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Doctor, Disease, and Divorce



Illustrations of the article entitled The Doctor, The Disease, And The Division / i

Illustration: Benjamin Currie

Shortly after the coronavirus invaded my busy Brooklyn hospital, I found myself caring for an elderly man with kidney problems. Let's call Mr Johnson. I am a kidney specialist, and I knew it had to be a regular visit.

John Johnson's kidney with diabetes has failed in the last five years. To survive, she had to go to the outpatient center three times a week for hemodialysis treatment to clean blood. At the end of the recent session she began to tremble and felt uncomfortable, so the nurses sent her to our emergency department.

In addition to poor kidney function, patients on dialysis have also weakened the immune system leaving them vulnerable to malignancies. Those burns can be the first sign of a viral infection in his blood, which may be deadly but not very curable with traditional remedies. But recently we are also concerned that these patients may be infected with SARS-CoV2, a novel coronavirus that causes the disease called Covid-19.

For the next three days he stayed in the hospital and received IV medications, just in case. The blood test showed no sign of the infection and his cold did not return. He felt good, in fact, and began to get so much pain from being stuck in the living room alone that he wanted to go home and sleep in his bed. I was ready to let him. We could make the best use of a coronavirus patient's next bed, which has had a lot. A recent coronavirus outbreak in New York City had reduced the hospital beds' supply so much that some patients were forced to wait in the emergency department for about 24 hours.

Mr Johnson & # 39; s SARS-CoV2 result came back the next morning. It was great.

Even with this virus Mr. Johnson was uncomfortable going home, because he had no symptoms and was healthy enough to isolate himself. To make sure he is still well, the doctor will meet him in solitary confinement at the dialysis center.

Leaving the hospital is something of a process. The social worker needed to arrange a taxi to dispose of him, and even print his references in a special pink paper that made it clear that his desire to sacrifice cardiopulmonary resuscitation or mechanical ventilation would go a long way in his life.

When her nurse came to her room that afternoon to deliver her discharge papers, she found that Mr Johnson had died quietly in bed.

Mr. Johnson was just one of the 285 New Yorkers we lost to Covid-19 that day.

I have never seen anything like it.

As I write it's been six weeks since first confirmed the Covid-19 case in New York City March 1. I was working shifts at three Brooklyn hospitals and with my colleagues in our advanced nephrology training program. We will eventually graduate as board-certified specialists in kidney disease, which we have never felt close to. I watched as the epidemic broke out in the outlying valleys, watching as my hospital started with maybe three people under investigation, and then filled up with hundreds of infected patients within a month. I thought I had gone through some difficult days in my previous training as a resident of internal medicine. I remember nights during the last flu when I wished I could hit the ambulance tires to prevent them from bringing in other patients.

Under normal circumstances my job is to care for chronic diabetic patients who are admitted to the hospital for whatever reason, to be sure that they end up getting regular, replacement tooth replacement therapy that they need to survive. I also help patients with severe kidney failure, and causes ranging from infection to urinary retention to heart failure. Usually their kidneys recover without much trouble, if the cause is controlled. From time to time, the damage is just enough to get rid of the body's balance improperly, and these stupid little ones may need urgent training for days to weeks until their kidneys cool.

Covid-19 is different. An alarming number of patients are now growing sudden kidney failure, usually requiring emergency dialing. We don't know why. All I know is that most of them are not getting better. Sometimes Covid patients die just a few weeks later, as their lungs suddenly shrink. Sometimes over days, as each organ becomes immune to the virus. Sometimes they die suddenly because of a traumatic heart failure, as I believe happened to Mr Johnson.

Outside of the hospital, I am limited to friends and family just like everyone else in New York, spending most of my spare time on my PC. I seem to escape diseases, or even hobbies. I've watched a lot of Korean drama both times State and whimsical hematology-themed anime Cells at Work!. I finally read Albert Camus' classic novel The disease. But mostly I always sign in to Ubisoft by accident, unfortunately for an online action game Article 2, in the United States lost in violent clashes after a devastating flu epidemic. As of today, I've put 79 hours into the game.

Category 2 & # 39; s destroyed the DC

Article 2has suffered from DC
Screen: Kotaku (Ubisoft)

The loss is not lost on me. Here I am, a doctor during an epidemic, spending my few free hours playing a game set in a fictionalized America. I first received this money diligently a few years ago, after studying for the first time Sec the game is set in Manhattan. I wanted to see my town revitalized as a playground of doom: somehow the weird stuff of wondering what might be going on in the streets I know, and the healthy dose of "I can see my house here" – a lot of excitement. The sequel to 2019 is set in Washington, DC. I've only been living outside DC early in my career, of course Article 2 give the same local appeal.

