Tagged Hospitals

College Tuition Sparked a Mental Health Crisis. Then the Hefty Hospital Bill Arrived.

Despite a lifelong struggle with panic attacks, Divya Singh made a brave move across the world last fall from her home in Mumbai, India. She enrolled at Hofstra University in Hempstead, New York, to study physics and explore an interest in standup comedy in Manhattan.

Arriving in the midst of the covid-19 pandemic and isolated in her dorm room, Singh’s anxiety ballooned when her family had trouble coming up with the money for a $16,000 tuition installment. Hofstra warned her she would have to vacate the dorm after the term ended if she was not paid up. At one point, she ran into obstacles transferring money onto her campus meal card.

“I’m a literally broke college student that didn’t have money for food,” she recalled. “At that moment of panic, I didn’t want to do anything or leave my bed.”

In late October, she called the campus counseling center hotline and met with a psychologist. “All I wanted was someone to listen to me and validate the fact that I wasn’t going crazy,” she said.

Instead, when she mentioned suicidal thoughts, the psychologist insisted on a psychiatric evaluation. Singh was taken by ambulance to Long Island Jewish Medical Center in New Hyde Park, New York, and kept for a week on a psychiatric ward at nearby Zucker Hillside Hospital. Both are part of the Northwell Health system.

The experience — lots of time alone and a few therapy sessions — was of minimal benefit psychologically, she said. Singh emerged facing the same tuition debt as before.

And then another bill came.

The Patient: Divya Singh, a 20-year-old student at Hofstra University.

Medical Service: Seven-day inpatient psychiatric stay at Zucker Hillside Hospital in Glen Oaks, New York.

Service Provider: Northwell Health, a large nonprofit hospital system in New York City and Long Island.

Total Bill: Northwell charged $50,282, which Singh’s insurer, Aetna, reduced to $17,066 under its contract with Northwell. The plan required Singh to pay $3,413.20 of that.

What Gives: Singh had purchased her Aetna insurance plan through Hofstra, paying $1,107 for the fall term. Aetna markets the plan specifically for students. Under its terms, students can be on the hook for up to $7,350 of the costs of medical care during a year, according to plan documents. Singh’s Northwell bill of around $3,413 is the plan’s requirement that she pay for 20% of the costs of her hospital stay.

Although such coinsurance requirements are common in American health plans, they can be financially overwhelming for students with no income and families whose finances are already under the extreme stress of high tuition. Singh’s Hofstra bill for the academic year, including room and board and ancillary fees, totaled $68,275.

As a result, Singh found herself beset by a double whammy of bills from two of the costliest kinds of institutions in America — colleges and hospitals — both with prices that inexorably rise faster than inflation.

For hospitals, there is supposed to be a relief valve. The Internal Revenue Service requires all nonprofit hospitals to have a financial assistance policy that lowers or eliminates bills for people without the financial resources to pay them. Such financial assistance — commonly known as charity care — is a condition for hospitals to maintain their tax-exempt status, shielding them from having to pay property taxes on often expansive campuses.

Northwell’s financial assistance policy limits the hospital from charging more than $150 for individuals who earn $12,880 a year or less. It offers discounts on a sliding scale for individuals earning up to $64,400 a year, although people with savings or other “available assets” above $10,000 might get less or not qualify.

The IRS requires hospitals to “widely publicize” the availability of financial assistance, inform all patients about how they can obtain it and include “a conspicuous written notice” on billing statements.

While the bill Northwell sent Singh includes a reference to “financial difficulties” and a phone number to call, it did not explicitly state that the hospital might reduce or waive the bill. Instead, the letter obliquely said “we can assist you in making budget payment arrangements” — a phrase that conjures installment payments rather than debt relief.

Image of signage outside Zucker Hillside HospitalWhen Hofstra University student Divya Singh mentioned suicidal thoughts to a psychologist, the psychologist insisted on a psychiatric evaluation. Singh was taken to Long Island Jewish Medical Center in New Hyde Park, New York, and kept for a week on a psychiatric ward at nearby Zucker Hillside Hospital. The stay resulted in a $3,413 bill.(Jackie Molloy / for KHN)

Resolution: In a written statement, Northwell said that although “all eligible patients are offered generous financial payment options … it is not required that providers list the options on the bill.” Northwell stated: “If a patient calls the number provided and expresses financial hardship, the patient is assisted with a financial need application.” However, Northwell lamented, “unfortunately, many patients do not call.”

Indeed, a KHN investigation in 2019 found that, nationwide, 45% of nonprofit hospital organizations were routinely sending medical bills to patients whose incomes were low enough to qualify for charity care. Those bills, which totaled $2.7 billion, were most likely an undercount since they included only the debt hospitals had given up trying to collect.

Singh said the worker who took down her insurance information during her hospital stay never explained that Northwell might reduce her portion of the charge. She said she didn’t realize that was a possibility from the language in the bill they sent.

Northwell said in a statement that after KHN contacted it about Singh’s case, Northwell dispatched a caseworker to contact her. Singh said the caseworker helped Singh enroll in Medicaid, the state-federal health insurance program for low-income people. Foreign students are not generally eligible for Medicaid, but in New York they can get coverage for emergency services. With the addition of Medicaid’s coverage, Singh should end up paying nothing if the stay is retroactively approved, Northwell said.

At the same time the caseworker was helping Singh, Singh received a “final reminder” letter from Northwell about her bill. That letter also mentioned Northwell’s financial assistance, but only within the context of people who completely lack health insurance.

“Send payment or contact us within 21 days to avoid further collection activity,” the letter said.

The Takeaway: Despite stricter requirements from the Affordable Care Act and the IRS to make nonprofit hospitals proactively educate patients about the various forms of financial relief they offer, the onus still remains on patients. If you have trouble paying a bill, call the hospital and ask for a copy of its financial assistance policy and the application to request your bill be discounted or excused.

Be aware that hospitals generally require proof of your financial circumstances such as pay stubs or unemployment checks. Even if you have health insurance that covers much of your medical bill, you may still be eligible to have your bill lowered or get on a government insurance program like Medicaid.

You can also find documentation online: All nonprofit hospitals are required to post financial assistance policies on their websites. They must provide summaries written in plain language and versions translated into foreign languages spoken by significant portions of their communities. Be aware that financial assistance is distinct from paying your full debt off in installments, which is what hospitals sometimes first propose.

Although the IRS rules don’t govern for-profit hospitals, many of those also offer concessions for people with proven financial hardship. The criteria and generosity of charity care vary among hospitals, but many give breaks to families with middle-class incomes: Northwell’s policy, for instance, extends to families of four earning $132,500 a year.

Portrait of Divya Singh at Hofstra University in Hempstead, New YorkThe bill that Northwell Health system sent to Hofstra University student Divya Singh following a weeklong stay in a psychiatric hospital included a reference to “financial difficulties” and a phone number to call, yet it did not explicitly state that the hospital might reduce or waive the bill.(Jackie Molloy / for KHN)

Singh’s family has paid off her fall tuition and half of her spring tuition so far. She still owes $16,565.

Singh said the back and forth over her hospital bill continues to cause anxiety. “The treatment I got in the hospital, after I’ve gotten out, it hasn’t helped,” she said. “I have nightmares about that place.” The biggest benefit of her week there, she said, was bonding with the other patients “because they were also miserable with the way they were being treated.”

Dan Weissmann, host of the “An Arm and a Leg” podcast, contributed the audio portrait that aired on NPR’s “Morning Edition.”

Bill of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

Learning to Listen to Patients’ Stories

Waclawa “Joanne” Zak, who now lives in Oxford, Wis., fought in the Polish resistance during World War II. As a teenager, she served as a scout, assessing German troop strength and positions. Later in the war she trained as a nurse and was liberated from a German P.O.W. camp. She told her story as part of the “My Life, My Story” program at the William S. Middleton Memorial Veterans Hospital in Madison, Wis.
Waclawa “Joanne” Zak, who now lives in Oxford, Wis., fought in the Polish resistance during World War II. As a teenager, she served as a scout, assessing German troop strength and positions. Later in the war she trained as a nurse and was liberated from a German P.O.W. camp. She told her story as part of the “My Life, My Story” program at the William S. Middleton Memorial Veterans Hospital in Madison, Wis.Credit…Andy Manis for The New York Times

Learning to Listen to Patients’ Stories

Narrative medicine programs teach doctors and other caregivers “sensitive interviewing skills” and the art of “radical listening” to improve patient care.

Waclawa “Joanne” Zak, who now lives in Oxford, Wis., fought in the Polish resistance during World War II. As a teenager, she served as a scout, assessing German troop strength and positions. Later in the war she trained as a nurse and was liberated from a German P.O.W. camp. She told her story as part of the “My Life, My Story” program at the William S. Middleton Memorial Veterans Hospital in Madison, Wis.Credit…Andy Manis for The New York Times

  • Feb. 25, 2021, 5:00 a.m. ET

The pandemic has been a time of painful social isolation for many. Few places can be as isolating as hospitals, where patients are surrounded by strangers, subject to invasive tests and attached to an assortment of beeping and gurgling machines.

How can the experience of receiving medical care be made more welcoming? Some say that a sympathetic ear can go a long way in helping patients undergoing the stress of a hospital stay to heal.

“It is even more important now, when we can’t always see patients’ faces or touch them, to really hear their stories,” said Dr. Antoinette Rose, an urgent care physician in Mountain View, Calif., who is now working with many patients ill with Covid.

“This pandemic has forced many caregivers to embrace the human stories that are playing out. They have no choice. They become the ‘family’ at the bedside,” said Dr. Andre Lijoi, a medical director at York Hospital in Pennsylvania. Doctors, nurses and others assisting in the care of patients “need time to slow down, to take a breath, to listen.”

Both doctors find their inspiration in narrative medicine, a discipline that guides medical practitioners in the art of deeply listening to those who come to them for help. Narrative medicine is now taught in some form at roughly 80 percent of medical schools in the United States. Students are trained in “sensitive interviewing skills” and the art of “radical listening” as ways to enhance the interactions between doctors and their patients.

“As doctors, we need to ask those who come to us: ‘Tell me about yourself,’” explained Dr. Rita Charon, who founded Columbia University’s pioneering narrative medicine program in 2000. “We have fallen out of that habit because we think we know the questions to ask. We have a checklist of symptom questions. But there is an actual person in front of us who is not just a collection of symptoms.”

Columbia is currently offering training online for medical students like Fletcher Bell, who says the course is helping to transform the way he sees his future role as healer. As part of his narrative medicine training, Mr. Bell has kept in touch virtually with a woman who was being treated for ovarian cancer, an experience of sharing that he described as being both heartbreaking and also beautiful.

“Simply listening to people’s stories can be therapeutic,” Mr. Bell observed. “If there is fluid in the lungs, you drain it. If there is a story in the heart, it’s important to get that out too. It is also a medical intervention, just not one that can be easily quantified.”

This more personalized approach to medical care is not a new art. In the not-so-distant past, general practitioners often treated several generations of the same family, and they knew a lot about their lives. But as medicine became increasingly institutionalized, it became more rushed and impersonal, said Dr. Charon.

The typical doctor visit now lasts from 13 to 16 minutes, which is generally all that insurance companies will pay for. A 2018 study published in the Journal of General Internal Medicine found that the majority of doctors at the prestigious Mayo Clinic didn’t even ask people the purpose of their visit, and they frequently interrupted patients as they spoke about themselves.

But this fast-food approach to medicine sacrifices something essential, says Dr. Deepu Gowda, assistant dean of medical education at the Kaiser-Permanente School of Medicine in Pasadena, Calif., who was trained by Dr. Charon at Columbia.

Dr. Gowda recalls one elderly patient he saw during his residency who suffered from severe arthritis and whom he experienced as being angry and frustrated. He came to dread her office visits. Then he started asking the woman questions and listened with interest as her personal history unfolded. He became so intrigued by her life story that he asked her permission to take photographs of her outside the hospital, which she granted.

Dr. Gowda was particularly struck by one picture of his patient, cane in hand, clutching onto the banister of her walk-up apartment. “That image represented for me her daily struggles,” he said. “I gave her a copy. It was a physical representation of the fact that I cared for who she was as a person. Her pain didn’t go away, but there was a lightness and laughter in those later visits that wasn’t there before. There was a kind of healing that took place in that simple human recognition.”

While few working doctors have the leisure time to photograph their patients outside the clinic, or to probe deeply into their life history, “people pick up on it” when the doctor expresses genuine interest in them, Dr. Gowda said. They trust such a doctor more, becoming motivated to follow their instructions and to return for follow-up visits, he said.

Some hospitals have started conducting preliminary interviews with patients before the clinical work begins as a way to get to know them better.

Darrell Krenz of Madison, Wis., recounted his Army days as part of the V.A.’s “My Life, My Story” program.Credit…Andy Manis for The New York Times
Orlando Dowell, a 16-year Marine Corps veteran and “My Life, My Story” participant, at his home in Dakota, Ill.Credit…Andy Manis for The New York Times

Thor Ringler, a family therapist, started the “My Life, My Story” program at the William S. Middleton Memorial Veterans Hospital in Madison, Wis., in 2013. Professional writers are hired to interview veterans — by phone and video conference since the onset of the pandemic — and to draft a short biography that is added to their medical record and read by their attending physician.

“My goal was to provide vets with a way of being heard in a large bureaucratic system where they don’t always feel listened to,” Mr. Ringler said.

The program has spread to 60 V.A. hospitals, including in Boston, where more than 800 veteran stories have been compiled over the past three years. Jay Barrett, nurse manager at the VA Boston Healthcare System, said these biographies often provide critical information that can help guide the treatment.

“Unless they have access to the patient’s story,” Ms. Barrett said, “health care providers don’t understand that this is a mother who is taking care of six children, or who doesn’t have the resources to pay for medication, or this is a veteran that has severe trauma that needs to be addressed before even talking about how to manage the pain.”

Dr. Lewis Mehl-Madrona, a family doctor who teaches at the University of New England in Biddeford, Maine, has been studying veterans who were undergoing treatment for pain. Those who were asked to tell about their lives experienced less chronic pain and rated the relationship with their physician higher than those who had not. The doctors who solicited the stories also reported more job satisfaction and were subject to less emotional burnout, which has become an especially worrisome problem during the Covid pandemic.

Demands have never been greater on health care workers’ time. But narrative medicine advocates say that it only takes a few moments to forge an authentic human connection, even when the communication takes place online, as it often does now. Dr. Mehl-Madrona argues that remote videoconferencing platforms like Zoom can actually make it even easier to keep track of vulnerable people and to solicit their stories.

Derek McCracken, a lecturer at Columbia University who helped develop training protocols for using narrative techniques in telehealth, agrees. “Telehealth technology can be a bridge,” he said, “because it’s an equalizer, forcing both parties to slow the conversation down, be vulnerable and listen attentively.”

The critical point for Dr. Mehl-Madrona is that when people are asked to talk about themselves — whether that happens in person or onscreen — they are “not just delivering themselves to the doctor to be fixed. They become actively engaged in their own healing.”

“Doctors can be replaced by computers or by nurses if they think their only role is just to prescribe drugs,” he added. “If we want to avoid the fate of the Dodo bird, then we have to engage in dynamic relationships with patients, we have to put the symptoms in the context of people’s lives.”

For Some Teens, It’s Been a Year of Anxiety and Trips to the E.R.

For Some Teens, It’s Been a Year of Anxiety and Trips to the E.R.

During the pandemic, suicidal thinking is up. And families find that hospitals can’t handle adolescents in crisis.

Lisa, a mother of three in Asheville, N.C., said that months of virtual classes and social isolation had changed her extroverted 13-year-old son “in profound ways I would never have anticipated.”
Lisa, a mother of three in Asheville, N.C., said that months of virtual classes and social isolation had changed her extroverted 13-year-old son “in profound ways I would never have anticipated.”Credit…Jacob Biba for The New York Times
Benedict Carey

  • Published Feb. 23, 2021Updated Feb. 24, 2021, 5:00 a.m. ET

When the pandemic first hit the Bay Area last spring, Ann thought that her son, a 17-year-old senior, was finally on track to finish high school. He had kicked a heavy marijuana habit and was studying in virtual classes while school was closed.

The first wave of stay-at-home orders shut down his usual routines — sports, playing music with friends. But the stability didn’t last.

“The social isolation since then, over all this time, it just got to him,” said Ann, a consultant living in suburban San Francisco. She, like the other parents in this article, asked that her last name be omitted for privacy and to protect her child. “This is a charming, funny kid, also sensitive and anxious,” she said. “He couldn’t find a job; he couldn’t really go out. And he started using marijuana again, and Xanax.”

The teenager’s frustration finally boiled over this month, when he deliberately cut himself.

“We called 911, and he was taken to the emergency room,” his mother said. “But there they just stitched him up and released him.” The doctors sent him home, she said, “with no support, no therapy, nothing.”

Ann and her son are like many families over the last year. Surveys and statistics show that for young people who are anxious by nature, or feeling emotionally fragile already, the pandemic and its isolation have pushed them to the brink. Rates of suicidal thinking and behavior are up by 25 percent or more from similar periods in 2019, according to a just-published analysis of surveys of young patients coming into the emergency room.

For these teenagers, there aren’t many places to turn. They need help, but it’s hard to come up with a psychiatric diagnosis. They are trying to manage a surprise interruption in their lives, a vague loss. And without a diagnosis, reimbursement for therapy is hard to come by. And that is assuming parents know what kind of help is appropriate, and where to find it.

Finally, when a crisis hits, many of these teenagers end up in the local emergency department — the one place desperate families so often go for help.

Many E.R. departments across the country are now seeing a surge in such cases. Through most of 2020, the proportion of pediatric emergency admissions for mental problems, like panic and anxiety, was up by 24 percent for young children and 31 percent for adolescents compared to the previous year, according to a recent report by the Centers for Disease Control and Prevention.

And the local emergency department is frequently unprepared for the added burden. Workers often are not specially trained to manage behavioral problems, and families don’t have many options for where to go next, leaving many of these pandemic-insecure adolescents in limbo at the E.R.

“This is a national crisis we’re facing,” Dr. Rebecca Baum, a developmental pediatrician in Asheville, N.C. “Kids are having to board in the E.R. for days on end, because there are no psychiatric beds available in their entire state, never mind the hospital. And of course, the child or adolescent is lying there and doesn’t understand what’s happening in the E.R., why they’re having to wait there or where they’re going.”

What Adolescents Are Feeling

Most teenagers and young adults have done fine through this pandemic year, provided that their families have stayed healthy and economically stable. They may be irritable or missing their friends, but their support networks have been enough to get them through the pandemic.

For the young people coming undone, however, pandemic life presents unusual challenges, pediatricians say. Most are temperamentally sensitive and after months of being socially cut off from friends and activities, they have much less control over their moods.

“What parents and children are consistently reporting is an increase in all symptoms — a child who was a little anxious before the pandemic became very anxious over this past year,” said Dr. Adiaha I. A. Spinks-Franklin, an associate professor of pediatrics at the Baylor College of Medicine. It is this prolonged stress, Dr. Spinks-Franklin said, that in time blunts the brain’s ability to manage emotions.

Jean, an artist and mother of two living in Hendersonville, N.C., said that her 17-year-old son was doing fine through last spring. But the months of virtual classes and loss of simple social pleasures — hanging out with friends, playing chess — changed him through the fall months.

“Now, he’s become very reclusive, he has mood swings, he cries a lot,” Jean said. “This giant boy, crying — it’s terrible to see.” The young man has had panic attacks, twice followed by a blackout. During one, he fell and injured his face.

Dr. Adiaha I. A. Spinks-Franklin, an associate professor of pediatrics at the Baylor College of Medicine, says it’s the prolonged stress that blunts the brain’s ability to manage emotions.
Dr. Adiaha I. A. Spinks-Franklin, an associate professor of pediatrics at the Baylor College of Medicine, says it’s the prolonged stress that blunts the brain’s ability to manage emotions.Credit…Brett Deering for The New York Times

Lisa, a mother of three in Asheville, said that the months of virtual classes and relative social isolation had changed her extroverted 13-year-old son “in profound ways I would never have anticipated.”

His grades slipped badly, and he began to withdraw. “Next, he was telling us he couldn’t make himself do the work, that he didn’t want to disappoint us all the time, that he was worthless. Worthless.”

These young people do not necessarily qualify for a psychiatric diagnosis, nor are they “traumatized” in the strict sense of having had a life-threatening experience (or the perception of one.) Rather, they are trying to manage an interruption in their normal development, child psychologists say: a sudden and indefinite suspension of almost every routine and social connection, leaving a deep yet vague sense of loss with no single, distinct source.

The result is grief, but grief without a name or a specific cause, an experience some psychologists call “ambiguous loss.” The concept is usually reserved to describe the experience of immigrants, displaced from everything familiar, who shut down emotionally in a new and strange country. Or to describe disaster survivors, who return to neighborhoods that are hollowed out, transformed.

“Everything that used to be familiar and give structure to their lives, and predictability, and normalcy, is gone,” said Sharon Young, a therapist in Hendersonville. “Kids need all these things even more than adults do, and it’s hard for them to feel emotionally safe when they’re no longer there.”

System Overload

The resulting changes in behavior can seem sudden: A bright sixth-grader is found cutting herself; a sweet-natured sophomore takes a swing at a parent or sibling. Parents, frightened, often don’t know where to go for appropriate help. Many don’t have the resources or knowledge to hire a therapist.

Families that land in the emergency departments of their local hospitals often find that the clinics are poorly equipped to handle these incoming cases. The staff is better trained to manage physical trauma than the mental variety, and patients are often sent right back home, without proper evaluation or support. In severe cases, they may linger in the emergency department for days before a bed can be found elsewhere.

In a recent report, a research team led by the C.D.C. found that less than half of the emergency departments in U.S. hospitals had clear policies in place to handle children with behavior problems. Getting to the bottom of any complex behavior issue can takes days of patient observation, at minimum, psychiatrists say. And many emergency departments do not have the on-hand specialists, dedicated space or off-site resources to help do the job well.

For Jean, diagnosing her son has been complicated. He has since developed irritable bowel syndrome. “He has been losing weight, and started smoking pot due to the boredom,” Jean said. “This is all due to the anxiety.”

