One Month Inside a Philly Hospital on the Front Lines of the COVID-19 Pandemic

An unfiltered look inside the Einstein hospital system as the novel coronavirus swept through the city.

Get a compelling long read and must-have lifestyle tips in your inbox every Sunday morning — great with coffee!

On Wednesday, March 11th, there were zero confirmed cases of coronavirus at Einstein Medical Center in Philadelphia. There were zero confirmed cases of coronavirus at Einstein Medical Center in Montgomery County, and zero confirmed cases of coronavirus at Einstein Medical Center in Elkins Park. There were zero confirmed cases of coronavirus anywhere in the health system’s 11 outpatient clinics or among any of its 8,500 staff. In all of Philadelphia, there was just a single case.

But the leadership at Einstein knew those numbers would change soon. That same day, Barry Freedman, the institution’s chief executive, established what’s known as an “incident command center”: a group of employees whose job it would be to radically transform the operating procedures of the system’s hospitals in a matter of weeks to prepare for what every statistical modeling program and every medical expert considered to be an inevitable inundation of coronavirus patients. At the time, Freedman thought Einstein was ahead of the curve. Looking back a few weeks later, in early April, he realized he was wrong: “At the beginning, we mistakenly thought we had the luxury of time.”

By that point, the number of COVID-19 or suspected COVID-19 cases at Einstein’s hospitals had grown from zero to 200, taking up 25 percent of the system’s 753 beds. In those intervening weeks, administrators had been convening on twice-daily calls — one at 7:30 a.m., another at 5:30 p.m. — to chart the institution’s response. Among the changes made in that time: The health system canceled elective surgeries to clear extra bed space, and it determined which newly emptied wings of its hospitals could become coronavirus wards. It took a skill-set census of its doctors and nurses, so that if the institution ever had massive shortages in staff, it could tap, for instance, an orthopedic surgeon who had done a brief specialization in infectious disease during residency. Freedman and his staff also began tracking supplies of “personal protective equipment,” known by the now-ubiquitous acronym PPE, and monitoring the (often conflicting) medical guidance coming from groups like the Centers for Disease Control and Prevention and the World Health Organization.

Freedman, who is 71 and has a chronic respiratory condition that left him hospitalized in the past year, was working from home on the order of his physician. He hadn’t been sleeping much, waking up every two hours in the middle of the night to check his phone and jot down woozy midnight ideas he could pass along at the next incident command meeting. When he and his staff first became aware of coronavirus back in January, the question they all tried to answer was: How can we avoid what’s going on in China? As the virus spread, the question mutated: How to avoid what was going on in Italy? Finally, it became: How to avoid what was going on in New York City?

What Einstein would go through over the course of a month — its preparation for a pandemic, the challenges its people faced as the cases grew — was by no means unique. Hospitals all over Philly, and throughout the rest of the country, were busy dealing with similar concerns. Transforming themselves. Planning. Tracking the various scenarios that suggested if — and when — they might run out of beds, or ventilators, or protective equipment. They all stood at the precipice of an outbreak, and when they peered over the edge, they could only see that there was a drop. How far was anyone’s guess.

In a sick person’s journey, the hospital is the final destination. That is to say, there’s only so much a hospital can do to prepare for a pandemic, because if a surge of patients arrives, society has already failed. A dispassionate auditor would likely identify no shortage of such failures in the U.S. when it came to coronavirus: a federal government that declined to take the risk seriously until it was too late; a nonexistent testing and contact-tracing system; an unregulated health-care supply chain that turned to price-gouging in times of crisis; a lack of societal buy-in among some people for social-distancing measures. For Einstein, it was like being the last player in a game of telephone — the one who has to guess the original phrase — when each person along the way was botching the answer, shifting the correct response a bit more each time.

So the best Einstein could do was wait. It could try to prepare for the worst. But all it could really do was wait.

