Twelve Patients Life and Death at Bellevue Hospital (The

Inspiration for the NBC Drama New Amsterdam)

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For Diana
 CHAPTER 1

The One-Strike Law

The view from my office at Bellevue Hospital looks north up the East
River. The south side of the UN building rises like a thin polished band, and
it cuts through the arc of the 59th Street Bridge that reaches east over
Roosevelt Island and then to Queens. On the southern tip of Roosevelt
Island, I can make out the skeleton of the smallpox hospital now in ruins.
FDR Drive pulses with white lights heading south as I look out at seven
o’clock on a still-dark morning. Red taillights string north in the dark
evenings as people head back to the outer suburbs locked in their cars.
The old Bellevue psychiatry building, now a men’s homeless shelter,
frames my window on the left. The building is stained with water and
neglect. Just to its right is the New York University School of Medicine
with its laboratories, classrooms, and hospital beds. Hidden beyond the
construction site exactly in the middle of my view is a small white tent. The
site had been our northern parking lot until September 11, 2001 when air-
conditioned freezer trailers were moved in and surrounded by a chain-link
fence. Guards monitored access. The remains of the dead from 9/11 were
brought to be identified, their DNA measured against the DNA extracted
from toothbrushes and clothes. It reminded me of the Zaka in Jerusalem
(the Hebrew acronym of an Israeli organization that aids disaster victims),
who came to the site of a suicide bombing wearing their tzitzis and
collecting brain matter and fingers into plastic bags for burial, so that the
souls of the dead would be able to join their people when the Messiah came.
The tent is still there, as I look out my same window eight years later,
though the refrigerated trucks and guards are gone. The view is being
progressively obliterated. The Economic Development Corporation has
taken over our north-side parking lot and leased the area to a California
company to build a biomedical laboratory building. I figure I have about
another three months before the UN disappears completely, and with it the
medical school, along with the old psychiatry building cum homeless
shelter.
When most people hear “Bellevue” today, they picture an old-fashioned
insane asylum—but that is just one aspect of this city-within-a-city where I
spend my days. For aficionados of Law & Order or Nurse Jackie, Bellevue
is synonymous with psychotic killers perpetrating random acts of violence.
But Bellevue is the oldest hospital in the country, 275 years old. It is also
arguably the most famous public hospital in the United States. The first
maternity ward, first pediatric ward, first C-section—Bellevue is full of
firsts. Its public sanitation programs date back to the Civil War. Yellow
fever, tuberculosis, typhoid, and polio epidemics were brought under
control here. Famous for psychiatry, Bellevue also pioneered child
psychiatry with the first inpatient unit complete with a public school for
children. Two Bellevue physicians won the Nobel Prize for heart
catheterization. The first cardiac pacemaker was developed at Bellevue. So
was the early treatment of drug addiction.
Today, the hospital continues to work at the cutting edge of public health
issues—HIV, lethal flu, potential terrorist epidemics. Bellevue also has a
hundred-bed prison unit to care for prisoners of Rikers Island, the largest
prison complex in the country. As part of the city hospital health system, we
look after the needs of all New Yorkers—from Park Avenue to the tenement
housing of recently arrived Fukienese immigrants, survivors of torture, and
everything in between. With thirty thousand discharges and half a million
visits in our hundred-plus different outpatient clinics, we see the effects of
global problems often before most people know the problems exist:
outbreaks, violence, climate change, tobacco, drugs, and the fast-food
industry. We are known for many things, in particular our emergency room.
If a cop gets shot in Manhattan, his first choice is often Bellevue. If a
diplomat gets attacked at the UN, he gets taken to Bellevue. If an
investment banker goes into cardiac arrest, his limo driver knows where to
take him. If New York is a microcosm of the world, then the doctors of
Bellevue are on the front line. We are a vibrant institution that moves to the
same rhythms as the city we serve.
Where in colonial times there was a farm named Belle Vue now stood a
vast hospital complex of several thousand beds with seven thousand
employees, and several thousand new New Yorkers being born every year.
The modern campus sits in Kips Bay, a few blocks south of the United
Nations, flanked by First Avenue to the west and the FDR Drive snaking
along the East River. The northern boundaries are the aforementioned men’s
homeless shelter spun out from the old psychiatric buildings, and an intake
center for kids in crisis; both were parts of the original sprawling hospital
campus. The southern boundary runs into a nursing school and the
Manhattan Veterans Hospital on 23rd Street. For the past 150 years,
Bellevue has also been the teaching hospital for the New York University
School of Medicine.
I arrived at Bellevue in 1997. After seventeen years as a physician at
Dartmouth, I was ready to be back in New York and in public health. As a
child growing up in the Bronx, I used to accompany my father, Dr. Robert
Manheimer, as he made house calls at night. A rheumatologist and internist
at Montefiore for more than fifty years, he took me on night rides in the
