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April 14, 2020

'If people saw this, they would stay home': Inside New York hospitals at Covid-19's peak

Daily Briefing

    In an unprecedented move, journalists are entering the "hot zones" of New York hospitals to witness how Covid-19, the disease caused by the new coronavirus, has turned the state's hospitals into "war zone[s]," the New York Times and CNN report.

    Your Covid-19 checklist to expand capacity

    Journalists enter New York Covid-19 hot zones

    Due to concerns over HIPAA violations and potential exposure to infection, it's been rare for hospitals to grant journalists access to their treatment units since America's Covid-19 epidemic began, leaving the general public largely in the dark on what it's like for health care workers treating patients on the front lines.

    Nicholas Kristof, an opinion columnist for the Times, writes, "Unfortunately, the shortage of gritty on-the-ground coverage means that to many Americans, the coronavirus remains distant and unreal."

    This month, Kristof and a video journalist on behalf of the Times, as well as reporters from CNN, separately were given access to experience the crowded EDs and overwhelmed ICUs of three New York City hospitals, to inform the public of the impact the epidemic is having on the country's health system, health care workers, and patients.

    Overwhelmed with alarms—and death

    According to Kristof, bedside alarms in the hospitals' hot zones are sounding constantly. The alarms warn clinicians that a patient's vital signs are in dangerous territory or when patients have stopped breathing. In one wing of the ED at the Montefiore Medical Center Moses Division in the Bronx, 20 alarms sounded simultaneously, Kristof writes.

    Some of the ringing is for false alarms that health care providers do not turn off, because doing so would require them to put on personal protective equipment (PPE) that is in short supply to enter patients' rooms. But as Covid-19 patients grow sicker, a lot of the alarms signal that the patient is deteriorating—and fast.

    "They're so sick you lose them in a heartbeat, they're that sick," Julie Eason, a respiratory therapist at SUNY Downstate Health Sciences University, told CNN. "They're talking to you and then a few minutes later you're putting a tube down their throat."

    Now, doctors are "overwhelmed by death," as patients who were previously stable deteriorate in front of their eyes, Kristof writes.

    "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."

    At SUNY, 94 patients had died from the time the epidemic began in March to April 6, CNN reports. And at University Hospital of Brooklyn, almost 25% of patients admitted to the hospital with Covid-19 have died, according to CNN.

    Before Covid-19, "you may have a code, maybe on a bad shift you may have two codes where you carry that emotion and you wonder if you did everything that you could," Cynthia Benson, an ED physician at University Hospital of Brooklyn, told CNN. "I think it's emotionally hard to prepare for this level of sickness and suffering and morbidity and mortality in such a short period of time. I don't think any of us are well prepared for it."

    So many patients have died in New York City that hospitals' morgues have reached capacity. Now, refrigerated trucks are parked outside hospitals to hold patients' bodies until they can be transferred to funeral homes—which also have been overwhelmed.

    Intubation: A patient's last resort

    For Covid-19 patients in severe respiratory distress, ventilators often offer their last chance at survival. For some patients, being intubated saves their lives. But many patients do not survive being placed on a ventilator. According to Kristof, data from New York City suggests that up to four out of five Covid-19 patients who are intubated may not survive.

    As a result, when a patient has to be intubated, doctors tend to prepare for the worst, Kristof writes. Many providers help patients to call their loved ones before the procedure in case they don't survive.

    Doctors also are worried they will have to make tough decisions on which patients to treat as the United States faces a looming ventilator shortage. New York Gov. Andrew Cuomo (D) has said the state needs more than 30,000 ventilators.

    "We're worried about, what if the day comes where we don't have enough ventilators," Lorenzo Paladino, an ED physician at SUNY, told CNN. "We don't want to make the decision between two viable patients by simply trying to decide who's more worthy or flipping a coin."

    Aside from the emotional toll ventilating a patient can take, the process poses a physical threat to health care workers, as well. Intubation causes virus particles to spray from the patient's lungs, meaning health care workers have to take extra precautions to prevent the new coronavirus' spread. In one instance, doctors put a plastic box over a patient's head and intubated the patient by putting their arms through holes in the box, Kristof writes.

    At-risk health care workers show patients compassion

    Health care workers are at a particularly high risk of contracting the new coronavirus, and several have fallen ill with Covid-19. Despite those risks, clinicians are still finding remarkable ways to comfort their sick and dying patients, Kristof writes.

