Dr. Lorna Breen was unflappable - until she faced a new enemy.
On an afternoon in early April, while New York City was in the throes of what would be the deadliest days of the coronavirus pandemic, Dr. Lorna M. Breen found herself alone in the still of her apartment in Manhattan.
She picked up her phone and dialled her younger sister, Jennifer Feist.
The two were just 22 months apart and had the kind of bond that comes from growing up sharing a bedroom and wearing matching outfits. Feist, a lawyer in Charlottesville, Virginia, was accustomed to hearing from her sister nearly every day.
Lately, their conversations had been bleak.
Breen worked at NewYork-Presbyterian Allen Hospital in upper Manhattan, where she supervised the emergency department. The unit had become a brutal battleground, with supplies depleting at a distressing rate and doctors and nurses falling ill. The waiting room was perpetually overcrowded. The sick were dying unnoticed.
Feist had taken to sleeping next to her phone in case her sister needed her after a late shift.
When Breen called this time, she sounded odd. Her voice was distant, as if she was in shock.
"I don't know what to do," she said. "I can't get out of the chair."
Breen was a consummate overachiever, one who directed her life with assurance.
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When she graduated from medical school, she insisted on studying both emergency and internal medicine, although it meant a longer residency. She took up snowboarding, cello and salsa dancing as an adult. Once, after she had difficulty breathing at the beginning of a half-marathon, she finished the race, then headed to a hospital and diagnosed herself with pulmonary emboli — blood clots in the lungs that can be fatal.
In addition to managing a busy emergency department, she was in a dual-degree master's programme at Cornell University.
Breen was gifted, confident, clever. Unflappable.
But the woman speaking to Feist that day was hesitant and confused.
Feist quickly arranged for her sister to be picked up by two friends who would ferry her to Baltimore, where Feist could meet them to take her to family in Virginia. When Breen finally climbed into Feist's car that night, she was nearly catatonic, unable to answer simple questions. Her brain, her sister said, seemed broken.
They drove together for a few hours, heading to the University of Virginia Medical Center. When they arrived, Breen checked into the psychiatric ward.
Breen, 49, had missed work in the past for torn knee ligaments and the pulmonary emboli. But this absence felt like a shameful fall from grace. She had suffered a breakdown when the city was desperate for heroes. And she was certain her career would not survive it.
Her family members tried to convince her otherwise. After all, she had no apparent history of mental health problems, and the past month had been one of extremes for everyone.
Breen was doubtful. An insidious stigma about mental health persisted within the medical community.
"Lorna kept saying, 'I think everybody knows I'm struggling,'" Feist said. "She was so embarrassed."
A life's calling
Even as a teenager, when Breen was just Lorna, she demonstrated an unusual capacity for empathy and a driving sense of duty.
"She always knew she was going to be a doctor, she was going to live in Manhattan — always knew kind of what her life was going to be," recalled Feist, 47, who was one of more than 50 family members, friends, and current and former colleagues who spoke to The New York Times for this story.
The sisters, along with their older siblings, Michael and Karen, had grown up in Danville, a small borough in Pennsylvania where everyone's parents seemed to be either farmers or health care workers at the regional medical centre. They were raised to believe that a vocation should be about service. Their father, Philip, was a trauma surgeon. Their mother, Rosemary, a nurse.
Lorna, an athletic and motivated student, headed off to Cornell University to study microbiology before earning a master's degree in anatomy. After medical school in Virginia, she was determined to study two specialities in her residency because she knew emergency doctors suffered high stress. She wanted to have internal medicine as an option down the road.
Tall and slim with a wide smile ("like Sandra Bullock," a friend described), she did her training at Long Island Jewish Medical Center, where she became a chief resident by her final year.
"You'd come into a shift in the morning, and the ER could be in chaos," said Dr. Gino A. Farina, director of the emergency medicine residency program at the time. "Everybody looked exhausted, their hair was a mess, and they looked like they were destroyed. And she looked like she was ready to start a shift."
In 2004, Breen joined the sprawling NewYork-Presbyterian medical system, working at Columbia University Medical Center and the smaller NewYork-Presbyterian Allen Hospital. Called simply "the Allen," the hospital served a low-income community in northern Manhattan.
There, she pushed residents to consider all possible diagnoses, even to take rectal temperatures because they were more precise. She was warm and compassionate but could also be more demanding and determined than other physicians.
"She had something that was a little bit different," said her colleague and friend Dr. Barbara Lock, "and that was this optimism that her persistent efforts will save lives."
As if to ensure relief from her intense job, Breen planned thrilling trips, joined a ski club, played cello in an orchestra, took her salsa classes and attended Redeemer Presbyterian, a church that attracted high-achieving professionals. Once a year, she gathered all her social circles at a party on her rooftop.
"Lorna didn't stream Netflix," said her friend Devana Cohen, 43. "You couldn't talk to Lorna about some cheesy show. She didn't do the normal, mindless things that most of us do to sort of relax."
People were drawn to Breen for her magnetic personality and ebullience. But her close friends knew she could also slide into rigidity.
