A New York Doctor’s Warning
China warned Italy. Italy warned us. We didn’t listen. Now the onus is on the rest of America to listen to New York.
About the author: Fred Milgrim is an emergency-medicine resident physician in New York City, currently working at Elmhurst Hospital.
In the emergency-department waiting room, 150 people worry about a fever. Some just want a test, others badly need medical treatment. Those not at the brink of death have to wait six, eight, 10 hours before they can see a doctor. Those admitted to the hospital might wait a full day for a bed.
I am an emergency-medicine doctor who practices in both Manhattan and Queens; at the moment, I’m in Queens. Normally, I love coming to work here, even though in the best of times, my co-residents and I take care of one of New York City’s most vulnerable, underinsured patient populations. Many have underlying illnesses and a language barrier, and lack primary care.
These are not the best of times; even for my senior attendings, it is the worst they have ever seen. Here, the curve is not flat. We are overwhelmed. There was a time for testing in New York, and we missed it. China warned Italy. Italy warned us. We didn’t listen. Now the onus is on the rest of America to listen to New York. For many people around the country, the virus is still an invisible threat. But inside New York’s ERs, it is frighteningly visible.
Every day, in our hastily assembled COVID-19 unit, I put on my gown, face shield, three sets of gloves, and N95 respirator mask, which stays on for the entirety of my 12-hour shift, save for one or two breaks for cold pizza and coffee. Before the pandemic, I would wear a new mask for every new patient. Not now. There are not enough to go around. The bridge of my nose is raw, chapped, and on the verge of bleeding. But I consider myself one of the lucky ones. My hospital still has a supply of masks—albeit a dwindling one—to protect me and my colleagues.
Many of my patients clearly haven’t received the message to stay home unless they’re in immediate need of professional medical assistance. Their fevers and coughs alone are not enough to even earn a test. I hand them discharge paperwork and a printout about how to prevent the spread of the coronavirus, tell them to self-isolate, and then I move on to the next person. If they didn’t have the coronavirus before coming to our hospital, they probably do now. So much for gatherings of 10 people or fewer.
Meanwhile, my colleagues tend to patients in the critical-care bay with dipping oxygen levels, patients who can barely speak and may need breathing tubes.
Earlier in the month, we were told that positive-pressure oxygen masks, such as CPAP machines, were risky, as they would aerosolize the virus, increasing health-care workers’ risk of infection. But in recent days, running dangerously low on ventilators, we have attempted using CPAP machines to stave off the need for medically induced comas.
Nevertheless, we need to perform an alarming number of of intubations. Our ventilators are almost all in use, and the ICUs are at capacity. Although our hospital has received extra vents here and there from other hospitals in the region that can spare them, those few additions are merely a stopgap. Will we soon have patients sharing vents? We wouldn’t be the first hospital to attempt that unusual and suboptimal practice, which gained traction after the Las Vegas shooting, when scores of young trauma patients were vented in pairs. But these COVID-19 patients have delicate lungs, which makes vent-sharing far more dangerous. Nevertheless, we’ve already started studying the mechanics of how to make this happen, as a last-ditch effort.
By next week, we may simply have no choice. Those hundreds of relatively healthy patients we sent home may return to the hospital en masse in respiratory failure.
On Wednesday, I greeted a patient I had discharged only one week prior. When I saw his name pop up on the board, my heart sank. He is just shy of 50, with hardly any past medical history, and he had seemed fine. Now he was gasping for air. His chest X-ray was no relief—COVID-19 for sure. I needed to admit him to the hospital, and set him up with oxygen, heart monitoring, and a bed.
Last week, I saw an elderly woman on dialysis. She had arrived with a mild cough. But her vital signs were normal—no fever. After her chest X-ray came back clear, we decided to send her home. But before her ride came, she spiked a fever to 102. Change of plans. With her age and complex medical problems, she would need to be admitted.
The next night, I saw a stretcher wheeling past me with a resident riding on top, performing chest compressions on the patient.
Only after we pronounced the patient dead did I learn her name. She was my patient from the night before. She went into cardiac arrest before she even got a bed in the ward. My first COVID-19–positive death. The numbers have been mounting ever since.
A few days ago, FEMA finally arrived to help with this crisis. It has brought more tests, hopefully more vents, and a morgue in the form of a truck to help with the ever-growing number of dead bodies. I wonder if this help will be enough. My colleagues and I discuss this pandemic with a sardonic sense of helplessness. Some of us are getting sick. Our reality alters by the moment. Every day, we change our triage system. Each day could be the day that the masks run out. There is much we think but are too afraid to say to one another.
I do not want to see you in my hospital. I do not want you to go to any hospital in the United States. I do not want you to leave your home, except for essential food and supplies. I do not want you to get tested for the coronavirus, unless you need to be admitted to a hospital.
For those of us at the forefront, knowing who has COVID-19 won’t change our ability—or inability—to treat patients. The problem is, and will be, our shortage of healthy personnel, personal protective equipment, beds, and ventilators. A nasal swab is not the answer anymore.
If you have mild symptoms, assume that you have the coronavirus. Stay home, wash your hands, call your doctor. Don’t come to the emergency department just because of a fever or cough. Receiving a test won’t change our recommendation that you remain in self-isolation. We don’t want you to expose yourself to those who definitely do have the virus.
Social distancing, while still crucial, came too late in New York to prevent a crisis. Maybe, just maybe, extreme measures can prevent this from happening in other cities around the country.
In spite of all this morbidity, the doctors at the hospital received one piece of good news yesterday. A coronavirus patient was successfully taken off a ventilator after two weeks, a first for our Medical ICU and a victory for the staff and, of course, the patient.