diary of a hospital

Losing Hope in the ICU

“I don’t know how long I can keep doing this for.”

Photo: Patrick Schnell M.D

As the COVID-19 crisis continues to unfold, the medical staff at Mount Sinai Brooklyn is providing regular dispatches about the daily experience fighting the virus. While there have been glimmers of good news lately, with indications that New York’s curve may be close to flattening, doctors on the front lines are still living a nightmare. Dr. Adam Brenner runs the ICU at Mount Sinai Brooklyn. It’s one of the hospital’s most difficult and emotionally demanding jobs, tending to the sickest patients with the least hope of recovering. Dr. Brenner, who works 14-to-15-hour days six days a week, says the demands of his job have increasingly started to weigh on him. While he is committed to fighting through to the end, he knows it’s going to be very difficult to go back to normal after this is all over. Here, his dispatch.

Today wasn’t a great day. We did the best we could. It just went on and on. A lot of people just dying in front of us. Due to the nature of the crisis, there are so many sick patients overwhelming the staff. It’s very difficult to get everyone into the ICU in a timely manner. We’ve tried to deploy other physicians and medical personnel to help manage the critical-care patients on the floor, but nonetheless it’s very overwhelming.

Maybe two or three patients died upstairs in our second ICU, but a lot of the deaths are of the patients that don’t make it to the ICU who are sitting on the regular floors and unfortunately can’t come here because there are no beds. In the ICU, you have specialized intensive care, specialized nurses and technicians that know how to manage the special medications. Ventilator management can be very complicated, and the staff on the floor are not as used to dealing with that and taking care of patients with those requirements.

Rationing ventilators hasn’t been an issue yet. We have enough protective materials, and we’ve had help in terms of staffing, but there’s no other disease in our lifetime where you see 170, 180 patients in the hospital with the same disease. We still just don’t have the staffing or the space for everyone. We had a 12-bed ICU, we opened up a second 12-bed ICU, and yet we still have 15 to 20 patients in the hospital that we need to find a place for. It’s overwhelming because the list just goes on and on and on. We realize we’re not going to get to all of these patients in the right way. And then there are new patients coming in that we have to evaluate. Even if people die, the list does not get shorter. It’s an ongoing process, and it makes us feel horrible. It makes us feel helpless.

Historically, for the most part, we can always get somebody an ICU bed in a reasonable time frame. Now people are waiting much longer. We’re still trying to get them into ICUs as soon as possible, and we’ve also been transferring patients to other hospitals in the Sinai system.

The virus is horrible. It’s a horrifying disease. It’s not just a disease of the lungs that we’re seeing; it’s also a disease of the kidney. We’re seeing around 80 percent of critically ill patients experiencing kidney failure. We’re finding that to be a very poor prognostic indicator. Upwards of 80 to 90 percent of patients with kidney failure have died. We don’t have enough dialysis machines to take care of these patients. And the disease of the lungs is like nothing you’ve ever seen before. There are so many theories about what this is and the best way to manage it, and it just suggests to me that nobody really knows.

The elderly patients seem to be the ones that just kind of die right away. The ones we’re seeing in the ICU who are just kind of lingering on the vents and not getting any better, or the ones who die after kind of a week or so, are the 50-to-60-year-old patients. They’re not that old. We’ve also seen some younger patients with comorbidities that have not done well. It’s horrible, they’re dying by themselves, we don’t have enough time to update the families as well as they deserve.

There have been a couple of cases that have been particularly tough. One of our first patients we were particularly aggressive with and put a lot of effort into trying to do the right thing for her in terms of her therapies. The nurses weren’t used to doing what we call proning, which is putting people on their stomach, but we got it done and she was initially improving and we were optimistic. Then the past few days she has just gotten worse and worse. Probably through a blood clot or a complication in the lungs, she’s very likely to die in the next 24 hours. She’s only 53 years old.

It’s important for the public to know that it’s not just old people who are suffering from this. It could be anybody, it could be any of us, any of our families, our parents, brothers, sisters. People sometimes get a sense of infallibility, but I think they need to realize how severe this is. We’re seeing such a high mortality rate in these younger patients. It’s not just a disease of the lungs; it’s a disease of the whole body.

We were able to take our first two people off ventilators today, and so far they are doing okay. That was a big emotional hump for us. But not many. That’s two out of the 40-some patients total who have come in and out of our ICU, not including the patients on the floor that we haven’t been able to take care of in the right way.

There are days that I’m convinced I’m going to get it and I’m going to die. I think that’s more emotional than scientific. At this point, if I was going to get sick from it, I probably would have already died. But it’s a concern. We could bring it home to our families. I’ve isolated myself from my family, which is hard, but I think it’s the safest way to handle it.

I don’t know how long I can keep doing this for. In my mind, I’m going to do it, I’m going to be there until this is done, but it’s going to be very hard to come back to work after this is over.

This whole experience has definitely been traumatizing. All we really have with this disease is supportive care. It makes me think about what we’re really doing — if we’re really doing good for people by just prolonging their death, when it’s just going to end up in mortality anyway.

In the beginning, we’d bring someone to the ICU and put them on a ventilator, and we would think they have a reasonable chance of getting better like any other disease. But as we get more experience with this virus, we’re seeing through the data we have in our hospital that most of them don’t do well. Other diseases we still have hope. This has really taken away all our hope.

Before it started, we expected it was going to come here and that it was going to be bad, and we knew it was overwhelming, but I didn’t imagine it was going to be like this. It’s worse than I thought.

I’ve been working extra hours. Our normal shift is 12 hours.
I’ve been there 14-, 15-hour days and working on days off. So I’m there six days a week. I try to take one day off a week. I try to sleep and catch up on things around the house. But I generally mostly find myself staring into space.

The hospital is offering resources for health-care professionals for psychological health. It’s going to be a big need, for sure. I think during the crisis, people are getting by, but I think after, when it’s controlled, it’s going to be a big problem. I want people to know that we’re doing the best we can under the circumstances. We know that we’re not the ones suffering from this disease and we feel for the family and the patients that are. But we’re still having a hard time trying to help everybody through it. A really hard time.

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Diary of a Hospital: Losing Hope in the ICU