Continuing our series of interviews with doctors and other medical personnel in the era of Covid-19: Dr. Carlos Salama is an infectious disease specialist at Elmhurst Hospital in Queens, N.Y. Elmhurst is a public hospital that is a part of the NYC Health and Hospitals system. Queens was among the hardest hit places in New York City, and Elmhurst Hospital was burdened as a result. The New York Times reported in late March that conditions were “apocalyptic” in the hospital at its peak, with 13 patients dying in one day. Dr. Salama told ClearHealthCosts about his experiences. Here’s a transcript of our conversation, lightly edited for length and clarity.
Ben Glickman (CHC)
First off, could you walk me through what the Covid-19 pandemic looked like from your end in the hospital? When did it really hit the hospital? And when did it get to the scary place that it became?
In the middle of March, we started seeing patients presenting with pneumonia or pneumonitis. That was typical of what was being described in China. And so that was one thing that started to happen.
Around the same time, we started seeing several patients who had entered the hospital a few days before with complaints that were not pneumonia or pneumonitis also testing positive for Covid. Before long, we began to realize that every single patient showing up in our emergency room tested positive for Covid or had a Covid-like illness. Not all of them tested positive, but they all had Covid based on clinical parameters.
The disease took over everything: Our entire hospital became filled with these patients. Over the next two weeks, the numbers grew so rapidly that we just became overwhelmed with the patients — just dozens and dozens of patients coming in every day with the same process. They were very hypoxic, which means needing oxygen to breathe, with pneumonia. Many of them were getting very sick very quickly and needed to be intubated right away.
By the beginning of April, we were really seeing just an overwhelming number of patients. Around that time, we started to get help from outside institutions, like FEMA, and that helped us manage all these patients.
Treating Covid-19 as an I.D. Specialist
How did it feel for you, as a specialist in infectious disease, to have to grapple with an enormous number of patients who had a disease that you didn’t really know much about how to treat?
We still don’t know how to treat it — not much has changed. There is some data that has come out showing that a few medications have an effect. But we don’t really have a very good treatment for the disease yet. It is very, very frustrating when your entire hospital has one disease and you can’t treat it. Even at the height of the AIDS epidemic in the late 80s and early 90s, it was not like this. AIDS patients still made up a minority of hospitalized patients. [With Covid,] we had a situation where every single patient had this disease and we have no effective known treatment.
I can tell you how we changed the way we did things very quickly. At the time when this started, the chief of [infectious diseases] was out because he had been exposed, so I was basically in charge of the infectious disease division for a while.
What I immediately did was I changed the way we practice medicine. We stopped practicing consult-based medicine in infectious disease and [instead] assigned infectious disease doctors to every single floor in the hospital so that each I.D. doctor had multiple floors to deal with. Then every single medical team was paired with an I.D. attending every day. That standardized the way we were taking care of these patients.
It was standardized to whatever literature was available: We looked at guidelines from the hospitals, we looked at studies to see what may work and what may not work. We decided on a treatment protocol to treat these patients in the best way that we could. And so we basically changed entirely the way we do things in order to manage this disaster — it was a crisis.
Was that overwhelming for your division?
I don’t think overwhelming for us is the right term. It was probably much more overwhelming for the hospital services and the intensivist services who were actually the primary teams managing them. We were basically the addition to the primary team. We were running through every list and helping them decide what to give to each patient.
But the hospitalists, the residents, and the intensivists are the ones who are having to deal with patients who are becoming more hypoxic or needing to be intubated. For them, it was, I would imagine, extremely difficult to deal with. For us, it was just a sense of just impotence. Nobody really knows exactly how to treat this disease right now. And we were with the rest of the world, figuring things out as data came out. I would say it was extremely stressful, and not so much overwhelming for us.
You touched on how this compares to the AIDS epidemic in the way that it manifests in the hospital. How would you compare Covid-19 to infectious diseases that you’ve dealt with firsthand in the past?
This is the single worst illness I’ve ever encountered, short of a severe bacterial meningitis. This is the single worst, most perplexing infectious disease I’ve dealt with because of the way it slowly attacks and destroys the body. It causes endovascular damage. And so you get a lot of thromboembolic events, leading to kidney injury, leading to lung injury and intubation and strokes and liver toxicity. It is really systemic; it’s just a horrible viral illness. I’ve never really encountered anything like this.
We were shocked at how horrible this disease was. As much as we’d heard from China about their experience, it did not prepare us really for what we actually experienced — a horrible, horrible illness.
What does that feel like, having patients dying of various different things that you can’t really do anything about?
Thankfully not everybody died.
