Mar 21, 2020

Hi there. Hope you’re staying in, staying well.

After evaluating several sites for case reports, I think this is the best–John Hopkins, It’s updated every 30 minutes and easy to dive into whatever part of the country or world you want to look at. Also reports the recovered cases, which is a key metric missing from many other sites. The true fatality rate is dependent on not only the number of cases, but the number of cases followed to recovery–which may be 2-4 weeks out. The fatality rate likely improves when we follow it out. Here’s the link:

Below is crib sheet for hospitalists admitting COVID suspect patients. Pretty much everything we know, on one page. We’d like to know a lot more.


The good news back at work today–people are discovering they really don’t need to come to the ER for everything. Our ER census is often 120 – 140 any given afternoon. Today it’s 30.  The bad news–some people are probably not coming in who should. I have 3 patients out of 10 who are isolated for covid testing (our census is down too–we normally have 12-18 patients). These are my patients to care for at this time–we are not allowing residents to care for them until/ unless we get overwhelmed.

Those of us in direct medical care are not feeling tremendously supported with PPE (personal protective equipment) anywhere in our country. We were told in January we needed to be fitted for N95 masks (tight-fitting microfiltration masks). Now we’re being told by CDC that we can wear simple surgical masks into COVID rooms if the patient does not have aerosol risks (a ventilator, high flow oxygen, specialized breathing masks called bipap, or having ordinary nebulizer treatments). This is not because we have any evidence the standard surgical mask is as protective as the N95 from coronavirus (it filters out some smaller viral particles, but mostly filters large droplets), it’s because we don’t have enough N95 masks. A patient who coughs or sneezes coronavirus creates an aerosol every time they do that. The aerosol has been shown to last up to 3 hours in the air.

Of course current world leaders didn’t create this novel virus. But some countries were prepared for pandemic with technology and systems in place, and their infections more readily controlled as a result. It’s disheartening to feel that our lives are at risk, in part, because of poor leadership, planning, and continued overt denial. We need the National Defense Act invoked now to manufacture PPE’s and ventilators in the U.S. Not only should medical personnel have masks available, those being forced to work in group/ public exposure settings for infrastructure support should have masks available too, if they choose. That’s not even possible at this point. Not to mention, those Americans who occasionally have to go to the grocery store.

My current rescue from anxiety? Among other things, the Calm app. There are some free features, but I fell in-love-at-first-listen with the “Rules of Cricket, Explained”–a howling, ridiculously boring recitation, and “The Shipping Report,” spoken by a man whose voice I want to marry. No kidding, the rules of cricket! There’s also a man who calls himself, “the French whisperer,” who reads the theory of relativity (20 minutes) –Einstein would be impressed. I sprang for the 59.95$ version, and haven’t regretted it. There’s a buffet of relaxation choices, sounds, music, stories, and a wonderful meditation app (I used a beginner module with Jeff Warren–30 days, 10 minutes per day guided by him). I’ve never meditated before–that has really not been my thing–but it has helped me remain calmer in difficult situations. I’m sure everyone who knows me will agree. Yep. I’m sure. Sure. 🙂

Stay in, stay well.









Mar 20, 2020

Things continue to escalate in U.S. for thee reasons:

  1. We still have no national edict to lock down population except for essential services. CA gov locked down our entire state yesterday–that’s commendable but a week too late. OH gov doing some to lock down–he started earlier, but every gov needs to act on its own since federal govt hasn’t. Every day lost = more infections, more deaths, and sooner, so bigger onslaught to health care system.
  2. Inadequate testing capability and reliability has led to far greater spread than individuals and those in charge (and we the people) have been aware. This is why you see marked changes in the number of cases appearing daily in parts of the country considered “rural” or “isolated”. As testing gets more widespread, so will the uncovered infections. In the last two weeks we have sent countless symptomatic people home WITHOUT testing, if they were not sick enough to warrant admission. When was the last time someone coughed in your face? I can’t ever think of a time–even as a doc. Yet, the infection is spreading–from casual contact and respiratory aerosols from people who don’t know they have the disease coughing and sneezing.  Large droplets fall to ground almost immediately, but the tinier droplets in aerosols can remain in the air for 2-3 hours.
  3. People not able to confine to home out of need to work–whether supporting the infrastructure society relies on, or from need to pay bills, and from those choosing not to abstain from social/ public gatherings.
  4. Increasing fear among health care workers, well founded but distressing and distracting nevertheless, that we don’t have enough PPE (personal protective gear) to stay well to continue our work through this pandemic. National Defense Act should have been invoked 2 months ago to manufacture masks, gowns, ventilators. Prez has still not done it.