She had exasperated friends numerous times with her extremist approach to getting at least eight hours of sleep. Even during vacation, Breen would skip an activity if it meant she would not get enough rest.
In 2011, Breen was promoted to the helm of the emergency department, where colleagues said she tended to solve problems with systematic precision and preferred concrete solutions.
"She liked structure," said Dr. James Giglio, who was then her boss. "She liked working in an organised world."
That world would later distort and crumple. By early this year, the coronavirus was slipping into New York, undetected and underestimated.
An insidious illness
In late February, as elected officials were still assuring the public that the virus did not pose a serious threat, Breen sat down at her computer and updated a contingency plan addressed to her family. It was a compilation of instructions on where to find her passwords, routes she would use if she had to get out of the city and how family members should contact one another.
She had created it after the September 11 terrorist attacks and revised it after Hurricane Sandy hit in 2012; it was her methodical response to calamity.
The coronavirus, she was convinced, would catch hospitals off guard.
A week later, she went on a planned vacation with Feist, her sister, in Big Sky, Montana. They sat in a hot tub and mused about going to Italy in a few years. By the time Breen returned from the trip, a state of emergency had been declared in New York.
At the Allen, discussions about staffing and supplies escalated. A lawyer from New Rochelle, New York, had been diagnosed recently with Covid-19 even though he had not travelled to any areas where the disease was known to be spreading. It was one of the first indications that the virus had already taken hold in the state and a red flag for the NewYork-Presbyterian system, where he was a patient.
Breen reported back to work March 14, arriving to questions about the department's stock of personal protective equipment and whether staff members could get Tyvek protective suits. Doctors and administrators were uneasy about the lack of space in the emergency department and pushed for converting other areas, such as a parking lot, where a tent could be erected.
"People I work with are so confused by all of the mixed messages and constantly changing instructions," she wrote that day in a message to her Bible study group. "Would appreciate any prayers for safety, wisdom and trust."
Four days later, Breen showed symptoms of Covid-19. Feverish and exhausted, she quarantined at home to recover. She slept up to 14 hours in a row, was drained by small tasks, lost 2kg. But she still tried to sort out work problems, like a shortage of oxygen tanks. When a doctor texted that she could not find any protective eyewear, Breen, without mentioning that she was out sick, promised to find a pair of goggles by the next day.
On March 23, Breen texted with Dr. Alexis Halpern, another emergency physician who was also home sick. "Tried to do a few very small things (like unload the dishwasher) yesterday and wondering if that was too much," she wrote.
"You need to just rest," Halpern replied. "It's the most uncomfortable thing for us who never sit still."
The Allen was inundated with patients who were shuffled around to free up critical care beds. People who seemed to be in decent condition would be discharged only to return in an ambulance much worse. A staff shortage was ongoing.
The last weekend in March, Breen went on a walk and felt wiped out. But she told her work she would be back soon. She felt she had stayed home longer than other co-workers who had been sick. She knew they needed more hands.
An overwhelmed hospital
Inside the Allen's emergency department, the pandemic struck swiftly and with little mercy.
The facility had opened in 1988 as a small community hospital that filled a void in the neighbourhood. Although it was later upgraded, it had been overburdened for years, unequipped to fully meet the needs of the area.
The coronavirus sent it reeling like never before.
Intubated patients on stretchers jammed the halls. Portable oxygen tanks operating at their highest capacity petered out at an alarming pace. An area meant for X-rays housed the bodies of those who had taken their final gasps while waiting to be saved.
One man, seemingly stable and about to be transferred to a different unit, was found dead in a chair, his skin blue.
The emergency department was clogged with about triple the number of patients it could normally accommodate. Outside, ambulances lined up as medics tried to get patients admitted. A new city policy that decreed patients had to be transported to the closest available hospital meant the Allen was flooded with people from upper Manhattan and the Bronx, where some neighbourhoods were hit particularly hard. The hospital was also ringed with nursing homes, adding to the backlog.
A hopelessness sickened the air.
When Breen returned to work April 1, the city was on the verge of a grim bench mark: Deaths would soon peak at more than 800 in a single day. The scene at the Allen prompted a disturbing realisation: She and her emergency department were outmatched.
She called her sister, Feist, upset about the chaos.
That same day, Breen had grown fatigued just from standing at her desk while replying to emails. She texted a colleague about protocols that had changed while she was away. "I'm totally lost," wrote Breen. "Trying to read up and get back to speed."
Around that time, the hospital attempted to relieve the strain on the emergency department by placing critically ill patients, many of whom were on ventilators, in a different unit to be treated by intensive care doctors. Yet the patients remained under the authority of the emergency department.
Breen found the arrangement stressful, according to a colleague, and felt a responsibility to keep an eye on those patients, staying longer at the hospital to do so.
Co-workers noted that she looked frazzled. And she was not exuding her usual confidence.
"Just baffled and overwhelmed," she wrote to a friend April 2.
Still, she managed that week to call in to a video meeting with her Bible study group. She also reached out to classmates in her postgraduate programme, concerned about a group project. She was anxious she was not doing her part.
'Hardest time of my life'
It did not take long for the structure that Breen had once so deliberately constructed to uphold her life to completely cave in.
