The COVID Cavalry
by Deborah Schupack
EARLY MARCH, 9:45 A.M., MIDWOOD, BROOKLYN—At the regularly scheduled bed board meeting to discuss the upcoming day at Mount Sinai Brooklyn, President Scott Lorin addressed the pandemic on the horizon. He pulled no punches, as Chief Nursing Officer Claudia Garcenot recalled: “He said, ‘You guys, you can’t imagine what it’s going to be like. It’s going to be bad.’ And he said, ‘People are going to get sick. We are going to get sick.’ He said, ‘People are going to die. Some people that we care about are going to die.’ ”
Like many of her colleagues, Ms. Garcenot could not yet wrap her mind around it. “I thought, ‘Geez, you’re being so pessimistic. Stop that. We’re tougher than that.’ I clearly remember thinking, ‘That can’t be. It’s not going to be that bad.’ And sure enough, in just a few weeks, it was.”
‡
IN THE BEGINNING
‘It was the perfect storm’
PARKED ON EITHER SIDE of the three-story brick building was a pair of trucks that laid bare the life-and-death struggle inside this small hospital: a second oxygen tanker to help the throngs of COVID-19 patients breathe and two morgue trucks to handle, with as much dignity as possible, the hundreds who would not survive the deadly virus.
Mount Sinai Brooklyn, a former nursing home that evolved over the years into a hospital with many iterations of names, sits in the Midwood section across Kings Highway from a block-long yeshiva and across smaller side streets from tidy single-family homes and townhouses. The hospital serves diverse neighborhoods of Orthodox Jews, Blacks, Caribbean-Americans, and Russian immigrants. These were communities that, it turns out, were right in the line of fire. In the first U.S. wave, which swallowed New York and its environs, five out of the top twenty ZIP codes with the highest rates of COVID were in Mount Sinai Brooklyn’s service area.
The hospital admitted its first known COVID-positive patient March 9. By March 16, the number of COVID admissions was doubling every two to three days, peaking in early April. Staff came to care for 50 percent more patients than the hospital routinely cared for; the emergency department cared for upward of 90 patients with only 16 bays. On April 1, there were 35 cardiac arrests or emergencies (compared with the usual two or three a day), 33 percent of patients required critical care, and 50 percent required respiratory support. Hence the additional oxygen tanker outside the hospital.
The first line of defense was the ED, ambulances streaming day and night to the humble emergency entrance. The higher acuity patients would be wheeled behind a plastic protective curtain and into the bustling ED itself. The movable walls between bays were all accordioned open, stretcher after stretcher after bed after stretcher packed together. The bays held more machinery and plugged directly into the hospital’s store of oxygen, so that was where the more acute patients would go if they could fit, those on ventilators, high-flow nasal cannulas, BiPAP. In the middle of the room were the less-acute-but-still-acute patients who could be on portable oxygen.
Those who were even less acute could be treated just outside the emergency room, in the portable tent. It could house ten to twelve people at one time, sixty or seventy over the course of the day. The tent’s grand opening in mid-March reflected the growingly familiar narrative arc of pandemic operations: it went up on a Friday during the surge with plans to open as needed, with staff training in the meantime. “As needed” became right now, and there was no “in the meantime.” “We opened it Monday,” said ED Nursing Director Robert (Bobby) Lynch. “We went live right then and there. There were no drills.”
Mount Sinai Brooklyn’s ED had become a massive bottleneck. Normally, Mr. Lynch explained, emergency clinicians stabilized patients and moved them upstairs. But now, patients were coming in at double the volume. And, with COVID patients, it was hard to tell when or if they were stabilized.
Secondly, space upstairs, in existing and newly converted ICUs, was not clearing out. COVID patients were, simply, not getting better. They were remaining in their converted negative-pressure rooms, gravely ill, often on ventilators, for much longer without getting better than patients with other illnesses usually did.
Thirdly, the Brooklyn hospital was seriously understaffed, with so much of its health care workers out sick with COVID or quarantining with symptoms. That wreaked plenty of havoc on the flow of patients.
When the hospital asked to divert ambulances—something it doesn’t like to do, but the small ED was bursting at the seams—the city declined. There was nowhere else to send people, no nearby hospital less overwhelmed.