OK. That’s the bad news.

Here’s a bit of good news. There’s evidence that those at the higher end of their healthy weight range–BMI of 20 – 25 is healthy–do better with critical illness than those at the lower end. Now, I’d really like to put on some of those calories back eating out at my favorite restaurants, but that’s not happening. I won’t even go for the new treat of my life, a date shake…not that I could, with everything closed for now. But the point is, eat up, all you skinny people! And I want you to get on line and do the actual calculation because your skinnier than you think. An explanation for why it’s better: think of it the same way you’re stocking your shelves for this period of staying in. The body needs energy when it’s sick, and if you’re too sick to eat, or cook, your body will break down fat first. If there isn’t much fat, you’re going to break down protein, which is your muscles and organs. Not good. In the hospital, we typically don’t begin feeding people artificially unless they’re going to be on a ventilator more than a day or 2. (And no one has written a word about how much artificial feeding supply we have.) So eat! (Those of you over BMI of 30 need to continue to pare down. In a gesture of magnanimity in these troubled times, I am leaving the 25-30 group off the hook altogether. No data.)

Here are the best 2 articles curated today. Tomorrow I post a copy of the google doc widely circulated among hospitalists in the last few days with the basic medical info we are using to manage our patients. I go back to work tomorrow–at least I still have protection whereas many workers out there don’t. Let’s send good thoughts to them and each other, around the world, every day.

Interview with Anthony Fauci, the most trusted man in America:

Before you get to Kristof’s article–which I had to cut and paste as share link wouldn’t work–here’s your mental health link to something wondrous: (Its a little long, but don’t stop before the monkey kisses the puppies. Different species getting along. What an idea!

Article by Nick Kristof in NYT: (the link wouldn’t function–had to print text)

The Best case Outcome for Coronavirus, and the Worst

Here’s the grimmest version of life a year from now: More than two million Americans have died from the new coronavirus, almost all mourned without funerals. Countless others have died because hospitals are too overwhelmed to deal adequately with heart attacks, asthma and diabetic crises. The economy has cratered into a depression, for fiscal and monetary policy are ineffective when people fear going out, businesses are closed and tens of millions of people are unemployed. A vaccine still seems far off, immunity among those who have recovered proves fleeting and the coronavirus has joined the seasonal flu as a recurring peril.

Yet here’s an alternative scenario for March 2021: Life largely returned to normal by the late summer of 2020, and the economy has rebounded strongly. The United States used a sharp, short shock in the spring of 2020 to break the cycle of transmission; warm weather then reduced new infections and provided a summer respite for the Northern Hemisphere. By the second wave in the fall, mutations had attenuated the coronavirus, many people were immune and drugs were shown effective in treating it and even in reducing infection. Thousands of Americans died, mostly octogenarians and nonagenarians and some with respiratory conditions, but by February 2021, vaccinations were introduced worldwide and the virus was conquered.

I’ve been speaking to epidemiologists about their best- and worst-case scenarios to gauge what may lie ahead and see how we can tilt the balance. Let me start with the best case, since we could all use a dose of hope — which may even be therapeutic — before presenting a bleaker prognosis.

“The best case is that the virus mutates and actually dies out,” said Dr. Larry Brilliant, an epidemiologist who as a young doctor was part of the fight to eradicate smallpox. Brilliant was a consultant for the movie “Contagion,” in which a virus evolved to become more deadly, but that’s the exception. “Only in movies do viruses seem to become worse,” he explained.

Two other lethal coronaviruses, SARS and MERS, both petered out, and that is possible here. “My hope is that Covid-19 will not survive,” said Dr. Charles G. Prober, a professor at Stanford Medical School.

