To spend time in New York City hospitals today is to see how wrenching the practice of medicine becomes in a time of plague. Photo / Getty Images
To spend time in New York City hospitals today is to see how wrenching the practice of medicine becomes in a time of plague. Photo / Getty Images
This is not a time to die.
Terror, pain and loneliness mingle in the air with the coronavirus in the "hot zone" of the emergency department at Jack D. Weiler Hospital in the Bronx. The room is jammed with patients whose frightened eyes peer above their oxygen masks as they struggle to breathe, feel that they are drowning, wonder if they will ever again see loved ones.
No family members are allowed here, yet the space is more than twice as crowded as normal. About 80 coronavirus patients, ranging in age from 31 to 97, are squeezed into the room, bed to bed, some near death. A group of newly arrived patients sits in chairs in a corner to await stretchers, and they look around in alarm. Doctors and nurses hurry about, so sheathed in protective garb — some of it makeshift, such as welding helmets over ski goggles — that even co-workers cannot recognise them.
Doctors with a patient in the Montefiore Medical Center Moses Division emergency room in the Bronx. Photo / Michael Kirby Smith
The truth is that the doctors too are frightened and exhausted, overwhelmed by death and their own helplessness. Dr. Nicole Del Valle, 29, told me that what shattered her was treating a 30-year-old woman with Covid-19 whose 23-year-old sister had just died of it; Del Valle called her own younger sister and ordered her not to leave her home.
All day in the hospital, Del Valle maintains her reassuring manner as she intubates patients, holds their hands, fights for their lives — and then, she acknowledged, she goes home and cries.
To spend time in New York City hospitals today is to see how wrenching the practice of medicine becomes in a time of plague. Two hard-hit Bronx hospitals, Weiler and Montefiore Medical Center Moses Division, each allowed me and a video journalist into their emergency departments for a day, into the hot zones where contagious patients are treated. We also produced a short video: The hope is that the more Americans understand Covid-19, the more committed they will be to maintain social distancing, thus saving doctors' lives and their own as well.
Journalists have rarely been allowed into hospitals in this crisis; reporters and photographers found it much easier to be embedded in Army units in Iraq or Afghanistan than to embed with doctors fighting Covid-19. Hospitals worry about HIPAA privacy rules, the dangers of infection and the possibility of embarrassing stories. Unfortunately, the shortage of gritty on-the-ground coverage means that to many Americans, the coronavirus remains distant and unreal — so they plan a large Easter dinner or gather friends for a game in the park.
The best way to understand the coronavirus is not by tuning into White House briefings but by tuning into the distress on the front line. The Bronx is one of the most diverse places in the country, and the patients I saw this past week were of all races and backgrounds but tended disproportionately to be black and brown. They were mostly feverish, drained — too sick to be interviewed. But there was no mistaking their anguish.|| "I hate it," said Chelsea Gifford, 29, a physician assistant at Montefiore Moses. "You have this horrible feeling in the pit of your stomach when patients say they're scared and you don't have any treatment."
Gifford recalled a patient who had come from an assisted-living centre. "I'm really scared," he told her. "I don't want to have Covid. I'm in a facility, and there are people dying there."
She looked into his eyes and held his hands. "We're going to do our best to make you comfortable," she told him. "We understand it's scary. But we're here with you. We're going to help you."
Gifford struggles to sleep at night and has nightmares — not of catching the coronavirus herself but of infecting her parents. She lives with them but stays in her room and uses her own plate and silverware; she talks to them only through a closed door. She washes her hands so much that angry red sores have broken out on her palms and wrists.
Then she drives to work and sees New Yorkers mingling in the parks, treating the pandemic lightly — and she seethes. "If people saw this," she said, gesturing to the frightened people gasping for breath around us, "they would stay home."
II.
The emblematic procedure of this pandemic is intubation, a last-ditch effort to connect a patient who cannot breathe to a ventilator. It is both lifesaving and terrifying — and unfortunately, for most Covid-19 patients, it doesn't succeed. There's no large-scale data, but in New York City as many as 4 out of 5 Covid-19 patients who are intubated may not survive.
For that reason, doctors and nurses try to give Covid-19 patients a chance to telephone loved ones before intubation, knowing that this may be their last chance to speak. But sometimes there isn't time. At Weiler hospital, I saw a 68-year-old woman deteriorate rapidly, her oxygen level plummeting. A team of a doctor, a nurse-anesthetist, an emergency nurse and a respiratory therapist urgently gathered in full protective gear.
