NEW YORK — The days upon ruthless days of battling covid-19 are such a blur that Joseph Lieber can't remember the exact date the military showed up at his hospital offering to help.
“You see, that was during our peak, peak, peak, peak,” he said. “We were in a bad way, let me tell you.” At one point, he described the situation — illness and daily death tolls beyond anything he’d seen working through every New York crisis in 36 years on the job — as “Dante’s Inferno.”
“I’m not going to lie to you,” he said. “This really feels like it’s the 11th plague.”
What few others know, though, is that the overwhelming of the hospital system came not just from incoming sick people, equipment shortages and deaths, but from what Lieber calls “an output problem.” That is, the bureaucratic entanglements of transferring or discharging recovering covid-19 patients, particularly the homeless, the mentally ill or undocumented day laborers living six to a room, heading back into the situations that made them vulnerable.
Even as this city seems to have escaped the gravest predictions, fear and uncertainty remain. There is a severe lack of testing to ensure people will be safe once more if the economy reopens. If a second wave of infection hits, and no lessons have been learned about the imperative of getting less-sick patients out of hospitals and into other types of care, Lieber predicts, the overload could prove deadly again.
That’s where the military was supposed to come in.
The USNS Comfort, the Navy hospital ship that arrived in Manhattan with great fanfare on March 30, departed Thursday, having treated 182 patients and run several rescue missions during its stay. A day later, a military field hospital built here inside the Jacob J. Javits Convention Center, discharged the last of eight remaining patients, from a peak of 453 in mid-April. In all, about 1,100 people were treated there.
The 680 military medical personnel remaining in the city will embed or stay embedded in local and state hospitals to help alleviate gaps in staffing — and to provide psychiatric care for health workers. Gov. Andrew M. Cuomo (D) has asked for a hold on dismantling the Javits in case it is needed for a resurgence of cases.
Of the city’s 42,400 hospitalizations, the military handled 3 percent.
However those numbers look compared with expectations, for doctors on the ground like Lieber, the mission was a success. Elmhurst is relatively small for being the only Level 1 trauma center in its area, with 550 beds to serve a catchment area of 1.7 million people in the largest and second-most populous borough in the city — and the most diverse county in the country. At the peak, Lieber said, they had twice as many patients as beds, and had to admit 100 patients into the emergency room because the intensive care unit was too full to take them, even after Lieber’s staff turned four other areas of the hospital into ICUs. In a bad flu season, for example, 35 people might get admitted to the ER.
In the end, the Javits took 56 of those patients and the Comfort took 12, small numbers on paper, but they led to a morale boost for the staff, Lieber said, because for the first time they could feel breathing room and an end in sight. “It was exciting,” said Lauren Clifford, social work supervisor and a discharge planner at Elmhurst, “because every time someone is stable enough to leave, that opens up the bed for someone who will die if they’re not in the hospital.”
The Army, Navy, and Air Force sent over nurses, doctors and pharmacists to fill in for the many members of Elmhurt’s staff who were out sick.
“They helped us tremendously,” he said. “For us, Javits was a rescue.”
A fresh face
Lt. Col. Guy Travis Clifton remembers the exact moment he stepped into Elmhurst. It was the morning of April 6. “And it was so jarring,” he said. “They were so overwhelmed. It reminded me of a scene from a mass casualty in Afghanistan. There were just patients everywhere. You couldn’t take more patients in there if you wanted to. It was really disturbing, actually, and they were doing a heroic job.”
So many patients and so many deaths, in fact, that the day Clifton first came, a few dead bodies had to be stored temporarily in showers, as has happened in cities across the country. The hospital had received two refrigerated trucks from the city medical examiner’s office to supplement the lack of space in the morgue, but, Lieber said, “sometimes even they’d get too full.”
Clifton had been deployed three times to Afghanistan. Now chief of general surgery at Brooke Army Medical Center, he’d left his wife and three young sons in San Antonio and was on site as the Javits and the Comfort came under fire from New York hospital directors frustrated about how few patients either field hospital was taking on.
They’d at first tried to screen only for patients without covid-19. But those patients never came. The Javits had only 11 admitted over the course of a week before Cuomo asked for it to become a facility for covid-19 patients only.
“It was a little disheartening, when they were like, ‘Oh, Javits has been open for 24 hours and they’re not full,’ ” Clifton said of the negative newspaper articles that came out.
The main problem seemed to be with an incredibly rigid set of 49 criteria the military had devised for admitting the right type of patient for these two facilities — each with the limitations of not being actual hospitals.
Even once they started accepting covid-19 patients, the Javits and the Comfort still used a modified version of that list of 49 criteria. Patients were still coming in at a trickle.
“I was very skeptical of how tight the criteria were,” Lieber said. Finding people whose condition met all 49 requirements was near impossible.