She started working long days that bled into one another, some of which required overseeing emergency departments at both the Allen and the main Columbia medical campus.
There could be no balance, no release, no pragmatic steps to a cure during a pandemic. There was only the sick and the unfathomable: There would be bodies every day. Ultimately, during the worst of the crisis, almost one-quarter of the people who were admitted to the Allen to be treated for Covid-19 would die.
On April 4, Breen spent about 15 hours at work, according to a colleague who recalled seeing her.
"Prayers to u Lorna," a friend texted her. "Stay strong."
"Hardest time of my life," she replied. "Am trying to focus."
The following day, she seemed confused and overwhelmed, said the colleague, who had never before seen Breen in such a state. Breen wrote a message to her Bible study group.
"I'm drowning right now — May be AWOL for a while," she typed.
She soon stopped replying to friends' messages altogether.
On April 6, Breen was acting as an incident commander, a disaster management post used in large-scale emergencies. She reviewed the notes that doctors filled out with details about patients who had died. The notes were written using a new electronic medical records system that had not been learned widely before the coronavirus arrived. As a result, many were inaccurate and needed to be fixed.
Breen pored over them, trying to impose a bit of order in the chaos. So many lives had been lost.
A call for help
Despite their often hero status, health care workers experience pressure that can be paralysing. Emergency doctors are particularly vulnerable to post-traumatic stress — while working in a profession that encourages toughing it out, according to researchers who have studied the effects of trauma on physicians.
The pandemic intensified both the demands made of doctors and the pressure to endure those demands. Recent studies of medical workers in China, Canada and Italy who treated Covid-19 patients found increasing rates of anxiety, depression and insomnia.
Breen, inclined to handle obstacles with a polished aplomb, was thrown into a drastic scenario that had no defined answers. Those who knew her said that working in a situation she could not fix or solve with a clear-cut strategy would have been exceptionally challenging for her.
When Breen finally called her sister for help April 9, she sounded so unlike herself that Feist wondered if the virus had somehow altered her sister's brain. Although research is still preliminary when it comes to Covid-19's effects on the brain, there is growing evidence that the disease, or the way the body responds to it, can cause a range of neurological issues.
Feist told her sister not to move. She called Dr. Angela M. Mills, who, as chief of emergency medicine, was Breen's supervisor.
When Mills arrived at her apartment in the West Village, Breen looked strange. "She always had this glimmer in the eye that was so welcoming and always had so much energy and enthusiasm," Mills said. "And that was missing."
Breen was quiet, only speaking when questioned. Even then she gave only one- or two-word answers.
Mills asked if she felt like she wanted to hurt herself. Breen indicated yes.
They sat together for about an hour and a half.
A friend of Breen's who was a psychiatrist arrived to pick her up. After spending some time in the car with Breen, the friend called Feist and said her sister needed to go to the hospital.
The last conversation
Breen spent about 11 days as an inpatient in the psychiatric ward. While in the hospital, she chatted on the phone with her friend Anna Ochoa, 45. The two were close, and Ochoa was relieved to hear Breen's voice. It was as if they were having an ordinary talk, and Ochoa felt good after hanging up. Her friend seemed strong.
Breen was soon discharged, and she stayed with her mother in Charlottesville, where she was a bit more herself, even making jokes, although her brown eyes had dulled.
She mentioned returning to her MBA studies, which she had initially pursued to gain leadership credibility and advance her career. She started going for long runs. Family members talked about getting her back to New York.
But on April 26, Breen killed herself.
It is impossible to know for sure why someone takes her own life. And Breen did not leave a note to unravel the why.
Still, when the casualties of the coronavirus are tallied, Breen's family believes she should be counted among them — that she was destroyed by the sheer number of people she could not save, that she was devastated by the notion that her professional history was permanently marred and mortified to have cried for help in the first place.
NewYork-Presbyterian said in a statement that it began offering mental health services to its front-line staff in late March to help them cope with their experiences.
"Dr. Breen was a heroic, remarkably skilled, compassionate and dedicated clinical leader who cared deeply for her patients and colleagues," the statement said.
If Breen is lionised along with the legions of other health care workers who gave so much — maybe too much — of themselves, then her shattered family also wants her to be saluted for exposing something more difficult to acknowledge: the culture within the medical community that makes suffering easy to overlook or hide; the trauma that doctors comfortably diagnose but are reluctant to personally reveal, for fear of ruining their careers.
"If the culture had been different, that thought would have never even occurred to her, which is why I need to change the culture," Feist said. "We need to change it — like, as of today." The family has established a fund to offer mental health support to health care providers.
For Breen's friend Ochoa, their last conversation has become especially crushing. At one point, Breen had gotten stuck on an idea and kept repeating herself.
Ochoa had not thought profoundly about it at the time, but now she cannot stop hearing that same relentless refrain: "I couldn't help anyone. I couldn't do anything. I just wanted to help people, and I couldn't do anything."
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Written by: Corina Knoll, Ali Watkins and Michael Rothfeld
Photographs by: Greg Vigliotti
© 2020 THE NEW YORK TIMES