A Brooklyn ICU Is Pushed to the Brink

Dr. George Nerantzakis, left, and Will Vanderwall, a physician assistant, prepare to perform a procedure for a patient stricken with the coronavirus at the Brooklyn Hospital Center in New York, March 30, 2020. (Victor J. Blue/The New York Times)
Dr. George Nerantzakis, left, and Will Vanderwall, a physician assistant, prepare to perform a procedure for a patient stricken with the coronavirus at the Brooklyn Hospital Center in New York, March 30, 2020. (Victor J. Blue/The New York Times)

NEW YORK — The night had been particularly tough. Patient after patient had to be intubated and put on a ventilator to breathe. At one point, three “codes” — emergency interventions when someone is on the brink of death — occurred at once.

Dr. Joshua Rosenberg, a critical care doctor, arrived the next morning at the Brooklyn Hospital Center. Within hours, he was racing down the stairwell from the main intensive care unit on the sixth floor to a temporary one on the third, where he passed one of his favorite medical students.

“Shouldn’t you be home?” he asked, registering surprise. Clinical rotations for students had been halted to avoid exposing them to the coronavirus. “My mom’s here,” the student replied.

Rosenberg, 45, let out an expletive and asked which bed she was in. “I’m rounding there now,” he said and made sure the student had his cellphone number.

Earlier, residents from the ICU had presented their cases to Rosenberg and others, speaking in shorthand and at auctioneer-like speed. There were so many patients to get through last Monday:

“Admitted for acute hypoxic respiratory failure secondary to likely COVID-19.”

“Admitted for acute hypoxic respiratory failure secondary to confirmed COVID-19.”

“Admitted for acute hypoxic respiratory failure, high suspicion of COVID-19.”

Nearly every person lying in a bed in the new intensive care unit, just as in the main one, was breathing with the help of a mechanical ventilator.

There were patients in their 80s and in their 30s. Patients whose asthma and diabetes helped explain their serious illness. And patients who seemed to have no risk factors at all. Patients from nursing homes. Patients who had no homes. Pregnant women, some of whom would not be conscious when their babies were delivered to increase their odds of surviving to raise their children.

This was the week that the coronavirus crisis pummeled the Brooklyn hospital, just as it did others throughout New York City, where the death toll reached more than 2,000, as the governor warned that vital equipment and supplies would run short in just a few days, as the mayor pleaded for more doctors and as hospital officials and political leaders alike acknowledged that the situation would get even worse.

At the Brooklyn center — a medium-size independent community hospital — that misery was evident. Deaths attributed to the virus more than quintupled from the previous week. The number of inpatients confirmed to have COVID-19, the disease caused by the virus, grew from 15 to 105, with 48 more awaiting results. Hospital leaders estimated that about a third of doctors and nurses were out sick. The hospital temporarily ran out of protective plastic gowns, of the main sedative for patients on ventilators, of a key blood pressure medication. The sense of urgency and tragedy was heightened by a video, circulating online, showing a forklift hoisting a body into a refrigerated trailer outside the hospital.

Amid the unfolding disaster, in a week in which he would see more deaths, counsel some families to let loved ones go and scramble to save others, a weary Rosenberg paused to watch his team tend to their patients. “It’s making the best of what you can do,” he said.

A Crisis Gathers Strength

Rosenberg had to stay home the previous week, battling a fever and intense fatigue from what he assumed was COVID-19 (a test, taken after he felt better, later came back negative). He could barely climb the stairs to his bedroom. Returning to work this past Monday, he told a reporter, was like walking into a storm.

“This is insanity,” Rosenberg said to a colleague that day.

Before he left, the intensive care unit had its usual 18 beds. The surge was then hitting the emergency department, leading the hospital to construct a tent outside and screen scores of people a day. Many, mildly ill, were reassured and sent home.

