“Dead on Arrival”: A New York Fire Chief’s COVID-19 Journal

Simon Ressner

Simon Ressner, a 9/11 survivor, was a sixty-year-old battalion chief with the Fire Department of New York based in central Brooklyn at the start of the pandemic. He kept a diary of a twenty-four-hour shift that began at 9:00 a.m. on Friday, April 3, 2020. It was first published by ProPublica.²

“10–37 Code 1.”

It’s fire department shorthand for “dead on arrival.” Word of such tough calls crackles over the citywide radio in bursts.

One of my engines just returned from a 10–37 Code 1, and a firefighter is at my office door. He hands me what’s called an “alarm ticket,” and asks for a new supply of protective masks.

“Need four,” he says, as if asking for some money for candy.

I ask about the run. “She had a fever, I reached out and touched her head and she was so hot.”

I hand him four N95 masks, grab a disinfected pencil from my desk and mark on the inventory sheet: “Engine 235, Box location 431, Madison Street between Nostrand Avenue and Bedford Avenue.”

It’s around the corner from the firehouse, and so close that I can walk to my office’s rear windows and see the building. Inside, an eighty-three-year-old woman with family nearby just died. Just outside my window.

While I’m attempting to get that to register, I hear several more 10–37 Code 1 signals come in. As I’m writing this, yet another one. The tone of the officer on the radio reporting the signal is matter of fact—not detached, more along the lines of, “Yep, another one.”

10–37 Code 1. Another one a minute later.

I begin my shift at 9:00 a.m. I grab the bleach wipe from the canister, wipe down the computer keyboard, mouse, phone, desk and twenty other places where I can imagine anyone has put their hands.

I am working as chief in Battalion 57 of the FDNY, located in Bedford-Stuyvesant, Brooklyn. Bed-Stuy is a historically African American neighborhood that saw its population grow during the time when huge numbers of Southern Blacks migrated north, leaving agriculture work for ostensibly better jobs. In the last few years, it has undergone major gentrification, but it still remains culturally and demographically an African American neighborhood with a history of both hard times and cultural richness. Since almost all the country’s past traumas have always hit the poor neighborhoods worst, I wonder what this worst situation, COVID-19, is going to entail and for how long.

I was a fireman here twenty-five years ago and now have returned as chief toward the end of my career. I thought that surviving September 11, 2001, would be the part of history I would tell grandchildren, but COVID-19 has clearly surmounted even that disastrous and heartbreaking day. The department lost 343; at least 50 of them were people I knew, including my chief, Dennis Cross. He taught me how to fight fires, but also how to sail a boat, and after his death his widow gave me use of his twenty-five-foot Catalina.³

I am focused on my work of supervising the four engine companies and two ladder companies of the 57, but I also have a ritual of checking the numbers: New York City Department of Health daily statistics; the Johns Hopkins website for worldwide information on COVID-19 cases and deaths. I quickly calculate the death percentages, taking comfort when I find the rate under 2 percent somewhere. But this morning the world figures show a rate of 5.23 percent, so I try and convince myself that it will drop because of the anomalies of Italy and Spain.

But the truth is that it is here in the United States where the percentages are climbing, and here in New York City where the numbers are headed toward the unfathomable. Every day I read the obituaries in the New York Times to remind myself of the pain that the families endure in a way that calculating the percentages can’t. But I am waiting. I want to see those bars in the graphs get dramatically shorter.

Yesterday, I was tasked with approving hospital and nursing home requests to use the streets around their buildings to construct tents for overflow patients. Around 11:00 a.m., I received the first request of several to use the streets for refrigerated trailers to store the accumulating bodies. In the moment, I can be detached enough to do the work of looking at street dimensions, trailer sizes, locations of hydrants, and entrances to buildings in order to make it work. It takes me five minutes to look at that information and email back, “FDNY has no objection.” And then a few more requests for more trailers. “FDNY has no objection.”

Simple as that, we have approved the refrigerated storage on public streets of someone’s relative.

I spend a good part of Friday morning rebalancing staffing in the fire companies in the battalion as well as the 31st Battalion in downtown Brooklyn. Staffing has become a challenge because, as of this morning, there are 1,056 firefighters, 686 EMS workers, and 115 FDNY civilians suspected of COVID-19 infection; 241 Fire personnel, 74 EMS, and 23 civilians have been confirmed. Fire companies that normally have twenty people on their roster are down to eleven, and so we move people from companies that have fared better to those companies that are depleted. Even now, there is still a fair amount of tangled paperwork to deal with.

After, I head down to the Chief’s vehicle and start the next disinfecting ritual. The firefighters assure me that it has been done, but they are young and I am not. And they clearly haven’t grasped the genuine risk we are facing with each contact with each other and each response for fires and emergencies.

I try to transmit a “10–18” as fast as I can when engines or trucks are responding to a fire. That signal allows me to hold one engine company and one ladder company at the scene and relieve the remaining three or four companies and get them back to their houses. I do this to limit the amount of time the firefighters hang out with each other talking, catching up, all typically done elbow to elbow. The faster I get the “18” out, the quicker I can keep them separated.

The sirens speak

Around noon, I watch Governor Andrew Cuomo’s daily briefing on my computer. I haven’t yet had a fire call, but I can hear the ambulance sirens regularly. People ask how I can tell what kind of siren it is, and I realize that I have to think about that: it’s the absence of the air horns (the blasting trumpetlike sound) of our trucks and the absence of the “rumbler” that the New York Police Department uses. I definitely can tell. Another siren off in the distance—no air horn, no rumbler. It’s EMS.

When you work twenty-four-hour shifts, it’s often easy to be confused about what day of the week it is. But with COVID-19, I realize that there is no rhythm for anyone anywhere. I stop myself when I ask my wife, “What’s going on this weekend?” There is no weekend, no beginning of the week. What does TGIF mean anymore?

For my wife, Moy, the load is devastating. She is an accountant for an urban planning firm, and like all her colleagues has been working from home. It is her job to get everything needed for a new PPP (payroll protection plan). The faster they get the money the more likely her firm can survive. She does all this while caring for her ninety-one-year-old mother, who lives with us and suffers from advanced dementia.

In the aftermath of 9/11, she attended every funeral from my company, six in all. And in “normal” years, she has endured all of the isolation, fear, and hardship that a family member of an active-duty firefighter can deal with. I never imagined in our lifetime we would be facing what is essentially an international plague. As late as February, we still couldn’t imagine a world where the streets of New York are empty during rush hour. Or a world where—years after having to worry about infections because of damage my lungs had suffered on 9/11—I would once again have fear that I could die of a virus! by going to work.

My nose starts itching. DON’T TOUCH YOUR FACE!!

Up until recently, the Fire Department was able to switch and swap shifts in a way that led to different people working together in a random but ordered way. But with the department’s response to COVID-19, we were organized into four platoons—A, B, C, and D. Everyone in each group would work with the same people each time their letter came up on the calendar. The idea was that if there was a person positive for COVID-19 in one particular group, it would only affect that particular group as opposed to infecting everyone in the company.

At the beginning of the outbreak, if someone tested positive and had been in close contact with other members, those members were directed to quarantine. Quickly that changed since the number of people testing positive was increasing rapidly. Within a week, the department revised the protocols and directed that members who were in contact with a suspected or known positive colleague should continue to work unless they exhibited symptoms. If symptoms came on, they would be placed on medical leave. During the “earlier” days of the pandemic, we all believed that you were only contagious if you had symptoms. And although we now know that is not the case, the manpower needs are such that without positive testing we continue to work until we have symptoms or if we have prolonged close contact with someone who has a positive test.

The interim lifesavers

The Fire Department started taking on medical calls in 1995 in order to help improve response time to serious medical emergencies by providing lifesaving care from a fire crew while awaiting transport and more advanced medical care by EMS. As a result, all firefighters are trained to provide some degree of emergency medical care, including the use of a defibrillator. But several hundred current firefighters are former EMS personnel who had transferred to the fire protection side of the department. With the number of COVID-19 cases accelerating daily, some of those more highly trained firefighters have been brought back to supplement EMS.

On medical runs, the firefighter’s role is to provide patient evaluation, basic life support and first aid, and if needed perform CPR until better trained help arrives. They wear protective gloves, and administer only what’s called BVM resuscitation efforts: bag, valve, mask, basically hand compressions and a device to get oxygen into lungs. Fire companies do not transport people to the hospital.

Those lifesaving protocols were shifted approximately a week ago. We always attempt to revive a patient and perform CPR, and still do. But now, our efforts are limited to twenty minutes, and so if there is no spontaneous pulse or defibrillation is unsuccessful, we cease. The exception is for what is called “obvious death,” like rigor mortis, decomposition, dismemberment.

In the afternoon, I get a phone call from Fire Operations Command Center, “How many N95 masks you have in stock, Chief? We’re doing the daily tally.” I tell him the truth—84—and a cheerful voice says, “Great, you’re in good shape then. Stay safe out there.”

