A 22 year old who tested positive for COVID several weeks earlier presents to the hospital with severe shortness of breath. When he was initially diagnosed, he had mild symptoms and quarantined at home. So it was strange for him to come in a month later with severe symptoms. In the emergency department, he was assumed to have COVID and started on standard treatment. But when I examined him, I felt that I was missing something. He looked to me to be in heart failure, the type of presentation we see in someone with multiple heart attacks. His X-ray didn't look like typical COVID but rather pulmonary edema, fluid accumulation as a result of an ineffective heart. I looked at his heart with an ultrasound and it was not beating as strongly as I expected. I also noted a rash and abdominal symptoms.

I had a suspicion, though I had never seen this disease before. I called our infectious disease consultants, and we agreed, this was the pediatric manifestation of COVID-19, called multisystem inflammatory syndrome (MIS-A for adults). At the time (this was many months ago), there were fewer than a hundred adult cases published in the literature.

Fortunately he recovered. But his course was prolonged; we even referred him for possible heart transplant. It turns out, his shortness of breath was entirely due to pulmonary edema and not COVID at all. COVID seemed to be targeting all his other organs instead.

At the beginning of the pandemic, we thought children were spared severe disease from coronavirus. It seems that though they get sick less frequently, manifestations like MIS-C can be devastating. It was a fascinating experience seeing an adult present with a predominantly pediatric disease; other than some genetic disorders I don't think of pediatric medicine much at all. It engaged a lot of diagnostic skills I haven't used in this pandemic and reminded me to stay sharp when patients present in unusual ways. I am glad I keep up with new findings, reports, and studies of this unbelievably strange, multifaceted, and deadly disease.

One final post on a hodgepodge of vaccine topics.

The current most common COVID-19 vaccines, made by Pfizer and Moderna, require two doses. The booster shot occurs about 3-4 weeks after the initial dose and is necessary to achieve ~95% protection to the virus. Initially, the plan was to distribute half the doses and to keep the other half for the second shot about a month later. Now, several governments and prominent scientists have suggested releasing all the available vaccine immediately so that more people can receive a shot.

I greatly trust and respect some of the voices advocating this second approach. Normally, I would be a stickler for the rules and give the vaccine as it was studied in the trials. Notably, the second method - releasing all the doses - doesn't preclude that; if manufacturing and procurement keep up, we could be able to supply everyone with the second dose by the time a month rolls by.

Although we only have good study data for two doses several weeks apart, in a crisis, we need to think creatively about whether other approaches can achieve better outcomes faster. I don't think answers are clear. We don't know how much partial immunity one gets from just one dose. And we worry that if someone doesn't receive the booster shot, the effectiveness of the vaccine will wane. But I do think a current priority needs to be vaccinating more people faster. Viral spread is exponential, and its prevalence is incredibly high in some communities right now. We need to engage all our tools to slow its spread. If modeling studies show releasing all the doses will tamp down viral spread, then it's worthwhile to entertain. But we still must attempt to get everyone their booster at the appropriate time.

I worry about the ability for developing countries to vaccinate populations at scale. Health care systems need to ensure follow-up for those who need two doses. Robust infrastructure is required to manage the storage conditions of mRNA vaccines. Fortunately, there are some vaccine candidates in the pipeline that may not have such challenging requirements; thus we need to keep pursuing COVID-19 vaccine research. We must not leave developing nations behind.

Lastly, I am pleased to see that the guidelines for vaccine prioritization cover all staff who work with patients and infectious materials. In this blog, I talk a lot about physicians, nurses, and respiratory therapists, but I would be remiss if I did not acknowledge all the other team members who make the delivery of care possible. I worry about the technicians who take X-rays of our COVID patients, the therapist who assesses how they swallow, our housekeeping staff that sanitizes the rooms, and the laboratory technicians who process COVID specimens. They are essential members. They absolutely need to be protected. 

Widespread vaccination will be a huge undertaking that will take a while. Until then, we must remember that even if we are vaccinated, we need to continue all the social distancing, masking, hand-washing, and other interventions that help us reduce transmission. 95% effectiveness is wonderful, but not perfect. We also have many unanswered questions like whether vaccinated individuals can be asymptomatic carriers. We cannot let our guard down until this pandemic is fully under control. I worry whether we can reach herd immunity with significant numbers of people declining the vaccine, but I believe that education and time can help improve our numbers. I think that reaching herd immunity will be the most effective way of reducing COVID-19 deaths long term and resuming our pre-pandemic lifestyles.

It is impossible to write about the pandemic without commenting on our government response, but I try to avoid overtly political matters. I think they are important, but that's not what this blog is about. I also live in a very liberal, and in many ways, privileged segment of this country, and my perspective is shaded by those influences. Nevertheless, seeing the shocking events unfold at the Capitol on January 6, I felt that our democracy was under attack. There is no justification for such domestic terrorism.

