Adam Bernheim got a good hard look at the enemy well before it invaded his own hospital. The white, round-shaped spots he saw clinging to the edges of people's lungs formed a pattern unlike any he had seen in patients suffering tuberculosis or any other respiratory disease. This was January, and Bernheim, a cardiothoracic radiologist with the Mount Sinai Health System, was studying CT scans sent from China with a researcher's dispassionate eye.
"It was very unusual," said Bernheim, whose long-standing partnership with West China Hospital in Chengdu and three other hospitals in different provinces gave him early access to their images, the first glimpse of the coronavirus now rampant in New York.
Nothing that Bernheim saw in those scans could have prepared him or other doctors for the onslaught of patients a few months later as New York City became the epicentre of the US outbreak, with more than 25,000 cases and 366 deaths as of Friday. In hospitals across the city, emergency rooms are swelling, beds are filling and intensive care units are poised to be overwhelmed with the peak still a week or two away.
On Tuesday night, emergency medical services workers received 6,406 medical 911 calls in the previous 24 hours, surpassing the total from Sept. 11, 2001, and the numbers keep mounting, said Oren Barzilay, president of the Local 2507 union, which represents emergency medical technicians and paramedics of the New York City Fire Department.
Now Bernheim is seeing those distinctive patterns again, this time as a clinician on scans taken in his own emergency department. "One after another after another after another," he said. "Yesterday more than the day before. In all ages. Men and women."
The Mount Sinai Health System is better positioned than most to weather the storm sweeping the city. It is as well-funded, world-renowned research and academic centre. It has invested in data modelling to plan for how many beds and intensive care units hospitals need. But it, too, may be nearing a tipping point as the disease consumes unprecedented resources and puts relentless pressure on nursing staff who sweat under layers of personal protective equipment.
"This is a fluid situation," said Ugo Ezenkwele, chief of emergency medicine at Mount Sinai Hospital in Queens. "In a week or two, who knows? ... This is unique in my experience, and I've been doing emergency management since 2002."
Hospital leaders had anxiously watched previous outbreaks, including the H1N1 flu and Ebola, and prepared for a pandemic they knew some day would come. "Now that day has come," said Charles Powell, chief of the Division of Pulmonary, Critical Care, and Sleep Medicine at the Icahn School of Medicine at Mount Sinai.
As well equipped as Mount Sinai is, doctors on the front lines battling Covid-19 are fearful they too could be overwhelmed. They are keenly aware of the harrowing stories from nearby hospitals, including Elmhurst in Queens, where 13 patients succumbed to the virus in a single day. Many were chilled by recent news that a 48-year-old assistant nursing manager at Mount Sinai West had died of the disease.
By midweek, eight nurses and four doctors in labour and delivery across the system had been diagnosed as positive, according to Michael Brodman, chief of obstetrics, who decided to stop partners attending births, despite the added stress expectant mothers might feel.
"I'd rather be stressed than dead," he said.
The forecast remains grim: The number of new cases in New York is doubling about every four and a half days - a slowing from when they doubled every two and a half days earlier in the outbreak. That's a positive development that may indicate social distancing and other measures are helping to slow the spread of the virus, health experts said.
But it also suggests that by the middle of next week, "we'll be at a crucial strain well beyond where we are right now," Powell said. "Every hospital system is preparing for a peak in the next week or so."
The daily rhythms of Mount Sinai have been upended. The radiology department has canceled non-urgent imaging and staggered shifts to accommodate the new workflow. Stringent new restrictions limit visitors. Staff make time to talk through Zoom and video conferences to share information they are gathering throughout their speciality areas, particularly with doctors in smaller community hospitals who may not have as much experience.
Despite the head start, the coronavirus continues to present surprises - like the patients admitted suffering from abdominal pain and diarrhoea. The lower parts of their lungs were visible on the abdominal scans - and there Bernheim saw the distinctive pattern of white spots, clinging to the periphery.
He doesn't know what the future holds or exactly when the cases will peak. If the situation worsens, radiologists like him could be called to work on the front lines, perhaps in the ICU. "There's been discussion," Bernheim said, "but it hasn't reached that point yet."
None of this comes as a surprise to doctors treating people in emergency rooms.
"We have seen a surge of sicker patients," said Ezenkwele. A week and a half ago, some showed up to the ER with symptoms mild enough they could be sent home to rest, he said. But now, nearly all the patients are running fevers and are short of breath. When Ezenkwele measures the oxygen levels in their blood, they are alarmingly low.
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"They require oxygen - now," he said. "They can't go home."
For the moment, the hospital is managing. Staff have enough masks and other protective equipment, Ezenkwele said. There are enough ventilators for patients who need them.
