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NYU's ER After Sandy—Optimists at Work

NYU Langone Perelman Center for Emergency Services

Dr. Lewis Goldfrank has an unusual painting hanging outside his office. A cherished present from a former patient, it depicts in a handful of vignettes the frenetic swirl of activity that, as director of emergency medicine for Bellevue Hospital Center and NYU Medical Center, he oversees each day. In one scene, a team of doctors and nurses huddle together to suture a wound, while in another a prisoner arrives escorted by two police officers. Still another depicts the shrouded body of someone who has died; a doctor washes up nearby.

The artist presented Goldfrank with the handmade gift after his recovery, as a memento of the moment he began to “see how things worked”—to discern purpose and pattern in all the hustle and bustle he witnessed from his bed in the emergency department. During the course of his treatment, he’d considered his surroundings anxiously, searching for signs that he was in good hands. Between visits from Goldfrank, he began to relax as he gathered that this was the senior physician in charge; doctors and nurses circled back to him again and again as they moved briskly between patients. In the painting he captured a glimpse of emergency medicine more or less as Goldfrank sees it—not as frightening chaos but as something closer to a carefully choreographed dance.

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Dr. Lewis Goldfrank

Dr. Lewis Goldfrank

On the eve of the grand reopening of NYU Langone’s emergency department—18 months after Hurricane Sandy’s 14-foot storm surge flooded the hospital with a 15-million-gallon torrent from the East River—Goldfrank’s staff did what any ballet company would do before opening night. They rehearsed.

With improved ventilation and hygiene systems, a dedicated wing for pediatric patients, and more room for family members at bedsides, the state-of-the-art Ronald O. Perelman Center for Emergency Services is roughly three times the size of the cramped facility it replaced—and everyone needed time to “learn about the space,” as Goldfrank puts it. For weeks, he says, the team worked through drills of various emergencies, testing everything from how quickly a pharmacy could deliver antibiotics for a patient with sepsis to who was likely to bump elbows with whom in the rush to resuscitate someone in cardiac arrest.

And on April 24, the day the new emergency department opened for business, doctors and nurses there were unruffled when a woman gave birth on a gurney upon arriving—days earlier, they’d practiced for just such a precipitous delivery.

Since January 2013, when much of the hospital reopened after the storm, NYU Langone had operated an urgent care center that accepted walk-in patients and those who arrived by private ambulance, but wasn’t equipped to serve NYC FDNY ambulances. Meanwhile, Goldfrank and the rest of the staff had a rare chance to reflect on how to improve workflow in a new facility. When it finally arrived, “the opening was exhilarating for the staff,” Goldfrank says. “The rooms are much larger. The space to do a resuscitation is exemplary. The air you breathe is removed from the ED continuously so that a new virus or a new bacteria one might have is not going to stay very long.”

While to an outsider ED doctors can seem to be in perpetual motion, Goldfrank says that the real work is done when members of the medical team find moments to pause and check in with one another. A patient might be visited and questioned four or five times by residents, nurses, and an attending physician—whose job is ultimately to piece all of the information that’s been gathered “back together again for a single human being,” Goldfrank says. “That’s why a space with more room around the bed, that puts the doctors and nurses side-by-side, is key. We don’t like a workspace where we’re not all together.”

Even as they’ve begun to settle in, Goldfrank and his colleagues continue to review lists of glitches that come up each day, looking for ways to improve the efficiency of communication in the new space. “In emergency medicine we’re looking to do things as fast as is safe,” Goldfrank says, “and yet also as slow as possible to avoid risks.”                                                     
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Hurricane Sandy—which forced an overnight evacuation of more than 300 NYU Langone patients, including 20 infants from the neonatal intensive care unit—was far from the first public health crisis Goldfrank had faced as an emergency physician in New York. There was, of course, the attack on the World Trade Center on September 11, 2001—“a tremendous psychological burden for all of us,” he recalls—and the anthrax scare that followed. Before that, there were summer power outages that sent chronically ill patients rushing to the hospital, unable to operate home ventilators or dialysis machines. And in the days before backup generators and emergency light systems, blackouts posed a grave threat to hospitals themselves. During a 26-hour outage in 1977, when Goldfrank was working in the North Bronx, doctors performed surgery in the hospital’s courtyard—using the sun for light.