With the coronavirus spreading and hopefully now widespread in New York, I've continued to play for a different reason: because I want to win something, instead of feeling completely powerless. I can solve every problem in Article 2 with a bullet, but with a coronavirus my entire set of weapons is empty. As a physician we feel a strong desire to perform something in our patients. This feeling also has the phrase: "Taken in action" is the tendency to intervene or in solitary situations, lest you hurt rather than recover. However Sec I could freely fight the disease – or at least the enemy groups represent the evil of its outcome – with my rifle and rifle, no reasonable consideration.

I think I also get some twisted satisfaction knowing that as things are bad now things can get worse. The economy may slow down, tens of millions are left helpless and paralyzed, with friends and families meeting only for sharp video chat, but the law is not broken by armed criminals roaming the streets. For now I'll take what I enjoy.

Loading screen. Connects to Tom Clancy & # 39; s The Division® 2 Online Services on Tom.

I came back after a long day at the hospital. Time to get into the White House, my headquarters upgraded Article 2, see what's new. My friend Matt says he'll come to his home in Queens and meet me there.

I've been known for Matt, online and offline. We have built neighboring districts on isolated hills e There is no human sky and it left the monster bloody like a spilled jam How to Expel. We shared a handful of bottled beers on dive bars in Manhattan & # 39; s East Village, and we ate our weight in Flushing, a neighbor in Queens who is currently the worst hit by the epidemic. Now, we are the patrons of the Strategic Homeland Division who are walking the remains of the disease Article 2It's Washington, DC.

Tonight we step out of the presidential telephone and weep under one of the broad billboards set by L & # 39; Enfant, ignoring the furnace layers and the cries of the people in the following blocks.

The big city is under attack and full of detritus, but DC buildings are still standing. The illness took thousands, and those who could, rich and well-connected, fled the city, leaving the remaining citizens.

First Sec The game, set in New York City, described the origin of the epidemic. A socialopathic ecofascist viressism expert obsessed with social Darwinism has created a rapidly spreading, deadly, flu virus (or, depending on the in-game source, unluckily, and smallpox) calling this "dollar flu." This infection has been a non-biological disease, designed as a terrorist weapon to expedite human ends. The errant scientist injected the virus into a money transfer to Manhattan during Black Friday. The infection spread like wildfire.

Soon violence broke out in the community.

Answers and other respiratory masks abound in the post-New York City and Washington, DC series, The Division

Repirators and other respiratory masks abound in New York City's postpartum disease and Washington, DC, Sec series
Illustration: Ubisoft

In response, the government immediately removed the Catfortophic Emergency Response Agency, the in-game version of FEMA, and the Joint Task Force, a military action that combines occupational units with the National Guard. Their mission is: to provide efforts to assist the accredited hospitals and to emphasize the placement of people across the country. CERA and JTF found themselves frustrated, and in one of the final actions before his mysterious death, the president called on the "Strategic Homeland Division," or SHD, a group of highly secretive people embedded in densely populated areas, to strengthen arms to continue government.

Now, seven months after the flu epidemic, a city left in Washington, DC, is home to terrorist groups, with civilian survivors caught in the middle. (Twisted terrorist hotspots, government secret organizations, heroic clandestine operators: These signposts Sec games as part of a short-lived multimedia empire inspired by the novel-laden department of the latest arch-Conservative technothriller Tom Clancy.)

Matt and I head to the war-torn fields of the National Mall, where the Division agent, Brooks, made a phone call. We crashed into a downstairs parking garage that was breaking up in a bid to help the injured comrades in a brutal fight against a group of thugs. I shoot a regular turret designed for you personally. Taking cover nearby, Matt releases a body armor device called a nest. With complementary fighting skills we have become a trusted team of two men. Immediately we enter the destroyed garage, killing enemy waves, and reaching the level of the ground. The day is ours, and so is the government aid camp we come from. With a friendly impulse going around the place, Matt and I look around.

I see containers and shipping trucks at CERA, let them carry medical supplies and food. Revealed, they are now building protective barriers for the camp. The same bold CERA insignia trucks are rested at the intersection and parking lots throughout the game.

The most popular trucks outside of New York's actual hospitals are the ferry trains that we use as temporary flights. A friend of mine from a hospital social worker took a picture of you. You can still see the Walmart logo on the side.

Throughout the garage parking lot I've shot a lot of stuff from my fallen enemies. I'm holding a sturdy, high-tech, long-wearing security guard for this 20-minute long drive rather than my N95 daily disposable masks. (To this day, I still get one N95 mask a day, and if I ask.)

In sports, heavy protective suits have respiratory systems consisting of hanging wall laboratories and field hospitals.

In real life, the emergency care units that are immediately in operation are separated by plastic sheets and duct tape.

Two weeks into my first month of coronavirus. I stopped associating with the families of my patients.

Visitors are immediately banned from many New York hospitals, because of concerns about the spread of the virus. One day I was following a coronavirus patient, Mr. Diaz (I've changed his name and those of the other patients in the article). Severely ill, his lungs failed with the support of an implanted air support, his other organs being blocked by the virus. When I look again at the chart that used to be painful, I reminded him that he was 83 years old, and that his health was declining for years as his chronic illnesses got stronger.

