How are two-career households with children — let alone single-parent households — going to manage with daycare centers and schools closed, perhaps for a long time to come? What damage will this do to career progress and earning potential if one parent must cut back on work? Will childcare demands inevitably delay or derail partnership or academic promotion?

When I was a young mother — my two youngest children are only 17 months apart — life revolved around childcare arrangements. As newly fledged attendings, my husband and I both wanted to practice full time, and with the confidence of youth we assumed we could make it work. For a time, we had a live-in nanny. As the babies turned into children old enough for school, we still needed a full-time nanny for drop-off, pick-up, and the days when the kids were sick and needed to stay home. We accepted the fact that a third or more of our joint income would be spent on childcare and other support services so that we could both keep working as physicians and stay sane.

But what if there had been no school?

Today, it’s hard to fathom the impact that the COVID-19 pandemic is having on families trying to find solutions to their childcare needs with the closure of private and public schools alike. Who’s going to watch, let alone educate, the kids? A nanny, no matter how conscientious and loving, may not be a good educator. When one parent has to work less in order to supervise learning at home, often that job falls to the mother. What happens to her career?

The vicious downturn cycle

As of early July, the Census Bureau estimates that half of American adults live in households that lost job income this spring. Many anesthesiologists lost income too during the periods in March and April when elective surgery in many states went on hiatus to keep beds open for COVID-19 patients.

In California, the CSA surveyed members and found that 74% reported experiencing financial hardship this spring, with medium and small private practices faring worse than academic departments. There was no overall difference in perceived economic hardship between men and women in anesthesiology, though women reported being furloughed or given involuntary vacation more often than men: 41% vs. 26% of survey respondents.

When people lose their jobs or work remotely, demand for childcare services plummets. The National Association for the Education of Young Children reports that on average, enrollment in childcare centers is down by 67%. Many that were operating on a slim margin have already gone out of business. The centers that remain open to serve essential workers are facing huge additional expenses for staff, PPE, cleaning supplies, and duplicate equipment and toys to allow cleaning after each use. At least 40% of the remaining childcare centers are likely to go out of business unless significant government assistance arrives soon. People trying to return to work after lockdown — in anesthesiology or any other field — are having trouble finding high-quality early childcare.

“It’s much harder for me to find safe childcare to be able to work,” said one woman anesthesiologist in a private conversation. Another in academic practice commented, “It’s very stressful for the mom!” A third woman is worried because her current au pair leaves in August but the new one may not be able to enter the country due to the hold on visas.

Many of us assumed optimistically that the school closures of the spring would be short-lived, and that September would mark the end of “learning from home”. That doesn’t appear likely. California’s Governor Newsom announced on July 17 that most California public and private schools will not reopen when the academic year begins.

In some states, elite private schools have more latitude to reopen than public schools as they can afford to reduce class size and adapt to strict infection control regulations recommended by the CDC. But many private religious schools that serve less wealthy families were in financial trouble even before the full effect of the pandemic hit. The Roman Catholic Boston archdiocese, for example, has already shuttered 10% of its schools permanently. No one knows yet how many students actually will be able to return to school this fall.

Even if schools reopen where state government permits, it isn’t clear that teachers will agree to return to work. In a July 19 New York Times op-ed, a teacher wrote that she is willing to take a bullet for her students, but exposing herself and her family to COVID-19 would be like asking her to take that bullet home. “It isn’t fair to ask me to be part of a massive, unnecessary science experiment,” she wrote. “I am not a human research subject. I will not do it.”

In anesthesia, you can’t “phone it in”

What are women in anesthesiology going to do if schools don’t reopen? If your job is purely administrative, or you can run a preop clinic using telemedicine, you might be able to work remotely. But you can’t “phone it in” if your job is delivering anesthesia to humans.

“I don’t see how this school year is going to work,” said one woman anesthesiologist. “It’s a hot mess.”

A recent New York Times article noted that women overall are doing less paid work since the COVID-19 lockdown began. Whether they worked remotely most of the time or not, though, they ended up being responsible for more of the home schooling this spring than their male partners. The survey also reported that mothers were primarily responsible for home schooling even when couples otherwise shared childcare duties. A sociologist commented, “What terrifies me for the future is if it will push women out of the labor force in a way that will be very hard to overcome.”

Women in anesthesiology also report a disproportionate share of responsibility for their children learning from home.