Still, Sandy was unique in that it temporarily shuttered three hospitals (NYU, Bellevue, and VA New York Harbor) that stand side-by-side along the East River, forcing personnel there to think creatively about how to work together to serve patients in its aftermath. In early 2013, Bellevue was operating a free-standing emergency department while the rest of the hospital remained closed, NYU Langone was open but operating a separate urgent care center instead of an ED, and much of the Manhattan campus of the VA New York Harbor Healthcare System remained closed entirely. It was a disorienting work environment for young medical students,  residents, and veteran physicians alike.

“It created a lot of uncertainty to imagine that your hospitals could be leveled and distorted so dramatically,” Goldfrank recalls. And yet the test of resiliency also provided an opportunity to explore just how adaptable medicine can be. “Yes, we were in makeshift spaces. But what do we do emergency medicine for? You can have the fanciest buildings in the world, but under duress you must be able to work in a hut.”

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Goldfrank is the kind of person who can convey great enthusiasm without ever raising his voice. In conversation, he is calm and thorough, underscoring his meditations on science and medicine with references to Picasso and Voltaire. When asked what traits he looks for when hiring emergency department physicians, he says, “I like people who are humanists—who like people and enjoy working with them, and who have a good sense of the social sciences and the humanities.”

There’s another requirement, too: “I make every effort to only select optimists,” Goldfrank says. “I’ve got to have people who believe the world can be better, and who will participate in the process of making it so.” When someone is injured in a car collision, Goldfrank and his colleagues use the phrase “traffic crash”—never “accident.” “I want everyone to believe every single day that they’re looking at a problem that doesn’t have to happen,” he says. The same goes for unrecognized cases of hypertension, diabetes, and the host of other health problems caused by “smoking or eating too much or drinking too much or driving too fast,” he adds. “These are all things that we can work on. Your job in emergency medicine is to float between caring for one person and thinking about the population as a whole.”

The struggle to refine that balance is one of Goldfrank’s enduring passions, and it runs through the history of his field, from when the nation’s first ambulance pavilion opened at Bellevue in 1879 to today, when hospital emergency departments benefit from the expertise of specialists in new fields like pediatric care, trauma care, and toxicology. When Goldfrank was finishing up medical school, emergency medicine was not yet considered a distinct discipline, so he’s among the very first generation of doctors to study the most frequent causes for grave injury and consider how to address them through public health initiatives. When he was working in the South Bronx, that meant setting up triage to handle victims of the heroin epidemic of the 1970s, and opening up neighborhood clinics to address asthma and other diseases associated with poverty. Today, Goldfrank points to efforts—like one led by Gbenga Ogedegbe, director of NYU Langone’s Division for Health and Behavior in the Department of Population Health—to reduce hypertension in minority groups by bringing educational programs on the disease to churches and barbershops.

Sometimes, it can all feel like an uphill battle. Part of Goldfrank’s task as a faculty member is to “help people develop the skills to deal with chaos,” he says. But even more essential is a strong belief in the human spirit and in one’s capacity to accomplish things that may never have been done before.

There’s also, he says, a saying that became a refrain among his staff in the days and weeks after Sandy. It’s paraphrased from Lewis Carroll’s Through the Looking-Glass but works just as well as a motto for emergency medicine in the big city.

“What did the Red Queen say to Alice?” Goldfrank asks with a twinkle in his eye. “You’ve got to believe at least two unbelievable things before breakfast every day.”

 

Photos: NYU Langone Medical Center

 

 

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