San Francisco Chronicle - (Sunday)
Lessons from N.Y. for next virus surge
Bay Area medical volunteers share what they learned
On his last day at North Central Bronx Hospital in New York City, Kristopher Jackson walked out the door and wondered what he’d accomplished.
The San Francisco nurse practitioner had taken a twoweek unpaid leave from UCSF to go to New York at the peak of its surge because he loves critical care, and it felt silly not to do what he loves in a place that desperately needed it.
But he’d arrived in a city buried beneath the novel coronavirus, in a hospital making contingency plans for its contingency plans, in a ward where health care workers without the requisite experience were outmatched against a relentless disease. After two weeks, most of his patients were still brutally ill and some had died. Few had recovered.
“I left feeling sort of beat down. I walked out of the hospital at the end of the 14th day, and I was like, ‘All right. I guess that’s it.’ ”
Now, Jackson and other local health workers who volunteered during the surge are watching California reopen with hope and trepidation. They’re seeing San Franciscans wade back into public life at protests and picnics, and recent case spikes in parts of the Bay Area. And they’re reflecting on their time in New York: what they saw, what they learned and what we should do differently in the next wave — or the next pandemic.
“This is all one big planning game,” Jackson says. “Since everyone’s figuring out how to do this as we go, it’s hard to see the light at the end of the tunnel. But I think we all need to start looking in that direction.”
One of the first things to vanish during the surge in New York City was the doors. When Jackson walked into North Central Bronx Hospital on April 6, every spare inch had been conscripted into treating COVID19. Intensive care unit rooms were long since full, and Jackson was assigned to an improvised ICU, a large, windowless space normally used for postoperative care that now housed about 15 COVID patients on beds and stretchers. “Everyone intubated, everyone in their full PPE, just sealed into this one big room.”
Across the city, ICU wards hit their capacity then quickly exceeded it, as severely sick patients arrived and stayed for weeks at a time. During April, New York City Health & Hospitals added 762 ICU beds to its 11 public hospitals. At North Central Bronx, capacity grew by 31 beds.
Private hospitals also expanded their critical care footprints. At NewYorkPresbyterian’s Queens medical center, UCSF nurse practitioner Kristina Kordesch had so many ventilated patients in one openair unit it was hard to fit all the machines keeping them alive. At Montefiore Medical Center in the Bronx, where Sutter Health nurse practitioner Brooke Carpenter volunteered for two weeks, “the entire place was COVID. Basically, patients on ventilators in every unit on every floor.”
In anticipation of a surge here, San Francisco identified an additional 312 ICU beds that could bolster hospital capacity, creating space for 591 ICU patients at any given time. But medical workers warn that any system can be overwhelmed if infections escalate as quickly as they did in New York City.
If California Pacific Medical Center Van Ness had the same influx as Montefiore, Carpenter says, “I think we’d be in the same boat.”
In some hospitals, the ICU even sounded different. Normally, an ICU is relatively quiet, with patients resting behind closed doors. Kordesch spent much of her day standing in the middle of the unit, triaging medication, monitor and ventilation alarms. Now and then, Journey’s “Don’t Stop Believin’ ” would blast over the hospital intercom, marking a COVID discharge, or someone would call a rapid response for a patient in distress.
“Those perk your ears up,” she says, “because you wonder if that’s a patient coming to you.”
As new critical care wards sprang up, New York hospitals also had to staff them. Temp agencies hired contractors from across the country; medical organizations begged for volunteers. Jackson responded to a call from the Society of Critical Care Medicine. Carpenter connected to Montefiore through a friend. Kordesch joined a UCSF team mobilized to work at two New YorkPresbyterian campuses with a casual understanding that if San Francisco surged later, they would reciprocate. New York City Health & Hospitals deployed thousands of additional workers to beat back the coronavirus spike.
But even while experienced staffers around the country sat in quiet hospitals or had their hours cut, the providers pouring in to help weren’t always those best suited to the job: furloughed primary care doctors, outpatient nurses or those fresh from school, people with scant critical care experience or who hadn’t worked the ICU in a long time.
Some landed at North Central Bronx, the public hospital in a neighborhood with the second most cases in the city. Its ZIP code alone has recorded 3,334 infections and 292 deaths since the start of the pandemic. All of San Francisco has had 2,698 cases and 43 deaths.
Inside the hospital, a fraction of the staff was sick, and the sheer volume of the outbreak had overwhelmed employee reserves. Jackson found himself alongside a crew of fellow outsiders, many of whom had limited critical care experience and all of whom were learning workflows and hospital protocols as they went. At times it felt more like a medical mission trip than a twoweek stint in the largest public health system in the United States. The situation speaks to a need to plan for how this may happen again, he says, “so at no point are you relying on outpatient providers to manage critically ill patients in makeshift ICUs.”