A lot of people did get better. The natural trajectory of this disease is that most patients who get it are probably not going to be admitted into the hospital — they get better on their own. There are the ones who get hypoxic and get admitted, and a large percentage of them get better.
Then of the sickest, many did die with this disease in New York. Yes, it’s a very stressful, anxiety provoking situation. We go into this field and most of us work in the public hospital sector. We’re really invested in our community, invested in taking care of our patients that really don’t have anywhere else to go. When something like this comes along and kills so many people, it’s devastating to us.
Day to Day in the hospital: the peak vs. now
Could you describe for me what the worst day in the hospital was like?
I don’t know if there was a worst day. It was just day after day of working 12 to 14 hours a day and trying to run through all the patients with every team, helping out as much as possible.
As much as I was doing, really it was the residents, the intensivists, the hospitalists — they were really the heroes of this. The doctors out there who are really dealing with every second of the patient’s difficulties. For us, we were just trying to be as helpful as possible to our colleagues who are truly the frontline people.
And the nurses — let’s not forget the nurses and the respiratory therapists who were working so hard. As an I.D. doctor, it was a different role. It was more of a role where people were looking to us for answers, and unfortunately, those answers were not available.
What does the hospital look like these days? Have things calmed down?
Well, at the height of it all, we had over 100 patients on vents in the hospital. I think that was the case in most of the large hospitals in New York City. Once Covid started to slow down — and that happened towards the end of May — patients without Covid were scared to come to the hospitals in New York City because they were scared of getting the virus. So we went through a period where our hospital was really not very busy at all in early June.
Now those patients are starting to come back, the non-Covid patients. We have very few patients being seen with Covid, maybe a few a day. Things are much, much calmer right now. The hectic feeling of having to deal with all the crises that were happening on all the floors is over, and we’re back to being able to be clearer about what we can do for each patient.
Is that an eerie feeling to have, seeing the hospital empty?
First I have to tell you that Elmhurst is always over capacity. It didn’t take Covid to do that. With Covid, we were just ridiculously over capacity. But we’re always over capacity at Elmhurst because we’re a public hospital and we serve a very large area. Once Covid really slowed down, and the regular patients hadn’t come back yet, it was very strange to be in a hospital that’s always full and be relatively empty. It was bizarre.
Personal impact of Covid-19
Are there any experiences that you have from working and seeing all these Covid patients that stick with you afterwards, or that maybe keep you up at night?
Unfortunately, many young patients got really, really sick. You don’t ever want to see young patients that sick.
Yes, there are cases that stick with me, that made me very sad and upset that this disease took them away. I’m not going to go into the specifics, but what happened in New York City was a tragedy.
I think in New York City there was a kind of a perfect storm — a city with such a large population, especially in the borough of Queens with a large amount of cohabitation, a lot of people living together in small spaces, a lack of access to what wealthier people have in life, an inability not to go to work and to socially distance.
That perfect storm resulted in a tragedy that I don’t think other cities have seen in the United States, or will see. It’s possible these kinds of things are happening or have happened in other large cities like Chicago or Miami or places like that. But, it’s hard to imagine that people went through what we went through, which was tragic.
What did your family think about you working on the front lines? Were you seeing them or were you isolating?
This is where the haves and the have nots have different outcomes. I have a home in another state, and in the middle of March as things were starting to happen, I told my family that they should leave and stay away from me because I didn’t think it was safe for me to expose them.
My wife takes care of my mother-in-law who is older and has medical issues, and we decided that for her sake it was better for them to separate from me. They went to North Carolina and stayed there until May.
Unfortunately, many other people did not have that ability. I know a lot of other physicians who did do that — they separated from their loved ones so that they wouldn’t infect them. I was on the phone with (my family) every day, multiple times a day when I got home. I was very lonely, which made things harder for me because the stress of the job was very, very bad. Not having my family to lean on made things even more difficult.
But, I was fortunate that I was able to send them away. Now they have come back — they’re all healthy and my mother-in-law is fine, so we were very lucky to be able to do that.
Doctors contracting Covid-19
Did you have access to full personal protective equipment? How did that change over time?
Compared to what I heard and what I saw on the news happening in other centers, I think that the city did an admirable job in keeping P.P.E. available for the staff at Elmhurst. I don’t know what happened in other city hospitals, but at Elmhurst I feel like we had the P.P.E. that was necessary to take care of our patients. I never really saw a shortage myself and I didn’t hear other of my colleagues complain about P.P.E. N95 (masks) were hard to come by at one point, especially early on, but I never really noticed a major problem with that at our institution.
