Marc Ayoub remembers the woman in her 50s who came alone to the emergency room. She went into cardiac arrest and was hooked up to a ventilator. Ayoub, a resident at hard-hit Elmhurst Hospital in Queens, tried to reach her family all night, and when he finally connected with her daughter, he had only bad news.
As he stood in his spacesuit of protective gear, holding his phone in front of the woman’s face so her daughter might see her one last time, Ayoub was indignant that this is what death had become during the coronavirus pandemic.
He looked away, trying to be respectful of the sacred moment. But he could not help but overhear as the daughter connected family member after family member, until there were more than a dozen people weeping on the chat. “Mommy, please come back,” the daughter begged. “Please.”
“I am a doctor. I spent years training to help people, but I have never felt so helpless in my life,” recalled Ayoub, 31. “There was nothing I could do for the patient or the family.”
Doctors, nurses and emergency medical technicians are supposed to be the superheroes of the pandemic. They are immortalized in graffiti, songs belted out from balcony windows and tributes erected from Times Square to the Eiffel Tower. But despite the accolades, many confide that the past months have left them feeling lost, alone, unable to sleep. They second-guess their decisions, experience panic attacks, worry constantly about their patients, their families and themselves, and feel tremendous anxiety about how and when this might end.
The unfathomable loss of more than 100,000 Americans within a matter of weeks — many in isolation, without family or friends — has inflicted a level of trauma few anticipated when they signed up for these jobs. At least 592 of those deaths were of health-care workers, according to a list compiled from news reports, social media and other sources by the National Nurses United union.
As the first wave of patients subsides, many are struggling with the death and devastation they saw close up and — perhaps most difficult — with their own inability to do more, to save more people’s lives.
A few became casualties themselves: Two health-care workers in New York City committed suicide within two days of each other in late April. John Mondello, 23, was an E.M.T. working in the Bronx. Lorna Breen, 49, was an emergency department physician at New York-Presbyterian Allen Hospital. Breen’s sister said she had been tormented by what she experienced. She quoted her as describing a scene “like Armageddon” and saying, “We can’t keep up.”
Ayoub said he was not surprised when a quarter of his classmates in the residency program at the Icahn School of Medicine at Mount Sinai revealed in a survey they had thought about suicide. “We know exactly how she felt,” he said of Breen. “We understood what she was going through. That could have been any one of us.”
“A lot of people were angry at the whole situation and the system,” he added. “How it all happened. How we weren’t prepared. The lack of support.”
Worried that the coronavirus might leave a whole generation of health-care workers with post-traumatic stress disorder, many hospitals and ambulance companies have brought in grief counselors via Zoom and started weekly mediation sessions, prayer circles and other support services. Mental health apps such as Headspace and Fitness Blender are offering free access for health-care workers. Online therapy company Talkspace donated more than 2,100 months of counseling to medical workers, and more than half of that time has been used.
Counselors seeing health-care workers describe symptoms of burnout, PTSD and “moral injury” — the effect of hundreds of decisions made each day on the fly and amid the chaos, creating conflict between deeply held beliefs and options considered inadequate or downright wrong.
Brittani Holsbeke, 31, emergency department nurse in a Detroit suburb, described sending home patients with blood oxygen levels lower than normal because of triage policies in place during the peak that raised the threshold for those who would get treated. “It got gray,” she said, especially when some of those people would show up even sicker a few days later.
Audrey Chun, 48, a New York City doctor, struggled with helping her elderly patients sick with covid-19 decide whether to stay home and die surrounded by family — or go to the hospital where they would get treatment but still possibly die, in that case, almost certainly alone. There was “no clear answer to give them,” she said.
Matt Kaufman, 51, a physician at Jersey City Medical Center, remembers the guy who came in at the peak of the crisis with minor chest pain. In normal times, it would have been “a no-brainer” to admit the man, if only for observation. But Kaufman was torn. “The concern was if he sticks around, he could get infected and be in an even worse situation.”
Clap-outs and crises
Images of health-care workers during the pandemic often show them cheering as a patient is wheeled out of the hospital, arms pumping, with the theme from “Rocky” or “Don’t Stop Believin’” playing in the background. The daily reality has been grimmer. In some medical centers, the ratio of deaths to discharges was as high as 9 to 1 among the critically ill on ventilators.
Signs of burnout, anxiety and frustration are widespread, especially as colleagues, friends and family members have gotten sick or died. That has provoked quiet despair in some medical workers and angry confrontations from others.
