On a recent shift, Gianna Tomassetti, a 22-year-old physician’s assistant who works in an emergency room in Manhattan, was treating a Covid-19 patient who urgently needed to be intubated. Like all of Tomassetti’s patients, the woman had come to the hospital alone, and like a significant subset of them, she was still fully conscious despite gasping for breath. Doctors are learning that one of the cruel and unusual features of the coronavirus is that people may arrive at the hospital with oxygen levels so low it appears miraculous that they are even alive, let alone alert enough to understand the gravity of their predicament.
Tomassetti’s patient wanted to phone her brother to say goodbye before she was placed on a ventilator. The data is still inconclusive, but it’s likely that most coronavirus patients who are placed on ventilators never come off them (although the data is further skewed as, generally, only the sickest patients are placed on ventilators). The phone rang and rang. The brother wasn’t picking up. The woman’s oxygen levels were plummeting. If she wasn’t intubated soon, she would surely die. It wasn’t an assessment Tomassetti and her colleagues had had to make before – how long should they wait? How important is a goodbye?
New York City’s medics are on the frontline of the new global epicentre of the coronavirus pandemic. By 27 April, almost 17,000 people in the city were thought to have died from Covid-19, equivalent to more than one in 500 residents.
In late March, doctors found their hospitals transformed, almost overnight. Emergency rooms began to resemble ICU units and medics from across the hospital were drafted to help out in ever-expanding Covid-19 wards. Battling a new disease as beds, medical equipment and supplies of their own protective gear dwindled, they were forced to improvise and to learn on the job. They fought to save lives and when they could not save them, they tried to facilitate goodbyes. While visitors remain barred from hospitals to prevent the virus spreading further, medical staff are learning how to break hard news by telephone.
“I’ve never experienced anything like this. I’ve never been afraid for my own life when going to work before,” Jules Beale, a paediatric neurologist now working on a dedicated adult Covid-19 ward in Queens, told me by email. He knows five doctors who have fallen ill with the virus. One of them had died. The father of two has recently updated his will.
Beale said he was worried about how his colleagues would manage psychologically in the aftermath of this crisis. “Medical professionals are being asked to make impossible ethical decisions about resource allocation and are having truly traumatic experiences. I’ve actually spoken with colleagues in psychiatry who have concerns that there will be an increase in anxiety and depression and even PTSD among medical providers as a result of what is happening now,” he told me.
On 16 March, Alaa Daghlas, a 32-year-old physician’s assistant, woke up at 5am, two hours before her next shift in an emergency room in the Bronx, feeling like her heart was racing. She assumed it was nerves. The day before the governor had announced the closure of the state’s public schools, and the city’s outbreak was worsening.
By the time Daghlas arrived at work she also had a dull headache, and her colleagues thought she didn’t look her usual self at all. Because she’d previously treated two patients with Covid-19 she was tested for the virus and sent home. The test came back positive.
For two or three days she had a constant headache and her whole body ached. Soon she felt better and she was relieved to have escaped with only mild symptoms. A few days later, her condition declined. First, she experienced chest pain, a disconcerting tightening sensation, and then she became so short of breath that even walking from her bedroom to the kitchen in her small downtown apartment would exhaust her. Her husband fell ill with Covid-19 too, and she worried for their two-year-old daughter. At times she’d wake up several times a night to check her husband and her daughter’s breathing. Her daughter’s hands are so small that she placed a pulse oximeter on her toe instead of her finger, to check her oxygenation levels.
By the time we spoke, in early April, Daghlas and her husband had recovered and she was preparing to return to work. Her parents had been calling her, telling her not to go back, and Daghlas was scared but felt ready. “I got into medicine because I wanted to help people, and I got into emergency medicine specifically because I want to help people right then and there. And this is that calling,” she told me, when we spoke by phone.
On 7 April, Daghlas drove to work so that she could deliver all the donated personal protective equipment she had collected for her colleagues. While she was on sick leave, she had raised almost $60,000 using the fundraising platform GoFundMe to purchase more protective gear for her team. Some companies had made donations in kind, too. A sports company had donated ski masks; Home Depot, a hardware chain, had donated shoe covers and overalls; Miriam AlSabai, a designer, had donated face shields.
The hospital had transformed in the three weeks she’d been away sick. “It sounds like an ICU, not an emergency room anymore,” she said when we spoke on the phone after her first shift. Every patient that arrived was being hooked up to a monitor, to check their oxygen levels, and the emergency room had expanded to fill the hospital’s lecture hall and the paediatric ER.
Daghlas said she felt heartbroken remembering the calls she’d fielded from anxious relatives. “Are they OK?” “Are they conscious?” they would ask of her patients, often apologising for bothering her. She hated that she could offer so little reassurance. She could tell them their loved ones were being cared for, that they were OK for now, that if anything changed the hospital would be in touch, but she could offer no prognosis. The disease is unpredictable; there is no guarantee that an otherwise healthy patient with no known risk factors might not suddenly decline.
Throughout April, Daghlas took on extra night shifts to cover for colleagues who were off sick. She and her coworkers were trying to keep their spirits up, but it was hard. At the end of each 12-hour shift it felt like a luxury to remove her two protective face masks so that she could breathe freely, and her face would be covered with red marks. She was starting to wonder if she’d always have to wear such extensive and uncomfortable protective gear. Was this “astronaut” outfit her uniform now?
“It makes you feel how it must be to be in the army or the navy. You’ve always known that you’ve volunteered, that you’ll have to step up to the plate when you’re in combat,” she told me when we spoke by phone in late April. “It’s a hard situation because you’re being brave, but inside you’re also fearful because you know what risks you’re taking.”
