The Desperate Hours: One Hospital’s Fight to Save a City on the Pandemic’s Front Lines

Abstract

When New York became the American epicenter of the COVID-19 pandemic in the early months of 2020, hospitals were totally unprepared for the chaos and catastrophe that ensued. Marie Brenner, author of The Desperate Hours: One Hospital’s Fight to Save a City on the Pandemic’s Front Lines, bears witness to a once-in-a-century event and to the ensuing war as it was waged on the front lines. She captures the riveting story of the pandemic through the lens of, arguably, New York’s “most elite hospital system,” the New York-Presbyterian behemoth that provides approximately 20% of New York City’s hospital care.Dr. Steven Corwin, president and chief executive officer of New York-Presbyterian, decided during the first weeks of the pandemic that it was crucial to document the experiences of the hospital system and its staff for posterity. Starting in August 2020, Brenner, an awarding-winning writer and author of seven previous books, was given unprecedented 18-month access to the entire New York-Presbyterian system, which represents a $9 billion enterprise with more than 4,000 beds and over 20,000 employees. The system encompasses 10 campuses in Manhattan, Queens, Brooklyn, and the northern periphery of the city. She interviewed approximately 200 people, including employees from multiple levels of the institutional hierarchy, as well as patients and their family members. Despite the heterogeneity of the interviewees, several themes consistently emerged.The initial several months of the pandemic were characterized by fear, panic, and uncertainty. Surges lurched forward and subsided, recommendations changed, purported therapeutics wandered in and out of favor, testing was all but impossible, and the availability of masks and personal protective equipment was woefully inadequate. Gear that had been designed for single use was jerry-rigged for multiple exposures. Sadly, both the government and the New York-Presbyterian corporate structure hindered, rather than facilitated, progress in patient care during the early phase of the pandemic, months before vaccines became available.Governmental failure was apparent at the federal, state, and local levels. The amount of misinformation and disinformation emanating from the White House was egregious. Moreover, since the “antediluvian structure” of the Centers for Disease Control and Prevention prevented the agency from gathering, processing, and interpreting data expeditiously, states were forced to compete against one another for suboptimal, outdated equipment and other supplies. While the Centers for Disease Control and Prevention continued to fumble, the New York State government refused to override the agency’s edicts. Then there was the fiasco that unfolded when the fatally flawed decision was made to send hospitalized COVID patients who had come from nursing homes back to their facilities, without adequate protection, owing to the predicted deficit of hospital beds and ventilators. Subsequently, an attempt was made to cover up the damage by keeping approximately 4,000 deaths off New York’s total count.Corporate missteps were also jaw-dropping. Indeed, many physicians believe the corporatization of American medicine that has occurred in the last several decades has notably changed not just the face of medicine but its soul as well. Medicine is big business. Carefully drawn lines of silos and hierarchies have impeded effective communication between the caregivers and the “suits.” Specifically, early on, when New York City hospitals had a paucity of masks and personal protective equipment, New York-Presbyterian’s chief operating officer, herself a pediatric orthopedic surgeon, assured staff that “masks would not be necessary” unless workers were in direct contact with infected patients. Although this “assurance” was consistent with Centers for Disease Control and Prevention guidelines, it defied common sense. Later, the chief operating officer threatened back-office workers with loss of employment if they continued to complain about working conditions.By mid-March, the health system needed 90,000 masks per day to protect front-line workers; this daily requirement reflected the total number of masks available in the system. Desperate corporate officials contacted disreputable vendors and paid $18 million for shoddy, ineffective masks from Shanghai before a U.S. company was finally able to fill the gap. Exacerbating these dire circumstances, the lack of available testing prevented an accurate assessment of the pandemic’s enormity. This was especially frustrating because modern, advanced testing machines were available at New York-Presbyterian but were not used because the “leadership” was awaiting government approval for their use. Meaningful guidance on how to best navigate the spiraling crisis was not forthcoming from corporate offices.In contrast to governmental and corporate incompetence, front-line workers exhibited courageous devotion to their duty to care for patients, even at risk to their own lives. They were navigating uncharted waters as they dealt with this new, virulent virus that produced mucus so heavy