Road to Resilience
Road to Resilience
Part II: Year of the Pandemic
When COVID-19 hit back in March, Brendan Carr, MD, MS, was the first person we turned to. He oversees emergency rooms at Mount Sinai's eight hospitals. And when we spoke, Dr. Carr was in battle-mode, facing a poorly understood virus that threatened to overwhelm the U.S. health care system. Nine months later, in the midst of a third wave and with vaccinations underway, we asked Dr. Carr for his reflections on fighting a once-in-a-century pandemic.
Dr. Carr is System Chair of Emergency Medicine at the Icahn School of Medicine at Mount Sinai and the Mount Sinai Health System. Full bio
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Road to Resilience brings you stories and insights to help you thrive in a challenging world. From fighting burnout and trauma to building resilient families, we explore what’s possible when science meets the human spirit.
From the Mount Sinai Health System in New York, this is Road to Resilience, a podcast about facing adversity. I'm Jon Earle. This is part two of our end-of-year episode. It features an interview with Dr. Brendan Carr. He's the Chair of Emergency Medicine at Mount Sinai, which means he oversees emergency rooms at our eight hospitals. Dr. Carr was the very first person I interviewed after the pandemic struck in March. And the word I would use to describe that interview is"sobering." And this one is, too. That's because Dr. Carr does not mince words about the weaknesses that COVID-19 has revealed in our health care system or the challenges that remain. But there is hope. There's the vaccine, and there's the incredible resilience that's been revealed all over. So here's Dr. Brendan Carr. Hope you enjoy it. This is the year unlike any other year. So we we decided that bringing back our first COVID guest to talk about what the year has been like for you was a fitting way to wrap this year up. One other reason we wanted you back is because, to use Nicci's words, you scared the[bleep] out of us in a very calming way when we spoke in March.[laughs]
DR. CARR:I see. So really this is all about, like, you want to know if you can sleep tonight or not?[laughs] Listen, the reality is that in a different life we could have met. And you would know that I'm actually a totally lighthearted person. I like to have fun. And I'm confident that is not the guy that you met nine months ago.
HOST:When we talked, you were literally starting the job. I think you were a few weeks in, not even a month.
DR. CARR:I started February 1. We diagnosed our first case of COVID in New York City on April 1.
HOST:March 1.
DR. CARR:Sorry, March 1. And April 1 we opened the field hospital. Like that's how rapidly it ramped up. And I gotta tell you, the more I think back to those times—before you play me a clip of where my head was then—when I think back to that, I think a lot about the uncertainty. I think about how scared we were. Because we didn't know the—we didn't know the disease at all. And we always know, you know? Even when we don't know, we sorta know. And this, we just, we didn't know what we were dealing with or how to deal with it. But I also think a lot, a lot, a lot about the fact that I had—and I don't know if I talked about this on the podcast—I had absolutely no relationship with the people that I was asking to trust me. And that is terrible. A lot of my management style, a lot of my leadership style, is based on the fact that I will very happily roll up my sleeves right next to you to focus on a problem. And I had none of that sweat equity. I had no credibility with these people.
HOST:You had to earn their trust.
DR. CARR:Yeah, I guess. But can you under those circumstances? Can the guy in the suit at the command center making decisions earn the trust of the people in the PPE racing into the fire? Not really. Anyway. Yeah, I mean, thinking back for me, that was a really, really hard part that I'm not sure I had insight into when I was just trying to problem solve. Because I very clearly remember just being in problem-solving mode.
HOST:If I remember correctly when we spoke there were about 450 inpatients give or take, and I know that number quadrupled in the course of just a couple of weeks.
DR. CARR:Yeah, that's right. Yeah, there were thousands. And people weren't going home, you know? Do you remember how we used to—we played music when they went home. We celebrated it. We played"Here Comes the Sun," because, you know, if it were a common occurrence, we wouldn't have been celebrating it each and every time. It remains hard in a lot of ways, but the amount that we understand about this disease is just so different
HOST:We're gonna come back to that in a little while. I do want to start at the beginning with this clip.