Nationwide Children’s Hospital in Columbus, Ohio, has an emergency department that is a decent size for a pediatric hospital, with capacity for 62 children or adolescents. But well before the arrival of the coronavirus, the department was straining to handle increasing numbers of patients with behavior problems.

“This was huge problem pre-pandemic,” said Dr. David Axelson, chief of psychiatry and behavioral health at the hospital. “We were seeing a rise in emergency department visits for mental health problems in kids, specifically for suicidal thinking and self-harm. Our emergency department was overwhelmed with it, having to board kids on the medical unit while waiting for psych beds.”

Last March, to address the crowding, Nationwide Children’s opened a new pavilion, a nine-story facility with 54 dedicated beds for observation and for longer-term stays for those with mental challenges. It has taken the pressure off the hospital’s regular emergency department and greatly improved care, Dr. Axelson said.

Over this pandemic year, with the number of admissions for mental health problems up by some 15 percent over previous years, it is hard to imagine what it would have been like without the additional, devoted behavioral clinic, Dr. Axelson said.

Other hospitals from out of state often call, hoping to place a patient in crisis, but there is simply not enough space. “We have to say no,” Dr. Axelson said.

“We had a shaky system of care in pediatric mental health prior to this pandemic, and now we have all these added stressors on it,” said  Dr. Rebecca Baum, a developmental pediatrician in Asheville, N.C.Credit…Jacob Biba for The New York Times

Dr. Rachel Stanley, the chief of emergency medicine at Nationwide, said that most hospitals have far fewer resources. “I worked at a hospital in Michigan for years, and when these kinds of kids come in, everyone dreaded seeing them, because we didn’t feel like we had the tools to help,” she said. “They have to go into a safe room; they can’t be in a shared area. You have to provide a sitter for the child, a staff person to stay with them all the time to make sure they’re not suicidal or homicidal. It could take hours and hours to get social workers involved, and all this time they’re getting worse.”

Anne, the consultant in the Bay Area, said that her son’s visit to the emergency room this month was his third in the past 18 months, each time for issues related to drug withdrawal. On one visit, he was misdiagnosed with psychosis and sent to a locked county psychiatric ward. “That experience itself — locked for days in a ward, with no one telling him why, or how long he’d be there — was the most traumatic thing he’s experienced,” she said.

Like many other parents, she is now looking after an unstable child and wondering where to go next. A drug rehab program may be needed, as well as regular therapy.

Lisa has hired a therapist for her son, a Zoom session every other week. That seems to have helped, she said, but it is too early to tell. And Jean, for the moment, is hoping the infection risk will diminish soon, so her son can get a safe job.

All three parents have become keen observers of their children, more aware of shifting moods. Listening by itself usually helps relieve distress, therapists say. “Trying to educate parents is a routine part of the job,” said Dr. Robert Duffey, a pediatrician in Hendersonville. “And of course we need these kids back in school, so badly.”

But medical professional say that until the health care system finds a way to equip and support emergency departments for what they have become — the first and sometimes last resort — parents will be left to navigate mostly on their own, leaning on others who have managed similar problems.

“Covid has put our system under a microscope in terms of the things that don’t work,” said Dr. Baum, the pediatrician in Asheville. “We had a shaky system of care in pediatric mental health prior to this pandemic, and now we have all these added stressors on it, all these kids coming in for pandemic-related issues. Hospitals everywhere are scrambling to adjust.”

If you are having thoughts of suicide, call the National Suicide Prevention Lifeline at 1-800-273-8255 (TALK). You can find a list of additional resources at SpeakingOfSuicide.com/resources.

For Some Teens, It’s Been a Year of Anxiety and Trips to the E.R.

For Some Teens, It’s Been a Year of Anxiety and Trips to the E.R.

During the pandemic, suicidal thinking is up. And families find that hospitals can’t handle adolescents in crisis.

Lisa, a mother of three in Asheville, N.C., said that months of virtual classes and social isolation had changed her extroverted 13-year-old son “in profound ways I would never have anticipated.”
Lisa, a mother of three in Asheville, N.C., said that months of virtual classes and social isolation had changed her extroverted 13-year-old son “in profound ways I would never have anticipated.”Credit…Jacob Biba for The New York Times
Benedict Carey

  • Feb. 23, 2021, 3:48 p.m. ET

When the pandemic first hit the Bay Area last spring, Ann thought that her son, a 17-year-old senior, was finally on track to finish high school. He had kicked a heavy marijuana habit and was studying in virtual classes while school was closed.

The first wave of stay-at-home orders shut down his usual routines — sports, playing music with friends. But the stability didn’t last.

“The social isolation since then, over all this time, it just got to him,” said Ann, a consultant living in suburban San Francisco. She, like the other parents in this article, asked that her last name be omitted for privacy and to protect her child. “This is a charming, funny kid, also sensitive and anxious,” she said. “He couldn’t find a job; he couldn’t really go out. And he started using marijuana again, and Xanax.”

The teenager’s frustration finally boiled over this month, when he deliberately cut himself.

“We called 911, and he was taken to the emergency room,” his mother said. “But there they just stitched him up and released him.” The doctors sent him home, she said, “with no support, no therapy, nothing.”

Ann and her son are like many families over the last year. Surveys and statistics show that for young people who are anxious by nature, or feeling emotionally fragile already, the pandemic and its isolation have pushed them to the brink. Rates of suicidal thinking and behavior are up by 25 percent or more from similar periods in 2019, according to a just-published analysis of surveys of young patients coming into the emergency room.

For these teenagers, there aren’t many places to turn. They need help, but it’s hard to come up with a psychiatric diagnosis. They are trying to manage a surprise interruption in their lives, a vague loss. And without a diagnosis, reimbursement for therapy is hard to come by. And that is assuming parents know what kind of help is appropriate, and where to find it.

Finally, when a crisis hits, many of these teenagers end up in the local emergency department — the one place desperate families so often go for help.

Many E.R. departments across the country are now seeing a surge in such cases. Through most of 2020, the proportion of pediatric emergency admissions for mental problems, like panic and anxiety, was up by 24 percent for young children and 31 percent for adolescents compared to the previous year, according to a recent report by the Centers for Disease Control and Prevention.

And the local emergency department is frequently unprepared for the added burden. Workers often are not specially trained to manage behavioral problems, and families don’t have many options for where to go next, leaving many of these pandemic-insecure adolescents in limbo at the E.R.

“This is a national crisis we’re facing,” Dr. Rebecca Baum, a developmental pediatrician in Asheville, N.C. “Kids are having to board in the E.R. for days on end, because there are no psychiatric beds available in their entire state, never mind the hospital. And of course, the child or adolescent is lying there and doesn’t understand what’s happening in the E.R., why they’re having to wait there or where they’re going.”

What Adolescents Are Feeling

Most teenagers and young adults have done fine through this pandemic year, provided that their families have stayed healthy and economically stable. They may be irritable or missing their friends, but their support networks have been enough to get them through the pandemic.

For the young people coming undone, however, pandemic life presents unusual challenges, pediatricians say. Most are temperamentally sensitive and after months of being socially cut off from friends and activities, they have much less control over their moods.

“What parents and children are consistently reporting is an increase in all symptoms — a child who was a little anxious before the pandemic became very anxious over this past year,” said Dr. Adiaha I. A. Spinks-Franklin, an associate professor of pediatrics at the Baylor College of Medicine. It is this prolonged stress, Dr. Spinks-Franklin said, that in time blunts the brain’s ability to manage emotions.

Jean, an artist and mother of two living in Hendersonville, N.C., said that her 17-year-old son was doing fine through last spring. But the months of virtual classes and loss of simple social pleasures — hanging out with friends, playing chess — changed him through the fall months.

“Now, he’s become very reclusive, he has mood swings, he cries a lot,” Jean said. “This giant boy, crying — it’s terrible to see.” The young man has had panic attacks, twice followed by a blackout. During one, he fell and injured his face.

Dr. Adiaha I. A. Spinks-Franklin, an associate professor of pediatrics at the Baylor College of Medicine, says it’s the prolonged stress that blunts the brain’s ability to manage emotions.
Dr. Adiaha I. A. Spinks-Franklin, an associate professor of pediatrics at the Baylor College of Medicine, says it’s the prolonged stress that blunts the brain’s ability to manage emotions.Credit…Brett Deering for The New York Times

Lisa, a mother of three in Asheville, said that the months of virtual classes and relative social isolation had changed her extroverted 13-year-old son “in profound ways I would never have anticipated.”

His grades slipped badly, and he began to withdraw. “Next, he was telling us he couldn’t make himself do the work, that he didn’t want to disappoint us all the time, that he was worthless. Worthless.”

These young people do not necessarily qualify for a psychiatric diagnosis, nor are they “traumatized” in the strict sense of having had a life-threatening experience (or the perception of one.) Rather, they are trying to manage an interruption in their normal development, child psychologists say: a sudden and indefinite suspension of almost every routine and social connection, leaving a deep yet vague sense of loss with no single, distinct source.

The result is grief, but grief without a name or a specific cause, an experience some psychologists call “ambiguous loss.” The concept is usually reserved to describe the experience of immigrants, displaced from everything familiar, who shut down emotionally in a new and strange country. Or to describe disaster survivors, who return to neighborhoods that are hollowed out, transformed.

“Everything that used to be familiar and give structure to their lives, and predictability, and normalcy, is gone,” said Sharon Young, a therapist in Hendersonville. “Kids need all these things even more than adults do, and it’s hard for them to feel emotionally safe when they’re no longer there.”

System Overload

The resulting changes in behavior can seem sudden: A bright sixth-grader is found cutting herself; a sweet-natured sophomore takes a swing at a parent or sibling. Parents, frightened, often don’t know where to go for appropriate help. Many don’t have the resources or knowledge to hire a therapist.

Families that land in the emergency departments of their local hospitals often find that the clinics are poorly equipped to handle these incoming cases. The staff is better trained to manage physical trauma than the mental variety, and patients are often sent right back home, without proper evaluation or support. In severe cases, they may linger in the emergency department for days before a bed can be found elsewhere.

In a recent report, a research team led by the C.D.C. found that less than half of the emergency departments in U.S. hospitals had clear policies in place to handle children with behavior problems. Getting to the bottom of any complex behavior issue can takes days of patient observation, at minimum, psychiatrists say. And many emergency departments do not have the on-hand specialists, dedicated space or off-site resources to help do the job well.

For Jean, diagnosing her son has been complicated. He has since developed irritable bowel syndrome. “He has been losing weight, and started smoking pot due to the boredom,” Jean said. “This is all due to the anxiety.”

Nationwide Children’s Hospital in Columbus, Ohio, has an emergency department that is a decent size for a pediatric hospital, with capacity for 62 children or adolescents. But well before the arrival of the coronavirus, the department was straining to handle increasing numbers of patients with behavior problems.

“This was huge problem pre-pandemic,” said Dr. David Axelson, chief of psychiatry and behavioral health at the hospital. “We were seeing a rise in emergency department visits for mental health problems in kids, specifically for suicidal thinking and self-harm. Our emergency department was overwhelmed with it, having to board kids on the medical unit while waiting for psych beds.”

Last March, to address the crowding, Nationwide Children’s opened a new pavilion, a nine-story facility with 54 dedicated beds for observation and for longer-term stays for those with mental challenges. It has taken the pressure off the hospital’s regular emergency department and greatly improved care, Dr. Axelson said.

Over this pandemic year, with the number of admissions for mental health problems up by some 15 percent over previous years, it is hard to imagine what it would have been like without the additional, devoted behavioral clinic, Dr. Axelson said.

Other hospitals from out of state often call, hoping to place a patient in crisis, but there is simply not enough space. “We have to say no,” Dr. Axelson said.

“We had a shaky system of care in pediatric mental health prior to this pandemic, and now we have all these added stressors on it,” said  Dr. Rebecca Baum, a developmental pediatrician in Asheville, N.C.Credit…Jacob Biba for The New York Times

Dr. Rachel Stanley, the chief of emergency medicine at Nationwide, said that most hospitals have far fewer resources. “I worked at a hospital in Michigan for years, and when these kinds of kids come in, everyone dreaded seeing them, because we didn’t feel like we had the tools to help,” she said. “They have to go into a safe room; they can’t be in a shared area. You have to provide a sitter for the child, a staff person to stay with them all the time to make sure they’re not suicidal or homicidal. It could take hours and hours to get social workers involved, and all this time they’re getting worse.”

Anne, the consultant in the Bay Area, said that her son’s visit to the emergency room this month was his third in the past 18 months, each time for issues related to drug withdrawal. On one visit, he was misdiagnosed with psychosis and sent to a locked county psychiatric ward. “That experience itself — locked for days in a ward, with no one telling him why, or how long he’d be there — was the most traumatic thing he’s experienced,” she said.

Like many other parents, she is now looking after an unstable child and wondering where to go next. A drug rehab program may be needed, as well as regular therapy.

Lisa has hired a therapist for her son, a Zoom session every other week. That seems to have helped, she said, but it is too early to tell. And Jean, for the moment, is hoping the infection risk will diminish soon, so her son can get a safe job.

All three parents have become keen observers of their children, more aware of shifting moods. Listening by itself usually helps relieve distress, therapists say. “Trying to educate parents is a routine part of the job,” said Dr. Robert Duffey, a pediatrician in Hendersonville. “And of course we need these kids back in school, so badly.”

But medical professional say that until the health care system finds a way to equip and support emergency departments for what they have become — the first and sometimes last resort — parents will be left to navigate mostly on their own, leaning on others who have managed similar problems.

“Covid has put our system under a microscope in terms of the things that don’t work,” said Dr. Baum, the pediatrician in Asheville. “We had a shaky system of care in pediatric mental health prior to this pandemic, and now we have all these added stressors on it, all these kids coming in for pandemic-related issues. Hospitals everywhere are scrambling to adjust.”

If you are having thoughts of suicide, call the National Suicide Prevention Lifeline at 1-800-273-8255 (TALK). You can find a list of additional resources at SpeakingOfSuicide.com/resources.

Medicare Cuts Payment to 774 Hospitals Over Patient Complications

The federal government has penalized 774 hospitals for having the highest rates of patient infections or other potentially avoidable medical complications. Those hospitals, which include some of the nation’s marquee medical centers, will lose 1% of their Medicare payments over 12 months.

The penalties, based on patients who stayed in the hospitals anytime between mid-2017 and 2019, before the pandemic, are not related to covid-19. They were levied under a program created by the Affordable Care Act that uses the threat of losing Medicare money to motivate hospitals to protect patients from harm.

On any given day, one in every 31 hospital patients has an infection that was contracted during their stay, according to the Centers for Disease Control and Prevention. Infections and other complications can prolong hospital stays, complicate treatments and, in the worst instances, kill patients.

“Although significant progress has been made in preventing some healthcare-associated infection types, there is much more work to be done,” the CDC says.

Now in its seventh year, the Hospital-Acquired Condition Reduction Program has been greeted with disapproval and resignation by hospitals, which argue that penalties are meted out arbitrarily. Under the law, Medicare each year must punish the quarter of general care hospitals with the highest rates of patient safety issues. The government assesses the rates of infections, blood clots, sepsis cases, bedsores, hip fractures and other complications that occur in hospitals and might have been prevented. The total penalty amount is based on how much Medicare pays each hospital during the federal fiscal year — from last October through September.

Hospitals can be punished even if they have improved over past years — and some have. At times, the difference in infection and complication rates between the hospitals that get punished and those that escape punishment is negligible, but the requirement to penalize one-quarter of hospitals is unbending under the law. Akin Demehin, director of policy at the American Hospital Association, said the penalties were “a game of chance” based on “badly flawed” measures.

Some hospitals insist they received penalties because they were more thorough than others in finding and reporting infections and other complications to the federal Centers for Medicare & Medicaid Services and the CDC.

“The all-or-none penalty is unlike any other in Medicare’s programs,” said Dr. Karl Bilimoria, vice president for quality at Northwestern Medicine, whose flagship Northwestern Memorial Hospital in Chicago was penalized this year. He said Northwestern takes the penalty seriously because of the amount of money at stake, “but, at the same time, we know that we will have some trouble with some of the measures because we do a really good job identifying” complications.

Other renowned hospitals penalized this year include Ronald Reagan UCLA Medical Center and Cedars-Sinai Medical Center in Los Angeles; UCSF Medical Center in San Francisco; Beth Israel Deaconess Medical Center and Tufts Medical Center in Boston; NewYork-Presbyterian Hospital in New York; UPMC Presbyterian Shadyside in Pittsburgh; and Vanderbilt University Medical Center in Nashville, Tennessee.

There were 2,430 hospitals not penalized because their patient complication rates were not among the top quarter. An additional 2,057 hospitals were automatically excluded from the program, either because they solely served children, veterans or psychiatric patients, or because they have special status as a “critical access hospital” for lack of nearby alternatives for people needing inpatient care.

The penalties were not distributed evenly across states, according to a KHN analysis of Medicare data that included all categories of hospitals. Half of Rhode Island’s hospitals were penalized, as were 30% of Nevada’s.

All of Delaware’s hospitals escaped punishment. Medicare excludes all Maryland hospitals from the program because it pays them through a different arrangement than in other states.

Over the course of the program, 1,978 hospitals have been penalized at least once, KHN’s analysis found. Of those, 1,360 hospitals have been punished multiple times and 77 hospitals have been penalized in all seven years, including UPMC Presbyterian Shadyside.

The Medicare Payment Advisory Commission, which reports to Congress, said in a 2019 report that “it is important to drive quality improvement by tying infection rates to payment.” But the commission criticized the program’s use of a “tournament” model comparing hospitals to one another. Instead, it recommended fixed targets that let hospitals know what is expected of them and that don’t artificially limit how many hospitals can succeed.

Although federal officials have altered other ACA-created penalty programs in response to hospital complaints and independent critiques — such as one focused on patient readmissions — they have not made substantial changes to this program because the key elements are embedded in the statute and would require a change by Congress.

Boston’s Beth Israel Deaconess said in a statement that “we employ a broad range of patient care quality efforts and use reports such as those from the Centers for Medicare & Medicaid Services to identify and address opportunities for improvement.”

UCSF Health said its hospital has made “significant improvements” since the period Medicare measured in assessing the penalty.

“UCSF Health believes that many of the measures listed in the report are meaningful to patients, and are also valid standards for health systems to improve upon,” the hospital-health system said in a statement to KHN. “Some of the categories, however, are not risk-adjusted, which results in misleading and inaccurate comparisons.”

Cedars-Sinai said the penalty program disproportionally punishes academic medical centers due to the “high acuity and complexity” of their patients, details that aren’t captured in the Medicare billing data.

“These claims data were not designed for this purpose and are typically not specific enough to reflect the nuances of complex clinical care,” the hospital said. “Cedars-Sinai continually tracks and monitors rates of complications and infections, and updates processes to improve the care we deliver to our patients.”

Look Up Your Hospital: Is It Being Penalized By Medicare?

Under programs set up by the Affordable Care Act, the federal government cuts payments to hospitals that have high rates of readmissions and those with the highest numbers of infections and patient injuries. For the readmission penalties, Medicare cuts as much as 3 percent for each patient, although the average is generally much lower. The patient safety penalties cost hospitals 1 percent of Medicare payments over the federal fiscal year, which runs from October through September. Maryland hospitals are exempted from penalties because that state has a separate payment arrangement with Medicare.

Below are look-up tools for each type of penalty. You can search by hospital name or location, look at all hospitals in a particular state and sort penalties by year.

Related Topics

Cost and Quality Health Industry Medicare States The Health Law

Montana’s Health Policy MVP Takes Her Playbook on the Road

Marilyn Bartlett might be the closest thing health policy has to a folk hero. A certified public accountant who barely tops 5 feet, Bartlett bears zero resemblance to Paul Bunyan. But she did take an ax to Montana’s hospital prices in 2016, stopping the state’s employee health plan from bleeding money.

“Marilyn is not a physically imposing person,” said Montana Board of Investments Executive Director Dan Villa, who worked closely with Bartlett in state government. “She is a blend of your favorite aunt, an accounting savant and a little bit of July Fourth fireworks.”

Bartlett, whose faith in data borders on fervent, hauls binders full of numbers everywhere she goes. “My focus has always been following the dollars,” she said. “You’ve got to roll up your sleeves and get down to the nitty-gritty detail, especially in health care.”

Bartlett’s success in Montana saved the state more than $30 million in three years by pegging hospital prices to a multiple of what Medicare pays. Now, she is an in-demand adviser to states, counties and businesses all trying to control health care costs. But as she’s hit the road, binders in tow, she’s found it difficult to replicate the Montana solution.

A Montana Miracle

Bartlett earned her reputation as administrator of the Montana state employee health plan, a role she assumed in 2014 as the plan hurtled toward insolvency. As Bartlett dug into the data, she discovered hospitals were charging the state as much as five times what they charge Medicare, the federal insurance program — for exactly the same services.

Historically, the state had accepted the seemingly arbitrary prices set by hospitals. Bartlett, staring down a $9 million shortfall, knew that had to change. She wanted the state to start dictating the rates they were willing to pay, but she needed a benchmark first.

She turned to Medicare. Unlike most payers, who bury prices in secret contracts, Medicare makes its payments public. Bartlett borrowed those rates and then more than doubled them — to 234% — knowing that hospitals often complain Medicare pays too little. This new kind of contract, known as reference-based pricing, was among the first attempted at this scale.

Bartlett expected the hospitals to chafe at the offer, but with Montana’s plan insuring 30,000 people, more than any other employer in the state, she had the upper hand. Despite what Bartlett described as “very, very tense” negotiations, all the state’s hospitals signed on.

Five years later, the state health plan regularly runs in the black. Villa, who was former Gov. Steve Bullock’s budget director, said governors dip into the plan’s reserves to fill budget gaps. “I now refer to the state health plan as the ATM,” he said.

The Player Becomes the Coach

Montana’s success became a small sensation, at least in health policy circles. Now, one big question remains — the same one that has deflated the highest hopes of so many health care leaders. Can it be replicated?