family’s baby-blue Peugeot with an adjustable spotlight to find house
numbers on Gun Hill Road or the little-known alleyways off the Grand
Concourse. The sounds, smells, and rhythms of medicine entered my
primitive brain’s limbic system. I had no choice. Though I loved everything
else—history, languages, archaeology—medicine was my passion.
In the 1970s, when I was a medical student at Downstate, in Brooklyn,
the city went bankrupt. Crime rates escalated. The city saw gigantic
unemployment, a crack cocaine epidemic, racial tensions, and escalating
economic and social disparities. As I made my way to pathology class
Monday morning, the Brooklyn morgue was lined with bodies. The late
1970s, when I was a resident at Kings County, a huge public teaching
hospital in central Brooklyn, were also crazy times for New Yorkers. The
city was homicide capital of the world. Son of Sam was one of my more
infamous patients of the time. There was nothing we had not seen after
years working through all of the services, each with its own building on the
campus. We had no on-call rooms, so we slept on empty stretchers. There
was no air-conditioning so in the summer we brought several extra shirts to
change into. We would meet at midnight in the break room for peanut butter
sandwiches and trade a CT scan for a barium enema before going back to
battle. After ten years I had seen almost everything.
After a physician was stabbed to death in the parking lot of the hospital
by a crack addict trying to rob him of five dollars, I answered an ad in the
New England Journal of Medicine for a job in New Hampshire.
 I met my wife, Diana, at Dartmouth—she was a young professor with
Canadian parents who had been raised in Mexico, where her dad worked as
a mining engineer. Diana’s work encompassed the world of arts, theater,
performance, literature, and politics, and I was seduced by it from the
beginning. From her early childhood in Parral, Chihuahua, a dusty mining
town whose only claim to fame was that Pancho Villa had been killed there,
her family had moved to Mexico City. In 1997 I followed Diana back to
New York City, where she was offered a position at NYU. I, like a true
homing pigeon, started working in the city public hospital system again.
Bellevue completed my inner circle, which consisted of Diana; my son,
Alexei; and my daughter, Marina.
Looking down out my window, I see a corrections van, “New York’s
Boldest” stenciled on the side, pull outside the “Blue Room” (holding pen)
between the emergency room and the adult psychiatric emergency room,
which goes by the acronym CPEP—that is, the “Comprehensive
Psychiatric Emergency Program.” The occupant of the van must be a high-
value prisoner from Rikers Island—seven police and corrections vehicles
surround it. The vehicles stop just below my window, and the corrections
tactical squad members emerge in full body armor, carrying battlefield-level
weaponry. They survey the perimeter, then create a human corridor through
which two corrections officers (who must be captains, judging by their
starched, formfitting white shirts) escort the shackled prisoner. He is Latino,
with dark disheveled hair and a wispy beard, wearing the standard baggy
orange jumpsuit. His skin is tattooed everywhere I can see. Blue, black,
green, and red. His neck, arms, and hands.
He looks up toward my window. Las Maras have arrived in New York.
They are one of the deadliest gangs. Their signature is extreme violence, no
holds barred, unsentimental murder and mayhem. Their initiation rights
involve peer beatings and an initiation murder or asesinato, as it is called in
Spanish. Many of them grew up undocumented in the street gangs of Los
Angeles, and were later deported as teenagers and young adults—some to
El Salvador, where their parents had fled from the horror of civil war, and
some to other countries of origin they had never known. Now they were
back, more lethal than ever, with a spiderweb network of drug trade from
Colombia and Peru all the way to Los Angeles and Long Island.
This guy’s hands and feet are bound with metal chains; another chain
connects the hands and feet, and everything is connected to a strong leather
belt around his waist. Is all this security to protect him from a rival gang
that wants his territory, or is it to prevent his gang from helping him escape?
This transport moment is the vulnerable point—he can’t escape from
Rikers, though someone could kill him there. Given the gang’s power and
codes, however, that’s unlikely. The guards push him into one of the cells in
the Blue Room.
“¡Hola, jefe!” Patty, my executive assistant, walks in around eight a.m.
and startles me out of my thoughts. “You have a full schedule today.”
“As opposed to every other day?” I ask.
“¿Quién te manda, jefe?” she rejoins. “You are your own taskmaster. So
today, the UN Secret Service folks are coming in to make sure we’re ready
for the upcoming General Assembly meeting next week. God forbid they
take a shot at one of those world-leader types and he ends up here. The
Mexican minister of health will pop in to discuss health care for Mexican
migrants.” She goes down the list and finishes with: “By the way, Budd
called down from the prison health unit asking if you would run up to say
good-bye to Juan Guerra, who is to be discharged on compassionate
release.”
I pause, speechless. “He’s finally going home? I can’t believe it.”
“Don’t believe it till you see it, jefe. You know how things are around
here.”
Juan Guerra going home—unbelievable.
“I’ll go see Guerra before the UN guys come—I’ll be right down. Get
them some coffee and donuts if I’m late, por favorcito.”

