The Only Way Out is Through

Date Published: March 24, 2020

Brendan Carr, MD, Chair of Emergency Medicine for the Mount Sinai Health System, had been at his job for less than a month when the first COVID-19 patient in New York City was diagnosed. Now he finds himself at the center of the largest coronavirus outbreak in the United States. With new patients flooding the city’s emergency rooms, Dr. Carr races to make sure his doctors and nurses have everything they need–from staff to ventilators. In this interview, he talks about the tough decisions he’s facing, and how he’s coping with enormous pressure to save lives.

Podcast Transcript

Host: 00:00
From the Mount Sinai Health System in New York City, this is Road to Resilience. I'm Jon Earle. Each episode we bring you interviews with resilient people and scientists who study resilience. Since our last episode dropped, coronavirus has upended life here in New York City. The streets are quiet. Schools and restaurants are closed. And nonessential gatherings have been banned. Everyone here is figuring out how to adapt to this new reality. They're coping with lost wages and social distancing and extreme anxiety about the future. Here on the podcast, we're going to do our best to help. Moving forward, we'll be exploring what it means to be resilient in the coronavirus era, gathering tips from a wide range of people—tips you can use to stay resilient right now. You'll hear from frontline health workers, psychologists, faith leaders, students, and everyday New Yorkers who are modeling resilience. Wherever people are coming up with creative ways to cope, we'll be there. We hope that these episodes will help you feel more grounded and hopeful. We're going to begin this series with an interview with Dr. Brendan Carr. He's Chair of Emergency Medicine here at Mount Sinai, which means he plays a key role in overseeing emergency rooms at our eight hospitals. In this interview, recorded over FaceTime, he walks us through the hard decisions he's facing and reflects on what it means to cope and lead in a pandemic. It's a sobering conversation. Dr. Carr does not sugarcoat how serious the situation is. But it also gave me hope. Hearing him describe the smart, dedicated people fighting the disease makes me feel like I'm in good hands. I hope it does for you too. Take us into your day-to-day right now, now that things have really changed and ramped up here in New York City and at Mount Sinai with coronavirus.

Dr. Brendan Carr: 01:45
So the day-to-day is long days, early days in the operations center focused on a list of priorities that have been generated as requests come in, broken out to different groups. There needs to be a clinical policy group, there needs to be HR, there needs to be folks from communications, and folks from environmental health, and security and logistics and operations. And so to put all these people in a room allows you to make decisions in a relatively nimble manner.

Host: 02:15
You think about it very much as a logistical problem, which it is. I guess what I'm wondering about is—what is this like for you as a person going through this? And how are you coping personally with what I imagine is a lot of pressure?

Dr. Brendan Carr: 02:31
It's nice of you to ask. The pressure comes from a couple of different places. I guess I would say the first is that I feel like there are a lot of people that I need to not disappoint. Let me start and tell you a story. One of my doctors, who is not allowed to work because she is self-quarantined, was reaching out to text me and to apologize that she can't be there helping all of us to take care of the increasing volumes of patients that we're seeing. And so just knowing that that is the way that folks that are on the frontline tick makes it really important— it feels extremely important to me not to disappoint them. I know how hard they're working. They're on the front line. They're scared. This is a scary time. They have families, they have kids.

Host: 03:21
What do you say to a colleague like that who reaches out? Do you have a message for frontline workers who are stressed, scared, anxious? 

Dr. Brendan Carr: 03:30
From my perspective, it really is just to remind them that they're extraordinary and that I am grateful to them and that the families of the people whose lives they will save are grateful to them. 

Host: 03:43
What are the challenges, I mean, looking forward—where are we right now in this and what do the next few months look like for you? 

Dr. Brendan Carr: 03:54
I'm really grateful that we got as serious as we did about planning so early on, and that credit goes to a broad group of people who started to have these conversations and finally said, "Okay, it's time to start making the hard decisions."

Host: 04:11
What's the next one coming up? The next hard decision?

Dr. Brendan Carr: 04:14
The series of next hardest decisions are going to be enormously dependent upon what we do as a society to decrease spread. The social distancing is an enormously important piece of this first line of defense. The public are the first line of defense, and the healthcare system is the very final line of defense. Once people are sick enough to need the healthcare system to take care of them, the decisions that are going to come our way that are difficult are going to be--there are going to be many of them. The framework that I lean on just because of my background and where I come from is an enormous body of literature that is called "Crisis Standards of Care." And the "Crisis Standards of Care" helps us to understand and articulate a pivot from conventional standards of care through contingency standards of care to crisis standards. So, we all know what a conventional standard is. You use this device for this procedure, and then you dispose of it and you get a new one for the next procedure. An example of a contingency standard might be that you use that device and you don't dispose of it because you're running short of them, so you put it in the autoclave and you clean it appropriately and you reuse it. And these are not, these are--people write about these often in the international setting. These are not conversations that we have in the United States.

Host: 05:44
It's very sobering to hear that. 