We all say it, we all mean it, but I know that it is, as the president would say, “aspirational.” A month ago I was thinking about how to surprise my wife for our thirtieth anniversary. Perhaps San Francisco or London. How quaint. On April 7, my anniversary, I will return for my next twenty-four-hour shift.

Another siren: no air horn, no rumbler. EMS. Lunch is ready.

In emergency work, if your mind, or at least your behavior, can’t adjust to what is actually happening and to deal with that as it is, you simply cannot help anyone. So the regular rhythm of 10–37 Code 1 mostly registers as a clear-eyed reminder of what is being confronted. Firefighters make this adjustment at lots of incidents: fires, car accidents, falls, construction accidents, and so on. But then there is a shift back to a world that is not tragic every day or even every week.

In 2019 there were sixty-six people who died in fires in all of New York City—in a year! So you deal with the fire, steel your emotions, revel in the action, recognize the loss, but then there is what seems to be a respite. I’m pretty sure that by the end of my twenty-four hours this shift, there will be at least sixty-six calls that I hear on the radio for COVID-19-related deaths.

Isn’t there a quote about the banality of evil? The radio goes off again: “10–37.”

At lunch, for all my desire to isolate from everyone, I stay longer than I should have because the laughter was soothing. Five young men, with some fear but mainly strength and youth on their psychological side.

Soon, the young firefighter who had got masks from me earlier was back. “I need four.” I ask him if the patient was an elderly person. “Yes, and he was really thin,” he tells me. I say that maybe it was a cancer patient, and sure enough, he hands me the dispatch ticket and right there it says, “Patient has Cancer.”

My questions are in part meant to maintain my sense of empathy and in part to soothe my fear. I’ll be okay even though I’m over sixty. I’ll be okay because I don’t have cancer.

“10–37 Code 1.” I have truly lost count. At one point, while watching Norah O’Donnell’s newscast, I hear several 10–37s. It feels like when it snows into your eyes, a little sting, a blink, a little sting.

The daunting curve

The message from New York State’s health commissioner plays for the fiftieth time. Mild mannered, even bland, he espouses social distancing as if he’s telling young kids to share their toys in the sandbox.

Returning from a fire run, we see a double-size city bus sailing down Nostrand Avenue. There are people seated throughout, and many sitting directly next to each other. That’s one bus with twenty-five people who may infect forty who then may infect eighty more. I’m a trained engineer as well as a firefighter, and my mind pictures the exponential curve from math class: mercilessly steep and ever steeper over time.

When I got to Bedford-Stuyvesant more than two decades ago, it was considered a tough and dangerous place. And it was a tough and dangerous place. Murders were through the roof. But it was a place we all wanted to be. Everyone who worked here, in fact, had to know someone in order to be assigned—“a hook,” someone who can pull a string or two.

Firefighters want to be where the action is, not because they are unfeeling or reckless but because we know that you can’t be good at this without actually doing it. Over time, dealing with fires is something that combines art, science, and the deepest psychophysiology of human performance under stress. It was exciting to be here in the nineties, it was a great place to learn this job, but I don’t remember ever feeling this sense of looming menace. A dangerous neighborhood filled with beautiful brownstones, weary frame houses, and blocks and blocks of public housing is something your consciousness can quantify and manage. COVID-19 is too big and too dynamic. Even twenty-four-hour news can’t give a sense of time passing. The numbers I saw before dinner were up by several hundred by the time I walked by the apple pie and went upstairs.

This isn’t firefighting, this feels more like the crew on a sinking ship desperately trying to load the boats while the water gets ever closer.

I wish I had taken a piece of pie.

Into the Storm

Phil Suarez

Phil Suarez was born in France, has lived in Spain, and resides in Easton, Connecticut. A paramedic in New York City with more than twenty-five years of experience, for the past decade he has worked in Harlem and Washington Heights. He stayed at his job during COVID-19 despite its risks. “We’re not special. We’re not heroes. But this is our job. I couldn’t live with myself if I abandoned my job in its most dire moment.”⁴

I’ve always worked in impoverished enclaves of New York City, immigrant communities.

As an immigrant I can relate to them better. I find them to be sometimes more real than more upscale areas like the Upper East Side where people may be more snobbyish or name dropping. I just find the underserved communities need the help. They need people that are probably a little more understanding of how they got there, what they may be going through. It probably comes from my background as an immigrant myself.

I’ve been doing this a long time. For me, it’s a very easy job.

I’m drawn to it because an old partner of mine that’s a writer said, “We knock on their doors, and they open their doors to us.” For that half hour, we’re an integral part of their crazy world, whatever that may be. And it’s really crazy. It’s almost like voyeurism. And it is addictive. Twenty plus years into this, I can still be stunned.

Most of our calls are very routine. And then you have your more chaotic scenes where there could be a trauma like a car accident, somebody stabbed, shot, for instance. You can go from doing nothing, from zero or five miles an hour to, all of a sudden, being like eighty miles an hour in this chaos. That’s what our forte is. Most of us that have been doing this for a while, we kind of thrive in that chaos. I can’t imagine working a controlled environment.

Preparing for the surge

I started preparing myself and with my supervisor we kind of took the reins. We started hoarding the PPE [personal protective equipment] as much as we could. Stashing it. People were kind of panicking and if they saw a roll of toilet paper, they would grab it. [laughs] If they saw N95s, they would grab them. So the hoarding became a problem ’cause you want to have stuff available for everybody.

I’ve worked many disasters and stuff like that. I was probably a little bit better prepared, and so saw that coming, I knew I would be good to the best of my abilities as far as PPE. That I would have enough for foreseeable future. And that’s being diligent.

And all of a sudden, for the better part of three weeks, it seems like everything that we did was COVID-19. I think 98 percent of our call volume was all COVID-19 symptoms. All of a sudden it was before us. Came in very violent.

Everything I’ve done, I tried to take what I call a calculated risk. I was an avid mountain biker. I was a mountaineer, a rock climber, and stuff like that. So everything I did, I tried to do a calculated risk. How much risk am I taking here? Am I okay with it? What are my chances of really getting hurt?

I approached everything through my knowledge base. I told my supervisors and bosses I will keep coming to work as long as I have no fever, and I have a N95 to wear for the shift. The day I have a fever or I don’t have an N95, I will not come to work. And that was my red line. There has to be a red line.

My personal feeling is that the health officials didn’t take into consideration the risk that we were taking and the repercussions of those risks because we expose ourselves, we expose others.

Seeing EMTs without masks or without proper gear

I’m a paramedic. We’re the highest level of care in prehospital. Then there’s the EMTs that are basic. And often times, we back them up.

I was taking as many precautions as I could. And I would go into their ambulance and see that they had no mask on. I would pull them aside.

“Hey, where is your PPE?”

“Oh, no. No. He’s got back pain.”

I said, “No. He’s got COVID-19. Back pain, mostly likely, is COVID-19.”

At times, some of the EMTs or crew—some of the other crews that may have known better—I actually yelled at some of them. I would take them aside and just like, “What are you—you got to be smarter than this.”

What was happening in March and April of 2020

We work in an immigrant community where there’s six, eight people living in a small apartment. And some of these apartments we go in there, and you’d have half or three-quarters of the home exhibiting flulike symptoms, which most definitely were COVID-19. So we’re not going to bring them to the hospital. There’s risk of them infecting others. And health care workers. They’re just going to be sent home. And was it ideal, looking back? Probably not. But it was what we had back then.

I carried a certain amount of guilt when we started realizing that some of these people that were having symptoms like low-grade temperature and mild shortness of breath within three days would go into the storm, and many ended up in life support or some of them succumbed to the virus.

But it’s what we had on hand. It’s what we knew. There was no alternative.

So I did my best to take my time in the homes and tell them about self-care. It seems that we have lost the ability to self-care over the years. Nobody has Tylenol anymore. Nobody knows to hydrate with water, not soda. Or to isolate yourself from the healthy.

I’d go into homes and the sick were sitting next to the healthy on the sofa. So that was kind of frustrating to see the public not doing their part, even the basics of self-care. And so I would tell them. Go take a shower. Hydrate. Eat good food. Build up your immune system. Stay away from fat and sugar and stuff like that. And drink a lot of water. Take Tylenol if you need to.

I made it a point to tell them to walk thirty feet. If they could walk thirty feet, just keep doing what they’re doing. But once they can’t walk a certain amount, you have to assume that they’re desatting, that their oxygen saturation may be dropping. Then you need to be hospitalized. So I felt that was the best I could do with the information and the tools we had on hand.

People were scared to go to the hospital. As a matter of fact, I had to convince people to go to the hospital because they were so scared of COVID-19. I would tell them, “You most likely have COVID-19. So you’re not going to recatch it. You have every symptom of coronavirus. You need to be hospitalized.”

