It isn’t that the coronavirus doesn’t come up during our staff meetings in the early days of 2020. It’s more that it’s crushed to the bottom of the agenda by a pending hospital inspection—the triennial, bureaucratic steeplechase that we must run in order to maintain our accreditation. The first formal mention of the virus to the rank and file of our medical clinic comes in the weekly staff e-mail, on January 24th:
Six years earlier, when Ebola attempted its global assault, Bellevue Hospital created its Special Pathogens Unit. The working philosophy on Ebola was: “If it’s coming to the U.S., it’s coming to Bellevue.” Our patients hail from nearly every country, the United Nations is just up the road, and, for nearly three centuries, Bellevue’s doors have remained open to all. With the coronavirus now percolating in Washington State, planning begins in earnest. The E-team, as it’s been known since Ebola, is reconstituted, and the four-room super-isolation unit is readied for the handful of patients expected to turn up.
The next week, the staff e-mail informs us that there are “isolated cases in the US (6 total),” and that the E-team stands “ready to respond for any patient admitted for potential coronavirus evaluations, quarantine, or confirmed cases.” The same message is sent out the following week, and the week after that, and the week after that.
On Monday, March 2nd, we’re told that the first coronavirus case has been documented in N.Y.C. “Remain vigilant at all points of entry at Bellevue and screen every person for fever, cough, rash AND travel history,” we’re advised. “In addition to the global outbreak of COVID-19, remember that there are also ongoing outbreaks of Ebola, Lassa, and MERS.”
On Tuesday, March 10th, we line up in the morning for P.P.E. training, with all its attendant goofiness. Get serially spritzed with aspartame while bobbling your head inside a tent-like contraption balanced on your shoulders—if you can taste the aspartame, the seal on your N95 is leaky.
In the evening, the first patient with the coronavirus is admitted to Bellevue. When we learn of this, there is a collective catching of the breath, and what feels like a communal churning of thought. Will this be like Ebola—intense but cordoned off into an isolated unit? Will it be like Hurricane Sandy—widespread havoc compacted into a single nightmarish week? Will it be like AIDS—ubiquitous, protracted, and exquisitely brutal?
Or maybe the coronavirus will end up like brucellosis, Chagas disease, leprosy, and plague—just another of the many offbeat infections that periodically find their way to Bellevue, a hospital whose catchment area includes the mayor, the N.Y.P.D., and the President as well as the undocumented and the homeless, and everyone in between. Maybe it will assume its place among the legions of oddball “zebras” that keep us on our toes at Bellevue but don’t otherwise perturb our daily routines, other than to remind us why we’d never want to work anyplace else.
Thursday, March 12th, is my first day in Bellevue’s new Primary Care Special Pathogens Clinic, a cramped three-room space which we all refer to simply as the COVID Clinic. Room 1 hosts two fathers and their three-year-old daughter. Room 2 holds a set of millennial roommates who have been trying to socially distance in an apartment with one bedroom, one bathroom, and two cats. In Room 3, a mother gamely distracts her seven-year-old with a card game while her own darting panic saturates the air.
To minimize contact, the initial medical evaluations are carried out by phone. Afterward, I gown up and gather supplies for the tests. A whirring, battery-powered hazmat helmet whooshes filtered air across my face. (“I wish I’d had this during menopause,” a colleague remarked.) The COVID Clinic has been open for only three days, but the testing protocol has already changed at least that many times—with or without an influenza test, nasopharynx vs. oropharynx, double-bag vs. single-bag. I squeeze into Room 1 with four swabs, eight specimen bags, four tubes, double sets of labels, and double sets of gloves and face a workspace the size of a breadbox, plus a charming three-year-old who needs the potty, stat. My biggest fear is that I’ll mix up the tubes, or the swabs, or the bags, or the patients. The fathers are both tall, slim, masked, dressed in mid-thirties-dad casual. They are immensely gracious as I ask who is who over and over during the ordeal.
For every patient I test, I duly recite the social-distancing guidelines issued by the Centers for Disease Control, but these feel tailored for suburbia: isolate in a separate bedroom, use a separate bathroom and eating area, keep six feet apart from the rest of the household. This is New York City. Six feet apart at all times means someone’s going to end up out on the fire escape.