Many of the country’s employers are desperate to find out. Their costs have risen 50% in just the past decade. Employee spending on health care is also on the rise, growing two times faster than wages. Leading economics researchers point to high hospital prices as a key culprit.

Since retiring from Montana state government in December 2019, Bartlett said she has spoken at numerous conferences, given hours of free advice, and answered a seemingly endless stream of calls.

One of the first calls came from Trish Riley, executive director of the National Academy for State Health Policy (NASHP). Riley hired Bartlett in 2019 to serve as “a coach, cheerleader and mentor” for officials from dozens of states trying to cut costs, including New Jersey, which passed a bill in 2020 overhauling the state’s health coverage for teachers and estimated to save the state $30 million annually.

Bartlett is also advising regional business coalitions stretching from Houston to Maine and seeing early signs of progress.

In Colorado, Bartlett is coaching a group of public employers, including city, county and state health plans, that have come together to negotiate with hospitals. The group recently notched its first win, signing one hospital to a Medicare-benchmarked contract.

In Indiana, Bartlett is advising the Employers’ Forum of Indiana, a coalition that recently pressured insurer Anthem to renegotiate its contract with a notoriously expensive health system.

Bartlett is even shaping legislation, including recent failed attempts in the Montana legislature to more broadly control hospital prices and in the U.S. Senate to increase transparency.

‘A Hard, Hard Thing to Tackle’

Bartlett has learned over the past five years just how difficult her model is to export. “It’s a hard, hard thing to tackle,” she said.

Opposition from hospitals is often fierce. In Montana, the deal Bartlett negotiated has actually boosted some hospitals’ bottom lines, but the Montana Hospital Association still criticizes it. MHA President Rich Rasmussen faults the contract for focusing on prices and largely neglecting issues of quality and access. “It doesn’t connect all the dots,” he said. Rasmussen also argued Medicare rates are an “inadequate” starting point for negotiations because they fall short of covering the full cost of care.

That opposition pales in comparison to what Bartlett has seen crisscrossing the country. “What I faced in Montana was nothing like North Carolina faced,” she said, her eyes widening as she described the sheer power of the “mega systems” she encountered while advising North Carolina officials.

North Carolina’s plan to pay hospitals roughly twice Medicare rates fell short in 2019 after just five hospitals agreed to the deal and several giant health systems refused to budge.

Bartlett understands that, as a result of decades of mergers, more states face hospital landscapes like North Carolina’s, with its immense consolidation, than Montana’s, with its more than 40 rural hospitals. And the insurance industry nationwide also is highly concentrated, leaving employers with fewer alternatives.

Saying No to Employees

For employers to have any chance at the negotiating table, Bartlett said, they must be willing to make tough calls. In practice, that might mean dropping a hospital that delivered an employee’s twins or a surgeon who cured a CEO’s cancer. “That’s pretty damn hard,” she acknowledged.

“Employers don’t want to disrupt their employees’ care,” said Elizabeth Mitchell, CEO of Purchaser Business Group on Health, which represents Fortune 500 companies like Walmart and Microsoft. “It takes a lot of fortitude to carve a marquee-brand hospital out of a network.”

A 2020 KFF survey found only 4% of employers had dropped a hospital from a network in order to cut costs. (KHN is an editorially independent program of KFF.)

Bartlett is quick to remind cold-footed employers that continuing to contract with expensive hospitals and doctors has a price, too. “You’re going to disrupt members when they get less and less benefits and pay more and more,” she said. High health care costs also eat up wage increases in the private sector and school funding in the public sector.

Will Covid-19 Be a Catalyst?

Bartlett’s work has hit a crossroads during the pandemic. It is harder to criticize hospitals and their business practices as they play such a vital role. Meanwhile, employers and workers are hurting financially.

“Many large employers are facing economic pressures they frankly haven’t had for a while. They’re laying off tens of thousands of employees,” said Mitchell. “There’s a new sensitivity to costs.”

Bartlett sees an opportunity and is hustling to help employers meet it. She has teamed up with researchers at Rice University on a NASHP project called the Hospital Cost Tool.

“It breaks open this black box and lets you ask where these dollars are going and why,” said Riley of NASHP. The tool aims to automate the kind of forensic accounting of hospitals’ finances that Bartlett had been doing on a one-off basis.

‘You’re Not Going to Be Liked’

There’s one final test Bartlett has tried to prepare employers for — one for which numbers won’t help. It’s the personal toll that comes with challenging the status quo.

While working for the state health plan and before her work delivered results, Bartlett lost close friends, was cut out of meetings and even discovered her co-workers had created a Facebook group to criticize her. “You’re not going to be liked. You’re going to be ridiculed.”

She reminds employers they have a moral and fiscal duty.

“The reality is this is hard work, and it became harder than I ever anticipated,” said Bartlett. “But employers have been given this money, by the taxpayer, by the member, for these benefits. They are responsible for every penny spent. You can’t turn your back on that.”

In Montana, the premiums and copays state workers pay have not increased a single cent since Bartlett and colleagues renegotiated with the hospitals. Over that same time, the average premium paid by American families with employer-based insurance rose 13%.

Dan Gorenstein is the creator and host of the Tradeoffs podcast and Leslie Walker is a senior producer on the show. Their Feb. 18 episode profiles employers’ efforts to purchase health care in new ways.

Rural Hospital Remains Entrenched in Covid ‘War’ Even Amid Vaccine Rollout

Editor’s note: KHN wrote about St. James Parish Hospital in April, when it was experiencing its first surge of covid-19 patients. Ten months later, we checked in to see how the hospital and its staff were faring.


The “heroes work here” sign in front of St. James Parish Hospital has been long gone, along with open intensive care unit beds in the state of Louisiana.

Staffers at the rural hospital spent hours each day in January calling larger hospitals in search of the elusive beds for covid-19 patients. They leveraged personal connections and begged nurses elsewhere to take patients they know are beyond their hospital’s care level.

But as patients have waited to be transferred out of the hospital, which is about 45 minutes outside New Orleans, doctors such as Landon Roussel are forced to make unthinkable choices. As recently as Jan. 29, he had to decide between two patients: Which one should get the sole available BiPAP machine to push oxygen into their lungs?

That’s like a “war situation, which is not a situation that I want to be in — in the United States,” he said.

As the nation’s attention shifts to the vaccine rollout, rural hospitals such as St. James Parish Hospital have struggled to handle their communities’ sick following the holiday surge of covid patients.

“We knew it was coming. We saw it coming,” Mary Ellen Pratt, St. James Parish Hospital’s CEO, said by phone. “It really has to happen to their family for them to really go, ‘OK, wow.’”

And even though the vaccines have arrived and caseloads continue to improve after the holiday surge, only about 30% of staffers have opted to get their shots. Disparities in the broader community persist: In the initial rollout, only 9% of those vaccinated were Black in a parish — the Louisiana equivalent of a county — that is nearly 49% Black.

Staff members are burned out from months of handling never-ending covid crises.

“They had been giving 150%, and they’re just getting really tired,” Pratt said. “It’s just exhausting.”

‘Sometimes, Your Best Isn’t Enough’

In mid-January, the closest intensive care bed the staff could find was some 600 miles away in Brownsville, Texas — so far that a plane would have been necessary to transport a patient. After three days, a closer bed was found at a Veterans Affairs hospital about 45 miles away.

Staffers have tried Mississippi and Alabama with mixed luck. One patient they tried to transfer four hours away couldn’t go because the ambulance didn’t have enough oxygen to make it that far. A hospital in Florida even called them looking for ICU beds at St. James Parish Hospital, which has never had any.

More than half of U.S. counties are like St. James Parish and have no intensive care beds, full or empty. Rural hospitals in those communities are designed for step-down care: They often serve as a stopping point to stabilize people before they can be sent to larger hospitals with more specialized staff and equipment.

Across the country, rural residents’ mortality rate from covid has been consistently higher than that of urban residents since August, according to the Rural Policy Research Institute Center for Rural Health Policy Analysis. That has occurred even though covid incidence has been lower among rural populations than urban ones since the middle of December, said Fred Ullrich, who runs the health policy department at the University of Iowa’s College of Public Health and co-authored the study.

But, he said, rural populations are typically older, sicker and poorer than urban populations. And the nation has lost at least 179 rural hospitals over the past 17 years.

“This crisis is just magnifying existing access issues in a rural context,” said Alan Morgan, the head of the National Rural Health Association. “If you don’t have a local hospital, that impacts the diagnosis, the initial treatment, the complex treatment. It has multiple impacts, all leading to what we’re seeing: higher mortality.”

And at the hospitals that remain, such as St. James Parish Hospital, the stress level is palpable, because the level of care needed for such sick patients is higher than what staffers normally handle, said Karley Babin, the hospital’s acute nurse manager.

“It’s just an uncomfortable spot,” she said. “You know you’re doing everything you can and that patient just needs more.”

That’s led to many sleepless nights for Pratt.

“Sometimes your best isn’t enough if you don’t have the right resources,” she said.

‘We Know All These People’

Radiology technologist Brooke Michel lives seven minutes from the hospital, where she works with her husband and five other relatives. Her grandfather, grandmother and aunt were hospitalized there in December with covid.

Her family brought folding chairs to sit outside her 83-year-old grandfather’s hospital window each day, keeping vigil through the glass on Christmas Eve. He died Jan. 3 while family members stood outside, taking turns looking in and praying.

“It gave us a sense of closure,” Michel said. “We were all together. We were with him. We would never have gotten that at a bigger hospital.”

Seeing multiple family members hospitalized at the same time is tough on the staff, said Scott Dantonio, the hospital’s pharmacy director. “We know all these people,” he said.

Dozens of hospital staffers also have battled covid, and three have been hospitalized. A nurse’s aide died last summer after contracting it. One staffer, who was particularly close to that aide, now has a hard time treating covid patients, said Rhonda Zeringue, chief nursing officer.

“It’s a reminder: ‘You took my person,’” she said.

Brooke Michel’s grandfather, grandmother and aunt were hospitalized with covid-19 at St. James Parish Hospital in December. Her grandfather, Richard Roussel, also had been hospitalized there in April when the family visited him outside his window amid covid-19 restrictions. When he returned there with covid, they also kept vigil outside his window. He died on Jan. 3. (Brooke Michel) Left to right: Tammy Hymel, Sandra Babin, Nadine Louviere, Brandi Zeringue, Caleb Zeringue. (Brooke Michel)

‘It’s Just Exhausting’

St. James Parish Hospital has been running short-staffed, because they haven’t been able to hire more nurses or pay traveling nurses — they’re just too expensive. Amid the pandemic, traveling nurses can command more than double what the staff nurses make.

So Babin’s kids ask often why she works all the time.

Community praise has died down, she said. People aren’t thanking them in grocery stores anymore. One upside? Pratt is happy to have finally lost the “covid 19” — the weight she put on from the community bringing food to the hospital back in the spring.

Pratt and Zeringue have offered staff members counseling, massage sessions, coffee and doughnuts. But it’s not enough.

Zeringue said the stress has gone through the staff in waves: First they were scared to death of being the front line in the spring. Now she sees burnout and sheer exhaustion.

The vaccines were supposed to offer hope. But when Pratt heard they would be distributed through CVS and Walgreens, she knew immediately the logistics of getting the ultra-cold Pfizer vaccine from its cooler into residents’ arms would fall to them. She said the community has no chain pharmacies nearby and the local health department is overloaded.

“We get an email at, like, 4:30 on Friday which says, ‘We’re going to send you another 350 vaccines on Wednesday and you have to respond in the next 10 minutes,’” Pratt said. “There’s not enough planning or time to do it.”

Staff members, who are juggling monoclonal antibody infusions and elective surgeries to deal with the backlog from the spring on top of the surge, must also call members of the community to let them know they have the vaccine available. And then the problems begin.

“People don’t answer the phone or they’re not available,” Dantonio said. “Or they can’t come at that time or they scheduled somewhere else.”

Most of the people coming in following the hospital’s advertising online and on Facebook have been white. So Pratt called on the people she had relied on during the rollout of the Affordable Care Act: Black preachers and well-respected Black local leaders such as Democratic state Rep. Kendricks Brass. After word from the pulpit spread and Brass’ team staffed a phone line, the vaccine distribution the next week jumped to 30% Black residents from the prior week’s 9%.

Even some among the St. James Parish Hospital staff have been reluctant. Many have told Zeringue they’re worried about their fertility. Others just don’t want to be first. So the hospital’s line of defense has many holes.

And the covid patients keep coming.

“This is a nightmare,” said Kassie Roussel, the hospital’s marketing director. “It’s crazy because it’s at the same time we marketed the beginning of the end.”

Covid-Linked Syndrome in Children Is Growing and Cases Are More Severe

Covid-Linked Syndrome in Children Is Growing and Cases Are More Severe

The condition, which usually emerges several weeks after infection, is still rare, but can be dangerous. “A higher percentage of them are really critically ill,” one doctor said.

Braden Wilson, of Simi Valley, Calif., with his mother, Amanda. He was hospitalized and placed on a ventilator and a heart-lung bypass machine, but he died on Jan. 5. “My boy was gone,” his mother recalled.
Braden Wilson, of Simi Valley, Calif., with his mother, Amanda. He was hospitalized and placed on a ventilator and a heart-lung bypass machine, but he died on Jan. 5. “My boy was gone,” his mother recalled.Credit…via Amanda Wilson
Pam Belluck

  • Feb. 16, 2021, 3:00 a.m. ET

Fifteen-year-old Braden Wilson was frightened of Covid-19. He was careful to wear masks and only left his house, in Simi Valley, Calif., for things like orthodontist checkups and visits with his grandparents nearby.

But somehow, the virus found Braden. It wreaked ruthless damage in the form of an inflammatory syndrome that, for unknown reasons, strikes some young people, usually several weeks after infection by the coronavirus.

Doctors at Children’s Hospital Los Angeles put the teenager on a ventilator and a heart-lung bypass machine. But they could not stop his major organs from failing. On Jan. 5, “they officially said he was brain dead,” his mother, Amanda Wilson, recounted, sobbing. “My boy was gone.”

Doctors across the country have been seeing a striking increase in the number of young people with the condition Braden had, which is called Multisystem Inflammatory Syndrome in Children or MIS-C. Even more worrisome, they say, is that more patients are now very sick than during the first wave of cases, which alarmed doctors and parents around the world last spring.

“We’re now getting more of these MIS-C kids, but this time, it just seems that a higher percentage of them are really critically ill,” said Dr. Roberta DeBiasi, chief of infectious diseases at Children’s National Hospital in Washington, D.C. During the hospital’s first wave, about half the patients needed treatment in the intensive care unit, she said, but now 80 to 90 percent do.

The reasons are unclear. The surge follows the overall spike of Covid cases in the United States after the winter holiday season, and more cases may simply increase chances for severe disease to emerge. So far, there’s no evidence that recent coronavirus variants are responsible, and experts say it is too early to speculate about any impact of variants on the syndrome.

The condition remains rare. The latest numbers from the Centers for Disease Control and Prevention show 2,060 cases in 48 states, Puerto Rico and the District of Columbia, including 30 deaths. The median age was 9, but infants to 20-year-olds have been afflicted. The data, which is complete only through mid-December, shows the rate of cases has been increasing since mid-October.

While most young people, even those who became seriously ill, have survived and gone home in relatively healthy condition, doctors are uncertain whether any will experience lingering heart issues or other problems.

“We really don’t know what will happen in the long term,” said Dr. Jean Ballweg, medical director of pediatric heart transplant and advanced heart failure at Children’s Hospital & Medical Center in Omaha, Neb., where from April through October, the hospital treated about two cases a month, about 30 percent of them in the I.C.U. That rose to 10 cases in December and 12 in January, with 60 percent needing I.C.U. care — most requiring ventilators. “Clearly, they seem to be more sick,” she said.

Symptoms of the syndrome can include fever, rash, red eyes or gastrointestinal problems. Those can progress to heart dysfunction, including cardiogenic shock, in which the heart cannot squeeze enough to pump blood sufficiently. Some patients develop cardiomyopathy, which stiffens the heart muscle, or abnormal rhythm. Dr. Ballweg said one 15-year-old at her hospital needed a procedure that functioned as a temporary pacemaker.

Jude Knott, 4, at home with his mother, Ashley Knott, was hospitalized for 10 days after developing a headache, fever, vomiting, red eyes and a rapid heart rate.
Jude Knott, 4, at home with his mother, Ashley Knott, was hospitalized for 10 days after developing a headache, fever, vomiting, red eyes and a rapid heart rate.Credit…Kathryn Gamble for The New York Times

Hospitals say most patients test positive for Covid antibodies that indicate previous infection, but some patients also test positive for active coronavirus infection. Many children were previously healthy and had few or no symptoms from their initial Covid infection. Doctors are uncertain which factors predispose children to the syndrome. Dr. Jane Newburger, associate chief for academic affairs in Boston Children’s Hospital’s cardiology department, who is a leader of a nationwide study, said patients with obesity and some older children seem to fare worse.

Sixty-nine percent of reported cases have affected Latino or Black young people, which experts believe stems from socioeconomic and other factors that have disproportionately exposed those communities to the virus. But Omaha’s hospital, where early cases were largely among children of Latino parents working in the meatpacking industry, is now “seeing a much more broad spectrum and every ethnicity,” Dr. Ballweg said.

Jude Knott, 4, was hospitalized in Omaha for 10 days after developing a headache, fever, vomiting, red eyes and a rapid heart rate.

“It was just a roller coaster,” said his mother, Ashley Knott, a career coach at an Omaha nonprofit helping low-income teenagers.

To explain to Jude the infusions of intravenous immunoglobulin doctors were giving him, she said they were “‘putting Ninjas in your blood so they can fight.’” For blood thinner injections, which he hated, she said, “‘Buddy, they’re making your blood go from a milkshake to water because we need it to be water.’ Anything to help him make sense of it.”

Jude recently returned to preschool full time. He has some dilation of a coronary artery, but is improving, his mother said.

“He’s definitely experiencing some anxiety,” Ms. Knott said. “I just worry that he’s kind of been saddled with some adult worries at 4.”

Doctors said they’ve learned effective treatment approaches, which, besides steroids, immunoglobulin and blood thinners, can include blood pressure medications, an immunomodulator called anakinra and supplemental oxygen. Some hospitals use ventilators more than others, experts said.

But though doctors are learning more, pediatricians can miss the syndrome initially because early symptoms can mimic some common ailments.

Mayson Barillas, 11, was hospitalized for eight days at Children’s National Hospital, where his doctors said he exhibited cardiogenic shock.Credit…Rosem Morton for The New York Times

On New Year’s Day, Mayson Barillas, 11, of Damascus, Md., started feeling sick. “My stomach started hurting, and then I went to my soccer game and then I got a fever,” he said.

His mother, Sandy Barillas, a medical assistant at a women’s health practice, gave him Alka Seltzer, Pepto Bismol and Tylenol. Several days later, he developed shortness of breath and they went to an urgent care clinic.

There, a rapid Covid-19 test was negative, as were evaluations for strep, influenza and appendicitis. Ms. Barillas said she was told, “It was just like a stomach flu.”

But the next day, Mayson had swollen eyes and lips with red blisters. “He started developing really bad body aches and he couldn’t walk anymore,” she said. She took him to an emergency room, which transferred him to Children’s National Hospital, where doctors said he exhibited cardiogenic shock.

“It was very scary,” Ms. Barillas said. “I’d never heard of this syndrome before.”

Mayson spent eight days in the hospital, four in the I.C.U. Since leaving, he has seen a hematologist, a rheumatologist and a cardiologist and is on blood thinners for now. The hardest part, said Mayson, a star local soccer player, is being temporarily sidelined from sports, as doctors advise for most patients for several months.

“It was very shocking for everybody in the community: ‘Wow, how did this happen to someone very healthy?’” Ms. Barillas said.

At a memorial service on Feb. 5, Braden Wilson was remembered as a kindhearted, creative teenager who loved filmmaking and fashion. His color-splashed oil paintings were displayed.

His mother read a poem he wrote that hangs on the refrigerator of his grandparents, Fabian and Joe Wilson, with whom he was close: “Hold fast to dreams/ for if dreams create/ life is a beautiful canvas/ a masterpiece painted great.”

Braden at his eighth-grade graduation with his grandparents, Fabian and Joe Wilson, with whom he was close.Credit…via Amanda Wilson

It’s unclear why the syndrome hit Braden so hard. Ms. Wilson said he did not have serious health issues. She said he was overweight but active, swimming three times a week and taking dance and yoga at his arts-and-science high school.

Symptoms started New Year’s Eve, when he began vomiting and spiking a fever. Ms. Wilson took him to an emergency room, where he tested positive for the coronavirus, received treatment that included a new monoclonal antibody drug and was sent home.

But his fever persisted and two days later, he developed diarrhea and his lips and fingers turned blue. Ms. Wilson called 911. When paramedics arrived, she said, he was “lying in his bed, like almost lifeless.”

At the hospital, he was hooked to a ventilator and transferred to Children’s Hospital Los Angeles, which like several hospitals has established a MIS-C clinic with various specialists.

“Braden was one of our most ill patients,” said Dr. Jacqueline Szmuszkovicz, a pediatric cardiologist there.

Doctors placed him on the heart-lung bypass machine, put him on dialysis and performed a heart procedure to relieve pressure. “He had what we would term severe multisystem organ failure: his lungs, his heart, his kidneys,” Dr. Szmuszkovicz said.

Through tears, Ms. Wilson said that after a few days, Braden began bleeding from his mouth, eyes and nose, and doctors ultimately could not detect brain activity. “I asked them specifically: ‘Is there any chance for him to recover from this?’” she recounted. “And they said no.”

Family members FaceTimed to say goodbye before life support was withdrawn. Ms. Wilson gave consent for doctors to take blood samples from his body for research studies.

Ms. Wilson had never written poetry before, but since Braden’s death, it has spilled out of her.

“Now your heart no longer beats / and I can’t hold you in my arms,” reads one. “But I remember back to those days / When my womb protected you from harm/ You lived a life of beauty/ of laughter, and of grace/ I hold you now inside my heart / We’ll always share that space.”