•

March 16th

Confirmed COVID inpatients: 1

Suspected COVID inpatients: 0

Coordinating Einstein’s daily response to the pandemic was Ken Levitan, a 56-year-old who, on top of his usual job as chief administrative officer, assumed the rather soldierly title of “incident commander.” Levitan, who’d left Einstein after a decade to work in consulting and was now back for a second stint, was effectively responsible for directing the flows of bureaucratic traffic. “My primary goal is to make sure that the right people are talking to each other,” he told me.

In an institution with 8,500 employees, that meant plenty of phone calls, the most important of which were the twice-daily reports from the incident command team, comprised of some 40 people ranging from accounting staff to doctors, who occasionally called in to give updates in the middle of their shifts — their speech muffled by face masks and full PPE garb. The calls, which could last up to two hours, always began with an update tracking the virus in the Philadelphia region. On March 15th: 20 cases in Montgomery County, four in the City of Philadelphia — none yet at Einstein. At that point, Levitan was in command of a squadron still very much planning its defensive fortifications. The group discussed that day how it would develop an employee testing program, whether or not the hospitals should cancel elective surgeries, and which employees could work from home.

Two days later, there was progress. Einstein would transform two of its outpatient clinics in Philadelphia into ad hoc testing locations for employees and patients. Clinical staff had done an audit of hospital space and decided a wing on the sixth floor of Einstein’s Philadelphia hospital would act as a site for ICU patients in the event of an overflow at the regular ICU. “In a normal cadence, these things would take three months,” Levitan explained. “We got them done in less than a week.”

For all of Einstein’s maneuverings, it was a tall order for the methodical gears of a large institution — greased though they were through the streamlined incident command structure — to keep pace with a virus. By March 16th, four days after Einstein had its first incident command meeting, the Montgomery hospital confirmed its first positive COVID-19 diagnosis. The anticipatory period of planning was officially over.

Emily Petipren, a 26-year-old ICU nurse four years out of nursing school, was one of the primary care nurses for that patient, a man in his 40s who was physically active and had no underlying health problems. By the time Petipren saw him, he’d already been intubated — put to sleep and temporarily paralyzed so a doctor could guide a plastic tube down his throat, through his vocal cords, to block off his airway and attach the tube to a ventilator that would funnel oxygen directly into his lungs. Whatever Petipren had imagined her first COVID patient might look like, it wasn’t this. “You expect older patients — patients who have been smoking, who have COPD, asthma, who are already compromised,” she said. “But to have somebody come in with no health history — healthy, active person — and see them decompensate so quickly?” She only needed to see this once to realize: Whatever the coming weeks would hold, it was going to be bad — for patients and hospital staff alike.

There are more unknowns than knowns about how, exactly, the coronavirus sickens an individual, but what the doctors suspect is this: In the sickest patients, the virus attacks the lungs. The lungs, stressed and overwhelmed, begin to ooze fluid, which clogs the air sacs that deliver oxygen to the blood. Blood that lacks oxygen starts a chain reaction, crippling the rest of the organs. A healthy individual should have a blood oxygen level of 95 percent. In the coming days, Petipren would see coronavirus patients come into the hospital with oxygen levels anywhere between 20 and 60 percent.

There is no drug treatment for coronavirus. Doctors at Einstein would try prescribing the anti-malarial medication hydroxychloroquine, but absent a controlled study, there was no way to know whether a patient improved because of the drug — or in spite of it. As with many viruses, maddeningly, the only guaranteed method for helping a patient in serious distress was to keep him alive on a ventilator, leaving caregivers to watch, helplessly, as the body tried to combat the virus on its own. Sometimes, the lungs are so decimated, even a ventilator fails to oxygenate. The body suffocates.

•

March 25th

Confirmed COVID inpatients: 12

Suspected COVID inpatients: 105

Like most hospitals, Einstein had stockpiled personal protective equipment in case of a pandemic. Before this one began, the institution believed it had enough N95 respirator masks — critical pieces of equipment that filter out air and viral particles and provide the best protection for caregivers who have close contact with infectious patients — to last a year even under dire circumstances.