Life on the Line

Young Doctors Come of Age in a Pandemic

Emma Goldberg

• Publisher: Harper
• Year: 2021
• ISBN:
  9780063073418
• Topic: Medicine
• Subtopic: Medicine Biographies

The gripping account of six young doctors enlisted to fight COVID-19, an engrossing, eye-opening book in the tradition of both Sheri Fink's Five Days at Memorial and Scott Turow's One L.

In March 2020, soon-to-graduate medical students in New York City were nervously awaiting "match day" when they would learn where they would begin their residencies. Only a week later, these young physicians learned that they would be sent to the front lines of the desperate battle to save lives as the coronavirus plunged the city into crisis.

Taking the Hippocratic Oath via Zoom, these new doctors were sent into iconic New York hospitals including Bellevue and Montefiore, the epicenters of the epicenter.In this powerful book, New York Times journalist Emma Goldberg offers an up-close portrait of six bright yet inexperienced health professionals, each of whom defies a stereotype about who gets to don a doctor's white coat. Goldberg illuminates how the pandemic redefines what it means for them to undergo this trial by fire as caregivers, colleagues, classmates, friends, romantic partners and concerned family members.

Woven together from in-depth interviews with the doctors, their notes, and Goldberg's own extensive reporting, this page-turning narrative is an unforgettable depiction of a crisis unfolding in real time and a timeless and unique chronicle of the rite of passage of young doctors.

Nine

JAY, April 2020

“Good morning.” The words were muffled, coming from the masked mouth of the woman behind the hospital’s front desk. “How can I help you?”

“I’m here for the new doctor orientation,” Jay replied.

“Take some hand sanitizer,” the receptionist said. “And please put this on.” Her gloved hand passed over a surgical mask.

Jay was already wearing a mask and had sanitized moments earlier, but not wanting to be a nuisance, she dutifully complied, placing the new mask over her first. Then she took the elevator upstairs, where a group of six other early graduates sat waiting for orientation to begin. Following the social distancing bible, they were scattered around the room at a distance of at least eight or ten feet from one another. Soon they would start to visit patients, and the luxury of distance would be one they couldn’t afford. But for now they all seemed to savor this moment of personal space. Jay had slipped a yogurt into her backpack for breakfast, but she quickly realized that was useless. She’d have to take her mask off to eat, and you couldn’t do that in here.

At the front of the room, another person with a covered-up face handed Jay her long white coat and new ID. Printed on the little piece of white-and-blue plastic were the improbable block letters: “Jay G., physician.”

The residency program director and assistant director, both hulking six-foot-three men with baritone voices, came to greet the group. Everybody drew their chairs away from the wall and formed a misshapen circle. Now they were closer together, and the synapses between them seemed almost alive. This was what Covid had done. It had turned distance—or its absence—into an electric force.

“Welcome aboard,” the program director said, his eyes flicking from masked face to masked face. “We’re glad to have you here.” He informed them that they would be functioning as interns, or first-year residents, a step up from the level of responsibility they had in their final medical school rotations. They would rotate units every two weeks, and each be given four or five patients. As they began reviewing the coming weeks of responsibility, Jay’s mind was suddenly awash in all the questions that she’d been damming up. How much PPE would they get? Would they be able to put in their own orders, arranging for medications and procedures, or would their residents have to approve the decisions? How many Covid cases did the hospital have?

Jay’s hospital had been designated as a Covid Center of Excellence, which meant it was accepting the bulk of coronavirus cases that came to emergency rooms within its hospital system rather than steering incoming patients to other hospitals. It was five weeks since positive swabs began surfacing in the city; more than ten thousand people had died in the tri-state area, and nearly a quarter million had been infected. Governor Cuomo had recently extended New York’s stay-at-home order through at least mid-May, meaning nonessential businesses and schools would remain closed.

Jay had read the news each day with a sense of purpose that enabled her to mute the voice in her brain responsible for angst production, but that mute button was gone now. “We’re going to go over allocation of PPE now,” said the director. “Each of you will get one N95 per week.”

Jay made eye contact with one of the other new interns. They were all familiar with the studies that said you should swap out your N95 every five to six hours to preserve its filtering mechanism. She resolved not to mention this N95 rule to her mom, at least for now.

“So how is everyone feeling?” the director continued. “Should we pick up your PPE?”

The group filed downstairs and outside, toward another area of the building designated for PPE distribution. Its main entrance was blocked off. Peering past the staff guarding it, Jay saw a long white refrigerated truck, which must have been filled with corpses. These trucks, kept at a chill 34 degrees and stationed throughout the city, could hold up to a hundred bodies. Some were marked by lettering on their sides that read, ominously: “Dead Inside.”

Some of the interns had been fitted for N95s before. But there was a grimness to it now, a level of palpable fear in the slow, clear instructions they were given. Each of them had to put on a mask and hood, which was sprayed with aspartame. Then they had to make sure they couldn’t taste it while doing a set of exercises. Jog in place, nod your head yes, shake your head no, say “Hello” and talk for thirty seconds. Jay received her one N95 for the week and was told to mark the side of it that was exposed, which would be important to track when she retrieved it for reuse. They were informed that the hospital had run out of foot and hair protectors, which was also added to Jay’s file of data she wouldn’t share with her mom.