A day to remember

My worst day was April 6 or something like that. In one day, I had a fifteen-year-old, a twenty-five-year-old, a forty-two-year-old, and a fifty-six-year-old in cardiac arrest.

And they all died except for the twenty-five-year-old. The fifteen-year-old was difficult, but I knew she wasn’t going to make it.

It was 6:00 a.m. I logged on to our computer in the ambulance and we get what’s called a sprint, basically a transcription of the 9-1-1 call. And it says, “Fifteen-year-old, cardiac arrest, CPR in progress by family.”

And I told the dispatcher, “You’re reading the same thing as I’m reading. It’s a child in cardiac arrest. Can you send me somebody? I’m coming from a distance. I’m coming from Manhattan.”

And they’re like, “You’re solo. Do your best.”

So we hauled over there to the Bronx. It’s a fifth floor walkup. We load up fifty pounds of gear, go up five flights of stairs.

At that point, fire got there. And she was asystolic. [Her heart had stopped beating.] We tried to work her up. I was very aggressive, obviously. And the best we got was a PEA, a pulseless electrical activity, briefly. Then she went right back into asystolic.

I know there was nothing more I could have done. But it still—fifteen years old. Obviously, it weighs very heavily on anyone. And the family was there. It was just very, very traumatic. But the rest of the day didn’t get any better.

And oddly enough, three of them that I had, they had the same scenario. They had these low symptoms. And they were about to go into the shower. And then they went into cardiac arrest. And all of a sudden they would just drop dead.

And this twenty-five-year-old was the same thing. It was bizarre. I don’t know why.

The twenty-five-year-old, he had just gone down. I wanted to give him every chance possible, so I’m like, “You know what? I’m just going to do a endotracheal intubation” [insert a tube into his windpipe to deliver oxygen], which is riskier obviously. And we worked him up for about fifteen minutes and got him back.

How he did, I don’t know. It was just too many patients to follow up on. But I think it was pretty promising. But I, unfortunately, don’t know his final outcome. I hope it was good. I told myself that it was maybe good.

So that was my worst day. I was averaging about three cardiac arrests a shift, which is unprecedented. That day was four, but that day made it worse. Just the ages. It was such young people. And that just puts a lot into perspective. It’s so frustrating to read and to hear what we hear knowing what we saw and witnessed.

Being in harm’s way

With COVID-19, I have to say, at first, I think I was going to get it, and I was likely going to die. And that was scary. I think that’s probably what caused a lot of anxiety. All these people are getting it. I’m not special. [laughs] And I’m a male. I’m well into my forties. I’m probably going to get it. And I’m going to die. Or be really messed up from it. And that was hard. That was one of the hardest things I’ve probably had to personally dwell with in my life.

I talked about it with my wife. Talked about it with myself a lot. And I just kind of liked my job. I know some people kind of stopped working because the risk was too much.

We’re not special. We’re not heroes. But this is our job. I couldn’t live with myself if I abandoned my job in its most dire moment. It’s what we chose to do. For better, for worse, we mitigate the risk, and we try to do our job. And that was what I told myself.

At the end of my shift, I would get in my car. I would take a bottle of Purell and literally rub it all over my face, shove it up my nose, in my ears, my hair. For the first week or so, we had Lysol, so we would spray ourselves down with Lysol. And if it was on us, at least try to kill it before you go home.

I would drive home for about an hour. Sometimes I would find myself with my mouth gaping open just staring. Just kind of trying to process what the last eight, sixteen hours have been like. It’s truly a profound moment.

I would get home, go in the garage, strip down to my birthday suit. My wife would be out there with a garbage bag, put all my stuff in there, then she would take the clothes, put it in the washing machine. And I would go into the shower and literally loofah five layers of skin off of me. I mean literally clawing my skin off to hopefully get rid of the stuff.

Anxiety

I had a huge amount of anxiety, which is something I’ve never really experienced before.

I wasn’t sleeping much. I was constantly thirsty. I was barely eating. I had no appetite. I was so thirsty. I could not drink enough water in a shift. And thereafter, when I was reading stuff, I started realizing these are all signs of anxiety. These are all signs of stress.

I tried to come home and decompress. Kind of just shut that out. I stopped reading a lot of media stuff, especially social media. That I avoided like a plague itself. I read just headlines. And then when I would come home, I would make it a point that with the family just try to talk about COVID-19 or get it out of your system. Talk about it. And then talk [laughs] about something else. But it was difficult. It dominated our whole lives for that time. It really did. I’m sure I’m not alone in this.

Sources of information

We had nothing. [laughs] And even if we did, I would take that with a grain of salt. It’s like reading the news nowadays. You really have to dig around five, six sources. I double check my sources. I only read what I feel are trusted sources and try to just drown out all the misinformation that is so prevalent [laughs] and so toxic. We really don’t get [laughs] memos, meetings. Nothing. It’s incredible but not surprising. [laughs]

Did the city provide services or debriefings?

No. No. No. [laughs] No. I had no expectations of it either. We never have. [laughs] As like 9/11. Just get back to work. [laughs] Sometimes—I always felt that that’s one of the bad things of our profession. There’s no sort of like decompression like somebody steps in.

But I do feel that it should be there for the psychological well-being of anybody, whether it’s a social worker, a doctor, nurse, whoever. We’re human after all. We have to process this stuff.

Challenging Times

Richard Brea

Richard Brea, commander of the 46th Precinct in the Bronx when COVID-19 struck, is the son of immigrants from the Dominican Republic. Brea was born in Queens and raised there in Richmond Hill, where his father was a cook and his mother was a seamstress. Brea became a police officer in 1993 at twenty-one and worked in Brooklyn, the Bronx, and Manhattan on patrol, special operations units, and on assignments ranging from narcotics to anticrime. He rose through the ranks to become a deputy inspector and precinct commander.⁵

The more we started learning about it, how COVID-19 was spreading, and how other countries were having challenges with it, more people started getting concerned about it.

Working in the New York City Police Department presented a challenge for us. Other employers allowed their employees to work remotely; we couldn’t do that.

Officers had to answer calls in apartments where people had died of COVID-19.

Some officers were concerned about their safety responding to a call where somebody’s coughing and fearing that they might be infected. They were also taking people to hospitals where there was a high rate of positive cases and posed a significant risk of transmission, which concerned many officers.

For those officers who were deeply concerned about COVID-19 exposure, I told them: “Unfortunately, this is no different than responding to an active shooter scenario, or somebody shooting a gun.” We must respond to these calls, that’s our profession, that’s what we chose to do. And we did. It was challenging, but we responded to these calls.

And I think most officers understood that and accepted it as another hazard of the job. It was like responding to a gun run, or a burglary in progress. It was dangerous, but they did it.

We accepted the dangers when we raised our hands and swore an oath to become police officers.

I told them you’ve got to do the best you can to protect yourself—wear masks.

The New York City Police Department and the city of New York supplied us with the equipment we needed at the time such as masks, gloves, and hand sanitizers. The response was fairly quick, and the supply was constant.

Some cops felt that we were very exposed to this virus. And we probably were. We saw a sharp increase in DOAs, dead persons in apartments. On a particular tour, we could have four or five deaths that were most likely the result of COVID-19.

Some officers were concerned. “Why is it safe for us to go into the apartment?” And I said, I understand that, and I understand your concern.

I went to some of these apartments with the officers so that they knew we were facing these challenges together.

It was a tough time, because anytime you deal with a death, it’s very emotional for the family.

But many of these deaths were untimely in the sense that, although many of them were elderly and suffered from other illnesses, these deaths were occurring virtually overnight. And that was shocking for many family members.

And sometimes people would die alone in their apartment because the family wouldn’t be able to travel. And sometimes the families were also concerned: If this person passed away from COVID-19, is it safe for me to go there?

There were a lot of unknowns at the time. How is this being transmitted? Early on, there were many different rumors.

So, my concern was, how is exactly is this virus transmitted, and there seemed to be, at the time, conflicting opinions about it.

There was a lot of anxiety because of that. There were a lot of things that made people upset because nobody really knew. And it was a tough position for the doctors and scientists —which is understandable for me. I’m not a doctor. I’m not a scientist. But I listen.

My focus was to reassure my officers that we had a job to do, and that we should use every precaution that we could to protect ourselves by utilizing the masks and hand sanitizers, which is what we were told at the time, the most effective way to combat this virus. My civilian cleaners in the precinct did a tremendous job of constantly cleaning all the hard surfaces to minimize exposure.

It was challenging when more of my officers began testing positive with COVID-19. Suddenly, our positive COVID-19 rate increased significantly. And that was very, very concerning for everyone. Especially for me, since I am responsible to ensure the safety of my officers.

The department kept track of positive COVID-19 status. And the 46th Precinct at the time had one of the highest rates of positive exposures.

Brea contacted officers who got sick.

I would call my officers frequently, to see how they were doing. Some of them I called two or three times a week.

