Moments after nurses in protective gear gently wrapped in a white sheet the body of a 58-year-old man who succumbed to COVID-19 at Mount Sinai South Nassau hospital, the Beatles' "Here Comes the Sun" played over the public address system to mark the discharge of a coronavirus patient.
Life and death fiercely competed last week during the frenzy of COVID-19 treatment at South Nassau, which, like other Long Island hospitals, has been strained by the surge of virus patients.
“Normally, we’ll have a death, honestly, every few weeks or a month or so" at the hospital, said Nydia White, the nurse manager for critical care. Now, the hospital is "wrapping quite a few bodies a day.”
South Nassau, which serves tens of thousands along the South Shore, had 59 coronavirus patients on ventilators and fighting for their lives Saturday. The hospital has seen 248 die from the virus since March 16.
Newsday spent Monday through Wednesday inside the hospital in Oceanside, including in the emergency department and intensive care units, and chronicled how COVID-19 has transformed South Nassau and the way medical professionals deliver care. Health care workers portrayed a hospital under siege by a disease that kills unmercifully and does so in a way that confounds the most experienced doctors and nurses. But they also were defiant in their determination to risk their lives to save others, and to harness their skills to give their patients a chance to survive.
“You worry for yourself,” said Courtney Ciesla, 38, a physician assistant who is nearly 30 weeks pregnant and afraid of the effect of COVID-19 on her fetus if she were to contract the virus. “But you also never want to see a 50-year-old male come in here with three kids at home and not make it past one of the rooms in the ER.”
Death toll likely undercounted
The number of COVID-19 patients at South Nassau is starting to fall, a sign the hospital may have passed its peak — at least for now.
The 248 deaths recorded at the hospital is surely an undercount, said Richard Murphy, the hospital’s president and CEO. Early on, he said, federal limits on testing meant some deaths attributed to, for example, pneumonia, also likely involved COVID-19.
Murphy said it took more than a week to get approval for a test for John Knox, the first South Nassau patient later confirmed to carry the virus. Knox, a retired New York City fire marshal from Queens, was admitted Feb. 26.
Knox died March 16 at age 83. Within a few days, “the floodgate opened and we just had a massive amount of patients requiring a lot of care,” chief nursing officer Stacey Conklin said.
The number of confirmed COVID-19 patients increased nearly tenfold in the week between March 21 and March 28, from 23 to 217, and the number in intensive care went from three to 30.
Dr. Joshua Kugler, chair of emergency medicine, worried he couldn’t keep up, as some of his staff got sick with the virus — roughly 15% have been out sick at some point — and the number of seriously ill patients spiraled upward.
On April 7, six people presumed to have COVID-19 died within two hours in the emergency department, he said.
“I was like, ‘If this keeps up, the way the change was so dramatic, I said we’re going to leave people dying outside,’ ” he said.
Kugler, who grew up on a farm in Melville, is convinced that if not for social distancing, “this is so transmissible that I think we probably would have tripled the speed or velocity that this thing took off,” leading to South Nassau and every other Long Island hospital becoming so overwhelmed that they would have had to ration care, making agonizing decisions about who lives and dies.
Conklin said she has little patience for members of her family who complain to her about social-distancing rules and work-at-home orders.
“This is so much more serious than they can even imagine,” she said. “They don’t see what’s going on.”
Conklin has never had COVID-19 symptoms, but "was extremely guilt-ridden" when her 23-year-old daughter, a student at New York Law School in Manhattan, had a mild, feverless case of COVID-19, although it's unclear whether she contracted the virus from her mother.
The hospital is staffed to take care of 353 people, but the inpatient census has hovered many days around 500, South Nassau spokesman Joe Calderone said. About three out of four in recent days typically have been COVID-19 patients, or those suspected of carrying the coronavirus, according to hospital records.
To handle the surge, some patients were transferred to other hospitals in the eight-hospital Mount Sinai system, to the temporary hospital at the Javits Center in Manhattan, or to repurposed spaces such as the hospital's oncology and infusion center, which was moved to a conference room to make way for COVID-19 patients, creating another red zone for those infected by the virus, Calderone said.
Dozens of patients sometimes were scattered around the emergency department, at times for a few days, until beds opened up elsewhere in the hospital.
Two climate-controlled tents with 10 beds each were erected late last month to handle the extra patient load, and two more were built last week, in case there’s a future spike in patients, Kugler said.
"I think we could see a resurgence if people become more lax about social distancing," he said.
The hospital more than tripled the number of ventilators it has, from 40 to 128, and nearly quadrupled the number of intensive-care beds, from 22 to 84. ICU beds now occupy spaces where in the past patients recovered from orthopedic surgery or cardiac catheterization.
Amount of grief is 'unimaginable'
In a repurposed orthopedic-recovery room, a 58-year-old man died of COVID-19 at 9:36 a.m. Wednesday.
White, the critical-care nurse manager, and nurse educator Katie DeMelis walked somberly into the man’s room to clean the corpse, remove the breathing, fluid and other tubes from his body, and put paper tags with his identifying information on his left toe and atop the white body bag and sheet that covered him.
