that forever. As different countries, states, and municipalities consider relaxing sheltering restrictions, they are effectively weighing the economy and jobs with lives.

Who makes that call? Ideally, it is something we agree on together, as a society. We accept the risks to ourselves and our health to regain some ground in preserving our businesses and livelihoods. But how do we do this in practice? We must have elected officials who listen to their constituents, weigh the testimony of medical and economic experts, and stay accountable for the decisions they make. We need a society that is flexible enough to shut things down again if the public health consequences look too dire. We need these decisions to be clear, transparent, rational, and based on data, free from partisan influence. I guess we'll find out soon how well we do.

No matter what a government, institution, or company does in response to coronavirus, there will be criticism. Even the best of decisions will draw second-guessing and doubt. At the beginning of this pandemic, with limited information and increasing urgency, these entities had to decide whether and when to start work-from-home, cancellation of elective surgeries, shelter-in-place orders, and economic relief bills. All of this is unprecedented. And all these decisions have such unforeseeable downstream impact that no matter what is decided, someone will be hurt. I am glad that, by and large, public health remains the primary motivating factor, though at the expense of economic uncertainty, social fragmentation, and societal disruption. I am sure when the dust settles, key stakeholders will be scrutinized for how they responded, but I personally have a lot of respect for them. Making necessary decisions without knowing all the consequences is a harrowing experience. Fortunately, in medicine and anesthesia and critical care, we operate with a good deal of data, experience, and expert consultation. Although there is uncertainty, I am able to mitigate it with nuanced, individualized clinical decisions and timely feedback to let me adjust. Even that is stressful enough. I cannot fathom what it's like to make decisions for something as big as the airline industry or public health department or preparation of a hospital system. Few people have the experience, foresight, and guts to do that. 

I suppose this is all to say that I really respect what has been done. I know there were failings, some egregious, and I don't want to apologize for those. But, for example, when the Bay Area issued its shelter-in-place order and continued to extend it at the expense of our economic prosperity, I don't protest too much. We saw a flattened curve of cases, allowing our hospitals breathing room, and for that I am grateful. I am sure if the orders came later or were less stringent or were lifted earlier, there would be other consequences.

I often say in this blog that this is all unprecedented, and I believe it is. But it means that we should draw crucial experience from it. We must learn from all the challenges, mistakes, and failings that we've made at small and grand scales in response to this pandemic. I am sure this will not be the last world-wide public health crisis we face. And I hope next time, our decision-making will be more nuanced, more refined, and more successful.

Early in the pandemic, before we had figured out all our procedures and policies, I witnessed a small but very important interaction. We were getting ready to transport a patient with possible COVID from the emergency department to the intensive care unit. She was on BIPAP, a form of noninvasive positive pressure ventilation that can aerosolize viral particles. We try avoiding BIPAP for this reason, but in this particular situation, it was necessary. To transport the patient to the ICU, we had the ICU nurse, respiratory therapist, and a transporter. The small interaction I witnessed was the nurse grabbing an N95 mask for the transporter who had been wearing a simple surgical mask. We recommend N95s for workers around infected patients on BIPAP due to the higher degree of aerosolization. It was a small thing, but it signaled to me: We look out for each other. Even amid shortages, we value each member of the team, and no title should entitle (ha!) anyone to more PPE over another. We make our PPE decisions based on risk, and it does not matter whether someone is a physician, nurse, therapist, technician, unit clerk, janitor, engineer, food services worker, or anyone else. (To be clear, N95s are specifically for high-risk aerosolization; otherwise everyone else is protected with standard mask, gown, and gloves). Even in crisis situations, we must approach rationing with an ethical and responsible mindset.

Random acts of kindness make a difference. I would say morale where I am isn't bad. We are supporting one another. Our hospital has worked hard to make testing and personal protective equipment available. Our staffing ratios are quite good, and we aren't asking many to take double shifts. But it has been a month and a half into this pandemic and we are still adjusting to the new normal in our work lives and in our home lives. Although there is less shock and horror in the news, we still feel the burden and uncertainty.

I write this post on call in the ICU because a local company donated a bunch of healthy meals through a local deli. Each of the meals had a little post-it note with words of appreciation, encouragement, motivation, and gratitude. While completely unnecessary, this small act of kindness (among many we have seen in the last few weeks) is also completely appreciated. I know many individuals and companies have gone out of their way to thank health care workers, first responders, and the "front-line." It helps. Morale is a funny thing. External affirmation of our work builds it disproportionately. In this marathon of a crisis, maintaining our good spirits is necessary to supporting our work force.

Should we perform CPR on critically ill patients with coronavirus who have a sudden in-hospital cardiac arrest? This is one of those questions that highlights the discrepancy between limits of medical intervention and a desire to "do everything." Much has already been written about the misconceptions of CPR, which I don't want to rehash, but I believe the harms of intervention are significant and the likelihood of success low. "Coding" a patient is most efficacious in acute reversible situations with effective treatments such as heart attack, arrhythmia, bleeding, pneumothorax, or tamponade. Unfortunately, the respiratory damage caused by coronavirus is not quickly reversible and has no proven treatments. If the cause of cardiac arrest is due to progressive deterioration from COVID, the likelihood of successful resuscitation is vanishingly small. We know from prior experience with acute respiratory distress syndrome (to which COVID has been compared) that CPR has little success in these situations.

At the same time, CPR puts health care workers at significant risk. Bag-mask ventilation while doing compressions on an infected person undoubtedly aerosolizes viral particles. Personal protective equipment, even if properly donned, can be easily dislodged, torn, or contaminated during a code blue situation. In the rush to get in, providers may not appropriately wear all the equipment. To do CPR on a critically ill patient with coronavirus is to put health care providers at some risk.

I don't mean this blog to push any medical opinions (and indeed, these are just my opinions), and there are definitely ethical, medicolegal, and cultural considerations to blanket rules regarding emergency resuscitation in this pandemic. These considerations can go both ways. Some providers may feel uneasy with withholding CPR from a patient who would want it, and other providers may not want to perform CPR at risk to their own health. It is a complex and nuanced topic. I decided to write this blog as a natural progression from the previous blog on end of life. But I don't want to espouse any blanket decisions, only reasoned consideration. I believe ideally, we should continue to have conversations with patients and their surrogates, making decisions as a partnership. But we must be honest with ourselves and with our patients regarding the harms and benefits of heroic interventions like this.