One awfully sad thing I've seen in this pandemic is guilt. An older man with metastatic cancer has been isolating himself. However, his son, worried about him, convinces him to allow a visit. The son brings his children - the patient's grandchildren - because they haven't seen him for over six months. This is complicated by the fact that the man's metastatic cancer gives him a survival prognosis of less than a year. His children and grandchildren may not be able to see him before the pandemic is over.

Several days after the visit, the man develops high fevers, shortness of breath, and cough. His oncologist by televisit sends him to the emergency department and he is diagnosed with COVID. Over the ensuing week he rapidly worsens. When he was diagnosed with metastatic cancer, he had discussed what he would want at the end of his life. He did not want to die on a ventilator. Eventually, his oxygen worsened to the point that we could not sustain him. He said that he was ready to move on.

The death, while tragic, is a common occurrence in this pandemic. We did what we could for him medically, and when we reached the limit of what we could offer, we tried to give him a painless, dignity-affirming end of life. But I was most affected by my conversations with the son. They were by phone because unfortunately, he tested positive for COVID as well. And as you may imagine, his sense of guilt was overwhelming. I struggled with what to tell him. 

What is it like to grapple with the guilt of Oedipus? How do we make decisions when each branch could lead to regret? Can we afford not to visit family dying of cancer? Can we live with ourselves if we think we might have hastened their death? Could this be happening around the country, around the world? It's easy to brush off consequences of our actions if they are far away and unknown, but how devastating it is to realize they are so close to home.

Our composition of COVID patients has changed a bit. We have begun seeing patients who require intensive care for other diseases but incidentally test positive for COVID. A few months ago, all patients with COVID in the ICU had respiratory failure from coronavirus, but now we have patients with heart attacks, strokes, diabetic crises, and other typical intensive care illnesses who also have COVID (since we test virtually everyone who presents to the hospital). What does this mean? I think it contributes to the finding that there is a community reservoir of asymptomatic people with COVID; these patients who tested positive would not have otherwise presented to the hospital. It also reveals the heterogeneity of COVID infections.

A young woman who is self-isolating because she knows she has COVID decides to pass the time by taking some hallucinogens. Unfortunately, she has a bad fall leading to brain bleeding; she is brought in by paramedics, intubated, and admitted to the intensive care unit. As we treat her brain bleeding, we notice that despite being COVID positive and having an abnormal chest X-ray, her oxygen needs are minimal. This seems consistent with the finding that COVID's effects on the lungs vary by age.

A young diabetic who gets COVID feels miserable, is unable to take his medications, and cannot eat or drink. He goes into diabetic ketoacidosis, his sugars eight times normal, his body unable to maintain its acid-base balance. He is admitted to the intensive care unit overnight. He doesn't require any supplemental oxygen, and he is discharged home several days later. Even mild COVID that doesn't cause significant alterations in oxygen can trigger other medical comorbidities that stress our hospital system. Although coronavirus in these patients may not require advanced oxygen therapies, it does limit which rooms these patients go to, nursing ratios, and use of personal protective equipment. With the high prevalence of coronavirus in our communities, we will have to remain cognizant of our resources and limitations. As this pandemic unfolds, we will have to be nimble in our hospital operations to handle the changing landscape of healthcare.

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.

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.

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.

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.