Bellevue

by David Oshinsky

  The greatest damage occurred at NYU’s Smilow Research Center, a few blocks north of Bellevue, where ten thousand rodents were housed. “Most of our knockout mice were destroyed,” a scientist recalled. “They’re the ones we alter by breeding out certain receptors to study disease. By the time we got down to the basement, only the top few rows of the cages were above water. The place stank of diesel fuel. It was dark and cold and the food was gone. Four years later, we’re just getting back to where we were.”

  It was an all-too-common story. Genetically engineered mice are essential to research in arthritis, brain disorders, cancers, diabetes, and other diseases. “I felt an awful sense of despair for the suffering and loss of the animals, for the years of work lost and for the impact this would have on the people in my lab who had put their hearts and souls into their research,” a biologist wrote of the carnage.

  When the power failed, the laboratory freezers clicked off. Bags of dry ice and tanks of liquid nitrogen were hauled up five, ten, fifteen flights of stairs by volunteer bucket brigades. “We made a dash to retrieve our thawing specimens,” NYU’s chief of medicine recalled. “We rescued nearly all of the current studies, but lost some of our archives—samples obtained from villages and patients all over the world….They were irreplaceable.”

  Instant decisions had to be made. One researcher got a frantic call from his department administrator. Electricians had just arrived to hardwire emergency lighting in the stairwells, he was told, and everybody in the lab could select one item to receive power. What would it be? The researcher picked his minus-80-degree freezer, which contained a career’s worth of yeast samples, knowing that all else would be lost. “It was,” he said, “like Sophie’s Choice.”

  Bellevue had its own problems. A number of its labs were devoted to AIDS and drug-resistant tuberculosis. It wasn’t simply a matter of saving precious research; some of the samples were hazardous if not properly contained. “We began packing up whatever we could in dry ice because my minus-80 degree [freezers] had warmed up to minus 49,” the director of Bellevue’s HIV/AIDS Trial Group recalled. “By the next day, they were at 4 degrees and all the remaining samples were lost.” In some places, she said, “it was like walking through a giant slushy.” But contamination was prevented.

  The loss of so many animals and specimens raised the obvious question: Was it avoidable? And the somewhat surprising answer along Bedpan Alley was: probably not. Most researchers pinned the blame on nature, not on human error (or, perhaps, a combination of both). Only a freakish mega-storm of Sandy’s size and violence could have flooded these buildings, they believed. And only a fortune-teller could have foreseen the catastrophic damage it left behind. “We knew that a hurricane was coming,” a particularly hard-hit researcher explained. “We put things away and checked that the emergency power was on. The animal care people gave our mice extra water and food; we couldn’t move the mice, because they had to stay in a germ-free environment to avoid infections, and there was nowhere large enough to put them.” Everything that could be done had been done.

  From a distance, however, a rather different portrait emerged. Animal rights activists skewered these facilities for leaving caged animals to die in the dark. “If you were one of the mice who drowned, it may have been more of a blessing,” wrote one, referring to the “pain and suffering” inflicted by medical research. But criticism also came from those who had suffered similar losses in the past. In 2001, Hurricane Allison drowned tens of thousands of caged mice at the Baylor and University of Texas medical research facilities in Houston, along with dozens of monkeys, rabbits, and dogs. Five years later, Katrina killed thousands more living underground at LSU and Tulane. As a result, all four universities had taken steps to prevent a recurrence. “We will never place animals or critical equipment in the basement again,” UT’s president declared.

  But few hospitals or universities followed suit. Even along Bedpan Alley, which rested on landfill abutting an ocean-fed river, a feeling of apathy—or false confidence—prevailed. Most of the buildings there predated Katrina, and moving heavy equipment to higher floors was expensive and gobbled up space needed for patient suites and state-of-the-art medical hardware. Put simply, infrastructure is invisible until the very moment it fails. As one expert put it: “People don’t pick hospitals based on which one has the best generator.”