and adhesive that it resembled rubber cement. Brenner celebrates the nobility of these heroes and heroines. Chief among them is Dr. Nathaniel Hupert, a mathematician and infectious disease modeler who practices clinical medicine at the Weill Cornell campus. Dr. Hupert presciently sounded the alarm about the potential scope of the pandemic in February 2020, admonishing, “This is going to be historically bad, rivalling the medical consequences of 1918, but far exceeding it in terms of global financial impact.” Delivering a message nobody wanted to hear, Hupert was largely ignored. Interestingly, his projections concerning the pandemic’s toll proved accurate and far superior to alternative prognostications.Several anesthesiologists are among the heroes lauded. In addition to providing expert airway management to thousands of critically ill patients, anesthesiologists performed in whatever capacity they could to facilitate patient care. After the New York-Presbyterian system cancelled elective surgery in mid-March, anesthesiologists spearheaded the conversion of operating rooms into intensive care units (ICUs), accomplishing the task within 96 h. Dr. Andrew Knapp, an anesthesiology resident, performed whatever chore was needed in the overwhelmed ICUs, ranging from cleaning waste, dumping sharps, changing sheets, and cleaning bed after bed. Professionals immersed themselves into roles for which there was a need rather than into the roles they preferred or felt most comfortable in. They carried on when as many as 10 patients were dying daily in each ICU. When consideration was being given to experimenting with modifying ventilators for use by two patients, many anesthesiologists and respiratory therapists vociferously expressed their ethical concerns. Their resilience and compassion enabled them to care for their beloved and revered colleague, the virtuoso transplant surgeon Dr. Tomoaki Kato, when he was unconscious and on extracorporeal membrane oxygenation for an extended period. Miraculously, Dr. Kato made a full recovery.When the crisis unmasked glaring care inequities, a group of concerned physicians drafted a letter to New York-Presbyterian administration soliciting more equitable distribution of resources. Their call went unheeded, even though Lower Manhattan Hospital had a COVID mortality rate more than twice that at the wealthy Weill Cornell campus.A review of The Desperate Hours by Sandeep Jauhar appeared in the June 19, 2022, issue of the New York Times.1 That review also highlighted the glaring errors, misjudgments, and contraventions mentioned above, including dismissal of Dr. Hupert’s early warning about the likely scope of the pandemic, the lack of proper masks and other personal protective equipment, the chief operating officer’s attempt to stifle justified criticism of working conditions, and the perceived inattention to concerns about patient care inequities.Fear cascaded through the hospital system. Dr. Arthur Evans, chief of hospital medicine at Weill Cornell, was a pillar of strength and support for his staff, standing by them when they were castigated by the administration for their “alarmist tone” and threatened with a draconian gag order. Dr. Evans also posted, shortly after midnight every day, an update of hospital deaths and staff COVID infections. Tragically, the carnage from this merciless disease included more than 30,000 New Yorkers and 35 New York-Presbyterian staff members.Another example of the necessity for open, honest, and frequent communication in times of crisis was provided by Dr. Craig Smith, surgeon-in-chief at New York-Presbyterian and Columbia, whose daily emails to his colleagues buoyed their morale and enhanced their ability to organize and manage patient care, Indeed, the Wall Street Journal’s Ben Cohen wrote, “Dr. Smith’s emails are Winston Churchill’s radio speeches of this war.”2The Desperate Hours is not an easy book to read, partly because, even for physicians, it is difficult to learn of hospitals using forklifts to haul dead bodies that could not be taken to funeral homes owing to lack of space. The book is also a challenge to read because, at times, the narrative thread(s) became a bit tangled due to the sheer number of people quoted. Perhaps limiting the number of individual stories might have produced a more cohesive chronicle. This cavil aside, Marie Brenner’s probing investigation has resulted in a cautionary tale for pandemic preparedness. Let us hope that the lessons learned from COVID-19 will not be forgotten. As Nobel Laureate Albert Camus wrote in 1947 in his masterful The Plague, “Dr. Rieux resolved to compile this chronicle, so that he should not be one of those who hold their peace but should bear witness in favor of those plague-stricken people; so that some memorial of the injustice and outrage done them might endure. . . .”3Dr. McGoldrick received no funding for this article. During the past 36 months, she received money from the Accreditation Council for Graduate Medical Education (Chicago, Illinois), Current Reviews in Clinical Anesthesia, and Up-to-Date. She is a graduate of Weill Cornell Medical College (New York, New York) but does not consider this to be a conflict of interest.