That’s when the military command decided the system wasn’t working and, instead of waiting on the hospitals, the Army needed to go to them.
Humanizing the system
“What I liked about him was once he came here he was willing to work with us,” Lieber said of Clifton. “You could sit down and schmooze and say, ‘Could you help me with this one?’ He wasn’t like, ‘These are the rules. I follow the rules.’ ”
As much bad press as the military was getting, Lieber had faith. He’s a big military history buff, “and what the military is very good at is logistics,” he said. “The best commanders understand how to move troops and supplies. So I was confident that we were going to get patients out because they know how to move things.”
They make a funny pair. Clifton is 40 years old, tall and Army-muscular, with a crew cut and an impeccable camouflage uniform. Lieber is 62, can be found in a rumpled polo shirt or a lab coat, in front of a towering wall of snacks and tchotchkes at his desk, and has a New York accent so thick you could butter bread with it. Both, though, are taking time away from their families to help with urgent needs.
“He’s a gentleman. He really wants to help,” Lieber said of Clifton. “He’s the kind of doctor I aspire to be,” Clifton said of Lieber, “just a really down-to-earth guy whose focus is on taking care of patients and teaching.
Clifton and his team approached that first visit to Elmhurst almost like a pitch meeting — explaining what the Javits could do for them. When he talked about the lack of an X-ray or a pharmacy at the Javits, “it kind of helped them understand why those restrictions were in place,” he said, “because I think it made intuitive sense.”
Likewise, Lieber said, it was good for the military to see how bad things were — in person: “I think that made them realize, ‘We’ve got to start moving faster and maybe the criteria can be cut.’ ”
The hospital gave Clifton access to medical records, and they quickly figured out they had to streamline the patient transfer process. Initially, the hospital would dial in to a call center and talk to a nurse who then connected them with a doctor at either the Javits or the Comfort, who would consult with a hospital doctor before ordering an ambulance. Or, Clifton said, “I could just do it all myself.”
That first day he moved 19 patients. Some days he’d move 25.
He also threw out most of that criteria list. “You can almost simplify it down to: They can’t have other active medical problems that are life threatening,” he said — like a heart attack.
Beyond the medical criteria were the intangibles. The covid-19 crisis hadn’t made the long-term crises of the neighborhood disappear. Elmhurst was hit hard, Clifford, the social worker, explained, because its patient population is largely uninsured and undocumented day laborers from China, Colombia, Peru, El Salvador — delivery men, construction workers — living six to a room, even sharing beds sometimes. They have to go to work or they won’t get paid, and they can’t socially isolate at home. “So if one person gets sick,” she said, “the whole household gets sick.”
People here were more likely to be distrusting of the system. “A lot of people came in in very late stages of the disease and died in the ER,” Lieber said. Moving them to a government-run hospital that had been built three weeks earlier was terrifying to them. But to the government’s credit, Clifford said, no one at a temporary hospital asked about insurance or documentation. “I was really shocked that it never came up,” she said, “because with our patient population that’s always the first question. This is the only time I’ve ever experienced that in nine years of discharge planning here.”
Rooms at the Javits had no privacy and the bathrooms were in trailers across a cavernous hall. Clifton had to screen for not only covid-19 patients who were too weak to stand on their own but also the disabled, people who were withdrawing from drugs and alcohol, and anyone with an uncontrolled mental health issue, since there was no on-site psychiatrist. Some schizophrenics would do fine, Lieber explained, “but if a patient is actively hearing voices and getting homicidal commands, that may not be the best place for them.”
More than once, a seemingly controlled mental health issue turned out to be out of control when on site and the patient had to be sent right back. “We expected that,” Clifton said.
As of Friday, he was looking forward to a long weekend run along the Hudson. Then he’d likely have a two week quarantine in Texas and finally see his family. “I feel like we did a good thing,” he said. “Was it perfect? Probably not. But on a whole I think we helped and it felt meaningful.”’
He and Lieber were planning to reach out to wish each other well.
The Elmhurst ER is back to normal capacity. The crisis phase is over, but covid-19 treatment isn’t and Lieber still wakes up for work most days at 3 a.m.
In another life, Lieber said, he hoped everyone would act weeks earlier, the city, the state, the nation. “It wasn’t till the s--- hit the fan, pardon my language, that things started to move,” he said.
He said he hoped in their next mission, the military might “do a little bit of reconnaissance on the front lines a few days earlier,” so they could plan for the types of patients the hospitals needed to transfer rather than waiting until the temporary facility was built and spending two weeks making adjustments.
Like so many experts, he’s anticipating a second wave but is “cautiously optimistic” that the hiccups of the system won’t be so jarring next time around.
“I’m numb and drained but glad that it worked. We learned from this,” he said. “The most important thing is, don’t let it happen again.”