I have been meaning to write a blog about how political views, "false news," "alternative facts," conspiracy theories, social media, and misinformation have worsened this pandemic. In the last five years, I have noticed a crescendo in the fervor, vitriol, and extremism in the political views of our society. There has also been a breakdown in healthy dialogue between competing opinions. 

I was a philosophy major in college, and I spent a lot of my time learning about logic, arguments, and rhetoric. I really do believe healthy debate can and should happen. It moderates our views, gives us insight on our own beliefs, and persuades others. It is also an important part of democracy. 

I have watched arguments about coronavirus and the vaccine play out over social media, and it has been eye-opening. It seems like we cannot agree on the facts or premises of the arguments. Conspiracy theories, "alternative facts," and "fake news" undermine our ability to agree on the simplest things: what sources we can trust and how to determine what is actually real. 

Furthermore, social media has acted as an echo chamber so that conspiracy theories, "alternative facts," and "fake news" become amplified. Those who subscribe to this hear it repeated on their feeds and become more entrenched in those beliefs. As our society diverges on what can be accepted as truth, we become more polarized with diminishing hopes of finding common ground. This is a problem politically as shown by the events several days ago, but also affects our ability to talk about and respond to the pandemic.

How can we address coronavirus if some people believe it is a hoax or even that it is caused by 5G wireless networks? Where do we start if misinformation has become so prevalent that basic scientific and medical facts are ignored? For example, a simple understanding of biology refutes the idea that an mRNA vaccine could alter DNA. A first year medical student understands what vaccines can infect someone with live virus and why. The COVID vaccines out there do neither. But I hear this echoed repeatedly. We must be able to accept some basic premises to start a conversation.

And we ought to have a conversation. Different political persuasions have differing opinions on how to balance businesses and public health, the pros and cons of drawing debt to provide economic relief, and the types of restrictions we can enact to reduce spread of disease. These are important and meaty topics that ensure our response to the pandemic is democratic and incorporates the voices of diverse stakeholders.

All this to say our fractured systems of belief concern me. It's hard to imagine a functioning society if we cannot have rational discourse. In an uneventful world, we may not notice that we exist in a bubble. But in times of political or public health stress, these divisions in our society become evident and hamstring our ability to work things out.

I've been thinking about vaccine distribution lately. In a worldwide pandemic with multiple competing interests, the best way to vaccinate isn't entirely obvious. What we're seeing now in the United States with a haphazard and slow rollout is a failure of planning. We spent so many resources on developing this vaccine yet little on distribution and actualizing the immunizations. 

At the most basic level, vaccines need to be given. We may debate about who gets priority and how to do it, but more doses need to be given, and soon. The pandemic is a raging fire, and we need to sap the fuel. Those logistics are not easy. In our fractured health care system with many providers, insurers, and systems, capturing everyone is going to be a nightmare. We need strong leadership and foresight to tackle that problem.

But even from a more theoretical standpoint, we should define our goals for vaccination. I think three important but competing goals are: (1) preventing unnecessary deaths, (2) getting the pandemic under control, and (3) maintaining our health care system. Strangely enough, these goals can be at odds with each other.

In the short term, to prevent unnecessary deaths, we ought to vaccinate those for whom contracting the disease could be fatal. Here we would immunize high-risk people, the elderly, those living in nursing homes, and those with medical comorbidities. Each person vaccinated could be a potential life saved.

Yet, to prevent deaths in the long term, we need to get the crisis under control faster. To stop spread effectively, we could immunize those who are likely superspreaders. One of my friends suggested that we stand outside bars and vaccinate everyone who comes out. Although this was said in jest, it's not a bad idea. There are modeling studies that show if you immunize the most likely spreaders in a population, you can get herd immunity quicker. In one such model, researchers asked college students who their most popular friend was and gave that person a flu shot. They found less community spread of flu with that plan compared to vaccinating a random sample of students.

Realistically, that type of plan wouldn't pan out. These days, we struggle to enforce mask wearing and social distancing. If we started vaccinating those who didn't follow the rules, there would be backlash. Even worse, people might stop following guidelines in order to get immunized.

But ultimately, our current vaccination scheme prioritizes one other important goal: the preservation of our health care system. First responders, nurses, respiratory therapists, physicians, hospital workers, and nursing home staff are at high risk for exposure. As our health care system reaches and exceeds capacity, risks to health care workers increase. This makes us vulnerable to a catastrophic spiral: our health care workers fall ill and can no longer work, our hospital system becomes even more strained, remaining staff are exposed to more risk, and more workers contract COVID. If our health care falls apart, we will have unnecessary deaths both from COVID and non-COVID causes.

