From the moment he wakes up, Dr. Peter Shearer, the chief medical officer at Mount Sinai hospital in Brooklyn, spends his day thinking about coronavirus. As one of the hospital’s leaders, his job entails coordinating with the doctors, nurses, and technicians on the front lines of patient care, something that has gotten increasingly difficult as Mount Sinai tries to contain the spread among its own employees. Like every other hospital in the city, Shearer’s ER and ICU are now inundated with COVID-positive patients. With 10 to 15 percent of his staff now sick themselves and three to four COVID-19 deaths per day, Shearer says that it’s hard to imagine things being worse than they are now. And yet scientists still estimate that the virus won’t peak for another two to four weeks. As a testament to that, a 20-foot cooler truck is now parked right outside Shearer’s window, a mobile morgue meant to house bodies when the hospital’s facilities inevitably overflow. Shearer knows this is only the beginning, and so he and his Mt. Sinai Brooklyn colleagues have agreed to keep us updated on life inside the hospital. This is the first dispatch.
I wake up around five o’clock and I start thinking about coronavirus. I look at my phone to see which patients decompensated [organ or system failure resulting in an urgent change in vital signs] or coded [a failure of the heart or lungs requiring resuscitation] overnight. And then I start to think about what the hospital resources are and look at the current status of my inpatient units, and my ICUs — plural because we’ve created an extra one — and my emergency department. And then I start to try and figure out how we’re going to get through another day.
The number of very sick COVID patients coming in is tremendous. I don’t know if the word is exponentially or logarithmically, but the curve goes up steeply. It’s scary. Mount Sinai Brooklyn is a moderate-sized community hospital. We have 220 beds, we’ve planned a surge of up to 240 to 260. At the current moment I have 135 COVID-positive patients. There are probably another 10 or 15 that just don’t have test results back yet. And they are sick. They are the ones who need to be admitted to the hospital. It’s a few debilitated elderly from nursing homes, but there’s a lot of patients who are between the ages of 40 to 60 who may have some underlying health problems like obesity, diabetes and high blood pressure, and their lungs are very inflamed. They go from being moderately sick to crashing and needing to put on ventilators very quickly.
I don’t think medical science has an understanding yet of why some people do so much worse than others. There are theories out there about the viral load and probably some genetic variation. It’s unclear. Certainly underlying things like diabetes and high blood pressure add to the equation. Smoking, lung disease, vaping absolutely doesn’t help. But I don’t think we know enough about the science of this yet to say what makes one person crash and burn when another person just has a fever and aches for a week.
The emergency department is just patient-to-patient lined up and packed in. It’s that awful picture you see of an overcrowded emergency department, just patient upon patient next to each other endlessly. It sounds like a low-level buzz of chaos. We have a no-visitor policy so that helps maintain a bit of control over things and allows a little bit of sanity, but it’s minimal. If every patient had one or two family members next to them, it would be unbearable.
Three weeks ago when we started to plan for this we came up with ideas like, This is the room that we’ll put a [seriously ill] coronavirus patient in. And then if there are a bunch of other patients, maybe four or five who are slightly sick, we’ll put them in this area where we close the door and keep them separate from everyone else. We were thinking about this room and that room. And now I’m up to 27 patients in my emergency department who are positive, waiting for beds in the hospital, and another 24 who are under evaluation. Those plans are ancient history now. In an ideal world, everyone has their own room, they would have negative pressure airflow and a face mask on and a dedicated nurse to care for them with a moderate ratio of patients. We can’t do that. No one can do that right now. Every hospital in New York is a variation of mine.
I would say 10 to 15 percent of the staff is out [sick with COVID]. Many of them have been tested, while some have just had symptoms and we know clinically that they’re positive. Some of the employees that are at higher risk for contracting the illness are our respiratory therapists. They’re putting people on ventilators and working around the part of the patient where they might get some aerosolized particles. They are uniquely skilled employees, and they’re dropping like flies. Normally I would have five on during a shift. I have two today, at the exact time I have more patients on ventilators than before.
I think we’re seeing three to four COVID deaths a day now. And that has changed in the past couple of days. There have been some younger people. The more upsetting things are the 50- and 60-year-old people are getting put on ventilators. They haven’t died yet. But there’s no treatment for this. We’re just giving supportive care to buy them some time, where we hope their lungs will heal. There’s no real improvement therapy. Everything you hear about things like Plaquenil (hydroxychloroquine) for the critically ill, it’s probably much less effective.
