A perspective from your friendly neighborhood ER doctor

Many thanks to all the friends and family who have written, texted, called, or otherwise messaged me to check in on how things are going. I really appreciate all the well wishes and positive thoughts. I also know a lot of you are also curious about what life is really like on the “front lines” of the pandemic here in San Francisco right now. Honestly I haven’t had the time or the headspace to reply to everyone, so I thought I would take a minute to do it here as an open letter/therapeutic brain dump.

As a disclaimer, I’m only aiming to provide an honest perspective from my singular point of view. I’m not speaking for ER doctors everywhere, nor even necessarily the ones I work with directly. My views don’t represent those of my employer. As you know I’m not a public health expert, nor an epidemiologist, nor am I a basic scientist/virologist, so I a not here to educate you on the sociopolitical aspects of COVID or what the next few months look like for your 401K. But I am a patient-facing Emergency Physician. Every few days, I put on fresh scrubs, park my car in the lot at my hospital, and then put one foot in front of the other to walk up the hill to the entrance of the ER where I have worked for the last decade, wondering if this is going to be the day when the “shift” hits the fan.

Firstly, let me cut to the chase and tell you about the thing that I know you’re all most curious about: what is it like in the ER right now?  I’ve worked roughly three shifts a week since the start of the pandemic in an urban community academic emergency department. I have been stationed everywhere from our outdoor triage tent to our normal everyday indoor ER. So far, I am very happy to tell you I would describe is using a word that we superstitiously never actually say out loud in the ER…wait for it: Q-U-I-E-T. Yes, there it is, I spelled it, but I didn’t say it, so it doesn’t count, right?  (It is common Emergency Medicine lore that to invoke that word out loud is to unleash the floodgates of hell upon your ER doorstep.)

What were you expecting? I know this doesn’t really jive with the numbers we are seeing in our country, our state, and our city about the pandemic, which conjures up images I am sure of people taking their last breathes in hallways as we doctors decide who gets the last ventilator.  There is a bit of a disconnect.  Maybe this is the proverbial calm before the storm.  My ER doc friends in Seattle and New York are having a different experience right now, and in a few weeks, we certainly could be there too.  That’s the assumption we are operating under, and I think that it’s a prudent assumption to make.  I have a few other theories, as well.

I believe that most reasonable people infer that hightailing it to the emergency department for a minor complaint during a pandemic is not a totally smart move.  (*On the other hand, please don’t be deterred from coming in if you think you may have a serious emergency eg., chest pain/left sided weakness/right lower quadrant abdominal pain, etc: keeping you away is certainly not what we are hoping to achieve here, and in fact we are trying to make this environment as safe for you as possible.) I also believe that most of our patients are also getting the message that if you think you have COVID, and you are otherwise healthy and doing okay, staying away is still the right move (*generally speaking–if you are feeling very sick, if you are elderly or immuno-compromised with symptoms of COVID, or if you just aren’t sure, we are always happy to take care of you in the ER. Anyone, anything, anytime. That’s the ER motto).

And yes, I believe the calm we now experience is also likely in large part because social distancing measures and shelter-in-place orders are working, and I am really thankful to our local government officials for acting quickly and decisively to put forth measures to make that happen. As I said, I am not an expert in epidemiology, I don’t know if we are truly “flattening the curve” or rather riding a sine-wave like roller coaster which will (hopefully) have dampening oscillations in frequency and amplitude as the months move forward, but either way, I am very thankful for the relative “flatness” of this early first-cycle.

Yes, we even have a plan for how the room will be set up when a sick patient arrives.

Being flat now is more important than at any other stage in the game.  It has given me, and other ER doctors like me, adequate time to prepare for the surge we all fear is on the way.  This includes things like: reading up on a novel disease, of which we had no prior knowledge or understanding; learning proper procedure for donning and “doffing” (the opposite of “donning,” for the un-initiated, and by far the more dangerous step) of personal protective equipment, to minimize our exposure risk; and, mentally steeling ourselves for the possibility of contracting an illness that will most likely be uncomfortable but hopefully not deadly, and the burden of knowing that at the end of every shift, we potentially bring that risk home to the people we love the most.

I am so thankful to those of you who have made the personal sacrifices to honor shelter-in-place.  I know it has not been easy.

This is not to say that we are not caring for COVID patients at all yet. Quite to the contrary, roughly two-thirds of the patients I have seen on my recent shifts have either been confirmed COVID-positive or patients that we highly suspect, coined “patients under investigation.” Because of a law called HIPAA I can’t really tell you more than that–except to say that, very fortunately, all the patients that I have personally cared for to date have felt sick, but objectively haven’t really been all that ill. Most of them I have been able to send home, some right away out of our triage tent, some after standard ER treatment with fluids, a chest X-ray, and some basic lab checks. Collectively, my group has seen a few of the critically ill, some have required mechanical ventilation and intensive care unit admission, but that hasn’t been my personal experience, yet.