Of course, as an intensive care physician, I am biased regarding vaccine prioritization. In general, health care workers are not at the highest risk for dying if they get COVID. Vaccinating me may not prevent me from dying. But if it prevents me from falling ill and quarantining for two weeks, that may translate into lives saved. I think the initial goal of protecting health care workers and nursing home residents makes a lot of sense.

Who do we vaccinate next? I don't know. I turn to the experts who can outline our objectives and weigh the risks and benefits. I see arguments for vaccinating other front-line workers, the elderly, those with comorbidities, and pockets of society with rapid spread. I'm not sure about the best approach. But I do think we should not let other factors, namely wealth, affect our vaccinations. In the last few months, I've had several instances of wealthy families trying to use their resources to get specific care. This is ethically indefensible. COVID vaccinations are in short supply. Taking them away from those who need it may mean the difference between life and death or another outbreak or a hospital forced to ration care. I hope our government and health policy experts are working on improving our vaccination plan.

Never in modern history has there been so much hope, fear, optimism, and sorrow tied to the turning of the year. This global pandemic, which began over a year ago and since visited every continent, has upturned our society to an unimaginable degree. It has taken an unimaginable number of lives. It will leave scars in our personal lives, our communities, and our collective histories. This New Year's I take a moment in memory of those who have died from this pandemic. 

When September 11 happened nearly twenty years ago, I struggled to put into words the enormity of such tragedy. I actually wrote every year about it for a decade. Disaster leaves deep impressions. Right now, we are losing more people each day than died on September 11. The numbers, statistics, and scope of what is happening - what has been happening - far exceeds my capacity to comprehend and make sense of it. For me, writing and reflection are ways of trying to, of coping.

Right now, working in the intensive care unit in the Bay Area, I am seeing a situation I have never before witnessed. Even though it is less severe than Italy, New York, or Southern California, and even though I had prepared myself for it, it is unbelievable. Never have I seen such immense strain on our medical system, and never have I seen such true heroism, sacrifice, compassion, and dedication from the caregivers I work with. 

There are so many aspects to this disease, the pandemic, and how our lives have changed, and I strive to capture them in this blog. This New Year's, I spend a little time contemplating the medical complexity of the disease, the miracle of such speedy vaccine development, and the humility of how much we still don't know. I think of the individual patients I have cared for, the stress and anxieties of the procedures I've had to do, the heartbreak in the families I've had to call. I think of our successes, the patients who have survived despite all odds. I think of our losses, the death certificates I've had to sign. I think of the comraderie I have with our critical care team, the nurses and respiratory therapists who work side-by-side with me every day, and the extended support team that make my job manageable. I think of our public health system, of those policies that have helped and hindered, of the work yet to be done at a local, national, and global level. I think of the sacrifices made by our families, communities, and businesses for this pandemic, of the postponed hopes and dreams, of the irrevocably changed way of life. I think of the Before Times.

In some ways, today is a day like any other in this pandemic. But I do think, for me at least, there is some value in recognizing even arbitrary occasions. 2020 is over. We look ahead to 2021. Without doubt, the first few months will remain a crisis. But I want it to be the beginning of a new hope, that equipped with a vaccine and renewed resolve, we will again flatten the curve, find a plateau, and rein this disease in. Our communities will adapt, remain creative, and thrive in ways we did not anticipate. We will mourn and cope and nurture and grow. We are facing a global challenge unlike any other in modern history. We did not get it under control in 2020. But I am optimistic that this year we can and will do better, finding humanity, hope, and a new future emerging from the darkest of times.

Fortunately, I received the COVID-19 vaccine. For most of us eligible for the vaccine right now - healthcare workers seeing coronavirus patients day in and day out - I believe this decision is easy. The benefits far outweigh the risks. I trust the scientists who developed the vaccines and the independent experts who reviewed the data. I trust the colleagues I've talked to, physicians and pharmacists, who agree that the vaccine appears both effective and safe. I am grateful that it is here, and that I was able to receive it.

American health care doesn't prioritize preventive medicine, but preventive medicine is probably the most important thing we can do. Our health depends on a balanced diet, regular exercise, avoidance of smoking, drinking, and drugs, and, indeed, appropriate immunizations. If we prevent ourselves from getting sick, we save ourselves so much grief, pain, disability, and complication. We save the system money and resources. Although our healthcare is designed around treating things when they go wrong, we should put more emphasis on preventing things from going wrong in the first place.