The first thing I ever noticed about Juan Guerra was his neck, which I
recognized from twenty-five yards away.
I was making rounds with Budd, the lead physician on the nineteenth
floor. Rail-thin, six foot six, Dr. Budd Heyman was an internist with a long
history of working in correctional medicine from the Tombs, Manhattan’s
prison adjacent to Chinatown. An indefatigable advocate for the
disadvantaged, he knew that the game of life could change quickly for
anyone and the only difference between the rich and his patients was that
the rich had options. We usually began at one end and walked our way
around. Even if the patients weren’t in their cells at the start of our rounds,
they would magically appear by the time we got there. There was too little
going on in prison to miss the opportunity to talk to someone new. There
were twenty-five men, between the ages of seventeen and seventy-three,
who had been there for as little as a few hours or for as long as five months
plus. The corrections officers at their posts were a reminder that they were
still prisoners, even though they wore hospital gowns. The gates were solid
metal and locked; there was no decor and no color. Mesh screens covered
all the windows.
With the guards, the gates, the IDs, more gates, it’s hard to “drop in” on
that unit, and I am a drop-in kind of doctor and medical director who
prefers to be on the floor rather than behind my desk. You get a feel for a
unit. People in the know can actually size up a hospital in a few hours just
by walking around it, talking to people, asking questions. You get a clear
sense of what’s going on. You don’t need ten inspectors spending two
weeks crawling through policies and procedures. A few sentinel scenarios
tell you if the hospital is a Potemkin village or the real deal.
Guerra was a slight man under five foot eight, thin, with hospital-issued
pajamas and slippers, short-cut pepper-gray hair, and a short goatee. And a
neck I would know a mile away. The swelling told the full story
immediately. I could anticipate every question, issue, side effect, treatment
option, and alternative. I had no idea what his personal story was, where he
was from, where he had been, and what his life trajectory had looked like so
far. But I certainly had a fair sense of what his future possibilities might be.
The left side had four golf-ball-size tumor-filled lymph nodes that stuck out
and left the skin over them stretched taut. They weren’t giving him any pain
or interfering with his swallowing. He was thin but not gaunt and had a
glass of water in his hand. His disease was advanced, and his chances of
making it very slim. I wondered in what way I, as a physician, could have a
positive impact on Guerra’s dwindling life.
Many physicians did not get into the boat at all and stayed on the shore.
Many became obsessed with lab values and the rituals of the white coat and
stethoscope, the computer now safely between them and the patient so that
hardly a glance was necessary before they could be off to the next. For this
type of doctor, the loss of a a patient is a narcissistic blow. It activates a
primal fear of loss. It represents a deep professional failure. It makes a sham
of what medicine is supposed to do. Regardless of the regimens, treatments,
expenses—regardless of other specialists brought in, the surgeries,
secondary options, drug trials, and rescue chemotherapies, the futile
treatments themselves are a symptom of the physician’s inability to accept
an ending. The doctor becomes frozen, protecting the illusion of power. But
the illusion is untenable—it goes against the laws of physics. Everything
dies. Nothing touches the inescapable outcome that is entropy itself. The
Second Law will prevail, it always does, the house never loses.
I hesitated before approaching Guerra. Something else held me back: I
was recovering from the same exact disease. My own treatment for SCC, or
squamous cell carcinoma, from a peanut-size lesion near my right tonsil,
had started on a Monday in mid-October a year earlier and finished with a
final dose of radiation therapy and chemo in early December. The
complications and recovery were still fresh. I had had a neck node that
wouldn’t quit, that sat out the radiation and the chemo nearly to the end and
then finally collapsed in a couple of days. Would his collapse? Would mine
stay collapsed? Would his fate foreshadow mine? Seeing his neck created
an anxiety in me I didn’t like to admit to myself and certainly couldn’t
share. It’s painful to see your own worst fears made real and immediate in
the person in front of you. It’s not simply a matter of the empathetic This
could be me. It’s more like This could very well be me sometime soon. I
pushed the thoughts as far back as they would go. I understood what lay
ahead of him in a way no healthy physician could.
I walked over to him, holding out my hand: “Buenos días, soy médico,
parte de tu equipo de médicos en el hospital. ¿Tienes un ratito para
platicar?”

