A woman and her husband are admitted to my ward; before the coronavirus, they were healthy, enjoying morning walks and evening cocktails.
Now, while her breathing improves each day, his declines.
By the end of the week, she is pacing the room, and he is on the brink of intubation.
Other couples go together.
One evening, we transfer a woman in her eighties to hospice; her husband of fifty years joins her the next morning.
His breathing is so labored that he can barely speak, but, between gasps, from behind an oxygen mask, he tells me that he can’t live without her.
I can’t work out whether the virus was merciful or merciless in taking them both.
Why does the virus cripple some lungs and not others?
There’s so much we don’t yet know.
At the beginning of medical school, during the “preclinical” years, students learn about diseases from books, not patients.
Reading about the signs and symptoms of illness, a student’s task is to create a mental checklist connecting presentation to diagnosis.
Fever, vomiting, and right-belly pain: appendicitis.
Sweating, chest pain, and unequal blood pressure in the arms: an aortic tear.
When students arrive in the hospital, senior physicians point out with some glee that patients are rarely textbook.
They present however they want to.
The only sign of a urinary-tract infection in an elderly patient might be fatigue.
But most covid-19 patients are textbook, at least at first.
They report fevers, usually high and persistent, lasting for many days.
Then a dry cough, and possibly diarrhea.
Then the inability to catch their breath, which triggers the decision to seek medical care.
The body’s inflammatory proteins skyrocket, while its lymphocytes plummet.
Chest X-rays show a diffuse haziness in both lungs, or, if things are really bad, a complete whiteout.
There’s no kidney damage initially; the liver looks good; blood pressure remains stable. covid-19 goes for the lungs.
The mystery isn’t how the virus presents but how it works.
In the nineteenth century, the medical profession seemed to stumble on a new disease every few years; doctors would set about describing its symptoms,
detailing its physiology, and proposing possible remedies.
Today, it’s rare to be in such uncharted territory.
And yet that’s where we find ourselves in my hospital: raising and debating new questions to which the answers are slow in coming.
Does ibuprofen really make things worse?
Should we give steroids or statins, Z-Paks or malaria drugs?
How long will patients stay on ventilators, and how many should we expect to come off them alive?
We’re exploring different medications and maneuvers, rapidly iterating our protocols in search of an approach that could halt the ruthless progression
from infection to intubation.
It feels odd to be both appalled by the virus and curious about it.
But careful observation today may mean the difference between life and death for other patients, in other states, in the not-so-distant future.
Many New York hospitals are rapidly introducing clinical trials to investigate which drugs and protocols are most effective; some also collect samples
—from nasal swabs, blood tests, urine, feces
—that might reveal how the virus spreads among people and what it does within bodies.
Other researchers hope to aggregate data from electronic health records.
They want to figure out whether it’s possible to predict
—using travel history, smoking status, medications, medical conditions, and other variables
—who will need to be intubated and who will be able to go home.
We receive an e-mail from our department heads.
From now on, we’re to ask permission to conduct an autopsy on every patient who dies of covid-19.
A single incision in the chest should be enough: we need to know exactly how the virus is destroying the lungs.
Perhaps the most hyped medication being tried for covid-19 is hydroxychloroquine.
Traditionally, the drug has been used to treat malaria and inflammatory conditions, such as lupus;
a recent study found that it can stop the coronavirus from infecting cells in petri dishes.
But it’s far from clear that the same will happen in human bodies.
The studies on the question are small and have yielded mixed results, or have been too poorly designed to allow doctors to draw reliable conclusions.
(One widely cited study was the subject of a “statement of concern” issued by the society that publishes the journal in which it appeared;
the society’s president wrote that the study had failed to meet its basic research standards.)
The history of medicine is littered with theoretically effective remedies that are later found to be useless or even harmful.
One-sixth of the studies published in medical journals are later reversed; another sixth seem to show effects that cannot be replicated.
Even randomized, controlled trials, the gold standard in clinical research, are overturned more than we’d like.
So the truth is that, at this point, talk about coronavirus therapies is more or less speculation.
Nevertheless, the President has tweeted that hydroxychloroquine, taken with azithromycin,
has a “chance to be one of the biggest game changers in the history of medicine.”
Patients and families ask me about it all the time.
Hydroxychloroquine can interfere with the heart’s electrical circuitry, and has harmful interactions with many commonly used medications.
Still, I prescribe it to some covid-19 patients, not because I’m convinced it works but because I think it might—and there’s little else we can do.
I try not to put too much stock in what happens next.
Most covid-19 patients present when their symptoms crescendo, and many go on to improve;
it’s nearly impossible to say whether hydroxychloroquine changes their path or is simply along for the ride.
What’s clear is that, even if it does work, it’s far from a cure: every day, dozens of patients who take it end up on ventilators.
Because we don’t have coronavirus-specific remedies, we mostly treat patients’ symptoms—fever, cough, diarrhea—with decades-old medications.
Then we keep watch.
Many patients remain stable.
They don’t need a ventilator—just oxygen, especially when eating, walking, or talking.
