The audio file is also available at: https://academic.oup.com/ofid/pages/Podcasts
In episode 29 of the OFID podcast, OFID Editor in Chief Paul Sax, MD, speaks candidly with Eric Bressman, MD, chief medical resident at Mt. Sinai Hospital, about confronting the onslaught of COVID-19 cases at Elmhurst Hospital, the disproportionate impact on the Queens community, and the toll on his colleagues and family.
Hello. This is Paul Sax. I’m editor in chief of Open Forum Infectious Diseases (OFID), and this is the OFID podcast. And just as a reminder, that’s O-F-I-D and not “Oh-fid.”
When the history of COVID-19 [Coronavirus Disease 2019] in the United States is written, it will portray New York City in early 2020 as the center of the storm, the city with by far the largest number of cases and deaths and with hospitals struggling to manage a flood of critically ill people admitted daily with fever, cough, and respiratory failure.
Joining me today is Dr. Eric Bressman [MD]— Chief Medical Resident at Mount Sinai Hospital in New York City. He recently wrote a powerful piece about his experience working in one of the Mount Sinai affiliated hospitals during the COVID surge, Elmhurst Hospital in Queens. We’re going to talk about that experience with him, but first thank you for joining me, Eric.
No problem. Happy to be here.
Start us off by telling us a little bit about yourself. What’s your story, and how’d you get into medicine?
I grew up outside of Chicago in a pretty observant Jewish family. My grandparents were all either immigrants or first-generation Americans, mostly having been displaced from Europe honestly either by antisemitism or directly by the Nazis themselves. And they grew up for the most part on Chicago’s West and South Side in pretty heavily Jewish immigrant communities, not unlike New York’s Lower East Side, with which many people are familiar. They eventually migrated out to the suburbs where they raised my parents and my parents raised me and my two brothers in what I think historically has been a pretty common trajectory for new arrivals to the U.S. I eventually came out east to Columbia [University] for college where I studied math and history, but actually initially thought I was going to be a rabbi. And I spent a little bit of that time in rabbinical school. And during that time period when I was still exploring a little bit, trying to discover maybe my true calling and wasn’t sure I had quite found it yet, I took an interest in bioethics.
I eventually shifted course and joined the post-baccalaureate program and headed down the pre-medical route.
Interesting. And you ended up settling in New York City and not going back to the Second City, Chicago?
Yeah. That started as medical school where I got in and that’s how it worked out, but I eventually met my wife in medical school, and we’re based here, her family’s here.
So is your wife a doctor too?
She is, she’s in her second year of the medicine residency of which I am a Chief Medical Resident. And so there is one very narrow domain in which I am her boss and that’s here for a short period of time.
Well, I met my wife during medical school also, actually the first day. But she went into pediatrics so I never had that experience. So you’re now chief medical resident, you’ve completed your residency, and you’ve got this leadership position. I want to get a sense of what your year was like in the first half of the year, because the first half year, of course, starts in July and goes through to December. So what was chief residency like at Mount Sinai for Dr. Eric Bressman in 2019?
For those who have been through a residency and especially have been through medicine residency have a picture in their mind of what the chief resident role is like. But it was pretty typical in that regard. We straddle this line between the residents and the administration. It’s a part desk / part clinical job where we spend time on the wards, we’re doing a lot of teaching, but we’re also doing a lot of scheduling work. And like I said, for people who are familiar with this role, they know what it is to be the least powerful position of anyone who has a little bit of power in the hospital. And probably to the interns on day one of orientation and maybe to the applicants on recruitment days, we may as well be the chair of medicine, but to a lot of other people, we’re also cleaning up lunches and doing that kind of stuff.
You’re the person who has to fix the PowerPoint system when it doesn’t go well.
Exactly.
At some point though, you must have realized that this thing was coming. I’m an infectious disease specialist, and we were hearing about it in January and starting to get butterflies in our stomachs soon after. But how about you?
My first memories of hearing about it were probably around that time, early-to-mid-January. It was when there were some WHO [World Health Organization] and CDC [U.S. Centers for Disease Control and Prevention] warnings coming out, there were articles in The [New York] Times, and those were probably my first indications that there was something brewing. But I think I read those with some passivity. At the time I was thinking that maybe this is another MERS [Middle East respiratory syndrome] or SARS [severe acute respiratory syndrome], which never quite made it to us. Locally, the heightened alarm did first start to come to us out of Elmhurst. And that’s no surprise because Elmhurst, just in terms of its geographic positioning, in terms of the makeup of the community, often gets hit first and in a lot of ways harder by a lot of these emerging infectious pathogens, certainly things that we don’t as commonly see here in the U.S. So even when we weren’t thinking about a pandemic necessarily, we were still worried that Elmhurst might get exposed to this.