“Luckily my husband is a stay-at-home dad,” said one anesthesiologist, “but he was not cut out to homeschool. I felt like I had to be his foreman to make sure the kids got everything done while working full clinical hours with in-house call. Definitely an adjustment for all of us. I’m in AZ so I don’t see things getting better soon. This could really last the whole academic year.”

Another woman said her hours were reduced early in the pandemic. “I’m working now but will probably need to cut way down if schools don’t open,” she said. Another anesthesiologist said that she has had to adjust her schedule this spring to work more nights and weekends in order to be home more in the daytime, but “assuming no in-person school, I will most likely have to work less.”

Still another anesthesiologist said she is back at work now since elective surgery resumed, “but am desperately looking for a solution should regular school not be an option. I’d likely have to pull back significantly and fear it would be the end of me…”

Poor prognosis for women’s advancement?

 COVID-19 does not affect everyone’s career equally. The journal Nature Human Behavior reported the results of an April survey of principal investigators in the US and Europe concerning their research productivity during the pandemic. Their findings indicate that “female scientists, those in the ‘bench sciences’ and, especially, scientists with young children experienced a substantial decline in time devoted to research. This could have important short- and longer-term effects on their careers, which institution leaders and founders need to address carefully.”  

The authors concluded that the most important variable was having a young dependent. Scientists with at least one child five years old or younger experienced a 17% larger decline than others in the time they could spend on their research as a result of the pandemic.

 There are no easy answers to the question of how severely or permanently women’s careers will be damaged by the disruption of the COVID-19 pandemic. The ASA’s Committee on Women in Anesthesia is planning a thorough survey of ASA members on the effect of COVID-19 on academic productivity and career potential. It will be distributed about September 1 for anticipated publication in early 2021, and should shed more light in a quantifiable way on all these issues.

The unhappy fact is that the careers of women in medicine who, like me, chose to have children, have depended on the army of other people — mostly women — who took care of those children. We relied on the nannies, the preschool teachers, the elementary and high school teachers, the after-school programs, and don’t forget the housekeepers. If they can’t work because their own children need to be watched and helped to learn from home, all of us are at economic risk. The scaffolding behind our careers was fragile all along, but it was too scary to think about it up to now.

Until we collectively support the common-sense public health measures that will control the pandemic, we risk the collapse of our economy and our educational system, and the wellbeing of millions of children who need all the benefits of school. Women’s careers will be part of the collateral damage.

Author’s note:  This article was written in July 2020 for the September issue of the American Society of Anesthesiologists monthly magazine, the ASA Monitor, and published online ahead of print.

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Luhby T. Half of US adults live in households that lost income in pandemic. Online publication at CNN.com, July 17, 2020. https://www.cnn.com/2020/07/17/politics/lost-income-jobs-covid/index.html

Hertzberg L, Merzel M. COVID-19 Economic Impact Survey, conducted on behalf of the California Society of Anesthesiologists. Personal communication from Dr. Linda Hertzberg, ASA Director from California.

National Association for the Education of Young Children. Holding on until help comes: A survey reveals child care’s fight to survive. Online publication July 13, 2020. https://www.naeyc.org/sites/default/files/globally-shared/downloads/PDFs/our-work/public-policy-advocacy/holding_on_until_help_comes.survey_analysis_july_2020.pdf

Centers for Disease Control and Prevention (CDC). Considerations for Schools. Website publication last updated May 19, 2020. https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/schools.html

Massachusetts State House News Service. Future of private schools in question with wave of closures. Online publication of MassLive.com, June 10, 2020. https://www.masslive.com/news/2020/06/future-of-private-schools-in-question-with-wave-of-closures.html

Martinson R. Please don’t make me risk getting COVID-19 to teach your child. Online publication of the New York Times, July 18, 2020. https://www.nytimes.com/2020/07/18/opinion/sunday/covid-schools-reopen-teacher-safety.html

Miller C. Nearly half of men say they do most of the home schooling. 3 percent of women agree. Online publication of the New York Times, May 6, 2020. https://www.nytimes.com/2020/05/06/upshot/pandemic-chores-homeschooling-gender.html?action=click&module=RelatedLinks&pgtype=Article

Myers K, Tham W, Yin Y, et al. Unequal effects of the COVID-19 pandemic on scientists. Nature Human Behavior, online publication July 15, 2020. https://www.nature.com/articles/s41562-020-0921-y

It’s early May in Los Angeles, and dystopian reality is here – storefronts boarded up; people (if they’re out at all) wearing sinister-looking black facemasks. Inside the hospital, everyone wears a mask all the time, no one gathers in clusters to chat, and even the tail-wagging therapy dogs must be sheltering at home because they’re nowhere to be seen.