Their symptoms varied a lot. Some officers had no symptoms. But other officers had some very severe symptoms, and I could hear them on the phone. And these were young officers. Some of them had difficulty speaking, they were coughing a lot. And they really sounded bad.

One of the officers that I spoke with was coughing a lot, could barely breathe, and had tremendous pain. It was so bad that I felt guilty even calling them because they were struggling just to talk.

And they gave me permission to relay their stories to other officers, and I would. Because I felt that it was important that they knew that COVID-19 was very serious, and this was affecting all of us. I would inform the other officers to keep our sick officers in your thoughts and prayers. Many officers would respond to them via email or text with encouraging messages, lifting their spirits.

When I started doing that, I noticed more officers taking COVID-19 seriously. It wasn’t just people in the street getting sick, we were getting sick, too. We have to do what we can to protect ourselves. That was part of my role as a precinct commander, to ensure that that the officers knew that this was serious and that they protected themselves.

I kept thinking to myself, wow, these are young officers. They’re in the twenties, early thirties. They’re having a tough time with this. I can only imagine if someone older like myself got it, how severe would the symptoms be?

Going home

For me, it was a challenge going home, and making sure that I didn’t bring something home to my family as well.

One officer, his parents were elderly, and he didn’t want to take that chance. They had a single-family home, and he would just stay in the basement. I felt bad for him since he didn’t have any personal contact with them. But at least he was grateful that he could do that. Some people couldn’t do that, they lived in small apartments and, unfortunately, going home meant you were exposing your loved ones.

I attempted to make some accommodations for officers who had difficult situations at home. One officer had an elderly mother who was very ill, and if she were to be exposed to COVID-19, it would probably be fatal. The officer was very scared that she would be exposed to COVID-19 at work and unknowingly bring it home to where they lived in a small apartment. So, I did what I could to try to limit her exposure in the field.

But unfortunately, you couldn’t protect everyone. Police needed to be in the streets. Most officers didn’t mind. Some of the younger officers thought that this virus was exaggerated, this wasn’t a big deal.

Within the 46th Precinct, to reduce transmissions of COVID-19, Brea reorganized procedures like roll call, signing out at the end of a shift, signing out equipment, and cleaning cars.

At the time, I had to stress the importance of wearing masks to the officers. I wore a mask in order to lead by example. I couldn’t tell someone else to wear a mask if I wasn’t wearing one either. So, I would always wear my mask. And then I would ask my officers, “Hey, where’s your mask?” And I always carried at least five masks with me. If an officer told me, “I don’t have one,” I would say, “Well, here you go, now you do.”

As commander of the 33rd Precinct in southern Washington Heights, Brea learned the challenges and rewards of working with neighborhood residents to address issues ranging from the mentally ill homeless to gangs. He carried lessons learned in the 33rd Precinct to his Bronx command.

Early in the pandemic, street crime decreased because there were fewer people in the street. Unfortunately, we quickly started seeing an increase in other crimes such as burglaries because many establishments were closed, and bad people knew that. So, the stores started getting burglarized. Jewelry stores, pawn shops, sneaker stores, and even restaurants were hit. Then unfortunately, as more people worked from home, we started seeing an increase in domestic violence cases.

Brea knew of police officers elsewhere in the New York City Police Department who died of COVID-19, but under his command the 46th Precinct did not lose any officers to COVID-19.

On the Frontlines of COVID-19, Echoes of AIDS

Steven Palmer

Steven Palmer is a physician assistant and clinical coordinator of the HIV vaccines unit who works with other clinicians and research assistants at Columbia University Medical Center. All were redeployed full time to treat COVID-19 in the surge of spring 2020.⁶

I don’t think I could have ever prepared for what the surge was going to be like. I heard about what was happening in Italy, but it was … Oh, God. My metaphor is we were like a bunch of ants standing on our back legs with our front legs in the air and a meteor is coming. And it was frightening. It was FRIGHTENING!

People have told me that I’m on the frontlines, and I want to show lots of deference to people who are on the fronter frontlines. The clinicians, the EMTs, the patient reps, anybody who was in the emergency room, anybody who was in the ICUs, I just want it known that they were the front-front-front-frontlines. Frontlines is a spectrum and I’m now willing to accept that I was on the frontlines, given some retrospect, but those folks were right there.

Palmer reviewed patients’ charts, drew blood from patients, monitored their treatment, and asked their permission to try an experimental treatment for COVID-19. When a patient was unable to give their consent because they were intubated, he sought permission from family members. One day, in the early weeks of the pandemic, when cases were increasing, he entered an ICU in the Allen Hospital in the Inwood section of northern Manhattan.

I noticed one nurse in front of her computer. She was very, very nice and very helpful. But she started mumbling to herself a little bit like, “How are we going to do this without getting infected?” The folks who were right there, the vision that they had wasn’t that 99 percent were going to be better. It was that you were going to be intubated, and that there was a good chance you might die.

And I still have to try to get that out of my head sometimes. You know? If I feel a little warm when I’m walking in the woods or something, you know, I’m like, oh geez. I better go take my temperature when I get back.

Conditions at the Harkness Pavilion in Washington Heights, site of his office

The patients were starting to take up the ICUs and then they had to convert the ORs into ICUs as well. And then the floor above me, the research floor, became COVID-19 patients only so the numbers started piling up. The oncology department people were redeployed. People who had worked in otolaryngology were now in ICUs and scared to death. They don’t know what they’re doing. It’s like being an oral historian and now you’re a cobbler, except that’s less scary.

There were many things that were disturbing. First is that the Harkness Pavilion, lots of the floors were vacated. People went home and did telemedicine. So, there was also a feeling of eeriness of all of these hallways with nobody in them. And then the oncology nurses were redeployed to us and started working with us. They were redeployed to us and they were great. They’re young. They’re nimble. They understand technology, all of this, in a way that I just never will and were able to help organize things for us in terms of entering data on patients and that made our lives immeasurably better.

Across the street is the Milstein building and on the second floor is a catwalk from one building to the other. I look out and I recognize that at the side of the Milstein building are two large refrigerator trucks and that’s where the bodies are going. There’s a tent set up before it and then there’s these two trucks and I just knew that they were just being filled.

Back to the OR ICU for one moment. It was my turn to go in there, and it’s when it was at its height and there were five operating rooms side by side and each one had people intubated. It was like walking into a horror movie. You walked in there, and I just felt like I’m a goner.

Every time I passed hand sanitizer, I put my hand under it. I probably cleaned my hands fifty, sixty times a day and that’s not an exaggeration. At first, I was going over with gloves on, and it became clear to me after a while that gloves give you the impression that you’re clean. You’re not remembering that you’ve contaminated them all along the way and then you’re touching something that somebody else may touch and then rub their nose because they weren’t thinking about it.

For Palmer, the COVID-19 pandemic brought up memories of the AIDS epidemic.

In early March, a friend and I went to a restaurant the last days before they closed. And I knew something was coming but I didn’t know it was going to crush us. I had no idea. And he said, “Steven, does this remind you of AIDS at all, your experience of the eighties?” And I kind of brushed it off. I was just like, “You know, I don’t think so. This is very contagious.” He was much more astute than I was. And over time, these parallelisms started happening. The reason I recognized them is because they came up emotionally.

I’m up in Liberty, New York, right now. The Woodstock site is fifteen minutes away. And I just felt like I needed some space. It’s a beautiful place, and I was there one day and there was a young guy probably in his mid-late twenties and he was just visiting also. He had in the last couple of years spread his mom and his grandfather’s ashes on the field. We were chatting and I’m noticing, you know, even though we’re talking forward that we’re like only two feet away from each other. I was like, “Oh geez, you know, what am I doing here?” Then I made it three feet and I’m thinking, “Well, you should make it six feet.” And then I thought, “Oh, he’s a handsome young man. Look at him. He’s very nice and engageable.”

And then it was time for me to leave and I got in my car and I felt like it had been 1986 and I had had drunken, wanton sex and did I use a condom?

What allowed me to not take care of myself? Was I taking care of myself? Maybe I was. I was like, holy crap. This is almost like the same feeling. And that’s when it occurred to me that there were parallels and that maybe other people had felt that too.

Visiting his partner requires precaution that recall the AIDS years.

We generally use a different bathroom. We sleep in different beds. So, it takes a toll. There’s an emotional toll to this to being on the frontlines, wherever I am on that spectrum.

As we lighten up about the pandemic, we’re reminded at times that it’s not over by any stretch of the imagination and we could still be exposed. And what does that mean for those of us who are working in this field? How are we able to be with others around us and how long can we put up with that for?

On top of everything we’re feeling, we’re not supposed to be near anybody. It’s a terrible combination. The first three weeks were terrible. I’d wake up and the first thing that came to my mind was coronavirus. I would actually have to talk to a friend of mine to help bolster myself. I was sobbing almost every morning.

With therapy, Palmer figured out that part of what he was experiencing during COVID-19 was post-traumatic stress from the AIDS years.