Several countries have shown that decisive action can turn the tide on Covid-19, at least for a time. China, astonishingly, on Thursday reported not a single new case of domestic transmission. While China is still vulnerable to a second wave, it has apparently shown that the virus can be squelched.

The West isn’t going to copy the coercive tactics of China, but Singapore, Taiwan, South Korea and Hong Kong have also demonstrated that, at least temporarily, the virus can be controlled.

Singapore and the other successful Asian models responded with the standard epidemiological tool kit: vigilance and rapid response, testing, isolating the sick, tracing contacts, quarantining those exposed, ensuring social distancing and providing reliable information. They did not shut down their entire countries, and Singapore managed to keep its schools open throughout.

“Singapore is a best-case scenario,” said Dr. Tom Frieden, a former director of the Centers for Disease Control and Prevention. He said that there was some possibility that with social distancing and limits on gatherings, the United States could knock down the numbers of infections and begin to adopt Singapore-style strategies to reduce new infections.

“The most important lesson is that the virus can be contained if people are responsible and adhere to certain simple principles,” said Dr. Christopher Willis, a physician in Singapore. “Stay calm. For most people it’s like the common cold.”

Dr. Tom Inglesby, an expert on pandemics at the Johns Hopkins Bloomberg School of Public Health, said, “The fact that Singapore, Hong Kong, Taiwan, South Korea and China — and to some extent Japan — have all flattened their curves despite having the initial onslaught of cases should give us some hope that we can sort out what they’re doing well and emulate it.” One encouraging sign is that in Washington State, which had an early outbreak, the number of positive tests appears stable.

The weather may also help us. Some respiratory viruses decline in summer from a combination of higher temperatures and people not being huddled together, so it is possible that Northern Hemisphere nations will enjoy a summer break before a second wave in the fall. That’s what happened during the 1918 Spanish flu pandemic: It hit in the spring of 1918, went away but returned worse than ever in the fall.

Of the four coronaviruses that cause the common cold, two diminish in warm weather, while two are more variable. SARS and MERS did not have clear seasonal variations, and even seasonal flu is transmitted in the summer, although less than in winter. So while experts hope that hot weather will shortly bring a reprieve from the coronavirus — the flu is already on the retreat — there’s no solid evidence.

One reason for measured optimism is the prospect that antiviral medicines will beat the coronavirus; some are already in clinical trials. Scientists have hopes for remdesivir, originally developed for Ebola; chloroquine, an old anti-malaria drug; and some anti-H.I.V. and immune-boosting drugs. Many other drugs are also lined up for trials.

Even without proven treatment, the coronavirus may be less lethal than was originally feared, so long as health care systems are not overwhelmed. In South Korea and in China outside Hubei Province, about 0.8 percent of those known to be infected died, and the rate was 0.6 percent on a cruise ship.

That’s still roughly six times the rate of seasonal flu, about 0.1 percent, but Dr. John Ioannidis of Stanford University argues that the fatality rate may end up even lower. He warns that we are engaging in hugely disruptive interventions without firm evidence of the threat that the virus poses. Singapore has had more than 200 confirmed cases of the virus and not a single death.

About four out of five people known to have had the virus had only mild symptoms, and even among those older than 90 in Italy, 78 percent survived. Two-thirds of those who died in Italy had pre-existing medical conditions and were also elderly; Dr. David L. Katz, the former director of the Prevention Research Center at Yale University, notes that many might have died soon of other causes even if the coronavirus had not struck.

That said, a new C.D.C. study finds that of coronavirus cases in the United States requiring admission to the intensive care unit, nearly half involved patients under age 65; there is also concern about lasting lung damage among survivors.

Putting it all together, Dr. Tara C. Smith, an epidemiologist at Kent State University, said: “I’m not pessimistic. I think this can work.” She thinks it will take eight weeks of social distancing to have a chance to slow the virus, and success will depend on people changing behaviors and on hospitals not being overrun. “If warm weather helps, if we can get these drugs, if we can get companies to produce more ventilators, we have a window to tamp this down,” Smith said.

So that’s the best case, and it’s plausible. If you want to feel upbeat, stop reading here.