One change I didn’t see coming was a metamorphosis in airway management.

Guidelines developed for the intubation of COVID-19 patients are evolving into the new normal whether a patient is infected or not. This is even more remarkable since anesthesiologists consider ourselves experts in airway management, and many of us (how can I put this kindly?) hold firmly to our opinions. Who would have thought old habits could change? But airway management this year is different and scarier. Remember when we didn’t think of it as hazardous duty?

Who still “tests” the airway?

Consider the question of whether to “test the airway” before giving any neuromuscular blocker (NMB) during a routine anesthesia induction. Some of us believe that it offers a measure of safety, because you can back out and wake the patient up if you can’t ventilate. Those (like me) who don’t do it quote studies that demonstrate more effective mask ventilation with larger tidal volumes after NMB, and point out that if you can’t ventilate, most people will give NMB anyway.

That controversy seems to have gone into hiding. Today, the guidelines for intubating a patient with proven or suspected COVID-19 recommend rapid-sequence induction (RSI) to reduce the risk of the patient coughing and spraying the area with aerosolized coronavirus. No one in that situation seems worried about testing the airway.

What about the patient who is asymptomatic, and has a recent negative COVID-19 test result? There is legitimate concern that the patient could still be in the early, asymptomatic stage of infection, and the incidence of false negative results from COVID-19 testing could be as high as 30%. By that logic, we should treat every patient as a PUI, and perform RSI on all comers. It would be interesting to survey anesthesia professionals and see how many now perform RSI as their default approach. Certainly, residents now ask me on nearly every case if the plan is RSI, and I hear from colleagues at other institutions that my experience isn’t unique.

What about extubation?

If we don’t want coughing on intubation in the era of COVID-19, logically we wouldn’t want it on extubation either. Awake extubation, especially in the hands of novices, can include an alarming display of coughing and struggling by the patient, accompanied by cries of “Open your eyes! Take a deep breath!” by the person at the head of the table. More coughing follows as the tube comes out. In contrast, a recent review article on the care of COVID-19 patients advises removing the endotracheal tube “as smoothly as is feasible”. For our colleagues in the United Kingdom who are accustomed to deep extubation, this is routine. In America, it isn’t.

Anecdotally, there is new interest stateside in the art of deep extubation. If you’re experienced with it, there couldn’t be a better indication for deep extubation than the COVID-19 pandemic, and you’ll probably hear less backtalk from those who still think it’s dangerous. However, anyone who hasn’t been well trained in deep extubation, or who hasn’t practiced it in quite some time, has no business trying it in a high-stress situation. There are other ways – dexmedetomidine, lidocaine, ketamine, opioids – to achieve a tranquil, cough-free emergence.

How will medical students and residents learn?

As the universities evacuated this spring, the medical students disappeared along with the undergraduates. It’s unclear when they’ll be back or how they’ll make up the lost time. The anesthesiology residents are here, but at many programs they’ve been kept away from the intubations in the emergency department (ED) and the COVID-19 wards.

In the operating room, it would be interesting to know how many anesthesiologists find that they’re less willing now to let a resident struggle with mask ventilation, if they allow it at all. Certainly, it’s not easy to teach mask ventilation today with so many obese patients. Residents with smaller hands have difficulty reaching the mandible even on normal-size adults, and need to learn alternate methods such as the modified chin-lift. If they have fewer opportunities to ventilate by mask, it will be tough to learn to do it well.

Will COVID-19 succeed in making the video laryngoscope (no matter what brand you choose) the default standard of care? Will residents ever learn fiberoptic intubation? The same guidelines that encourage RSI also recommend video laryngoscopy and avoiding fiberoptic intubation for any patient suspected of COVID-19. Cost may be the only reason keeping many departments from adopting video laryngoscope use today for every case. Why drive without headlights when headlights can be had? Those of us who are old enough will recall when we had the same kind of standard-of-care discussions about pulse oximetry, end-tidal CO2 monitoring, and the use of ultrasound for central lines. Perhaps COVID-19 simply will push us sooner toward video laryngoscopy for everyone.

Aerosol generation?

Here’s a question: Is routine airway management in the operating room, under controlled conditions, really the same in terms of aerosol generation as airway management in the ED or the ICU? Does it make sense to treat them as equivalent?