I was able, to some extent, to compartmentalize that this is an old thing—this overlap with HIV, and then gradually over time it took its kind of rightful place in my own emotional history. And then I was just dealing with what was right in front of me and was able to get past this parallel experience with HIV in the 1980s.

It was helpful for me to figure it out because it made me recognize a way in which I was going to be able to deal emotionally with what was coming up. There was a precedent to it, and I had the help I needed to move on. The early days of HIV became a reference point – something I could relate to quite concretely rather than just being in this nightmarish cosmic blur of bodies piling up, and you have to run over there quick to help out, and the wind is blowing at you from the OR, and you’re feeling grief. We had been here before in some form or fashion, and that helped me think about how we’d get through this too.

About two and a half weeks ago I heard that only 500 had died, which is awful for every one of those people and everybody grieving around them. So, this odd split of being like, oh wow, only 500. Oh, now we’re down to only 450. And being glad about that, you know, that it’s not 800 anymore. It’s a weird split when you’re in the momentum of this kind of thing.

Coping strategies outside of work

I walk a lot. I try to walk every day up to Fort Tryon Park. Springtime, the Heather Gardens up at Fort Tryon Park, that kind of beauty, verdant beauty, green coming in, that helps.

Since January 2018 I’ve started taking Fridays off, so I have three-day weekends. I was working five days a week when the surge started because that’s how it had to happen. I’m back to four days until future notice and I take lots of walks in nature. Nature really helps. A friend who is a yoga instructor is giving free thirty-minutes to essential workers, and I’ve used that a few times and that has been very helpful. Having therapy. Saying to myself that I can quit this if I want to at a certain point, knowing that I won’t. That would sit terribly on me but just reminding myself that there’s a way out.

And there’s one other aspect. It’s a little new-agey if you don’t mind. The therapist I work with does EMDR [eye movement desensitization and reprocessing] and for years and years she brought people to Peru on shamanic journeys. It’s the reminder to myself that the warrior spirit is in place and it’s moving forward. And even though when the surge first came, my images of me were me crumbling—seriously just crumbling, like I was one of the ants with my hands in the air—this plays a role at least to me as an initiation rite into the next chapter of my life. And there’s kind of a scarification aspect of it, but that I will emerge and it’ll be okay, and that in some ways things that seemed important, or scary, or worrisome to me earlier will take their place of being, “so what?” That’s the hope. It’s a vision I have of how this can work itself through with me.

I’m going back to the city tonight. It does help to have that perspective in place because these things do subside even if we think it’s never going to. In a grander spiritual vision, I wish humanity would change. We’re the only species who doesn’t live in symbiosis with the earth. We come in and we command that it conform to us.

I wish mother nature wouldn’t have to take a breath just to deal with us. And she unleashes. And I just hope we don’t miss this moment.

I’m going to take the dog for a nice long walk. The birds are singing. It’s a beautiful—it’s almost like sixty-five degrees out right now. I’ll absorb nature as much as I can so that I can go back there and put up with it for four days or whatever.

At the Gates of Hell

Patricia Tiu

Patricia Tiu, a nurse, is the daughter of immigrants from the Philippines and a lifelong resident of Queens who lives in Fresh Meadows. She was working at NewYork–Presbyterian/Weill Cornell Medical Center in Washington Heights when the pandemic hit; she recorded her observations in video journals that were posted online.⁷

March 29, 2020

Even though I understand the severity of this virus, I underestimated the impact it would have on the American health care system, for damn sure. I never thought it would get to the point that it is now. It shouldn’t have ever gotten to this point. Everyone needs to know what exactly is happening, because it’s not going to end well.

The week that just passed we officially all went to the ICU and no longer the ER because the ER, they’re flooded. The hospital made every single nurse step up from what they usually are doing. Nurses have to become full blown ICU nurses. And to become a full blown ICU nurse you usually need at least very minimum six months orientation. All of a sudden, a week. It’s like throwing a golfer to go play basketball, in a week they should learn and compete in the NBA.

The FDA was saying because we’re so short of supplies, if you have a patient with the same disease, it’s okay to use the same pair of gloves which is disgusting. The N95s: we were given one and they said keep it for a week.

I just want to give you a heads up of what it means to be on a ventilator. You need a vent because your lungs get so filled with fluid you’re drowning in your lungs.

The biggest part has been getting people off the vents. When you’re on a vent, it’s usually maybe two or three days depending on how sick you are. When you’re on a vent as a COVID-19 patient, your minimum is two weeks. We’ve had patients on it for a month.

Cuomo has been begging for vents. And you know that the whole thing was the supplies. And then Trump was saying that New York City is exaggerating the amount of vents we need. I really hope so because pretty soon you are going to have to choose who gets vented and who doesn’t get vented. And what that entails is basically who gets to live and who doesn’t get to live. Does your sixty-five-year-old grandma get to live or your forty-year-old neighbor?

As an American, born and raised in Queens, it is a fucking shame that our government can’t get us the supplies that we need. You can’t say we don’t have the resources. This is not oil that we’re fucking asking for. This is things that we can find and make on our soil, and it’s absolutely disgusting how they just show that they don’t give a fuck about us. Not just the nurses and the health care staff just us in general, like the majority, the working class. And they made that very apparent.

So what does it mean to be a COVID-19 positive patient that’s on a vent? It means that you’re in the room alone. And when we come in and care for you, we’re not trying to be in there long. You’re paralyzed. You’re sleeping. I don’t know if you hear us maybe you can, maybe you can’t. But you’re just there.

And as for our COVID-19 patients if you die, you die alone. Your family never gets to see you again. Not at least while you’re breathing. You can’t say goodbye; you can’t even see what’s happening.

Here’s an example. And it’s going to be a lot to hear.

There was an eighteen-year-old that was positive and vented, and I don’t know what the full story was, but became brain dead. So the doctors need the vent. So they called his mother. They explained that we got to pull the plug. Mother said, “Please no don’t pull the plug just put the phone next to him. He will hear me and he’ll wake up.”

Like where does that put all of us? Where does that put every single person, the doctors, the mother, the eighteen-year-old, the staff, the person who’s going to need the vent? Like what do you say to that? How would you handle that? What decision would you make? What if there was another eighteen-year-old who needs that vent? What are you supposed to do?

I don’t know what you do with a situation like that. And if we run out of vents, that’s what’s going to happen. You’re going to pick and choose. We have no choice but to see who would survive.

One of the patients had surgery. I forgot what she had, but she wasn’t the healthiest person. I think maybe she had some sort of cancer. She’s in the hospital now for like a week.

Then she just progressively didn’t do well. She came into the hospital negative. She is now positive. She had to get intubated. She did not want to get intubated.

The last word she was saying is “I don’t want to die alone.” She asked the nurse if the nurse could stand where she could see her until she falls asleep from the sedation because she doesn’t want to die alone. That was the last thing she said. [Gets emotional] So that’s just like a hint of what’s been going on.

Our own staff got hit. We have two doctors and a nurse as well are intubated and they’re COVID-19 positive.

As for nurses: None of us are sleeping. I don’t sleep anymore. Everybody has that high anxiety deep in them. Although I’m proud of our nurses, they’re functioning and they’re fighting through, that high anxiety twenty-four hours a day, seven days a week is killer.

We are not expendable. So all my nurses if you do not get the proper gear, your life is not worth losing. You deserve to come home to a family too.

April 6, 2020

I’m wearing a bandana not to look cute, but because of all the stress, my hair has started to fall out, which is not the worst thing in the world. It’s hair. I’ll grow back. But it’s just really annoying.

I am now in hospital housing, which is basically a hotel. It was nice of them to offer, but I don’t got a microwave here. I don’t have any amenities. So I made the best of it.

The last time I spoke, I said New York City was on fire. Well, welcome to hell. Because we are basically at the gates of hell. We are very close from the tipping point, reaching the peak, we’re almost there. We haven’t reached it yet.

I have accepted the fact that our government, our president, and no one is coming to help. So New York, it’s just us. No one is coming to help us. And working in this ICU, the number-one goal is basically to save as many lives as possible. Everybody’s dying, and you’re just doing your best to keep every single one of these people alive. Every minute that I have gone into work, you are working at like 150 percent. You don’t even have time to think your own thoughts. You do everything, everything you can to make sure they’re breathing.

The one thing I really feel is anger. And I’m angry. We are in war. You know New York is in war when we’re by ourselves. And I’ve accepted that. But I’m never going to forget anything that’s happened here.

The nurses are being spread so thin, so thin. What they’re asking for us to do is beyond God’s work. We’re going to keep fighting, it’s our city. So just keep spreading awareness, stay inside.

I stepped out today to do some groceries and errands and it’s amazing to me how many people are still outside walking around even with no mask acting like nothing happened. I just I don’t understand.

And we are not at the worst yet. These next two weeks are going to be brutal. Like brutal. I’m telling you. [sighs] And no one is coming. No one is coming to help us. So for all my nurses hang in there. Stay strong. Have each other’s back.