  Many researchers, moreover, preferred keeping their animals below-ground. There were all sorts of rationalizations—it was cheaper space; rodents thrive in low artificial light; the microbes they carry have less chance of escaping—but the desire to keep them hidden almost certainly played a role. “[Our] centers are the site of massive rodent slaughter…,” a researcher noted. “It’s ugly work, even when it’s useful and important.”

  Whatever the logic, the lesson was widely ignored, despite repeated warnings from those who knew best. “I talk about disasters all over the world,” said a researcher who suffered through Hurricane Allison, “and I just tell them, ‘Get your animals out of your basement.’ ”

  —

  Bellevue reopened in stages over the next ninety-nine days. First a few outpatient clinics and the pharmacy, then several more clinics and the Emergency Department—and, on February 7, the main hospital and its 828 beds. During this time, the staff faced a problem rarely seen, much less navigated, in the past: how to monitor the hundreds of patients who were evacuated and the thousands more who relied on Bellevue’s multitude of clinics for their primary care. Tracking them became a logistical nightmare. Prescriptions had to be filled and operations rescheduled. X-rays, blood tests, dialysis, methadone—all had to be provided somewhere else. The crisis took on a name: the Bellevue diaspora.

  Cooperation was essential. The hospitals that admitted the evacuees also provided space for the displaced Bellevue doctors and nurses. Glitches arose over things like record sharing and credentialing, but a rough kind of order soon emerged. “Hand-scrawled messages were taped to our cubicle,” an internist recalled. “Psychiatry was at Metropolitan; the Cancer Center at Woodhull Hospital in Brooklyn. Dermatology was seeing patients in Manhattan, but only on Wednesdays and Thursdays. Dialysis was at Jacobi in the Bronx….Each day a few locations were crossed out and new ones added.”

  If there was a silver lining, it was the recognition of how valuable Bellevue’s services were, and how hard it was to get on without them. Doctors at other city hospitals were struck by the level of coordination and sophistication among the teams of Bellevue residents, nurses, and attending physicians who arrived to treat their evacuated patients. It was a level of care, some acknowledged, rarely seen at their own institutions. In the weeks after Sandy, moreover, the emergency room at Weill Cornell Medical Center, forty blocks to the north, was so jammed that the normal four-to-six-hour wait for a bed soon reached twelve to fourteen hours. The same held true for specialty clinics across the city—now forced to handle a surge of new patients, many of them foreign-speaking and uninsured. Bellevue averaged 500,000 visits a year. Its closing had proved a grim reminder of its worth.

  —

  In October 2014, exactly two years after the superstorm, a story aired on NBC News about the recovery efforts then under way. Titled “A Tale of Two Hospitals,” it compared the paths of Bellevue and NYU Langone Medical Center, which included Tisch Hospital. Both had been forced to evacuate during Sandy and both had suffered catastrophic damage. Yet, standing just two blocks apart, their stories could not have been more different.

  As the NBC report noted, NYU Langone had already received $1.2 billion from the Federal Emergency Management Agency (FEMA), the second-largest payout in the agency’s history. And the money had come in one lump sum, rather than the usual approach of doling out funds piecemeal as repairs were made and bills submitted. On top of this, the National Institutes of Health had given NYU Medical School another $218 million for its research recovery plans, which included the construction of a new vivarium for lab animals on a higher floor.

&
nbsp; Bellevue, meanwhile, had received only $117 million from FEMA to this point, and would be sharing just a fraction of the NIH largesse. Digging deeper, the NBC investigative team discovered that NYU Langone held an insurance policy to cover some of the storm damage—including $150 million for “research losses”—and that questions had been raised by FEMA officials about “using vast sums of money to bail out a private medical institution, especially one with ample private insurance.”

  While not explicitly crying foul, the NBC report dropped some strong hints about the lobbying clout behind the NYU Langone awards. The Medical Center’s Board of Trustees read like a Who’s Who of Wall Street titans: JPMorgan Chase CEO Jamie Dimon, Goldman Sachs president Gary Cohn, and BlackRock CEO Larry Fink. And the center’s namesake, Home Depot cofounder Ken Langone, had close ties to Republican House majority leader Eric Cantor and to New York’s senior Democratic senator, Chuck Schumer, who publicly announced the awards. This stark difference in funding, said NBC, “raised uncomfortable questions about disparities in the way FEMA has treated the two hospitals in the wake of Sandy.”