CLIP (DR. CARR):I feel the weight of the importance of getting this right for New York City and getting this right for all the people that trust me enough to put me in this chair while they are on the front lines, taking care of people who are sick and scared. It feels extremely important to me not to disappoint them.
DR. CARR:I do every day really still feel that weight and think about the importance of that. Except it is a little bit easier. It's a little bit easier because I have personal relationships with people now. It's a little bit easier because I believe that missteps, mistakes will be seen in the context of someone trying really hard to do the right thing, rather than someone that you have no relationship with making the wrong decision.
HOST:I know another stressor for you was, uh, I think your family was—you either couldn't see your family or they were still, there was some distance there.
DR. CARR:That remains a stressor, although it really is secondary compared to the—I guess I would say it is the normal stressor of people who work hard and travel now. That is different than, again, thinking about where we were in those moments. It was about the fact that we were all afraid. We were afraid that we were gonna die! Did I talk about it on the podcast that we, I mean the number of people that needed people to notarize their wills and their power of attorney for someone to take care of their kids?
HOST:No, you didn't mention that.
DR. CARR:Oh, God. Right. Like, I mean, those are the things that we were figuring out."Hey, could we get someone to come in on the overnight shift who's a notary?" This was before there was—there's now virtual notaries that you can use. Maybe there were then, too, but I didn't know about them. Before we were fully a"Zoom" world, I used to think of a notary as somebody you had to see in real life.
HOST:I want to zoom out a little bit. What's been the most surprising thing about how played out, the pandemic.
DR. CARR:It's a super nerdy answer.
HOST:Go for it.
DR. CARR:So in my heart I'm a policy nerd. And I wear that hat as well as the emergency physician hat. And so I have conversations with smart friends who have a hard time wrapping their head around why we are going bankrupt when we have twice the number of patients in our hospitals that we normally have. Doesn't really make sense. How could that make sense? That we are putting ourselves out of business by doing twice the amount of work that we normally do. Find another industry that works like that. Sell twice as many cars or pick a thing, and you have better than expected profits. Meanwhile we can't stay afloat. And so this is the piece that tortures me—the reason we can't stay afloat is because we don't value this type of work financially. The payment structures, the way that health care gets paid for, values some things and doesn't value other things. The only way that we can take this next surge on is to not shut down the normal stuff that we do. We have to keep doing the normal business of health care because there's no reimbursement model for this type of work. We don't have the ability to sort of really understand our capacity in the health care system. We don't have the ability to have visibility of our supply chain. We don't have the ability to have unused capacity that is waiting for"just in case." We have perfectly just-in-timed everything. We're always exactly at 100 percent full because that's how it works. And so, your question was,"What has surprised me?" What has surprised me is the lack of awareness. That the way that we have designed this system, design the finances of the system, set us up to fail again with whatever the next thing is. And that next time doesn't need to be a pandemic. You see this when people are displaced by weather-related events. You see this when people are displaced by mass shooting, terror events. You see this during flu season, frankly.
HOST:What you're talking about is a certain type of fragility that comes as a result of the payment structure.
DR. CARR:Yeah, it's a good word. I don't use the word"fragility," but you're right. It's a balance, and we have it perfectly balanced under normal use cases. It's not so much about finding blame. It's about thinking about the fact that we are by definition fragile unless we decide that we're going to do something differently. Unless we decide to design the system different. Anyway, it's a big lift and I know it's dry and God help you trying to bake it into a podcast that people listen to. But it is the kind of thinking that will make our system more resilient if we engage with it. When our solution is,"Let's hope there's a bailout," it's not a sustainable solution.
HOST:Yeah. I know you've been thinking a lot about burnout and you've written about burnout and you've talked about burnout since the beginning of the pandemic. My first question for you is—have you felt burned out?