The CAPR “spacemask”, our most cautious level of PPE.

It is still scary though. Even with meticulous use of personal protective equipment, I have to say it does take nerves of steel to enter an enclosed space with a patient who has known COVID. All sorts of doubt and psychological fears permeate my mind: is my surgical mask really good enough, as the WHO has recommended? Or should I be in an N-95 like the CDC recommends? The party line at my hospital is to wear a plain surgical mask; if I chicken our and grab the N-95, what kind of message am I sending as a team leader to the nurses who bravely enter the room next to me with a surgical mask? When the patient is violently coughing, isn’t the virus leaking around the sides of their mask, and how much of that is aerosolized and potentially headed my way? After I place my stethoscope upon the patient to auscultate her heart and lungs, will it be good enough to simply wipe down that stethoscope with a bleach wipe and carry-on? Should I double-bleach it just to be sure? Did I leave the room and properly remove all the PPE? Did I accidentally touch my face somewhere in the process? When thinking like this invades your consciousness, it is difficult to perform even a basic history and physical on a patient, a skill which should feel second-nature after almost twenty years of practice.

Further, all the soft skills that I normally pride myself on, and have perennially impressed upon medical students whom I’ve worked with over the years–entering the room and giving a firm handshake, sitting by the patient’s bedside, leaning in while listening and offering the gift of gentle touch when the situation calls for it–all those things are out the window when everybody is a “patient under investigation.” Worse yet, when a patient with an unrelated complaint like a broken wrist or a laceration looks at me suspiciously as a potential source of infection for themselves (they are not wrong to think this), then none of the usual waltz that typically defines the doctor-patient relationship seems appropriate anymore. I wonder to myself, will it ever feel appropriate again?

To answer a  question many of my friends and family have had, it does feel like we are being cared for by my hospital administration.  I am thankful to my local hospital leadership for all the pre-work that has been done to help us. From the start, we have rapidly altered our hospital operations to be COVID-ready. Communications from leadership have been frequent and transparent.  There’s been rapid efforts to expand our labor pool, and everyone from general surgeons to endocrinologists to family physicians have shown up to offer help and take on some of the burden.  I am not sure we will use them, but it is heartening to see their faces as they come to orient with us.  We have re-vamped our schedule for the upcoming months, with layers of emergency coverage and sick call including the “full-blown Italy” all-hands-on-deck plan.  Tough decisions have been made, like canceling money-generating elective surgeries to preserve precious PPE for doctors like me who will experience the highest risk.  Even our physical plant has been transformed almost overnight to increase our capacity to care for the ill.  This is no small feat given the real estate challenges of San Francisco.  Our waiting room has become a patient care area.  Our ambulance bay is now a triage tent, and we even have a giant circus-tent like disaster treatment area which makes me think of the movie E.T.  

Within my department, it has never felt so cohesive.  We are educating ourselves on the best medical data regarding COVID recognition, resource-minded testing protocols, and management of patients on the spectrum from gonna-be-fine to the maybe-sicker? to the obviously critically ill.  Also, I’ve been working closely and concertedly with nurses, techs, and registration staff in the ED.  It feels like we are getting closer as an ED family and we all have each other’s backs, which is important as we prepare for a harrowing challenge ahead.

Practicing intubation in a protective box. It’s easy to make mistakes performing a familiar procedure with unfamiliar circumstances. I tried to make this simulation high-fidelity but the astute among you will notice a major mistake I made. (Hint: look at my mask(s).

To be sure, the biggest challenge for me so far has not been within the confines of the hospital. Like many of you, I am a parent of young children.  I am blessed to come home after every shift to two awesome but energetic middle school age boys, and a six-month-old beautiful baby girl. It only took a few days for Iris and I to realize that we were in trouble with school cancellation.  We lack the knowledge, discipline, and child development expertise to be effective home-schoolers.

God bless our school teachers, I don’t think any of us understood how difficult your job was before all this.

Iris has been a hero in this regard for at least trying.  She’s built terrariums with them to teach science, she’s started Isaiah on multiplication and division, and she arranged an interview with grandpa by FaceTime for social studies.   The days have been very long as we attempt to prevent our children from devolving into a feral state.  We vacillate between concern that they will fall behind academically, and fear that maybe we are pushing too hard when they start to fall apart after 20 minutes of reading and maybe we should just focus on being parents and loving them through a difficult time. All this while doing our best to shield them from some of our own fears about the pandemic.  All this while trying in the background to keep up with endless online work meetings, watching medical lectures, and reading to keep up with everything I need to know to provide the best care I can to the unfortunate patients who do get really sick with COVID.  All of this while changing a bunch of dirty diapers in a constipated seven-month-old who is starting out on solid foods. It’s a lot.