The hospital had made various physical adjustments for the weeks of crisis care. The hallways were lined with red signs: “Do Not Enter without an N95” and “No Visitors.” The hand-sanitizer dispensers were being frequently refilled, but still they ran out at least once a day. New workstations were erected in rooms that hadn’t been used in years, where the floors and tables were coated in filmy layers of dust.

Before receiving her list of patients, Jay returned to the lobby to activate her badge. She waited in the hall by the receptionist’s desk. As the line inched forward toward the security guard on duty, she studied the linoleum floor. The lobby felt foreboding in its uncharacteristic hush; it was all bleak gray and the smell of antiseptic.

When Jay got to the front, she introduced herself. “Hi, I’m a new . . .” She trailed off. She found that she literally couldn’t form the syllables to say “physician.” It felt too foreign. “I’m new.”

The guard squinted at her, nodded listlessly. “We gotta take your photo,” he told her. “Stand over there.” He gestured toward a nearby wall. “Oh, but first take off your mask.”

Jay froze. “Uh. What?”

“You gotta take off your mask for the photo,” he said.

Jay’s heart started hammering. Her panic was disproportionate to the situation, but it felt like some sort of test—a “gotcha!” moment to see if, hours after entering the hospital, she would casually remove her protective equipment. But the guard just stared at her expectantly, so she slipped off her mask and smiled for the camera.

As Jay stepped aside, waiting for her ID to be ready, the middle-aged man standing behind her in line moved forward. He swaggered toward the guard like they knew each other, ran a hand through his thinning white hair, and adjusted his black leather jacket. “I’m here for a body pickup,” he said in a thick Irish accent.

Jay turned her head to catch the man’s facial expression, wondering if he could be joking. He laughed at her look of alarm, and his bright blue eyes glimmered like they, too, were in on the joke. “This is my sixth one today,” he said, waving a pink slip of paper in the air. “I’m a funeral director in the area. I’m used to it by now.”

“Oh, okay,” Jay said.

As she turned to head to the elevator, he called back to her. “Make sure you wear that thing.” He pointed to her mask. “I don’t want to have to come back here for you.”

As young doctors do, Jay had envisioned the things that might go wrong with her first patient. A rapid response. An airway code. She could overlook a possible diagnosis, give too large a dose of medication or, alternatively, one too small. The margin for error might be nonexistent. And the stakes were no longer a grade on a med school exam; it was somebody’s life.

But at least medical care is typically collaborative, a choreography set by other doctors, by the patient’s family, and by the patients themselves. What Jay hadn’t anticipated for her first assignment was how isolating it would feel. Her patient, Ms. Parker, was nonverbal and had no family contacts on file.

Ms. Parker’s information was handed over to Jay unceremoniously. She sat down in the workroom and opened her electronic medical records to review the facts. The woman was fifty-four years old, had tested positive for the coronavirus, and had recently had a stroke. She was homeless.

Since Ms. Parker was nonverbal and asleep, the attending physician said there was no reason to visit the bedside right away. After all, the hospital was trying to conserve PPE. But Jay decided to pass by anyway and peek through the window. It would feel wrong not to lay eyes on the first-ever person placed in her care. The patient’s body was covered by a heap of blankets, her face concealed by a mask, and her eyes closed. She was on a high-flow nasal cannula, a thin plastic tube threaded through her nose to deliver her oxygen.

The woman had received a cognitive examination when first admitted, which had revealed that she wouldn’t be able to make her own decisions on care. For other patients like her, the doctors would call up her family. But Ms. Parker had no emergency contacts, nobody to weigh in on whether she should be resuscitated or intubated if her lungs or heart failed. She had no primary-care provider, and her electronic records had zero information on her medical history. Jay wished for a moment that she had some other first case—someone who could communicate with her the way she’d envisioned for a first patient, who validated her training instead of scrambling all the clinical norms. She couldn’t even rely on many of the typical protocols for patients with shortness of breath and altered mental status, because it was still unclear what applied to Covid treatment. The guidelines kept shifting.

Jay learned that the hospital ethics committee had been consulted about Ms. Parker’s case, which brought a measure of relief. There were other voices involved. The committee had determined that if her heart failed, she shouldn’t be resuscitated. The odds were too slim that she could survive. Jay settled at her desk in the workroom to study the patient’s chart. She noticed that Ms. Parker hadn’t eaten since her admission a week ago. She’d been sustained only by sugar in her IV fluids. Jay wondered if they could give her IV nutrition, but the decision had to be routed through the ethics board. She called the board and reached an answering service, so she left a message and made a mental note to call back the next morning.

The day slipped by in a flurry of new faces and information. On the 6 train home that evening, Jay pictured her patient in that tangle of hospital linens. She would do anything in her power for Ms. Parker’s comfort. After years of school, years of wondering whether she was qualified to be a real doctor, of hoping she was qualified to be a real doctor, Jay didn’t want to lose her first patient. Besides, Ms. Parker was only fifty-four.