DR. CARR:We don't ask that question, Jon! Yes, I have. I have felt myself many times be short in circumstances where it's not okay to be short with people, short with patients, and short with my family. I have not ended up, I mean, there, but for the grace of God, right, do I end up not able to function through it. And I have been really, really lucky in that I can find time to recharge. And specifically that just means time with my family. It's so easy these days to be grateful for what you have. Even though we don't go outside and do things like we used to, we have downtime. I get demolished in Monopoly by a terrifying nine year old. Those things are really, really important, and I have had them and I'm grateful for them. But, yeah, of course there are times where it just feels overwhelming.
HOST:If there's one thing that's really important to do right now for burnout, for frontline workers, what's the most important thing?
DR. CARR:It's the one thing that's hardest, which is, I mean, I really think it's to unplug. We all recharge differently. But none of us recharge by another 24 hours with a thick mask on, sweating underneath a gown, worrying about whether or not we're getting sick. And yet, you can imagine, if you're wired as someone who knows how to do this and feels drawn to do this, and we're short and, P. S., there's money to be made and it's been a long several months and the holidays are coming. You know, that's the trap. The trap is that if you just pick up an extra couple 24-hour shifts, it can make your finances a little bit better. It seems like a path forward, but you end up in this spiral and that—. I mean I think people just—it is the ability to supported by someone. We were taught by a guy who is on our faculty who is also an Army reservist about the military's battle-buddy system. And it was implemented by another couple of our faculty members. We just paired people up and ask them to check on each other. It's such a simple intervention. And yet talking about what it's like to watch someone die alone with someone else who lives that life is easier and different than it is to try to talk about it for someone who's not in that universe. You know, even if you have a support system, if that support system is not in health care, it can end up, you know, you pull punches. You don't tell the stories because they're just too dark, and who would want to talk through them? So having somebody who lives in that world and who you can tell those stories to can be cathartic. My goodness, clearly I don't know how to say it in a concise way. But I do think we need to recognize that they need to be allowed to go somewhere safe, mask off, with support and not feel the weight of knowing that if they went back to work, they could probably help some more people. But that's near impossible. When you're not there your friends are. And if you go back there to help carry the weight, their load is lighter, except that, you know, it's just insidious the way it takes a toll.
HOST:I wonder how you—I don't know quite how to say this, like, get through to somebody who's in that giving mindset, who will give until they burn out.
DR. CARR:I don't know. I mean, the people that are in it, the people that are wired that way, I don't know how to get through., You know, maybe, and this is off the cuff, but I think a piece of it might be by framing it as increments. You're not walking away, you're not leaving the fight. You really are just taking a little bit of time on the sidelines so that you can catch your breath and hydrate a little bit. And then you will go back in and when you go back in, you'll be more effective at helping them. Because you're able to run at full speed. I know it's a bad analogy. I don't have an answer. And we talk about it a lot, and I don't know that we're going to have an answer. We talked, I mean, I can't remember in what context, but I had a conversation with somebody about how long the adrenaline can last. Because it's not 10 months, and it's certainly not two years. And yet here we are at around 10 months. And there's still a lot of people that are, it's not all adrenaline, you know, but still survival mode. Someone asked me how I was doing the other day and without really thinking too much about it, I said,"I'm just in a holding pattern. Just getting through each day and each week." And I think a lot of people are feeling that way.
HOST:Does the vaccine feel like a light at the end of the tunnel?
DR. CARR:Oh, boy does it. But, um, surprising to me that so many of us in healthcare are so relieved and excited that there is light at the end of the tunnel. And that others, their doubts are significant. Their fears around the vaccine are significant. I can't believe that a third of the people that I'm interacting with are expressing uncertainty about taking it. Because it really will drive—that and the production and distribution capacity—really will drive how much longer, how much longer.
HOST:Can I assume that you're in the"take it" camp?
DR. CARR:[ laughs] I'm in the"take it day one," probably with someone filming it so that we can put it on social media and tell everybody else to take it.
HOST:One final clip. This one's called"the only way out."
CLIP (HOST):How do you stay level-headed and just keep making smart, rational decisions under the circumstances?
