What An E.R. Doctor Wants You To Know About Covid-19
Dr. Calvin Sun on the stresses of fighting coronavirus in New York City.
Dr. Calvin Sun, a per diem Emergency Medicine physician, has never seen anything quite like what New York City is experiencing now: Sun recently worked for 20 days straight — 17 shifts total — fighting Covid-19. He told me about his experiences working across the city’s healthcare system, and the tough ethical decisions medical professionals have been required to make about human life.
Katie Couric: So how would you describe the situation at most of the hospitals you’ve been working at?
In the last three weeks, things have been increasingly more dire. We were already short on personal protective equipment, resources and support staff before the pandemic was even on our radar.
And patients are just coming in sicker and sicker. Some of them are borderline — they’re not sure whether they should go home or sit in the hospital. There are a lot of ethical dilemmas. Which is the safer place? Going into a coronavirus-only floor where they’re exposed to other sick patients, or somewhere cleaner like home — that doesn’t have enough medical support? And now, we’re also getting patients in cardiac arrest, some dead on arrival. But it wasn’t a sudden jump overnight.
A friend of mine told me that she lost a friend this morning who waited 13 hours in an emergency room to go to an intensive care unit, and clearly never made it in. Have you seen that happening?
In my experience, that was last week. I’ve already posted screenshots of patients who waited up to 55 hours on social media. Waiting thirteen hours was terrible. But now it’s going from 13 to 70.
And those are the patients that go into cardiac arrest in the emergency room when they have acute respiratory distress syndrome. It’s very typical of the end-stage of COVID-19 infection when your lungs are full of fluid and you can’t breathe. If patients are waiting 50, 60, 70, hours for an ICU bed upstairs, their hearts stop because they can’t breathe.
And then there are still more patients coming to the emergency room, and stretchers triaged up to five hours outside. That’s the reality of the past few days.
How are the medical staffs coping in the hospitals you’ve been working in?
I’ve never seen the way people come to me in the middle of a shift — crying and telling me that they’re scared, not only for their patients but also for their own safety.
We’ve been running in naked without any protections — no gowns, not enough masks. It’s like when you go running into a burning building. The building is about to collapse and we’re doing our best, trying to get everyone out before it collapses on us. We feel like we’re trapped inside this building.
What about the patients you’re seeing that are not necessarily just old and infirmed?
Older patients still are dying at a faster rate in my personal experience, but I have seen younger and younger patients coming back more critically ill — electing for the breathing machine. I think the age groups are still going to be younger and younger than we had expected.
It may depend on the strain or the intensity of the virus that you contract because no one really knows why some people are showing severe symptoms and other people aren’t even symptomatic.
That’s correct. You have to look at the data from China which is the best thing that we have in terms of hard data that has had time to marinate. The younger healthcare workers or people who end up dying, tend to be the ones who are exposed to a higher viral load.
That’s why we’re worrying. When I admit patients to the hospital, that is the ethical dilemma — do I make you go to the hospital where you’re going to be exposed, but you have medical staff? There’s no right choice anymore.
Well, this is a major ethical dilemma, increasingly, for doctors everywhere, because some hard decisions are going to have to be made if the numbers continue to climb. You told me that there is a public document [that] gives some guidance to doctors about these tough choices. Can you tell us about that?
If you go to the New York State Department of Health Website, there’s a public document that details the psychology and the ethical dilemmas involved in determining who gets a ventilator in a scenario when we run out.
They estimated we need 90,000 ventilators in a six-week period. So if we’re able to get 40,000, at the high end, we are still lacking 50,000 ventilators. That means 50,000 people will have to be counted out — from this critical instrument that might help them survive.
Some other states use a lottery system. But New York State creates a committee that essentially takes the power of making that decision unilaterally away from the doctor. The physician makes clinical recommendations based on their patient and tells the committee whether they’re getting better or worse. The committee decides ultimately whether the patient gets a ventilator.
That’s pretty scary, even though no single person has the responsibility. What are the guidelines telling you about who would not get better — even with the ventilator? How do you make those decisions?
Your age, your ableness, your station in life, how much money you make, your socioeconomic status, should not matter. Hence why a lottery system in some states makes sense.
