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.

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.

"...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.

"...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.

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.

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.