By Claire Panosian Dunavan, MD, Photography by Jessica Pons
Six UCLA infectious diseases physicians share their stories of an unfolding crisis from the frontlines of the novel coronavirus pandemic.
In January 2020, I received an email from a friend at The New York Times.
Can I ask: Are you as nervous about this coronavirus as I am? I’m not normally an alarmist, and I wasn’t one as late as yesterday morning. But last night,
as I was doing the math in my head on the subway,
I became one.
Two weeks ago: 50 cases in China and 1 death
One week ago: 500 cases, mostly China, 20 dead
Yesterday: 10,000 cases, 200+ dead
That doesn’t sound like SARS or MERS. Case spread that rapid with mortality at or below 1 percent sounds like 1918.
At the time, I was unsure if I would ever write about the virus in Hubei Province. In January, the threat was unclear, and it had not yet touched our shores. But this note from award-winning reporter Donald G. McNeil, Jr. — who specializes in writing about infections and plagues — got my attention.
Milestones followed. On February 11, the International Committee on Taxonomy of Viruses christened the foe SARS-CoV-2 — severe acute respiratory syndrome coronavirus 2 — and the illness it causes COVID-19, and, two weeks later, a memo from Daniel Uslan, MD, clinical chief of infectious diseases and co-chief of infection control for UCLA Health, marked another defining moment.
Dear ID colleagues,
As you are all aware, the situation with COVID-19 has been changing dynamically, and over the weekend cases were reported in South Korea, Italy, Iran and others.
In short, although UCLA’s hospitals would not admit their first patient for another 14 days, the “game-on” moment had arrived.
Now I knew my mission: to capture once-in-a-lifetime perspectives from newly trained physicians. What follows are selected thoughts and experiences from six younger colleagues in UCLA’s Division of Infectious Diseases — Paul Adamson, MD, (FEL ’21); Mary “Catie” Cambou, MD ’15 (FEL ’21); Amy Vijay Dora, MD (RES ’17, FEL ’20), Pryce Gaynor, MD (FEL ’19); David Goodman-Meza, MD (FEL ’18); and Ashrit Multani, MD — collected from conversations recorded over their first three months spent tackling the virus. I applaud their commitment and thank them for sharing from their hearts.
Dr. Amy Vijay Dora
“It’s like something from a movie, this global pandemic with sheltering in place and social distancing. In the last week or so, we’ve gone from monitoring symptoms at home to universal masking to temperature checks before entering the hospital. Now we’re screening every admission, and there are no more elective cases. I also feel like the other shoe is going to drop, the “second surge” of patients who are thinking: ‘Oh, I won’t come to the hospital just yet, I’m worried about getting COVID. Let me see if I can wait it out and take care of this at home.’ The last time I felt truly terrified was as an intern or early resident. Now, things just don’t register in quite the same way. In medicine, you learn to compartmentalize. You control your emotions, so you can do your job.”
Dr. Paul Adamson
“In January, I remember reading about cases of pneumonia in China and thinking, ‘I wonder if this could spread?’ A month later, when the answer became clear, I realized that our public health system is so underfunded, we couldn’t control the epidemic. I mean, even though California is better than some states, when we had only 100 or 200 or 300 cases, ideally we would have done contact tracing — figured out who the patients lived and worked with —tested their contacts. And if you found infections, you’d isolate and test the next set of contacts. But then I was thinking: There’s like only 15 or 20 people in County Public Health working on a COVID response. Our system is broken in many ways. Already, this crisis has revealed that.”
Dr. Pryce Gaynor
“Right now, every COVID patient gets discussed as
a division because we’re all in uncharted territory. So we have come together to manage patients, which is good. At the same time, the hospital census is down. That feels bizarre. I like that L.A. County is selecting random individuals to test for COVID. We know that people who appear healthy can transmit it. Last week, when I was covering the EID [emerging infectious diseases] pager, I was called about a patient who got tested before his angiogram. He was positive and totally asymptomatic. In the future, I believe cases may ease, but that COVID will definitely come back. I’m also worried about dealing with flu and COVID at the same time. What will that do to our health care system?”
Dr. David Goodman-Meza
“On my first COVID weekend, I had 13 patients to see — about nine of them in intensive care units — and everybody did well. They all went in the right direction. Most of the ICU patients got extubated. I should have taken a picture. They had this beautiful poster counting the patients who’d been in the ICU, how many they’d extubated, how many they’d discharged. So yeah, it was actually uplifting. As for emotions, I don’t know how many doctors are talking about panic attacks, but I’ve awakened at 2 am and maybe had an extra cover and felt hot and it’s: ‘Oh my God. Do I have a fever? Oh my God, I got it.’ Plus, my wife is pregnant, and sometimes she’s a little bit sick in the middle of the night. So she’ll wake me up, and we’ll have panic-attack conversations together. I mean, for a lot of docs, it’s not a question of if. It’s a question of when will I get it, right?”