Pandemic Lessons in Improving the Medical System

Personal Health

Pandemic Lessons in Improving the Medical System

The pandemic may prompt American medicine to become less expensive, more efficient and more effective at protecting people’s health.

Credit…Gracia Lam
Jane E. Brody

  • Feb. 8, 2021, 5:00 a.m. ET

If there is a silver lining to the devastation wrought by the coronavirus pandemic, it likely lies in the glaring inadequacies and inefficiencies it exposed that are inherent in traditional American medicine. At the same time, it suggests ways to improve medical practice that can ultimately give us more bang for our health care buck.

The Biden administration currently faces overwhelming challenges to stifle Covid-related disease and deaths, responsibly regrow the economy and curb the environmental and dollar costs of climate change. But as the new president and his team strive to get a handle on these critical issues, they might also confront the myriad failings and needed improvements to health care exposed by the pandemic. We’ve paid too high a price for wasteful procedures and inconsistent medical care delivery in this country. And too many people paid with their lives as a result.

Dr. Robert Steinbrook, an editor at JAMA Internal Medicine, said in an interview, “The pandemic exposed serious vulnerabilities in our health care and created opportunities to solve problems for the long term.”

Although the pandemic prompted many people to miss or delay medical care that sometimes resulted in more serious disease and more costly treatment, it also suggested steps American medicine can take to become less expensive, more efficient and more effective at protecting people’s health.

Exhibit No. 1: Half a century of evidence has documented the health-saving, lifesaving and cost-saving benefits of preventive medicine, yet this country has retained a chaotic, penny-wise-and-pound-foolish medical system that too often puts the treatment cart before the health-promoting horse.

As many experts have told me during decades of medical reporting, we really don’t have health care in this country; we have sickness care. We’re not getting more, we’re simply paying more. The United States spends 25 percent more per person on medical care than any other highly developed country and gets less benefit from it. And the care we get leaves us shamefully behind other developed countries in important health metrics, like maternal and infant mortality and healthy longevity.

“Our system is set up to produce a lot of health care but not necessarily a lot of health,” said Dr. Amol S. Navathe, a health economist at the University of Pennsylvania.

Even the routine annual “wellness visits” covered by Medicare are of minimal value for healthy adults and often result in a cascade of follow-up tests that yield little but cost plenty.

Dr. William H. Shrank of Humana, a national health insurance company, and lead author of a report on waste in the current health care system, said, “We’ve just been through a natural experiment that we can learn from.” Our yearlong battle with a deadly virus suggests ways to improve how medicine is practiced and utilized in the United States to foster better health for its inhabitants.

One of the most dramatic examples was the abrupt substitution of telemedicine for in-person visits to the doctor’s office. Although telemedicine technology is decades old, the pandemic demonstrated how convenient and effective it can be for many routine medical problems, Dr. Navathe said.

Telemedicine is more efficient and often just as effective as an office visit. It saves time and effort for patients, especially those with limited mobility or who live in remote places. It lowers administrative costs for doctors and leaves more room in office schedules for patients whose care requires in-person visits.

Even more important, the pandemic could force a reckoning with the environmental and behavioral issues that result increasingly in prominent health risks in this country. We need to stop blaming genetics for every ailment and focus more on preventable causes of poor health like a bad diet and inactivity.

Consider, for example, the health status of those who have been most vulnerable to sickness and death from Covid-19. Aside from advanced age, about which we can do nothing, it’s been people with conditions that are often largely preventable: obesity, Type 2 diabetes, high blood pressure, coronary artery disease and smoking. Yet most physicians are unable to influence the behaviors that foster these health-robbing conditions.

“Many people need help to make better choices for themselves,” Dr. Navathe said. But the professionals who could be most helpful, like dietitians, physical trainers and behavioral counselors, are rarely covered by health insurance. The time is long overdue for Medicare and Medicaid, along with private insurers, to broaden their coverage, which can save both health and money in the long run.

Policy wonks should also pay more attention to widespread environmental risks to health. Too many Americans live in areas where healthful food is limited and prohibitively expensive and where the built environment offers little or no opportunity to exercise safely.

Individuals, too, have a role to play. The pandemic has fostered “an opportunity for patients to take on a more active role in their care,” Dr. Shrank said in an interview.

Covid-based limitations gave prospective patients a chance to consider what procedures they really needed. Most elective surgeries were put on hold when hospitals and medical personnel were overwhelmed with the challenges of caring for a tsunami of patients infected with a deadly virus.

Dr. Shrank suggested that people ask themselves, “How did you do without the procedure?” Maybe you didn’t really need it, at least not now. Maybe instead of costly surgery for a bad back or bum knee, physical therapy, home exercises or self-administered topical remedies could provide enough relief to permit desired activities.

Does every ache and pain require a doctor visit? Short of a catastrophic sign like crushing chest pain or unexplained bleeding, my approach is to wait a week or two to see if a new symptom resolves without medical intervention. I awoke one January morning with pain in my right wrist and forearm so intense I couldn’t brush my teeth. Perhaps I did too much crocheting or slept on it wrong. Ice didn’t help, but I applied an anti-inflammatory ointment, took two naproxen, wrapped my wrist in a brace from the local pharmacy and refrained from crocheting for two days, by which time the pain had resolved.

When professional health care is needed, new approaches have become more acceptable during the pandemic, Dr. Shrank said. Emergency room visits and hospital admissions declined precipitously (though not always wisely by people with symptoms of a heart attack). Noting that many patients can be treated effectively at home by a visiting nurse, Dr. Shrank said, “No one wants to go to the hospital or a rehab facility if there’s a good alternative.”

Filing Suit for ‘Wrongful Life’

the new old age

Filing Suit for ‘Wrongful Life’

More Americans are writing end-of-life instructions as the pandemic renders such decisions less abstract. But are medical providers listening?

When Elaine Greenberg’s husband, Gerald, was diagnosed with early-onset Alzheimer’s, his specific advance directive — comfort measures only — went unheeded at the hospital where he was treated.
When Elaine Greenberg’s husband, Gerald, was diagnosed with early-onset Alzheimer’s, his specific advance directive — comfort measures only — went unheeded at the hospital where he was treated.Credit…Jackie Molloy for The New York Times

  • Jan. 22, 2021, 10:31 a.m. ET

Gerald and Elaine Greenberg married in 1976, as dental students. They practiced on Long Island and in Manhattan and raised two sons. Then in 2010, she noticed that her husband, the math whiz, was having trouble calculating tips in restaurants. “He just didn’t seem as sharp,” she said.

The devastating diagnosis from a neurologist: early-onset Alzheimer’s disease.

“We knew what could be ahead for him,” Elaine Greenberg said. “He didn’t want to lie there with tubes and diapers. That’s not how he wanted to end his life.”

Together, they called a lawyer and drew up advance directives in 2011. “We gave it a lot of thought,” she said. His directive was very specific: If he became terminally ill, permanently unconscious or seriously and irreversibly brain damaged, he wanted comfort measures only. No cardiac resuscitation or mechanical respiration. No tube feeding. No antibiotics.

Gerald Greenberg died in 2016 at Montefiore New Rochelle Hospital in Westchester County — and a recent lawsuit brought by his widow charges that when he was unresponsive and near death from sepsis, the hospital and an attending physician there failed to follow his directive.

The suit alleges that they also disregarded a New York State MOLST — medical orders for life-sustaining treatment — form and his spouse’s explicit instructions to a doctor who called to seek her guidance.

Medical records show that her husband received antibiotics and other unwanted treatments and tests. The suit charges that he survived for about a month in the unresponsive state that he had sought to avoid. (A Montefiore spokesman said the hospital could not comment, given ongoing litigation.)

“They made the end of his life horrible and painful and humiliating,” Dr. Greenberg said. “What’s the sense of having a living will if it’s not honored?”

Lawsuits charging negligence or malpractice by hospitals and doctors typically claim that they have failed to save patients’ lives. More recently, though, some families have sued if providers failed to heed patients’ documented wishes and prevented death from occurring.

“In the past, people have said, ‘How have we harmed you if we kept you alive?’” said Thaddeus Pope, a professor at the Mitchell Hamline School of Law in St. Paul, Minn., who follows end-of-life legal cases. “Now, courts have said this is a compensable injury.”

The campaign to persuade people to document end-of-life instructions goes back decades, but it remains an uphill battle. A 2017 analysis of 150 studies, involving nearly 800,000 Americans, found that among those over 65, only 45.6 percent had completed an advance directive, including barely half of nursing home residents.

But recent evidence suggests that those proportions have climbed during the coronavirus pandemic. The crisis has made such questions less abstract and the need to honor documents more urgent.

Dr. Greenberg with Gerald Greenberg and their first grandchild in 2016.
Dr. Greenberg with Gerald Greenberg and their first grandchild in 2016.Credit…via Elaine Greenberg

Patients themselves may bear some responsibility for mix-ups. Advance directives go astray, get locked in desk drawers, become so outdated that designated decision makers have died. Or they use language like “no heroic measures,” so vague that “it’s hard for doctors to comply with,” Mr. Pope said.

The state MOLST or POLST (portable orders for life-sustaining treatment) forms strive to make the decisions concrete by providing detailed documentation of patients’ wishes and functioning as physicians’ orders. Studies in Oregon and West Virginia have demonstrated the forms’ effectiveness, but as several of these cases show, that is not universal.

Sometimes — nobody has tracked how often — institutions overlook the documents in patients’ charts or ignore conversations with health care proxies. Doctors who doubt that a patient actually prefers to die may override the instructions.

“Their attitude is, ‘Nobody was hurt,’” said Gerald Grunsfield, the lawyer representing Dr. Greenberg. “But there was physical hurt, emotional hurt, a lot of hurt.”

In an interview four years ago, Mr. Pope noted that nobody at that point had received compensation from any “wrongful life” suit. Since then, several plaintiffs have received hefty payments, and courts have weighed in as well.

In Georgia, Jacqueline Alicea won a $1 million settlement from Doctors Hospital of Augusta and a surgeon there (from their insurers, more accurately). They had placed her 91-year-old grandmother on a ventilator, disregarding both Ms. Alicea’s instructions as her grandmother’s health care proxy and her grandmother’s advance directive. That meant Ms. Alicea had to eventually order that life support be removed, a wrenching decision.

Settlement amounts often remain confidential, but “we wanted this settlement to be shouted from the mountaintops,” her lawyer, Harry Revell, said. “We wanted it to have a deterrent effect on health care providers who think this isn’t important.”

The Alicea case, already being cited in other lawsuits, may have an impact because after the trial court denied a motion to dismiss it, the state’s Court of Appeals and its Supreme Court both ruled that the suit could proceed. The parties settled on the eve of a trial in 2017.

In Montana, a jury delivered what is believed to be the first verdict in a wrongful life case, awarding $209,000 in medical costs and $200,000 for “mental and physical pain and suffering” to the estate of Rodney Knoepfle in 2019.

Debilitated by many illnesses, Mr. Knoepfle had a do-not-resuscitate order and a POLST form in his records at St. Peter’s Health, Helena’s largest hospital. “He’d suffered more pain than anyone should in a lifetime and was comfortable with going, if it was his time to go,” said Ben Snipes, one of his lawyers.

But a medical team resuscitated Mr. Knoepfle — twice. Tethered to an oxygen tank, he lived another two years before dying at age 69. “The last few months, he was almost incoherent with pain, living in a hospital bed, getting morphine crushed into his pudding,” Mr. Snipes said.

Beatrice Weisman, 83, had been hospitalized after a stroke in 2013 when doctors at Maryland General Hospital found her turning blue and resuscitated her, an action that her advance directive and MOLST form specifically prohibited.

The Weisman family sued and in 2017 received a “satisfactory” sum through mediation, said Robert Schulte, their lawyer. He could not divulge the amount but said it had helped pay for seven years of round-the-clock care, until Ms. Weisman died last October.

The Greenbergs on their wedding day in 1976.Credit…Jackie Molloy for The New York Times

A California case developed differently. Dick Magney had opted for palliative care, and his doctors were complying, until someone reported potential neglect to Humboldt County’s adult protective services agency. The county filed a petition to take over his health care, removing his wife as his decision maker, and ordered that Mr. Magney receive antibiotics he had earlier refused. At one point, the county won temporary conservatorship.

“It just led to him suffering longer,” said Allison Jackson, the lawyer representing Mr. Magney’s wife. Mr. Magney died in 2015.

A state appellate court ruled that the petition to remove Mr. Magney’s wife had been fraudulent. She eventually won more than $200,000 in reimbursement for lawyers’ fees and pursued a federal civil rights complaint, leading to a $1 million settlement from the county. Two lawyers representing the county now face disciplinary charges from the California state bar.

Such awards and rulings, and news coverage, have led more families to seek legal remedies and have encouraged lawyers to take such cases, said Mr. Pope, who is a consultant to the Montana lawyers and a testifying expert witness in the upcoming California disciplinary hearings.

Now similar suits are pending in Georgia, Maryland and New Jersey, in addition to two malpractice cases that Mr. Grunsfeld has brought against Montefiore in New York.

Lawyers for Montefiore have moved to dismiss the Greenberg suit; even if the court allows it to go forward, resolution could take years. But Dr. Greenberg and her sons are in it for the long haul, she said.

During the month her husband survived, after his directive would have permitted him to die, he lay unconscious, diapered, in restraints and moaning in pain, she recalled.

“He tried to make choices, and his choices weren’t respected,” Dr. Greenberg said. “I don’t want anyone else to go through what we went through.”

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Pressure Grows for States to Open Vaccines to More Groups of People

Pressure Grows for States to Open Vaccines to More Groups of People

Some states are already expanding eligibility to people 65 and over, even though millions of people the C.D.C. recommends go first — health care workers and nursing home residents — have yet to get shots.

Gov. Ron DeSantis of Florida, right, during vaccinations at the John Knox Village nursing home in Pompano Beach, Fla., last month.
Gov. Ron DeSantis of Florida, right, during vaccinations at the John Knox Village nursing home in Pompano Beach, Fla., last month.Credit…Marta Lavandier/Associated Press
Abby Goodnough

  • Jan. 9, 2021, 12:00 p.m. ET

Just weeks into the country’s coronavirus vaccination effort, states have begun broadening access to the shots faster than planned, amid tremendous public demand and intense criticism about the pace of the rollout.

Some public health officials worry that doing so could bring even more chaos to the complex operation and increase the likelihood that some of the highest-risk Americans will be skipped over. But the debate over how soon to expand eligibility is intensifying as deaths from the virus continue to surge, hospitals are overwhelmed with critically ill patients and millions of vaccine doses delivered last month remain in freezers.

Governors are under enormous pressure from their constituents — especially older people, who vote in great numbers and face the highest risk of dying from the virus — to get the doses they receive into arms swiftly. President-elect Joseph R. Biden Jr.’s decision, announced Friday, to release nearly all available doses to the states when he takes office on Jan. 20, rather than holding half to guarantee each recipient gets a booster shot a few weeks after the first, is likely to add to that pressure.

Some states, including Florida, Louisiana and Texas, have already expanded who is eligible to get a vaccine now, even though many people in the first priority group recommended by the Centers for Disease Control and Prevention — the nation’s 21 million health care workers and three million residents of nursing homes and other long-term care facilities — have not yet received a shot.

On Friday afternoon, New York became the latest state to do so, announcing that it would allow people 75 and over and certain essential workers to start receiving a vaccine on Monday.

But reaching a wider swath of the population requires much more money than states have received for the task, many health officials say, and more time to fine-tune systems for moving surplus vaccine around quickly, to increase the number of vaccination sites and people who give the shots, and to establish reliable appointment systems to prevent endless lines and waits.

Some states’ expansions have led to frantic and often futile efforts by older people to get vaccinated. After Florida opened up vaccinations to anyone 65 and older late last month, the demand was so great that new online registration portals quickly overloaded and crashed, people spent hours on the phone trying to secure appointments and others waited overnight at scattered pop-up sites offering shots on a first-come first-served basis.

Similar scenes have played out in parts of Texas, Tennessee and a handful of other states.

Still, with C.D.C. data suggesting that only about a third of the doses distributed so far have been used, Alex M. Azar II, the health and human services secretary, told reporters this past week: “It would be much better to move quickly and end up vaccinating some lower-priority people than to let vaccines sit around while states try to micromanage this process. Faster administration would save lives right now, which means we cannot let the perfect be the enemy of the good.”

Boxes of Moderna’s vaccine were prepared for shipment at a distribution center in Olive Branch, Miss., last month.
Boxes of Moderna’s vaccine were prepared for shipment at a distribution center in Olive Branch, Miss., last month.Credit…Pool photo by Paul Sancya

The C.D.C. guidelines were drawn up by an independent committee of medical and public health experts that advises the agency on immunization practices; it deliberated for months about who should get vaccinated initially, while supplies were still very limited. The committee weighed scientific evidence about who is most at risk of getting very sick or dying from Covid-19, as well as ethical questions, such as how best to ensure equal access among different races and socioeconomic groups.

Although the committee’s recommendations are nonbinding, states usually follow them; in this case, the committee suggests that states might consider expanding to additional priority groups “when demand in the current phase appears to have been met,” “when supply of authorized vaccine increases substantially” or “when vaccine supply within a certain location is in danger of going unused.”

Dr. Kevin Ault, an obstetrician at the University of Kansas Medical Center who serves on the advisory committee that came up with the C.D.C. guidelines, said that it was reasonable for states to start vaccinating new groups before finishing others, but that they should be careful about exacerbating inequities and biting off more than they can chew.

“Obviously if you’re going to vaccinate that group you need to have a well-thought-out plan in hand,” he said, referring to the over-65 population. “Having people camping out for vaccine is less than ideal, I would say.”

He added, “We put a lot of thought and effort into our guidelines, and I think they are good.”

After the first vaccines were given in mid-December, a dichotomy emerged between governors who were adhering precisely to the guidelines and others who moved quickly to populations beyond health care workers and nursing home residents.

Until Friday, Gov. Andrew M. Cuomo of New York, a Democrat, had threatened to penalize hospitals that provided shots to people who are not health care workers. By contrast, Gov. Ron DeSantis of Florida, a Republican, traveled to retirement communities around his state to emphasize the importance of getting people 65 and older, who number more than five million there, immunized fast.

“In Florida we’ve got to put our parents and grandparents first,” Mr. DeSantis said at The Villages, the nation’s largest retirement community, just before Christmas.

Gov. Andrew Cuomo of New YorkCredit…Andrew Kelly/Reuters
Gov. Mike DeWine of OhioCredit…Tony Dejak/Associated Press
Gov. Greg Abbott of TexasCredit…Eric Gay/Associated Press
Gov. Larry Hogan of MarylandCredit…Jonathan Ernst/Reuters

Decisions on how soon to expand eligibility for the shots have not fallen neatly along partisan lines.


Covid-19 Vaccines ›


Answers to Your Vaccine Questions

While the exact order of vaccine recipients may vary by state, most will likely put medical workers and residents of long-term care facilities first. If you want to understand how this decision is getting made, this article will help.

Life will return to normal only when society as a whole gains enough protection against the coronavirus. Once countries authorize a vaccine, they’ll only be able to vaccinate a few percent of their citizens at most in the first couple months. The unvaccinated majority will still remain vulnerable to getting infected. A growing number of coronavirus vaccines are showing robust protection against becoming sick. But it’s also possible for people to spread the virus without even knowing they’re infected because they experience only mild symptoms or none at all. Scientists don’t yet know if the vaccines also block the transmission of the coronavirus. So for the time being, even vaccinated people will need to wear masks, avoid indoor crowds, and so on. Once enough people get vaccinated, it will become very difficult for the coronavirus to find vulnerable people to infect. Depending on how quickly we as a society achieve that goal, life might start approaching something like normal by the fall 2021.

Yes, but not forever. The two vaccines that will potentially get authorized this month clearly protect people from getting sick with Covid-19. But the clinical trials that delivered these results were not designed to determine whether vaccinated people could still spread the coronavirus without developing symptoms. That remains a possibility. We know that people who are naturally infected by the coronavirus can spread it while they’re not experiencing any cough or other symptoms. Researchers will be intensely studying this question as the vaccines roll out. In the meantime, even vaccinated people will need to think of themselves as possible spreaders.

The Pfizer and BioNTech vaccine is delivered as a shot in the arm, like other typical vaccines. The injection won’t be any different from ones you’ve gotten before. Tens of thousands of people have already received the vaccines, and none of them have reported any serious health problems. But some of them have felt short-lived discomfort, including aches and flu-like symptoms that typically last a day. It’s possible that people may need to plan to take a day off work or school after the second shot. While these experiences aren’t pleasant, they are a good sign: they are the result of your own immune system encountering the vaccine and mounting a potent response that will provide long-lasting immunity.

No. The vaccines from Moderna and Pfizer use a genetic molecule to prime the immune system. That molecule, known as mRNA, is eventually destroyed by the body. The mRNA is packaged in an oily bubble that can fuse to a cell, allowing the molecule to slip in. The cell uses the mRNA to make proteins from the coronavirus, which can stimulate the immune system. At any moment, each of our cells may contain hundreds of thousands of mRNA molecules, which they produce in order to make proteins of their own. Once those proteins are made, our cells then shred the mRNA with special enzymes. The mRNA molecules our cells make can only survive a matter of minutes. The mRNA in vaccines is engineered to withstand the cell’s enzymes a bit longer, so that the cells can make extra virus proteins and prompt a stronger immune response. But the mRNA can only last for a few days at most before they are destroyed.

Gov. Larry Hogan of Maryland, a Republican, announced Tuesday that he would immediately switch to what he called the “Southwest Airlines model” for vaccine allocation, referring to the airline’s open seating policy. “We’re no longer going to be waiting for all the members of a particular priority group to be completed,” he said, “before we move on to begin the next group in line.”

Gov. Mike DeWine of Ohio, a Republican, urged patience in a news briefing Tuesday as he declined to estimate when the state would start vaccinating people beyond the first priority group, known as “1a.”

“We’re asking every health department, ‘Don’t go outside 1a, stay within your lane,’” he said, adding about the vaccines, “This is a scarce commodity.”

By Thursday Mr. DeWine had set a date for people 80 and older to start getting the vaccine — Jan. 19 — and said he would phase in everyone 65 and older, as well as teachers, by Feb. 8.

