By Nicholas Kulish
Orphaned as a youth in Bangladesh, Jamal Uddin worked in a ribbon factory in Lower Manhattan while attending high school, before graduating from college and ultimately finding a career helping people with H.I.V./AIDS.
Over his 68 years he had proved that he was a survivor, but the battle of his life would take shape in a Brooklyn intensive care unit as the new coronavirus swept the city.
He had a ventilator to help him breathe, the one piece of equipment everyone feared would be unavailable if the hospitals were overwhelmed. What Mr. Uddin lacked, his family says, was adequate access to dialysis, a common treatment for impaired kidney function that was not available in sufficient quantities to deal with wave after wave of Covid-19 patients arriving in ambulances at the emergency rooms.
His wife, Jesmin, and son, Shehran, grew increasingly anxious and then desperate over four days in April as Mr. Uddin received no dialysis treatments. “As a physician it’s hard for me to fathom that that’s even a possibility,” said Dr. Rasel Rana, an orthopedic surgeon and Mr. Uddin’s brother-in-law, who said that he and his sister begged for dialysis in calls with the hospital as tests showed worsening kidney function.
At the peak of the outbreak, the number of Covid-19 patients fighting kidney failure led to soaring demand for dialysis at hospitals around New York City, including at NYU Langone Hospital-Brooklyn, where Mr. Uddin was being treated. Nephrologists sounded the alarm that they did not have the medication, staffing or machines to deal with the unexpected influx of patients.
The hospital’s own records indicate that the specialized dialysis known as continuous renal replacement therapy was in short supply when Mr. Uddin was severely ill with Covid-19 there. A note in his file on Tuesday, April 14, said it was not “currently available for the patient in his current location,” even as Mr. Uddin’s potassium level, a crucial indicator of kidney function, soared to a critically high level.
“Every day there were decisions made as to whether he was stable, whether he required an emergency intervention, and on each of these days he did not,” said Dr. Joseph M. Weisstuch, chief medical officer at NYU Langone Hospital-Brooklyn, where Mr. Uddin was treated. “We went above and beyond taking care of an extremely sick patient.”
Mr. Uddin’s struggle with the coronavirus is chronicled in the notes his brother-in-law scrawled on a white pad during those anguished phone calls with doctors and unspools in meticulous detail over 1,403 pages of digitized medical records, obtained from the hospital by The New York Times with the consent of his family.
With his potassium level spiking to a new, dangerous high, Mr. Uddin went into cardiac arrest that Tuesday evening, but doctors were able to jump-start his heart and resuscitate him. The head of nephrology requested the specialized dialysis for Mr. Uddin, which family members said they had pleaded for over the phone for days. The treatment was scheduled to begin almost immediately, if he could just hold on.
NYU Langone-Brooklyn was not the only place where shortages left doctors making life-or-death decisions. “I was basically just trying to hold the floodgates back from bursting open. It burst open a couple times,” said a physician in another New York City hospital treating I.C.U. patients with Covid-19 without enough advanced dialysis machines for the number of patients with damaged kidneys.
“Had these people received what they needed, some of them, at least, would have lived longer,” said the doctor, who requested anonymity for fear of workplace retaliation for speaking out.
In response to the unexpected demand for emergency dialysis, Dr. Howard A. Zucker, the state health commissioner, last week requested specialized dialysis machines from the federal stockpile. This week, the state received 50 of the advanced machines and is looking at how to distribute them where the need is greatest.
It would be difficult to calculate how many patients have died during the coronavirus outbreak because of a lack of kidney treatment. Many of the most severely ill were dealing with multiple-organ failure, and even with adequate dialysis their lungs, hearts or other organs might have given out later.
“What we’ve seen with this disease, over and over, is people that have transient improvement and crash despite everything that we’re doing,” Dr. Weisstuch said.
Mr. Uddin’s hospital records detail just how much effort went into keeping him alive, the dozens of doctors, nurses and technicians, the ventilator and medications including hydroxychloroquine — the unproven treatment touted by President Trump.