Spontaneous ukulele jam for our neighbors from our driveway. We are going to call it “The Quarantine Album.”

Of course, there are plus sides here. Like all of you, I’m certainly spending a lot more time with my wife and children than I ever have before.  Iris and I feel strong in our relationship, something that I think crisis mode does for us.  I’m learning a lot more about the way my children think, and what they think.  And holding sweet baby Daphne as often as possible has been like my Ativan-equivalent.  Her sweet little oblivious gummy smile calms me in those moments when I feel like everything is falling apart.   Her huge radiant blue eyes transmit a message of trust and love that erases all doubt.

I know we will get through this, and so will you and your family.  Thanks for staying home.  Remember, you are not just keeping yourselves healthy–you are keeping all of us healthy.

 

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Elliot 3.5

The kids are getting older and life is been so busy that they’re barely seems a moment to reflect.

Here’s a funny anecdote about Elliot. One thing that really defines him as a growing boy is his absolute hilarity.

Last Friday we were on a school field trip to Angel Island, which she and I have done together for the last two years.

After a hike up to the top of the mountain, he suddenly looked at me and said matter-of-factly, “I have to go to the potty.”

OK, no worries. We got this. I am glad he has such good body awareness that he is able to give me at a good morning. Down the hill, there is a an out house which looks like a good option. We had inside, it is poorly maintained and smells kind of gross. Anyways for a P, no big deal.

Except, Ellie informs me that he needs to P and poop.

So we head into the small, cramped, single stall in the outhouse. There’s graffiti on the walls, No seat liners, it’s stinks. But you got to do what you Gotta do.

Elliot drops travel. Because he is still kind of a little guy for a big toilet seat opening, I stand in front of him holding him so he doesn’t fall in. The usual routine. I am now his breathing and trying not to inhale.

I say. I met her to myself, “this is love. ”

Suddenly Elliot looks up to me and makes a Kissyface.”Huh? Now? You are pooping, I don’t want to kiss you.”

He calls me out. “If it’s love, we gotta kiss.”

Resume Kissy face, pants around his ankles, a few small poop balls already plopped in to the water below.

This is simultaneously really gross, absurd, and just too cute. So I give him a little kiss.

Now that, that is love.

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16 things I am thankful for in 2016

It seems like the pervasive feeling of this year has been that it has been a bad year that everybody is ready to have over with. Yes, we have lost a bunch of notable iconic figures and celebrities. Yes, many of us where I live feel like we lost our country and years of social progress in November’s election. And yes, it is true that the Giants lost their “even year magic” that fueled us through October.

But I feel like there’s a lot to be thankful for in 2016–personally, and in the world at large. So here is my shortlist of 16 things that I’m thankful for this year. Presented in no particular order.

(1) the continued good health, physical and mental, of both of my parents.

(2) A very strong relationship with my amazing wife. Yes, on some level as we are business partners keeping this family running. But I am please to say there is still a lot of passion in our relationship six years into our marriage. And by passion I mean sex.

(3) Mission Bay Kaiser–earlier this year, my medical center opened up a satellite clinic where emergency physicians like myself have been enlisted to provide acute injury care as well as act as an “emergency consultant” for the building.  I have absolutely embraced this opportunity to expand my presence in the medical center, expand my field of knowledge to include more long-term management of various orthopedic conditions, and to try my hand at short and intermediate term follow up of various patient conditions, all very new to me.

(4) a great ER save: emergency medicine is actually a whole lot of non-emergencies strung together and occasionally punctuated by some critical cases. Many of these end up being futile effort’s to save a life that’s gone, but occasionally we do get to make a big difference. This happened to me over the summer, when I let the recessive Tatian of a patient who experienced a cardiac arrest in our waiting room. Thanks to the care our team provided, he was brought back from the dead, successfully had his heart stented, and walked out of the hospital a week later to have more time to spend with his wife and children. He even came back to visit us in the ER and thank us, gifting us with a pallet of Redbull, chocolate, and other well-intentioned but totally unhealthy treats. I’m going to hope that was him expunging these behaviors from his life!