And then interestingly, there was an intern in our program who sometime in February really started raising the alarm bells for us at a time when a lot of us still weren’t overly concerned. She in a prior life had been an anthropologist and has worked in Wuhan [China] and had a lot of personal connections there. So she was talking to people there and hearing probably a lot of things that weren’t being reported in the news at the time, and was really pushing us to get ready, to push the administration to be ready in terms of PPE [personal protective equipment] and developing protocols for testing. And that definitely lit a fire under us, but I don’t think anyone really could have been prepared for what was to come.
Well, even though I mentioned that we infectious disease doctors – it was on our radar screen – I don’t think anyone could anticipate what ultimately happened back then in January. But at some point, the hospital administration must have noted and, of course, the epidemiologists noted that there were a lot of cases in New York City. How was this communicated to you as chief resident, and how did it change your experience of being chief resident?
It changed everything, if not overnight, in the span of a couple of weeks. It started with trying to understand what were the right testing algorithms for these patients and trying to develop the appropriate infection protocol. Because early on it was just a handful of cases and they could put on the hazmat suits and treat this almost like Ebola in a way, where they could put them in negative pressure rooms in the ED [Emergency Department], of which there are very few. I think that persisted for a couple of weeks, but pretty soon we were just completely inundated, both at Sinai and Elmhurst, Elmhurst even more so. And while we were working a lot on the weekends, during the week it was all administrative in terms of completely remaking the structure of our floors, completely remaking the schedules of the residents to design a safer experience, both for the patients and for the residents. And we were pretty quickly working 24 hours [a day] to try and get that done, and I probably didn’t have a day off for two months.
That sounds overwhelming. And you must’ve also been responding to a lot of fear on the part of the residents that you were supervising.
Absolutely. Early on before we saw a lot of cases, that fear centered around having appropriate PPE because there was confusion. It was coming straight from the top. The CDC had mixed guidelines about what was appropriate PPE, that decision to go from wearing N95s to surgical masks were probably okay under a lot of circumstances, unless there were aerosolizing procedures going on, that sparked a lot of fear from the residents. We were definitely dealing with a lot of that backlash at that time to try and communicate the party line, but also empathize with them because we ourselves who were working clinically on the weekends also weren’t sure we totally felt comfortable going into rooms without N95s at that time. So that was a big part of it.
In large teaching hospitals, the residents are very much on the front lines from a physician standpoint – more than anybody.
Yes. And in a lot of ways are a little bit disenfranchised. They don’t have a big voice and follow instruction and really are at the whim of the leadership because they trust the hospital to make the right decisions on their behalf, but they don’t necessarily have the power to get up and say, “I’m not doing this,” either.
Let’s now shift to talk more about Elmhurst. For people who are not New Yorkers, give us a comparison between Elmhurst, Queens and the Upper East Side of Manhattan.
Elmhurst is, as I wrote a little bit about in the piece, is just a few miles away but a world apart from life in Manhattan. Seventy percent of the community in a recent survey is immigrants who weren’t born here in the US. It’s really such a beautiful tapestry of culture. Any direction you walk in from the hospital, you’re transplanted to a different place. Part of what the residents love about spending time at Elmhurst is the food there is just amazing.
I can imagine.
And it’s such a warm and special community too. I really have such fond memories of the time that I spent at Elmhurst, the months I spent there through my years of medical school and years of training, because it really is a gracious and grateful community for everything that we provide to them and in a lot of ways really are dependent on Elmhurst Hospital.
Did the fact that it’s just a largely immigrant community, did it influence the way that COVID hit them?
Yeah, I think there are aspects that were tied back to it being a large immigrant community, but it’s also very much a working-class community. A lot of the people in that community hold jobs that we now recognize as essential jobs, maybe before the pandemic we wouldn’t have necessarily thought of them as such. But for a number of reasons, Elmhurst was hit pretty hard and pretty fast. A lot of people live in multigenerational family homes. A lot of workers who maybe have families in their home countries who are living here in close quarters together with other people in similar situations. For all those reasons, social distancing measures were not easily adopted in that community. And it really ripped through the community very fast.
So did the experience give you any insights or thoughts about our healthcare system?
Certainly as it pertains to Elmhurst in Queens, the fact that Elmhurst was hit so hard was an outgrowth of years of a developing situation where, in the past decade or so, a few hospitals have closed. Attention has been turned away from the community that has a lot of under and uninsured individuals in common, hospital management parlance, you might call an unfavorable payor mix. And it left Queens with fewer than 200 ICU [Intensive Care Unit] beds. There was a [New York] Times article recently that identified maybe threefold fewer acute care beds per person in the population in Queens as compared to neighboring Manhattan. And all of those things made the capacity to handle any sort of surge astronomically lower than what neighboring Manhattan had to offer.
