I rarely make appeals on my blogs. But as we are seeing pandemic fatigue and a rise in cases related, I believe, to human behavior, I think it important to say: our decisions can have profound consequences. Deciding to wear a mask or postpone an unnecessary social engagement or ask someone to step back for social distancing can change the course of this pandemic and our ability to weather it. Our actions have exponential and unforeseeable consequences. Infecting one person or preventing one infection may, over the course of months, impact the health and livelihoods of dozens, maybe hundreds of people.

I don't think we need to isolate and become hermits again. But there's a spectrum of social and economic activities, and with a holiday weekend coming up, I think we ought to consider the risks and benefits of our plans. In my opinion, the risks of a large social gathering are just too high to the attendants and to the community. We all need to see family, interact with others, and celebrate what we can, but I urge you to do it in a responsible fashion.

Right now, we have as many COVID patients in our intensive care unit as we did in April. However, the community has less social distancing and caution, and I worry our resources will be strained. Since there is a lag between when someone gets infected and when they seek emergency care (thought to be 1-2 weeks), we're only seeing the consequences of what happened mid-June. Even if we all adhered to better measures now, things will get worse for a week or two before they get better. This lag makes it hard for us to connect our community's collective decision-making and our case numbers.

The goal is that if you or someone you love or even someone you've never met needs an ICU bed, a ventilator, a doctor, a nurse, a respiratory therapist, bloodwork, X-rays, or medications, he or she can get it. Even if what that person wants and needs is a peaceful, pain-free death with dignity with family present, we want to be able to provide that.

As a doctor, I have not yet been in a situation where I was giving significantly suboptimal care because what I felt a patient needed was not available. I hope I never have to be in that situation. I cannot imagine what it was like for professionals who had to face that reality in other hospitals at the beginning of the pandemic.

At that time, there wasn't a whole lot anyone could do to prevent those situations from happening. It was already too late. But now, right now, we have a chance to prevent that sort of crisis from reoccurring.

I wouldn't ask this if I didn't think it mattered. Our health care system is here for you if you need it. And we are readying ourselves for what's to come. But responsibility for our health and our health care system is a collective, community responsibility. Every individual contributes. Thank you for your help and sacrifice.

As predicted, we are seeing a resurgence of infections and hospitalizations, especially in parts of the country that opened up earlier. We're seeing mixed responses - some states are slowing their process of opening while others are ignoring the increase in cases while others are mandating mask usage. What's the ideal thing to do?

I don't think there is a clear answer, and I think in the coming months to years we will have regular surges and declines in the number of cases. A lot depends on local outbreaks, seasonal variation, events with congregation, and coronavirus fatigue. So I approach this problem with clear public health goals. We must protect our vulnerable populations. Even if states press ahead with reopening the economy, we must remain vigilant regarding the health of our older citizens and those with other medical problems. They bear the brunt of illness, hospitalizations, and death in this disease. I do think policies and innovations to help this population makes a difference (like senior shopping hour). I also think we have to watch for outbreaks as we relax visitor restrictions at nursing homes and hospitals.

Since I am science and numbers oriented, I think we should have in place thresholds or triggers that determine our public health actions. For example, if available hospital or ICU beds drop below a predefined threshold, we should reenact more sheltering-type restrictions. Defining these numbers removes that decision-making from politics or external influences. For the most part, California has defined metrics for counties to meet to progress through stages of opening, and I think this is a logical and reasonable way to do it.

We must also continue to gather data. Where are outbreaks happening and why are they occurring? What are the trends for infections, hospitalizations, and deaths? What socioeconomic, racial, educational, or other societal disparities exist? Are citizens and communities adherent to social distancing or mask requirements? In any scientific enterprise, we have to gather data before we can determine what difference our interventions make.

So what's it like to intubate a patient with COVID? Intubation - the placement of a breathing tube into the windpipe for someone who needs mechanical ventilation - is one of the highest risk procedures for aerosolization of the virus, and also one of the more common procedures for COVID patients requiring ICU level care.

At the beginning of the pandemic, it was more stressful than it is now. I think the most important thing is to intubate under controlled conditions. I've intubated a suspected COVID patient (who thankfully ended up testing negative) who had cardiac arrest and ongoing chest compressions, and that's a disaster situation we absolutely must avoid. The risk of contamination if a patient actually has coronavirus is astronomical with CPR, many providers in the room, and possibly inadequate personal protective equipment.

I believe that even when a situation is dire, a controlled intubation is possible. A young otherwise healthy man with COVID presents with a week of fever and several days of dry cough, shortness of breath, and malaise. In the emergency department, his oxygen saturation is 75% on room air and 90% with oxygen by face mask. Unfortunately, over the ensuing several hours, his oxygen levels continue to drop; he is transitioned to high flow nasal cannula and then to BIPAP. Even with optimal delivery of oxygen, we cannot get his oxygen saturation over 85%.