The reasons so many doses received by states have not yet been administered to the first priority group are manifold. The fact that vaccination began around Christmas, when many hospital employees were taking vacation, slowed things. More health care workers are refusing to get the vaccine than many of their employers expected, and some hospitals and clinics received more doses than they needed but felt constrained by state rules from giving them to people outside the first priority groups. Some initially worried they could not even offer leftover doses in open vials to people in lower priority groups and let them go to waste.

Frontline health care workers and people age 65 and older waited to be vaccinated at a sports complex in Fort Myers, Fla., last month.Credit…Octavio Jones for The New York Times

And federal funding for vaccination efforts has been slow to reach states and localities: They got only $350 million through the end of last year, a little more than $1 per resident of the country. The economic rescue package that Congress passed in December included $8 billion for vaccine distribution that state health officials had long sought, but the first tranche of it, about $3 billion, is only now starting to be sent out.

“There was great funding in the development of these products, great funding in the infrastructure to ship them and get them out,” said Dr. Steven Stack, commissioner of the Kentucky Department for Public Health. “But then there was no funding provided of meaning for administering the vaccine, which is the last mile of this journey.”

The C.D.C. has recommended that a “1b” group consisting of people 75 and older and certain essential workers, including teachers, corrections officers and grocery store employees, be vaccinated next. The second group is much larger, about 50 million people. And the third recommended priority group — people 65 to 74, anyone 16 and older with high-risk medical conditions, and essential workers not already reached — numbers almost 130 million.

Pfizer and Moderna have pledged to deliver enough vaccine doses for 100 million people to each get the two necessary shots by the end of March, and many more in the second quarter. Several other vaccine candidates are far along in the pipeline, and if approved for emergency use here could help ramp up distribution more quickly.

The C.D.C. committee initially considered recommending that a wide range of essential workers get vaccinated before older Americans. Its rationale was that many essential workers are low-wage people of color, who have been hit disproportionately hard by the virus and had limited access to good health care. That sparked a backlash, and several governors, including Mr. DeSantis, quickly made clear they would cater to older people first.

Alex M. Azar, the health and human services secretary, left, and Surgeon General Jerome Adams, right, during a vaccination at George Washington University Hospital on Dec. 14.Credit…Pool photo by Jacquelyn Martin-Pool

Dr. Mark McClellan, who formerly headed the F.D.A. and now runs Duke University’s health policy center, said that while pushing ahead to vaccinate older people and other particularly vulnerable groups would accelerate the overall effort, “we’re going to be missing a lot of higher-risk individuals along the way.”

“I do worry about that becoming uneven in terms of access,” he said during a press briefing, “with lower-income groups, minority groups maybe in a tougher position if we don’t make it very easy for people in these high-risk groups to get vaccinated.”

Dr. Marcus Plescia, the chief medical officer for the Association of State and Territorial Health Officials, said he was surprised to hear federal officials like Mr. Azar and Dr. Jerome Adams, the surgeon general, advocate expanding vaccine access so broadly so soon.

“We didn’t come up with priority populations to slow things down, but because we knew there would be limited numbers of doses,” Dr. Plescia said. “If we try to do this in an equitable, fair way, it’s not going to be as fast as if our only goal is to get vaccine into as many arms as possible.”

Whether or not they are widening access now, governors are ramping up pressure on hospitals to use their allocated doses more quickly. Mr. Cuomo threatened to fine those that did not use their initial allocations by the end of this past week and not send them any more.

Mr. Hogan warned hospitals this past week, “Either use the doses that have been allocated to you or they will be directed to another facility or provider.”

A Night in the Hospital, From Both Ends of the Stethoscope

Doctors

A Night in the Hospital, From Both Ends of the Stethoscope

As a doctor writing about medical errors, I saw potential risks lurking everywhere when my daughter was hospitalized with appendicitis.

Credit…Xiao Hua Yang

  • Jan. 5, 2021, 5:00 a.m. ET

Just as the first coronavirus reports were emerging from China in late 2019, the medical world was observing the 20th anniversary of “To Err is Human,” the seminal report from the Institute of Medicine that opened our eyes to the extent of medical error. The news media jumped on the popular aviation metaphor, that the number of Americans dying each year as a result of medical error was the equivalent of a jumbo jet crashing every day. Those numbers remain difficult to accurately quantitate, but we know that they are not small.

The conversation has now been broadened to include all preventable harms to patients, even ones that are not errors per se. As I set about writing a book on medical error, I wanted to see both sides of the story. I drew upon my own experiences as a physician but also interviewed patients and families to get the view from the other side. But I soon realized that the distinction between those two “sides” was rather fluid.

Midway through writing the book, my teenage daughter experienced a stomachache. My kids know that fevers, colds, coughs and sprained ankles do not get my pulse up, and that “if you’re not bleeding out or in cardiac arrest” they should seek medical sympathy from their computer programmer father. They often accuse me of ignoring their medical complaints altogether, but as a primary care doctor I know that most aches and pains of daily life get better on their own and are best left unobsessed about.

But this time I became suspicious of my daughter’s inability to find a comfortable position and so pulled out my stethoscope. When I heard complete silence instead of gurgling bowel sounds, I shuttled us straight to my hospital’s E.R. My correct diagnosis of appendicitis modestly redeemed me in my daughter’s eyes, though she was mortified that I chatted it up with colleagues.

Surgery was planned for the next morning, so I stayed in her hospital room overnight, reading the stack of journal articles I’d been reviewing for my book. Hospitals have always been a comfortable setting for me, but the familiar ward suddenly felt apocalyptic, with medical errors and harms lurking everywhere. The population of a midsize city traipsed in and out of my daughter’s room that night, each armed with potentially dangerous things to administer or extricate. And even if they were all batting 99 percent, the denominator of “things” was so enormous that some amount of error was all but guaranteed.

When the pediatric resident arrived at 3 a.m. to assess my daughter — after she’d been evaluated by the triage nurse, the E.R. resident, the E.R. attending, the surgery resident, the surgery chief, and then the surgery attending — I put my foot down.

“She’s on pain meds now,” I hissed, “so you won’t find any abdominal tenderness. And the ultrasound already showed an inflamed appendix.” The resident eyed me warily, clearly calculating the risk/benefit ratio of pressing her case with an ornery, sleep-deprived parent.

“But if you are going to wake her up, jab on her belly, and then come to the grand conclusion that she has appendicitis and needs surgery, forget about it,” I snapped. The resident backed off, and I flopped back into my chair to read yet another cheery article about medical calamities.

The surgery team came by with another option: giving just IV antibiotics, with no operation. With antibiotics alone, they said, there was a 50 percent chance of appendicitis recurring. Which meant that for half the patients, surgery could be avoided altogether. But we had to decide right away so they could know whether to book the O.R.

I asked the surgery resident how strong the data were. I wasn’t going to make a half-baked decision just because he was time-pressed to set the O.R. schedule. He groaned mightily but stood by while I searched up some studies. The data were preliminary but seemed encouraging.

Just getting a flu shot reduces my daughter to a sobbing mess huddled in my lap even though she’s a head taller than me. So I was sure she’d jump at the chance to avoid surgery.

It turned out that she had an utterly different take. The experience of getting an IV in the E.R. was so miserable that she never wanted to repeat it. The definitiveness of surgery was much more appealing than the possibility — however small — of going through this again in the future.

The next morning, that dangly tail of residual colon was successfully snipped. When my daughter was coming out of anesthesia, I asked her if she’d like some Toradol, the pain medication that the nurse was offering. “Tortellini?” she mumbled foggily. “Are we having tortellini?”

I was impressed, yet again, by the marvels of modern medicine, knowing full well that had this taken place a century earlier I might have been digging a grave for my child that evening instead of digging through the freezer for tortellini.

As a physician, I’m stunningly proud of the medical care our hospitals can provide. But during our stay as civilians, every aspect felt like harm waiting to happen. I’m sure I ruffled a few feathers with all of my questions, but addressing family members’ worries is part of the job — even if the family member isn’t a physician, and isn’t on the faculty of that institution, and doesn’t coincidentally happen to be writing a book about medical error while sitting at the bedside.

It’s not comfortable being the squeaky wheel. Being on guard for my daughter 24/7 was frankly exhausting. But once you are on the patient side of the stethoscope, everything looks like a minefield.

Of course, the burden should not have to be on the patient or family for ensuring safe medical care. That is the job of the health care system. But as we well know, the system has not yet achieved pristine perfection, so it behooves patients and families to stay engaged as much as possible.

The Covid-19 pandemic has surely demonstrated the professionalism of health care workers. But even the most dedicated staff need extra sets of eyes on the ground.

My advice to patients is to be polite but persistent. Don’t let unspoken annoyance deter you. Offer appreciation for the things that are going well — and acknowledge that everyone is working hard! — but plow forward. At the very least, ask what each medication is and why you are getting it.

And if you are too nauseated or too sleepy or too feverish, don’t rack yourself with guilt because you are not interrogating every staff member. Get the rest you need. Before you doze off, though, use some leftover surgical tape to affix a sign across your chest that says “Wash your hands!”

The onus is on the medical system to make health care as safe as possible. But patients and families shouldn’t feel shy about taking a forthright role. Keeping those jumbo jets from falling out of the sky is a team effort, and the team includes the folks on both ends of the stethoscope.

Dr. Danielle Ofri practices at Bellevue Hospital in New York City and is a clinical professor of medicine at New York University. Her newest book is “When We Do Harm: A Doctor Confronts Medical Error.”

He Was Hospitalized for Covid-19. Then Hospitalized Again. And Again.

Credit…Emily Rose Bennett for The New York Times

He Was Hospitalized for Covid-19. Then Hospitalized Again. And Again.

Significant numbers of coronavirus patients experience long-term symptoms that send them back to the hospital, taxing an already overburdened health system.

Credit…Emily Rose Bennett for The New York Times

Pam Belluck

  • Dec. 30, 2020, 3:00 a.m. ET

The routine things in Chris Long’s life used to include biking 30 miles three times a week and taking courses toward a Ph.D. in eight-week sessions.

But since getting sick with the coronavirus in March, Mr. Long, 54, has fallen into a distressing new cycle — one that so far has landed him in the hospital seven times.

Periodically since his initial five-day hospitalization, his lungs begin filling again; he starts coughing uncontrollably and runs a low fever. Roughly 18 days later, he spews up greenish-yellow fluid, signaling yet another bout of pneumonia.

Soon, his oxygen levels drop and his heart rate accelerates to compensate, sending him to a hospital near his home in Clarkston, Mich., for several days, sometimes in intensive care.

“This will never go away,” he said, describing his worst fear. “This will be my going-forward for the foreseeable future.”

Nearly a year into the pandemic, it’s clear that recovering from Covid-19’s initial onslaught can be an arduous, uneven journey. Now, studies reveal that a significant subset of patients are having to return to hospitals, sometimes repeatedly, with complications triggered by the disease or by the body’s efforts to defeat the virus.

Even as vaccines give hope for stopping the spread of the virus, the surge of new cases portends repeated hospitalizations for more patients, taxing medical resources and turning some people’s path to recovery into a Sisyphean odyssey that upends their lives.

“It’s an urgent medical and public health question,” said Dr. Girish Nadkarni, an assistant professor of medicine at Mount Sinai Hospital in New York, who, with another assistant professor, Dr. Anuradha Lala, is studying readmissions of Covid-19 patients.

Data on rehospitalizations of coronavirus patients are incomplete, but early studies suggest that in the United States alone, tens of thousands or even hundreds of thousands could ultimately return to the hospital.

A study by the Centers for Disease Control and Prevention of 106,543 coronavirus patients initially hospitalized between March and July found that one in 11 was readmitted within two months of being discharged, with 1.6 percent of patients readmitted more than once.

In another study of 1,775 coronavirus patients discharged from 132 V.A. hospitals in the pandemic’s early months, nearly a fifth were rehospitalized within 60 days. More than 22 percent of them needed intensive care, and 7 percent required ventilators.

And in a report on 1,250 patients discharged from 38 Michigan hospitals from mid-March to July, 15 percent were rehospitalized within 60 days.

Recurring admissions don’t just involve patients who were severely ill the first time around.

“Even if they had a very mild course, at least one-third have significant symptomology two to three months out,” said Dr. Eleftherios Mylonakis, chief of infectious diseases at Brown University’s Warren Alpert Medical School and Lifespan hospitals, who co-wrote another report. “There is a wave of readmissions that is building, because at some point these people will say ‘I’m not well.’”

Many who are rehospitalized were vulnerable to serious symptoms because they were over 65 or had chronic conditions. But some younger and previously healthy people have returned to hospitals, too.

When Becca Meyer, 31, of Paw Paw, Mich., contracted the coronavirus in early March, she initially stayed home, nursing symptoms such as difficulty breathing, chest pain, fever, extreme fatigue and hallucinations that included visions of being attacked by a sponge in the shower.

Ms. Meyer, a mother of four, eventually was hospitalized for a week in March and again in April. She was readmitted for an infection in August and for severe nausea in September, according to medical records, which labeled her condition “long haul Covid-19.”

Because she couldn’t hold down food, doctors discharged her with a nasal feeding tube connected to protein-and-electrolyte formula on a pole, which, she said, “I’m supposed to be attached to 20 hours a day.”

Feeding tube issues required hospitalization for nearly three weeks in October and a week in December. She has been unable to resume her job in customer service, spent the summer using a walker, and has had a home health nurse for weeks.

“It’s been a roller coaster since March and I’m now in the downswing of it, where I’m back to being in bed all the time and not being able to eat much, coughing a lot more, having more chest pain,” she said.

Readmissions strain hospital resources, and returning patients may be exposed to new infections or develop muscle atrophy from being bedridden. Mr. Long and Ms. Meyer said they contracted the bacterial infection C. difficile during rehospitalizations.

“Readmissions have been associated, even before Covid, with worse patient outcomes,” Dr. Mylonakis said.

Some research suggests implications for hospitals currently overwhelmed with cases. A Mount Sinai Hospital study of New York’s first wave found that patients with shorter initial stays and those not sick enough for intensive care were more likely to return within two weeks.

Dr. Lala, who co-wrote the study, said the thinking at overstretched hospitals was “we have a lack of resources, so if the patients are stable get them home.” But, she added, “the fact that length of stay was indeed shorter for those patients who return is begging the question of: Were we kicking these people out the door too soon?”

Many rehospitalized patients have respiratory problems, but some have blood clots, heart trouble, sepsis, gastrointestinal symptoms or other issues, doctors report. Some have neurological symptoms like brain fog, “a clear cognitive issue that is evident when they get readmitted,” said Dr. Vineet Chopra, chief of hospital medicine at the University of Michigan, who co-wrote the Michigan study. “It is there, and it is real.”

Dr. Laurie Jacobs, chairwoman of internal medicine at Hackensack University Medical Center, said causes of readmissions vary.

“Sometimes there’s a lot of push to get patients out of the hospital, and they want to get out of the hospital and sometimes they’re not ready,” so they return, she said. But some appropriately discharged patients develop additional problems or return to hospitals because they lack affordable outpatient care.

Antibiotics and other medications belonging to Mr. Long.
Antibiotics and other medications belonging to Mr. Long.Credit…Emily Rose Bennett for The New York Times

Mr. Long’s ordeal began on March 9. “I couldn’t stand up without falling over,” he said.

His primary physician, Dr. Benjamin Diaczok, immediately told him to call an ambulance.

“I crawled out to the front door,” recalled Mr. Long. He was barefoot and remembers sticking out his arm to prop open the door for the ambulance crew, who found him facedown.

He awoke three days later, in the hospital, when he accidentally pulled out the tubes to the ventilator he’d been hooked up to. After two more days, he’d stabilized enough to return to the apartment where he lives alone, an hour north of Detroit.

Mr. Long had some previous health issues, including blood clots in his lungs and legs several years ago and an irregular heartbeat requiring an implanted heart monitor in 2018. Still, before Covid-19, he was “very high-functioning, very energetic,” Dr. Diaczok said.

Now, Mr. Long said: “I’ve got scarred lungs, pulmonary fibrosis, and I’m running right around 75-to-80 percent lung capacity.”

He was rehospitalized in April, May, June, July, August and September, requiring oxygen and intravenous antibiotics, potassium and magnesium.

“Something must have happened to his lungs that is making them more prone for this,” Dr. Diaczok said.

Mr. Long, a former consultant on tank systems for the military, is also experiencing brain fog that’s forced a hiatus from classes toward a Ph.D. in business convergence strategy.

“I read 10 pages in one of my textbooks and then five minutes later, after a phone call, I can’t remember what I read,” he said.

“It’s horrible, ”Dr. Diaczok said. “This is a man that thinks for a living, and he can’t do his job.”

And his heart arrhythmia, controlled since 2018, has resurfaced. Unless Mr. Long, who is 6-foot-7, sleeps at an incline on his couch, his heart skips beats, causing his monitor to prompt middle-of-the-night calls from his doctor’s office. Unable to lie in bed, “I don’t sleep through the night.”

Small exertions — “just to stand up to go do the dishes” — are exhausting. In July, he tried starting physical therapy but was told he wasn’t ready.

In August, he got up too fast, fell and “I was very confused,” he recalled. During that hospital readmission, doctors noted “altered mental status” from dehydration and treated him for pneumonia and functional lung collapse.

In late October, Mr. Long developed pneumonia again, but under Dr. Diaczok’s guidance, managed at home with high-dose oral antibiotics.

In December, when a pulmonologist administered a breathing test, “I couldn’t make it six seconds,” he said.

Mr. Long repeatedly measures his temperature and pulse oxygen, and can feel in his chest when “trouble’s coming,” he said. Determined to recover, he tries to walk short distances. “Can I make it to take out the trash?” he’ll ask himself. On a good day, he’ll walk eight feet to his mailbox.

“I’m going to be around to walk my daughters down the aisle and see my grandkids,” said Mr. Long, voice cracking. “I’m not going to let this thing win.”

How Midwives Have Stepped in in Mexico as Covid-19 Overshadows Childbirth

Doctors released Alejandra Guevarra Villegas, 19, from the operating room after delivering her baby girl by emergency C-section in San Luis Acatlán, a small town in the Costa Chica zone in the Mexican state of Guerrero.
Doctors released Alejandra Guevarra Villegas, 19, from the operating room after delivering her baby girl by emergency C-section in San Luis Acatlán, a small town in the Costa Chica zone in the Mexican state of Guerrero.

In Mexico, Childbirth in Covid’s Shadow

Midwives and doctors struggle to help women give birth safely during the grim days of the pandemic.

Doctors released Alejandra Guevarra Villegas, 19, from the operating room after delivering her baby girl by emergency C-section in San Luis Acatlán, a small town in the Costa Chica zone in the Mexican state of Guerrero.Credit…

  • Dec. 22, 2020, 3:00 a.m. ET

Rafaela López Juárez was determined that if she ever had another child, she would try to give birth at home with a trusted midwife, surrounded by family. Her first birth at a hospital had been a traumatic ordeal, and her perspective changed drastically afterward, when she trained to become a professional midwife.

“What women want is a birth experience centered on respect and dignity,” she said. She believes that low-risk births should occur outside hospitals, in homes or in dedicated birth centers, where women can choose how they want to give birth.

In late February, Ms. López and her family were anticipating the arrival of her second child at their home in Xalapa, Mexico, while following the ominous news of the encroaching coronavirus pandemic. She gave birth to Joshua, a healthy baby boy, on Feb. 28, the same day that Mexico confirmed its first case of Covid-19. Ms. López wondered how the pandemic would affect her profession.

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Rafaela López and her partner, José Hernández, awaiting the birth of their baby, with Rafaela’s daughter, Johana, 11, nearby.

Accompanied by midwife Pilar Victoria Rosique, Rafaela López Juárez tried to manage intensifying contractions when her labor started inside her home. Her partner José recorded the timing of the contractions.

Rafaela López examined Jessica Garcia Pérez, 32, while Ms. Garcia’s son took a photo during a prenatal home visit in Xalapa, Veracruz.

About 96 percent of births in Mexico take place in hospitals that are often overcrowded and ill-equipped, where many women describe receiving poor or disrespectful treatment. The onset of the pandemic prompted concern that pregnant women might be exposed to the virus in hospitals, and women’s health advocates in Mexico and globally expressed hope that the crisis might become a catalyst for lasting changes to the system.

A national movement has made determined but uneven progress toward integrating midwifery into Mexico’s public health system. Some authorities argue that well-trained midwives would be of great value, especially in rural areas but also in small nonsurgical clinics throughout the country. But so far, there has been insufficient political will to provide the regulation, infrastructure and budgets needed to employ enough midwives to make a significant difference.

During the first few months of the pandemic, anecdotal evidence suggested that midwifery was gaining traction in the country. Midwives all over Mexico were inundated with requests for home births. The government encouraged state authorities to set up alternative health centers that could exclusively focus on births and be staffed by nurses and midwives.

As Covid outbreaks spread, health authorities around the country started to see sharp declines in prenatal consultations and births in hospitals. At the Acapulco General Hospital in Mexico’s Guerrero state, Dr. Juan Carlos Luna, the maternal health director, noted a 50 percent decline in births. With skeletal staffs at times working double shifts, doctors and nurses pushed through under dire conditions. “Nearly everyone on my team has tested positive for the virus at some point,” Dr. Luna said.

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Funeral workers remove the body of a patient who died from Covid-19 at the General Hospital in Acapulco, Guerrero, Mexico.

Employees of a German company, Sanieren, based in Mexico City, sanitized the Covid triage area of the Acapulco General Hospital.

Medical personnel assisted María de Jesús Maroquín Hernández, preparing her for discharge from the Covid-19 intensive care unit at the Acapulco General Hospital.

María de Jesús Maroquín Hernández contracted Covid when she was 36 weeks pregnant, and was hospitalized for five days at Acapulco General Hospital, four hours from her home near Ometepec, Guerrero, Mexico. Later, she gave birth to a baby girl, who she and her husband named Milagro, Spanish for miracle.