    Katherine Chavez, a nurse at Montefiore Moses, spent 12 hours with a 40-year-old man who was intubated due to Covid-19. "He would grab my hand, and I just kept telling him that everything is going to be OK," she told Kristof. Chavez said she could "see the fear" in the patient's eyes, but added that she was also worried about her own safety. "I don't know whether the virus is airborne, and I was in the room 12 hours straight," she said.

    Physician Michael Tarr said he was most affected by a 27-year-old patient with no underlying conditions who had to be intubated due to Covid-19. The patient, who is currently in the ICU, is still doing poorly.  "It oftentimes feels like a roll of the dice," Tarr told Kristof. "Every day you're thinking, 'Am I going to get really sick? … Am I going to be one of those young people that, for whatever reason, dies?'"

    According to Kristof, Michael Jones, leader of the physician resident program for the EDs at Moses and Weiler Hospital in the Bronx, in an email sent to the residents last month outlined how they should show compassion toward Covid-19 patients. "[T]alk about patient's families, their lives, their dreams. Ask if there is a loved one you can call," Jones wrote. "And lastly, two very difficult things: Hold your patient's hand for a minute as they near death or pass, and ask your entire team to stop for five or 10 seconds, bow your heads, state the patient's name, and ask for silence."

    Will the ED ever be the same?

    As patients fall ill at striking speeds, EDs have changed drastically due to Covid-19, Kristof writes.

    For example, Kristof writes that many hospitals have changed their approach to conducting CPR. Although it is a potentially life-saving emergency practice, performing CPR can cause virus particles to flow from a patient's lungs and into the air, Kristof writes. So while doctors used to perform CPR for up to 30 minutes to revive a patient, physicians now are less likely to continue the process if it seems unlikely to succeed, Kristof reports.

    Physicians also are having more frank conversations about death amid the Covid-19 epidemic, and more and more patients' beds are marked "DNR" which stands for "do not resuscitate," as well as "DNI," meaning do not intubate, Kristoff notes.

    Jones recalled one patient with long-term dementia who was critically ill with Covid-19. Under usual circumstances, the hospital would have put the patient on a ventilator, but instead they called her family and asked them whether they should intubate her. The family decided against it, and the woman died "peacefully" later that day, Kristoff writes.

    Another notable change is that, while many EDs are full of Covid-19 patients, they have practically no patients seeking care for other ailments. While it's possible that people are enduring fewer accidents because they're staying home, it's possible that some families are letting their older loved ones die at home instead of taking them to the hospital, Kristof writes.

    Increasing capacity—and urging people to practice social distancing—remains a priority

    As Covid-19 cases peak, New York hospitals are still trying to make space for new patients.

    Cuomo mandated that all hospitals increase bed capacity by at least 50%. Some hospitals, like University Hospital of Brooklyn, were required to turn all of their resources toward addressing the epidemic, meaning all patients being treated at the hospital have Covid-19.

    To increase capacity, Weiler Hospital regularly transports patients to Montefiore Moses, but sometimes new patients are admitted faster than others can be transferred out. Kristof writes that there are sometimes "traffic jams of stretchers" at the hot zones' entrances.

    The hospitals also have increased ICU capacity. For example, Weiler's ICU has doubled in size since the start of the epidemic.

    University Hospital of Brooklyn has added tents to its parking lots, which are now equipped as negative pressure spaces to treat Covid-19 patients. Next, the hospital will open an overflow space at another facility in Brooklyn.

    Despite these efforts, hospitals remain overwhelmed with patients. At Weiler, more than 80 Covid-19 patients were crammed in the ED at one time, Kristof writes. Meanwhile, employees at SUNY are working mandatory overtime and vacations are canceled indefinitely, CNN reports.

    "The hospitals are still very overwhelmed," Nicole Del Valle, an emergency physician at Weiler, told Kristof. "It's been a very hard time for everyone here. We are telling people to please stay home."

    Gifford told Kristof it's difficult for her to leave the hospital and see New Yorkers gathering in parks and not heeding social distancing guidelines. "If people saw this," she told Kristof as she gestured to Covid-19 patients struggling to breathe in the ED, "they would stay home" (Kristof, New York Times, 4/11; del Valle/Marquez, CNN, 4/6).

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