I know we may have stubborn attitudes towards getting vaccinated, but this is important. It is preventive medicine. It is effective at protecting us from coronavirus, and these days, all of us are at risk for getting COVID. With over a hundred thousand Americans hospitalized with it right now and thousands dying daily, avoiding this disease is no small thing. It is certainly worth the mild discomforts associated with the vaccine (and so far, I have not experienced any problems). And though long-term outcomes are unknown, I believe the clear direct benefit outweighs any nebulous concerns that haven't yet come to light. As with everything, there are exceptions, and so those with severe allergies, history of vaccine reactions, pregnancy, or complicated medical histories should discuss with their physician.

I feel relieved after being vaccinated. Working long hours in an intensive care unit filled with COVID patients is stressful. Seeing its devastating effects on young patients is scary. I worry about bringing the virus home or transmitting it to others (though currently, we do not know whether a vaccinated individual can be an asymptomatic carrier). Seeing our communities struggle amid this pandemic is heartbreaking. But after receiving my first dose of the COVID-19 vaccine, I am beginning to see a bit of hope that these stresses, worries, and concerns will not last forever.

What a strange dichotomy, the arrival of a promising vaccine and the deepening crisis of the pandemic. So much hope juxtaposed with so much grief. At the same time health care providers are receiving the first dose of immunity, we are breaking records with the numbers of people infected, hospitalized, and dying. But I think this may signal the turning point of this global disaster.

It will take a lot of time. The rise in cases is still meteoric from Thanksgiving gatherings. Even with shutdown measures, it will take weeks to level off and plateau. And unfortunately, I believe we aren't as adherent to these shelter-at-home directives as we should be. As a result, we're not close to containing this virus, and measures like contact tracing have limited effectiveness. This skyrocketing number of infections has downstream effects on the number of people requiring hospitalization and intensive care, taxing our resources and leading to excess deaths. 

Unfortunately, the effects of the vaccine will take time. Two doses several weeks apart are required, so there will be a delay there, though there is partial immunity after a first dose. Logistically, it will take many months to vaccinate everyone who wants to receive it. Unfortunately, vaccine skeptics, false information, and distrust of the system will hamper our outreach efforts. Even those who may not disbelieve vaccines may be slow to sign up due to worry about side effects or feeling that they don't need it.

While on an individual level, someone may weigh the risks and benefits and elect not to get immunized, at a population level, we need as many people to receive it as soon as possible. The effectiveness of a vaccine at a population level depends on herd immunity, the point at which there are enough vaccinated individuals that it protects non-vaccinated individuals. This requires the majority of a population to have immunity. This also protects individuals who may not be able to get vaccinated for whatever reason. However, herd immunity may be challenging to maintain once our global community opens up. There will inevitably be cross-over between well-immunized populations and poorly-immunized populations which will dilute out the herd immunity effect.

All of this is to say that although I think we are at a turning point, we are not at the peak of the crisis. Things will still get worse before they get better. We will start turning things back, but the momentum of this pandemic is tremendous. As reiterated by our public health agencies, we need to continue masking, distancing, and avoiding risk even as the vaccine rolls out. We cannot get complacent. There is still a long way to go.

Over the past nine months in the Bay Area, we've bounced back and forth between stricter and looser regulations, trying and unable to find an equilibrium. We locked everything down in the spring, watching the East Coast in trepidation. Then in the summer, we navigated changing restrictions when the Midwest became overwhelmed. Up until recently, the Bay Area has avoided disaster. Unfortunately now, disaster is here.

It might feel like the boy who cried wolf. Before this, whenever we got scared, we shut things down, and went more or less unscathed. Now, we cry alarm, but our communities are exhausted, our businesses flailing, and our holiday hopes dashed. We are reluctant to listen to these cries, and now the wolf is real.

I don't think the analogy reflects what exactly happened. We avoided a surge in the spring and summer because we cried wolf. Our shutdown measures made a difference. We weren't giving false alarm. But I worry that with time and repeated calls for caution, fewer take heed.

Now, like the rest of the nation, California and the Bay Area are in a crisis. We reinstituted severe lockdown measures, to criticism from small business owners and struggling communities. I can't imagine how hard it must be to try to run a restaurant, or to worry about when unemployment benefits expire, or to feel trapped in one's home for nine months. There are devastating hardships and consequences from shutting things down. And the benefits may not be immediately appreciated from afar.

This is how bad the health care system has and will become. We are seeing a steep rise in cases. Before Thanksgiving, our COVID patients occupied less than a third of the intensive care unit, nicely sequestered in our COVID-specific "pod." The following week, the numbers surged and we didn't have enough room in our COVID-designated areas. Our engineers scrambled to convert rooms to accommodate COVID patients. A few days ago they made up two thirds of our intensive care patients, and most recently, 80% of them. Our ICU still needs to care for strokes, heart attacks, sepsis, cardiac arrests, overdoses, and all the other life-threatening illnesses that come to our door. We have opened up additional intensive care availability in our post-anesthesia recovery area. We have boarded patients on ventilators in the emergency department as they wait for beds. Every day we are discussing mitigation strategies to make it through that day.