It’s a grim task they’ve performed too many times. It’s always emotionally draining.
“The amount of grief this is causing the staff is unimaginable at this point,” White said.
Critical-care nurses are used to death. But, “we haven’t seen this many people pass in a day, every day,” she said.
After anyone dies, the medical staff gathers in honor of the patient and observes a moment of silence.
As White talked, “Here Comes the Sun” started playing, the hospital’s signal that another COVID-19 patient had been discharged. White and DeMelis began smiling, and White sang along.
“That feels amazing,” DeMelis said. “It makes all the late nights and the countless hours and the stress and when you just want to go and cry — it’s all for something. Someone gets to go home and see their family.”
The song came on again, and then a third time, giving them brief respites from the death that surrounds them daily.
If this were any other disease, the man would probably be alive, Conklin said. He was admitted to the hospital March 31 and was in a non-ICU bed for two weeks. On Tuesday, he was transferred to intensive care. By Wednesday morning, he was dead.
“We’re seeing that a lot where the patient is doing OK and then just get to a point in their illness where they just completely drop off, they completely decompensate,” Conklin said. “No one can explain it. No one seems to understand why.
“It’s a horrible disease,” she added.
The day before, in another intensive-care area, Dr. Frank Coletta, the chief of critical-care medicine, was standing near the bed of a South Nassau employee in a medically induced coma. The man is a patient care technician who Coletta has known since the doctor arrived at the hospital 26 years ago.
“It’s very difficult to watch this,” Coletta said.
The man was admitted March 22 with respiratory problems, but it was later discovered that he had multiple areas of bleeding in the brain from a stroke. It’s rare that a stroke causes bleeding in more than one area, although multiple doctors have seen that in COVID-19 patients, Coletta said.
“We’ve gotten used to it, all the surprises, all the frustrations,” he said. “It almost becomes normal.”
Another frustration is the lack of a lifesaving treatment protocol, Coletta said. COVID-19 patients at South Nassau receive experimental drugs such as the anti-malarial hydroxychloroquine as long as there is not the potential for harmful side effects, he said. Patients are participating in clinical trials for medications like the antiviral medicine remdesivir, which has shown some promise, he said.
Some patients improve with the treatments, and some don’t, so it’s unclear if the patients would have improved anyway, he said.
“For most disease processes, we have a certain protocol to follow, that these medications work for that, and the expectation is that the patient will get better,” Coletta said. “With this, we have no particular medicines that we know have any impact on the course of their disease, and we’re constantly trying everything that we possibly can.”
Worried about taking virus home
The uncertainty about the disease and its effects is why Ciesla debated whether to take time off during her pregnancy from her job as the emergency department’s chief physician assistant. Her pregnancy with 20-month-old son Nicholas had complications.
“My biggest fear is that because it’s so new, we don’t really know the effects on the fetus or the effects on myself being technically considered immunocompromised as a pregnant PA sitting in the emergency room surrounded by COVID,” Ciesla said. She sat a few feet from one of the dozens of coronavirus patients crowded into the emergency department and near an electronic dashboard that had a red infectious disease marker next to all but a few patient names.
She’s worried she’ll bring the disease home to Nicholas and husband Michael Ciesla, 38.
Yet Ciesla decided that, despite the risks, she will work until she has a cesarean section June 25.
“When you see what’s going on around you, you really can’t just leave everybody, your co-workers, high and dry,” she said.
Michael Ciesla, a FDNY firefighter in Bayside, Queens, said his wife is “very, very dedicated and very selfless,” and he supported her decision.
When Ciesla comes home from work, she first washes her hands outside with soap using a hose, and then enters through a back door where her husband and son don’t go. She leaves her shoes outside, takes off her clothes and immediately throws them in the washer before taking a hot shower, during which she scrubs herself intensely.
Many South Nassau employees have gotten sick, and at least three have died, according to the hospital. An attending physician at the hospital also has died. The highest illness rate may be among phlebotomists, who draw blood and are close to where the patient is breathing. Twenty-eight percent have contracted the virus, said Lisa Righter, the hospital’s assistant vice president of clinical and ancillary services.
Dr. Eugene Perepada, 37, an emergency-medicine doctor, is one of those who fell ill. He represented Ciesla’s nightmare scenario, as he likely infected his then-6-week-old daughter, Blake, and his wife, Brooke Perepada, 32.
He immediately feared that Blake would die. He knew children are less likely to have serious illnesses stemming from COVID-19, but, he said, “You always fear for the worst because in my profession, you see the worst.”
Blake was hospitalized for two days for a mild fever, and Brooke Perepada had a mild fever for a few days and then lost her sense of taste and smell, a common coronavirus effect, he said. He said he believes he transmitted the virus when he was asymptomatic, because he isolated himself in the guest bedroom once he started getting sick.
Perepada was scared by the shortness of breath he felt while sick and worried about dying and leaving his wife and infant alone.