Dr. Brendan Carr: 05:47
Those decisions are coming and they're coming in a lot of different ways. They're coming in the policy-making way, but they're also coming in a really personal way. They're coming to individuals on the front lines who are going to have to think differently about what they're doing. And maybe we're wrong, and maybe the numbers aren't overwhelming, and maybe we fix all of the bedding and supply-chain challenges. But if anybody's reading the literature from Italy, and it's a very different healthcare system, but the literature from Italy tells clear stories of sort of making artificial thresholds.

Host: 06:23
You're talking about "treat this person, not that person" kind of decisions? 

Dr. Brendan Carr: 06:27
I am. I'm talking about that, and we all hope we never get there. But it would be irresponsible not to think about it. I trained in West Philadelphia and unlike New York City, West Philadelphia has an enormous, or Philadelphia actually, has an enormous firearm problem. And you watch a lot of people die. You watch a lot of people survive heroically. And although in pleasant company we often don't talk about it, when multiple people show up at the same time who are critically injured, on a much smaller scale than what we're talking about is about to happen, people make decisions. You make a decision about likelihood of survivability and who's first to get intervention X, Y or Z. 

Host: 07:18
I just want to return to something I've asked you before. When you're facing these sorts of issues in the setting right now, how do you stay level-headed and just keep making smart, rational decisions under the circumstances?

Dr. Brendan Carr: 07:33
I mean, "the only way out is through" is I guess what I keep thinking. I don't know what the alternative is. A lot of people who feel the weight and who are leaning on each other to make sure that we get this as right as we can get it. Yeah, I know it's inadequate, and maybe we're early in this and there's another three months of this coming. And maybe I will have better answers once the adrenaline's gone, but right now, it just feels like a burden to get it right without a whole lot of time to. 

Host: 08:13
You've talked about leadership, and you've talked about the team effort. What does good leadership look like right now? 

Dr. Brendan Carr: 08:20
I think a lot about allowing people to rise to the level that you know that they can. We're unbelievably lucky. I work at a place where everybody's brilliant and it's dumbfounding and there's all of these folks who if you just let them run, they will do extraordinary things. I guess I think that that's a lot of what this is—that's a lot of what leadership is about. It's about recognizing the talent around you and allowing the talent around you to do the job. Because, boy, they know how to do the job. 

Host: 08:55
Is there anything that is under-covered, or that's new, or that you really think is not being represented accurately and that people need to understand?

Dr. Brendan Carr: 09:04
Yeah, thanks a couple. I mean, the first is the surreal disconnect between the things that—maybe I should start by saying it is totally possible that I have lost perspective, and I know that, but it is pretty surreal to leave, to take a break from trying to sort through these things and to get home to get a couple hours of sleep and to see people out and about with each other, kids on playgrounds, and not think about the fact that we're not doing enough. And we're not doing it because it's not proximate enough. If it were happening now, we would recognize the importance of not spreading this to each other. If it were happening now in a visible way, but it's, you know, 30 or 40 days away. But I think another story that I worry is not recognized enough is how many people are working so hard to respond to this. You watch the news and it's about things that seem important: "How do I get a test?" and "Can you believe it took this long for me to get a test?" There is a series of incredulous stories in prominent journal outlets that sort of talk about how hard it is for people who are well to get a test that, from the doctor's perspective, changes absolutely nothing about the way that I care for them. And I get it. I get it from the patient perspective that people are concerned and they want certainty in the face of uncertainty and they are afraid and they believe that a test is going to tell them whether or not they're going to get sick from the virus. But it doesn't. It tells them if they've been infected with the virus. And we know that, as I said before, 80 percent of people have really mild symptoms, and if we knew the 5 percent who were going to get critically ill or the 1 percent or 2 percent that were going to die, that would be a different story if we had that test. We don't have that test. We have a test that tells you whether or not you've been infected with it. So I guess, I mean, it's hard to see all of that focus and to not be a little bit frustrated with the idea that we're not getting told the story of all the people within private sector healthcare, within public sector healthcare, on the front lines, at state governments, federal governments that have spent their lives planning for something like this. I know more about it than most because of my time inside of the federal government. But pandemic influenza plans have been around for a very long time. Stockpiled supplies as a part of the strategic national stockpile are very carefully thought through all the time. The enormous assets of the United States being brought to bear to respond to this should get and they deserve a good narrative, a good explanation so that the American public can know how many people are trying really hard to keep us safe.

Host: 12:11
Well, we will do our very small part to make sure that message gets out there. And thank you so much again for taking the time to talk with us.

Dr. Brendan Carr: 12:20
It is very, very nice to talk to you guys. Thanks so much. 

Host: 12:25
Dr. Brendan Carr is the Chair of Emergency Medicine for the Mount Sinai Health System. That's all for this episode of Road to Resilience. We're a production of the Mount Sinai Health System in New York City. This episode was produced by Katie Ullman, Nicci Hudson, and me, Jon Earle, with help from Ilana Nikravesh. Lucia Lee is our executive producer. We'll be back as soon as we can with more episodes. But in the meantime, how are you coping? We're gathering creative coping strategies for future episodes and we'd love to hear from you. Email us at Until next time, thanks for listening, and be well.