And what happens when there’s no home at all in which to isolate? In the afternoon, a patient with a fever and a cough arrives for testing; he isn’t sick enough to be admitted to the hospital, but it’s too risky to send him back to the shelter where he’s living. Hours pass as we make calls, trying to figure out what to do. One nurse brings him a sandwich; another passes a urinal into the room. The clinic will be closing soon. We wonder if his shelter could somehow provide a single room and bathroom, but he doesn’t remember its name or its phone number.
But this is Bellevue. Someone figures out the name of the restaurant next door to the shelter, calls the restaurant, persuades a waiter to run over and procure the phone number, calls the shelter, works out an arrangement for a private room, and then gets the patient home, all before the sun shimmers down over the Hudson River.
According to Mayor Bill de Blasio’s briefing today, there are ninety-five confirmed cases in all of New York City, with twenty-two New Yorkers hospitalized. Italy is experiencing a steep rise. Bellevue’s Special Pathogens team has been strategizing about where extra hospital beds could fit.
It’s Monday, March 16th: I’ve been desperately checking for the results of my COVID Clinic tests. This afternoon, they finally start arriving from the testing lab, which, it turns out, is conveniently located in Alabama. I look first at the family of three. Father One is negative; the daughter’s test is still pending; Father Two’s test is “sample spilled.” Spilled? After all that preparation and anxiety? I’m crushed.
The millennial roommates are next. Her test is negative. His, however, is marked with a garish red rectangle highlighting the word “Detected!!” next to the words “Novel Coronavirus.”
It’s hard to convey how earth-shattering this first positive result is. On the day I’d swabbed him, COVID-19 was still a disease in China and Italy; there hadn’t yet been a single coronavirus death in all of New York City. We had more gallstones in Bellevue than we had coronavirus.
Now, for the first time, the virus feels in-my-hands real.
It’s Wednesday, March 18th, and the COVID Clinic has been reconstituted alfresco, in the shadow of Bellevue’s imperious, turn-of-the-century brick building. Open-sided to decrease infection risk, the white tent sits primly in the courtyard, hugged on three sides by a flowering dogwood, a magnificent magnolia, and a Callery pear tree laden with snowy blooms.
But the open-sided tent of Abraham feels decidedly less welcoming amid the flood of Noah. The rain is furious; the corner where I’m swabbing one anxious patient after another has become a muddy lagoon. The temperature hovers near forty degrees, and we take turns doing jumping jacks to stay warm, looking like harbor seals with our bright yellow surgical gowns bulging over our down jackets. The steady, pelting rhythm of rain, the musty dampness of canvas, the petrichor of wet springtime lawn—this singular sensory combination evokes the gloriously sodden camping trips of my childhood, despite the surreal circumstances.
On Saturday, March 21st, one of our nurses has a fever. We’re both in the COVID tent, bundled up against yet another day of frigid rain, but I’m the only one wearing P.P.E., because she’s now the patient.
As I ease the swab inside her nasopharynx, my mind scours frantically over the previous two weeks. Did we experience any breaches of protocol? Did we inadvertently expose her? In the urgency of reinvention, did we grow careless?
I slip her sample into the bag and pray that it will be negative.
It’s Monday, March 23rd. Over the past week, the number of coronavirus patients admitted to Bellevue has tripled—there are now close to a hundred. Meanwhile, the outpatient side of the hospital has screeched into reverse gear: a battalion’s worth of staff works the phones, doing its best to keep our seventy thousand outpatients away from the hospital at all costs.
At his press conference, the Mayor announces that there are now twelve thousand three hundred and thirty-nine cases in the city, and that there have been ninety-nine deaths. New York is officially the epicenter of the pandemic. As of last night, the city is on lockdown. There are practically tumbleweeds on Madison Avenue.
It’s Tuesday, March 24th, and I’m back at the primary-care clinic where I normally work. It’s strange to be inside after working outdoors in the tent for the past week. I’ve gotten used to prodigious natural light and crisp spring air. Sequestered in my six-by-six exam room, with its fluorescent lights and obdurate walls, I feel twitchy and trapped.
