Baby Health in Winter
In late March, Scott Aberegg, a critical-care doctor at the University of Utah, was eating lunch in his hospital cafeteria. On his phone, he noticed an e-mail that was circulating among the trainees in his department. It was from the American Thoracic Society, a professional organization of physicians who treat lung disease and critical illness. “As you have undoubtedly heard, there is a coronavirus surge in New York City,” the message read. “The situation is dire . . . and your colleagues need your help.” The e-mail offered same-day credentialling and licensing, as well as free travel, housing, and meals to doctors who volunteered to work in the city’s hospitals. The e-mail was so extraordinary that Aberegg wondered if it could be a scam.
Aberegg grew up on a small horse farm in Alliance, Ohio, about sixty miles southeast of Cleveland. His father worked in retail at Sears and later trained horses and sold livestock equipment; Aberegg was the first in his family to attend college. In the winter of 1997, when he was in his third year of medical school at Ohio State, he did a rotation with James Gadek, a legendary critical-care doctor. A few weeks in, Gadek heard that a trainee’s relative was dying in a hospital several hours away. The medical team there believed the case to be hopeless; Gadek rode down in an ambulance, brought the patient back, and started treatment himself, in his own I.C.U. The patient recovered. Watching his supervisor go to such lengths, Aberegg thought, I want to be like that guy. Now, in Salt Lake City, he replied to the e-mail from the American Thoracic Society, saying that he was available.
Around the same time, Tony Edwards, a third-year critical-care fellow who worked at Aberegg’s hospital, got the same e-mail. He and his wife, Ashley, a former I.C.U. nurse, had been working in Dallas in 2014, when the first Ebola patient on American soil—a man fleeing the outbreak in Liberia—grew sick there, and the virus threatened to spread. Tony was a medical resident in the infectious-disease service; Ashley’s I.C.U. was chosen as the one to which Ebola patients would be sent if the outbreak grew. Though the virus was contained, a patient died and two nurses were infected. The Edwardses felt that they’d experienced a near-miss. “We kind of went through the drill before,” Ashley said. “Being through that got us ready for this.”
At dinner, Tony told Ashley about the e-mail. She’d seen it, too, and also wanted to go: the need for I.C.U.-trained nurses was, in many cases, even greater than the need for physicians. Soon afterward, the Edwardses learned that Aberegg had volunteered as well. The three began making preparations. Aberegg backed out of a family vacation. The Edwardses began arranging child care for their fourteen-month-old daughter. Tony’s mother, Marianne, cried when she heard that they’d volunteered; she agreed to drive from Denver to Salt Lake City to take care of the baby. Before leaving, Tony and Ashley bought life-insurance policies, which wouldn’t take effect for another month. They tried to make a joke out of it. Tony told his mother, “If we get sick, make sure you keep us alive until then!”
In early April, when New York City was recording around five thousand new coronavirus cases per day, I met Aberegg in a makeshift I.C.U. in the hospital where I work, on the East Side. We stood near the central nursing station. Doctors and nurses darted around us; alarms sounded; monitors flashed red warnings. The wooden doors on the patients’ rooms had been taken down and replaced with metal ones; they had large glass windows that allowed us to see the patients, connected to ventilators. On each window, dry-erase markers were used to record ventilator settings, oxygen levels, medication rates, and the number and location of the tubes and catheters keeping each patient alive. Aberegg, muscular and no-nonsense, seemed relatively at ease. “When someone says they need help, you go help them,” he told me, describing his decision to come. “If they didn’t need help, they wouldn’t be asking.” He had arrived a few days before, and was staying in a hospital-run hotel across the street, in a room two floors up from the Edwardses. He had already seen dozens of critically ill COVID-19 patients. In the mornings, he met Tony in the I.C.U., and they talked about what had happened overnight: some patients had improved and might be extubated, others had worsened and needed immediate attention. Then they started their rounds.
Later, I went to see Tony and Ashley in their hotel room, where we sat pushed back from the small dining table, six feet from one another, with our masks and surgical caps on. They recalled the frenzied week between their decision to volunteer and their arrival in New York. Ashley, who had changed her specialty from critical care to interventional radiology, had reviewed I.C.U. procedures online and in old textbooks; Tony, while caring for patients in his Utah I.C.U., had tried to sort out the requirements for New York State credentialling. Twelve hours before they were set to depart, the airline cancelled their flight. They scrambled to book another. On the way to the airport, Tony became apprehensive. “He was freaking out,” Ashley said. “He was shaking and couldn’t talk. That’s when I think it hit him.”