  The report sparked more anger than surprise. Who didn’t expect a well-connected private hospital to get preferential treatment in such circumstances? “When NYU has an army of wealthy donors, whilst Bellevue is consigned to treat the city’s uninsured,” there was no hope of equity, a critic wrote—though he, like many others, was startled by the “obscene” gap between the two awards.

  There was more to the story, however. As a private operator, free of government red tape, NYU Langone put its FEMA proposal together within months of the storm. Bellevue, on the other hand, endured numerous inspections and estimates, while the city’s final application to FEMA included three public hospitals besides Bellevue seeking relief. In truth, Schumer had fast-tracked the document when it finally arrived. Three weeks after the NBC story broke, he announced a FEMA commitment of $1.6 billion for New York City’s storm-damaged public hospitals, with Bellevue receiving $376 million for projects that included a 3,200-foot-long wall to protect the hospital’s perimeter and the movement of essential equipment to higher ground.

  For some, the timing of these FEMA funds was hardly accidental. The NBC report played a role but so, too, did a global health alert that soon became the year’s most terrifying news story. At the very moment Senator Schumer was making his announcement, the streets surrounding Bellevue were clogged with TV trucks and satellite dishes. A patient had just arrived with a deadly infectious disease. Fears of a pandemic were spreading, and few American hospitals appeared ready for what lay ahead. Bellevue, Schumer confidently declared, was one of those few.

  —

  In the summer of 2014, with Ebola tearing through the West African nations of Guinea, Liberia, and Sierra Leone, a group of Bellevue staffers began preparing for its likely appearance in New York. Selected for the role by state officials, the hospital seemed a natural choice. Its history stretched from the yellow fever outbreaks of the 1790s to the AIDS epidemic of recent decades, and it already contained a unit for treating critically ill patients in quarantine—mainly those with drug-resistant tuberculosis. If and when an Ebola victim turned up, most likely at Kennedy Airport, Bellevue would be the destination.

  In the meantime, Americans got a tragic lesson in all that could go wrong. In late September, a Liberian national named Thomas Eric Duncan arrived in Dallas for a family visit. Feeling ill, he went to the emergency room at Texas Health Presbyterian Hospital, complaining of a headache and abdominal pain. Duncan had a slight temperature; his vital signs seemed “unremarkable.” The nurse who examined him jotted down “came from Africa, 9/20/2014” on his chart, but nobody took notice—not even when his second temperature reading hit 103 before dropping two degrees with medication. The doctor who finally saw Duncan prescribed an antibiotic, which has no effect on viruses, and sent him home.

  Duncan was rushed back to Presbyterian by ambulance a few days later with a high fever, vomiting, and diarrhea. This time the examining physician, noting the patient’s travel history, donned protective gear and cleared the intensive care unit before admitting him. By now, however, it was too late. With virtually no preparation for Ebola, the technician charged with handling Duncan’s blood work had to search the web to see if he had followed proper procedure (he hadn’t), and it took four days to get back the results. The nurses caring for Duncan were unsure of what clothing to put on or how to properly dispose of it. They, too, relied on the Internet, with growing alarm. “We were looking at the pictures…and saying, ‘We’re not wearing anything like that,’ ” one of them recalled. Thomas Duncan died at Presbyterian on October 8; two of his nurses contracted Ebola, but survived.

  Ironically, the hospital enjoyed a good reputation in Dallas. With nine hundred beds, a $600 million annual budget, and a well-respected staff, it attracted numerous celebrity patients, including former president George W. Bush. “In all fairness, critics have overlooked the role that bad luck played in Presbyterian’s medical missteps,” wrote a local columnist. “Duncan could have turned up in any emergency room in the country and it’s disingenuous to suppose that every one of them was fully prepared for the unexpected, unprecedented arrival of the first undiagnosed Ebola patient on the continent.”