Inside the Covid-19 intensive care unit at Acapulco General, doctors treated María de Jesús Maroquín Hernández. She had developed breathing problems at 36 weeks pregnant, prompting her family to drive her four hours to the hospital. Doctors isolated Ms. Maroquín while her family waited outside, watching funeral workers carry away the dead Covid patients and worrying that she would be next. She was discharged after five days and soon gave birth, via emergency cesarean section, in a hospital near her home. She and her husband decided to name their baby girl Milagro — miracle.

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A central hub for dozens of mostly indigenous communities, San Luis Acatlán, a small town in the Costa Chica area of Mexico’s Guerrero state, became a “zone of high contagion” during the pandemic. Signs warned residents to wear masks.

Soldiers guard the Ometepec General Hospital in Mexico’s Guerrero state. As the Covid pandemic intensified, the public sometimes stormed hospitals and threatened doctors.

Ometepec General Hospital was nearly empty at times, as the public shunned hospitals in fear. State health authorities had ordered the reconfiguration of many public hospitals to create separate Covid and non-Covid sections.

In Mexico’s Indigenous communities, women have long relied on traditional midwives, who have become even more important today. In Guerrero, some women have given birth with midwives at dedicated Indigenous women’s centers called CAMIs (Casas de la Mujer Indígena o Afromexicana), where women can also seek help for domestic violence, which CAMI workers say has increased. But austerity measures related to the pandemic have deprived the centers of essential funding from the federal government.

Other women have chosen to quarantine in their communities, seeking help from midwives like Isabel Vicario Natividad, 57, who keeps working though her own health conditions make her vulnerable to the virus.

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Salustria Leonídez Constancia and her daughter in-law, Citlali Salvador de Jesús, examining Juliana Toribio Teodoro, 27, in Yoloxóchitl, a small Mixteco community located near San Luis Acatlán in Mexico’s Guerrero state.

Midwife Alma Delia Felipe Hidalgo attending a birth at Casa de la Mujer Indígena Nellys Palomo Sánchez, in San Luis Acatlán, a small town in the Costa Chica zone of Guerrero state.

In the remote community of Pueblo Hidalgo, in the Southern mountains of Guerrero state, Isabel Vicario Natividad, a midwife, approached the home of one of her clients, Guillermina Francisco Flores, 38, pregnant with her fifth child.

As Covid-19 cases surged in Guerrero, state health authorities reached out to women and midwives in remote areas with potentially high rates of maternal and infant mortality.

“If the women are too afraid to come to our hospitals, we should go find them where they are,” said Dr. Rodolfo Orozco, the director of reproductive health in Guerrero. With support from a handful of international organizations, his team recently began to visit traditional midwives for workshops and to distribute personal protective equipment.

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Ms. Vicario performing a prenatal check on Ms. Flores.

Melquiades Villegas Feliciano, 23, supporting his wife, Luisa Ortega Cantu, while Ms. Vicario helped the couple prepare for the birth of Ms. Ortega’s third child.

Luisa Ortega Cantu’s newborn was kept attached to the umbilical cord and placenta for several minutes after delivery, a practice of traditional midwives.

Isabel Vicario with Ms. Ortega’s baby.

In the capital city of Chilpancingo, many women discovered the Alameda Midwifery Center, which opened in December 2017. During the initial phase of the pandemic, the center’s birth numbers doubled. In October, Anayeli Rojas Esteban, 27, traveled two hours to the center after her local hospital could not accommodate her. She was pleasantly surprised to find a place with midwives who actually allowed her to give birth accompanied by her husband, José Luis Morales.

“We are especially grateful that they did not cut her, like they did during her first hospital birth,” Mr. Morales said, referring to an episiotomy, a surgical procedure that is routine in hospital settings but increasingly seen as unnecessary.

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Hoping to avoid the coronavirus, many women in Mexico sought maternity care at places like the Alameda Midwifery Center in Chilpancingo in Guerrero. During the initial months of the pandemic, the center’s birth numbers doubled.

Members of the Maternal Health Unit of the Guerrero health care sector teaching local midwives about Covid protection measures and breast cancer detection methods.

Midwives who took part in the course by the Maternal Health Unit received a set of P.P.E.

Anayeli Rojas Esteban, 27, tries giving birth in a standing position at the Alameda Midwifery Center.

While Mexico’s state health authorities struggled to contain the virus, the situation in the nation’s capital further illustrated the dangers and frustrations that women felt.

In the spring, health authorities in Iztapalapa, the most densely populated neighborhood of Mexico City, scrambled as the area became a center of the country’s coronavirus outbreak. The city government converted several large public hospitals in Iztapalapa into treatment facilities for Covid-19 patients, which left thousands of pregnant women desperate to find alternatives. Many sought refuge in maternity clinics such as Cimigen, where the number of births doubled and the number of prenatal visits quadrupled, according to the clinic’s executive director, Marisol del Campo Martínez.

Other expectant mothers joined the growing ranks of women seeking a home birth experience, for safety reasons and to avoid a potentially unnecessary cesarean section. In Mexico, roughly 50 percent of babies are delivered via C-section, and pregnant women face pressure from peers, family members and doctors to have the procedure.

In July, Nayeli Balderas, 30, who lived close to Iztapalapa, reached out to Guadalupe Hernández Ramírez, an experienced perinatal nurse and the president of the Association of Professional Midwives in Mexico. “When I started to research about humanized birth, breastfeeding, et cetera, a whole new world opened for me,” Ms. Balderas said. “But when we told our gynecologist about our plan, her whole face changed, and she tried to instill fear in us.” Undaunted, Ms. Balderas proceeded with her home birth plan.

Her labor, when it came, was long and increasingly difficult. After 12 hours, Ms. Balderas and her husband conferred with Ms. Hernández and decided to activate their Plan B. At 3 a.m., they rushed to the private clinic of Dr. Fernando Jiménez, an obstetrician-gynecologist and a colleague of Ms. Hernández, where it was decided that a C-section was needed.

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Janet Jarman

Juan Luis de la Torre Islas joined dozens of other parents waiting to receive vaccinations for their children at Cimigen, a small maternity hospital in Iztapalapa, Mexico City’s most populous and most densely populated delegation, that had become the epicenter of the virus.

Nayeli Balderas, 30, in labor, with her husband, Javier Basilio Lara, 31, in their Mexico City apartment, where they hoped she would give birth. Ms. Balderas had expected a hospital birth, but after the pandemic began, the couple decided to try for a home birth to avoid the coronavirus.

After hours of labor, Ms. Balderas’s baby still had not rotated into the right position for birth. The nurse midwives advised different birthing positions, but the infant still would not budge. Twelve hours later, the midwives took her to a small, private clinic for a cesarean birth.

Ms. Balderas with her son, born by cesarean section in a small private clinic at 4 a.m.

Maira Itzel Reyes Ferrer, 26 and her husband, Hugo Alberto Albarran Jarquin, 33, attended a class offered by an obstetric nurse and a 92-year-old traditional midwife who together blend traditional practices and modern medicine. Ms. Reyes had her first child a week later.

Elva Carolina Díaz Ruiz, the obstetric nurse, massaged Ms. Ferrer as her contractions begin to intensify. Pilar, her midwife, right, was in attendance.

In September, on the other side of Mexico City, Maira Itzel Reyes Ferrer, 26, had also been researching home births and found María Del Pilar Grajeda Mejía, a 92-year-old government-certified traditional midwife who works with her granddaughter, Elva Carolina Díaz Ruiz, 37, a licensed obstetric nurse. They guided Ms. Reyes through a successful home birth.

“My family admitted that they were sometimes worried during the birth,” Ms. Reyes said. “But in the end, they loved the experience — so much so that my sister is now taking a midwifery course. She already paid and started!”

As winter begins, Mexico is confronting a devastating second wave of the coronavirus. Hospitals in Mexico City are quickly running out of space. The much-discussed government midwifery birth centers have not yet come to fruition, and medical workers at prestigious hospitals like the National Institute of Perinatology, or INPer, are working around the clock.

Early on in the pandemic, INPer personnel discovered that roughly one-quarter of all women admitted to the hospital were testing positive for the coronavirus. Administrators set up a separate Covid-19 ward, and Dr. Isabel Villegas Mota, the hospital’s head of epidemiology and infectious disease, succeeded in securing adequate personal protective equipment for the staff. Not all frontline workers in Mexico have been this lucky; the Covid-19 fatality rate for medical personnel in Mexico is among the highest in the world.

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Grecia Denise Espinosa tested positive for the coronavirus at the National Institute for Perinatology in Mexico City, and was admitted to the Covid unit where she gave birth by cesarean.

Minutes after the births, Ms. Espinosa’s twins were examined and tested for the virus.

Because Ms. Espinosa and her babies were in good condition, doctors encouraged her to breastfeed, provided that she wore a mask and face shield.

When Grecia Denise Espinosa learned she was pregnant with twins, she made plans to give birth at a well-known private clinic. But she was shocked by the high cost and decided to consult doctors at INPer instead. To her surprise, when she entered the hospital in November, she tested positive for the virus and was sent to the Covid-19 unit, where doctors performed a C-section.

Maternal health advocates have long said that Mexico’s obstetric model must change to center on women. If ever there were a moment for health authorities to fully embrace midwifery, now is the time, they say, arguing that the thousands of midwives throughout the country could help alleviate pressure on an overburdened and often distrusted health care system while providing quality care to women.

“The model that we have in Mexico is an obsolete model,” said Dr. David Meléndez, the technical director of Safe Motherhood Committee Mexico, a nonprofit organization. “It’s a model in which we all lose. The women lose, the country loses, and the health system and medical personnel lose. We are stuck with a bad model at the worst moment, in the middle of a global pandemic.”

Sunset over the Casa de la Mujer Indígena Nellys Palomo Sánchez  in San Luis Acatlán, Guerrero.
Sunset over the Casa de la Mujer Indígena Nellys Palomo Sánchez  in San Luis Acatlán, Guerrero.

Janet Jarman is a photojournalist and documentary filmmaker based in Mexico, and director of the feature documentary “Birth Wars.” She is represented by Redux Pictures.

In Mexico, Midwives Step in as Covid Overshadows Childbirth

Doctors released Alejandra Guevarra Villegas, 19, from the operating room after delivering her baby girl by emergency C-section in San Luis Acatlán, a small town in the Costa Chica zone in the Mexican state of Guerrero.
Doctors released Alejandra Guevarra Villegas, 19, from the operating room after delivering her baby girl by emergency C-section in San Luis Acatlán, a small town in the Costa Chica zone in the Mexican state of Guerrero.

In Mexico, Childbirth in Covid’s Shadow

Midwives and doctors struggle to help women give birth safely during the grim days of the pandemic.

Doctors released Alejandra Guevarra Villegas, 19, from the operating room after delivering her baby girl by emergency C-section in San Luis Acatlán, a small town in the Costa Chica zone in the Mexican state of Guerrero.Credit…

  • Dec. 22, 2020, 3:00 a.m. ET

Rafaela López Juárez was determined that if she ever had another child, she would try to give birth at home with a trusted midwife, surrounded by family. Her first birth at a hospital had been a traumatic ordeal, and her perspective changed drastically afterward, when she trained to become a professional midwife.

“What women want is a birth experience centered on respect and dignity,” she said. She believes that low-risk births should occur outside hospitals, in homes or in dedicated birth centers, where women can choose how they want to give birth.

In late February, Ms. López and her family were anticipating the arrival of her second child at their home in Xalapa, Mexico, while following the ominous news of the encroaching coronavirus pandemic. She gave birth to Joshua, a healthy baby boy, on Feb. 28, the same day that Mexico confirmed its first case of Covid-19. Ms. López wondered how the pandemic would affect her profession.

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Rafaela López and her partner, José Hernández, awaiting the birth of their baby, with Rafaela’s daughter, Johana, 11, nearby.

Accompanied by midwife Pilar Victoria Rosique, Rafaela López Juárez tried to manage intensifying contractions when her labor started inside her home. Her partner José recorded the timing of the contractions.

Rafaela López examined Jessica Garcia Pérez, 32, while Ms. Garcia’s son took a photo during a prenatal home visit in Xalapa, Veracruz.

About 96 percent of births in Mexico take place in hospitals that are often overcrowded and ill-equipped, where many women describe receiving poor or disrespectful treatment. The onset of the pandemic prompted concern that pregnant women might be exposed to the virus in hospitals, and women’s health advocates in Mexico and globally expressed hope that the crisis might become a catalyst for lasting changes to the system.

A national movement has made determined but uneven progress toward integrating midwifery into Mexico’s public health system. Some authorities argue that well-trained midwives would be of great value, especially in rural areas but also in small nonsurgical clinics throughout the country. But so far, there has been insufficient political will to provide the regulation, infrastructure and budgets needed to employ enough midwives to make a significant difference.

During the first few months of the pandemic, anecdotal evidence suggested that midwifery was gaining traction in the country. Midwives all over Mexico were inundated with requests for home births. The government encouraged state authorities to set up alternative health centers that could exclusively focus on births and be staffed by nurses and midwives.

As Covid outbreaks spread, health authorities around the country started to see sharp declines in prenatal consultations and births in hospitals. At the Acapulco General Hospital in Mexico’s Guerrero state, Dr. Juan Carlos Luna, the maternal health director, noted a 50 percent decline in births. With skeletal staffs at times working double shifts, doctors and nurses pushed through under dire conditions. “Nearly everyone on my team has tested positive for the virus at some point,” Dr. Luna said.

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Funeral workers remove the body of a patient who died from Covid-19 at the General Hospital in Acapulco, Guerrero, Mexico.

Employees of a German company, Sanieren, based in Mexico City, sanitized the Covid triage area of the Acapulco General Hospital.

Medical personnel assisted María de Jesús Maroquín Hernández, preparing her for discharge from the Covid-19 intensive care unit at the Acapulco General Hospital.

María de Jesús Maroquín Hernández contracted Covid when she was 36 weeks pregnant, and was hospitalized for five days at Acapulco General Hospital, four hours from her home near Ometepec, Guerrero, Mexico. Later, she gave birth to a baby girl, who she and her husband named Milagro, Spanish for miracle.

Inside the Covid-19 intensive care unit at Acapulco General, doctors treated María de Jesús Maroquín Hernández. She had developed breathing problems at 36 weeks pregnant, prompting her family to drive her four hours to the hospital. Doctors isolated Ms. Maroquín while her family waited outside, watching funeral workers carry away the dead Covid patients and worrying that she would be next. She was discharged after five days and soon gave birth, via emergency cesarean section, in a hospital near her home. She and her husband decided to name their baby girl Milagro — miracle.

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A central hub for dozens of mostly indigenous communities, San Luis Acatlán, a small town in the Costa Chica area of Mexico’s Guerrero state, became a “zone of high contagion” during the pandemic. Signs warned residents to wear masks.

Soldiers guard the Ometepec General Hospital in Mexico’s Guerrero state. As the Covid pandemic intensified, the public sometimes stormed hospitals and threatened doctors.

Ometepec General Hospital was nearly empty at times, as the public shunned hospitals in fear. State health authorities had ordered the reconfiguration of many public hospitals to create separate Covid and non-Covid sections.

In Mexico’s Indigenous communities, women have long relied on traditional midwives, who have become even more important today. In Guerrero, some women have given birth with midwives at dedicated Indigenous women’s centers called CAMIs (Casas de la Mujer Indígena o Afromexicana), where women can also seek help for domestic violence, which CAMI workers say has increased. But austerity measures related to the pandemic have deprived the centers of essential funding from the federal government.

Other women have chosen to quarantine in their communities, seeking help from midwives like Isabel Vicario Natividad, 57, who keeps working though her own health conditions make her vulnerable to the virus.

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Salustria Leonídez Constancia and her daughter in-law, Citlali Salvador de Jesús, examining Juliana Toribio Teodoro, 27, in Yoloxóchitl, a small Mixteco community located near San Luis Acatlán in Mexico’s Guerrero state.

Midwife Alma Delia Felipe Hidalgo attending a birth at Casa de la Mujer Indígena Nellys Palomo Sánchez, in San Luis Acatlán, a small town in the Costa Chica zone of Guerrero state.

In the remote community of Pueblo Hidalgo, in the Southern mountains of Guerrero state, Isabel Vicario Natividad, a midwife, approached the home of one of her clients, Guillermina Francisco Flores, 38, pregnant with her fifth child.

As Covid-19 cases surged in Guerrero, state health authorities reached out to women and midwives in remote areas with potentially high rates of maternal and infant mortality.

“If the women are too afraid to come to our hospitals, we should go find them where they are,” said Dr. Rodolfo Orozco, the director of reproductive health in Guerrero. With support from a handful of international organizations, his team recently began to visit traditional midwives for workshops and to distribute personal protective equipment.

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Ms. Vicario performing a prenatal check on Ms. Flores.

Melquiades Villegas Feliciano, 23, supporting his wife, Luisa Ortega Cantu, while Ms. Vicario helped the couple prepare for the birth of Ms. Ortega’s third child.

Luisa Ortega Cantu’s newborn was kept attached to the umbilical cord and placenta for several minutes after delivery, a practice of traditional midwives.

Isabel Vicario with Ms. Ortega’s baby.

In the capital city of Chilpancingo, many women discovered the Alameda Midwifery Center, which opened in December 2017. During the initial phase of the pandemic, the center’s birth numbers doubled. In October, Anayeli Rojas Esteban, 27, traveled two hours to the center after her local hospital could not accommodate her. She was pleasantly surprised to find a place with midwives who actually allowed her to give birth accompanied by her husband, José Luis Morales.

“We are especially grateful that they did not cut her, like they did during her first hospital birth,” Mr. Morales said, referring to an episiotomy, a surgical procedure that is routine in hospital settings but increasingly seen as unnecessary.

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Hoping to avoid the coronavirus, many women in Mexico sought maternity care at places like the Alameda Midwifery Center in Chilpancingo in Guerrero. During the initial months of the pandemic, the center’s birth numbers doubled.

Members of the Maternal Health Unit of the Guerrero health care sector teaching local midwives about Covid protection measures and breast cancer detection methods.

Midwives who took part in the course by the Maternal Health Unit received a set of P.P.E.

Anayeli Rojas Esteban, 27, tries giving birth in a standing position at the Alameda Midwifery Center.

While Mexico’s state health authorities struggled to contain the virus, the situation in the nation’s capital further illustrated the dangers and frustrations that women felt.

In the spring, health authorities in Iztapalapa, the most densely populated neighborhood of Mexico City, scrambled as the area became a center of the country’s coronavirus outbreak. The city government converted several large public hospitals in Iztapalapa into treatment facilities for Covid-19 patients, which left thousands of pregnant women desperate to find alternatives. Many sought refuge in maternity clinics such as Cimigen, where the number of births doubled and the number of prenatal visits quadrupled, according to the clinic’s executive director, Marisol del Campo Martínez.

Other expectant mothers joined the growing ranks of women seeking a home birth experience, for safety reasons and to avoid a potentially unnecessary cesarean section. In Mexico, roughly 50 percent of babies are delivered via C-section, and pregnant women face pressure from peers, family members and doctors to have the procedure.

In July, Nayeli Balderas, 30, who lived close to Iztapalapa, reached out to Guadalupe Hernández Ramírez, an experienced perinatal nurse and the president of the Association of Professional Midwives in Mexico. “When I started to research about humanized birth, breastfeeding, et cetera, a whole new world opened for me,” Ms. Balderas said. “But when we told our gynecologist about our plan, her whole face changed, and she tried to instill fear in us.” Undaunted, Ms. Balderas proceeded with her home birth plan.

Her labor, when it came, was long and increasingly difficult. After 12 hours, Ms. Balderas and her husband conferred with Ms. Hernández and decided to activate their Plan B. At 3 a.m., they rushed to the private clinic of Dr. Fernando Jiménez, an obstetrician-gynecologist and a colleague of Ms. Hernández, where it was decided that a C-section was needed.

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Janet Jarman

Juan Luis de la Torre Islas joined dozens of other parents waiting to receive vaccinations for their children at Cimigen, a small maternity hospital in Iztapalapa, Mexico City’s most populous and most densely populated delegation, that had become the epicenter of the virus.

Nayeli Balderas, 30, in labor, with her husband, Javier Basilio Lara, 31, in their Mexico City apartment, where they hoped she would give birth. Ms. Balderas had expected a hospital birth, but after the pandemic began, the couple decided to try for a home birth to avoid the coronavirus.

After hours of labor, Ms. Balderas’s baby still had not rotated into the right position for birth. The nurse midwives advised different birthing positions, but the infant still would not budge. Twelve hours later, the midwives took her to a small, private clinic for a cesarean birth.

Ms. Balderas with her son, born by cesarean section in a small private clinic at 4 a.m.

Maira Itzel Reyes Ferrer, 26 and her husband, Hugo Alberto Albarran Jarquin, 33, attended a class offered by an obstetric nurse and a 92-year-old traditional midwife who together blend traditional practices and modern medicine. Ms. Reyes had her first child a week later.

Elva Carolina Díaz Ruiz, the obstetric nurse, massaged Ms. Ferrer as her contractions begin to intensify. Pilar, her midwife, right, was in attendance.

In September, on the other side of Mexico City, Maira Itzel Reyes Ferrer, 26, had also been researching home births and found María Del Pilar Grajeda Mejía, a 92-year-old government-certified traditional midwife who works with her granddaughter, Elva Carolina Díaz Ruiz, 37, a licensed obstetric nurse. They guided Ms. Reyes through a successful home birth.

“My family admitted that they were sometimes worried during the birth,” Ms. Reyes said. “But in the end, they loved the experience — so much so that my sister is now taking a midwifery course. She already paid and started!”

As winter begins, Mexico is confronting a devastating second wave of the coronavirus. Hospitals in Mexico City are quickly running out of space. The much-discussed government midwifery birth centers have not yet come to fruition, and medical workers at prestigious hospitals like the National Institute of Perinatology, or INPer, are working around the clock.

Early on in the pandemic, INPer personnel discovered that roughly one-quarter of all women admitted to the hospital were testing positive for the coronavirus. Administrators set up a separate Covid-19 ward, and Dr. Isabel Villegas Mota, the hospital’s head of epidemiology and infectious disease, succeeded in securing adequate personal protective equipment for the staff. Not all frontline workers in Mexico have been this lucky; the Covid-19 fatality rate for medical personnel in Mexico is among the highest in the world.