Nurses placed empty white shoes in front of the White House to protest lost colleagues who they contend became ill and died as a result of inadequate protective equipment. Residents at NYU Langone and the University of Washington clashed with hospital administrators over hazard pay and life insurance. Ten nurses were suspended at Providence Saint John’s Health Center in Santa Monica, Calif., after they refused to enter a coronavirus patient’s room without N95 masks.
Almost invariably, the hardest thing many health-care workers describe about their experience is their fear and sadness over families — their patients’ and their own.
Susan Hopper, a 57-year-old nurse practitioner in the emergency department at Montefiore Medical Center in the Bronx, described how colleagues lived in cars, stayed at hotels or sent family members to live with relatives to avoid infecting loved ones.
“There was such fear,” she said. “That all plays a part on the human psyche.”
Hopper, who has been staying with her sister, eventually tested positive for the virus. So did her sister.
Even before the pandemic, many doctors and nurses struggled with stress. There is growing evidence this crisis will take an even larger toll. A study of 1,257 doctors and nurses in China during that country’s coronavirus peak found that half reported depression, 45 percent anxiety and 34 percent insomnia. Another, looking at 1,400 health-care workers in Italy and published in JAMA Network Open, found half showed signs of post-traumatic stress, a quarter depression and 20 percent anxiety. In both China and Italy, young women were most likely to be affected.
Gregory Hinrichsen, a clinical psychologist at Mount Sinai Hospital in Manhattan, said the mental, emotional and physical burdens borne by health-care workers have been overwhelming. Witnessing the pain and death of so many other human beings, Hinrichsen said, reminds you of your own suffering and pain and brings home the reality that you, too, will die.
“It’s something that is hard to take straight on,” he said. “Like looking at the sun. You know it’s there and glance at it. But you don’t stare at it for hours at a time, day after day. That’s what working during the virus has been like for some.”
Brian Smith was in his ambulance truck at about 2:50 p.m. on April 17, during his shift as a paramedic for the Jersey City Medical Center, when he felt a storm of emotions.
“It’s complete war out here,” he typed on his phone to his therapist on Talkspace. “People just dying in front of us, one minute talking, the next they aren’t.”
Within a few weeks, Smith had to pronounce more than 30 people dead in their homes and had brought dozens more to the hospital whom he wasn’t sure would make it. “You think that you did right by them,” he said. “But then you find out two to three days later, they died.”
Smith wondered a lot about those people. Where were they now? Were they able to get cremated or buried? Were those who loved them able to say goodbye?
He heard about one funeral home where police found dozens of decomposing bodies in a trailer, and he was furious. “These are people’s family — at least give them the decency of letting people say goodbye. At least give them that. Don’t forget about them in the damn trailer,” he said.
“I don’t know what I would do if my mom or dad died, and I couldn’t say goodbye,” Smith added. “That would be the worst thing in the world.”
Smith has been living on his ex-wife’s couch since the outbreak began. She’s also a paramedic working insane hours, and it makes it easier to trade off taking care of their two young children. But the situation leaves him no time to process what he is going through.
“I’ll start sobbing, and I will have to gather myself because I can’t let my kids see me like that. A lot of times, I’ll scamper into the bathroom and clean myself up and see what they are doing,” he said. “PTSD is no joke.”
The virus also has changed the way he views parties and sports events, gatherings he used to think of as happy occasions. Looking out his window one day, seeing blue skies and feeling the sun, he could think only of crowds at the park, less than six feet apart, respiratory secretions flying.
“This weekend is gorgeous,” he said. “It’s going to be horrible.”
The man they pulled out of his car was young, probably in his 30s, and they had to tell his wife she couldn’t come in because of the contagion. Brittani Holsbeke, a nurse at Beaumont Hospital in Farmington Hills, Mich., was trying to stabilize him as his wife stayed on the phone. She learned they had been together a long time, and she felt the couple’s love.
“She was crying and crying and begging him to breathe,” she said.
The emergency room those weeks was a blur of faces and names, of constantly bringing people in, and then handing them off to other departments, wondering how they fared. She remembers thinking about what it must be like to work on some of the inpatient floors or intensive care units. “They get to see the recovery process, and it must bring some joy.”
The low point was having to turn people away who, in normal times, would have gotten treatment.
