Adam Jarrett recalled the moment it all came crashing down.
Mr. Perez, a 45-year-old man those at Holy Name Medical Center suspected had COVID-19 since he came to their emergency department a little more than a week before, wasn’t getting better.
“He continued to worsen and was placed on a ventilator,” Jarrett wrote. “By that point, most of us were convinced he had COVID-19, as most young healthy patients with pneumonia just did not get this sick. Ten days into his admission, I received a call from the head of Infection Prevention. ‘Adam, Mr. Perez is our first confirmed case …’
“Any doubt that remained was gone; it was here. I sat back in my chair, took a deep breath, closed my eyes for a brief moment, and then got back to work.
“When I went home that night, I climbed into bed with my wife, exhausted, and for the first time wept, really wept. I wept because I feared that we might not be able to keep up, that we might end up having to compromise care, and that many patients and families were going to suffer. And I knew that some of my co-workers, people I knew and truly cared for, were likely going to die. My wife hadn’t seen me break down like this since my first week on a New York City AIDS ward over 30 years earlier. She knew that the situation at the hospital was serious and getting worse.”
The personal reflection is one of many in Jarrett’s self-published book, “In the Time of COVID: One Hospital’s Struggles and Triumphs.”
Jarrett, the chief medical officer at Holy Name, co-wrote the book with Paul Rosengren. The book provides an inside look at how the staff at Holy Name — perhaps the hospital at the epicenter of the pandemic in the country in its first week — handled a health care crisis like no other.
There are insights about how the staff managed to create zero-pressure rooms and then a zero-pressure wing, which Jarrett credits with saving lives. There are looks at difficult discussions about whether relatives should be able to see their loved ones in their final moments and whether new mothers who were infected with COVID-19 should be able to see their babies in their first days.
Jarrett describes how the hospital managed when its own CEO, Mike Maron, contracted COVID-19 and had to quarantine, how being one medical center as opposed to being part of a large system helped them — and how they used dry erase markets and a bunch of white boards to plan and track their strategy.
Jarrett talks about the failures and lessons learned — how collaborating with nearby hospitals that always had been competitors saved lives and advanced treatments. The disappointment and shock he felt when there weren’t enough tests early on (a problem that persists, he said), and how, when the first shipment of masks from the federal stockpile came, they were so old and damaged that they were never used.
Jarrett compares and contrasts the situation with his time caring for AIDS patients early in his career and times spent at Holy Name’s sister hospital in Haiti. He dissects the pros and cons of using experimental drugs and therapeutics when nothing else is available or known.
And, of course, he discusses the emotional and psychological toll the pandemic took on the Holy Name. More than 250 Holy Name employees contracted the disease — two of whom died. Many others had family members stricken by it in the hospital. Some of them died, too. The toll has been tremendous, Jarrett said.
“In the Time of COVID: One Hospital’s Struggles and Triumphs” is an almost real-time inside look at the pandemic that will become more valuable with each passing year, as a new generation of health care workers wonders what it really was like at Ground Zero.
Jarrett, however, said he did not write it for the health care field. He wrote it for himself (he says it was cathartic) and society in general, hoping it will give them a look behind the health care curtain. You won’t find these excerpts in the New England Journal of Medicine, he joked.
“I think it’s more for the for the lay public than it is for the medical community,” he said. “It is not a scientific book that references a whole lot of specific studies. It’s not meant to be that type of book, although I do think that medical people or scientists who are interested in what happened at a specific hospital might find it interesting. But I don’t want to pretend that it that it belongs in a scientific journal.
“I think there’s a good explanation of why this virus is so dangerous, how it affects us, why the vaccine is important and why it works, how the how some of the medications work — all done in layman’s terms. But it’s really meant for the lay public to understand what one hospital system, one hospital went through in the middle of the pandemic, and how we actually came through OK, because of the good work that my colleagues did.”
Jarrett, who has been the CMO at Holy Name for a decade, never considered himself a writer. But, now that the book is done, he said he is glad he spent the time this summer — between waves of the virus — to save his thoughts for the historical record.