“It was the perfect storm,” said Mr. Lynch.
AS MOUNT SINAI BROOKLYN went from bad to worse, over capacity with primarily COVID patients, gone were such clinical luxuries as checking on each ventilator three or four times in a shift, said Vadim Leyko, a respiratory therapist who was also in charge of monitoring the hospital’s oxygen usage. “You just respond to emergencies, go from one room to another,” he said. “And there were some instances when we responded to an emergency, and the patient was already pronounced [dead]. It was too late.”
COVID most often (though not always) manifested first as a respiratory disease, restricting the ability to breathe. On a macro level, the hospital itself mirrored the human struggle with oxygen. Normally, Mount Sinai Brooklyn is served by one external oxygen tanker, known as an oxygen farm. But after refueling demands proved too frequent, Mr. Leyko received another portable tanker, on wheels, which sat outside the hospital’s emergency entrance, doubling the oxygen supply. The backup supply of portable oxygen cylinders was refilled every day rather than the usual once or twice a week, and went from an average of 70 cylinders on hand to 275.
The oxygen farm was working so hard that its ventilator coils were icing over as they labored to convert the negative-300-degree liquid oxygen to a usable gas. The nimble, if overwhelmed, hospital quickly stationed someone next to the oxygen farm to pour hot water on the vaporizers almost around the clock, until employees could rig a solution: securing a hose over the vaporizers to keep a steady stream of hot water ensuring the flow of oxygen from tanker to lung.
IT WAS THE LAST FRIDAY in March. The 212-bed hospital was beyond capacity, mostly with COVID patients. Eleven patients would die that day, the most yet in a single day (although the hospital would go on to lose upward of eleven, twelve, thirteen patients a day for the next week). Scott Lorin had contracted COVID and was trying to run the hospital from a bed at the Mount Sinai Hospital. Claudia Garcenot, too, was seriously ill, and her twenty-five-year-old daughter would soon drive her to the same Manhattan emergency department.
That’s when Dr. Lorin, struggling to breathe between COVID and asthma, called [THEN-COO] Margaret Pastuszko from his bed at the Mount Sinai Hospital and pleaded for help. As dire as the plea was to an already hard-pressed organization, Ms. Pastuszko saw the full potential of the Mount Sinai Health System—both that it was Mount Sinai, and that it was a Health System. “Hold on,” she told Dr. Lorin. “You are not alone.”
Then she phoned Michael McCarry, a nurse by training and on the leadership team as head of perioperative services at the Mount Sinai Hospital. “We’ve got to go there,” she told him. “He needs our help, our personal help.” She knew that it was about more than just transferring patients and sending teams—although that was vital,and Mount Sinai would certainly go on to do that. It was now about getting boots on the ground in the devastated hospital, restoring leadership, and letting the exhausted staffers know “that we have their backs.” She also hoped that an infusion of interim leadership would allow Dr. Lorin to sleep for a few hours as he battled COVID.
As the straight-talking Northern Irishman Mr. McCarry remembered it, Ms. Pastuszko began the call to him with, “Don’t hate me for this,” then she made her ask.
Answered Mr. McCarry, “I’ll be there tomorrow morning.”
‡
THE BENEFITS OFA SYSTEM
‘It really felt like the cavalry’
SIX-THIRTY TOMORROW MORNING, to be exact. Mr. McCarry picked up his colleague Linda Valentino, the system’s vice president of nursing, who would return to her old stomping grounds—she used to be CNO at Brooklyn—to co-lead the team with him. The two drove to Mount Sinai Brooklyn, a journey they would make every day for the next couple months. “Just about every corner of it was overwhelmed with COVID patients,” Mr. McCarry said of his new hospital. “The ambulance sirens just kept coming and coming. The ED was packed. The scene in the emergency room was like something out of a war zone. A number of their staff were furloughed at home with COVID or suspicion of COVID. Everybody was just overwhelmed.”
Opportunities to make change presented themselves from the moment he stepped in the front door. The current setup had health care workers enter the lobby, climb a few stairs to the right, snake down a narrow corridor, turn left down another corridor, and there, at the nursing office, was where they’d get their PPE. That’s an awful lot of steps through a nearly COVID-endemic hospital without PPE, a lot of time for virus to gather, anxiety to build, fear to mount.