I don’t think we necessarily need a reminder of this, but our healthcare system is driven by profits. In some ways this is something that maybe drives excellence and other ways drives massive inequity. This is the eternal conundrum probably of capitalism. But I think for those of us who don’t think that healthcare should be subjected to the whims of capitalism and view healthcare as a right, and I’m one of those people, it’s a difficult thing. Pandemics are among other things a stress test of the healthcare system, and communities like Elmhurst were exposed as major fault lines.
Yes. Well, you’re talking to an ID doctor and as you probably know, we skew very much in the same direction in our thoughts about the healthcare system.
Do you want to comment at all about how your family reacted to your being right there in the center of it all?
Yeah. There was fear. They were afraid. At the same time they were reliant on me to explain the situation, to explain what the risk of this pathogen was to myself and to my wife and our 10-month-old child. We were getting calls on the regular to make sure that we were okay. In a lot of ways, I was handling them the same way I handled the residents, which was to empathize and to share in their fear a little bit, but to also try and provide as much reassurance as possible. Because I went into the pandemic and the clinical time that I spent at Sinai and Elmhurst with the expectation that eventually I am going to be infected with this virus. I still believe that’s the case, although it didn’t happen as quickly as I expected. But understanding that I’m not necessarily the one who’s at highest risk, but a lot of the patients that we care for are.
Anything you wish that we as a country could have done differently in hindsight, there in New York or about you personally? This is all using the “retrospect-o-scope,” but feel free.
I, like a lot of other people, wish that we had an earlier and quicker response, there’d been early and wide-scale testing, maybe even the ability to do contact tracing, earlier stay at home orders. Certainly the mayor [Bill de Blasio] tweeting in early March that everyone should go out and enjoy themselves and not worry probably wasn’t that helpful. But it’s not necessarily that helpful to compare us to other countries that had more success because part of what makes America so unique is also what made us particularly vulnerable in this situation. We take great pride in our civil liberties and we have states with very different outlooks on the world, on their personal rights, and we have open borders between those states. If you were to put it in medical terms, as a society we aren’t the most compliant patient.
I have family in other countries, in Israel and Switzerland. And in a lot of other countries, if you tell people, “You can’t leave, you can’t walk a hundred feet from their house,” they’re going to follow those orders. They’re going to do whatever the government says. That’s not America. Americans aren’t going to necessarily listen to those orders. And so I think we needed to take that for what it is, and accept that we have to deal with the population that we have.
So how are things now?
Things are better. The cases have slowed down dramatically, as I’m sure you’ve heard, for a period of some number of weeks. Up until probably the past week or two, there was this kind of calm after the storm, which was this eerie silence. On the one hand, the social distancing measures had worked, the curve had been flattened, the number of COVID cases was dramatically lower, but at the same time, a lot of the typical patients that we were seeing – and we’re still wondering, “Where are they?,” –
weren’t coming back to the hospital yet.
Elmhurst in particular really saw this, because I think a lot of the media reporting that surrounded it made people a little bit afraid of the hospital. Among the many things that is going to emerge as all the dust settles from this is the toll that this took on non-COVID patients who were otherwise chronically ill and may become acutely ill. We’ve already started to see this, who probably suffered as a result of it. They started to trickle back and the numbers are getting back to more routine census. So that’s been pretty reassuring.
As a chief resident, even though my year now is wrapping up, a lot of what we’re going to reflect on and try and address as all of this settles down is the toll that this took emotionally on a lot of our frontline staff and on our residents. Because it was traumatic. One of the things I really wish I had been better prepared for was dealing with the emotional and cognitive trauma that caring for patients in the early part of the pandemic would take on the residents.
There was so much uncertainty and a lot of the calls that I was getting, especially from our residents at Elmhurst, would be post-call, 8 a.m. / 9 a.m., just tears and wondering, “What happened? What went wrong? Why did so many patients die overnight? Why are they getting worse? And what could we have done differently?” To have to reflect on those cases, even in small numbers, is pretty traumatic. I think we all have cases that we look back to from our careers that we still remember in pretty fresh terms and are still traumatic for us. And to have 10 to 20 of those in a shift or a hundred of those in a week, the collective toll of that is going to be PTSD [post-traumatic stress disorder] for a lot of people.
Yeah. So what’s next for you?
I’m going on to do a health policy research fellowship through what used to be called The Robert Wood Johnson Foundation Scholars Program. It’s now called the National Clinician Scholars Program. So I’ll be at Penn [University of Pennsylvania] next year studying some of these big health systems issues and thinking how we can be better prepared as a country, as a healthcare system, infrastructurally for next time.
Well, I want to thank you for taking the time to talk today. I look forward to hearing about your career in the future. And once again, this is Paul Sax and I’ve been joined by Eric Bressman, who is chief medical resident at Mount Sinai, talking about his experience dealing with COVID-19 in New York City. Thank you very much.
Thanks for having me Dr. Sax.