Don’t be afraid. This is a very scary situation. It’s a very anxious situation. Be smart about things but don’t be afraid; if anything, be angry and let that anger fight because I’m angry.

In an interview with Jamie Beckenstein of the Queens Memory Project in June 2020, she recalled the hardships of the first stage in the pandemic.

I think one of the toughest moments for me was preparing this one patient to see his daughters. This was a single father who might have been in his fifties who had two daughters. I think one might have been my age and the other one was like twenty years old. And from the background history that I got, their mom might have passed away a while ago. It was just them three, there was no other family.

Preparing the room for them to see their father, I had to make a barrier between him and another patient that was in the room so they can have privacy. So we got two IV poles and tied a sheet and put it in between them. Just so the family members could have privacy and tell their dad that they love him.

God forbid, what would you do if this was your father that you had to say goodbye to with a tube down the throat, their eyes closed? And as I put it up, I remember walking out the room feeling very defeated.

But you just have to keep going. You shake it off, walk out, get your one minute of emotion that you’re allowed to feel and go straight back to work. I think that might have been one of the hardest things I’ve ever done in my life.

It Was Not Business as Usual

Christopher Tedeschi

Christopher Tedeschi, an emergency physician, works at the Columbia Medical Center and the Allen Hospital in northern Manhattan, where he has additional responsibilities for teaching and operational planning. A lover of the outdoors, he focuses his work on disaster medicine and wilderness medicine. At the start of the pandemic, he was living in Harlem with his wife, Kiran, who is also an emergency physician at the Medical Center, and their two daughters. He was one of several people responsible for managing the response in the Medical Center emergency department.⁸

We ramped up things really, really quickly because the number of patients was enormous. We were overwhelmed in many ways.

The last week in March was the week where we saw the most patients in the ER. We were seeing more than two hundred patients per day in the ER on 168th Street, just for COVID-19. No one came to the ER for anything else. We were joking for a month that “nobody’s had appendicitis in Manhattan.” We still don’t know what happened to them, or had a heart attack or a stroke, for that matter.

The single memory I’ll take with me clinically is of the Allen Hospital, our smaller hospital. It’s on 220th Street and Broadway, Manhattan. It serves Inwood and Riverdale and part of the South Bronx, that’s where one of the highest concentrations of cases were.

Everyone always refers to the ER as “organized chaos,” or something tacky like that. But for the most part, things are not out of control. It’s an emergency department. It’s meant for emergencies. People get shot. That’s what we’re there for.

When it becomes overwhelming, not only are you sailing through a storm, but you’re not steering the boat, you’re just hoping the boat doesn’t tip over. In that hospital, we got to that point. And when I look back on it, I just see myself in the middle of that ER in the middle of the night making sure people’s oxygen didn’t run out. And it did. And that was not business as usual.

Lorna Breen, director of the Allen Hospital Emergency Department, contracted COVID-19 in March 2020. On April 26, she took her own life.

That lack of being able to steer the ship, to my mind, contributed greatly to Lorna taking her life. I don’t know much more about her psyche than you’ll read in the newspaper, but she was interested in being in control of her environment. And when that’s taken away from you, it’s very unsettling.

In their responses to COVID-19, doctors and hospital staff combined planned responses and improvisation.

We have a pretty robust preparedness. Not to speak the party line, but we did pretty well. Were we prepared for this one? Not entirely. Absolutely not. Should we have been? This is a once in a lifetime event. A lot of improvisation went on.

The biggest problem was, there was not enough nurses. It’s as simple as that.

And what was even more unsteadying was that we were improvising medically. It’s not like this was a disease we knew much about. We intubated so many people, put them on mechanical ventilators in the beginning. We learned over weeks that we probably didn’t need to, and that was probably not the best thing. But we learned that from going through it.

Medically, we’ll be on a little bit better footing next time. But that’s unsettling to a bunch of physicians who, not only do they not have the stretchers to put the patients in, but they’re not so sure even what to do with the patient once they’re in the stretcher.

The biggest challenge that Tedeschi faced

The thing that is still hardest is that it comes home with you. I worked in Puerto Rico after Maria, I worked in Haiti after the earthquake. I worked after Sandy, but none of those things come home with you. None of those things come home to your two kids not going to school.

The other thing that was additionally energy consuming was having this group of people that we work with filter lots of needs and questions and concerns and anxieties. One of my jobs during all of this was doing the point person for communicating with our group. So I was the one that was sending the email every night, and I was the one who was answering people’s questions and picking up the phone.

There were a lot of unanswerable questions, and a lot of anxiety. It’s one of those situations where the uncertainty was really high, because no one knew what was going on. And the real risk and the perceived risk were really high, too; 25 percent of our nurses and beyond were out sick. Two of our staff members in the ER died of COVID-19.

So, the risk is real. Especially at the beginning. Everyone that got it, got it in those first few weeks because we were looking for people who had traveled from China and the cat was out of the bag, long before that.

I remember somebody saying, “Unless you see the person get hit by the car in front of you, and that’s why they’re in the ER, just assume they have COVID-19.” And then, it became, “Even if they get hit by a car and they come into the ER, just assume they have it anyhow.” And once we got to that point, seeing your colleagues get sick didn’t happen as much.

Oftentimes with a big event, you can wake up the next morning and you can say, “It’s over.” 9/11, the next day it was horrible, but it was over.

I think one of the things that lots of people are struggling with are, we still wear our masks all day every day. We still have COVID-19 patients in the ER and we’re not going to wake up one particular morning and brush ourselves off and say, “That’s over now.” That makes it hard.

Established hierarchies and improvisation in the emergency room

Our hospital system to begin with is very hierarchical, top-down, although it seems like 90 percent of the people are in middle management. The verdict comes from the top, so to speak. But there were definitely points where big gaps got exposed.

We encountered a lot of situations that we hadn’t encountered before. The example that has come up in that regard was, again, at the Allen. The Allen ER has about twenty-four beds. And one night, when there were seventy-something patients there, it became clear that these people needed to go somewhere. But there was not one person who had the knowledge and power and authority and responsibility to make that happen. So that’s where the organizational improvisation came in.

Sometimes it worked, and sometimes it didn’t. That night, it worked because one of the administrators in our group just made it happen. We got a bunch of people transferred from one hospital to another. But I think that if you were to talk to a lot of more frontline types, you might find a lot of different opinions as to how well it was organized or how it was organized.

The problem at the Allen was, we had nowhere to put these critically ill patients. There are obviously other spaces to expand into. One of those spaces was the place where they do minor surgeries, like ambulatory surgeries. That was converted into an ICU, and it was great. They did it overnight, they put these air filters in. It just worked out. It was nice.

It was an enormous effort on the part of the hospital, and you can’t create staff and nurses out of thin air. So, I don’t think we could have been much more prepared. I think that there’s a psychological thing that clicks that enables you to say, “Oh boy, we better turn this unit into an ICU.” There’s a hump to get over and you’ve got to jump. And we did. We did, for the most part.

In emergency rooms, doctors and nurses typically confront problems that are open to an immediate solution. Facing COVID-19, they were forced to provide palliative care that eased patients’ suffering without being able to provide an immediate solution to their illness.

We experienced palliative care in the ER in a way that we never had before because so many people were sick and so many people were there for days, even more than usual. Our nurses did things during those few weeks that they don’t do, from the technical ICU type stuff to turning off the ventilator on people. That’s not part of our normal thing. We’re not wholesale, not dozens of people at a time.

Last words

There’s a tablet and a family member who doesn’t know what’s going on and an interpreter because they’re not speaking the same language as you. There’s all these layers between you and the person you’re trying to talk to. And what you’re trying to say is, “Your loved one’s not going to survive.” That’s not day-to-day ER nursing or doctoring. But a lot of that happened.

Looking back on the pandemic in late March and early April of 2020

We’re so lucky that this wave has passed us, and we can certainly look back analytically and figure out what we did wrong and what we need to do next time and all that. But also, I’m realizing how it was very consuming. I didn’t exercise. I put on weight. I put everything aside. Everything stopped. We lost some co-workers. The impact of all of that is a little clearer now. People asked me throughout this, “How are you doing? How are you doing?”

And I would routinely say to them, “Ask me in six weeks.” And luckily, here we are, six weeks later and I think that, looking back, you can see the bigness of it from the perspective of spending time in an ER.

I look at my kids. The impact has been enormous. My daughter Lena, she was in first grade. The last day she went to school was in the middle of March and thank God her closest companion is her four-year-old sister. That’s an enormous impact on a seven-year-old. She didn’t see her friends, she didn’t go to school.

We have learned a lot, and we have learned our lesson, to some degree. But it’s not fun.