He initially received the specialized dialysis treatment often used in intensive care units. But at the height of the crisis, New York hospitals, including NYU Langone, began to run low on the more specialized machines. The hospital turned to a procedure called peritoneal dialysis that can be quite effective for some patients, but is not always optimal in hospital patients whose conditions are less stable. Even that was delayed for several days until Mr. Uddin’s condition had deteriorated significantly.
“I just want this out so people know about this so the next time they are prepared,” Jesmin Uddin, his wife, said of the need for more dialysis resources in future Covid-19 hot spots. “I don’t want anybody to go through it anymore.”
Dialysis takes over the essential role the kidneys usually play, cleansing the blood of toxins and removing excess fluids, among other tasks. Around the country, kidney specialists estimate that 20 percent to 40 percent of I.C.U. patients with the coronavirus suffered kidney failure and needed emergency dialysis. In some hospitals in New York City, demand for dialysis rose threefold during the crisis.
“They said his numbers are so good,” said Ms. Uddin, crying as she spoke. “There are other patients doing worse than him. We need to do the dialysis machine to them,” she recalled the doctors telling her.
Aches, Fever and No Tests
Mr. Uddin was born in Chittagong, Bangladesh, where the Karnaphuli River flows into the Bay of Bengal. He was not poor, but he knew what it was like to share a small bowl of rice with his brother as his only meal before school. After his parents died, he immigrated to the United States, where he had an uncle.
On a visit back to Bangladesh in 1985, Mr. Uddin met a young woman, Jesmin, and they soon married. She recalled how as newlyweds in New York they would drive around the city in his Toyota Starlet, going to movies or parks. They moved to a red brick house in Bay Ridge and had a son, Shehran, now 23 and preparing to attend CUNY law school in the fall.
A neatly dressed man who favored sports jackets with an open collar, Mr. Uddin worked as a supervisor at the city’s H.I.V./AIDS Services Administration and was active in the union there. “Everybody knew that although he worked in a cubicle, his door was always open to anyone,” said his boss at the administration, Elnora Whitten.
He liked to jog along the water under the Verrazzano-Narrows Bridge and down toward Coney Island. On weekends, Mr. Uddin enjoyed driving to his old neighborhood in Manhattan for pastrami sandwiches at Katz’s Delicatessen.
Mr. Uddin loved to travel and to garden and combined those two passions by bringing home tulip bulbs from the Netherlands and planting them in a small plot in front of the house in Bay Ridge, where he also planted a weeping cherry tree.
On March 20, Mr. Uddin told his wife that his body ached and he had a fever. Like many in the city, Mr. Uddin had trouble getting tested for the coronavirus. His cough worsened and his fever climbed, but he was sent home from nearby Maimonides Medical Center without a test or chest scan. His wife and son also fell ill but could not get tested either.
On March 31, the family bought an oximeter to measure his lung function and an oxygen tank to help him breathe. They discovered that his oxygen saturation had fallen to 78 percent and the family called an ambulance.
Shehran watched his father walk down the steps to the back of the ambulance while his mother collected medications. Jesmin said she put on her shoes “to run to him,” but the paramedic “stopped me, saying I couldn’t go.” She waved goodbye to her husband from the front door as they drove away.
“I said, ‘Fight, fight, fight,’” his wife recalled.
By his fifth day in the hospital, Mr. Uddin’s blood oxygen saturation had slipped to the low 70s. Just before he was sedated and placed on a ventilator, his wife and son spoke to him.
“We just got to see a minute on the FaceTime,” Ms. Uddin said. “He said he loved us. We told him we loved him. We started to pray.”
A Bad Sign
Mr. Uddin’s lungs improved a little, but his kidney function began to falter.
Rising potassium levels can be an indicator of how badly a patient’s kidneys are doing. “When the level rises much above 5, it’s a sign something is wrong,” said Dr. Alan Kliger, a Yale nephrologist and co-chairman of a Covid-19 response team for the American Society of Nephrology. “If it continues to rise, then you say before it gets dangerously high, we start the dialysis.”
Mr. Uddin’s potassium level climbed to 6.3 on April 7, a critical high according to his records. But he received dialysis for the first time and his numbers improved.
“If this was the only concern left, the only thing he needed was dialysis, I finally was able to breathe,” his son, Shehran, said. “He would come home,” he recalled thinking. “This was a simple thing.”