Dr. Mary “Catie” Cambou
“We have friends in New York who have tested positive — several of my husband’s co-residents in emergency medicine and a former attending as well as one of my co-residents and his family. It’s challenging when you know you have to go back a week or two later. What they’re describing is unreal. I mean, their institutions have been supportive, but COVID hit so quickly. They didn’t have time to prepare the same way we have here. I had a COVID shift last weekend. The nurses, the assistants… it does seem like people recognize how important they are. But other essential workers also make the hospital function. I’m sure they’re scared and nervous to go into those rooms, but they do it. I admire their courage. There’s no way they could have anticipated something like this when they signed up to work in the hospital. COVID has also made me recognize my own privilege. Since my husband is also a physician, we’re not surviving paycheck to paycheck. On the other hand, I doubt we’ll return to the way things were. Right now, nobody wants to get on a plane or walk into a busy restaurant. So the economy has changed until we deal with COVID.”
Dr. Ashrit Multani
“I don’t think I’ve ever said ‘I don’t know’ to my transplant patients as much as I have during the last few weeks. Patients are always looking to us for answers. We’re the doctors, we have all the science and technology and research, and we’re supposed to know. But because the current evidence is in people without transplants, I can’t predict how my patients will fare. At least testing has ramped up. Early on, [the UCLA lab] could only do 30-to-40 tests per day, which were mainly run on super-sick people. Now that we can do 800-plus per day, we can find out who has it and who doesn’t. That’s a huge step forward. I’ve also seen everybody in our division sacrificing and helping each other out. That’s a positive aspect of COVID, at least for me, just seeing how unified and supportive everybody is.”
“If we’ve learned anything, it’s that we have to look at larger patterns and trends. For a while, it seemed like the numbers were starting to go down, but yesterday the U.S. reported the highest number of cases in a single day. Our friends in New York are seeing trauma patients who also have ground-glass changes in their lungs. I can’t help but wonder: Did they have that car accident because they’re not oxygenating due to COVID? There’s still so much we don’t know. The best analogy I’ve heard is that we’re building the plane as we’re flying it. When this all started, I had trouble sleeping and lost my appetite. Then I became more sensitized. But my heart still goes out to others. A cafeteria worker said, ‘We’re so proud of you, keep doing God’s work.’ And I said, ‘Well, I feel the same about you. We all have a role to play, we have to do this together.’ Those are moments when the best of humanity shines through.”
“There was someone in the ICU on 15 liters of oxygen just sitting there and texting on his phone. Another woman who had just been transferred [had a blood-oxygen saturation level] in the 70s and was taking stuff out of her purse, putting it back in — you could tell she needed more oxygen. And it’s not just the silent hypoxia we’re seeing, but other conditions — the strokes, the pulmonary emboli. It’s terrifying what this virus can do to the body. In addition, families [who can’t be in the hospital to be with patients] are at the mercy of doctors and nurses calling them when they can. Otherwise, they don’t know what’s going on. It made me think about my 96-year-old grandmother who was recently hospitalized. Because that was on my mind, I spent a lot of time this week speaking with patients’ families.”
“We basically have three types of patients in the hospital. There are people who come into the emergency room and get intubated within 12 hours, people who come in and tank four or five days later and people who get admitted for a day or two and go home. But, overall, our survival rates have been good, especially compared to places like New York. Maybe that shows what happens when you don’t reach capacity, or maybe it’s because UCLA provides excellent care. ICU care is one thing we’re really known for. Eventually, I believe, we’ll have a vaccine, but I’m also concerned. Today, there’s so much mistrust and misinformation that vaccine uptake could be challenging. Plus, there’s the tension between wanting a vaccine and pushing it through so fast that we skip the usual safety checks.”
“The last time we spoke on the phone, I said something like: ‘We know what we know, we know what we don’t know.’ Now I need to revise that and say, ‘Caveat: We don’t know what we don’t know.’ Everyone is in overload. Everyone is desperate for the latest information. Then you start to get overwhelmed with, ‘Well, how do I even decipher all of this? There’s so much literature. If I don’t read even half of these articles, am I going to miss something crucial?’ This year, my trip to Peru was canceled because the hospital in Iquitos is overwhelmed. One of my Peruvian friends hasn’t seen his family in weeks. We’re going to Zoom to help him keep up because, if you’re dealing with that kind of patient load, how can you even process?”
“The hard part is keeping up. I spend most of my free time reading, but questions remain. For example, what works and what doesn’t? You still can’t predict who’s going to crash and when. A transplant patient who never required oxygen joined our remdesivir-placebo trial. I don’t know what he got, but he left the hospital five days later. Then there’s: How long are they shedding virus? How long do we continue isolation? Should we repeat tests? Having these conversations with patients has been challenging because sometimes I’m saying the opposite of what I said the previous week. But I’ve been very honest. It’s, like, ‘Hey, we’re learning as we go, and now our guidance has changed.’ Even at home, I can’t escape. At least I saw the bioluminescence. Beaches are officially closed, but I needed to be outdoors, and everyone was socially distanced and masked. Just seeing the neon blue going through the wave, hearing the crash of the ocean, feeling the serenity — it was gorgeous.”