For health workers, intubation is nerve-wracking because it causes the virus to spray out from the lungs into the air. In this case, the procedure was performed in a room on the edge of the hot zone with negative air pressure so that the virus would remain in the room. A plastic box was placed over the patient's head, and the nurse-anesthetist put her arms through holes in the box to perform the intubation.
Doctors in the emergency room at the Jack D. Weiler Hospital in the Bronx, on April 8. Photo / Michael Kirby Smith
The patient was put to sleep and paralysed, and a device was inserted into her mouth to lift the epiglottis and make way for a tube that was passed through her vocal cords about 10 inches down to her lungs. The outside end was then connected to a ventilator, which pumped oxygen in.
Because it would be ghastly to wake up unable to speak with a tube down one's throat, patients are sedated so that they do not rip out the tube; doctors say that for some reason, Covid-19 patients seem to require more sedation than other patients. To be safe, their hands are also tied down.
Next to the woman was an elderly man who had been intubated earlier in the day, and he was declining quickly. For Covid-19 patients, ventilators are sometimes the only hope — but they aren't much hope.
Neither, perhaps, is hydroxychloroquine, the anti-malaria medication that President Donald Trump has hailed as a possible "game changer." Most patients at both hospitals I visited have been receiving hydroxychloroquine, sometimes combined with the drug azithromycin, but people are still dying in large numbers. Some doctors think that these drugs help if administered early, but I spoke to no one on the front lines who believed they were a game changer.
III.
What is most impressive in the hospitals is not the ventilators, CT scanners or other high-tech wizardry. It's the compassion and courage of health workers, and the intervention that struck me the most was decidedly low-tech: the hand-holding.
Katherine Chavez, a nurse at Montefiore Moses, recalled a man in his early 40s with no medical history. He was intubated, and she spent 12 hours by his bedside as he struggled for life. "He would grab my hand, and I just kept telling him that everything is going to be OK," she said.
Dr. Michael Jones, who runs the physician resident program for the emergency departments at both hospitals I visited, sent his young doctors an email last month asking them to go out of their way to comfort the Covid-19 patients:
Take a few moments if you can to talk about patient's families, their lives, their dreams. Ask if there is a loved one you can call. And lastly, two very different things: Hold your patient's hand for a minute as they near death or pass, and ask your entire team to stop for 5 or 10 seconds, bow your heads, state the patient's name, and ask for silence.
This helps us retain our humanity in times of such crisis and gives our patients' families some solace that they were treated with dignity.
Health workers are particularly at risk of infection and death, perhaps because they absorb such large quantities of the virus. Several of the young physicians at the hospitals I visited have Covid-19, and one is in the intensive care unit.
Dr. Michael Tarr, 29, was particularly shaken after he treated a 27-year-old woman who came in severely ill with Covid-19. "We ran every test on her," he said. "There had to be something underlying that would make her so vulnerable. And we found nothing." The patient is still alive on a ventilator in the ICU, he said, but doing poorly.
Courage is not fearlessness; courage is what soldiers exhibit when they charge into battle despite their fears. And it's what apprehensive physicians like Tarr or worried nurses like Chavez display when they walk into the hot zone each day. The same is true of physician assistants, technicians, respiratory therapists and cleaners (who face similar peril but get less credit and pay). These front-line workers take great risk, yet we've let them down.
A medical worker dons personal protective equipment at the Montefiore Medical Center Moses Division emergency room in the Bronx, on April 5, 2020. Photo / Michael Kirby Smith
"There's a lot of frustration," Tarr acknowledged. "You'd like a country as advanced as the US to act like a first-world country. But you see the US struggling to have enough ventilators, running out of supplies we never thought we could run out of."
Trump squandered two months that could have been spent assembling personal protective equipment, or PPE, rolling out mass testing and manufacturing ventilators. Many states and cities (including New York) were also too lackadaisical at first. That's one reason the death rate from Covid-19 has been more than 50 per million inhabitants in the United States, versus 4 per million in South Korea, 1 in Singapore and 0.2 in Taiwan. Doctors and patients have died unnecessarily.
"Washington failed us, and now patients and health care workers alike are getting ill and dying," Jones said. "We could have avoided this whole situation if we had listened to the doctors and scientists and not worried about politics and ratings."
PPE is short at most hospitals, but those I visited seemed for now to be getting by and also to have enough ventilators. But while I was at Weiler, staff members suddenly realized that they were almost out of bag valve masks, which are needed for intubations, and that they would not be available from a supplier for weeks. A frantic search turned up enough for the time being, and they are now locked up and doled out only as needed.