However, beyond beds, our biggest shortage will be staffing. Nearly every shift I have in the intensive care unit, I see the clerk calling nurses at home, seeing if anyone can come in on short notice. When that fails, we ask nurses that are working 12 hour shifts if they can extend to 16 hours. Our intensive care doctors are stretched thin. At the busiest, I am responsible for intensive care patients in three areas of the hospital on three different floors. 

We are experiencing burnout. The physical and emotional stresses of caring for these patients are enormous. Many of them are young. Many of them are dying. Many require heroic interventions and efforts to save them. And working longer hours, more shifts, with busier services, we don't have the bandwidth to process these emotions or even to eat or drink water. This is not sustainable, and yet, we anticipate this surge to last for weeks to months.

Does intensive care make a difference? I think this is an important question, else we are scrambling and stressing for little benefit. It does. We have patients who arrive in extremis, requiring complex coordinated intensive care and life-support who survive when we weren't sure they would. The hospital stays are long and they face an arduous recovery, but we can save lives. Each critically ill coronavirus patient requires weeks of intensive care, dozens of doctors, nurses, and therapists, and a lot of love, care, and support. We have love, care, and support in abundance, but hospital beds and providers will get scarce.

I don't think it is easy to weigh the benefits and consequences of a lockdown. In the spring, a lockdown made sense; businesses did not have the masks, sanitizer, gloves, barriers, guidelines, and education necessary to run safely. I know that a lockdown now, when there is no federal support for businesses, will have drastic and long-lasting consequences. Asking people to isolate during the holidays is not a small thing. Our communities are weary and battered. And a complete shutdown isn't ideal; it's a blunt instrument when perhaps selective restrictions may strike a better balance between protecting the health care system and preserving parts of our lives we can conduct safely. But here we are, and we need to do something.

Because from the ground, from the intensive care unit where I reside, we need all the help we can get, and I'm appreciative of all the sacrifices made to make that happen.

A pregnant woman at term with severe pre-eclampsia presents in labor. She tests positive for COVID during standard screening. She is asymptomatic and does not need any oxygen. However, her pre-eclampsia is concerning; she requires several medications to control her blood pressure, and the fetal heart strip is flat, abnormal. The obstetricians worry that she may eventually need a C-section, though one is not emergently required now. They ask what the optimal plan should be.

How much should a COVID diagnosis change care?

One important goal in any pregnancy is to avoid an emergent "crash" C-section - the kind that involves running to the operating room, inducing anesthesia as quickly as possible, splashing iodine onto the belly, and getting the baby out immediately. These scenarios are uncontrolled, stressful, and chaotic. Occasionally they cannot be avoided, but with early identification, prevention, and planning, they can be kept to a minimum.

In any pre-eclamptic with a concerning fetal heart strip, we need to mitigate risk. But how do we take into account asymptomatic COVID positivity? There are several possible decisions we can make. The most extreme would be scheduling a C-section so we could deliver the baby in a controlled, planned fashion. It would avoid pushing, which may aerosolize the virus. A more moderate approach might be placing an early epidural which can be used for anesthesia in the case of an urgent C-section (though there still may be a small risk of needing general anesthesia).

We know from early COVID studies from China that general anesthesia in a patient with COVID has significant mortality. Intubating a patient with COVID, even if she is young and healthy, puts her at real risk. In addition, emergency COVID surgeries place staff at risk. Although we would ideally be wearing all the necessary protective gear, in the real world, such things don't always happen. I've been in "crash" C sections (pre-COVID) where surgeons didn't have time to put on a surgical cap, a mask, or (once) even shoes (they were asleep when the C-section was called). Expecting perfect PPE adherence in an emergency is unrealistic.

So how much does COVID change things? If the patient were COVID negative, I would recommend an early epidural, but if she declined, I would be amenable. But here, I felt a stronger imperative to explain why an epidural could be life-saving. And if the obstetricians scheduled a C-section, it wouldn't be unreasonable. Like all aspects of medicine, decision-making is a shared responsibility between patients and their providers. I'm learning how to incorporate what we know about COVID into that discussion. Medical decisions should not be unilateral, but the invested parties should think of all the ramifications of this disease including protecting the staff from unnecessary exposure, reducing harm, and keeping the health care system sustainable through this pandemic.

For those in the United States, wishing you a safe, healthy Thanksgiving. This year is unlike any other, and most of us are feeling upset, pain, sorrow, anger, and disappointment. I can certainly commiserate with that. But I also hope that we can identify a few things to be grateful for. 