He recovered, and now, “I’m back to work saving lives,” he said. Like Ciesla, he said he didn’t want to leave behind his colleagues.
“I hated being at home when my colleagues were out here fighting the fight, and I was at home sitting there, and I felt helpless,” Perepada said.
'Rapid response' in emergency room
“Rapid response, F3,” blared a loudspeaker in the emergency room. It was the all-too-frequent call to urgently assist someone who was deteriorating.
This time, it was a 58-year-old Lynbrook man who, after being rushed in and sedated, was quickly surrounded by medical staff, including a doctor who inserted a breathing tube into his trachea in a desperate effort to save his life.
EMTs had arrived at the man’s home to find him confused after a fall. It was only in the ambulance that he began gasping for breath and became unresponsive, said Morgan Ortiz, a Northwell Health ambulance EMT.
“He deteriorated in front of me,” Ortiz said. Family members said the man had tested positive for coronavirus, he said. A day later, the man was still in intensive care, Kugler said.
As recently as Monday, the hallways and nooks of the emergency department were lined with beds holding COVID-19 patients. Nearly a dozen ambulances outside were bringing in more people, who were lined up in a hallway in ER beds, with emergency medical technicians waiting to hand them off to nurses.
Hospital officials said Monday was one of the worst days in the 92-year history of the hospital, with far more deaths and far more seriously ill patients than usual. Yet in the throes of a COVID-19 pandemic that has killed more than 1,800 people on Long Island, it was an early sign of hope.
“This is nothing compared to last week, believe it or not,” Kugler said, recalling how several days before “you couldn’t even walk in here” because of the flood of patients, including more than 60 people admitted to the hospital and waiting for an inpatient bed. By Monday, the number of admitted patients in the ER was down to 40, and by Friday, it was at the pre-COVID level of five, he said.
Hospitalwide, the number of confirmed and suspected COVID-19 patients had dipped Saturday to 273, the lowest number since March 31. Only five days before, there were 369.
Visible from outside the emergency department doors are three 40-foot refrigerated trailers that the hospital bought because its small morgue could no longer handle the rising number of bodies. 44 corpses were in them Wednesday morning.
Conklin said she’s “very worried about the emotional state of the nursing staff and all the staff in the hospital seeing so much sickness and quite honestly so much death, so much more death than we’re ever used to experiencing in maybe even a lifetime, in the amount of a month.”
The hospital created a 24/7 hotline for employees. Murphy, who praised employees for their “tremendous commitment” during the crisis, said the hospital is planning a program to address the long-term mental health effects of the pandemic, because “when it’s all over” employees will be “much like a soldier coming out of the battle lines.”
Conklin said the gestures of community support — including car and firefighter caravans, and restaurants and residents buying food — have helped lift the spirits of employees.
Help comes from other states
One of the biggest challenges for South Nassau has been deploying enough staff to treat patients who are greater in number and more seriously ill.
“Everybody’s pitching in extra, extra time, extra shifts, whatever we need to do,” Conklin said.
Nurses and other medical staff also have been redeployed, some from elective surgeries, which were canceled because of the crisis, others from hospital-owned outpatient medical offices, she said.
Dr. Scott Roethle is one of at least four out-of-state anesthesiologists temporarily assisting South Nassau. Roethle, who works at Bothwell Regional Health Center in the small town of Sedalia, Missouri, arrived April 8 through a health-care staffing agency and is working 17 straight 12-hour days.
Dr. Philip Fracica, chief medical officer of the hospital, said Roethle told him that, with few coronavirus cases in the Sedalia area, “he was feeling a little helpless and inadequate during this momentous health crisis this country is experiencing."
“I feel like it’s my mission as a Christian physician to help others and to do my part,” Roethle said before slightly moving an endotracheal tube that had been leaking air and tweaking the ventilator setting to increase oxygen flow.
Six days in ICU
Debbie Rifenbury, 61, was one of only 28 coronavirus ICU patients at South Nassau who had come off ventilators as of Friday. The others still need the machines’ help to breathe.
She spent six days in the ICU, with the last few days designed to wean her off the ventilator, Coletta said.
Rifenbury had a 105-degree temperature, felt weak and had trouble breathing — “it felt like straps around my back pressing against my lungs” — when her doctor urged her in a telemedicine appointment to seek help at an urgent-care center, where doctors found she had pneumonia. She was rushed to South Nassau.
One reason Rifenbury may have been able to get off the ventilator is she does not have an underlying respiratory or other condition that could have exacerbated the COVID-19 illness, Coletta said. Rifenbury is grateful she quit smoking 39 years ago.
“I feel that, because of that, it saved my life,” Rifenbury said as she sat up in a hospital chair.
On Friday morning, she walked for the first time in more than two weeks without added oxygen. The nasal oxygen tubes had been taken out the day before. The walk was only to her hospital room door and back, and she felt a little winded afterward. But she was buoyed by the short journey powered by her own lungs.
“I still have the pneumonia, and I do have coronavirus,” she said. “But I will survive and I will get better. I guarantee it.”