Now we get to the other end of the range of possibilities. Dr. Neil M. Ferguson, a British epidemiologist who is regarded as one of the best disease modelers in the world, produced a sophisticated model with a worst case of 2.2 million deaths in the United States.

I asked Ferguson for his best case. “About 1.1 million deaths,” he said.

When that’s a best-case scenario, it’s difficult to feel optimistic.

Ferguson questions whether South Korea and other countries can sustain their success for 18 months until a vaccine is ready, even as new cases are constantly being imported. Indeed, a burst of new cases has been reported in recent days in Singapore, Hong Kong and Taiwan.

As for the hope that the United States can emulate Singapore or South Korea, that may be a leap.

America and South Korea reported their first Covid-19 cases on the same day, but South Korea took the epidemic seriously, promptly created an effective test, used it widely and has seen cases go down more than 90 percent from the peak. In contrast, the United States badly bungled testing, and President Trump repeatedly dismissed the coronavirus, saying it was “totally under control” and “will disappear,” and insisting he wasn’t “concerned at all.” The United States has still done only a bit more than 10 percent as many tests per capita as Canada, Austria and Denmark.

By some counts, the United States is just eight days behind Italy on a similar trajectory, and it’s difficult to see how America can pirouette from the path of Italy to that of South Korea. The United States may already have 100,000 infected citizens — nobody knows. That’s too many to trace. Indeed, one can argue that the U.S. is not only on the same path as Italy but is also less prepared, for America has fewer doctors and hospital beds per capita than Italy does — and a shorter life expectancy even in the best of times.

Mitre, a nonprofit that does work on health care, calculated that coronavirus cases are doubling more quickly in the United States than in any other country it examined, including Italy and Iran.

The nightmare is a surge that overwhelms the hospital system. A Times colleague, Stuart A. Thompson, and I worked with two epidemiologists to develop an interactive model of the virus that suggested that up to 366,000 I.C.U. beds might be needed in the United States for coronavirus patients at one time, more than 10 times the number available. A Harvard study reached a similar conclusion.

This is an interval of quiet when the United States should be urgently ramping up investment in vaccines and therapies, addressing the severe shortages of medical supplies and equipment, and giving retired physicians and military medics legal authority to practice in a crisis. During World War II, the Ford Motor Company turned out one B-24 bomber every 63 minutes; today, we should be rushing out ventilators and face masks, but there’s nothing like the same sense of urgency.

Peter Hotez, an eminent vaccine scientist at Baylor College of Medicine, told me that he and his colleagues have a candidate vaccine for the coronavirus but still haven’t been able to line up sufficient funding for clinical trials.

Already there are stunning unmet needs for personal protective equipment. After initial missteps in Wuhan, where the coronavirus was first discovered, China adopted protocols for protective gear that are more rigorous than those in the United States, involving N95 masks and face shields, double gowns, gloves and shoe covers, plus special areas to remove protective clothing — and all this worked. Not one of the 42,000 health workers sent to Wuhan is known to have become infected with the coronavirus. The United States isn’t protecting health workers with the same determination; it seems to be betraying them.

Dr. Irwin Redlener, director of the National Center for Disaster Preparedness at Columbia University, said he had received a phone call from a major Florida hospital that had run out of masks. A doctor wanted to know: Could cloth be used to construct makeshift masks?

The answer: not very well, but it’s better than nothing. The need is so acute that the C.D.C. has posted official guidance advising that doctors and nurses “might use homemade masks (e.g., bandanna, scarf) for care of patients with Covid-19 as a last resort.”

“If people think that a hospital crisis is coming, it’s important to know that it’s already here,” Redlener said. “It’s affecting front-line health workers, who are probably the highest risk group. These are like combat troops on the front lines of a war.”

In Italy, 8.3 percent of coronavirus cases involve health workers. A doctor in the Seattle area who is forced to reuse N95 masks told me that she and her colleagues fear that the lack of supplies will be deadly.

“We are all making dying contingency plans at this point just in case,” she said. “Wills, backup people to take care of kids, recording bedtime stories.”

In the worst-case scenario, will social services collapse in some areas? Will order fray? Gun sales are increasing, because some people expect chaos and crime.