Where the system failed

Well it’s political, right? It failed in communication. It failed in messaging. But on the deeper level, it’s a little bit about just compassion. There was a quote in the paper today from a twenty-something-year-old who isn’t wearing a mask somewhere: “Well if I get the virus, God forgive me. I’m not going to stop my life for some virus.” While I see where someone’s coming from—the messaging and the communication has been so inconsistent and horrible, and the leadership on the national level has been so counterproductive, it’s criminal—compassion is this desire to avoid suffering, prevent suffering, or relieve suffering. I don’t know that that guy interviewed in the paper was coming from a place of being motivated to relieve suffering or thinking about relieving someone’s suffering. That’s the story of the last several years of our American culture to some degree.

From a political standpoint and from a health security policy standpoint, we’ve made a lot of bad decisions over the last five years, which is too bad. But frankly, I can’t say I’m surprised at the outcome. When you take the system apart, the system doesn’t work. And to some degree, we took the system apart. And to hear the political rhetoric, the politically motivated rhetoric about how states are on their own, or the federal stockpile is not for you, that kind of quote you see in the news, it’s disheartening.

What the future might look like

You could be an optimist and you could start with looking at public health or looking at whether having health insurance come from employers is the right way to do it. But it still kind of goes down to those cultural divides that we’ve experienced.

Yes, it’ll be great to think that we’ll have a robust public health system and that the health security system will be rebuilt and that people won’t politicize that and the way we talk about it and report it. The media is not to be believed in lots of people’s minds, and it’s very frustrating to experience that.

The whole thing about public health is that when it’s working well, it’s not really a story. Nobody writes a news story about a bridge not falling down. That’s what public health is about. And it’s about protecting the public.

We live in this, “You can’t tell me to wear a mask,” this fetish of personal liberty makes it really difficult.

That system should be reimagined. Probably health coverage should be reimagined. The federal government’s role in all of this should probably be reimagined. So yes, you can be optimistic about it. People might open their eyes, but I think that it’s frustrating. Even talking to people in my own family, making that kind of argument and hearing as a response, “Oh, it’s not that bad. Oh, people are just trying to make the administration look bad.” There’s a lot of notions that people have that they’re going to be hard to convince, like, “It’s not our fault. It’s the Chinese’s fault.”

I’m not sure how that’s going to be overcome. I think you do it on a community level. You do it in your own backyard to start with to some degree.

What will happen next?

I think if we’re lucky, we’ll see a vaccine early next year and if we’re even luckier, people will want to get the vaccine, which is certainly not to be assumed.

From my point of view just at work, we’re going to see so many changes just because the way we treat patients is different, now. The way we bring patients to the hospital. The use of telemedicine is a whole other conversation which is not going to go away. The way we see patients in the ER. All these things are not going to go back to the way they were.

I think that we’re going to be living with it as a chronic illness. And we’ll hope that it calms down when there’s some sort of vaccine and we can go to work without two masks and an eye shield on, but that’s not anytime soon.

Hard Choices

Richard Jenkins

Richard Jenkins (a pseudonym) is a board-certified medical doctor with a specialty in kidney medicine. He was a nephrology fellow (a kidney specialist in training) at a Manhattan hospital when the COVID-19 pandemic struck New York City.⁹

A typical day in the surge of April 2020

We’d come in around 6:30, 7:00 a.m. In the ICU, usually I went through my list and look at who died that day. On a typical day, maybe every week you’d lose about two people or three people off your list. Here it was more like two or three people every night. And you kind of had an idea of who you thought was not going to make it.

You start by going through your list and seeing who’s missing and say, “oh boy, okay, so those people died.” Kind of not really have time to deal with that, because you have to then look at who on the other renal fellows’ lists ended up in the ICU, anyone new from overnight, and establish your list of patients for that day. Then you do this whole whirlwind tour of everyone’s latest vitals, latest labs. You look at their notes to see what kind of events had been going on over the past twenty-four hours. And the whole time, you have your pager there, and you’re getting paged with either new patients, which are going to take a good hour of your time to really research and figure everything out, or the team’s kind of panicking about lab values, and they’re asking for advice or paging, saying, “Hey, I think we need dialysis, when are they going to get the dialysis?” So that’s the morning.

In the beginning we’d see all our patients, that’s what we always do. But mid-April, we started not actually seeing people, if we could avoid it. With the whole PPE shortage, what was happening was that if you worked in a unit, you’d have your gown, you’d have your mask, and you kind of kept it on you the whole time, and that was it. That was what you did.

Not everyone on our list had COVID-19. Most of them did, but not everyone. And we also were running around between ten different units, because we’re just seeing anyone in the hospital with kidney issues, as opposed to being assigned to one unit.

If we put on an N95 we’d have to get rid of it the moment we saw the patient, because you don’t want to be dragging the mask that you wore in one room to another room. I mean, we’d basically be vectors. And we were also scared of getting it, no lie.

So we basically tried to limit how often we would see the patients. We’d rely on the physical exam of the primary team taking care of them, and if we felt that there was something that would change in our management, if we physically saw them, then we’d go see them. If there was something like a real hardcore debate and disagreement about how much extra fluid they had or not, we would see them, because at that point, we need to justify our point of view by actually examining the patient.

Whether we saw everyone or some of them or none of them, I’d then convene with the attending. We’d sit down, go through all the patients, go through the plan for the day, any things we felt needed to be changed with their IV fluids, with their medications, whether they needed dialysis or didn’t need dialysis. If they did need it, was there anything special that we had to consider, given everything else going on?

Then the next step would be to call the teams, notify them of what we’re thinking, then go to the team, depending on how busy we were, tell them our recommendations. We talked to our dialysis charge nurse, and mentioned who we think needs dialysis that day, who should wait for tomorrow, who needs it immediately, who can wait a few hours. And that’s the typical day.

And all through the day, the pager is going off nonstop with more new consults that you have to look at and talk with the attending and see them, and figure out what to do, and constant questions about, “Wait, what should we do here?” Or “Wait, I know we said we weren’t going to do dialysis, but look, their potassium level went up, and they’re not making any urine today, and I’m getting worried, and what do you think?”

Really extremely busy, not any moment to breathe. I didn’t eat anything or drink. It was just work nonstop.

But the worst part of the day, by far, was around 4:00 p.m., where normally our shifts end at 5:00, and we sign out to the nighttime nephrologist who deals with everything overnight. That’s a really awful role to be assigned to. Luckily, I never ended up having to do that.

But at 4:00 p.m.—and this is not something that happened before COVID-19—we would end up with a situation where there were ten or fifteen patients that were supposed to get dialysis that day, that we all agreed needed dialysis, that there were not enough nurses to do. As simple as that. Maybe they could do about three of them, but the other twelve can’t be done.

And at any moment, you can get a call about another case that might be more emergent than any of those, and then that pushes even those three that were going to get done. And that really, really, really sucked, because that wasn’t medicine anymore.

That didn’t feel to me like you’re being a doctor. It felt like you’re doing triage, but when you’re triaging between fifteen people that are all cared for by different kidney specialists that are all running around and are not really available, and you know that you’re going to be pushing people to the next day, and some of those people—I mean, I can’t think of one case that definitely died because they didn’t get dialysis the day they were supposed to, but I’m sure that happened.

But that, for me, was the toughest part of the day.

And these decisions, we’re using clinical judgment, we’re looking at the labs and their oxygen requirements and all sorts of things to decide. But you’re dealing with four or five other nephrologists that each are carrying twenty people, and you’re all trying to just figure this out. And it was really rough. And there definitely were times when it did become arbitrary.

It just was random. And, you know, I cried a lot when I would walk home after that, because it felt awful. It felt like it’s not really what we trained for, it’s not what we signed up for.

The intensity of the surge forced improvised solutions.

There wasn’t a lot of time then to reflect. Coming up with ideas and solutions—that was where all our minds went. We didn’t really want to think about what was happening, just more of what we could do to make it not happen as bad.

This was a problem with patients in every New York City hospital that needed dialysis. But what we ended up doing is, things that we had never done before, really crazy things. Most dialysis sessions are supposed to be three to four hours. We started cutting everyone to two and a half hours, which is not enough—and the thing about dialysis is, the time on dialysis makes a huge difference in terms of the adequacy. It’s actually a big deal to lose thirty minutes or lose an hour of time on dialysis.

We ended up with the common good mentality. Not every individual person was getting greatly efficient dialysis, but we were limiting the amount of people who had to get pushed to the next day, so that more people were at least getting something. So that was one big change, we started putting everyone for two and a half hour dialysis sessions.

We change the dialyzer membranes, which we don’t usually do because there’s always a risk of creating a bit of disequilibrium in the patient, which can mess with their blood pressure or cause certain problems. But the idea was, they need dialysis, but they’re not getting it. Now when they do get it, it’s going to be shortened, so we need to make it as efficient as possible, even though high efficiency brings some risks. So we started doing that.

Doctors who had previously gathered in meetings communicated by Zoom.

It was really cool, in a weird way. Normally, any change or any big decision just comes from the top down. But because we as fellows were the ones really giving the patient care the most, they would take our ideas and they would actually listen. And they’d let us bounce things around, including all this stuff we’re talking about, like limiting the dialysis time, and getting an acute peritoneal dialysis program set up.