On their flight, there were fewer than a dozen passengers, all wearing masks. There was no food or drinks service on board, and they were hungry when they landed at J.F.K., a little after midnight. As they walked through the empty terminal, past a lone T.S.A. officer sitting in a chair, their sense of unease grew. Their Uber driver seemed tense. At the hotel, they ate a pizza they’d ordered from a food-delivery app. Five hours later, Tony picked up his I.D. badge and got to work. Later, Ashley went to an office in midtown to complete her credentialling process. Afterward, she walked to Times Square. The lights were on and the signs were flashing, but the streets were deserted. They’d been to New York before, but not this version.
For Tony, nervous energy quickly gave way to reflexive action. There was almost no time to meet his new colleagues. His first day was marked by a constant flow of patients: just as one was stabilized, another arrived, gasping for breath or already intubated. When a spare moment presented itself, he and his team would swap theories about the coronavirus and discuss the few studies that had been published. He felt disoriented, not just by the tumult of the ward and the uncertainties of the virus but by the unfamiliar faces and layout of a new hospital. One morning, he entered a break room and sank, exhausted, into a chair. “Hey! You’re the Utah guy,” one doctor said. Around him, many others were reviewing cases and debating treatments. He had known that all of the units on his floor had been transformed into COVID-19 wards; only now did he realize that the same was true of nearly the whole hospital. He took the stairs down to a surgical floor and made his way along a hallway with operating rooms on both sides. There, he got a hint of the pandemic’s true scale: in each room, rows of unconscious patients were connected to ventilators, their alarms echoing eerily down the empty corridor. “It was straight out of a science-fiction movie,” he recalled.
In the evenings, Tony would head back to the hotel. Sometimes, Aberegg would stop by for a drink or dinner. They’d eat leftovers or takeout from any place that would deliver; then Aberegg would go to his room to FaceTime with his family, while the Edwardses would do the same with Marianne and their daughter. With each passing day, it got harder to be away from home. Ashley’s credentials had been held up, and she began making plans to head back to Utah early. But the need for critical-care clinicians in New York was growing, and Tony Edwards’s and Aberegg’s duties were expanding. In addition to treating patients, they were now teaching doctors from other specialties—hospitalists, cardiologists—the specifics of work in the I.C.U. Masked, gowned, gloved, and goggled, Edwards and Aberegg led these doctors from room to room every morning; they repositioned patients, fiddled with ventilator settings, adjusted sedative medications, and explained their choices. A day on which a single patient was extubated was cause for celebration. Ashley flew home; Edwards and Aberegg continued working with their team. They started staying late at the hospital after their shifts had ended, to talk with the group about what had happened and to plan for the following morning.
In the days that followed, the surge peaked—there were nearly a thousand COVID-19 deaths a day in New York during this time—and then diminished. As the flow of new patients ebbed, and new doctors started work, Edwards and Aberegg began preparing to go home, too. Near the end of their time in New York, Justin Kingery, a doctor with whom they’d grown close in the I.C.U., handed them a goodbye letter. Addressed to “Scott and Tedwards”—his nickname for Tony—it began with a description of “the overwhelming sense of community” that Kingery had experienced while growing up “in the coal fields of West Virginia.” There, Kingery wrote, the desperation that set in after the coal mines started to fail had been offset by the feeling of “everyone helping, everyone pushing forward.” Recalling the death of a neighbor in the mines, Kingery wrote, what stood out in his mind was not the tragedy itself but the communal response to it. When he’d left West Virginia for New York, he had imagined that this communal feeling would never be replaced.
Then I met you two. Two renegades from Utah who flew literally into the most dangerous city in the world from a viral perspective. Two people who weren’t required to help but were standing in front of me nonetheless. Two people who could have easily lived great lives and “prayed for us,” etc. like the rest of the world. But here you were, helping with top notch ICU care, teaching us physiology along the way . . . in short, kicking ass and taking names in the face of danger.
In the envelope, Kingery included a piece of coal-mining scrip: one of the metal coins, for use at the company store, with which past generations of miners in his town had been paid. It was, he wrote, “a physical symbol of a deep sense of Appalachian community, very very similar to the sense of community you brought here.”