She said she was struck by the courage and the kindness of the nurses on her team, who were often most exposed to the virus. “They are the people I’ve seen cleaning up after someone if they’re incontinent. These are Covid-19 patients and [the nurses] will go above and beyond to take care of that person as if they were their own parent,” she said. “That is the essence of a hero. Because they are literally exposing themselves to,” she paused a moment, “less than ideal situations, to make sure that even if it’s in the last moments of their lives these people are treated with dignity.”
When she was growing up, Lavita Payton, a 50-year-old nurse who works in Manhattan, had planned to become an accountant. She was raised by a single mother in a housing project in East New York, one of the poorest neighbourhoods of Brooklyn, and she was hard-working, smart and ambitious. Then when she was 20, she fell seriously ill with a rare neurological condition while pregnant. The nurses who cared for her during the months she was bedridden were “the best people on earth”, she concluded, and she wanted to repay their kindness.
After she graduated, in the early Nineties, she worked on the HIV unit, caring for people who were dying of AIDS. She worked in the emergency room on 9/11 and after Hurricane Sandy, and still nothing prepared her for the magnitude of the current crisis.
Her ward has a notification line so that ambulances can phone ahead when patients are arriving at the hospital after having suffered strokes or heart-attacks or other life-threatening illnesses. The phone used to ring around six times a shift. Now it rings constantly. “You get all these patients coming in, coughing, coughing, coughing, their oxygenation levels are low, the nurses are literally running out of space for where to put them, they can’t even clean the rooms fast enough,” she told me, when we spoke by phone.
She was worried about shortages of protective equipment. Usually, she would discard her surgical mask after visiting each patient, but she was no longer able to do so. She was reusing her goggles too. As the number of Covid-19 patients swelled and ever more of her colleagues fell sick, nurses’ caseloads grew. Payton, a union member and a political activist, gave a broadcast interview to MSNBC in late March to raise the alarm. “We’re being asked to go out and protect people, which we love doing, but we’re being asked to do it ill-prepared,” she told the broadcaster.
When we spoke in late April, Payton had herself been off sick for two weeks. She had a cough and a fever and had been wheezing, despite the doctor prescribing her ever-stronger medication for her asthma. The morning before our conversation she had finally felt well enough to drive to a clinic to get a Covid-19 test.
“Part of me is hoping that the result is positive, because I’m so afraid that with my asthma and diabetes [Covid-19] will kill me, so I’m hoping if the test is positive that means my body fought of the virus and I have some kind of immunity. And the other half of me hopes I’m not positive because even though I’m being super careful maybe I’ve put my family and other people at risk,” she said. She had quarantined herself in the bedroom of the home she shares with her husband and her stepdaughter, leaving her room only to go to the bathroom. She was looking forward to being able to see her five-year-old granddaughter again.
When the coronavirus outbreak spread throughout New York in March, Payton was transferred from working on a recovery ward back to the emergency room, a part of the hospital where she had avoided working ever since her son died of a cardiac arrhythmia aged 22. The emergency room always brought back painful memories.
Now Payton was starting to wonder if, once the pandemic is over, she might leave nursing altogether. She was already studying for a Masters in education, and was contemplating teaching full-time and helping to train a new generation of nurses. “I mean, I love nursing. I really do. But this is making me second guess it.”
Gianna Tomassetti, the physician’s assistant, graduated from medical school under a year ago, and had been working in the neurosurgery department before she was called to help out in the emergency room as the Covid-19 caseload surged. She amazed herself with how adaptable she was, how well she seemed able to rise to the challenge.
Her housemate had returned to her family in Long Island, and so Tomassetti was living alone. That was hard sometimes, and she missed her parents, but she was glad not to be putting anyone else at risk. After her shifts she liked to do yoga or other at-home workouts or to read self-help books that helped her stay positive. She had almost finished reading Good Vibes, Good Life by Vex King when we spoke. “It’s a very motivational book, like how to basically stay away from negative energy and make the best out of all your situations,” she said.
When Tomassetti heard about how many people were struggling to get updates on their loved ones who were in hospital with Covid-19 she posted a message on Facebook inviting people to get in touch with her to see if she could help speed up the process. To date, around ten people have messaged her. Once she had taken down their details, she would use her hospital group’s internal messaging system to prod the relevant doctor. In one instance, a family had been waiting for three days for news of their sick relative. After Tomassetti intervened they heard back within 20 minutes. It felt good to be able to make this difference.
Tomassetti understood how such delays happened: her colleagues were overwhelmed. When she was on shift her telephone rang constantly as relatives called for updates, and Tomassetti was learning how to balance their needs with those of the patients she was tending to.
The mobile phone reception is bad in the emergency room, and so when her patients were able to speak Tomassetti would often let them use her work phone, which she kept safe inside a ziplock bag, to call their relatives. “That’s the saddest part. [The relatives] will get very emotional on the phone. They start crying, they tell them how much they love them, and not to be afraid. They say that other family members are watching over them, and that everyone’s there for them even if they can’t be physically there for them. It’s a very emotional process.”
At the very last minute, the brother of Tomassetti’s critically ill patient phoned back, and the siblings were able to say goodbye before she was intubated. The woman was transferred to the ICU, and Tomassetti doesn’t know if she survived.
“I think after talking to multiple family members you kind of become numb to it,” she said. “At first it was very challenging but after a while you realise you have to be strong for them because, you know, it’s hard for them to be strong for themselves.”