Late that night, around 3:00 a.m., Ms. Parker’s lungs started to fail. One of the night nurses saw and paged the overnight team. Night float—the residents on overnight call—rushed over, but by the time they arrived, it was too late. When Jay came in the next morning, there was nothing for her to do.

“We’ve already filed for the death certificate,” the overnight resident told her.

Normally the next step would be for Jay to call family and let them know Ms. Parker had passed. Here all she could do was take her own private moment to mourn.

The rational part of Jay knew there was nothing she could have done differently. But God. That didn’t change the fact that she’d lost her first patient. Day two of her medical career, and there were no lives saved, just another added to the death toll. Had she missed something?

One of the residents must have noticed the look of alarm in Jay’s eyes. “I looked at her chart too,” he said quietly, tugging her to the side. “There was nothing you could have done differently.”

The resident was doing a residency in psychiatry but had been redeployed for frontline Covid care, and he seemed attuned to the emotional register of the room. Perhaps due to his training, he knew the right words to counter a wave of panic, even if it was the doctor who was in crisis and not the patient.

Soon Ms. Parker’s body would be wrapped up and taken to an overflowing city morgue. Jay wondered how many had died alone like this in the last month, people whose hearts stopped short in the middle of the night with no phone calls to place the next morning. The phone calls to family were impossibly heavy, but the knowledge that there were no calls to make brought its own kind of heartbreak.

Later that week, Jay was assigned another patient who had recently coded with a pulmonary embolism, or a clot in the lungs, most likely caused by Covid-19. This time the patient had survived the code. But she was younger than Jay, just twenty-three years old. Jay felt a visceral jolt of fear. The masks were still in short supply.

Around the time Jay first reported for hospital duty, the city was at four times its normal death rate. There was a New Yorker dying almost every two minutes. Jay’s first day came just past the peak of city Covid deaths—but that was only clear in hindsight. At the time, she and her team wondered if the count might continue to mount. The uncertainty bred its own kind of nebulous angst.

It wasn’t just rookies like Jay feeling the weight of the frontline care. Even the country’s veteran doctors found themselves tested by the weeks of Covid crisis. There were doctors who served on the front lines of September 11, Hurricane Katrina, the AIDS crisis, the West Nile virus scare, the anthrax scare, Ebola, some combination of the above. But Covid felt worse—the fear heavier, the death toll higher.

The difficulty for frontline providers was partly in the lessons that had to be unlearned. Many of the mores of medicine were challenged, some cast off entirely. Dr. Fred Valentine, who helped treat Bellevue’s first HIV patients, developed a lecture for his trainees on treating novel infectious diseases entitled “We’ve Never Seen This Before.” He quickly realized that some of the lessons from the AIDS crisis held true during the Covid era: namely, when treating new diseases, sometimes old rules and traditions no longer applied. “Figure things out. You guys are smart,” he told his trainees. “Particularly in the area of infectious disease, you’re frequently seeing things no one has seen before. That means you gotta think. Put things together.”

During the early weeks of Covid, one of the new challenges for providers was widespread concern about ventilator allocation. The country’s hospitals were estimated to have about sixty-two thousand ventilators at the start of the pandemic, and the Strategic National Stockpile didn’t have sufficient backups because of a contract with a private firm that fell apart in the years preceding the Covid outbreak. As the surge of Covid patients mounted, many doctors worried that ICUs would become overwhelmed, and there wouldn’t be enough ventilators for everyone in need. That led to difficult questions. In a choice between two sick patients, who would get priority access to a ventilator? And how could this decision be made fairly? Some patients, and doctors, worried that racial bias could affect these choices, just as Black and Hispanic patients were getting harder hit by the disease.

In 2015 the New York State Task Force on Life and the Law (created during the AIDS crisis) worked with the New York State Department of Health to revise earlier guidelines on how to allocate ventilators during a pandemic. The task force decided that rather than giving out ventilators on a first-come, first-served basis, the decision had to be made by taking people’s health conditions and likelihood of survival into account. The crux of the decision should be a person’s sequential organ failure assessment (SOFA) score, which measures any dysfunction in six organs and systems (respiratory, coagulatory, liver, cardiovascular, renal, and neurologic). The task force stipulated that ventilator access should never be determined by nonmedical factors, such as race, ethnicity, sexual orientation, socioeconomic status, or ability to pay. It was important to be as objective as possible.

Still, these were guidelines, not hard-and-fast rules. Doctors, patients, and their families worried about what extraneous factors might mold these life-or-death decisions. If the surge kept mounting, if ICU beds got more overwhelmed, would someone uninsured, Black, or Hispanic be shunted aside? As early as March and April there had been cautionary tales of Black people in New York denied...

Table of contents

• Cover
• Title Page
• Dedication
• Contents
• A Note from the Author
• Introduction
• One
• Two
• Three
• Four
• Five
• Six
• Seven
• Eight
• Nine
• Ten
• Eleven
• Twelve
• Thirteen
• Fourteen
• Fifteen
• Sixteen
• Seventeen
• Eighteen
• Nineteen
• Twenty
• Twenty-One
• Acknowledgments
• A Note on Sources
• About the Author
• Copyright
• About the Publisher