Each morning, I turn the oxygen knob down a few notches and tell them about their progress.
We also watch, however, as many patients decline precipitously.
We try one oxygen-delivery device after another—a nasal cannula, an oxygen mask, maybe a cpapmachine.
The body of a person who can’t breathe spontaneously recruits new muscles to help pull air into the lungs.
Neck muscles tense; bellies rise and fall; the tissue between the ribs retracts inward.
Oxygenation plummets, and lips and fingertips turn blue.
Too frequently, under the too bright fluorescent lights, doctors, nurses, and respiratory therapists congregate outside a patient’s room.
Time to administer sedation, insert a tube, and start the ventilator.
Physicians who have worked in the same institution for decades are meeting for the first time; everyone wants to talk about stopping the virus that’s stopped the world.
A friend at another New York hospital, a cardiology fellow, tells me about a chance encounter in his cardiac-care unit, which,
like almost all I.C.U.s, is now a coronavirus-care unit.
A senior surgeon whom he’s never met is rounding on a nearby patient; the surgeon overhears my friend asking a question with which he’s also been struggling.
They spend the next half hour comparing notes: Should they use more blood thinners?
Why do clots keep forming in patients’ catheters?
Who should be enrolled in a new clinical trial?
They agree to keep in touch as the pandemic evolves.
My friend has been training to be a doctor for fourteen years.
“This is by far the most stimulating time in my medical education,” he tells me.
He’s a basketball fan: “At this point in the year, I’m usually refreshing ESPN and watching N.B.A. highlights.”
Now, he continues, “I’m scrolling through Twitter, trying to figure out how we’re going to treat covid tomorrow.”
The medical news swirling around covid-19 makes the twenty-four-hour news cycle look slow.
Between patient visits, I pull out my phone to scour Web sites covering the latest covid-19-management tips.
(You can, I’ve learned, use an iPhone through a pair of thin latex gloves, even when it’s covered with a specimen bag; you cannot,
however, unlock it while wearing a mask on your face.)
I scroll the Twitter feeds of coronavirus thought leaders, many with newly minted blue check marks.
I maintain text chains with residency and medical-school friends around the country.
Between gifs and baby photos, we ask, What’s Boston doing with blood thinners?
Are California I.C.U.s using steroids?
In the absence of hard evidence, we pool what knowledge we have.
Like everyone else in the hospital, I have my go-to gurus—physicians with decades of experience or unusual clinical acumen.
I accost them in their offices to discuss complex patients, or to make myself feel better about a hard decision I’ve made.
Sometimes, the conversation makes me feel worse.
But we’re always talking.
At the coffee machine, someone will tell you about a case they saw, a tweet they read, an article they reviewed, a group thread that says we’re doing it all wrong.
A colleague at the actual water cooler hears me mention a new report suggesting that a certain drug might help.
Another points out grievous flaws in the study’s design—might as well go back to bloodletting and leeches!
Soon, a half-dozen of us are debating the physiology and immunology of the coronavirus.
In here, it’s all covid-19 all the time.
Each morning, we receive an e-mail from the hospital’s leaders on the state of the crisis and our response: admissions, discharges, deaths, new protocols.
One of the messages announces that it’s Day 32—four and a half weeks since our initial rise in coronavirus cases—and that, for the first time,
covid-19 discharges have exceeded admissions.
It’s a milestone—a moment to savor.
In New York, a cautious optimism is budding: the curve has started to flatten, and hospitalizations seem to be slowing.
And yet the I.C.U.s remain full.
Patients continue to die.
The virus has killed more than a hundred thousand people worldwide; the U.S. economy has cratered.
A friend calls as I’m finishing my morning rounds, to ask if the good news is true.
What am I seeing on the wards?
Overnight, a patient of mine was intubated.
Another has just died.
It’s hard to stay afloat amid the flood.
One afternoon, after I learn that another colleague has fallen ill and that another of my patients is to be intubated, a volunteer physician offers to relieve me.
Exhausted and grateful, I accept. I remove my bonnet, goggles, gown, shoe covers, and mask, then make my way to the lobby.
In the hospital’s main hall, a “wall of hope,” covered with drawings by young children, has replaced the desolate dining area.
On a small sheet, Jenni, the artist, has sketched a doctor and nurse.
“We don’t know how we can pay you back,” she writes.
“Well, money I guess?
Any who, thank you so much for your work!”
Winter has given way to spring.
The sun is shining and it feels good.
I don’t have sunglasses and I don’t want any.
I start to walk; the area near the hospital vibrates with activity, as doctors, nurses, and the occasional visitor arrive and leave, but soon it’s quiet.
I walk on the sidewalks, and sometimes, since there’s no traffic, down the middle of the street.
Nail salons, restaurants, barbershops, liquor stores—all empty, handwritten signs taped to their windows.
My pace quickens. I start to jog, then to run.
I can’t stop, not knowing what I’m running from or where I’m running to.
My chest hurts.
I stop and sit on the curb.
Clouds are gathering overhead.
I pull the mask dangling around my neck back up, to cover my face.
An Uber takes me the rest of the way home