In the afternoon I called his eldest son, who had taken the responsibility of making decisions on behalf of his lifeless father.

“At present, your father is too ill to tolerate normal rhythm, so the next option is something called chronic hemofiltration. It does the same thing as regular dialysis does, removes blood from the body and cleanses toxins that his kidney would do before the virus injures itself, but does it slowly, gently, over twelve to twenty-four hours. I need your permission to start this process, but I have to be honest with you: Patients with severe lung injuries your dad has kidney damage, and by his age … they haven't done well. "

I thought I was fine when I broke the bad news to patients and families, but I don't know how to tell her that every coronavirus patient I saw at the intensive care unit and who needed urgent care has died. Continuous chemotherapy, except that it was much better for the severely ill compared to my usual treatment, was of no avail. The care physicians who specialize in the unit have told me that they do not feel confident about Mr Diaz's passing. They have seen this same story played out over and over the last two weeks, and it lives on its own.

I listen as his son tells me his dad is fighting. He had done it with a heart attack and diabetes, and his family believed he would pass away, and we should do our best.

A quarter to five I received a call from a hospice resident in the Covid ICU, one of the four dedicated units. There was a problem with Diaz's hemofiltration. According to the nurse manager there was only one machine available. They had not started in Jordan until now. What should they do?

Mr. Jordan was 37 years old. He died on dry land as his lungs collapsed, saturated with fluid as the virus invaded, unable to exchange oxygen even with the settings for ventilation. His kidneys were closed days ago, first bleeding from the small amount of urine they could, they had just given up, leaving water and spilled out and trapped in his failing body. Like Mr Diaz, he was very sick with traditional hemodialysis, his blood pressure was unstable, heart rate like a hummingbird & # 39; s.

I asked the ICU to start working on her this morning. Like Mr. Diaz, he would certainly die without a kidney transplant incorrectly. I don't know when. I don't even know what his face was like, because his bed was hidden with plastic sheets lined up and down on the roof to shut off the virus. (The resident I met in the ICU compared the incident to something out of it Resident Evil.)

Mr. Jordan recently saw his doctor, and has also received clean health insurance without needing to lose weight. Why a man so close to my age was on the verge of dying at the hospital when I stood left, I couldn't. ICU doctors do not feel confident about her hope, either. The damage to many organs was very, very severe. Trying to support his disfigured kidney with dialysis would give him hours, perhaps a day, knowing nothing about medical malpractice, until his broken body arrives at an inevitable point.

“Fuck, you'll play me,” I said. "They're both free … We, ah, we have to make Jordan first. I'll … get something from Diaz and get back to you."

I have nothing else.

Both died the next morning.

One night and I'm back in the game. Matt is turning the alley just off F Street in downtown, perhaps three blocks east of the White House. We track inventories.

“Brother, if you keep moving forward as you are then you will be taking over the empro,” I remind you (as he well knows) why all the nearby enemies have been taught about guns. "Hold on, I'm fine."

I rubbed the rug behind the dumpster where Mati slept, painfully in her hand. The bullets connect the metal. The space is a small minority of two government ambassadors against the True Sons crowd for blood. Well, blood is my money, too. No arresting anyone in this game: It's always a gun. I always get my marks back dead. But right now I have to rehab my injured friend.

"I got it, I got it."

I held the fifth mouse button, feeling a stream of reassurance as I rescued her again. The progress bar around his body fills in green. He stops and sacrifices himself.

A happy chime is ringing and a notification pops up in the corner of my screen. “Hey, did I get XP for that? It's fun. ”

Regeneration in the real world, of course, is not a smooth task with a single button. Gritty 2008 first person shooter Far Cry 2 and its sequences have a way of understanding the injury, allowing you to quickly clear scary characters from the flesh through the pipes and touch the wounds before hitting the morphine ampule. I think so Sec

Jobs uses some kind of magical nanotech that quickly digs in and cures great grief; things don't explain.

Trying to revive someone in real life is, in fact, more powerful than simply pressing a button. We fail at the worst, and those failures are hard to process. Death, by nature, is a normal part of hospital operations. Learning how to live with it, adapting to the best of your ability, is part of a quiet medical curriculum, things that no speech or textbook can teach you.

To give you a sense of the mortality rate we are seeing, the human cost of the epidemic, I want to share a common situation with just one person too much, a condition that has played out many times in my training. A situation like my colleagues now face many times a day.

Flashback before the virus came and changed everything. Get into the shoes of your resident doctor for internal medicine.

It's 4 p.m. and you sit down to eat for the first time that day. You start to open the graham crackers and chocolate pudding you brought out of the pantry unit but first hear the hall speaker give a warning of a cardiac arrest and notice in shock that the room number is where your patient is, but he just saw me this morning and, while he didn't look too big, he didn't look very bad, too.