“I’m very proud of it,” he said. “It certainly was a little cathartic for me. And I think it tells an important story of what a hospital can do.”
Here are a few more excerpts:
On reconfiguring the hospital
“On Wednesday, March 11, just a week after we had admitted our first COVID-19 patient (or our first known COVID-19 patient), we realized that six COVID-19 beds would not be enough. We began to expand our COVID-19 ward in the ED: first, nine more beds on that Wednesday, then five more on Thursday and four more on Friday. By this time, half of the ED was dedicated to COVID-19 patients — a total of 24 beds. We ended each day thinking, ‘We dodged a bullet, but we’re fine.’ But each morning, we would scramble to meet the needs of even more COVID-19 patients — an increasing number of who were in critical condition.
“As the flow of COVID-19 patients steadily grew, it became clear that isolating COVID-19 patients in the ED was not going to be enough. We needed to take more dramatic action. By March 13, we had added COVID-19 beds on a medical floor, creating an additional 10 negative pressure rooms for non-critical COVID-19 patients. The demand for intensive care beds continued to rise, however, and very quickly outstripped the capacity of our ED. On March 14, we added six COVID-19 beds to our regular ICU — then added 10 more COVID-19 ICU beds a few days later.
“When you think of hospital workers, you might think of nurses, doctors and maybe a friendly receptionist who greets you at the front desk. You probably do not think of facility workers and engineers, employees who design and build. But these people are critical to the working of a hospital — especially in times of rapid-fire challenges, both large and small.
“Each time we expanded our COVID-19 facilities to new areas of the hospital, these workers constructed walls, installed vents, and made the other changes necessary to enable us to care for COVID-19 patients. Most notably, this team converted ordinary patient rooms to negative pressure spaces — and they got quite good at it.”
On allowing new mothers to be with their newborns
“While the hospital saw a drop in routine appointments, some non-COVID-19 wards were still busy — for instance, babies kept coming. Maternity wards presented several challenges during COVID-19. Early on, we did not know if pregnant mothers who had COVID-19 could pass it on to their children before birth or during delivery, but the initial evidence suggested that they did not. There now seems to have been a handful of cases where there was “vertical transmission” from mother to baby, although the science on this is not yet definitive. However, we did know that a mother with COVID-19 could infect a baby once born.
“This caused a debate amongst medical staff as to whether we should test every expectant mother. The anesthesiologists, who are physically closest to a patient’s airway during delivery, argued yes. Obstetrics and nursing staff argued no; they didn’t want to separate mothers and newborn babies. The first few days after birth are a crucial bonding time for both the mother and the baby, and can have a huge impact on a child’s overall development. Initially, I sided with those who said no, and we only tested pregnant patients who had symptoms of COVID-19 or who had been exposed to the virus. Contributing to my decision was that we had a shortage of tests, and it took so long for results to come back that they were often irrelevant by the time they were received.
“Information coming out of New York Presbyterian Medical Center, however, showed that there were expectant mothers who were COVID-19-positive but asymptomatic. Were we putting the soon-to-be-born babies at risk? We changed our policy and began to test every pregnant patient — and found several who were positive and asymptomatic. All staff were already wearing full PPE when interacting with patients, so we did not need to make any operational changes. However, if a mother had COVID-19, she could not interact with or hold her child during the critical first two weeks of life — a heart-wrenching situation.”
On national stockpile failures
“Early on, we received a supply of 7,000 N95 masks from the national stockpile, a supply of medical items that the government can provide to supplement hospitals in public health emergencies. Mike had been in constant contact with New Jersey Gov. Phil Murphy, explaining to him how hard we had been hit and how desperately we needed PPE. Murphy delivered: We were one of the first hospitals to receive our share of masks from the government. He called us one day to let us know the masks were coming, although he didn’t know when or how. One early morning, we simply discovered a large pallet of boxes on our loading dock.
“Like all disposable medical supplies, the masks were marked with an expiration date — which had already come and gone. At first, we weren’t worried; a few weeks prior, the FDA had announced that masks from the federal stockpile were safe to use, regardless of their expiration date.
