Alexander Norbash

2020–2021 ARRS President

_{Published June 22, 2020}

On Thursday, March 19, the governor of California issued a mandate for state citizens to stay at home and not congregate, except for essential and emergency needs. I manage the radiology department at the University of California-San Diego, and needless to say, this mandate was therefore of particular and great interest to me. At the time, I saw this as a brave and decisive move on the governor’s part. Given the lack of other governors showing the wisdom of consensus in such an action, I also felt this instance of decisiveness demonstrated a high degree of confidence in his advisors and his own perspective. Many of us were paying attention to a number of news stories that suggested our lives were about to be significantly disrupted.

Ever since December 2019, as with many of my acquaintances and family members, I had been following at a distance and with one eye the epidemic in Wuhan. My attention and interest increased exponentially as December proceeded and Wuhan locked down tighter and tighter, then as December turned to January with mounting casualties, and more so as various reports regarding the impact of the epidemic and control measures on citizens came to light. Perhaps many of us even preceding this pandemic have a personal story regarding the invisible erstwhile masters of the universe, or something related. I certainly did. My personal story dealt with the swine flu vaccination of 1976. I was very close to my maternal grandparents. My maternal grandfather was on a ventilator for two weeks, and at one point, he could only blink due to Guillain-Barré syndrome. We held our own breaths as he very slowly improved. It took him two long years to fully recover. As a consequence, I was fascinated by virology in medical school as a result of my grandfather’s misadventure, which regrettably was about 34 years in the past. Perhaps I paid just a little more attention to epidemics and cures than the average citizen.

Somehow, seeing two hospitals erected in one week—the first with 1,000 beds and the second with 1,300 beds—was a firm nudge in the ribs for me. Firstly, I felt that was an impossibility for any of the environments that I have worked, meaning if we ever had to add a thousand hospital beds in a week, we couldn’t possibly do it. Second, it underscored the seriousness of the situation and that the epidemic may well be headed to our shores.

So, I read up on the popular culture sounding boards dealing with the 1918 influenza epidemic, SARS in 2002, H1N1 in 2009, and MERS in 2012. Naturally, I also went back to the bubonic plague. Reading did not build up my confidence. 

As the shelter edict was issued in California, immediate and rapid changes in our delivery of health care took place. These changes influenced and affected our faculty, our residents and trainees, our patients, our clinical operations, our research, and our staff. Research came to a near grinding halt, and clinical volume dropped by 75% overnight, levelling off at 45% down. We wrestled with a span of consequences, from “how do we teach remotely?” to “what do we do with idle staff?” 

Our elective cases nearly instantaneously and precipitously dropped in number as patients sheltered at home, and we realized how much of our volume was truly nonurgent and nonemergent. Our residents and technologists and faculty bravely and selflessly provided the same exceptional level of service they had always provided, only now with the understanding and belief that there is increased risk of harm to self. We watched the calendar and counted the days, preparing to the best of our abilities for the inevitable tsunami to hit. Our leadership assembled emergency plans with exceptional sophistication and creativity, doubling our ICU beds and creating standard operating procedures overnight in droves. Nearly three weeks later, the tsunami hasn’t hit us. We have, however, watched closely and day by day as our worst nightmares unfolded across the country, in New York City, where unparalleled compassion, ingenuity, and creativity have been demonstrated by our remarkable colleagues. The rest of us are petrified that what New York City is experiencing could be our future, and we convince ourselves that our lesser population density and lack of success with mass transit somehow protects us.

We really don’t know when and how this is going to end. Maybe, by the time you read this, the whole thing is over and solved. Maybe we are seeing multiple tsunamis scattered across the country battering us on a daily basis. As I write this, we certainly don’t know if San Diego is relegated to a gentle slope for an infinity, necessitating masks and social distancing forever, rather than a bump or a tsunami with an implied and potential resolution of sorts. In the meantime, we are relieved to have been spared massive carnage up until now, although there still are lost lives with the accompanying scarring, sorrow, and regret one would expect. In the meantime, we are trying to understand how to provide our faculty and staff some semblance of a paycheck when revenue is down by 40%, giving them a heightened sense of purpose with a sprint that is turning into a marathon, which will be progressively more difficult if and as this crisis stretches into the summer, fall, and possibly beyond. Not knowing is the most difficult part. We need to salvage the critical, scientific, and teaching missions that distinguish us, in preventing irreparable damage to what keeps us distinct and gives us unique value: teaching and discovery.

Many predict that the lockdown will be extended to the end of May, and some predict the end of June. Just today, a newsfeed quoted an extremely influential billionaire stating we won’t be over COVID-19 until Fall 2021. There’s much discussion regarding how much unemployment and financial instability we collectively will tolerate. We, as a people, are not in all instances risk averse. After all, we have states where motorcycle riders can ride without helmets, and legions of humans still smoke cigarettes. We also have too many people who suspect the value of immunizations. There is also much discussion regarding how we will deal with multiple recurrent waves of COVID-19 rising proportionately with our inevitable societal lapses in vigilance and awareness, if COVID-19 becomes an annual affair. 

In the moment, I am inspired by my colleagues throughout the health system. My fellow radiologists are optimistic and creative, perpetually showing their innovative and flexible spirit. Every day there are new solutions and new approaches percolating among them, as they do their best to ensure optimal deployment of our tripartite mission. All this in graceful partnership with technologists, nurses, front desk staff, and trainees. Our brilliant departmental resident AI scientists have even deployed an intelligent tool in our PACS that will catch pneumonias, which may be too subtle for the naked eye to see. In the middle of this crisis, there are blinking flashes of creativity going off like lightbulbs. Everywhere under this roof, radiologists as tinkerers and creative spirits who are solving problems, as we elevate and illuminate each other’s vision. 

I can’t imagine a better group of compatriots to have in my lifeboat.