Twelve hundred patients have me listed as their primary-care doctor. Internal medicine can often feel pedestrian—there are no edgy Netflix series about primary-care physicians counselling patients on sciatica. With the acute rupturing of our clinic system, primary care is suddenly a minefield. I call patient after patient, undertaking rudimentary triage without the aid of labs, X-rays, vitals, nurses, or even eye contact. Swollen joints, fevers, and abdominal pain have to be evaluated without a physical exam; some of my diabetic patients have started rationing their insulin; home-care arrangements for my elderly patients are splintering because necessary forms have gone missing. Some patients are holding up well; others are panicked and floundering. To a one, though, their foremost worry seems to be about us, the staff: they thank us, they bless us, they inquire after our families and admonish us to take care.
All the patients with the coronavirus are being admitted to the general-medicine service, and at noon there’s a staff meeting. We learn that there are now almost thirty COVID-19 patients in the I.C.U., and more than ninety on the wards. Attending physicians are being pulled from everywhere—clinic, cardiology, G.I., rheumatology, retirement. Senior residents from urology, orthopedics, surgery, and ophthalmology have been drafted to be interns on the medicine service. The staffing schedule looks like a NASA flowchart for the moon landing.
Between Wednesday night and Thursday morning, another dozen patients have been intubated, and apparently there are only a few ventilators left in the hospital. A committee is being formed, we’re told, to start working on the practical aspects of “resource allocation”—a grim euphemism for deciding who will get a ventilator and, conversely, who might be extubated if their improvement stalls.
Resource allocation is something we actually do all the time in medicine. Usually, though, it’s a low-stakes affair, measuring your patient’s situation against some abstract concept—clinical appropriateness, cost, availability, the risk of adverse outcomes. You aren’t measuring up against another flesh-and-blood patient in the next bed over.
This is the first night I can’t sleep.
On Friday, the magnolia tree next to the COVID tent bursts into riotous blossom despite the chilly weather. Until now, the flowers have been delicate cups of pink and lavender, spaced along the spindly gray branches. Now they’ve abruptly reversed their concavity, spilling open into an unbroken blanket of defiant white.
Normally, the inner workings of the hospital are invisible to doctors and nurses. We show up every day and the patients are there, the beds are there, the supplies are there, the lights turn on, the floors are clean. Now it’s as if we can feel the pulse of the hospital’s vasculature—the complex network of administrators, suppliers, maintenance workers, technicians, housekeepers, phone operators, transporters, and I.T. support staff that keep the clinical enterprise afloat. An influx of ventilators arrives that morning. New wards are opening up. Beds are materializing. The tent gets a sink with running water and an air-filtration system. It’s nothing short of miraculous.
But the patients keep coming. On the news, Boris Johnson, the Prime Minister of the U.K., is diagnosed with COVID-19. On Twitter, an E.R. doctor says that he’s just had to intubate one of his colleagues.
Every day, the rules of engagement reshuffle. Medical teams are reconfigured, treatment guidelines are revised, infection-control protocols are modified, sick-call procedures are altered, testing criteria change, P.P.E. rules evolve, pharmacy policies shift, a new ward opens, another I.C.U. is created, new C.D.C. recommendations are announced, another batch of research data is published, much of it not peer-reviewed.
This Monday, March 30th, is no different—six new updates are announced at our morning meeting, and we dutifully recalibrate the way we’re going to practice medicine today, mentally jettisoning all of last week’s protocols. Our section chief, whose unpretentious competence and unflappable effervescence have made this ongoing cyclone feel manageable, usually conducts our morning meetings from a hospital conference room. Today, her babysitter has called out sick, and so she’s broadcasting from home. Over the video chat, strains of “Frozen” drift in from another room.
Daily life feels vertiginous, and these morning check-ins have become vital ballast. The meetings are part war room and part family reunion: our now scattered colleagues log on from the wards and the I.C.U, from the COVID tent and the medical clinic, from offices and exam rooms, from overnight call rooms, from home, from East Twenty-eighth Street as they rush to the hospital. One colleague on the wards describes feeling like a medical student again, learning absolutely everything from scratch. Another recounts adjusting a patient’s oxygen: the patient stopped her and asked, “Should you really be touching me?”
One doctor is spending his evenings persuading phone companies to donate chargers for patients whisked here by ambulance without time to pack. A chief resident is training medical students to call patients’ families with daily updates. Someone is working from home on depositions for patients who were applying for political asylum when the pandemic hit. Someone else is single-handedly insuring that every homeless patient with the coronavirus gets a place to isolate. Another colleague is coördinating follow-up care for the waves of COVID-19 patients discharged from the hospital. Yet another is tackling the avalanche of studies about hydroxychloroquine, remdesivir, and tocilizumab, steadily synthesizing the otherwise dizzying data for us.