Patty is ushering the two Secret Service men into my office through the
front door as I enter through the back. I intended to see Guerra first thing
this morning, but was stopped in the hall by one of the chiefs telling me
there was a problem in an operating room. Figuring out a solution has taken
the best part of an hour, and I need to get back. I ask Patty to find out what’s
happening with Guerra ASAP, and then greet the two men.
They are standard government issue. Beefy, short haircuts recently
clipped, cheap gray suits off the rack, plastic white earpieces with a cord
disappearing down their necks, and the omnipresent clipboards. The
president and other heads of state are due to meet at the UN next week, so
these men are here to check the hospital security and trauma and cardiology
readiness, as Bellevue is the receiving hospital for heads of state. They are
here for a walk-through, very hands-on. As part of the emergency-
management system, we rehearse a variety of different activations such as
biological attacks, mass trauma, and dirty bombs. I make them coffee with
my new espresso machine that Diana gave me. A box of Dunkin’ Donuts
has miraculously materialized on the polished wooden conference table.
This is not the quiche-and-Perrier crowd. Even though they come every
year, we always go down the same checklist.
Randy, the senior Secret Service officer, says, “You have 24/7 in-house
trauma attendings?”
Check.
“Dedicated trauma operating room?”
Check.
“Examples of current emergency escalations?”
“We had a gunfight two weeks ago with three cases in the trauma slot
and in the OR in a few minutes,” I responded. “Rival gangs involved in
narcotics turf warfare. Fifty units of blood and product for the cases. We
can access an enormous quantity from the blood bank and sister hospitals
quickly.”
Randy looks up and smiles: “Like Maryland. Except their business is car
crashes, not the knife and gun club. Do you have helicopter access?”
Check.
Jim, the junior guy, texts on his BlackBerry throughout the meeting. We
schmooze comfortably and eat donuts as they complete their paperwork.
We then take the walk around the central administrative hub of the
intensive care unit (ICU), where a safe space is secured in the event a high-
profile politician or diplomat comes in with trauma or another life-
threatening condition. I stop to introduce them to Maria, the secretary to the
surgical intensive care unit, and the chief resident on neurosurgery. I look in
on the fifteen members of the trauma team that surround the bed of a young
woman who lies in a coma after her motorcycle was hit by a distracted
octogenarian behind the wheel. She was launched into a low orbit that
caused multiple cranial fractures, internal bleeding, and swelling that killed
all tissue above her brain stem. The doctors are carrying out some of the
tests we relied on completely before the age of CT scans. Do the pupils
react to light? Are they equal in size? Do you see doll’s eyes moving
together when you rotate the head to one side and the other? She has fine
features and long dark hair. For an instant she reminds me of my daughter,
and I look away. They are around the same age. Too painful to think about.
My cell phone goes off, and I check it as I walk the Secret Service men
to the elevators. It’s Patty—the Mexican minister of health has been
delayed at the mayor’s office. We have a meeting to discuss the partnership
that Bellevue has developed with the Mexican consulate to provide health
care for the influx of documented and undocumented Mexican immigrants
—more than five hundred thousand of whom live in the greater
metropolitan area alone, and twelve million in the United States. I ask her to
call me when he arrives.
She assures me she’s on the Guerra case. “Jefe, thought you’d like to
know that Dr. Faruz is waiting here to see you. I told him you’re busy
upstairs but he says he’ll wait. He wants to complain to you about…” I pray
for patience and hang up.
“A happening place,” says one of the Secret Service men.