“When we hit a spot when the ER was full and we had people in the hallways it got tricky,” she said. “We could not take in everybody. We had to send people home.”
Things have slowed down, but the quiet has given her too much time to think.
“Certain moments trigger something that makes me really sad,” Holsbeke said. “I can be at home and be totally fine, and at bedtime, all of a sudden, sobs and anxiety kick in.”
Christian Plaza, 41, a nurse practitioner who with his husband runs Cross Valley Health & Medicine in Newburgh, N.Y., had been screening patients for the coronavirus when he found out he had become infected. About a week after his diagnosis, Plaza was so short of breath he had trouble finishing sentences.
His condition worsened; his blood oxygen levels plummeted to the 80s — 96 and higher is considered normal — and he was admitted to the hospital in April. He was there for three days on oxygen, running a 103-degree fever.
Plaza said he was seized with “fear that I was going to die, that I was going to leave my family alone.”
After he was discharged, Plaza returned to work to consult with patients virtually. “It has given me a whole new level of insight,” he said, into the anxiety that coronavirus patients experience.
At home. he found little time for rest. “It’s a constant worry and constant juggling and constant management,” Plaza said, describing caring for his patients through a computer screen while also wearing a mask and staying isolated from his family for days after he left the hospital. “If there was any doubt of physician or nurse practitioner burnout, or health-care burnout in general, this is the writing on the wall.”
In one particularly brutal 10-day period, Audrey Chun lost seven patients — some of whom she had treated for decades. As a doctor in the geriatrics department of Mount Sinai Hospital in New York City, she was used to death, but this was different.
A number of her patients chose to endure their sickness at home, and amid shortages, Chun struggled to get them essentials — oxygen and medication for pain, shortness of breath and nausea.
The enormity of the responsibility weighed on her: “They put their trust in us to get them through this time, to get their families through this time,” she said. “To make sure they are as comfortable as they can be. It’s an honor and privilege. You can’t take that lightly. You have to get it right.”
“I would get calls at 2 a.m. from family members, saying, ‘She’s not looking good. What do I do?’ A few hours later, they would call to ask if I can sign a death certificate,” she recalled.
Every Friday, the doctors in her department gather for a moment of silence led by a chaplain, and during one recent session, Chun wrote down the names of every patient she lost and thought about each one in turn.
“There’s been so much profound loss,” she said. “You have to try to find positives even through that death and sadness. … To celebrate their lives and remember who they were as people.”
The patient with coronavirus on the other side of the glass was dying. It was March, still early in the pandemic, and Marc Ayoub could see on the monitors that the man’s oxygen levels were falling by the second. As he hurried to don his mask, gown and gloves, Ayoub’s mind raced: If he resuscitated the man with the equipment on hand, he risked sending virus into the air and putting himself and everyone else in the room at risk of infection. But if he did nothing, the man — 40-something with a wife and children — almost certainly would die.
He and a nurse manually pumped oxygen into the patient’s lungs. The patient went into cardiac arrest, and the two of them, along with others who jumped in, revived him with chest compressions. But the victory was short-lived. The patient died a few hours later.
Ayoub did become sick with covid-19 and home for several days with a fever and painful cough, he drove himself crazy second-guessing his actions. “Someone in that room could have gotten coronavirus,” he theorized, “and maybe they gave it to a family member and what if they passed away?”
In the end, he concluded he would do it again. “I couldn’t watch a man die in front of me,” he said. If anything, he wishes he could have entered the room sooner and maybe saved his life.
One of the hardest parts of the last few weeks, Ayoub said, is how impossible it became to practice what he had learned in medical school — to get to know his patients and listen to their stories.
“Everything was happening so quickly,” he said. “Everyone was dying so quickly. We had to go from one death to another and the next. I was imagining it happening to my family and being in a situation like that.”
Recently, he found himself thinking again of his patients as he dodged crowds of passersby, laughing and chatting in masks as he took his first break since March 9 — “Day Zero,” as he and the other residents refer to it, when they got their first crush of confirmed covid-19 patients. He thought of the 50-something woman who had so many people who loved her but who died alone.
“A lot of it is a blur. A lot of it doesn’t seem real,” he said.
Instead of enjoying what was a gorgeous day, Ayoub felt a deep sense of dread.
“Like all the work we did has gone unseen,” he said. “In the back of my mind I kept thinking it’s all coming back — and probably worse than the first time.”
Photo editing by Bronwen Latimer. Design by Audrey Valbuena.