“This last time on the COVID service, I was surprised how slow it was. But it was still draining because every day I saw four or five patients in the ICU who’d been vented so long. We don’t know when they’re going to improve, yet some still walk out. One ICU attending said, ‘This is just the new normal we need to adapt to.’ Then I hear certain people say it’s not as big as the media or government claim. And I’m thinking, ‘You’re sitting all day in your house on Zoom. How dare you make that statement?’ Yesterday, at a campus rally, someone called systemic racism a public health emergency. I agree with that. Going forward, I hope we change policing, but I also hope we change health care. Until people of color have the same care as everyone else, this won’t go away.”
“It feels like we’re always putting out fires. In some way COVID has pushed science faster than ever before. Who knew we would have multiple anti-viral trials across the world and get results so quickly? It’s astounding. Then I think about the next problem. Because we don’t have enough, how do we ration the drug? Who do we give it to? Science is marching on, but without its normal checks and balances. Plus, we need to publish data quickly. What used to take a decade is happening over four months. My wife — an occupational therapist for special-needs children — sees it through a different lens. A lot of her families were already living on the brink. When the pandemic began, there was a run on baby formula. They couldn’t find it anywhere except for local stores that were price-gouging. My response was outrage. I told my wife her patients should report this to a hotline. My wife was like, ‘Oh, let’s just buy it.’ So she ended up buying formula and delivered it to three families in South Central.”
“This weekend I was covering the VA Hospital, and because experimental treatments are more available, I was coming up to speed on enrolling patients in the remdesivir lottery. About half of the patients were on ventilators and couldn’t talk, but one person said: ‘I get that you’re offering these treatments, but I don’t want to be experimented on.’ We need to be honest about our lack of evidence. In the end, it’s up to patients to decide whether to take drugs that may or may not help them. At the start, my greatest fear was: ‘How will this impact me and my family?’ I still fear for my parents. But my biggest fear going forward is: ‘How do we change who’s affected in the future?’ Finally, the conversation is switching from ‘what are the genetic risk factors?’ to ‘what are the social determinants of health?’ Plus, history teaches that pandemics come in waves. The lessons we’re learning today are important for the future.”
“Because of the protests, yesterday and today I left work early after tucking everyone in. In Santa Monica, I had a bird's-eye view. We saw the looting at REI. The building on fire was right across the street. There was noise and smoke into the late evening. There’s so many mixed emotions. On one hand, you’re feeling everyone’s pain, but at the same time, it’s, like, isn’t this distracting from the conversation we need to have? And of course we can’t ignore what this might do to COVID. Being a first-year attending is difficult enough. Being a first-year transplant ID attending at a new institution during a pandemic is quite a challenge. This pandemic has highlighted the importance of ID physicians, which is good, but eventually, I expect things to go back to the way they were. On the other hand, I hope some things like telemedicine and working from home are here to stay.”
“I dreamed that the summer heat would affect the virus, but in reality, our public health efforts didn’t quell it like SARS1, and now it’s really latched on. We may have flattened the curve and 5-to-10 percent of people in L.A. have already been infected, but that just means there’s another 9 million to go. In my personal life, the hardest thing is my wife’s pregnancy. Zooms are great, but there’s nothing like holding a baby. My mother is willing to come [when the baby is born], but is that a risk we’re willing to take? Three months ago, the question was unthinkable. Now, we’re going to have to decide.”
“The protests have been emotional, but they’ve also been a long time coming. After 400 years of oppression, we can’t go back. There are just too many people living on the edge. We have to do better. I think this applies to COVID as well. This idea that individuals can solve the crisis seems like a false American ideal. We need the support of hundreds of thousands of people. So, yes, I struggle because right now is dark. But we still have to hope we can build a more just and equitable society. Otherwise, as my husband said this week, ‘Why are we even doing this?’ That has to be our guiding principle.”
Dr. Claire Panosian Dunavan is a UCLA infectious diseases specialist and a medical writer. Her writing has been published in the Los Angeles Times, The New York Times, The Washington Post, Discover magazine and Scientific American, among others.
Editor’s note: Dr. Amy Vijay Dora requested that this article be dedicated to the memory of Dr. Luis “Lucho” Alberto Panduro Rengifo of Iquitos, Peru, an infectious diseases specialist who was a friend and mentor to many visiting UCLA trainees. Although he initially improved from his own COVID-19 illness, Dr. Panduro Rengifo returned to his crowded hospital to care for other infected patients and then quickly relapsed and died in mid-May. Our hearts go out to his family and his many colleagues, friends and patients who continue to mourn his loss, as well as to those who mourn the deaths of the more than 1,200 caregivers in the United States and the many more around the world who have lost their lives in the fight against this pandemic.