It's been a long time since my last post, and for that I apologize. Coronavirus has been surging in California, and we have seen a frightening rise in the number and acuity of cases. I attended in the intensive care unit last week, and it was one of the hardest weeks I've seen. News articles in the last few months have interviewed doctors who say they have never seen anything like this. I feel the same way. Although where I am in the Bay Area is not bad compared to New York, Florida, Texas, Arizona, and even southern California, it is nevertheless remarkable and scary.

COVID is a strange disease. Most patients do not require hospitalization, and of those who are hospitalized, most do not require intensive care. But the ones I see, the ones who need the ICU, are very sick and remain so for a long time. These patients stay for weeks. Any day-to-day progress is tiny, and for many of these patients, we see very little improvement even over weeks. We treat them with dexamethasone and remdesivir, prevent complications like blood clots, support them with high flow oxygen or non-invasive positive pressure, and encourage them to position themselves in ways that help lung-oxygen matching (what we call self-proning).

But, it seems, at some point, if there is progressive decline, patients reach the edge of a cliff and then decompensate incredibly rapidly. We see the usual complications of intensive care: delirium, arrhythmias, acute kidney injury, secondary infections, gastrointestinal bleeding, or blood clots. And then, it seems, the patients tip over the edge and all the organs fail simultaneously. Patients get intubated, require vasopressors, need dialysis, and receive transfusions. We begin seeing complications that are incredibly rare in the medical ICU. This week, I saw a tension pneumothorax from high ventilator pressures, and I had to do an emergent needle decompression - a procedure many (non-trauma) intensive care physicians never do. Once the patients become truly unstable, they die within a few days, even if they had seemed "okay" for weeks. Once they go into multiorgan failure, it seems, they begin actively dying, and there is nothing we can do to reverse that.

This is part of why our intensive care units are full and our nurses and physicians exhausted. Patients with COVID stay for a long time, and when they deteriorate, they do so shockingly rapidly, requiring a huge amount of physician and nursing resources. When one of my COVID patients died this week, I was at the bedside for hours along with three nurses and two respiratory therapists. Right now, our intensive care unit isn't full or overflowing. I can't imagine hospitals in those areas where ICUs are over capacity. Stay safe. Protect yourself and protect others and protect the resiliency of our medical system.

We have trouble with comprehending large numbers. What does it mean that 60,000 Americans tested positive yesterday? Or that there are 3.1 million total U.S. infections? The numbers are big, but it's hard to know how big. Additionally, these are only proven positive infections; the numbers are undoubtedly higher with limited testing and asymptomatic carriers. Although the distribution of COVID is uneven over geography, socioeconomics, age, and profession, about 1% of the U.S. population has or had COVID. Although we may think we don't know anyone with coronavirus, we probably do. I know several people who have gotten COVID, primarily health care workers. You probably know someone too. Should you wear a mask for a social meet-up with someone you know? Probably.

COVID has been prevalent in the United States for about four months and killed 134,000 people (probably more from deaths without a proven test). This is more than the number of people who die from Alzheimer's disease or diabetes or pneumonia or kidney disease or liver disease in an entire year (2017 statistics). It's close to the number of people who die from strokes in an entire year. The numbers are only increasing; it's conceivable that by the end of the year, COVID will rival cancer deaths (600,000/year) or deaths from heart disease (650,000/year). We all know someone who has died from heart disease or cancer. Maybe many people. This is how bad the disease is.

Statistics are not my strong point and are difficult to convey. Those who are good with infographics or other comparisons may be able to make even more compelling arguments. But I think we're at the point where we should assume we may be exposed to it even from people we know and that those we care about may have it. You wouldn't get into a car without a seat belt. Social distancing, mask wearing (particularly indoors), and hand hygiene should be similar instincts.