“Unfortunately, this was not the case. When we tested the masks, several of them ripped apart — surely not something you want to happen when you are dealing with this type of infection. I am not sure if the poor performance was related to the quality or the age of the masks, but, either way, we didn’t want to risk a mask tearing while a staff member was in a COVID-19 room. We continued to use other, safer masks instead, and put the federal stockpile masks in storage, just in case; if the situation became desperate, they might be better than nothing. To this day, we have not used them.”
On the mood in the hospital
“The ban on visitation contributed to Holy Name’s eerie atmosphere. The hospital did not look or feel like a war zone, as one reporter stated, but more like something out of a futuristic dystopian novel. Non-clinical staff worked from home, there was no visitor foot traffic in the hallways, and we strongly felt the absence of chaplains, medical students, therapy dogs (and their owners) and our regular volunteers.
“The quiet halls were frequently interrupted by the scramble to reach a patient in cardiac arrest. Unfortunately, death was an all too frequent visitor on the wards.”
On the ban on visitors
“Since family members were not allowed at the hospital, we made extra efforts to keep communication flowing between patients and their families. Our nurses did their best using FaceTime, Skype, Zoom, and Google Meets to keep patients in touch with their loved ones. Having some form of communication was unbelievably valuable to the patients and their families, but it in no way replaced the in-person interactions that they would have had under normal circumstances. Having loved ones nearby can be a pleasant distraction for sick patients, but, more importantly, it is an essential component of both a healthy recovery or the dying process. Being with family and friends is good for the soul; virtual communication does not have the same impact for either patients or visitors.
“Under normal circumstances, a critical care physician keeps an ICU patient’s family informed of their loved one’s status and, if necessary, informs the family if the patient has died. In the age of COVID-19, our critical care physicians were overwhelmed with direct patient care. They simply didn’t have time to also manage communications with families. I decided that we needed to shift the responsibility of communicating with families about all issues, including end-of-life issues, away from these doctors.
“Instead, we created a team of physicians, many of whom were available because elective procedures and surgeries had stopped, whose main function became communicating with families. Before talking with a patient’s family, a member of this team reviewed the patient’s medical records and had a brief discussion with the treating physician. These conversations with families focused on the patient’s condition, treatment options (including experimental treatments) and, when necessary, end-of-life care.
“When possible, we tried to assign each patient a single physician so that the family had a single point of contact and knew who to speak with to get information. We aimed to build trust and consistency that families could rely on throughout a patient’s stay at the hospital.”
On wearing masks
“My favorite explanation of how masks work is a simple one: Imagine a place where no one wears pants. If another person pees on you, you get wet. Now, if you put pants on and someone pees on you, you still get wet, but less so. But, if the other person wears pants and pees, you will be fine. Maybe a little graphic, but it makes the point. Wearing a mask provides you some protection, but, more importantly, wearing a mask helps prevent you from infecting others.
“It amazes me that wearing or not wearing a mask has become political — and that many people resist wearing one because they feel it infringes on their freedom. Once COVID-19 was prevalent in our community, it simply made sense to put on a mask. In retrospect, we all should have been more open to wearing masks from the very beginning. In the New York metropolitan area, mask-wearing is likely the single most impactful thing we have done to decrease new infections. If we had embraced wearing masks sooner as a nation, and if there was not still resistance to this simple act, we could have significantly decreased the COVID-19 infection and mortality rates.
“We can’t deny that the medical community gave poor advice regarding masks at the start of the pandemic. There’s no shame in admitting we made a mistake, especially if we learn from that mistake and then apply what we learned, as we have done in this situation.
“I like to compare wearing a mask with smoking. Until relatively recently, smoking was unregulated. Nonsmokers may not have been happy to breathe in secondhand smoke in restaurants or planes, but it was thought to be nothing more than a nuisance. Once the scientific evidence became clear that breathing in secondhand smoke was harmful, the laws changed. It is unfair and, frankly, wrong to allow innocent bystanders to be harmed by the action of others. That is why you cannot smoke in an indoor public space, and that is why you should wear a mask during a pandemic.”