So, first things first. He and a team secured some wire carts and moved all the PPE to the lobby, so as soon as staff arrived in the morning, they secured the necessary equipment to do their day’s work. It also became clear to Mr. McCarry that every staff member at the cramped, overrun hospital should be wearing an N95 mask. Health care providers working directly with COVID patients, of course, already were. But everyone, including people in housekeeping, pharmacy, and food services, should have the highest measure of protection available. In addition, everyone should have scrubs to change out of at the end of the day and leave, along with any contagion, safely stored for cleaning at the hospital. “Things were getting bizarre at one stage,” Mr. McCarry said. He’d heard reports of people driving home naked, changing on the street outside the hospital, or stripping in their apartment hallways to keep the virus from coming home on their clothes.
Once Mr. McCarry was assured the health system had enough N95s on hand, the new mask policy went into effect immediately. “When we were able to hand out those masks to every single staff member at the door of the hospital, and a pair of scrubs that they could leave at the hospital so they weren’t bringing things back to their family, you could feel the relief in the air,” he said.
THE KEY TO THE TURNAROUND was when redeployed staff began to be dispatched out to Brooklyn—ultimately, almost 200 nurses and physicians from across the health system. Nurses from the New York Eye and Ear Infirmary helped out medical teams, plastic surgeons worked in the ICU. In addition, 90 temporary visiting staff—known as locums—came to Brooklyn from all over the country. They worked in new positions, outside comfort zones, at all hours of the day and night.
That included people like Dan Herron, chief of bariatric surgery at the Mount Sinai Hospital in Manhattan, who came to Mount Sinai Brooklyn and did whatever needed doing, whether that was transporting patients on gurneys down the hall, adjusting ventilators, or carrying out old oxygen tanks and bringing in new ones. “Everyone did everything,” Dr. Herron told New York magazine, which published a series about the small hospital’s response during the COVID surge in March and April. “It was heartwarming seeing everyone rising to the occasion and figure out what needed to be done and doing it. It’s such an awful situation and yet it was also an extraordinary learning experience.”
And that included people who could hit the ground running, for whom Peter Shearer was eternally grateful. “I had a fifty-five-year-old Staten Island cardiologist essentially staffing a unit like a medical intern, and very enthusiastically so, because he could identify patients who were improving, identify patients who were deteriorating, be a constant resource for nurses and their questions—which is something that we don’t always have here in the hospital,” said Dr. Shearer.
There were even enough nurses now to connect sick or dying patients with families, something that heretofore had been a luxury with a staff pressed to its limits. Said Ms. Garcenot, “We were now able to have redeployed nurses go from bed to bed or stretcher to stretcher and set up FaceTime calls between patients and their families.”
From Mount Sinai hospitals and outside agencies, the emergency department received teams that each included a doctor, nurse, and medical assistant, Deborah Dean explained, gesturing to the entrance of a quieter ER many months later but as if she could see the mirage of them now, riding in to help with battle.
“It really was like the cavalry came,” said Bobby Lynch.
That outside staff included certified registered nurse anesthetists (CRNAs), a much-needed clinical force during a pandemic that steals breath. “They brought a very valuable skillset,” said Dr. Shearer. “They would be here days and nights. They could help put people on ventilators. If a patient was on a ventilator on a unit that usually doesn’t manage patients on ventilators, the nurses on those units have never worked with the machines or the strong sedative medications like propofol that you need to give. These nurse anesthetists, then, were there not just to help administer the medication but also to teach nurses on the fly what they needed to know.”
Visiting CRNAs brought Vadim Leyko his first moment of hope during the pandemic. Early April. Sunrise. He had been at the hospital all night. Now, he was going to meet three new CRNAs reporting for duty at Mount Sinai Brooklyn’s east-facing glass-fronted lobby. “The sun is coming up on that side, so it’s very bright and warm that early in the morning,” he recalled. “They walked in and just said, ‘Hi, we’re here, we’re CRNAs.’ ”
In four hours, Mr. Leyko oriented the out-of-state travelers on the hospital’s processes and equipment, an orientation that typically takes four weeks. And, for the first time in many days, he went home and slept in his own bed.
No comments:
Post a Comment