There’s an unspoken recognition of how oddly fortunate we are. In this quarantine culture of aimless boredom, we have a fraternity of purpose. In a world now riven by isolation and loneliness, we have one another. Before the pandemic, staff meetings were modestly attended. Now they are standing room only.
The next day, March 31st, Bellevue begins distributing masks for the whole staff to wear all day, even when not involved in patient care. This is so we don’t infect one another. There are now over forty thousand cases in New York City; the death toll has passed a thousand.
In the tent, I triage a patient who’s been diverted from the overwhelmed E.R. I watch him plod unsteadily toward us. It’s another chilly day, with temperatures in the low forties, but he is overdressed even for this, wearing sweatpants over jeans and an overcoat over a parka over a hoodie. He tells me that he’s been feeling tired for the past two months. He’s been living in Penn Station, having long since lost touch with his family. When I ask him how long he’s been smoking, he mumbles, “Four years.” When I ask him how long he’s been drinking, he says, “Four years.” Heroin? “Four years.”
I stop my rundown of medical questions and lean forward. “What happened four years ago?” I ask.
“I got my heart broken,” he says. We sit in silence, the March wind chiselling around us.
His oxygen saturation is ninety-five per cent, but when we walk him along the garden path it plummets into the low eighties; he has to be admitted to the hospital. I swab his nasopharynx for the coronavirus, but I perform the rest of the physical exam, too. The bulbous clubbing of his fingernail beds could indicate chronic pulmonary disease or possibly lung cancer. Distant heart sounds could reflect pericardial effusion—fluid accumulating around the heart. Edematous legs swollen with interstitial fluid could mean heart failure, or liver failure, or kidney failure. These other diseases still exist.
After work I head up First Avenue. Two blocks north of Bellevue is the chief medical examiner’s office. As a first-year medical student, I’d had nightmares for weeks after visiting the infamous “Evidence Room” on the fifth floor, where a century’s worth of New York’s gruesome oddities—the bone crushers used by serial killers, the severed factory workers’ fingers found in cans of ill-prepared food—sit on display. As I pass by now, I see that a C.M.E. van has blocked off traffic to East Thirtieth Street. I turn down the now silent block toward F.D.R. Drive. Four construction workers are slivering planks of fresh plywood over a sawhorse. Through the open back of their truck, I can see what look like triple-level bunks, constructed from raw two-by-fours.
At the end of the block, where Bellevue faces the East River, I count eleven trailers. They are lined up with military precision. They occupy the same site as the 9/11 tent, the cavernous white structure that served as an extension of the C.M.E.’s office for a decade, safeguarding the remains that awaited identification.
Kalustyan’s—the venerable purveyor of Middle Eastern and Indian food on Lexington Avenue—is joining its neighbors on lockdown, but doesn’t want its fresh food to go to waste. On Thursday, the restaurant loads up cartons with hummus, mujadara, za’atar, ful, t’hina, and zhoug, plus enough pita for a minor caliphate, and I lug it all to Bellevue. It’s oddly comforting to watch my colleagues scarf down the food. Two years ago, almost to the day, my Yemenite-Israeli father passed away. Ful and zhoug were his elixirs, and he slathered them on anything that didn’t move. “They ward off bacteria,” he swore to me. I load up my pita—it can’t hurt.
As of Monday, April 6th, the coronavirus-case count in New York City is almost a hundred thousand. The inpatient count at Bellevue has pushed past three hundred. Our partner city hospitals—Lincoln, Jacobi, Elmhurst—are being pummelled even harder. Bellevue has begun taking patients from them, at first in handfuls and then in batches of thirty or forty; almost six hundred patients make their way across the East River to Bellevue, a staggering feat of coördination.
Carpenters and engineers have been working their way through the I.C.U. floor, converting all the rooms into the negative-pressure spaces required to keep highly contagious pathogens out of circulation. As soon as the workers exit a room, an intubated patient is wheeled in behind them—and so it goes, for every one of the fifty-four rooms. The coronavirus has now taken over the entire I.C.U. It’s as if all the other calamities—heart attacks, strokes, traumas, appendicitis—have evanesced on cue. A flash mob in reverse.