In the middle of April, Edwards left for the airport. The pandemic had begun weighing on him: the flow of COVID-19 patients was unending, and many were dying. “I don’t think I could have done one more shift,” he said. At J.F.K., the terminal was as empty as it had been when he’d arrived; he trudged along its automated walkways, now frozen and empty. The trip home added to his exhaustion: with routes severely restricted, he had to fly from New York to Detroit and then to Minneapolis before landing in Salt Lake City.
Aberegg left soon afterward. He arrived home on a Sunday evening and, the next morning, went back to work in the University of Utah Hospital’s I.C.U. Everyone wanted to know about his experience. “All I could tell them was COVID is real,” he said. “It makes people really sick—a ton of them.” Later that week, he and Edwards presented what they’d learned at a division meeting. Doctors and nurses wanted to know the details of managing the disease; hospital administrators sought to understand the physical and emotional toll the pandemic took on clinicians. What could be done to support them? How could they be kept safe? Should schedules be redesigned? Edwards emphasized the importance of camaraderie. “If you don’t have a core group of people to talk to, you’re going to burn out really fast,” he said.
In anticipation of a surge, administrators cancelled elective procedures, pushed back office visits, and restructured wards. But, for much of May, the hospital was quiet. “We called it Mundane May,” Aberegg recalled. Case counts were so low that half a dozen more critical-care doctors left the hospital to volunteer in New York. The Mormon Church may have been partly responsible for the state’s gentle curve: Russell M. Nelson, the Church’s prophet and president, is a ninety-five-year-old cardiothoracic surgeon, who, in the early nineteen-fifties, helped pioneer the use of the heart-lung machine for bypass surgery. There are 3.2 million people in Utah; two million of them are members of the Mormon Church. On March 12th, while Mayor Bill de Blasio was encouraging New Yorkers to dine in restaurants, and while Utah schools remained open, the Church suspended in-person services and moved to church from home; it announced that its General Conference, scheduled for April, would become a virtual event. Nelson spoke about the importance of both spirituality and science, and church elders joined other local religious organizations in urging everyone in Utah to wear masks, asking them to forgo “a small measure of comfort for the sake of saving lives.”
As new cases slowed in New York, people in Utah began to hope that the virus might not spread beyond the country’s initial epicenters. When a spike failed to arrive immediately, a kind of ennui set in. People who had worn masks and kept their distance grew impatient with sacrifices that, they thought, might not be warranted; elected officials began to move forward with plans to reopen the state. On trips to the grocery store, Edwards saw people congregating in groups, often without masks. When Aberegg and his wife, who is an I.C.U. nurse, visited a sporting-goods store to buy bear spray for a camping trip along the Colorado border, they saw so many customers close together, without masks, that they grew anxious and left empty-handed.
“We had COVID under control for a long time,” Lindsay Keegan, an assistant professor of epidemiology at the University of Utah, told me. “People took it very seriously at first, but, when there wasn’t an immediate rise in cases, they understandably got tired of the restrictions. The weather got nice. We started loosening up.” Keegan identified Memorial Day weekend as an inflection point: on June 5th, ten days after the holiday, Utah recorded what was then its highest single-day increase in coronavirus cases (five hundred and fifty-four). Sharon Talboys, who leads a contact-tracing program, a collaboration between the University of Utah and the state’s Department of Health, said that, at the end of May, each newly identified coronavirus carrier in Utah had, on average, five recent contacts to call; several weeks later, patients often had thirty contacts—a sign that people were becoming more socially integrated even as cases were rising.
Aberegg and the Edwardses had left their families to fly across the country, sleep in hotel rooms, and help a city with which they had no connection at the peak of a pandemic. Now, months later, they were realizing that they were about to face the same conditions at home. As Mundane May gave way to June, and Aberegg watched his hospital fill up, he began to think of the pandemic as a war of attrition. The virus was patient and relentless. It would wait for human resolve to weaken, then pounce. Aberegg and Edwards had witnessed the virus’s destruction firsthand. Now they found themselves wondering whether each state would have to experience the chaos and death of the pandemic for itself. “It’s only when people see their community, their friends or family, affected that they start to take COVID seriously,” Edwards said. “But by then it’s too late.”
