For most of us, March feels like a blur. The last day of quasi-normalcy for me and my bioethics team at the University of Kentucky was March 11, 2020. The University of Kentucky had announced its first COVID-19 case on March 7, 2020, and our Governor, Andy Beshear, declared a state of emergency. UK Healthcare set up an Incident Command, and held a town hall meeting on Monday, March 9, 2020 fielding questions from healthcare providers who were beginning to panic – about personal protective equipment (PPE), quarantine issues, availability of testing, and whether to continue as usual. That afternoon, the Endocrine Society, for the first time in its history, cancelled its conference (see: https://www.magnetmail.net/actions/email_web_version.cfm?ep=XbhxMxoKOt-hJVO2DScV1H0SHN7SRsrPp8ldJNpY5STfUjqYyfqaAUx9PER-kEq_ATX9xG6wmXV2CfZvGXMSkdT_lheragRlZMbSk4qrb1uIP1odE6QYmRZIAcP0bqCr). It was the right thing to do, but punctuated the gravity of the moment. I could only imagine the organizational ethics angst in making that decision, and the financial costs involved for the Endocrine Society.
When I got the message from the President of the Endocrine Society, I was hosting a colleague from Case Western University, scheduled to give a talk on March 10th. As the Endocrine Society BOD was likely debating cancellation the weekend of March 7th, my colleague and I exchanged emails as to whether to cancel, but as he was driving and not flying, we decided to go forward as planned. We hosted him for dinner Monday, March 9, 2020 at a chic Lexington restaurant that was half-full. I glanced at my newsfeed and began reading the shocking news out of Italy; it they had gone to full lockdown and closed its borders, which seemed like something out the Middle Ages. As my colleague and I strolled from his hotel to the restaurant, I commented: “See – we’re still open for business – not like Italy yet…”. (At this point, parts of Seattle had already been shut down). We all were careful to wash our hands prior to sitting down. We discussed the inevitability of community spread across the U.S., and wondered aloud when things would change for us. On March 11th, my team bid my colleague farewell and safe travels home, and we made the decision to cancel our April and May bioethics events out of caution. I dusted off a 2009 “Pandemic Ethics Resource” I had written for our institution in preparation for H1N1, revised it based on COVID-19, and circulated it for review to our Hospital Ethics Committee. I began to plan for drafting specific COVID-19 ethics policies. On Thursday March 12th, when the NBA cancelled its season, and New York City shut down its restaurants, it was the signal to many who were holding out to cancel everything. And then an avalanche of cancellations and shut downs began across the country and academia: moving all classes online and into virtual spaces; cancellation of conference after conference.
On Friday, March 13, my husband (Dr. Kenneth Ain, a thyroid oncologist) and I kept reservations at a nice restaurant to celebrate a family birthday that night. I took a picture and posted it on Facebook, with the statement: “Our last dinner out for a long time. Before we peak”. It was the last time I was in a restaurant. That weekend, all stores were stripped of supplies like toilet paper, hand sanitizer, and cleaning products, as we stocked up for three months.
The week of March 16th, healthcare institutions across the country set up incident commands, while governors in several states issued states of emergency and executive orders to brace for impact: build hospital capacity by cancelling elective procedures, and begin to ration PPE because nobody had enough to go around for a coming pandemic. Several states, including ours, also closed all non-essential businesses and issued stay at home orders. What was driving these decisions were projections that we needed to severely social distance based on reports. (See: https://www.nytimes.com/2020/03/16/us/coronavirus-fatality-rate-white-house.html?action=click&module=Spotlight&pgtype=Homepage&fbclid=IwAR3YAY2PA5KmSmM1YvajL7HS6w5g37x4OBjtYnyNx7YbAibBaPhWYAN2w_M)
Prior to that week, the term “PPE” was not a commonly known term for the general public. As for testing, it needed a rationing protocol as well. Finally, as American healthcare providers began to read about the Italian experience with ICU rationing, every clinical ethicist in the U.S. began to draft or share “Crisis Standards of Care” triage and rationing protocols designed specifically for COVID-19. As of mid-March, accurate data surrounding the exact risks to healthcare workers were unclear, but the experiences based on China and Italy suggested that 20-30% of exposed healthcare workers were becoming infected. There were three significant pieces of COVID-19 medical news that informed most of our decisions in March: (1) an Anonymous healthcare provider wrote a warning to the cavalier Americans, published in Newsweek (see: https://www.newsweek.com/young-unafraid-coronavirus-pandemic-good-you-now-stop-killing-people-opinion-1491797); (2) a JAMA interview with an Italian ICU physician, entitled “Coronavirus in Italy – Report from the Front Lines” (see: https://www.youtube.com/watch?v=TKS1pahoPRU); and (3) the Italian Society for Anesthesia Analgesia Resuscitation and Intensive Care (SIAARTI) released its newly drafted triage guidelines. See: http://www.siaarti.it/SiteAssets/News/COVID19%20-%20documenti%20SIAARTI/SIAARTI%20-%20Covid-19%20-%20Clinical%20Ethics%20Reccomendations.pdf
The Italian guidelines were alarming because they suggested rationing ICU resources based on age. But by the end of March, a shortage of testing, tracing, and PPE was a real game changer, and U.S. hospitals in surge areas were in dire need of functional triage protocols. Indeed, COVID-19 presented unique and new challenges for U.S. hospitals, and many tasked their clinical ethicists with drafting specific COVID-19 rationing protocols that had new considerations for this particular pandemic, including the risks of performing CPR.
In the context of the U.S., healthcare stakeholders were facing a total collapse of an already inequitable and dysfunctional healthcare system and a death toll of over 1 million citizens. At that time, the “bioethics” calculation of shut down favored expanding hospital capacity; triaging based on sound ethical frameworks, and saving lives. Shut down was a mitigation of last resort.
It seemed that clinical ethicists were all sharing one giant nationwide “reactive consult” that needed our attention. Healthcare providers began to report high levels of moral distress and moral injury, and several clinical ethics, mental health and spiritual care providers began to deal with a deluge of healthcare provider distress calls. By March 30, the number of Americans who had died from COVID-19 reached the same number as Americans who were killed on 9/11, yet there were still states that had not called for shut downs and stay at home orders. The following column appeared in the New York Times: https://www.nytimes.com/2020/03/30/opinion/republicans-science-coronavirus.html?action=click&module=Opinion&pgtype=Homepage&fbclid=IwAR3qxm4VokhV7am4fBwPRbt3DVtd-ogycaOOUR4R2aDQ4uLTcJKa-dcMMi8
On March 31, the White House Coronavirus Task Force, which began daily briefings in mid-March, soberly projected that between 100,000-240,000 Americans would likely die even with strict mitigation efforts of shutdown to flatten the curve; without mitigation, the number would be over 1 million Americans dead. The White House based its projections on an evidenced-based British study by the Imperial College of Medicine that demonstrated the need for mitigation through shut down was the only defense in the absence of any other tool (see: https://www.imperial.ac.uk/media/imperial-college/medicine/sph/ide/gida-fellowships/Imperial-College-COVID19-NPI-modelling-16-03-2020.pdf ). Additionally, the University of Washington’s Institute for Health Metrics and Evaluation (IHME) provided similar predictions (see: http://www.healthdata.org/covid/updates).
As March began, many Americans were already affected by travel advisories, stories of stranded cruise ships, and were preparing to see isolated pockets of outbreaks, such as the early cases in Seattle. By March 31st, the country was transformed, and “3/11” – the day the WHO declared the pandemic — was the marker between the pre-COVID and post-COVID world as we braced for the wave that hit Italy.