You throw away your food and the speed that goes down the hall and up the stairs and into the corner. Running is always a bad idea in hospitals, there are so many things you can go into or keep going. Not to mention that it can be very embarrassing to be accepted into your job.

Your patient is lying there on his bed, looking fat, with a small, hot body with the desire to throw his hands deep into the old man's chest. The nurse's assistant is standing next to important manageable symptoms: constant heart rate, blood pressure is unreadable, oxygen levels are critical. Ping, ping, ping.

The delicate care that goes to the doctor is gone, the dark look in his eyes, lingering until the next scan, which asks where the best team is. Best group: It's you. Checking the patient chart on your phone, explaining that her pneumonia was getting better, she needed less oxygen, her labs had less damage … well, less.

Interns form a line to switch on chest pressures. Nurses passed on prescription drugs from a broken cart. The white EKG line on the defibrillator only shows vague wrinkles (but does not light up, or emits a long tone where there is a flatline; no one turned on that feature). It has no intention of scaring her. The electrical system of the heart is not a problem now. Anesthesia group is emerging, here is the best airway. They just open her smooth mouth while the winner breathes and removes the oxygen mask, probing her deeply into her throat with a wide metal fence. He stubbornly forces the thick plastic tube down his airless trachea, lifting and pulling and moving along those tiny flats that have given him a voice once, in better times.

Time is running out. A petite intern now doing chest pressures can't get on the bed. One gets a foot pedal to get up, but no one can squeeze it.

The code is called code for a reason. You are following an algorithm. He does certain things in a certain sequence over and over again, hopefully this gathering will be his last. But even if they are well organized, somehow the codes still feel chaotic. Maybe the rubberneckers are standing around the hall, the other nurses and doctors checking the door, looking and wondering, wondering if he's too old, too sick, this is not right, but what can you do about it?

Fifteen minutes pass. A pull check. There is not even a stroke in the heart. In the last five minutes this has gone from terrible to monotonous. People are sweating and tired. Side-eye is contagious. Can it be done? The critical care that he says he calls it. The collective human recovery team begins to flood, moving back into their daily activities. Maybe it's better this way. Her misery is over now, instead of continuing for a few hours of sadness before it is over.

Sometimes you make a resignation and review how everyone did, but not tonight. No one calls time to die. Looks at the clock on the wall and writes it down. You will need to file a death certificate before you can leave for the day. Hopefully the brother's married phone number is correct. I hope they will.

Those who are lucky enough to survive a cardiac arrest without serious brain injury are often deal with depression or post-traumaatic stress disorder even months later. I'm not surprised: The powerful medicine we provide in large volumes of regenerating hearts is the same chemicals the body produces to give the fight response or flight, our animal environment. But the sadness of the participants in this code is becoming more and more fragile. Confidence creeps in. Is there anything wrong that led to this? Could you have blocked it? Did he do a better job saving her? And if a still heart was unavoidable, perhaps for someone with terminal cancer or terminumma of a deadly disease, would you have just confirmed that they died on their own, suffering from needles and tubes, long in fear and fear and pain? The patient and their family say they want to live at any cost, and now you have to make sure the payment will be paid.

Each renewal failed to participate, and most successful ones, too, shed tears in your eyes. You have to find your time to be sad, because work doesn't give you away. Sometimes she looks sad in the mirror, alone. Sometimes it is the beginning after you leave your arms in arms, raising the glass with the last words of Edgar Allen Poe: "Lord, have mercy on my poor soul." Your patient, or you? Probably both.

Once a month, once every few weeks – not uncommon but unfortunately expected – have grown significantly. Now you face it several times a day.

Back in Washington, DC. After the dollar flu.

We are back at the Theater Settlement, one of two major camps for residents who have been in conflict. Before I return to the free fire place where we met our temporary illness, I stop to enjoy our handiwork. This once shoddy castle for a shocked and needy man now has a hydroponic herb garden, a children's playground, and even a pirate radio station. We unlocked each and every improvement over the hours of gameplay, fighting the flow of the story and wiping out the enemies. The tough leader of the public nails, Odessa, was a SHD agent himself, torn apart by the pain of fighting that lost his foot. The PA program plays out the declarations he wrote, words of pride and resilience for his people, which they accomplished together to build a home (with the utmost help of us). A smiling and confident smile replaces the downcast eyes and fears encountered when we first arrived here.

Article 2

Article 2
Screen: Kotaku (Ubisoft)

But it doesn't sound like a living, deep District I knew, DC I still love: a proud city of many, welcoming and growing alien communities, sharing a living heritage of arts and culture and food. The city where my adult life began. The region for gin smokers and smokers, the location of the Bad Brains home with Fugazi and Duke Ellington. The first home that I didn't supervise for my parents or college life. The not-so-distant region of the walled city of the museum where Matt and I used to place armed robbers in large numbers.