I am thankful for the hard work, dedication, sacrifice, and persistence of the health care community that has stepped up during this pandemic. The team I work with in the intensive care unit is incredible. I could not ask for better nurses, respiratory therapists, consultants, and colleagues. Day and night we work shoulder-to-shoulder (figuratively - we distance when we can) taking care of the sickest patients, talking to their families, and performing high-risk procedures. Our infectious disease specialists have been a great boon, sifting through literature and helping us navigate this new illness. Our department and hospital leaders are aware of the mental, emotional, and physical toll this prolonged pandemic has taken, and are doing the best they can to alleviate the burnout. Our care of COVID patients also depends on an army of seldom-recognized co-workers, from those who source the PPE to those who dispose of it when we are done using it. We have so many people behind the scenes helping us in a myriad of ways so that we clinicians can focus on bedside patient care. Thank you.

In our larger communities, I am grateful for those tireless scientists who make my work possible, who give us hope, and who equip us with the knowledge and tools to tackle this disease. I appreciate those leaders in our communities and governments that have taken this threat seriously and done what they can to enact policies to protect public health. I am grateful for those in our community that have changed their lives and made sacrifices in order to social distance, avoid gatherings, and reduce transmission.

Most importantly, I appreciate my family, friends, and support network during this difficult and trying year. I think back to the beginning of 2020 and can't believe things have changed so much, but my friends and family have held steadfast through all these months. We will get through this together. Thank you.

As the holidays near, we try to navigate the complex interplay of risk and reward. On the one hand, we crave our families, miss our traditions, want to "live our life," feel that we can take precautions, and believe holidays can be an exception. But on the other hand, the virus is spreading exponentially, hospitals are at or beyond capacity, mass travel during this time compounds risk, and holiday get-togethers gather multiple households.

To me, the math is clear. Unfortunately, these should not and cannot be the holidays you remember from last year. They will probably not be the holidays you want. Frighteningly, the case trend even before Thanksgiving travel has gotten out of control. Our community prevalence is so high everywhere that you cannot eliminate risk even with a negative test and appropriate precautions. And without seeing signs of a peak or plateau, I think holiday gatherings will dig us into a deeper hole, something we cannot afford.

All that said, I do think it's a complex and hard call. Most public health recommendations say that we should only get together with those of our household. For traditional nuclear families, that might work pretty easily. But our country has a diverse mix of households. What about those living alone, those sharing custody of a child, a college student who has to go home for the end of the semester to a household with grandparents, or families with a newborn that need childcare assistance from relatives?

Ultimately, our country thrives on self-determination. We make our decisions, trying to weigh not only the risks and benefits to ourselves but also the risks and benefits to our communities. I really believe that if we have a well-informed citizenship that acts deliberately and with integrity, we can make it through together. The holidays have different types of significance for each of us, and a one-size-fits-all strategy isn't appropriate. But we cannot ignore that in this pandemic, our decisions will translate into life and death. Part of this blog is trying to arm ourselves with the information we need to do the right thing.

Scientists, public health officials, doctors, and news outlets are sounding the alarm. Each day this pandemic hits new records. Our health care system is facing incredible strain, and the death toll is rising. I have written in recent blogs about the responsibilities of our government and of individuals. But looking at this crisis, I think we need to be creative about who can help and how.

Should large, wealthy companies help? They have - at the beginning of the crisis, we received generous donations of N95 masks from local tech companies who stockpiled them for wildfire season. Other companies pivoted to learn to make ventilators. Many businesses offered discounts to front-line workers and first responders. Most companies transitioned to remote work. These actions make a difference.

But there is room for more. Companies have a lot of expertise and resources to contribute. For example, once the vaccine is available, distribution will not be easy. We can and should tap into companies that have figured out how to deliver nearly anything anywhere within a couple days. Vaccine storage may be a challenge because it requires incredibly cold temperatures; we should start identifying who can provide appropriate storage in our communities. Early in the pandemic, we faced serious PPE and ventilator shortages; manufacturing companies should consider if they can help maintain that supply. There are numerous roles for motivated volunteers to help with contact tracing, food banks, meal delivery to seniors. Companies should encourage their employees to help the community. I heard some companies paid volunteers to be poll workers; how incredible it would be if they decided to include pandemic volunteering.

Nobody wants a widespread shutdown. The economy is already teetering. One way to ameliorate the need for a complete lockdown is for wealthy businesses to give the health care system more buffer, more resources. I'm not calling on the small businesses that are struggling - they need all the help they can get, and I am advocating for another economic stimulus package - but on the companies that have the means. It may take a little creativity to figure out whether and how different industries can contribute, but since it looks like the federal and local governments and individual behaviors are insufficient to curb this crisis, we need to think outside the box.