On Carpenter’s unit in New York, the staff included an epileptologist, a gastroenterologist, ear, nose and throat surgeons and a psychiatry resident, all deployed as “ICU interns.” A hospitalist was in charge as the attending physician, but most days Carpenter was the provider with the most critical care experience, an outofstate visitor helping lead the ICU.
“The nurses there were turned into ICU nurses overnight,” she says. “Some of them just had tears in their eyes. I was terrified to take care of ventilated patients when I first started as an ICU nurse, and I was trained to do it. How can you blame them?”
Kordesch hopes a legacy of the pandemic will include better communication and resource sharing across cities and state lines, that more medical systems will follow UCSF and come to each other’s aid in times of crisis. It doesn’t make sense for one hospital to be overwhelmed, she says, while another sits empty. Jackson envisions a formalized system for coordinating between institutions, moving a skilled workforce around and expediting credentials so it can get into hospitals and get to work.
“I wish this was all ICU people,” Carpenter thought as she flew across the country on a nearly empty flight in April. “That’s what was needed. We should have just hauled a bunch of us out there.”
The lack of experienced ICU workers in New York had an inevitable impact on patient care. Jackson says patients who refused intubation may have fared better because there weren’t enough people to manage ventilators. He wonders how many patients died because hospitals weren’t prepared to treat them.
“When some epidemiologist tallies up these numbers, when all of this is said and done, we’re never going to really know the number of preventable COVID deaths that happened in New York that were the result of a lack of critical care providers or just basic critical care knowledge.”
Even as the curve of infection falls and flattens, for frontline health care workers, the psychological fallout may only be beginning. They’ve spent the past few months working beyond capacity, watching coworkers and family members fall ill and coping with death and sadness on a daily basis. Now, experts warn, they may be at greater risk of burnout and PTSD.
Carpenter spent her first two days in New York on a consult team, triaging people in the ER for higher levels of care and responding to “code blue” calls for patients in cardiac arrest. On a normal day at CPMC, she might field one code blue. In a single shift at Montefiore, she responded to 10 or 12.
“Generally, if they’re coding, they’re not going to make it,” she says. “I think maybe one that day made it.”
Carpenter has been in critical care for more than a decade. Dealing with death is part of the job. But this was a volume of death she’d never seen before. “It didn’t matter what we did,” she says. “These patients were just so sick.”
“We came into the profession accepting that you will have wins and you will have losses,” Jackson says. “But when you have zero wins and thousands of losses, that’s going to take a toll on a workforce.”
He remembers calling an older man who brought his wife to be admitted and then heard nothing for four days. The husband didn’t know if she was alive or dead, or whom he should to call to find out. The UCSF nurse practitioner was tasked with telling him that she wouldn’t survive and that with no visitors allowed, his wife of 25 years was going to die alone.
“You’re sitting there in your PPE behind your glasses trying not to cry,” Jackson says. “Everything you hold near and dear about endoflife human compassion kind of just gets stripped away.”
He worries about the mental health of colleagues who’ve been in the thick of the coronavirus for months on end, how they’ll cope when the last COVID patient is wheeled out of North Central Bronx. We have to rally around medical workers, he says, to care for the people who’ve been caring for us.
Kordesch expects burnout among clinicians who’ve seen their communities ravaged by the coronavirus and had the hardest day of their professional lives again and again. One of the residents she worked with was donating plasma between shifts, trying to share antibodies from his own infection.
“I can’t say enough about their resilience, but the people in New York, they’re so fatigued,” she says. “I think at the end of this there will be a huge emotional toll.”
And the pandemic isn’t over yet.
Now, as the Bay Area inches toward reopening and people flood the streets in protest, medical workers are eyeing the coming weeks warily. Already case counts are climbing in parts of California, and Alameda County recorded a recent spike.
Jackson gets depressed seeing resistance to mask orders and lingering restrictions, people questioning the validity of moving slowly when they’ve spent the past three months safe at home. He thinks back to the 30 and 40yearolds he saw dying, and “my head explodes. I feel physically sick.”
Without the collective trauma of New York, Kordesch fears that the Bay Area will sprint back into public life too quickly. Like everyone else, she’s eager to resume normal rhythms, but sometimes she wants to shout at the people outside her windows in San Francisco, to tell them what she has seen and make them understand: “There isn’t a vaccine. There isn’t a cure. There’s not a forsure, slamdunk way to treat these patients. None of that has really changed.”
She worries about a second wave coinciding with flu season. She worries about the additional burden on the medical system of chronically ill people recovering from COVID complications. The rest of this year will be hard, she says. Next year, too.
Jackson has been thinking about the lessons of New York, reflecting on his time on the front lines of the pandemic. He hopes that by sharing his experience, we’ll be able to fix the issues he witnessed and better support hospitals, providers and their patients. So that whatever comes next, we’re ready.
Sarah Feldberg is The San Francisco Chronicle’s assistant features editor. Email: sarah. feldberg@sfchronicle.com Twitter: @sarahfeldberg