Dr. Michael Connor Jr., an associate professor of medicine and a nephrologist at Emory University School of Medicine in Atlanta, said that under normal circumstances, patients who require dialysis for sudden kidney failure in the I.C.U. have a mortality rate as low as 40 percent and as high as 60 percent.
“It’s always better to intervene with more invasive means of life support before they get into extreme situations, and it’s true in kidneys, too,” Dr. Connor said.
To prevent further infections, relatives cannot visit loved ones in the hospital during the outbreak, which has reduced, even scrambled, communication between front-line medical personnel and family decision makers.
That became clear when, three days after Mr. Uddin first received specialized dialysis, the hospital asked for permission to place a catheter in his abdomen so he could receive the alternative form of treatment, known as peritoneal dialysis. Mr. Uddin’s family members were worried that with the tube in his abdomen, he could not be turned over to increase air flow and did not see the need for what they believed was unnecessary surgery.
Mr. Uddin received hemodialysis on April 10, a common form of outpatient dialysis. The family said that the doctor in the I.C.U. told them that after a few more dialysis treatments there was a chance he could be taken off the ventilator. But each time they checked in the following days, he had not received dialysis.
NYU Langone-Brooklyn was facing three to four times the usual number of I.C.U. patients, and doctors were working grueling shifts of up to 18 hours a day. The hospital was treating more patients with those specialized machines than ever before, “sharing” one machine between two patients for 12 hours each instead of the usual 24. All with some of the trained dialysis nurses out with Covid-19 themselves.
On April 12, a note in his file called for the specialized treatment “today if available,” but Mr. Uddin did not receive it. He was scheduled for hemodialysis the next morning, but it was held off without explanation. Hospital officials said they made multiple calls to convince the family of the need for the operation.
The Plans Unravel
Family members realized that Mr. Uddin would not receive sufficient treatment without the surgery, and reversed course, agreeing to the catheter operation. Had they understood earlier that kidney care was so scarce that it could be the peritoneal option or nothing, the family said, they would have consented immediately.
Mr. Uddin’s catheter surgery was planned for April 13, but the operation was delayed a day by what appeared to be a miscommunication between the surgical and I.C.U. teams. Still, Mr. Uddin was not given dialysis.
“I was desperate,” said Dr. Rana, the brother-in-law. “I said, ‘You’ve got to get him some dialysis tonight.’”
Mr. Uddin had the surgery on April 14, but his potassium level shot up in the afternoon, cresting at 7.2, the words “Critical Hi!!” in his records. Instead of waiting till morning to start the peritoneal dialysis as planned, it was begun early that evening. Mr. Uddin went into cardiac arrest at 8:15 p.m. and had to be revived.
Finally, the doctors scheduled him for specialized dialysis starting at 9 p.m. Before he could receive the treatment, Mr. Uddin flatlined a second time. Doctors could not bring him back. His time of death was officially declared as 9:01 p.m.
“Jamal Uddin’s life mattered to us and his death mattered to us,” said Dr. Tanzib Hossain, who spoke with Mr. Uddin in his native Bengali before he was intubated and would check on him at night while he was ventilated.
“What is sometimes leading to despair and despondency among some of us is, in spite of our best efforts to do everything possible, patients are dying,” said Dr. Tshering D. Amdo, who oversaw the I.C.U. while Mr. Uddin was a patient.
Fighting their own likely Covid-19 infections, mother and son remained angry with the hospital.
“The only thing I asked was, give us the body clean,” the younger Mr. Uddin recalled. “The tube was still there,” he said, incredulous at the equipment left lodged in his father’s mouth. “They didn’t have the decency to wipe the blood off his cheek.”
He was saddened by the thought that his father would not be there to see him start law school or someday meet his grandchildren. Jesmin and Shehran found solace in a pair of birds nesting in the weeping cherry tree Mr. Uddin had planted, flowering pale pink as they mourned.
“You give everyone an equal chance to survive,” Shehran said. “Instead of proceeding, they decided to take a chance with his life just to give those other people a chance.”
“He was someone who was supposed to come home.”
Katie Thomas contributed reporting.