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Grecia Denise Espinosa tested positive for the coronavirus at the National Institute for Perinatology in Mexico City, and was admitted to the Covid unit where she gave birth by cesarean.

Minutes after the births, Ms. Espinosa’s twins were examined and tested for the virus.

Because Ms. Espinosa and her babies were in good condition, doctors encouraged her to breastfeed, provided that she wore a mask and face shield. 

When Grecia Denise Espinosa learned she was pregnant with twins, she made plans to give birth at a well-known private clinic. But she was shocked by the high cost and decided to consult doctors at INPer instead. To her surprise, when she entered the hospital in November, she tested positive for the virus and was sent to the Covid-19 unit, where doctors performed a C-section.

Maternal health advocates have long said that Mexico’s obstetric model must change to center on women. If ever there were a moment for health authorities to fully embrace midwifery, now is the time, they say, arguing that the thousands of midwives throughout the country could help alleviate pressure on an overburdened and often distrusted health care system while providing quality care to women.

“The model that we have in Mexico is an obsolete model,” said Dr. David Meléndez, the technical director of Safe Motherhood Committee Mexico, a nonprofit organization. “It’s a model in which we all lose. The women lose, the country loses, and the health system and medical personnel lose. We are stuck with a bad model at the worst moment, in the middle of a global pandemic.”

Sunset over the Casas de la Mujer Indígena o Afromexicana in Guerrero.
Sunset over the Casas de la Mujer Indígena o Afromexicana in Guerrero.

Janet Jarman is a photojournalist and documentary filmmaker based in Mexico, and director of the feature documentary “Birth Wars.” She is represented by Redux Pictures.

Cesarean Sections May Increase Infection Risk in Babies

Babies born by cesarean section may have an increased risk of being hospitalized with infections, a new study suggests.

The analysis, published in PLOS Medicine, used data on 7,174,787 singleton births in Denmark, Scotland, England and Australia from 1996 to 2015. Of these, 1,681,966 were by C-section, 43 percent of them elective. They followed the children through their 5th birthdays, tracking infection-related hospitalizations.

More than 1.5 million of the children were hospitalized with infections over the course of the study. Babies born by C-section had a 10 percent higher risk of infections that required hospitalization than those born vaginally. The risks persisted over five years, and the rates were highest for gastrointestinal and respiratory infections.

The study controlled for many factors that may increase the risk of infection, including the mother’s smoking, gestational diabetes and high blood pressure; the family’s socioeconomic status; and the baby’s gestational age and birth weight. But the researchers had no data on breastfeeding, vaccination or postnatal smoke exposure, which could also affect infection rates.

“This is not about telling women how to deliver, or making them feel guilty about how they deliver their babies,” said the senior author, Dr. David P. Burgner, a senior research fellow at the Murdoch Children’s Research Institute in Melbourne, Australia. “That decision is for the woman in consultation with her doctor. This is a large-scale observational study that shows a small but consistent risk.”

A Shifting View on Telemedicine

In March 2019, a robot entered a patient’s room in California and a doctor on its screen told him and his granddaughter that he was dying.

This experience, posted to the granddaughter’s Facebook page, was treated as a scandal. Newscasters questioned the humanity of a health care system that would do such a thing. Words like callous, heartless and cold were used to describe this apparent lack of compassion and care.

Bad news, it seemed, should be delivered only by compassionate individuals, with good communication skills, who are actually in the room with the patient. Not at a distance over a screen.

Just a year later, Covid-19 changed all that.

We had a highly contagious virus devouring hospital resources, a combination of factors that made hospitals inhospitable to families. Almost overnight, most American hospitals strictly limited visitation.

In the early days of the pandemic, some staff members could not ignore the human toll of isolation they were witnessing, and started using their own cellphones to connect patients with their families, if only for a few moments. This would never have happened pre-Covid, when fears of HIPAA violations and a mandate for personal privacy had always kept personal phones in pockets.

These virtual reunions were powerful and almost always positive — not only for the patient and family, but for staff. They brought humanity to days filled with stress and sadness.

And for the patient, alone in the hospital, the iPad on a stick represented not a cold robot but a portal to their loved ones. Where just last year, communication through a screen felt crass, all of a sudden, it became the only compassionate thing to do. Hospital teams expected families to be resistant, but we discovered receptivity and profound appreciation for the ability to connect, by whatever means available.

Before we all realized it, we had entered the era of tele-health — where instead of an iPad representing coldhearted indifference, it now symbolizes our human desire to connect and communicate. Just as we have found creative ways to continue to connect socially through life-cycle events — video cocktail hours, Netflix parties, Zoom weddings and funerals — we have realized that technology can provide so much more to the care of patients than we thought it could.

At the beginning of the pandemic, when I knew I would have to start interacting with families virtually, I was apprehensive. The hallmark of a palliative care team’s work has always been in-person, human connection. As facilitators of arguably the most difficult conversation topic of all — death — we literally lean into emotions that most people would run from. Unlike most medical interactions, we are not transactional, extracting a vial of blood, a signature on a consent form. Our service is to witness, reflect, and be truly present. We have been trained to provide a certain physicality, pulling up a chair, making eye contact, holding a hand. Could we really do that on a screen?

But our team had no choice, and having no choice can be clarifying. It was clear we needed to bring in the technology and at least try it. We received an emergency grant from the San Francisco-based Stupski Foundation and got to work, deploying 30 new iPads to various teams in the hospital so they would be able to access our services more readily.

The choreography of this experience varied, depending on the technology and staff available. The set up could sometimes feel like we were on a film set, the med student encased in PPE playing the role of camera operator, minus the professional training, holding the iPad shakily over the patient’s face as the Zoom panel looked on. Sometimes I was the person “bringing” others — family members, our chaplain, or our social worker — into the patient’s room on the rolling iPad. Other times I was “rolled” into the room, the virtual consultant, sitting on my couch, my poodle curled next to me.

I was working offsite for our first virtual encounter. The patient had Covid pneumonia and had been in the intensive care unit on a ventilator for weeks. The intern who consulted us warned us that his family was frantic, angry, calling incessantly in search of information. We arranged for all six siblings to join us in our “Zoom room” to meet with us, get a medical update, and see their father, intubated in the I.C.U.

I was surprised by how nervous I was, nervous that I didn’t know what I was doing, that I would be perceived as a fraud. “You’re not even with my father, right now?” I imagined his irate daughter saying to me as I fumbled with the technology.

Before the meeting started, I joined our chaplain and social worker in the “Zoom room” to strategize our approach to this uncharted virtual territory. Having worked together for a decade, we are adept at reading each other’s body language in person, but we knew this would be different, all of us facing forward in a grim Hollywood Squares. We anticipated it could so easily get out of control — family members grieving alone in their homes, anger brewing, even a Zoom-bomber, which I’d been hearing about. We devised a subtle hand signal so that we would be less likely to trip over each other during the video visit. “Ready?” I asked, before holding my breath and pressing “admit.”

To our surprise, it turned out to be less challenging than we expected, as did all the ones that followed. Any initial doubts I had about this medium were erased by the relief of families connecting in this desolate time. True, they didn’t have much of a choice, having been shut out of the hospitals. But their heartfelt appreciation of a physician’s presence was a striking contrast to the national sentiment expressed just 12 months earlier, where an iPad on a stick was seen as a cold robot. Now, it was perceived as a lifeline. One patient said to me as I hovered from home in one of the Zoom squares, “I don’t know who you are, but thank you for bringing my family here to be with me.”

Over the next few months we learned how to better translate our in-person presence to an online format. Where I would normally hug or touch a patient on their shoulder, now I put my hands over my heart. Instead of looking directly into their eyes, I made sure to always look directly into the green light of my computer’s video camera. I stayed quiet as the families wept and spoke to their unresponsive loved ones.

I discovered that I can be compassionate on and off the screen, which made me wonder: Is the most important factor for delivering excellent care physical proximity? Or is it depth of focus, and quality of communication? Is it dependent on technology or the person using the technology?

In this work I have discovered that telehealth is not merely a pale substitute for in-person care but rather a viable alternative, even offering some distinct advantages. It allows patients to see their loved ones from all over the world. It reduces the risk of exposure to Covid or other hospital-borne infections. It also allows us to preserve precious PPE for the primary teams who need it.

Telehealth has been in the background of health care for a while, primarily in rural communities where distance limits access. Now that Covid has pushed it into the mainstream, many more of us have seen and felt its benefits. Health care teams are grateful to have it available, and patients and families are not shocked when an iPad is rolled into a room or they are invited to a Zoom call. While I look forward to a time when face-to-face interactions are the norm again, I am grateful for the wide acceptance of this new tool that will continue to help us support patients and families everywhere.

We’ve learned that it’s not about the medium, it’s about the message, and the way it’s delivered.


Jessica Nutik Zitter (@JessicaZitter), a palliative medicine and critical care doctor in Northern California, is the author of “Extreme Measures: Finding a Better Path to the End of Life.”

Doctors and Nurses Are Running on Empty

About 2 a.m. on a sweltering summer night, Dr. Orlando Garner awoke to the sound of a thud next to his baby daughter’s crib. He leapt out of bed to find his wife, Gabriela, passed out, her forehead hot with the same fever that had stricken him and his son, Orlando Jr., then 3, just hours before. Two days later, it would hit their infant daughter, Veronica.

Nearly five months later, Dr. Garner, a critical care physician at the Baylor College of Medicine in Houston, is haunted by what befell his family last summer: He had inadvertently shuttled the coronavirus home, and sickened them all.

“I felt so guilty,” he said. “This is my job, what I wanted to do for a living. And it could have killed my children, could have killed my wife — all this, because of me.”

With the case count climbing again in Texas, Dr. Garner has recurring nightmares that one of his children has died from Covid. He’s returned to 80-hour weeks in the intensive care unit, donning layers of pandemic garb including goggles, an N95 respirator, a protective body suit and a helmet-like face shield that forces him to yell to be heard.

As he treats one patient after another, he can’t shake the fear that his first bout with the coronavirus won’t be his last, even though reinfection is rare: “Is this going to be the one who gives me Covid again?”

Frontline health care workers have been the one constant, the medical soldiers forming row after row in the ground war against the raging spread of the coronavirus. But as cases and deaths shatter daily records, foreshadowing one of the deadliest years in American history, the very people whose life mission is caring for others are on the verge of collective collapse.

In interviews, more than two dozen frontline medical workers described the unrelenting stress that has become an endemic part of the health care crisis nationwide. Many related spikes in anxiety and depressive thoughts, as well as a chronic sense of hopelessness and deepening fatigue, spurred in part by the cavalier attitudes of many Americans who seem to have lost patience with the pandemic.

“This is my job, what I wanted to do for a living. And it could have killed my children, could have killed my wife — all this, because of me,” said Dr. Orlando Garner, a critical care physician in Houston.
“This is my job, what I wanted to do for a living. And it could have killed my children, could have killed my wife — all this, because of me,” said Dr. Orlando Garner, a critical care physician in Houston.Credit…Michael Starghill Jr. for The New York Times

Surveys from around the globe have recorded rising rates of depression, trauma and burnout among a group of professionals already known for high rates of suicide. And while some have sought therapy or medications to cope, others fear that engaging in these support systems could blemish their records and dissuade future employers from hiring them.

“We’re sacrificing so much as health care providers — our health, our family’s health,” said Dr. Cleavon Gilman, an emergency medicine physician in Yuma, Ariz. “You would think that the country would have learned its lesson” after the spring, he said. “But I feel like the 20,000 people that died in New York died for nothing.”

Many have reached the bottom of their reservoir, with little left to give, especially without sufficient tools to defend themselves against a disease that has killed more than 1,000 of them.

“I haven’t even thought about how I am today,” said Dr. Susannah Hills, a pediatric head and neck surgeon at Columbia University. “I can’t think of the last time somebody asked me that question.”

Dreading the darkness of winter

For Dr. Shannon Tapia, a geriatrician in Colorado, April was bad. So was May. At one long-term care facility she staffed, 22 people died in 10 days. “After that number, I stopped counting,” she said.

A bit of a lull coasted in on a wave of summer heat. But in recent weeks, Dr. Tapia has watched the virus resurge, sparking sudden outbreaks and felling nursing home residents — one of the pandemic’s most hard-hit populations — in droves.

“This is much, much worse than the spring,” Dr. Tapia said. “Covid is going crazy in Colorado right now.”

Dr. Tapia bore witness as long-term care facilities struggled to keep adequate protective equipment in stock, and decried their lack of adequate tests. As recently as early November, diagnostic tests at one home Dr. Tapia regularly visits took more than a week to deliver results, hastening the spread of the virus among unwitting residents.

Some nursing home residents in the Denver area are getting bounced out of full hospitals because their symptoms aren’t severe, only to rapidly deteriorate and die in their care facilities. “It just happens so fast,” Dr. Tapia said. “There’s no time to send them back.”

The evening of Nov. 17, Dr. Tapia fielded phone call after phone call from nursing homes brimming with the sick and the scared. Four patients died between 5 p.m. and 8 a.m. “It was the most death pronouncements I’ve ever had to do in one night,” she said.

Before the pandemic, nursing home residents were already considered a medically neglected population. But the coronavirus has only exacerbated a worrisome chasm of care for older patients. Dr. Tapia is beleaguered by the helplessness she feels at every turn. “Systematically, it makes me feel like I’m failing,” she said. “The last eight months almost broke me.”

At the end of the summer, Dr. Tapia briefly considered leaving medicine — but she is a single parent to an 11-year-old son, Liam. “I need my M.D. to support my kid,” she said.

Dr. Shannon Tapia, a geriatrician based in Denver, mourns the nursing home residents she cares for. “It just happens so fast,” Dr. Tapia said of patients whose conditions deteriorated after being discharged from hospitals. “There’s no time to send them back.”Credit…Daniel Brenner for The New York Times

It goes on and on and on

For others, the slog has been relentless.

Dr. Gilman, the emergency medicine physician in Yuma, braced himself at the beginning of the pandemic, relying on his stint as a hospital corpsman in Iraq in 2004.

“In the military, they train you to do sleep deprivation, hikes, marches,” he said. “You train your body, you fight an enemy. I began running every day, getting my lungs strong in case I got the virus. I put a box by the door to put my clothes in, so I wouldn’t spread it to my family.”

The current crisis turned out to be an unfamiliar and formidable foe that would follow him from place to place.

Dr. Gilman’s first coronavirus tour began as a resident at New York-Presbyterian at the height of last spring. He came to dread the phone calls to families unable to be near their ailing relatives, hearing “the same shrill cry, two or three times per shift,” he said. Months of chaos, suffering and pain, he said, left him “just down and depressed and exhausted.”

“I would come home with tears in my eyes, and just pass out,” he said.

The professional fallout of his Covid experience then turned personal.

Dr. Gilman canceled his wedding in May. His June graduation commenced on Zoom. He celebrated the end of his residency in his empty apartment next to a pile of boxes.

“It was the saddest moment ever,” he said.

Within weeks, he, his fiancée, Maribel, their two daughters and his mother-in-law had relocated to Arizona, where caseloads had just begun to swell. Dr. Gilman hunkered down anew.

They have weathered the months since in seclusion, keeping the children out of school and declining invitations to mingle, even as their neighbors begin to flock back together and buzz about their holiday plans.

There are bright spots, he said. The family’s home, which they moved into this summer, is large, and came with a pool. They recently adopted a puppy. Out in the remoteness of small-town Arizona, the desert has delighted them with the occasional roadrunner sighting.

Since the spring, Dr. Gilman has become a social media tour de force. To document the ongoing crisis, he began publishing journal entries on his website. His Twitter wall teems with posts commemorating people who lost their lives to Covid-19, and the health workers who have dedicated the past nine months to stemming the tide.

It’s how he has made sense of the chaos, Dr. Gilman said. What he’s fighting isn’t just the virus itself — but a contagion of disillusionment and misinformation, amid which mask-wearing and distancing continue to flag. “It’s a constant battle, it’s a never-ending war,” he said.

Reaching the breaking point

Nurses and doctors in New York became all too familiar with the rationing of care last spring. No training prepared them for the wrath of the virus, and its aftermath. The month-to-month, day-to-day flailing about as they tried to cope. For some, the weight of the pandemic will have lingering effects.

Shikha Dass, an emergency room nurse at Mount Sinai Queens, recalled nights in mid-March when her team of eight nurses had to wrangle some 15 patients each — double or triple a typical workload. “We kept getting code after code, and patients were just dying,” Ms. Dass said. The patients quickly outnumbered the available breathing support machines, she said, forcing doctors and nurses to apportion care in a rapid-fire fashion.

“We didn’t have enough ventilators,” Ms. Dass said. “I remember doing C.P.R. and cracking ribs. These were people from our community — it was so painful.”

“We’re there to save a person, save a life, stabilize a person so they can get further management,” said Shikha Dass, an emergency room nurse at Mount Sinai Queens. “And here I am, not able to do that.”Credit…Kholood Eid for The New York Times

Ms. Dass wrestled with sleeplessness and irritability, sniping at her husband and children. Visions of the dead, strewn across emergency room cots by the dozens, swam through her head at odd hours of the night. Medical TV dramas like Grey’s Anatomy, full of the triggering sounds of codes and beeping machines, became unbearable to watch. She couldn’t erase the memory of the neat row of three refrigerated trailers in her hospital parking lot, each packed with bodies that the morgue was too full to take.

One morning, after a night shift, Ms. Dass climbed into her red Mini Cooper to start her 20-minute drive home. Her car chugged onto its familiar route; a song from the 2017 film “The Greatest Showman” trickled out. For the first time since the pandemic began, Ms. Dass broke down and began to cry. She called her husband, who was on his way to work; he didn’t pick up. Finally, she reached her best friend.

“I told her, ‘These people are not going to make it, these people are not going to survive this,’” she said. “We’re there to save a person, save a life, stabilize a person so they can get further management. And here I am, not able to do that.”

Shortly after, she phoned a longtime friend, Andi Lyn Kornfeld, a psychotherapist who said Ms. Dass was in the throes of “absolute and utter acute PTSD.”

“I have known Shikha for 13 years,” Ms. Kornfeld said. “She is one of the strongest women I have ever met. And I had never heard her like this.”

The sounds of silence

Long gone are the raucous nightly cheers, loud applause and clanging that bounced off buildings and hospital windows in the United States and abroad — the sounds of public appreciation at 7 each night for those on the pandemic’s front line.

“Nobody’s clapping anymore,” said Dr. Jessica Gold, a psychiatrist at Washington University in St. Louis. “They’re over it.”

Health workers, once a central part of the coronavirus conversation, have in many ways faded into the background. Some, like Dr. Gilman, in Arizona, have had their salaries slashed as hospitals weigh how to cover costs.

Many have guiltily recoiled from the “hero” label emblazoned in commercials or ad campaigns, burdened by the death march of the people they could not save and the indiscriminate path of the coronavirus.

The word “hero” evokes bravery and superhuman strength but leaves little room for empathy, said Dr. Nicole Washington, a psychiatrist in Oklahoma. When portrayed as stalwart saviors, health workers “don’t have the room or right to be vulnerable.”

But the trope of invincibility has long been ingrained into the culture of medicine.

Dr. Tapia, the Colorado geriatrician, began taking an antidepressant in September after months of feeling “everything from angry to anxious to furious to just numb and hopeless.” The medication has improved her outlook. But she also worries that these decisions could jeopardize future employment.

Many state medical boards still ask intrusive questions about physicians’ history of mental health diagnoses or treatments in applications to renew a license — a disincentive to many doctors who might otherwise seek professional help.

“I don’t want to be a hero,” said Dr. Cleavon Gilman, an emergency medicine physician in Yuma, Ariz. “I want to be alive.”Credit…Caitlin O’Hara for The New York Times

Being on the front lines doesn’t make health workers stronger or safer than anyone else. “I’m not trying to be a hero. I don’t want to be a hero,” Dr. Gilman said. “I want to be alive.”

As social bubbles balloon nationwide in advance of the chilly holiday months, health care workers fret on the edges of their communities, worried they are the carriers of contagion.

Dr. Marshall Fleurant, an internal medicine physician at Emory University, has the sense that his young children, 3 and 4 years old, have grown oddly accustomed to the ritual of his disrobing out of work clothes, from his scrubs to his sneakers, before entering his home.

“I do not touch or speak to my children before I have taken a shower,” Dr. Fleurant said. “This is just how it is. You do not touch Daddy when he walks in the door.”

A week of vacation with his family startled him, when he could scoop the little ones up in his arms without fear. “I think they must have thought that was weird,” he said.

Bracing for the next wave

Trapped in a holding pattern as the coronavirus continues to burn across the nation, doctors and nurses have been taking stock of the damage done so far, and trying to sketch out the horizon beyond. On the nation’s current trajectory, they say, the forecast is bleak.

Jina Saltzman, a physician assistant in Chicago, said she was growing increasingly disillusioned with the nation’s lax approach to penning in the virus.

While Illinois rapidly reimposed restrictions on restaurants and businesses when cases began to rise, Indiana, where Ms. Saltzman lives, was slower to respond. In mid-November, she was astounded to see crowds of unmasked people in a restaurant as she picked up a pizza. “It’s so disheartening. We’re coming here to work every day to keep the public safe,” she said. “But the public isn’t trying to keep the public safe.”

Since the spring, Dr. Gilman has watched three co-workers and a cousin die from the virus. Ms. Dass lost a close family friend, who spent three weeks at Mount Sinai Queen’s under her care. When Dr. Fleurant’s aunt died of Covid, “We never got to bury her, never got to pay respects. It was a crushing loss.”

In state after state, people continue to flood hospital wards, where hallways often provide makeshift beds for the overflow. More than 12 million cases have been recorded since the pandemic took hold in the United States, with the pace of infection accelerating in the last couple months.

Jill Naiberk, a nurse at the University of Nebraska Medical Center, has spent more of 2020 in full protective gear than out of it. About twice a day, when Ms. Naiberk needs a sip of water, she must completely de-gown, then suit up again.

Otherwise, “you’re hot and sweaty and stinky,” she said. “It’s not uncommon to come out of rooms with sweat running down your face, and you need to change your mask because it’s wet.”