(5) Isaiah’s empathy–One really strong memory from this year was one regular evening when Isaiah and Ellie were playing. Isaiah slammed the door on Elliot to keep them out of the room but accidentally slammed the door on all of his fingers, of course causing Elliot to cry like a banshee. But that’s not the story. The story is that this was a window for me into Isaiah’s personality and his level of empathy. Isaiah immediately realized that he had done something horrible, and began to cry himself, making sure I knew that it was an accident. I put him into time out – something we seldom do for him now that he is five years old – and he sat on the bed, crying, sobbing away, full of regret and what he had done. And although I obviously am not proud that this happened, it was a really wonderful moment for me to see into the soul of my elder son. He genuinely had empathy and regret for hurting his brother. I think for me one of the top things I want my sons to have is a sense of citizenship and empathy for others. It was really memorable for me to see that Isaiah, At just five years old, is already showing strong emotional and social presence.

(6) fine dining experiences in SF: this year, Iris and I had the pleasure to dine at Lazy Bear, Nightbird, and on the final night of 2016, we will ring in the new year at State Bird Provisions. And on our trip to  NYC: Blue Hill and Bohemian. We feel incredibly blessed to live in the city with these dining opportunities, have the good fortune to have the means to afford the occasional splurge, and to be able to enjoy these things together.

(7) a nostalgic week in NYC: this year marks the 15th year since I left New York City. Thus it was fitting and appropriate to be invited back there to give a lecture at Metropolitan Hospital, just blocks away from my old medical school. It also gave me the opportunity to see some old friends I haven’t been in touch with in a while, and reflect on our time there, including being in New York City in September 2001. I also got to visit the new 9/11 museum which was both an incredibly heartening and totally heartbreaking experience at once. I was really thankful for the opportunity to be there, at that time, to reflect on this moment which was pivotal in my life.

(8) I got my sense of smell back and will never take it for granted again. In August out of the blue I got a terrible sinus infection. It became so bad that he virus or bacteria or whatever eight right through my old factory nerve and I completely lost my sense of smell. I know that sounds somewhat silly but let me tell you, I would not wish this disability on my worst enemy. It basically Robs you of all the pleasure in your life. Thankfully, within about two weeks it returned spontaneously. I will always remember being on the escalator in the mall, taking a deep breath Inn, and smelling the Mrs. fields cookies very faintly, signaling the return of my smell.

(9) sabbatical planning: five years ago, Iris and I had a dream. We will take a family sabbatical to South America, improve our Spanish, and help our children see a little bit more of the world. Incredibly, this year we have made it happen. We’ve been working practically all year with a rough timeline to get everything taken care of, and somehow everything seems to of just falling into place. Is it possible there’s something we are forgetting? Yes. Actually, is it probable? Yes. Nonetheless, planning for the trip in retrospect really doesn’t seem like it was any harder than it should’ve been.

(10) still training capoeira-it’s been 15 years and I’m still doing it, amazingly. No major injuries, still enjoyable, still a great workout. Our group is now eight Batizados in, Tightknit and stronger than ever. Well physically at age 38 it is not quite as easy to do the things I once did, I can say my skills with the instruments are improving and I am a presence with the children’s classes has been satisfying for me.

(11) Elliot’s antics-it’s a standard parent worry: is my kid normal? When he tantrums, is it because he is “on the spectrum: or is it just normal two-year-old behavior? The good news is, Elliot is so funny and charismatic and loving that it’s pretty obvious he’s a normal kid. I thank God for this every day.

(12) almost 3 weeks spent in Maui: every year for the last five years we have made a trip out to Hawaii. Every time I’ve said to myself, “if only I had a few more days. ” so this year we gave our self of days. We stayed nearly 3 weeks, experienced everything now he has to offer, and had an amazing time. I think I have finally gotten Hawaii out of my system for a while. No plans to go there in 2017. Easter island instead!

(13) Giants baseball: final game of the regular season. So, the playoff run was really short this year. How disappointing ninth-inning to feet if you’ll recall. Still, people forget about the victories when is season ends into feet. How about that second to last postseason game versus the cubs at home? That was something. Or the last regular-season series against the Dodgers which was a satisfying sweep. Glad I will always have baseball to look forward to.

(14) Iris’ work fulfillment: it is no small thing for your significant other to be happy in their professional life. I am very thankful that Iris seems to have found this this year with her combination jobs of primary care at Highland and allergy at UCSF.

(15) I am thankful for my social media presence. My blog is going great, it’s giving me the opportunity to collaborate with many interesting people inside and outside of my field. And I have a whole bunch of followers on Twitter, though I barely understand how to use it.

(16) I am excited that today Iris and my boys and my mom will embark on an amazing adventure that we only dreamed would actually be happening just a few years ago. It is sure to broaden our horizons,give  us some perspective on things, and  and enrich our kids learning. We can’t wait.

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