Imagine that we have a patient who is afebrile and asymptomatic, with a negative COVID-19 test result documented within 48 hours. We are preparing for a routine surgical or diagnostic procedure. We preoxygenate and administer an hypnotic agent and NMB. Assuming a good mask seal and easy ventilation, what quantity of aerosolized respiratory secretions actually would escape into the air? What is the real risk of coronavirus transmission?

Intubating this patient, who is completely paralyzed, should generate no coughing at all. It’s completely different from approaching the critically ill patient in the ED or ICU with a high viral load, who is likely to be coughing relentlessly and receiving high-flow oxygen. Similarly, smooth extubation of the normal surgical patient should produce little or no coughing, and minimal aerosol generation. It’s still reasonable, if you wish, to wear higher-level personal protective equipment (PPE) than the simple surgical mask and eye protection we wore before COVID-19, but the practical risk seems far less, and wearing full head-to-toe PPE seems wasteful.

The “post-aerosol pause” – a waiting period after intubation and extubation before allowing personnel in or out of the operating room – is meant to allow time for air exchange to clear the air of contaminants. Should it be done only for patients with confirmed or suspected COVID-19, or expanded to all patients, given the risk of asymptomatic infection and false-negative tests? The time required to remove airborne contaminants varies with the room’s air exchange rate per hour. The pause would need to last 14 minutes to achieve 99 per cent removal in a room with 20 air exchanges per hour, or as long as 46 minutes if there are only 6 exchanges per hour. Now that elective surgery is ramping up again, production pressure and sheer human impatience has buried the post-aerosol pause except for urgent cases in patients with proven or suspected COVID-19.

Will we ever get back to “normal”?

No one knows the answer. Writing today, I suspect that many anesthesia professionals may be wearing N95 masks for intubation, extubation, bronchoscopy, and upper endoscopy (including TEE) for a long time to come, even after the pandemic is over. It’s hard to walk back PPE recommendations, or eliminate worry about some new lung pathogen yet to come.

As long as we don’t let fear stand in the way of common sense, or let donning and doffing PPE distract us from patient care, we can make productive use of some lessons learned from COVID-19. But how we think about  airway management may never be quite the same.

Author’s note: This article was written in May 2020 for the American Society of Anesthesiologists’ monthly magazine, the ASA Monitor. It was published online ahead of print on June 29, 2020.

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Selected references:

Warters RD, Szabo TA, Spinale FG, DeSantis SM, Reves JG. The effect of neuromuscular blockade on mask ventilation. Anaesthesia 2011; 66:163-167. DOI: https://doi.org/10.1111/j.1365-2044.2010.06601.x 

Sachdeva R, Kannan TR, Mendonca C, Patteril M. Evaluation of changes in tidal volume during mask ventilation following administration of neuromuscular blocking drugs. Anaesthesia 2019; 69:826-831. https://doi.org/10.1111/anae.12677

Priebe HJ. Another nail in the coffin of the practice of checking mask ventilation before administration of a muscle relaxant. Anesth Analg 2019; 129(3):e103-e104. doi: 10.1213/ANE.0000000000004260

Broomhead RH, Marks RJ, Ayton P. Confirmation of the ability to ventilate by facemask before the administration of neuromuscular blocker: a non-instrumental piece of information? British Journal of Anaesthesia 2010; 104(3): 313-317. https://doi.org/10.1093/bja/aep380

Kheterpal S, Martin L, Shanks AM, Tremper KK. Prediction and outcomes of impossible mask ventilation. A review of 50,000 anesthetics. Anesthesiology 2009; 110: 891–897. https://doi.org/10.1097/ALN.0b013e31819b5b87

Orser B. Recommendations for endotracheal intubation of COVID-19 patients. Anesth Analg 2020; 130(5):1109-1110. DOI: 10.1213/ANE.0000000000004803

ASA and APSF Joint Statement on Perioperative Testing for the COVID-19 Virus. Online publication April 29,2020. https://www.apsf.org/news-updates/asa-and-apsf-joint-statement-on-perioperative-testing-for-the-covid-19-virus/ [Accessed April 30, 2020]

Infectious Diseases Society of America Guidelines on Infection Prevention in Patients with Suspected or Known COVID-19. Online publication April 27, 2020. https://www.idsociety.org/practice-guideline/covid-19-guideline-infection-prevention/ [Accessed April 30, 2020]

Anesi GL. Coronavirus disease 2010 (COVID-19): Critical care issues. UpToDate online publication, last updated April 24, 2020. https://www.uptodate.com/contents/coronavirus-disease-2019-covid-19-critical-care-issues?source=related_link#H3884198318 [Accessed April 30, 2020]