It’s her ninth straight month of Covid duty. “My unit is 16 beds. Rarely do we have an open one,” she said. “And when we do have an open bed, it’s usually because somebody has passed away.”

Many of her I.C.U. patients are young, in their 40s or 50s. “They’re looking at us and saying things like, ‘Don’t let me die’ and ‘I guess I should have worn that mask,’” she said.

Sometimes she cries on her way home, where she lives alone with her two dogs. Her 79-year-old mother resides just a couple houses away.

They have not hugged since March.

“I keep telling everybody the minute I can safely hug you again, get ready,” she said. “Because I’m never letting go.”

Think Like a Doctor: The Boy With Nighttime Fevers

Photo

Credit

The challenge: A healthy 7-year-old boy suddenly starts having fevers and night sweats. Can you figure out why?

Every month, the Diagnosis column of The New York Times Magazine asks Well readers to sift through a difficult medical case and solve a diagnostic riddle. This month we present the case of a boy who has fevers topping 102 degrees every night for over a month. His parents sought help from nearly a dozen doctors in two states before a diagnosis was made.

Below I’ve given you the information that was available to the doctors who figured out the cause of the boy’s fevers. It’s up to you to use this information to put his story together for yourself.

As usual, the first person to crack the case gets a copy of my book, “Every Patient Tells a Story,” and, of course, that fabulous feeling you get when you solve a really tough puzzle.

The Patient’s Story

“I think you need to take him back home.” Her brother’s voice was calm, but she could hear an undertone of anxiety even over the poor cellphone reception that was all she could get from rural Colorado. “He needs to see a hematologist. It could be a virus, but it could also be something else.” He didn’t say it, but she knew what he was thinking: cancer.

Her son, just 7 years old and always a little delicate, had been sick for nearly a month. He was fine during the day, but every night he’d spike a fever of 102 or 103.

Even before they’d come to the mountains for a much needed vacation, she’d taken him to see his pediatrician at home in Minneapolis several times. At each visit, the doctor or one of his partners had looked the boy over closely, and each time he’d seemed fine.

It was probably viral, she was told, time after time. But he seemed to be having one viral infection after another.

A Vacation Cut Short

The day before they left for Colorado, the boy’s father took him to the doctor’s office one more time.

Maybe it wasn’t viral, the pediatrician acknowledged, and prescribed a “Z-pak” — a five-day course of azithromycin. Don’t cancel the trip, the doctor reassured him. He’ll get better.

But he hadn’t. While on vacation, his mother took him to a walk-in clinic, where they’d checked his blood. A worried looking doctor told her that he didn’t know what was wrong with her boy. He should probably see a cancer specialist.

Now she was really worried. There weren’t any specialists anywhere near the bucolic town where they were staying. That’s when she’d sent the test results to her brother, a researcher in immunology. He wasn’t a doctor, but he passed the results to friends who were, and they were worried, too.

Thin and Pale

The family headed home right away, but the 4th of July was coming. They couldn’t get in to see a hematologist until Tuesday.

By now the boy was starting to look sick. He was pale and had dark circles under his eyes. Small for his age — consistently in the fifth percentile for height and weight — he now looked even smaller, thinner. He was a quiet child, always had been. Thoughtful and comfortable in the company of adults, as so many only children are. Even now he never complained.

Nothing hurt. He was simply tired. His fevers started coming a little earlier, peaking a little higher. His mother noticed a cough and wheezing sometimes. Always a picky eater, with these intermittent fevers, very few foods seemed appealing. She tried to hide the terror she felt when he seemed to be fading as she watched.

A Long Line of Specialists

The hematologist examined the boy and sent off more blood. Definitely not cancer, he said. He suggested seeing a gastroenterologist.

The gastroenterologist got an M.R.I. of the child’s digestive system. Nothing there. He noticed the boy’s wheezing and gave him an inhaler, then referred mother and child to a rheumatologist and an infectious disease specialist.

It seemed to the parents that this had to be an infection, but the earliest they could get in to see the infectious disease doctor was the following week. For the boy’s mother, the delay now seemed intolerable.

It had been five weeks since the fevers first started. In that time, the boy had lost nearly 10 pounds. They’d seen eight doctors in two states. They’d all been very nice, thorough, thoughtful, but had no answers.

By the weekend she was desperate. The boy needed to be in the hospital. Couldn’t they see how sick he was? She couldn’t wait for the specialist. She took him to the emergency room of the big university hospital.

The E.R. doctors, like all the doctors they’d seen so far, were kind and thoughtful, and so gentle with her delicate son. But like all the other doctors, they had no answers. They prescribed another inhaler for the boy’s wheezing, since the first hadn’t helped. They also urged her to see the infectious disease specialist. His appointment was just a couple of days away.

TB or not TB?

The boy was sitting quietly between his parents watching a video on his tablet when Dr. Bazak Sharon and the infectious disease fellow he was training entered the exam room. Dr. Sharon’s first thought was that the child looked as if he had tuberculosis.

He’d seen a lot of TB in this clinic, but it was usually among immigrant families who had traveled to Minneapolis from countries where the disease was common. Like this boy, kids with TB were usually thin, sickly looking, pale and quiet. But based on what his fellow told him, the child had no exposures that would put him at risk for this disease. He’d only been out of the country once – to Canada. He’d visited the beaches of South Carolina and the deserts of Arizona, and most recently the mountains of Colorado. But TB was rare in all these locales.

Dr. Sharon introduced himself to the child, who looked up immediately and smiled. How do you feel, he asked the boy? His temperature had been recorded at 103 degrees. I feel good, he’d answered pleasantly. Does anything hurt? No.

His heart was beating rapidly – nearly 140 beats per minute, but that was probably due to the fever. There were several enlarged lymph nodes in the child’s neck and his groin, though none under his arms. Otherwise his exam was unremarkable.

Getting Worse

Dr. Sharon had reviewed the blood tests that had already been done but wanted to see if anything had changed. And given that the only localized complaint was cough and wheezing, he wanted to get another chest X-ray.

Reviewing those studies that night, Dr. Sharon saw that the boy was slowly getting worse. He saw patients at that clinic only once a week and was reluctant to wait that long before having him seen again. He thought they needed an answer much sooner than that.

You can see the note from Dr. Sharon and his fellow here.

Dr. Sharon’s Note

The note from the patient’s visit to the hospital.

To the Hospital

Dr. Sharon called the family the next morning. He’d reached out to one of his friends and colleagues, Dr. Abraham Jacob, who could see them. They should go to the University of Minnesota Medical Center Fairview, where Dr. Jacob would orchestrate a thorough workup. That would be the fastest way to get an answer.

Based on the assessment by Dr. Jacob and his resident and the recommendations from Dr. Sharon, the team reached out to specialists in hematology-oncology and in rheumatology. And since his chest X-ray was abnormal and he had enlarged lymph nodes, they wanted to get a CT scan as well.

You can see the note from Dr. Jacob and his resident here.

Dr. Jacob’s Notes

Here are the notes from the pediatrics department.

Breathing Through a Straw

It was the results of the CT scan that really got things moving. It was the middle of the day when the resident was paged by the radiologist. The pictures showed that the lymph nodes in the boy’s chest were so swollen that they were pressing on the trachea – the breathing tube – so that it was almost completely cut off. Essentially he was breathing through the equivalent of a cocktail straw.

Any additional swelling could cut off the boy’s breath completely. You can see an image from the CT scan here.

Photo

This CT scan shows the patient’s chest. In a child of this age, the trachea is normally eight to 12 millimeters wide. Much of the gray tissue surrounding the trachea and esophagus is swollen lymph nodes.

This CT scan shows the patient’s chest. In a child of this age, the trachea is normally eight to 12 millimeters wide. Much of the gray tissue surrounding the trachea and esophagus is swollen lymph nodes.Credit

A normal trachea in a child this age is four to six times the size seen in the scan. The image added even more pressure to make a diagnosis and treat the child before he got sicker.

Solving the Mystery

A diagnosis was made within the next 24 hours. Can you figure out what the boy had, and how the diagnosis was made?

The first person to offer the correct answers to these two questions will get a copy of my book and that sense of triumph that comes from nailing the right diagnosis when it really matters.

Rules and Regulations: Post your questions and diagnosis in the comments section below. The winner will be contacted. Reader comments may also appear in a coming issue of The New York Times Magazine.

In a Hospital, Health Care Until the Clock Runs Out

Photo

Credit Jordin Isip

A 37-year-old man was admitted to a hospital several months ago with seizures. His M.R.I. was frightening, showing a brain full of holes. Medication controlled the seizures, but the drugs were just Band-Aids on a big, undiagnosed problem.

The patient was not particularly alarmed (which in itself was fairly alarming). His brain was riddled with infection or tumor, but all he wanted to do was get out of the hospital and go back to his life.

By all accounts, it was a troubled, isolated, drug-ridden existence in a fleabag hotel, a life free from anything resembling regular medical care. Still, he was ready to be on his way.

The only way to diagnose his problem was a brain biopsy. “Anything to get out of here,” the patient said, and signed a consent form.

The biopsy was performed uneventfully, and small specimens of the abnormal tissue were sent to the lab for a diagnosis. That was on a Friday.

By Monday, everyone was ready for an answer. By Tuesday, it was hard to tell who was more impatient, the patient pacing the hallways or his doctors pestering the lab.

On Wednesday, with the specimens still being processed and another weekend looming, the case had attracted the notice of the administrators known in hospital vernacular as the discharge police.

Within minutes, it seemed, the patient was out of that expensive acute-care bed and on his way to the subway, clutching a thick sheaf of instructions, appointment slips and prescriptions, still without a diagnosis, brain full of holes, but free at last.

Your reaction to this story will almost certainly depend on your understanding of the word “hospital.” The word has connotations of care and comfort dating to the Middle Ages, but its meaning is changing so quickly that even the people who work in one cannot agree on what it is.

Once hospitals were where you found a doctor when you suddenly needed one; now doctors are all over the place, from big-box stores to storefront clinics. Hospitals were where you were headed if you were very sick; now you can heed your insurer’s pleas and choose a cheaper emergency center instead.

Hospitals were where you stayed when you were too sick to survive at home; now you go home anyway, cobbling together your own nursing services from friends, relatives and drop-in professionals.

Once hospitals were where you were kept if you were a danger to yourself or others. They still serve this function — although, perhaps, the standards for predicting these dire outcomes have tightened up quite a bit.

These days, it may be easier to define hospitals by what they are not. They are not places for the sick to get well, not unless healing takes place in the brief interval of time that makes the stay a compensated expense.

Hospitals are definitely not places for unusual medical conditions to be figured out, not if the patient is well enough to leave.

Like the hospital, the patient with holes in his brain was also a puzzle of ill-defined words. He was very sick, yet not all that sick. Whether he could survive at home depended strongly on the meaning of “survive” and “home.”

He was well enough to be an outpatient, but he was far from well, and had never managed to be a successful outpatient. He was not suicidal, at least not in any immediate sense. The big holes in his brain made it even less likely that he would adhere to the complicated instructions for his new outpatient life.

But then again, a hospital is a place where hope reliably springs eternal.

The patient’s young doctors certainly hoped for the best for him. They gave him a slew of prescriptions, and expressed their hopes that he would take the pills and keep his far-flung appointments, at one of which his brain biopsy report would be retrieved and his medications adjusted accordingly.

Not so long ago, the multiple ambiguities of this patient’s case would have kept him in the hospital until at least some of the uncertainty had been resolved. In fact, it would have been considered close to malpractice to let a patient like him out the door. Now it is considered downright medieval to keep him in.

I’m sure you would like to know what happened to the patient. His doctors would, too, but he is missing. His phone goes unanswered. The name of an emergency contact is blank in his records — he refused to provide one.

It’s anyone’s guess if he filled his prescriptions. He kept none of the appointments made for him.

The results of his biopsy showed a perfectly treatable condition, an infection that the pills he was sent home with should have helped. Perhaps he got better, perhaps not.

The young doctors will never know if they managed his case correctly — that’s “manage” in its medical sense. In the word’s other senses (“succeed despite difficulty” among them), they now have a reasonably good sense of how they failed.

A Doctor on Schedule, Rarely on Time

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Credit James Yang

The minute I got on that bus, I knew I was in trouble. The driver sat at the stop just long enough to miss the green light. Then he inched along till he missed the next light and the one after that. He stopped at every stop even though not a soul was waiting.

The 20-minute trip to work stretched to a half-hour, then longer. I was late, late, late.

But this was a driver with a mission, clearly way ahead of schedule and trying to get back on track. He was very early; now I was very late. We were two people with competing, mutually exclusive agendas, and the one in the driver’s seat was bound to win.

A half-hour later, still sweating from racing the last five blocks on foot, with patients piling up in the waiting room, I became the one in the driver’s seat, with the mission and overriding agenda. Woe betide those with competing plans.

Just like that driver, I work under two mandates. One is professional: getting my passengers from point A to point B without breaking the law or killing anyone. The other one is less exalted but generally far more visible: I run according to a schedule that I ignore at my peril.

“She’s running late,” they mutter out in the waiting room. And indeed, she runs late for exactly the same reasons your bus runs late: too many slow-moving passengers lined up to board. Not enough buses or drivers. A person in a wheelchair requiring extra attention. Horrible traffic.

Not only does she often run late, but your poor driver — er, doctor — can run only so late before disaster ensues. She has obligations not only to you and your fellow passengers twitching in annoyance, but to a host of others, including the nursing and secretarial staffs and the cleaning crew at the end of the line. She can’t pull that bus in at midnight if everyone is supposed to leave by 7 p.m.

So when there is enough work to last till midnight, my agenda shifts, and not so subtly. Everyone can tell when I begin to speed. Every visit is pared down to the essentials. All optional and cosmetic issues are postponed, including most toenail problems and all paperwork. Chatting is minimized.

As a bus driver once said to me when I was foolish enough to start a conversation about his speed: “Lady, just get behind the white line and let me drive.”

Medicine is full of competing agendas. Even at the best of times, the match between the doctor’s and the patient’s is less than perfect, sometimes egregiously so. Some residents are now trained specifically in “agenda setting,” the art of successfully amalgamating all concerns.

But when it’s all about speed, an advanced skill set is required.

A patient has been waiting weeks for his appointment, anxiously rehearsing his lines. Bad luck that he showed up on a day I need him in and out in 19 minutes. He spends his first 18 unwisely, pretending everything is fine, making small talk, not quite mustering the courage to say what’s on his mind.

Then just as he is being ushered gently to the door, he pauses. “Oh, by the way …”

“Oh, by the way” is an infamous schedule buster. It means something bad: a suspicious lump, a sexually transmitted disease. Further, it is so common that an entire literature now addresses the “oh, by the way” phenomenon and how to tame it.

One favored tool is: “What else?” That question, asked by the doctor early in the visit, is intended to probe the patient’s agenda before it trumps the doctor’s.

As one set of researchers wrote: “The ‘what else?’ technique uncovers pertinent fears and anxieties up front and prevents an ‘oh, by the way, I have been having some chest pain’ from surfacing at the end of a visit.”

In other words: My agenda is to adopt your agenda, and then rework it so that I can drive on. Brutal, perhaps, but effective.

Very rarely do things work out for me the way they did for that driver who made me so late to work. Occasionally I have so much time that I can dawdle along the route.

I remember clearly the last time that happened. “How’s work?” I began. “What are you doing for exercise?” “Any hobbies?” “Your family, are they well?” I progressed rapidly through seatbelts, bike helmets, family medical history, end-of-life preferences — every single stop my bus typically has no time to make.

Every answer was “fine,” “yes,” or “I dunno.” Then the patient stood up: “Look, I have places to be. Are we done?”

We were two people with competing, mutually exclusive agendas. But that time the one in the driver’s seat lost.

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Think Like a Doctor: The Tired Gardener

The Challenge: Can you figure out what is wrong with a lively 67-year-old gardener who develops a daily fever and shaking chills along with chest pain and a dry cough?

Every month, the Diagnosis column of The New York Times Magazine asks Well readers to solve a real-life diagnostic mystery. Below you will find the details of a case involving a retired maker of surgical supplies who starts having daily fevers along with chills, chest pain and a dry cough.

I’ll give you the same information the doctor was given before he made this diagnosis. Will you be able to figure out what’s wrong?

As usual, the first reader to submit the correct diagnosis gets a signed copy of my book, “Every Patient Tells a Story,” and the pleasure of puzzling out a tough but fascinating case.

The Patient’s Story

“NoNo says he doesn’t feel good,” the 9-year-old girl said of her grandfather, handing her mother the thermometer. The woman dried her hands on her apron and took the device. She squinted at the little electronic numbers. Just under 102 degrees.

Her father had been sick for weeks. Feverish, weak, not eating. It was late summer and the tomatoes and eggplants in the garden were ripe, but he hadn’t even walked through his garden for days, so she knew he wasn’t feeling well. But this was the first time he’d admitted that something more serious might be going on.

It was about time. She’d taken her 67-year-old father to several doctors over the past two months. They’d looked him over and given him antibiotics, but it hadn’t helped.

“Tell NoNo that if he’s feeling sick he’s got to go to the hospital,” she told the little girl. She darted back to her grandfather’s room then quickly returned. “He says he’s ready to go.”

The woman wasn’t sure exactly when her father had started to get sick, but six or seven weeks earlier she had noticed that he was no longer the first one out of bed. Instead of being up and out before 7 a.m., he wouldn’t get up until late morning. And he started to have strange shaking chills each afternoon and evening, followed by a fever — regular as clockwork.

He looked sweaty and pale. She asked him what was wrong, but he said he was fine. Or sometimes he’d say he felt a little tired. After an hour or two the fever would pass and he’d just look tired, but the next day, or sometimes the day after, the fever would be back.

The First Diagnosis

The woman first took her father to his regular doctor. Knowing how much he loved to work in his garden, the doctor figured he probably had Lyme disease. It was summertime, and Lyme was common in the area of Connecticut where they lived. Plus, he practically took root in the half-acre garden back behind the house where he lived with his wife and their children and grandchildren.

This was the first summer the woman could remember where her father wasn’t out in his garden every single day. This year it seemed that whole weeks would go by when he did nothing but look out the window at his beautiful handiwork.

Her father took antibiotics for the presumed Lyme. It didn’t help.

A Second Diagnosis

When the patient went for a follow-up visit, he told his doctor that his stomach was bothering him a bit. So he was referred to a gastroenterologist. That doctor diagnosed Helicobacter pylori – a bacterium tough enough to survive the acid environment of the stomach that can cause pain and ulcers.

He took two weeks of treatment for that — three medications to kill the bug, and one to neutralize the acid they thrive in. That didn’t stop the daily fevers, either.

Recently the man’s wife noticed that he’d developed a dry cough. Was this a pneumonia? His doctor gave him yet another antibiotic. And he was still taking that pill when he agreed to go to the emergency room.

Pneumonia?

So three generations — wife, daughter and granddaughter — got in the car with the man they loved and drove to the hospital where the daughter worked.

The emergency room was quiet when they arrived, and after explaining that the patient had been having fevers for weeks, the patient and his entourage were taken into the back so he could be seen right away.

He did have a fever but otherwise looked pretty healthy. The doctors there seemed to focus on the cough and fever. They figured he had a pneumonia that wasn’t responding to the antibiotics he was taking. And when a chest X-ray failed to show any sign of pneumonia at all, the doctors sent him home.

You can see the note from that first visit to the Emergency Department here.

First ER Visit

If Not Pneumonia, Then What?

The next day, the man felt no better. His daughter was distressed. Her father was sick. Antibiotics weren’t working. And he was getting worse.

She called his primary care doctor again. He was also worried, he told her. But he didn’t know what to suggest.

What if she tried a different emergency room?, she suggested. They had gone to Yale-New Haven Hospital initially because that’s where she worked, but what if they went to the smaller branch of the hospital, St. Raphael’s Hospital, less than a mile away. They had different doctors there, and the hospital had a different feel — local and friendly rather than big and academic. Maybe they would find a doctor there who could help them figure out what was going wrong. It was unorthodox, the doctor told her, to shop around emergency rooms. And it wasn’t clear what another E.R. visit might do. But he was also worried about the patient, and it was certainly worth a try.

Another E.R. Visit

So early that evening they all got back into the car and drove to the St. Raphael campus. The E.R. was bustling when the family came in. Once again he had a fever – 101.6 degrees. His family explained how sick he’d been, how tired. And yet when the doctor examined him, he seemed well enough. He couldn’t find anything abnormal beyond the fever.

The labs told a slightly different story. His red blood cell count was low. So were his platelets – a type of blood cell that helps blood to clot. What was particularly strange was that these two findings had been checked the day before at the other E.R. and had been fine. And there was some evidence that he had some liver damage.

And when tested for viral hepatitis — a common causes of abnormal liver tests — he tested positive for hepatitis A and possibly hepatitis B as well.

He was admitted to St. Raphael’s Hospital because of his worsening anemia and viral hepatitis.

You can see the note from this second emergency room visit, and the admission note from the night team here.

The Second ER Note

Admission Note

Fitting the Pattern

The next morning, Dr. Neil Gupta saw the patient. Hearing the patient’s story, and the diagnosis of hepatitis A infection, was a little puzzling. Patients with hepatitis usually have mild flu-like symptoms, with a loss of appetite, nausea and vomiting, plus fatigue, low-grade fever and a generalized sense of being unwell. Certainly this patient didn’t feel well, but he had no nausea, no vomiting. And his fever came in spikes. The pattern didn’t really match.

Dr. Gupta sat down with the patient’s family and reviewed all the symptoms and the timeline. Then he reviewed all the labs. He sent off a bunch of tests.

You can see Dr. Gupta’s note here.

The Doctor’s Note

Solving the Mystery

Dr. Gupta was finally able to figure out what was wrong with this man. Can you?

The first person to figure out what is really going on with this 67-year-old gardener gets a copy of my book and that lovely sense of satisfaction that comes from making a tough diagnosis.

Rules and Regulations: Post your questions and diagnosis in the comments section below. The winner will be contacted. Reader comments may also appear in a coming issue of The New York Times Magazine.