Not one of the DC cases seems to have done so Article 2, and whether it was through ignorance or by design this might have been a good choice. Washington's monuments and legislatures are public thought, but this District is a people who have made their living there, with the city's memory and history on their shoulders. I caught a glimpse of her heart during my brief time there.

As we leave the scene, as the gate suggests, we hear a recording that hasn't changed since we first arrived. Odessa warns tourists that if you need a place to stay, go somewhere else; we can provide you with food and street water but stranger, you will find no comfort here.

With the global spread of the coronavirus and the deceptive response of the American government, Article 2 It has been a mirror of current events and public policy, a game with a political message around the past, weak opposition from its creators. Of course, video games have always been political. From what is said in thesis mythology you have already been assigned a place The Oregon Trail, to a fantastic unsubtle Martian analogue of the Iraqi founder in Red Faction Guerrilla, this is not a difficult concept to understand.

Of course, medicine has always been political, too.

Every time I do medicine I do politics. Each time I call a pharmacist I urge my patient's insulin to be less expensive for a month's rent. Every time I tell someone their kidneys are slowly deteriorating and their health is about to change forever and we have the means to keep them alive and kicking, but I can't give them the best and the cheapest treatment – kidney transplants – that are appropriate for their migration status.

Now I always ask all my colleagues to put their health, safety, and families at risk of a life-threatening viral patient, wondering if I am denying anyone else a chance in life. Now is where my colleagues and colleagues, working for the largest and richest New York hospital systems, ask for an accident fee for the miserable, miserable work we all all risk our lives to do now with very little money, only to see their requests being chased cold by senior leadership.

Bekunendaba ukuthi ngithuthukise ngokuphelele i-Theatre Settlement uma u-Odessa esesaxosha ababaleki?

Isigaba 2

Isigaba 2
Screen: Ubisoft

Nayi iphazili yakho.

Uchithe usuku esibhedlela eligcwele iziguli zeCovid. AbakwaSARS-CoV2 bathantaza emoyeni. Inamathela ezindaweni eziphezulu, ihlala igciwane lapho amahora angama…? Injongo: Fika ekhaya ngaphandle kokuza negciwane nawe.

Ukuhamba ngezinyawo:

  1. Geza izandla zakho, insipho namanzi, imizuzwana engu-20 ubuncane, womile ngethawula lephepha, bese ucima isikulufu ngesitofu sephepha bese uvule umnyango wokuhlanza ngethawula lephepha njll.
  2. Thatha utshwala. Sula ifoni yakho, umazisi wakho, izicathulo zakho, ikhibhodi yekhompyutha, ifoni yehhovisi, noma yini enye ocabanga ukuthi kungenzeka ukuthi uyithinte.
  3. Ngena ekhaya. Susa izicathulo zakho ngaphambi kokuvula umnyango. Susa izicucu zakho bese uziphonsa emgqonyeni okhethekile. Susa konke okunye, isihogo, kufake konke emgqonyeni wezibi. Hlamba izandla futhi. Geza ngesisefo.
  4. Eshu, ukhohliwe ukuhlanza i-pager yakho.
  5. (Dark Souls-style) UFA

Mhlawumbe ngiyamangala, kepha bengingazenzi eziningi zalezi zinto. Ngigeza izandla zami ngokunakekela, yebo, negwebu lesiphuzo sotshwala esesandleni sami ngaso sonke isikhathi lapho ngidlulisa indawo lapho ngisebenza khona esibhedlela. Ngikhumula izilahla zami lapho ngifika ekhaya, bese zingena hamper ejwayelekile (phansi). Angisuli izicathulo zami. Kungani yonke le theatre yokuphepha kwenhlanzeko sengivele ngisesakhiweni eqinisekisiwe ukuthi ngineziguli ezisebenza nge-coronavirus, ngisebenza ehhovisi okwabiwe ngalo laphaya ehholo kusuka ewadini ye-Covid? Isinyathelo ngasinye esedlule ukugeza izandla zakho nokushintsha izingubo sinembuyiselo enciphile.

Lokho bekushilo, ngingahle ngikwazi ukuba umgibeli omncane kunabaningi. I have the good fortune of being able to do most of my work without direct physical contact with patients, and I need not fear infecting loved ones at home, since my only roommate is a cat.

Sunday morning. Matt and I wander Foggy Bottom, on our way to finding a hidden cache of SHD technology, when the building we’re approaching through the fog, a curved modern facade next to a plaza with a Metro station, strikes me with a sudden sense of familiarity.

“Matt, that’s the George Washington University Hospital… I had a fellowship interview there last year. I was here.”

The virtual hospital, whose real-world analogue is famed for treating presidents, senators, and cabinet secretaries, now sports the red biohazard icon that denotes a quarantine zone. Each zone has a dark nickname; this one’s named “The Slaughterhouse.” Silent ambulances are parked haphazardly on the curb, empty stretchers tipped over.