But during the time he was gone, the number of people progressing to severe illness skyrocketed, and the ICU had to expand, then expand again, effectively doubling. “In a week’s time, we’ve transitioned from a crowding outside to a crowding inside,” said Lenny Singletary, the hospital’s senior vice president for external affairs.

Even before the morning report had started, Rosenberg and other staff members had to rush to an outpatient unit. A middle-aged man had come to the hospital for dialysis but was sweating profusely. Staff members were about to help him breathe using a mask with pressurized air, known as a BiPAP machine.

But Rosenberg, chair of the hospital’s infection control committee, thought it was a poor idea. There was no way to know right then whether the man’s illness might be caused by the coronavirus, and there were fears that the device could release virus particles into the air, potentially spreading the disease. The patient was moved to the emergency room. “He has a high chance of getting tubed” and needing a ventilator, Rosenberg told colleagues.

In the new ICU, a repurposed chemotherapy infusion unit, blue plastic gowns fluttered from door hinges, drying after being wiped down for reuse. A patient bed, tilted up like a slide, held pink plastic bins overflowing with patient supplies. Rosenberg’s critical care team assembled in mismatched clothing, masks and protective eyewear, hair and foot coverings — wearing much of the scarce equipment all day, not changing between patients.

With so many staff members out and so many new patients, the array of doctors, nurses, pharmacists and respiratory therapists who were accustomed to working in the ICU needed reinforcements. Rosenberg welcomed a podiatrist and two of her resident trainees, a neurosurgery physician assistant, surgery residents and a nurse anesthetist. “All people who are good with knives and big needles,” Rosenberg quipped.

Now, some nurses were caring for five critically ill patients at a time, a ratio he called “crazy.” The norm for experienced ICU nurses at the hospital was just two.

At 10 a.m., Rosenberg and Dr. James Gasperino, chief of medicine and critical care, jumped on a call with the hospital leadership about challenges the center was facing and how it was coping with them.

The chief medical officer, Dr. Vasantha Kondamudi, later summed it up: Staff was short, medical residents were falling ill every day, and the number of patients with suspected or confirmed COVID-19 was ballooning in nearly every area of the hospital. Yet the crisis had not peaked.

Nurses and others from departments that had cut back on services, like elective surgery and outpatient clinics, were being trained and redeployed. “You’re working completely differently,” said Judy McLaughlin, senior vice president and chief nursing executive. But even that wasn’t enough: The hospital had requested more than 100 volunteer doctors and nurses from the city’s Medical Reserve Corps and was rapidly working to vet them.

After the call, Gasperino conferred in the hallway with the director of respiratory therapy. The hospital had 98 ventilators, many acquired in recent days, including small portable devices from the national stockpile. Employees were running simulations to practice how they might use each ventilator to treat two patients, a difficult and risky proposition. “We’re doing this because the alternative is death,” Gasperino said.

An alert sounded on the loudspeaker, interrupting the conversation: “Code blue, 6B. Code blue, 6B.”

The critical care team was designed to respond to emergencies anywhere in the hospital. Although he was supposed to be on his way home after an overnight shift, Gasperino joined more than than a dozen others pouring into the patient’s room.

“COVID?” someone asked.

“No, not COVID,” came the answer.

Young residents stood on either side of the man’s bed and took turns doing chest compressions. Nurses ran out of the room and back in with supplies. Gasperino threaded a catheter into a large vein to infuse medication into the patient’s body. The man’s pulse returned.

At about the same time, one of the pregnant patients was wheeled from the intensive care unit and into an operating room for a cesarean section. She was in her early 30s and her baby was being delivered nearly two months early in an effort to save the mother’s life. Over the past day, doctors had ordered two doses of steroid medication to help the infant’s lungs mature.

During rounds earlier that morning, a resident presented the woman’s case. She had been put on a ventilator and sedated the previous evening. Rosenberg cursed under his breath: This disease was cruel.

Grasping for Solutions

As Rosenberg walked down the corridor, nearly every door he passed had a neon colored sticker warning that personal protective equipment must be worn inside. “COVID” was handwritten on many of them.