Winter is coming. I think this may be one of the hardest winters this nation will face in recent history. The pandemic is out of control, and it will get worse. Tens of thousands of people will die. Hundreds of thousands will be infected. Many will have long-lasting health effects from the virus. Some of this death and disability will result from suboptimal care due to overwhelmed health facilities and health care providers. Some hospitals may even talk of rationing care. Non-coronavirus illnesses may be undertreated or neglected. The next few months will substantially change the health of our population. It is a terrible thing.

Unfortunately, this is on top of economic fallout, political divisiveness, social isolation, and industry upheaval. It occurs when we are fatigued and afraid and angry. Our mental, physical, social, and societal resources are being depleted. We have little reserve left. Our ability to meet outdoors is diminishing, and riskier indoor activities will rise. We face challenges in deciding how to celebrate the holidays; without doubt, they will cause a surge in cases, hospitalizations, and deaths.

There is some hope. Vaccine trial data is coming out and is promising. We may be able to begin developing a national immune system. A change in the White House may mean stronger leadership, closer adherence to expert recommendations, and more support to those who need it. Scientists are learning more about the virus, the disease, and the epidemiology. And our clinical experience in the last nine months have helped those of us on the ground take care of patients a little more effectively and efficiently.

I suppose I write posts like this every few months, and each time it feels just as pressing. Acting immediately and acting drastically will change the course of winter. We need to reduce viral spread now. Individuals need to take responsibility of masking and distancing, and governments need to take responsibility of educating, mandating, and enforcing. Health care systems need to look ahead, and governments need to provide resources to mitigate the oncoming deluge. We need to rethink our holiday and travel plans. We need to reimagine businesses. We need to reach out to each other in support. The more we do now and the fewer risks we take, the quicker we can make it through this pandemic.

Voting matters. Ever since medical school, I have become more and more certain that the most effective, most overlooked, and most cost-conscious way to improve the health of populations is through changing the socioeconomic milieu. I believe this matters more than costly subspecialist care (including the medicine I practice) and even more than primary care (for which I have immense respect). We can make the biggest impact on long-term health through bigger-picture interventions: addressing the economy, jobs, poverty, housing, food-insecurity; education and literacy; crime, violence, discrimination, racism, incarceration; access to health care and mental health services; even thinking of the environment. Although many of the diseases we struggle with today result directly from obesity, hypertension, diabetes, and other common conditions, I was encouraged in medical school to think even bigger than that: they result from the way our communities are structured, the unequal distribution of wealth in this country, and the ways our government does and does not support us.

Over time, I have become convinced that voting is not only essential to giving us a voice in matters directly related to health care, but also to shaping a wide range of issues that indirectly affect the health of our communities. There are few issues that will not impact your health or the health of your children or grandchildren. 

Which is to say that I am echoing the many messages that have been circulating recently: vote. Take charge of your health. When I rotated through family medicine as a student, I wrote "prescriptions" for a healthy diet or exercise regimen. These days, with my practice, I don't write many prescriptions anymore. But today's Rx is Vote. Make your voice heard.

"And we are here as on a darkling plain
Swept with confused alarms of struggle and flight,
Where ignorant armies clash by night."
-Matthew Arnold, "Dover Beach"

I didn't quite get the chance to blog on President Trump's COVID diagnosis, but I did have several thoughts about it. Most importantly, I try (though it may be impossibly difficult) to divorce my political opinions from the medical nature of an elderly man getting COVID. Although President Trump's policies have made this pandemic what it is and his personal beliefs and behaviors contributed to his infection, his becoming ill is not cause to push political views. Each COVID infection is a terrible tragedy.

But I did have several random thoughts about this situation. How do we think about health privacy? Anyone who remotely deals with medical data knows a host of privacy laws protect our individual health information. Does this apply to the president? What rights does the public have to know about the health condition of the president of our country? What about Congress or the principal officers of the executive department?

Coronavirus and its treatment (particularly the steroid dexamethasone) may affect someone's mental capacity, executive function, and decision making. Should the medical team actively assess that? Should the President of the United States with his attendant powers and responsibilities be held to a specific standard of capacity? When do we start talking about the twenty-fifth amendment?

The President's infection with COVID also illustrates the stark realities of socioeconomic disparity. At the start of the pandemic over half a year ago, I read a lot that the virus does not care if you are rich or poor. This is both true and not true. Like the vast majority of diseases, illness can strike the wealthy, but it tends to do so less often than it strikes the poor. Money can provide significant protection. I remember at the height of the first wave, wealthy New Yorkers fled to second homes. Even now, the majority of those who can work at home are richer than those who have to physically go to work. 