There’s a quip I used to tell new interns as a senior resident, my weary thousand-yard stare greeting their fresh faces. “I thought I had seen some shit in med school, that I knew how the medical sausage is made. Guess what: I was wrong. I didn’t know nothing. Today, you’re starting work in the slaughterhouse. Get ready.”

Was that really only a year ago? It feels like so much longer, now.

“You know what, Matt, I don’t think I’m ready for this. Let’s go find a control point or something to raid instead.”

Another afternoon, four weeks into the coronavirus outbreak.

I went to the emergency department to speak with one of my patients, hoping I could just shout my handful of questions across the hallway at her. The place was crammed with stretchers, coughing patients everywhere. I was wearing my N95 mask (covered with a surgical mask), a hair net, and a plastic face shield. I hadn’t planned to get closer than six feet from her, but unfortunately she was dozing. Next to her was a man freshly intubated, occasionally stirring to gag and gnaw on the tube driven down his throat. I asked a resident if I should get a gown before I moved closer to wake her up. He told me that I was already in the worst place in the hospital. It didn’t matter at this point.

These days I try to avoid physically seeing patients unless I absolutely have to. Those are the orders from the top to minimize staff exposure. I recently called a patient on her cell phone to ask how she was feeling. She was staying in a hospital room two floors up.

For all of us, here on the front lines, it feels like it’s not a matter of if, but when we get infected. Two of my close friends I trained with in residency are infectious disease medicine specialists, one in Manhattan, one in New Orleans. Every time I don’t hear from them for more than a few hours I wonder if the virus has come for them. Are they gasping for breath on the floor at home? Imprisoned in a drug-addled sleep in the ICU, a machine forcing air into their clogged chests? Maybe they just got busy.

Every scratch I feel in my throat, twinge I feel in a joint, ache in the back of my head: Is this the harbinger, or do I just need to get a good night’s sleep? Perhaps I already had the virus and didn’t notice, the infection coming and going silently like a burglar casing the joint and finding nothing worthwhile to steal.

Word is that anosmia—losing your sense of smell—is an early and sensitive sign of an active infection. I try to go find things to smell to make sure I’m still alive, and remember what they’re like if the day comes when I can’t.

One sense video games have hardly ever engaged with is smell, I suppose for obvious practical and technical reasons. Probably not a bad thing, as Matt and I tactically advance down the hallway of an abandoned field hospital once run by the “Department to Control Diseases,” aka the “DCD.” It’s occupied by a faction called the Outcasts, whose motivations perplex me.

Apparently they want to weaponize the dollar flu virus, which was already created as a bioweapon, as some manner of elaborate vengeance? The mission coordinator is worried that they could find dangerous viral samples in improperly disposed bodies. There are plenty of bodies here: neatly sealed up in long black bags with the CERA logo, crude skulls spray painted on them, piled high in corners like so much garbage. DC isn’t known for its balmy summer weather, and I can only imagine the astonishingly awful odor this morgue turned pressure cooker must have (perhaps like gingko tree fruiting season).

A challenge in The Division 2

A challenge in The Division 2
Screen: Kotaku (Ubisoft)

The environmental hazard of countless marinating corpses passes without comment, as always, from the silent agents we play. I’ve killed 3,911 enemies in my time playing this game. Who’s been taking away all the bodies I’ve left in the street?

A group of yellow-jacketed Outcast goons charge in and we add a few more bodies to the pile.

The leader of the Outcasts is apparently an asymptomatic carrier of the dollar flu, which SHD leadership seems to think makes her a walking bioterror weapon of some sort. Asymptomatic carriers are not exactly uncommon with viral illnesses, or for that matter even some bacterial infections. The best known of those is the Irish immigrant cook Mary Mallon, notoriously dubbed Typhoid Mary. If I’m an asymptomatic carrier for SARS-CoV2, I might be putting all my coworkers at risk every time I go into the office we all share—but they could be asymptomatic carriers, too. Only those few of us who developed concerning symptoms have been tested. All negative—so far.

This crisis was a long time in coming, fed by short-sighted hospital and government policies over many years. “Lean” management strategies for staff and supplies, either to compensate for budget cuts or maximize revenue, created a perfect storm of perverse incentives. Frontline medical workers are at high risk of getting sick during a pandemic, yet highly trained, experienced staff like dialysis nurses and critical care nurses, already in short supply, aren’t easily exchanged or replaced. Nor are essential medications and equipment. One task every resident physician knows is keeping up with which commonly prescribed medications are on national shortage that month. Will it be an antibiotic, a sedative, an opioid, a heart medication?

Sometimes it’s as simple as the 100cc saline bags we use to reconstitute IV medications. These small plastic envelopes, which hold about a half-cup of sterile fluid, were missing for months in 2018 after Hurricane Maria devastated the supply chain of their primary American manufacturer in Puerto Rico. We learned to make do with substitutions and workarounds, like ordering alternative, sometimes inferior medications, or having nurses slowly infuse a syringe of medication by hand instead of with a programmed pump.