We’ve had some tragic situations. We’ve had two married couples where they’re both hospitalized. There was a couple in their late 80s. The husband died and his wife is in another ward of the hospital. They’re both isolated. We couldn’t even get her there. We have another married couple in their late 50s where one is doing much worse than the other and is on a ventilator. It’s very overwhelming.
We have very small morgues that can only hold five bodies at a time and they do tend to get picked up relatively quickly. There’s a truck parked outside my window now. It’s around 20 feet long, I assume it could hold 30 bodies minimum. It looks like a big trailer with a refrigerator unit on it. We haven’t had to use it yet. Inside it’s just a cold metal space. It’s not very respectful at the moment. I’m not going to hang curtains in it, but it needs to be a little bit more … something.
People have compared this to the early days of HIV. It feels like I can imagine how that was, but the numbers are more now. If you went back to that time, it was predominantly the gay community and focused in certain geographic parts of the city. This is every single hospital in the city, multiple patients dropping their oxygen levels surprisingly fast and being put on ventilators with no way to make them better. I’ve been through the blackout. I’ve been through Sandy. I’ve been through the 2009 H1N1 influenza pandemic. And this is different. 9/11 was a horrendous thing, but there was no impact like this on hospitals. Sandy, some hospitals were completely devastated, and it was horrendous and awful, but the weather got better. And you could start cleaning up. But this is just getting worse. I have never been in a war. It feels like a war.
From the governor’s office, and from the modeling I get through the Mount Sinai health system, the peak will be somewhere between two to four weeks from now. But it’s pretty fucking awful right now. To think that somehow it’s going to get worse is hard to imagine. The governor has charged us with doubling the capacity of our hospital. I can put three people in rooms that should accommodate two. But I need nurses to care for them. It’s going to be tough.
I think conversations [about triage] will come into play in the next week or so. We don’t have medical therapy for this, all we have is supportive care. There are patients for whom that’s not going to save their life, it may actually add to their suffering. There are some patients who it’s not even really an option to put them on a ventilator. Just because you can do something doesn’t mean you should. My father died in mid-December before this all started, at the age of 85. It was an acute perforation of his bowels. And in that situation, the doctor comes to you and says, “He’s dying and there’s nothing we can do, and we will make him comfortable and make sure that he doesn’t suffer.” And those are the conversations that we need to be having with patients and families now for whom ventilation is not an option.
We’re not quite there yet in terms of [choosing which patients should get ventilators over others], allocating resources. It’s hard to know, things change very quickly. There’s a document from the New York State Department of Health which has guidelines for how to allocate ventilator resources at the time of a pandemic. Basically, you give scores to patients based on how sick they are, and that helps you to assign a triage level to different people and then make those decisions of: I have one ventilator and two patients, which one am I choosing. Or: I have a 30-year-old in my ER and an 87-year-old in my ICU, and it gives you guidance to take the person in the ICU off the ventilator and give it to the 30-year-old.
Two weeks ago as we were ramping up, myself and the other members of our leadership team would round on the units and talk to the staff, because we knew they were becoming concerned and worried about what was coming. It was important for us to be out there to meet with the night shift, the day shift, nurses, techs, all those people, to really help prepare them and to show that we had their backs. I’m not doing that as much now because I don’t want to over-risk my exposure. I’m just one person and there’s not another department where other people can replace me. But I feel very badly about it, because I think the staff definitely needs it. It’s a sort of a sad part of this. Now we’re doing everything on the phone. We feel a bit more disconnected. It’s difficult. At a time where everyone needs to feel closer, we’re feeling apart.
I have a COVID-positive 41-year-old who just died about five minutes ago. I just got the message. He’s been in the unit for about a week. Initially he seemed to be doing better and then he didn’t. In terms of preexisting conditions, he had obesity and maybe some diabetes. Not a lot. We’re very tight on visitors, but they were able to get his wife up there a few times. It’s devastating. But I’m not the one at his bedside taking care of him, which would be our ICU director and the nurses. Among my people, people already know that for medical staff, the repercussions of this months and years down the road are going to be extreme. It goes back to the wartime analogy — people being in World War One being shell-shocked. Now you call it PTSD. It will be like that.
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