Rajappa GC, Parate LH, Tejesh CA, Prathima PT. Comparison of modified chin lift technique with EC technique for mask ventilation in adult apneic patients. Anesth Essays Res 2016; 10(3):643-648. doi: 10.4103/0259-1162.191111

Wald SH, Arthofer R, Semple AK, Bhorik A, Lu AC. Determination of length of time for “post-aerosol pause” for patients under investigation or positive for COVID-19. Anesth Analg 2020; published ahead of print April 28, 2020. https://journals.lww.com/anesthesia-analgesia/Citation/9000/Determination_of_Length_of_Time_for__Post_Aerosol.95646.aspx [Accessed April 29, 2020]

Sibert K, Long J, Haddy S. Extubation and the Risks of Coughing and Laryngospasm in the Era of Coronavirus Disease-19 (COVID-19). Online publication at Cureus.com, May 19, 2020. https://www.cureus.com/articles/31997-extubation-and-the-risks-of-coughing-and-laryngospasm-in-the-era-of-coronavirus-disease-19-covid-19

ANESTHESIOLOGY 2019 may have been the last old-school, convention-size, professional meeting I will ever attend. I could be wrong, but it may mark the end of an era. Disruptive change to the convention business model was inevitable, though hastened by COVID-19. On June 5, ASA leadership announced that the 2020 annual meeting will be virtual — for the first time, but perhaps not the last. Does this news herald disaster or opportunity?

When I was a resident attending my first ASA annual meeting, the huge convention center struck me as the mother lode of anesthesiology knowledge, with lectures and workshops that couldn’t be found anywhere else. Today, I wonder why I would travel across the country to attend a refresher course lecture in a freezing-cold meeting room, when I can watch similar content on YouTube or VuMedi for free, in comfort?

Professional associations could take this moment to move decisively into the video/podcast market. Speakers could record their own lectures, pro-con debates, and panel discussions, and societies like ASA and CSA could post all the content on proprietary video and podcast channels for members to access year-round. Think of the money we could save in travel and the cost of renting convention centers. Giant conventions at the ASA level are limited to only a few cities, most of which wouldn’t be my choice to visit.

The future of exhibit halls?

Corporate interest in buying exhibit space at anesthesiology meetings was fading fast, even before COVID-19. Why pay to send people and equipment to exhibit halls when mergers and acquisitions have centralized all the purchasing power? As recently as ten years ago, many anesthesiologists were able to influence which laryngoscopes or epidural kits their departments would order. Today, people who negotiate purchasing contracts typically work in the central offices of health systems, not in operating rooms. Today, most of us can do little more than complain about our inadequate stock of video laryngoscopes or the maddening electronic health record we’re compelled to use.

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Author’s note: This article was written in late March, 2020, for publication in the American Society of Anesthesiologists’ monthly magazine, the ASA Monitor. It was published online ahead of print on May 8, 2020.

As you read this, we will be at least six weeks further down the road of the COVID-19 pandemic than we are today. We may have answers to the questions that are causing us sleepless nights. With the benefit of that hindsight, what should we have done differently if we had known in March what we know today, in May?

There are two ways to look at this: the “macro” view and the “micro” view. The first refers to national policy, and the second looks at what we are doing as physicians, in our own hospitals. Let’s start with “micro”, as that’s what we have the most ability (perhaps) to influence.

Did we get serious about personal protective equipment (PPE) too early or too late? Did we waste it on asymptomatic, healthy patients before the pandemic really got started? Or did we fail to take it seriously enough, endangering ourselves, colleagues, and patients?

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I live and work in Los Angeles, one of the plastic surgery capitals of the world. Quite a few of my patients have “had a little work done” — the blandly euphemistic term you’ll hear for plastic surgery makeovers of all kinds. That’s fine. Plastic surgeons have children to feed too.

The problem is this: many of my patients want to convince everyone that their “look” is entirely natural. They don’t want to admit that they’ve had a tummy tuck, an eyelid lift, or breast implants. One patient tried to tell me that the perfectly matched scars behind her ears were the result of a car accident, not a face lift. In front of family members, patients will even deny having dentures. That’s understandable, but unwise from a medical point of view.

The fact is that plastic surgery has implications for future medical care. Your anesthesiologist needs to know about it, and your surgeon does too. It may be cosmetic, but it’s still a bigger deal than getting your eyebrows waxed.

Here’s why we need to know the cosmetic secrets our patients may NOT want to tell us.

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