Compounding matters is the complex fee-for-service payment system for hospitals, in which revenue-generating enterprises like elective procedures, outpatient imaging, and cancer treatments essentially subsidize the cost of money-losers like intensive care units. Take away routine colonoscopies and suddenly the fragile financial balance collapses. “Safety net” hospitals in less affluent neighborhoods and rural areas can’t compete against massive (often ostensibly non-profit) healthcare conglomerates, and have been regularly acquired (and then sometimes closed) by these medical giants. America’s long legacy of systemic racism created many of these inequities, and continues to sustain them—I’ve borne personal witness to this in my career. Caring for the sickest and most vulnerable people, with the least ability to pay, might be medicine’s most important mission, but it’s a poor business proposition.

For years, dedicated caregivers have found ways to keep things going, but the coronavirus has laid bare how broken the system really is. Under stress at every point simultaneously, the American healthcare apparatus simply can’t compensate. This week, anticipating running out of protective gowns, my hospital started issuing plastic ponchos instead.

We each received one poncho.

I’ve felt for a long time that 2013’s Surgeon Simulator is perhaps the most accurate depiction of the experience of practicing medicine in the United States. Contrary to its name, Surgeon Simulator is an absurdist comedy game with an intentionally convoluted control scheme using individual keys for each finger of the one hand you use to awkwardly pick up surgical instruments and household tools to perform increasingly bizarre and complex medical procedures.

Surgeon Simulator

Surgeon Simulator
Screen: Bossa Studios

It’s not unlike navigating the real healthcare system: Things that should be straightforward are made bafflingly, overwhelmingly difficult by a system seemingly designed to be as clumsy and discouraging as possible, and you drop things and break things and slap them back together and just hope that you didn’t do any permanent damage to someone who’s trusted their life to your flailing hands. You rage and laugh at the surreal efforts it took to do the right thing. Perhaps a claw hammer isn’t the best tool for a heart transplant, but that and a power drill and a coffee mug are all you’ve got.

I could always cope with the heartbreak before, believing that we could keep muddling through until it became obvious to everyone else that we couldn’t go on this way. I guess I never expected it would come so soon, with so much death in so little time.

The timeline of The Division 2’s dollar flu lore is at best confusing, but the in-game evidence of the federal government’s action at least seems like it was rapid, visible, and vigorous, in stark contrast to the Trump Administration’s disoriented and delayed response to the coronavirus. I’ve visited, in the game, sprawling quarantine refugee camps, abandoned wards filled with sophisticated medical equipment, mobile triage centers. Meanwhile in real life, confusion has marred even the better efforts of the federal and state government responses, like the drive-through viral testing center that New York State set up in a parking lot in my neighborhood that flatly refused to take people on foot or bicycle, in a borough where barely two in five households own a car. One pedestrian turned away was told to call a cab if she wanted a test.

Of course, all of CERA and JTF’s efforts are purely fictional. Perhaps these pretend lettered agencies were as sluggish responding to the dollar flu as FEMA and others have been with the coronavirus. Obviously they ultimately failed, since the game’s fictionalized New York City and DC are reduced to anarcho-primitivist hellholes.

Headlines from a virtual pandemic

Headlines from a virtual pandemic
Screen: Kotaku (Ubisoft)

For me, the most surprisingly painful fictions portrayed in the Division are of basic competence and preparedness. In this branch of the greater Clancyverse the dollar flu exploded, shaking the foundations of American society, pushing its brave civil servants beyond their already great efforts as the union collapsed. And out from the shadows, by secret executive order, steps the Strategic Homeland Division, ready and willing and able, trained and primed. It’s the very image of a state fully prepared for even unimaginable contingencies, and the very opposite of what we’ve just seen in real life.

That said, the America we see in the game isn’t exactly admirable. The core concept of The Division is alarming to even the most casual of civil libertarians. Its idea of thousands of sleeper agents of the “Deep State,” now activated and empowered with an indefinite mandate to act as judge, jury, and executioner in the defense of American society, is like something out of an Alex Jones fever dream. But as a premise for an open-world online game centered around collecting exotic firearms and warfighting technology to unleash against increasingly robust domestic enemy combatants? That works for me.

They knew this was coming, and they did next to nothing.

We were warned, we all saw the evidence coming right from ground zero, well in advance, and the president alternately dithered and raged during the weeks when intervention might have made a difference. In January his closest advisors frankly informed him of the possibility of millions of Americans dying should the virus spread unchecked. Epidemiologists estimate that implementing stay-at-home orders a few weeks, even just days earlier, could have cut deaths up to tenfold.

As the healthcare supply chain stretches to the breaking point, the president is encouraging rebellion against the very restrictions that are saving lives, tweeting “LIBERATE MICHIGAN” soon after small bands of protestors, egged on by conservative lobby groups, gridlocked the streets of Lansing, blocking ambulances entrance to a local hospital. Incredibly, the federal government is now accused of seizing shipments of protective gear ordered by hospitals and state governments and spiriting them elsewhere for mysterious redistribution after insisting that states are on their own to obtain equipment.