New York determined the system would be based on the patient’s ability to benefit from the ventilator. You have to make a certain cutoff, where you are very critically ill, but you’re not past the point of futility. Citywide, there’s been a strong nudge of, “Start thinking about, if this patient needed a ventilator, what recommendations would you make to the committee?”
Can you give us an example of somebody who probably would be recommended to not get a ventilator?
I can imagine a scenario. A patient might get put on a ventilator, and then get worse. Then, we might completely paralyze them, so the machine can breathe better for them. And then in an hour and a half, they get worse. That’s where I would have to tell the clinical truth to the committee, that the patient has required more and more assistance to survive, and they don’t look like they’re turning around. Then this committee would then make a decision to pull the plug — regardless of what the family wants or the patient wanted, and give it to somebody else who would actually benefit.
That is not what we are used to seeing. We used to think, “A patient stays on the ventilator until they completely die or they get better.” No one kicked them off the breathing machine.
Is that terrifying for you to think about a group of doctors making those decisions?
Personally, I’ve been in this position before, internationally, where we were resource-poor. In Haiti, there were times when there was only one certain treatment, and I had to choose which patient had to get it.
I’m more terrified for my colleagues, who will not be able to sleep making such positions — where they give up their autonomy of their patient care — to a committee.
When do you think the apex of this pandemic is going to take place in New York City?
I think every day we feel like we’re at the apex. When I’m in the trenches, breathing in my mask, sweating bullets and trying to take care of 40 to 50 patients a day, you feel like it can’t get any worse than that.
And the next day, you realize the patients are not going anywhere. It takes about 10 to 12 days for patients in the ICU to get better, and even longer for them to get discharged. And I already know some of my colleagues intubated on breathing machines.
The military is sending a ship to help us, but last time we had coronavirus on a ship, look what happened? They said they’re not going to take any COVID-19 patients, but how do you know for sure?
Will the Javits Center help?
The Javits Center will help if you completely lock that building down and make it coronavirus-only like Wuhan did with those with mild symptoms. And they were able to do that because it’s China. They were able to go door-to-door, pull people who tested positive for the virus and put them in recovery centers. I can’t imagine that being possible in this country — it would be a violation of your civil rights and privacy.
To actually break the cycle, we need the infrastructure to build a new hospital that takes COVID-19-only patients in negative pressure rooms to prevent spreading among staff and other patients.
You’ve had some young patients who have died and that must’ve been very difficult for you. Can you describe any of those situations?
I’m only accustomed to intubating when you’re on death’s door — you don’t have oxygen going to your brain or the capacity to choose right there. What is agonizing to me is that this virus is different. You can be in acute respiratory distress, your lungs full of water, and yet you still look great.
The young patients look great, and all of a sudden within hours, they die. And that’s scary because there’s no slow progression. And they’re scared. They don’t want to be put onto a breathing machine. So they rationalize any means necessary to refuse. And it’s hard for us to see them avoid something that could save their lives.
It’s just agonizing trying to choose what is the right thing for them because we don’t know enough about the virus. Anything is possible.
I saw that the New York Attorney General launched a hotline this week for people to report hate crimes, and biased incidents, against Asian Americans, during the pandemic. As an Asian American, have you encountered any of that?
I am grateful that I haven’t been on the receiving end of anything too drastic, but my friends have been victims of physical assault and bullying. It’s disheartening. I believe in it. I grew up a victim of Asian American racism.
I’m only really personally facing micro-aggressions, comments by patients who look at me and kind of cringe a little bit.
And do you think that the PPE problems are starting to be solved?
No, absolutely not. I’ve become a defacto N-95 mask dealer. I’ve been delivering masks to former colleagues because they have completely run out at other hospitals.
Thankfully, I have gotten a shipment of hundreds of masks from nurses and doctors I’ve worked with around the country, who have yet to be hit like New York City has. When the hospitals receive new shipping, it’s rationed. This is the United States of America in the year 2020. And we are making our nurses lineup outside an office for the one mask that they rationed— when the mask was designed to be swapped out and be disposable in between each patient encounter.