But as patients keep coming, Ezenkwele can see the ER under strain. The first patients suspected of having Covid-19 were sequestered to keep the virus from spreading. But now, staff must place two patients in some rooms. "Once those are at capacity, we'll put patients in open bays, with curtains separating them," Ezenkwele said. "There will be a point where it's a moot discussion, and anyone in the ER with respiratory problems is presumed to be a Covid patient."
The virus is confronting doctors in unexpected ways.
"You have to be ready to reorient at any moment," said gastroenterologist Ryan Ungaro, who is seeing patients with GI symptoms who turn out to be suffering from Covid-19. He is preparing to adjust to a new schedule of 12-hour shifts.
"You almost have to assume everyone is positive now," he said, describing how colleagues are ramping up their research even as they treat patients.
Looking back, some can see that the wave cresting over them now was already forming at their feet weeks ago.
"I get the sense that we were starting to see infections way back, even in January, but we just didn't realise it," said Kamal Kalsi, an emergency room doctor. "It was people that were coming in with coughs and symptoms for two weeks."
"Once we got our first diagnosed cases, we started to lose staff, because initially, if you had contact with these covid patients, you had to be sent home for a two-week quarantine," Kalsi said. "We were initially just haemorrhaging all types of staff."
Heart surgeon John Puskas has repurposed a cardiovascular care facility consisting of an ICU with 26 beds and a ward with 31 beds into a new unit - 98 per cent of it now packed with Covid-19 patients.
"It's like saying Ford makes great cars. But from now on, don't make cars, make submarines - it's the same team doing very different things," said Puskas, who had just come off a Zoom call pooling information on treatment and strategies with 24 other doctors, ranging from infectious disease experts to anaesthesiologist's.
Although Covid-19 is largely a respiratory disease, it has in a few instances caused a dangerous form of myocarditis, or inflammation of the heart muscle. It is rapid - and fortunately rare so far.
Puskas has one such patient, an 83-year-old woman, now on his floor.
"To my knowledge I don't know of a survivor. It seems to be a terminal event," he said.
The challenges he is looking at going forward are immense, with patients requiring five to 20 days on ventilators, rather than the hours his cardiac patients typically receive after surgery.
"It's a whole different ballgame," Puskas said, reflecting on the mounting burden on both nursing staff and resources.
Experts attribute the rapid spread of the virus in New York to the fact that it is the most densely populated city in America. Adding to that challenge, hospital occupancy rates before the outbreak were around 74 per cent citywide, considered close to full because it can be hard to accommodate new patients, said Christopher Kerns, a vice president at the Advisory Board, which provides research and consulting services to hospitals.
The city also has a low number of intensive-care beds relative to its population, another factor straining hospitals.
No state or city hospital system can withstand a "major surge" of the kind happening now without adding extra or temporary beds, as New York officials are doing, Kerns said.
The changes weigh heavy even on the hospital's smallest denizens. While children have largely escaped the need for intensive treatment, they are still experiencing the fear that pervades the city.
"Even very young children understand something serious is going on," said Diane Rode, director of the Child Life and Creative Arts Therapy Department.
The virus has introduced a new level of vulnerability for families grappling with a child's recent diagnosis of leukemia or cancer. And it has made the death of a parent, in the last throes of Covid-19, even more inaccessible.
"With this virus, right now, it's very hard to have family members at the bedside," said Rode, who said her team was called upon recently to help explain to children that their mother would not be coming home.
With increased restrictions placed on visitors - no siblings, only one parent - the department has been trying to compensate, often through technology, including creating handwashing karaoke videos.
Rode worried that a 3-year-old might be frightened seeing everyone with their faces covered, and only their eyes peeking out. "That must be super weird," she said. So this week, her team began taking close-up pictures of themselves smiling, and turned them into buttons to wear on their scrubs.
But Rode is looking at what almost certainly lies ahead. "There's going to be a lot of loss," she said.
For all the pressure mounting by the day on emergency rooms and intensive care units, there are cautiously hopeful signs that New York and its hospitals will absorb the virus' blow.
"The needle moved after the stay-at-home orders," said Powell, the chief of the pulmonary division at the medical school. He credits school closures and social distancing. But whenever he sees New Yorkers congregating on the streets, he fears that needle will start to move the other way.
For all the preparations, the modelling and the early access to the Chinese scans, Powell acknowledges he could never have imagined how a virus would change the face of health care in America's largest city.
"It has been a transformation," he said, admitting covid-19 is draining his optimism."I'm a glass half-full person. But I'm not sure how much water is left in the glass right now."