Weiler and Montefiore Moses hospitals, unlike some others, allow staff members to bring their own PPE. Tarr bought a welding mask on Amazon to put over his donated ski goggles. Some 23,000 ski goggles have been given to hospitals by skiers through a group called Goggles for Docs and are hugely appreciated because they are both very comfortable and very protective.
Everyone I spoke to was grateful for the public's donations of PPE, food and other assistance — but also acknowledged that the emotional toll is almost unbearable.
A shift schedule at the Montefiore Medical Center Moses Division emergency room, in the Bronx, on April 5. Photo / Michael Kirby Smith
"I listen to the residents," Jones said, speaking of the 84 physician residents he supervises. "They're fatigued, they're emotionally drained, they're frustrated that facts aren't being listened to, that there's misinformation.
"Can we keep going for another two weeks?" he asked. "Yes. Then can we go for another two more weeks? Maybe. Can we do two more after that? I don't know."
IV.
Hospital emergency departments are transformed in the age of Covid-19. The eeriest change is that bedside alarms chime constantly: In just one wing of the emergency department at Montefiore Moses, 20 alarms were howling simultaneously.
Doctors explained that most are false alarms, and patient vital signs can be monitored through displays at the nurses' station. To turn the alarms off requires someone putting on PPE and walking to the patient's bed.
"You want to use PPE wisely," noted Dr. David Esses, head of the emergency department. "You can't burn a gown every time an alarm goes off."
So they let them ring.
CPR has sometimes become more perfunctory. In the past, doctors might have spent 30 minutes trying to revive an elderly patient, but today each chest compression can unleash a toxic brew of virus that could kill someone else. So when it's unlikely to succeed, CPR may now stop after a few minutes.
There is also today a greater willingness to have blunt conversations about death, something that medical systems have never been good at. With resources scarce, health workers are thinking through what happens if they must ration ventilators: Who will get one, and who will be left to die?
Jones recalled an older patient with long-term dementia who was fading from Covid-19. Normally, the team would have intubated her, but in this case he telephoned her family members: Did they really want to proceed? In the end, the family decided not to intubate, and the woman died peacefully that day.
With the symphony of alarms, the harried staff and the overhead announcements summoning medical teams to one emergency after another, the atmosphere is already taut. And then the red telephone rings.
It's the phone that gets calls from ambulances, announcing that a severely ill patient is on the way.
Weiler Hospital tries to make space by transporting patients regularly to Montefiore Moses, but the ambulances bring new patients faster than others can be moved out. There are triage tents outside, but still there are sometimes traffic jams of stretchers at the entrance to the hot zone.
From the emergency department, many patients eventually migrate to the ICU. Weiler's ICU has more than doubled in size since the pandemic hit, and it was calm and still, so different from the emergency department. Most patients lie sedated in beds in negative-pressure rooms; the only motion was in the squiggly lines on the electronic monitors. One patient recovering after 10 days on a ventilator waved to me happily, but she was the exception; many coronavirus patients in the ICU never make it home.
New Yorkers have been dying of Covid-19 at a rate of almost 800 per day, and that's probably a significant undercount. Upon a death, doctors fill out paperwork for the death certificate, and nurses and technicians prepare the body and attach a toe tag. In the old days, the body would be covered with a sheet and rolled to the morgue; now it is encased first in one body bag and then in a second, and a team takes the body to the hospital morgue and then, because there is no space, to a refrigerated truck outside that is replaced every couple of days.
"We are working with the funeral homes" to claim the bodies, said Linda Berger Spivack, the clinical director of nursing at Weiler. "However, the funeral homes are also extremely overwhelmed."
Death is often an undignified and wrenching transition, but it's particularly brutal now. We humans evolved to support one another, but viruses evolved to take advantage of our bonds — and so in a time of plague, people often die alone.
The Covid-19 wave may now be passing over New York — which means it will soon hit other places that were too relaxed about social distancing. "They should learn from New York," Esses said. "Because if they don't learn, then the same thing will happen there. And by the time they realize this, it's too late."
Let me give the last word to Del Valle, the young doctor who bravely reassures patients all day and then goes home to cry. I asked her what message she has for those who live in places not yet battered by the virus, who doubt the calls for masks and social distancing.
"The hospitals are still very overwhelmed," she said. "It's really hard as an emergency physician to see people suffer without their families at the bedside. It's been a very hard time for everyone here.