Staff members had separated control boards from some of the ventilators, so they could adjust their settings and monitor patients without going inside their rooms unless necessary, reducing exposure to the virus. Nurses were making a similar adjustment with the pumps that delivered intravenous medications, adding extension tubing that snaked across floors into hallways.

Workers rushed in and out of the rooms preparing for procedures. “Watch out, don’t trip!” Rosenberg warned a colleague. Moments later, he had to repeat the warning. “Watch out, don’t trip!”

Later that day, when a patient became unstable, Rosenberg passed out masks with a face shield — “they’re clean, save them, they’re gold” — to staff members before they entered the man’s room. Rosenberg put on a sterile gown and ski goggles, which he said he preferred because they didn’t fog up. He inserted a narrow tube into a patient’s artery to better monitor his vital signs. Procedures performed inside the room, close to the patient, posed the greatest risk of exposure.

Amid the grimness, Rosenberg tried to keep the mood positive, his energy fueled by espresso from an automatic machine in his office. He called his colleagues “dude,” made sports analogies to explain his points and sometimes asked how their families were dealing with the stress. Even in the thick of a crisis, he directed questions to trainees that forced them to think hard about the next step in care for each patient.

Being a teacher came easily to him. He had studied science at Wesleyan — earning his degree in three years to save on tuition costs — and then taught it to first graders at the Choir Academy of Harlem, a now shuttered public school that was the home of the famous Boys Choir. He went on to medical school in Israel, later returning to New York, where he now lives with his wife and two daughters.

Rosenberg and his team reviewed the status of one of the many patients who were receiving a “COVID cocktail” of the antimalarial drug hydroxychloroquine, held up by President Donald Trump as a potential cure, and the antibiotic azithromycin. Rosenberg referred to it as a “maybe-maybe-this-will-work cocktail,” because only a couple of tiny studies supported its effectiveness against COVID-19. Still, the doctors were prescribing it aggressively now, early in the course of hospitalization, in the hopes that it could prevent the lung damage that led patients to need ventilators.

The cocktail is generally considered safe, though it may have serious side effects in certain patients. One man in the ICU developed a deadly arrhythmia and had to be shocked back to life the night before Rosenberg’s Monday shift. The doctor told his residents that the patient should not go back on the drug.

“I don’t think the public realizes how often we don’t really know” whether something works, Rosenberg said. Different coronaviruses can cause the common cold, which “affects all of us,” he said. “There’s no medicine to get better from it — it’s just time, patience.” What scared him with this new coronavirus, though, was the thought that “time and patience when somebody’s on a ventilator is different from time and patience when someone has the sniffles.”

His team had also begun treating some patients with another medication, an experimental antiviral drug called remdesivir. But the hospital had to apply to the manufacturer, Gilead, for emergency permission to use it on each patient, who had to have a confirmed diagnosis of COVID-19.

“Do we have a positive test?” Rosenberg asked about one patient. A colleague replied, “Not yet.” Test results from a Quest commercial laboratory in California had been taking about a week, making it harder to isolate infected patients within the building, provide certain treatments and even discharge people. Laboratory workers at the Brooklyn hospital managed to retrofit equipment and start their own testing last weekend, which doctors considered a game changer.

But with one problem resolved, another arose.

This past week, there were days when the hospital ran short of a drug to treat life-threatening low blood pressure in many of Rosenberg’s ICU patients, as well as a sedative that many were receiving to relieve the distress of being on a ventilator. The doctors ordered substitutes.

The chief pharmacist at the Brooklyn hospital, Robert DiGregorio, worked until after 2 a.m. on Thursday to try to source more of one drug. Going forward, Rosenberg predicted, “the biggest threat will be medication shortages.”

Painful Conversations

Rosenberg was struck by the range of the patients felled by this illness — various ages, ethnicities and medical histories. Some who had been critically ill, most of them younger, were starting to recover enough to be taken off a ventilator and breathe on their own.