So here are two different models of a failed state: The Division’s, in which the crumbling state has lost its monopoly on violence, and ours, the fatally embarrassing confusion of a state stripped of expertise. I’m not an economic analyst, epidemiologist, or any sort of special expert on public health or healthcare administration (outside of a policy class in medical school). But it seems pretty obvious that a coordinated, effective response to a pandemic disease isn’t supposed to look like this.

Trump, and perhaps a distressing proportion of the American public, have decided that qualifications are meaningless. But deciding the experts were overrated came with heavy collateral damage.

After this is all done, the last of the mass graves tilled over, the curve flattened into oblivion, will there be an equivalent of the 9/11 commission, delving into the systemic failures and willful, arrogant blindness that led to tens, perhaps hundreds of thousands of Americans dying?

Maybe instead of demanding accountability it’s just easier to imagine a conspiracy in which the virus is the singular product of a deranged scientist, and a highly prepared and technologically adept secret arm of government already has a strategy to fight back, with plans upon plans and scenarios prepared all the way up to and beyond the collapse of contemporary civilization.

If only we could blame this all on something so simple as a conspiracy. In the real world, no one designed the coronavirus, no monologuing villain unleashed it. There’s no Deep State waiting in the wings to save us when all hope is lost. The institutions that were meant to protect us against the biblical threat of plague were instead deliberately and systematically dismantled for reasons of greed and cowardice, experience and expertise thrown out and replaced by obsequious incompetence, in a decades-long project that has now inevitably resulted in avoidable catastrophe.

Now, all we have is each other.

Friday night, my first full weekend off in a month. Matt and I find ourselves on the Mall, as I stare utterly flabbergasted at the neoclassical edifice housing the Smithsonian’s National Museum of Natural History, apparently transformed into a dedicated flu field hospital, exterior wrapped in quarantine-yellow tarps like a Christo installation. The entrance is protected by an airlock with a searing ultraviolet biocidal light. My hospital doesn’t have an airlock! (We probably don’t need one, virologically speaking, but still.) We drop down and move inside, automatically putting on respirators as we cross the border. Just five minutes ago outside we were in a brutal firefight, and I keep checking the angles for hostiles, but the only thing here is the eerie quiet of the tomb.

For a tomb is precisely what this place is. Bodies wrapped in shrouds, neatly stacked. Humans now as extinct as the dusty mammoth in the foyer.

The Division 2

The Division 2
Screen: Kotaku (Ubisoft)

The murmur of voices leads us into a deeper room, faintly glowing with the dim light of life. A lone nurse still stands vigil here, tending to a scant few patients yet suffering from the flu, asking for any help we might provide.

The game tells us our goal here is to find three audio recordings, to hear them and remember the voices of the dead, to bear witness to the grief and loss each and every survivor still holds within.

We gather our collectibles and leave as silently as we came.

Games have been a part of my life from a very young age. They’ve brought me some of my most joyous memories, and helped me through some of my lowest hours.

In these grim days of social distancing, playing The Division 2 has been my way to reconnect with friends, to put aside for a little while the awful things I’ve seen that day, and to chuckle at how darkly appropriate it is playing a game set after civilization is destroyed by a pandemic. Three dollars well spent.

Regarding my work, I don’t want to give the impression that tragedy’s my only lot. I’ve witnessed quite a few of my hospitalized Covid-19 patients perk up and go home on their own two feet. Facebook friends have reported how they suffered through the symptoms at home and are now back to baseline. And my own hospital liberated its first two critically ill viral patients from the ventilator about three weeks ago after they slowly but steadily improved, hopefully for good, and hopefully the first of many.

Two nights ago, I finally got around to something I’d been avoiding for almost a month: I pulled a certain patient’s chart to find out if they’d survived. It felt unbearable to think he might’ve suffered another intubation, forced to depend on mechanical ventilation for what would likely prove his final hours. But my fears didn’t come to pass. He went home, alive and well, a few days after regaining the ability to breath on his own.

Still, the tragedies are what stick with me, and the hurt never really fades.

I could always cope with the heartbreak before, believing that we could just keep muddling through until it dawned on everyone that we couldn’t keep going on that way. But I guess I never expected that moment would come with so much death, and in so little time.

“I know, but what do you want me to do? I mean, seriously Jon, let’s get real, what do you want me to do?” —Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases

¯_(ツ)_/¯ —Emoticon, frequently seen as graffiti in The Division 2

Siddhartha Bajracharya is a nephrology fellow in Brooklyn. Look for his gaming and culture thoughts at @postwaranemone.

Since I had my first console when I was 10, I've never stopped playing. I'm a multiplatform player and my favorite genre is RPG.

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