Utah has now recorded more than thirty-nine thousand cases, half of which are in Salt Lake County. The rise in numbers pales in comparison with the surges in Texas, Florida, and Arizona, which has a population about twice that of its neighbor Utah but has been recording five times as many new cases each day. In Arizona, more than three thousand people have died of COVID-19, while in Utah the death toll is less than one-tenth that. Still, Utah’s growth has been several times what’s needed to trigger a pause in reopening. According to the state’s public-health officials, new distancing restrictions should be imposed when there are around two hundred new cases each day. In mid-July, Utah recorded a daily average of six hundred and fifty-one new cases; the state’s daily new-case count has quadrupled since the end of May. A recent mask mandate in Salt Lake County has helped flatten the curve, but not enough. “The game has shifted from ‘Let’s prevent a significant number of cases’ to ‘How can we control this thing enough to have some semblance of a functioning economy?’ ” Keegan, the epidemiology professor, told me.
When Aberegg and Edwards see each other now, they discuss the time they spent together in New York, but also the challenges that lie ahead for Utah. According to their hospital’s C.E.O., administrators will have to make major changes to accommodate the volume of critically ill COVID-19 patients—such as converting surgical wards to I.C.U.s—if the current rate of case growth continues unabated. Even so, Utah is pressing ahead with reopening. In much of the state, indoor gatherings of up to three thousand people are allowed; bars and movie theatres are open; you can eat at a buffet. Utah is trying to walk a fine line; the hope is that the discretion of individual citizens will allow the state to avoid restrictions while mitigating the spread of the virus. But, of course, that’s a gamble that could turn out badly. A central challenge is the series of delays that separate infections from symptoms, symptoms from confirmed cases, confirmed cases from hospitalizations, and hospitalizations from deaths. By the time the threat is fully recognized, a dangerous cycle is in motion.
As in many parts of the country, a rift has opened between Utah’s public-health officials and its politicians. The governor, Gary Herbert, has avoided statewide mask mandates, despite recommendations from the state’s medical leaders. In recent weeks, reports have emerged of medical experts being sidelined amid a push to ease economic restrictions. “It feels as though we’re headed for a disaster,” Arlen Jarrett, the chief medical officer of Steward Health Care, which runs several medical facilities in Utah, said at a news conference. “If we stay on this same path, we’re going to maximize our hospitals’ capacity very soon.” When Herbert has moved to confront the virus more aggressively, he has encountered populist pushback. In Provo, a hundred and fifty angry, unmasked parents packed into a town hall to protest his decision to require masks in schools this fall; on Twitter, a commissioner from a rural county compared Herbert to a Nazi.
Half a year into the American pandemic, this sort of infighting has become a predictable consequence of our fragmented, leave-it-to-the-states approach. The federal government has abdicated its role in leading the nation’s coronavirus-response efforts, in terms of testing, tracing, communications, and equipment production and distribution. Each state must fend and decide for itself, engaging in its own high-stakes calculus, following or ignoring public-health guidance as it sees fit. State by state, we re-litigate the basics of the pandemic response. Collective, coördinated action—a communal reaction to the deaths of our neighbors—seems beyond us.
Recently, Aberegg decided to cancel a trip to see his parents at their Ohio farm. He worries about their level of viral exposure and the attitudes of those around them. “There’s a lot of disbelief among their peers,” he said. “My parents have to be the ones carrying the banner about how serious this is, based on my experiences.” The nights that he and Edwards spend working together in the I.C.U., meanwhile, feel like both déjà vu and a glimpse of the future. On a recent shift, Edwards cared for a charming older man who spoke only Spanish. With each passing hour, the man’s breathing grew more labored, the hiss of oxygen getting louder with each turn of the dial. When alarms from the various machines became constant, Edwards brought an iPad to the bedside, and opened FaceTime: he wanted the patient and his family to know that the ventilator was the only remaining option. He patched in an interpreter, who struggled to speak over the din of the I.C.U.: alarms, groans, the commotion of doctors preparing for an intubation. Eventually, Edwards saw tears come to everyone’s eyes: they understood. “I’ve seen this story play out too many times,” he said.
Down the hall, Aberegg was attending to a patient who already knew intubation was imminent. He asked only that his family be on speakerphone while the anesthesiologists put him to sleep. He told them he loved them. They asked him to stay strong. His breaths were short and quick, but eased as the medication took effect, and the phone fell from his hand. New York in April; Utah now; where else tomorrow?
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