Also, there’s this giant WhatsApp group, where all of my coresidents that finished our training program for internal medicine were shouting ideas and stuff, and experiences. I actually sent some screen shots to my brother, because I thought he’d be interested. It really got nuts. Everyone was just talking about things.

“What if we tried this?”

”Guys, why don’t we try this? Let’s do this.”

Or, “I heard that they tried this in this hospital, and I actually saw it work here. I think we need to do this, or do that.”

A lot of horror stories got shared, too. In one hospital, they had so many people having cardiac arrests from low oxygen that their oxygen system broke down in the hospital. And they had to call an engineer to fix it in an hour, or immediately, and all the people who were on ventilators, because the machines were useless without the oxygen, they had to actually take a bag of oxygen and squeeze it in order to apply oxygen into their mouth. And they called a bunch of medical students and residents to come in and just stand there and squeeze the bags to give them oxygen, which sounds like something in a Third World country. That one stuck with me.

By May 2020, the worst days of the surge were beginning to seem like the past.

It’s definitely much better than it was before. We’re in this weird limbo right now, because the hospital cancelled all the elective surgeries and all the typical things they do. We’ve had a really bizarre lack of typical medical emergencies. We’re not seeing as many car accidents, we’re not seeing as many heart attacks and strokes. I don’t know if people are just afraid to come in the hospital, or what it is. But we’re slowly starting to see a trickle of the normal stuff we’re used to.

But there’s still a good amount of COVID-19 in the hospital. We’re not getting a bunch of new COVID-19 admissions, but we’re struggling with a lot of the people who came in with COVID-19, ended up on a ventilator, ended up on dialysis, and are now on their horrible fifth week ICU course, unable to come off the ventilator with permanent kidney damage, with neurological damage, when the family still has hope that they’ll wake up, and we don’t really think so.

We’re dealing with a lot of that right now, on top of seeing things slowly come back to normal. So it’s kind of a really weird place. It’s different than it was in the peak, but it’s not normal.

What he sees on social media.

I’m on Facebook. I’ve got a lot of friends with different backgrounds, and I’m seeing so much BS going around that is so frustrating to deal with. I follow certain science groups that I find interesting. And they’ve turned into ridiculous battlegrounds in the comment sections. You have a lot of people that feel that the mortality rate is overestimated, and then when you ask them how they know that, they say, “Well, because they’re calling every death COVID-19, even if it’s not.”

I know everyone who does the death certificates. I work with these ICU physicians. And I have not seen one person ever fraudulently put COVID-19 as a cause of death when it wasn’t. And it’s frustrating to see a large segment of people really believing this, and believing things like that when I see with my own eyes that that is not true. And that’s definitely been very frustrating.

I never imagined there would be a situation where health care workers get lumped into a group of people that are lying. It already happens to some extent, when people are upset about the health care system. But to see it happen with this pandemic as things are evolving, that’s something that’s really frustrating.

And you can’t really convey it to people because they’re not there. They’re not seeing what we’re going through. And I’m okay, like, I’m sad, I’ve cried a few times.

But there are definitely friends of mine, other people that are not doing so well mentally through this. And I just kind of think of it as spitting on their face, when people say things like, “Oh, they’re just lying on the death certificate, it’s all just manufacturing this and that.” It’s not. And it’s not even a debate. It’s wrong. You can say grass is pink, and that’ll be the equivalent.

Everyone just seems to be really fighting and losing their minds. It seems like there’s the solid “this is all a hoax” crowd, and I hate them. I hate their guts.

There’s the people who are, like, “Well, it may not be a hoax, but it’s the same as the flu.” And while I don’t hate them, they’re wrong and I know they’re wrong. And you can try all you want, but people are going to feel what they feel, and that’s it.

And then, you have the whole attention to the economy. A lot of people are saying, oh, the cure is worse than the disease, and when is the lockdown going to end?

I’m not an epidemiologist, so I don’t really know when things should open up and when they shouldn’t. But I get it. People are not able to pay rent, people are not able to pay bills. I’m fortunate in that that’s not something I’m dealing with. I’m not worried about my job, and I think most health care workers are not that worried about their job.

But at the same time, in the middle of a really bad day in the hospital, I’m, like, “I would kill to be stuck at home doing nothing right now.”

Coping with Gallows Humor

Steven Palmer

Steven Palmer, a physician assistant at Columbia Medical Center, reflects on the role of gallows humor in helping hospital workers endure the surge in the spring of 2020. In the face of fear, disease and death, he recalls, “it would slice the tension.”¹⁰

Everything was 100 percent COVID-19. For several months.

Our whole unit, me as a physician assistant, and then Rusty Greene, nurse practitioner, and Marvin Castellon and Brit Sovic, research assistants, were all deployed to COVID-19, working on that front completely.

It seemed like this immeasurable nightmare that was going to take us all over.

Rusty Greene, nurse practitioner, was the first person to go to the OR ICU of all of us. He had just gotten back and he was standing at my door and he looked at me and said, “Have you been to the OR ICU?” And I said, “No.”

He gave me the fisheye and said, “It’s like a horror show. It’s a horror movie.” I just laughed at that moment.

A once-routine walk from one part of his hospital to another could produce a bizarre juxtaposition that led to laughter.

There was one time that I was going over from the Harkness Pavilion to the Milstein building, to collect labs on a patient who was going to be in our study. As you cross over, the catwalk brings you to the second floor of the Milstein building, and you’re able to look over either side to see the lobby of the Milstein building.

On the right hand side you see the gift shop, which was closed down. And behind the gift shop are large plate glass windows that looked out to two refrigerator trucks, where they were storing the bodies of people who had deceased.

As I’m walking by, I’m seeing the refrigerator trucks but then I’m noticing that right in front of the plate glass window in the gift shop I see this large stuffed giraffe. It was this eerie, weird sense of things that perhaps were once meant to help bring you joy or happiness and now meant nothing.

In my head, I knew I was going to be bringing this story back. I was already formulating it into a bit of a comic moment.

When I was talking to another colleague I said, “Gee, I went across and I look to the right and I see the plate glass windows with these refrigerator trucks. And then I looked and I noticed there’s a big stuffed giraffe in front of them.”

And I knew by my delivery it was funny. She put her hand over her mouth and bent her knees and went all the way down to the floor, laughing. I don’t know that the image of a big stuffed giraffe in front of refrigerator trucks translates, but everybody who heard it laughed quite a bit about it.

In a zone of death, an errand to collect blood samples from a patient brought up memories of war movies.

I went with Brit, who was a research assistant at the time. It was always good to bring a colleague with you because they could help you navigate what you needed to do, putting on PPE, bagging the labs, etc.

In front of each one of the rooms were little shelves that had all the face masks and the gowns and gloves, the face shields, and everything that we needed to go in. We stopped in front of the room and, I let out a sigh.

Brit was standing there and I leaned forward, bent over to take my ID chain off from around my neck. As I handed it to him I said, “Here’s my dog tags, give them to my kids. “

Brit laughed then and if I bring it up Brit will laugh now. He would bring it up often, hysterical.

The tension of the potential of death or going through some terrible, unusual sickness could affect you. You’re just scared to death, gallows humor would slice the tension around it.

It seems irreverent. In fact, it is irreverent. We were making light of death. And when you’re making light of death, you’re inadvertently being irreverent to the people who are dying around you. But it worked. It helped break some of the tension. Almost like by mocking death, we had a power over it, even though we didn’t.

Gallows humor is an absolute must. Now when I look back at MASH, I recognize that it was an entire series based on gallows humor. It’s funny and it helped.

So much of the time we had to be, forgive the term, dead serious about the work. It was quite regimented. We had to keep moving through in the face of terrible fear, and a lot of death.

You’re in the trenches, and you’re going forward, and you’re on a mission.

Gallows humor was a way of taking that linearity and breaking the hold it had on us. Allowing that heavy duty energy to spill out into a different zone that allows you to relax a bit, allows you to recognize that we’re all going through this together.

And one of our ways of surviving with each other or, being colleagues with each other that helped increase that bond, was to laugh.

Palmer reflects on how he uses military metaphors in his COVID-19 stories.

I feel self-conscious about doing that; odd to say since I did it so often. And now in particular because the urgency and the fear of that time has worn off a lot. I feel even more self-conscious about it.

But there was a security person who I met up on the street who said it was like being at war and I just I knew what she meant. And it didn’t feel wrong to say that.

I used to use the analogy of being at the storming of the shores of Normandy and you’re supposed to run toward the bullets that are coming at you. It’s a metaphor. And of course, I wasn’t at the shores of Normandy. I do recognize that in total deference to people who were in the military.

It did feel like we were asked to be running into the middle of something that could kill us. Being asked to go forward in the midst of the potential of death just aligns best with military metaphors.