  This, no doubt, was true. But New York City, unlike Dallas, had anticipated the likelihood of Ebola by designating its flagship hospital to lead the fight. Drills began that August, when the World Health Organization declared an “international health emergency.” Staffers trained in layers of protective gear comparable in weight and mobility to the gear they employed during earlier sarin gas attack drills—fluid-resistant gowns, knee-length booties, double gloves, and a PAPR (Powered Air-Purifying Respirator) with a face shield. Special equipment was tested, such as an electronic stethoscope that didn’t expose the ears. “It’s a cool gadget,” said Laura Evans, Bellevue’s director of critical care. “It looks like a hockey puck, but you get a nice sound quality—much better than the disposable stethoscopes we’ve tried.”

  A thirty-one-page “Ebola Response Guide” set down the rules. “Blood draws should be kept to an absolute minimum to decrease the risk of needle sticks,” it stated, adding that samples “must be double-bagged in a special transportation box, which is then wiped down with bleach.” To prevent the sort of mistakes that had doomed Thomas Duncan, “special shoppers” were dispatched to the ER to see how well the staff took travel histories and recognized Ebola-like symptoms. Dozens of suspicious cases were reported; none tested positive for Ebola, though a fair number were found to suffer from malaria and typhoid fever.

  As a leading teaching hospital, Bellevue relied heavily on interns, residents, and even students for its medical care. The house staff at Bellevue was well known for taking “ownership” of the patient; it was one of the attractions of working there. Thus, when Ebola appeared, the house staff expected to play a major role. A petition was even circulated with the names of volunteers. Almost everybody signed.

  But this time would be different. No one expected Bellevue to be flooded with Ebola patients. The virus was deadly, fast-moving, and extremely infectious. There was no time to waste training dozens of superfluous people who might contract the disease and spread it to others. The best option was to recruit a group of veterans from the relevant units—infectious disease specialists, ICU nurses, and the like. Containment was key. “Our philosophy for Ebola,” said a Bellevue official, “is to have as few people as possible exposed to the patient, and that those people are at the highest level of experience and competency.”

  The test came in late October. “EBOLA HITS NYC,” warned the New York Post. The news that Craig Spencer, a volunteer with Doctors Without Borders, had tested positive after returning from a field hospital in Guinea set the city on edge. Where, exactly, had Dr. Spencer been in the days before he began to show symptoms? And what threat did he pose to the people he’d come into contact with? One point was certain, though: Spencer would be spend
ing his days at Bellevue until he fully recovered or succumbed to the disease.

  His new quarters were a guarded suite in the isolation ward on the seventh floor, where patients with drug-resistant tuberculosis, an outgrowth of the AIDS epidemic, were housed in rooms with negative air pressure, ultraviolet lights to kill airborne bacteria, and HEPA (High Efficiency Particle Air) filters. With its own waste disposal systems and a laboratory for on-site testing, the ward was fully self-sufficient. Each suite contained an anteroom to “don” and “doff” protective clothing and an inner room for the patient, with extra power for lifesaving equipment. Nurses worked in pairs—a kind of buddy system to prevent careless mistakes—while a team from the CDC provided round-the-clock supervision.

  When Dr. Spencer arrived at Bellevue, he was still in the early stages of the disease—similar to Thomas Duncan during Duncan’s first trip to Presbyterian’s emergency room. The staff kept Spencer hydrated and monitored his vital signs. (Falling blood pressure caused by fluid loss from vomiting and diarrhea is one of Ebola’s great dangers.) In addition, he received experimental antiviral drugs as well as plasma from a donor who had survived Ebola while working as a missionary in Liberia—and whose blood type, fortuitously, matched his. How well these treatments worked, if at all, isn’t known. But they point to the larger truth that everything possible was done to save Spencer’s life during his time at Bellevue—unlike the tragedy in Dallas.

  Nineteen days later, Spencer was declared “virus-free” and discharged. His ordeal demonstrated that Ebola wasn’t necessarily a death sentence, that a well-prepared hospital, treating the disease early and aggressively, stood an excellent chance of saving the patient’s life. Indeed, all seven victims admitted to the Ebola centers at Emory and the University of Nebraska, including the two Dallas nurses, made full recoveries. Only Thomas Duncan died.