Intubating a patient with such little oxygen reserve is a stressful situation; in the process, oxygen levels will drop until the breathing tube is placed, and starting at that level means there's a real risk of cardiac arrest. There's been a lot of discussion in critical care circles of when to intubate patients because waiting this long carries substantial risk. On the other hand, intubating too early might mean unnecessary intubations and a shortage of ventilators, drugs, and equipment. In this case, the patient simply deteriorated so incredibly rapidly. It was one of the most severe cases of COVID I've seen so far.

But when I can, I insist on a controlled intubation. I limit the number of personnel in the room and I try not to take any unnecessary equipment in to avoid contamination. But I also detail backup plans if I cannot intubate the patient or if he has a cardiac arrest. Nurses are suited up outside the room who can come in to assist without delay, and emergency equipment is ready to go if needed. Intubating in all the protective gear isn't really that cumbersome, though it does get quite hot even using a purified air powered respiratory that has a fan. I try not to deviate much from my usual process during the actual intubation. Even in stressful situations, and perhaps especially in such situations, keeping to a routine minimizes mistakes. So far, I am grateful that my intubations have gone well without complications, and no providers have gotten ill. I hope to keep it that way.

Most cities, counties, and states are slowly opening things back up. As sheltering restrictions relax, we now have to assess our own risk tolerance. How much do we feel comfortable doing? Should we eat at a restaurant outdoors or just take the food home? Can we swim in a pool with others? Should we send our kids to summer camps? When we will next get on a plane?

Fundamentally, not a whole lot has changed. The number of infections rises and will continue to rise. Treatments are still being investigated. We await a vaccine. And although we know more now than before and our hospital and intensive care capacities have improved, COVID still has substantial morbidity and mortality. 

We cannot remain cooped up forever, and our lives need to continue. But we also cannot flip a magical switch and go back to life six months ago pretending this disease never existed. So we tread out into the world, cautious, testing, trying to find a new balance, a new normal. As guidelines become more free, our own risk compass must kick in to tell us what to do.

It's interesting. Among my own group of friends and coworkers, I've noticed a wide range of behaviors. I think it's good. I see us weighing the risks and benefits of controlled social interactions, physical activity, and support of businesses. We think of who we live with and our own medical problems. We also think of our own emotional well-being and how baby steps to a normal life may help. We try to weigh social justice and attending a protest against avoiding crowds of strangers. It's a whole new world, and one that requires individual responsibility, measured decision-making, and (indeed) trial and error.

Race and racism are challenging but necessary topics to write about. As America struggles with another crisis, one that involves racism, violence, activism, protest, and institutions, we must confront our own beliefs and feelings on these issues. Unlike my writings about medicine, I don't have any particular expertise or wisdom regarding race or how to think about it, but I wanted to contribute to the conversation.

I see, within myself, and in nearly every aspect of the world I encounter, prejudice, discrimination, and bias. Acknowledging this is important. Social injustice is endemic in this country. I believe the studies that show conceptions about race begin early in childhood. I believe the implicit bias tests that highlight the prevalence of racial biases. I also believe these long-standing, deep-rooted, and subconscious prejudices manifest themselves materially in our perceptions and behaviors. I have been a target of racism (and have noticed an uptick since the pandemic started), and I have, I am sure, unwittingly been a perpetrator of racism. This is a complex, multifaceted problem at the individual, institutional, and societal level that requires active, conscientious work to address. 

Within medicine, race (along with socioeconomic status and level of education) is an overlooked but key determinant of health and disease. Unfortunately, this pandemic, like most diseases, has disproportional effects on minority communities. We are certainly seeing that in the Bay Area. I often think of health care disparities in diseases and treatments, but the murder of several African Americans highlights the fact that racism and violence, too, are health care disparities. This is a public health crisis that we have discounted or ignored far too long. Physicians and health care workers can contribute to this conversation by voicing what we see - that racism, intolerance, and discrimination underlie violence and trauma that constitutes an unacceptable health care crisis.

I support those advocating for social justice at peaceful protests, but I also acknowledge the other public health crisis going on today. I do worry about the spread of coronavirus. Like all decisions in life and medicine, there are risks and benefits to what we do. Activism, protesting, and speaking up are important. We will brace ourselves for another spike in cases, if that comes. We acknowledge that sheltering in place can build tension and bottle up emotion, and we try not to let conflict escalate. We also search for other venues, conversations, and dialogues that can help our communities and nation come together peacefully. We go out and vote, to bring the change we want to see.