Did you ever contract Covid-19?
I did not. I never had symptoms and I got tested for antibodies recently and I am negative.
Did you get the sense that it was rare to not contract the disease at your hospital?
My sense is that most did not get infected. I think that if you were able to wear P.P.E., the chance of infection was pretty low — it was very effective in preventing infection. I’m not sure about this because I have not looked at the numbers, but my sense is that our infection rate in the hospital was not super high among staff. Having said that, there were some people who did get very sick in our institution. So I don’t I don’t want to belittle that at all — people did get sick, unfortunately, and there were some bad outcomes. It was an issue, but I think that most of the providers and nurses who had access to P.P.E. were not infected.
Public hospitals and dealing with the crisis
Do you think that with this much awareness around the dangers of being a frontline physician and the shortcomings of some hospitals’ resources, things will change in the future for public hospitals?
The public hospital system in New York City does an amazing job with the funding that it has. Funding comes from taxpayer money and from whatever payments the hospital receives. I think that we provide an amazing level of medical care to our patients. I really do. And I think that was the case before Covid, and it will be the case after Covid.
If you ask any doctor in a public [hospital] setting, they’ll tell you that they could use more help — that’s the nature of the public hospital setting. Having said that, I think the level of care is truly outstanding at our institutions and I’m very proud to work for the Health and Hospitals Corporation.
What surprised you most during the Covid-19 era, either about the illness itself or about how it was handled in New York City?
It’s very easy to be a Monday morning quarterback and say that things should have been done this way or should have been done that way.
I have my strong feelings on things, but the bottom line is that this is an unprecedented tragedy. Everything that was done by all the hospitals in the city was a true attempt to take this tragedy head-on and save as many patients as possible. I can tell you that all hospitals are the same in their missions to help patients.
I think that we at Elmhurst did everything we could to save as many patients as we could. I saw with my own eyes how hard everybody worked. I am so grateful to the people who came from all over the country to help us take care of our patients because without them, it would have been much more difficult to do. I don’t know what we would have done, to be honest with you. They really came and did a service for us that we cannot repay them for.
What really was difficult about this disease was the severity of the illness. Like I said before, I have never seen an illness come with such malice and attack a population like this one did. It was unbelievable. That’s what this disease leaves me with: how horrible it was. But the effort that our staff put in, it was unprecedented. It was really, truly amazing. And I know we did everything we could to save every patient we could.
Is there anything that you regret about your work or the hospital’s handling of it?
When you’re dealing with an illness for which there is no known treatment and very little experience of care for, it’s hard to have regrets of what we could have done better.
In hindsight, knowing what we know now, we might have done things differently. We have now data to show that certain medications may do more — maybe we would have used them more. We started anti-coagulating and proning pretty early and we also used steroids pretty early — those have been shown to be the treatments that are most effective.
I regret that people died — it’s horrible to see people go like that. But I don’t know what we could have done differently with the situation that we were up against. I can tell you that everybody worked 12 hour days. People were coming in every day on the weekend for weeks — working, working, working to help people. So in that scenario, it’s hard to say what we could have done differently. We didn’t know how to treat this disease, and we still really don’t. There were a lot of things that we tried that just didn’t pan out. I don’t think regret is the right word.
moving forward and a second wave
Is there anything you would like to add about your experience?
I would add that New York State and New York City are faced with a very interesting situation right now. We need to open up our economy, but we also know that a second wave may be inevitable in as large a city as New York City.
I would hope that everybody remembers that masks are so important in preventing transmission, both in preventing people from exposing others but also in preventing [Covid-negative] people from being exposed. So whenever we open, which I understand is a necessary part of life now given that our economy needs to come back, masks are so important.
People need to wear masks even when we go back to work. I’ve been wearing a mask non-stop at work for the past three months — that’s the way it should be now until we’re out of the woods with this disease. And we are not out of the woods with this disease. This thing is going to come back, and we have to be ready for that until there’s a vaccine.
Just one quick follow up on that: Do you worry about a second wave and its impact on the hospital after you’ve already gone through this tumultuous and backbreaking period of work?
Of course, we’re very, very worried about that. We have learned a lot and we’re more prepared now than we were before. We’ve logistically changed the way we do things in preparation for a second wave, but it’s very concerning that this second wave could come.
If you look at the sero-prevalence (the proportion of people who have antibodies) in the communities, it’s still not high.
So we are ripe for a second wave. Only time will tell. The factors that resulted in that horrible first wave are still in play in Queens and in Brooklyn and in the Bronx — the most hard-hit areas. So yes, I’m extremely concerned about a second wave.