Juan Guerra is going home—unbelievable. After half a life in prison, his

throat cancer might actually save his life. Maybe. I think back on my
earliest discussions with him, a fifty-nine-year-old man born in New York
of Dominican parents.
As a child in the Bronx, Juan Guerra had made several lengthy trips to
the Dominican Republic, first living on a ranch, riding horses near the
Haitian border, and later in the capital city, Santo Domingo. Timing was
everything, Guerra had told me. And his timing had always been terrible.
Coming of age when Vietnam was exploding like a grenade with the pin
pulled, his lottery number had been 11 and he went to war with the
neighborhood. This was not a Crawford, Texas neighborhood with street
names like Harvard and Princeton Place. There was no question of a
deferment for an injury or conscientious objection or a family that could
stash him safely in the National Guard to ride out the waves of Hue that
would bring the nightly death counts onto living room televisions across the
country. Guerra and his family knew he was the one who would always be
caught. A black cat had walked across his mother’s path when she was
pregnant, he said.
Guerra had served in Vietnam in a combat unit, though in fact he was in
Cambodia ferrying U.S. troops illegally into the border areas to find and
destroy Vietcong storage tunnels. What he didn’t know was that not all the
risks in the army were booby traps in the jungle or black-pajama-clad locals
who might be soldiers, sympathizers, or just villagers trying to survive one
side or the other depending on the time of the day. What he didn’t know
was that a pure white powder would claim his future and, in many ways,
remake him into another person before he was twenty-one years old.
He came back, like many in his unit, addicted to heroin, and for the next
thirty years tried dozens of times to kick the habit, relapsing regularly. He
was caught in possession of drugs, sent to Rikers and occasionally upstate
for longer sentences of over a year, and put on parole again and again. The
last time he was sentenced to prison was for being fifteen minutes late for a
meeting with his parole officer. His adult life post-Vietnam had been one
extended coda with the Department of Corrections of New York State. It
was like his second family—maybe even his first at this point. He had a
wife and a son whom he missed terribly and who’d supported him
unconditionally through thick and thin over decades, an aging mother and
father, and an extended family in the Dominican Republic. In fact, a lot
more than many non-felons could claim.
Guerra and I had talked about this often over a hospital meal at his
bedside. I asked him why he would make such bad decisions knowing the
consequences—and how the police needed to make their arrest quotas.
These were minor drug offenses, possession or selling tiny amounts of
methadone. How could he take the risks?
He said that he was an addict and had been one for thirty-five years
courtesy of the U.S. Army. His entire social network was made up of
addicts, dealers, and minor neighborhood drug types who couldn’t get any
type of employment.
“I made a lot of bad decisions and pay the piper every time. After a
certain point it doesn’t matter. You will get picked up and charged with
someone else’s crimes since they know you cannot say no and you plead
down so you don’t have to go upstate.”
“So can’t you play it extra safe, knowing that?”
“I need methadone. Once the clinic shut me out, paperwork they forgot
to file. They told me to come back in five days. I had to choose between
withdrawal and getting some drugs to tide me over. There is no slack. You
do anything not to withdraw.”
 Guerra paused, then continued. “A year ago I was arrested for walking
Tiger off a leash. He weighs four pounds. He is my grandkid’s Chihuahua.
It was the end of the month and the rookie needed to fill his quota. The
senior cops all laughed at the rookie for such a stupid arrest. I went to
prison and they laughed at him.
“Doc, try living in the stop-and-frisk world of the NYPD. Just for a
week.”
“How does your family take it?”
“Es una locura. And why my wife has stayed with me for over thirty-
five years. Who knows! She knows hard time with her brother for the real
bad stuff. Mine is petty stuff and I am faithful and I love her and our kids.
Our world includes prison time and probation and the likelihood you will be
back again.”
After his latest incarceration, Guerra’s disease was diagnosed, and he
began his treatment with radiation therapy. Every morning at ten thirty the
guards would escort him per protocol in handcuffs and leg shackles through
the metal gates to the elevator bank for supplies. They would go down to
the ground floor and walk out to the Blue Room. He would wait there until
a prison van arrived to take him three blocks north to the basement of the
university hospital. Two officers would escort him to the radiation therapy
area. He would be unshackled and assisted onto the table, where he would
lie back on the thin metal gantry covered by a sheet.
The technician would fasten the plastic gridded molded mask over his
face and screw it into the table. His throat was burned raw by the radiation
treatments. Two circles of hair loss on the back of his head marked the
radiation fields. To relax him during the procedure, a nurse injected him
with Ativan, a sedative to take the edge off the anxiety and discomfort of
being locked down on a metal table with stomach acid lapping up his
esophagus, the nausea from the chemotherapy threatening spontaneous
spasmodic vomiting. His stomach tube dangled down the table, almost
touching the floor.

Very few people in the United States know that the largest penitentiary
system in the country is in New York City. For most, Rikers Island exists
simply as a TV set. Only the guards who go there and the prisoners and
their families have a clue about the scale and operational routines of the