The United States is in a weaker position than some other countries to confront the virus because it is the only advanced country that doesn’t have universal health coverage, and the only one that does not guarantee paid sick leave. With chronic diseases, the burden of these gaps is felt primarily by the poor; with infectious diseases, the burden will be shared by all Americans.

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So where is the United States headed? Will we endure the worst case, with 2.2 million deaths? Or will we manage to turn things around, with help from summer?

No one knows, so the optimal path forward is to hope for the best while preparing for the worst. Dr. Brilliant, whom I quoted above as hoping that the virus mutates and dies out, also warns that the coronavirus may “cause global disruption on a scale we have not seen from any epidemic in more than 100 years.”

Outcomes depend in part on us — and my conversations with experts leave me concerned that we still are not doing enough.

“If anything, we’re still underreacting,” said Dr. Chaz Langelier, an expert on respiratory infections at the University of California at San Francisco. “In the last week, in terms of public health response and testing, we’ve maybe gotten to the pace we should have been at a month ago.”

This crisis should be a wake-up call to address long-term vulnerabilities. That means providing universal health coverage and paid sick leave — and if you think that the coronavirus legislation Trump signed on Wednesday achieves that, think again. It guarantees sick leave to only about one-fifth of private-sector workers. It’s a symbol of the inadequacy of America’s preparedness.

More broadly, the United States must remedy its health priorities: We pour resources into clinical medicine but neglect public health. What’s the difference? If you get lung cancer, surgeons operate to save your life, but public health professionals keep you from smoking in the first place. If you get the coronavirus, a doctor will treat you; public health aims to keep the pandemic from getting near you. The United States has a decentralized and spotty public health system, and it has endured painful budget cuts, yet historically public health has saved more lives than clinical medicine.

We may dodge a bullet this time, but experts have been warning for decades that a killer pandemic will come; typically, they expected an avian flu like the 1918 pandemic rather than a coronavirus. Singapore and South Korea did well this time partly because they had been frightened by SARS and MERS and were vigilant; if we, too, can be scared enough to invest in public health and fix our health care system, then something good can come from this crisis — and in the long run, that may save lives.

The Big One is approaching, whether now or later, whether we’re prepared or not. Dr. Ferguson, the infectious disease modeler who predicted deaths in the United States might reach 2.2 million, came down with a cough and fever a few days ago. He tested positive for the coronavirus.



March 19, 2020

This is your source for

-evidence based data on corona virus

-articles curated by me on a variety of topics affected by the pandemic, some of which is data based, and some of which is opinion, all of it in my opinion, offering something valuable.

-my frontline experience of working as a hospitalist in southern California, admitting our sickest patients

-my habits/ advice on same


Having written a novel about pandemic almost 15 years ago (Virion), I confess even my imagination and research then was not up to the reality of the current situation. The rapidity with which this virus has arrived, and the bungling of the U.S. response have, in particular, been astonishing to me, the world having become even smaller and more accessible than 2005, and the leaders more incompetent. Having said that, we are called to create the best response we can muster individually, socially and professionally, as family, friends and loved ones doing their best in an unprecedented global crisis of health, social circumstances and finance. We will persist–this is not the end of the world, but it is a time of great upheaval, and of untimely death for far too many of our most vulnerable, and unfortunately even some of our healthy.

I’ve been curating articles and writing emails to friends and family, and decided the best option for anyone interested is to place all the info on my blog. Of course you may pose questions here through blog email (, or on my personal email for those of you that have it.

Severity of infection:

Disease is non-severe for about 80% of those who get it. The more frail one is (by age or other chronic, uncontrolled conditions or immune compromise) the higher the risk of severe disease and death. Children are readily able to acquire the virus and may have very mild cases, but are still profuse shedders of live virus and potential spreaders of disease. Children under the age of five seem to have higher risk of apparent disease than kids older than 5. Do not take them to grandma’s house!