But as he and his team stopped outside each room, they saw many who were from nursing homes and had multiple medical problems — the type of patients who filled the intensive care unit during flu season. Now some were extremely sick, with failing organs.

“Very poor prognosis,” Rosenberg said about one man, in his 70s, who had developed kidney damage. “He’s going to pass from this.”

“Has anyone been in contact with the patient’s family?” he asked. He asked a variation of that in front of other rooms. “All of these patients need a palliative care” consultation, the physician said of the seriously ill.

The patients were alone. Visitors were no longer allowed into the hospital, and doctors had to call family members to update them, get their permission for doing procedures and — for many — discuss end-of-life care.

That day and continuing through the week, Rosenberg had many difficult conversations, on the phone and often through translators, about shifting from trying to extend life to withdrawing life support and focusing on comfort.

“A lot of family members don’t realize how sick the patients are or how bad the prognosis is with this disease if you develop respiratory failure,” he said, particularly in the context of advanced age and other health conditions. “The families really want to see their loved ones.” The team was using iPads and smartphones to connect them.

He said that the state’s laws governing withdrawing patients from ventilators were complicated. The default, generally, is for doctors to initiate and continue providing life support unless the patient or proxy has clear directives otherwise. “It reflects on the need for these conversations in primary care well before somebody gets sick and for that information to be disseminated to family members.”

He added, “There are an awful lot of really young patients in their 50s and 60s who I’m sure never thought about this.”

There were fears throughout the week that New York’s hospitals would soon run out of ventilators and be forced to ration them, but doctors at the Brooklyn center said they had enough for now. Rosenberg worried more about having enough staff members and medications.

Still, Rosenberg said that he and his colleagues were looking at protocols for how to ration care, developed by intensive care doctors at other medical centers, in case conditions worsened.

The goal was to expand capacity to avoid the need to limit treatment. Gary Terrinoni, the hospital’s president and chief executive, said he had received donations of food and supplies, but was appealing to the city and state for physical beds, equipment and funds to “ensure we can serve the community” as his clinical colleagues fought “the good fight.”

But even discharging those who no longer needed hospital care to make space for new patients was sometimes proving difficult. Rosenberg worried about getting one of his patients, ready to leave the ICU, accepted back into a nursing home, where across the city staffing had fallen short. Government officials were working on sites to accept released patients, but those had not yet opened.

Even death did not always guarantee an exit. By the end of the week, the hospital had accepted two refrigerated trailers from the city’s medical examiner. Workers were building shelves in one of them to make space for more bodies, as overwhelmed funeral homes were failing in some cases to retrieve them. A tent discouraged onlookers from recording more cellphone videos.

Meanwhile, patients continued to arrive at the ICU — some of them with ties to the 175-year old institution, near Fort Greene. “It’s like home for us,” said Kondamudi, the chief medical officer.

Dr. Antonio Mendez, the vice chair of the emergency department, was born at the hospital, and his mother, Josefina, was admitted as an ICU patient. “She is a fighter and so are her doctors,” he said.

On his first day back, Rosenberg checked her blood gas, a measure of the effectiveness of her breathing support. It “looks pretty darn skippy,” he said and praised his team for their management of her care.

Late in that long day, Rosenberg learned that one of the hospital’s own medical residents, whom he knew well, was in the emergency room, with symptoms of COVID-19 and a worrisome chest X-ray.

“He comes right up,” he told his team, “because he’s at high risk of getting intubated.”

To admit the physician to the ICU, however, Rosenberg had to get more staff. “We need more nurses,” he said. Given how overwhelmed they are, “they’re getting killed.”

Soon after, two nurses who normally worked in the cardiac catheterization lab walked into the unit to offer their assistance. Rosenberg applauded. “This is the cavalry,” he said.

This article originally appeared in The New York Times.

© 2020 The New York Times Company

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