The I.C.U. service has spread well beyond its own floor, usurping two sections of the E.R., the endoscopy suite, the post-op units, plus another surgical ward. Walking through the E.R. that evening, I notice that every patient is hooked up to a different model of ventilator, each with its own arrangement of buttons, dials, and touch screens. These are the ventilators that averted our harrowingly close call two weeks ago. The basics are the same, but operating them is like being saddled with ten different TV remote controls.
I’m helping one of the nurses when a patient erupts into a cytokine storm—a runaway immune-system response, resulting in life-threatening inflammation. She’s already intubated, sedated, and paralyzed, but her temperature has started to jump the rails: first it’s 103.8, then 104.5, then 105.3. Three of us gingerly roll her to one side and attempt to slide an electric cooling blanket beneath her, without dislodging her breathing tube, arterial line, cardiac monitors, or I.V. drips.
Her temperature hits 106.1. We cram specimen bags with ice as quickly as we can, tucking them into her armpits, under her neck, and between her legs. They turn to water almost on contact. Her temperature is now 106.9, and her pulse has soared to a hundred and seventy.
Someone says that there’s a cooling tub, but no one knows where it is. One nurse is from the surgery department. The other is from Ohio. The patient’s temperature climbs to 107.6, then 108.2.
I’ve never seen a temperature this high in my life. It hits 108.8, and I worry that she’ll start seizing. A veteran E.R. nurse materializes like a demigod, lugging three bulging trash bags of ice, procured from who knows where. We heave the bags up over the bed rails, and they buckle across the contours of her body, the ice cubes sloshing and clanking.
Slowly, slowly the mercury eases down, settling at 103.1.
With all the commotion, the patient’s arterial line has been dislodged from her right wrist; she now needs one on the left. But the subcutanous tissue of her arm has swollen up on either side of her hospital I.D. band. Slender friendship bracelets—beaded and braided in an assortment of colors—carve parallel lines into her skin.
As the I.C.U. resident preps the boggy wrist with antiseptic, I pull scissors from a suture kit and snip off each bracelet in turn. The resident and I catch eyes over our masks: “It’s like the last bit of her,” she murmurs. I put the bracelets in a specimen bag and crouch down to the base of the stretcher, where patient belongings are stored. For a moment, I contemplate slipping the bag into my pocket. Something like this could so easily disappear in the general tumult—knocked over, stepped on, slipped on, swept up. But it’s not my place to take it, even if to protect it. I bury the bag as deeply as I can within her clothing and hope for the best.
On Thursday, April 9th, I spend the morning rounding with the palliative-care team in the I.C.U. Usually, they follow a dozen or so patients suffering from the standard gamut of terminal illnesses: cancer, cirrhosis, congestive heart failure. But today there are more than sixty-five patients on the list, and just about only one diagnosis.
Sunshine cascades through the generous windows of the I.C.U., but the rays seem to flounder once in the rooms—an aubade without an audience. A few glass doors are distinguished by a hastily taped-up E.K.G. or a phone number scrawled in black marker. Otherwise, there is a wearying sameness as we make our way around the unit. The patients are starkly sedated, chemically paralyzed, and mechanically ventilated. They seem entirely without agency. In truth, so do we: we set up ventilators, fluids, vasopressors, and the crapshoot antiviral drug of the day, and then stand back and wait. The churn of physiology that will determine the patients’ outcomes is shrouded within their unnaturally still bodies while we watch from behind the glass.
Afterward, I hole up in my office to tackle my mountain of phone calls. I’ve known most of my twelve hundred patients for years, a few even since I was an intern at Bellevue. Ten calls in, I decide to check on a woman whose fragile diabetes often flies out of control. She’s in her mid-sixties, but slim and scampery as a teen-ager. Last year, she fell into a severe depression. She was unrecognizable—lethargic, sobbing, unable to find a reason to live. But her family was dogged, as was her psychiatric team, and toward the end of November the pall had lifted. Two months ago, she’d bustled into my office as bright as a freshly tuned violin, her ebullient Spanish galloping faster than my brain could translate. Slam-dunk success stories like this are rare in primary care, and I was effusive in her chart. “Incredible improvement of mood! Back to cheerful, happy baseline,” I’d written.