CLIP (DR. CARR):Yeah, I mean,"the only way out is through" is I guess what I keep thinking. I don't know what the alternative is.
DR. CARR:Yeah, you know, I remember saying that. I mostly remember because a friend who listened to the podcast sent me a text and was like,"Oof. Man, that one really sunk in." There's just, there's no side door. There's no escape hatch. We're really just going to weather this storm. You know, here's one last piece that I didn't say a couple moments ago when we were talking about some of the things that have been hard about this and what we learned or didn't learn. It's really hard to watch people make decisions that I know I have to clean up after and my colleagues and friends have to clean up after. It didn't have to get this bad. We could have done more to prevent these numbers from being these numbers. And we didn't,
HOST:Are you talking about the politics and masking up and all that?
DR. CARR:I am. I'm talking about decisions to not wear a mask, decisions to congregate, decisions that feel selfish. And I guess I didn't think we were that selfish. I thought there was a little bit more collective ownership of the problem, a little bit more community than we have ended up seeing. How did we go dark again?
HOST:I think it was that clip. I was introducing it as, like,"This is going to be about your mantra. This is going to be— we're going to be positive." And then I played it and I was like,"Oh, no. That's not what it's about at all. And that's not where our heads are." And that's totally fine.
DR. CARR:It's so interesting because it was. I mean, listen, I don't know what conversations we're having about,"I wish this. I wish that." There's no wishing right now. We're just sort of, we're getting through. That's what we're doing. But that was—you know what felt different. It felt different because it was in our control. It was in our control. It was us, it was us standing shoulder to shoulder—docs, nurses, techs—all the people that make the health care system go around, taking this on. And we did. We did it really, really well. We saved a lot, a lot of lives. And then, you know, standing next to me, shoulder to shoulder to shoulder, was the scientific community. And, boy did they do it really well. Here we are looking at tons of therapies that exist, including multiple different vaccines, unbelievably rapidly. But now it's out of our control. Now I need to trust other people to accept this. And I guess that is hard. They don't live my reality of knowing that the front line troops are really getting tired.
HOST:The idea of"moral injury" comes to mind.
DR. CARR:The idea of"moral injury," is that what you said?
HOST:It's almost, like, to feel betrayed by the public. Or to feel betrayed by people who should've known better. And that's a really hard one.
DR. CARR:You know, I think all the time about,"the right to swing my fist ends where the guy's nose begins." I'm sure I'm getting it wrong. It's a famous quote from a Supreme Court justice. And it's about public health, right? I think the original case was actually about forced vaccination. Fascinating. I should probably Google that. Um, you know, but that is what it feels like. Make any decisions you want to make, that's fine. But the second that means that you're putting all the staff in the hospital at risk physically, psychologically, I don't know. But I get it, like, I shouldn't minimize—we shouldn't minimize people's fears. The fears are real and have a strong foundation. The health care system has not been, across the board, fair to people. Especially people who are without resources, especially people of color and people that are otherwise marginalized. It's not resistance for resistance's sake. It's resistance grounded in mistrust. And we have to earn trust. Maybe we are full circle, right? We talked about me entering a job, having no trust of anyone who I was about to ask to do stuff. And here we are, again. The American public has lost trust in health care and health care delivery and in public health. And we need to figure out a way to win back some trust and get through this together.
HOST:That's all for this episode. 2020 is almost done, but we have one more episode to go. It's a conversation with trauma researcher Dr. Rachel Yehuda about MDMA-assisted psychotherapy for PTSD. It's fascinating. So look for that in a couple of weeks. Road to Resilience is a production of the Mount Sinai Health System in New York City. It's produced by Katie Ullman, Nicci Cheatham, and me, Jon Earle. Lucia Lee is our executive producer. If you enjoyed this episode, as always, please go to Apple Podcasts, give us five stars, write us a nice review. We hugely appreciate it, and it helps other listeners find the show. So thank you, thank you, thank you. In the meantime, thank you for listening and from all of us—happy holidays, and we'll see you soon.