Data regarding communicability of the virus and surface survival are limited but here’s what we have so far:

–Respiratory droplets (larger particles) from cough, sneeze, and nose, are the most laden with virus. Respiratory aerosols–smaller particles that can last in air around sick person up to 3 hours–are also infectious, though smaller size. Mask (N-95) when worn and disposed of properly, prevents infection close to 100%. Surgical masks keep out large particles and some smaller. BUT if you don’t know how to wear a mask or take it off you can actually contaminate yourself with the mask.

–Fomites–viral particles contaminating surfaces–seem to live up to 3 days on steel and plastic, however the number of viral particles decreases dramatically over that time so may not be enough to be infectious. Other surfaces have even shorter contamination times.


–Tests are still not broadly available enough to have an accurate estimate of how much disease is really here. Many locations have had to send patients home without testing if they had no known exposure and were not sick enough to be admitted to the hospital. Until we get testing ramped up enough to test large numbers of people in their cars, stay away from the ER unless you are sick enough to be admitted. Your county health department/ and /or hospital should have a hotline advising you of testing capability. Expect this to change frequently (for the better).

–COVID tests are not very reliable. In medical-ese they have unknown/ or low sensitivity. Actually we can’t even find sensitivity of U.S. tests anywhere yet as most of these tests are so new, there are no studies to verify how accurately a negative or a positive test reflects true disease. We do know that Chinese and Korean tests were/ are only 30-60% accurate, meaning 40-70 people out of 100 with known COVID disease will test negative the first time. If we do 2 tests 2 days apart the sensitivity improves to 70%–this is why people who do have the disease are being forced to remain in quarantine until 2 negative tests, 2 days apart.


The virus is here and spreading. The best we can do now is mitigate the effects by stretching out the time line–you’ve also heard it called flattening the curve–to keep the health care system from imploding from too many sick people at one time. Also hoping for effective treatment (there is none yet except supportive care–oxygen, ventilator if needed) and vaccine before everyone has contracted disease.

I”m going back to work Saturday, the 21st, having had a week off after admitting my first corona virus suspect patient last week. Like you, I have some fear of contracting the disease. Even when I think I’m fine, I’m not sleeping well at times, I suspect from sublimated anxiety. I’m over 60 with underlying mild asthma, but otherwise pretty good shape. But to put things in perspective, at this point, with modest patient census, sinks in every room, antibacterial gel hanging from the wall every 20 feet, and adequate PPE (personal protective gear), I’m more concerned about exposure at the grocery store than at the hospital. Frankly, I strip naked when I get home from the hospital, drop clothing directly into the washer, and shower immediately. Shoes that can be washed is all I’m wearing right now. News flash: I’m flashing at the condo! Cover your eyes, remember I’m over 60!

Whenever I get anxious about my own exposure, I think about all those people who support our infrastructure, who are still working to provide us with canned veggies, and apples off the tree, who deliver the mail, maintain our water supply, and fill the gas stations. They are in far higher potential exposure situations than I. Please keep them in your thoughts. I love the Calm app on my phone, and am using the breathing techniques regularly. They do have free options.

Link with graphs re: case for social distancing:

Atlantic: Now Is the Time to Overreact:

Interesting report from Morgan Stanley number crunchers–with “bear, base, and bull” pandemic scenarios for those of you into financial lingo. I have not figured out how to link it yet–it’s a PDF that I couldn’t find anywhere except in the email sent to me. If you want it, email me, and I’ll email it to you directly–or if you find a URL/ link, please send to me so I can upload.


Any produce that can be washed with soap and water is fine. I’m leaving non-perishable items in the garage until I need them. If they sit there longer than a week, I don’t wash them. 3 days or less, I wash everything before it comes into the house. In between 3-7 days, use your own judgment.

Personally, after public errands, I’m changing clothes and showering before I sit on any of my furniture. Not sure I need to do that, but as a physician I’ve been trained for years to see germs everywhere. I don’t worry about running out of toilet paper, just laundry detergent!

Finally, we are all beginning to notice the effects of social isolation. Be good to yourself and those around you. Practice kindness, patience. Find something soothing at least once daily. We can still be in touch with one another through our devices in ways we never could before.  At least we have that, and it’s no small thing.  Here is your link to the lovely world still going on outside–maybe even better without us gassing up the air…     Birds and Bees:

Stay in. Stay well.