Clearly, President Trump's infection can be traced to poor distancing, mask-wearing, and preventive measures. But after he acquired the disease, we see the second big socioeconomic disparity. He received treatments that are in short supply. I don't have access to antibody cocktails, and my county has a limited supply of remdesivir antiviral. I strongly believe that care shouldn't depend on who you are, in either direction. I've taken care of death-row inmates and millionaire CEOs and personal acquaintances, and though I'm sure that has a subconscious effect, I actively try to provide the same care. Unfortunately, the reality is that wealth and status make a difference.

There are many other ways to look at this outbreak happening at the top of our government, but these are just my initial takes. We ought to recognize that perhaps the most important and influential person in the world acquired this disease, and he had the opportunity to change the course of the pandemic many months ago. But I also think we must acknowledge that his infection is one among millions. Tomorrow I will still go to work and do what I can for the tragic victims of this pandemic.

I haven't said much about the possibility of a COVID vaccine in this blog. The main reason is that I don't know much about vaccine development. We learn the principles of immunology, how clinical trials are designed, and the ethics of vaccine development (since vaccines are given to healthy individuals, the risk-benefit analysis is different than, say, a chemotherapy given to someone with cancer). But among the panoply of things we learn in medical school, vaccine development is given little weight. The vast majority of practicing physicians do not participate in designing, developing, and trialing a vaccine.

That is not to say that I don't understand and believe in the vaccines we have. Vaccines work and we should trust them. I've never seen a case of polio or the measles, all because of vaccines. I have seen the devastating consequences of someone without a spleen who did not receive the appropriate vaccines (asplenic patients are highly susceptible to certain preventable infections). Edward Jenner's discovery led to the elimination of smallpox, which had a mortality rate of 40%. It's easy to forget or overlook the incredible public health benefits of vaccines. Those who do not believe in the science and medicine of vaccines pose a serious threat to both individual and public health.

So what will happen when we hopefully get a coronavirus vaccine? I think there must be several safeguards in place. The testing of the vaccine needs to be scientifically rigorous. We already have established safety thresholds for vaccine development, and we should not cut any corners. We are pushing the vaccine through a lightning fast timeline with tons of resources, but we cannot relax our standards. Similarly, we cannot let political, pharmaceutical, or other interests influence the science. They can debate how we produce it, how much it costs, how we distribute it, but I want scientific integrity free of bias when it comes to determining the efficacy and risks of the vaccine. In this world, nothing is completely free of bias, but we must resist using the vaccine as a political pawn. And if we get a vaccine that has been studied and endorsed by unbiased, independent, recognized scientists and physicians, then I will get in line. We wait to see how effective it will be, and what side effects it might pose, but having seen the individual health impact of COVID and the community impact of this infectious pathogen, I think a vaccine will be critical in getting us closer to normalcy.

We know how much coronavirus has changed our subconscious when, in our dreams, we find ourselves avoiding the unmasked.

What a challenging summer it has been. With heat waves, wildfires, power outages (including a brief outage at the hospital which required us to switch to generators and halt non-essential activities), and blanketing smoke, the Bay Area has felt a little fire and brimstone. I am ready for 2020 to be over. 

I don't generally like complaining. But as this pandemic grinds us down and crises keep coming, I feel that it is important to acknowledge what this is doing to our psychological health. It's a different type of exhaustion than we had at the beginning of the pandemic. In March and April I sensed a stress related to uncertainty, fear, and clinical overload. We didn't know enough about the disease, we didn't have enough personal protective equipment, we worried for ourselves, our families, and our patients. We saw what was happening in China, Europe, and the East Coast, and we braced ourselves.

This activates a type of stress that some of us actually thrive on. I would say most critical care physicians and anesthesiologists function well under pressure. We self-select into these specialties that encompass rapidly changing clinical situations, acute life-threatening illnesses, and complex problems requiring immediate responses. The nurses, respiratory therapists, and other providers I work with have that personality as well. 

Unfortunately, six months later, this pandemic generates a different type of stress. It's a chronic stress of one thing after another, slowly wearing us down with no end in sight. I am not the type of doctor that handles this kind of long-term impending doom. I have so much respect for those outpatient doctors who care for progressive dementia or metastatic cancer. Perhaps the analogy isn't great, but it's one I've been thinking about. For those of us who run on adrenaline, our glands are tapped, and we are struggling to cope. I am exhausted.

So we try to accept that this is the way the world is now and prepare ourselves for the long grind. I have never been that interested in self-help literature, but I admit I've been reading more articles on how to build resilience, develop self-awareness, accept that we are grieving for a lost world. I've also paid more attention to reaching out to friends, finding activities that fulfill me, and caring for myself. We must continue to support each other.

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.