Learning their stories: Hear from those treating COVID-19

 

The calm between the storms

Bellevue Hospital was in utter chaos.

The halls in March buzzed with announcements, paging respiratory therapists who raced from room to room, intubating those struggling through the worst of COVID-19. 

In a hospital where most patients usually had their doors open so doctors and nurses could pop in to check on them, the doors now stayed shut. The N95 masks were all but gone, and surgical masks and face shields were running low.

The dwindling supplies startled Celine Gounder, a physician who serves two-week rotations at Bellevue in between her teaching duties. She had battled the Ebola virus in Guinea, and even there, in one of the poorest nations on earth, she always had enough equipment.

“I never felt in West Africa like there was a PPE [personal protective equipment] shortage, at least for me,” Gounder said. “Later in the response, that stuff was under control. Whereas we’ve definitely had those issues around this time with COVID.”

But that was then, when New York was registering 5,000 to 10,000 new COVID-19 cases a day. That number has plateaued, and while the city’s economy remains shuttered, Bellevue feels a little saner.

Gounder returned for her latest rotation in early May. Now, the walls in the hallway connecting two wings where she gets to check out an N95 mask three times a week are plastered with cards from patients who have recovered from the coronavirus, layered between homemade posters labeling doctors and nurses heroes.

“It’s still a COVID hospital. Of the patients I have on service, only one or two doesn’t have COVID. It just feels more controlled,” Gounder said. “We’re in a much better place now.”

There are tambourines now, and maracas, cheering the patients who have recovered and who can leave. Instead of urgent pages over the intercoms, Jay-Z’s “Empire State of Mind” plays when a patient is discharged.

But she knows the virus still menaces her city, and that when restrictions on business and movement are eventually lifted a new wave will hit. 

“We’re well aware that we’re going to have another wave of COVID in the fall, and that’s going to be on top of the flu. It’s hard to prepare totally, for example staffing schedules, because we have no idea when it’s going to hit,” she said. 

 

 

Protecting elders where it matters most

Heather Kovich leans into the car that has just pulled into the fever clinic set up in the parking lot of the Northern Navajo Medical Center. There are seven people jammed together, all of whom took the 50-mile journey to get here.

“I know. We’re supposed to be 6 feet apart, but this was the only way to manage today,” says the driver, who is ill. One passenger, who has already tested positive, is growing increasingly short of breath, Kovich wrote in a commentary published in the New England Journal of Medicine. The grandmother coughs when Kovich swabs her throat, and Kovich envisions the viral particles swirling around her protective gown.

The doctors and nurses working to care for the Navajo residents in and around Shiprock, N.M., arrive at 7:30 a.m., when the night shift briefs them on the patients who have taken a turn for the worse. They have admitted 130 people to this tiny hospital, 22 of whom are still there. The worst cases are airlifted to Albuquerque for more intensive treatment.

The residents of Navajo Nation have been hit particularly hard by the coronavirus, which began spreading months ago. They have adapted to a world of social distancing and isolation, something entirely foreign to a community that is close-knit and reveres the family unit.

“It’s 180 degrees from our traditional and cultural teachings where ceremonial life is structured around the family and coming together,” said LaWanda Jim, a physician and head of internal medicine who has been practicing in Shiprock for seven years. “There’s definitely a resilience, not only in the staff but in the people and our community across Navajo, not just in Shiprock.”

It falls to Chris Percy, the hospital’s director of community health services, to monitor the other 600 confirmed coronavirus cases around the community, those who are well enough to try to beat the virus at home. His usual strategy for combating a public health crisis is to convene a community meeting. That can’t happen now. He spends most of his days on the phone, checking in.

“We’re following all of them and their families with daily phone calls, home visits when they need it, those with food insecurities, we can deliver food to them,” Percy said. “About one out of eight people walking around, driving around is positive, so that’s community transmission. It’s not an uncommon thing anymore.”

Percy’s days begin before dawn when he logs on to the hospital’s laboratory site to see who else has tested positive. Almost every day, he sees someone he knows on the list. He watched, helpless, as a co-worker in the office next door got sick, was sent to the hospital at the University of New Mexico and died.

His days end late at night when he calls those who have tested positive. Each call can last an hour or more as he soothes patients terrified of the disease that has claimed so many of their family and friends.

“Part of the challenging thing with this is sitting with so many families as they’re coping with loss and grief of something they don’t understand and frankly we don’t understand all that well,” he said. “I’m not seeing any light at the end of this tunnel. I know it’ll be there, but I don’t see it yet.”

But the Navajo know their history. They know about ancestors who struggled through the 1918 Spanish flu, the other diseases that have hit them and other Native American tribes at hugely disproportionate rates compared to the rest of the population.

“From the traditional standpoint, when there’s illness or sickness coming around, our elders tell us stay at home, protect yourself, protect your children,” Jim said. “That’s how we’ve survived in the past.”

 

 

The first epicenter

Nimalie Stone had just returned home to Atlanta from a conference when her phone rang on a Friday night in late February. A patient at a nursing home outside of Seattle had tested positive for the coronavirus. 

By the next day, she and a team of her colleagues from the Centers for Disease Control and Prevention (CDC) were on a plane to the other side of the country.

Over the course of her career, Stone, the CDC’s lead epidemiologist overseeing long-term care sites, has witnessed a substantial change to the way nursing homes operate. They were once homes, places where older people moved in and lived their lives. They are now more transient, skilled nursing facilities where patients from hospitals come to rehabilitate, recover and heal before they can safely go home.

Stone was concerned about that evolution as the coronavirus began to spread: More people moving in and out means more opportunities for a virus to invade a community, especially in a community defined by older people, many of whom had underlying conditions that make them even more at risk.

“I remember thinking I had already worried a lot about what would happen if COVID had been able to get into our community more substantially than we were trying to contain through all of the travel restrictions and all of the observations of people who were returning,” Stone said in an interview. “Long-term care populations by definition are all of those people with all of those risk factors.”

By Sunday morning, Stone and a colleague from Seattle-King County Public Health pulled into the parking lot of the Life Care Center of Kirkland. She expected a quiet reception, but it seemed the entire team had showed up — from administrators to nurses who cared for the residents.

“You could tell it was all hands on deck,” she said. “They were like soldiers. They were there from 5 in the morning until midnight, past midnight. Every case, every individual was important to the staff to support them, to figure out how to protect their families and educate everybody, monitor and track them.”

More residents became ill. So did the facility’s medical director. Dozens went to the hospital. At least 37 people connected to Life Care have died. News cameras hovered outside, nurses held up sheets over residents who were being transferred to ambulances to protect their privacy.

The stigma has extended even to those who have not gotten sick. A staff member told Stone his roommates wanted him to move out. Others were asked to leave stores.

“It’s a small community, and people know one another. It was heartbreaking to hear that,” she said.

But new nurses kept showing up, on loan from other Life Care facilities or even on their own time. As her list of long-term care facilities with confirmed cases in the Seattle area grew, Stone found less time to spend at the Kirkland facility. On one of her last days, she asked one volunteer nurse who had been working 16-hour shifts how she was holding up.

“Well, I’m exhausted,” the nurse told her. “But I’m here. I want to be here.”

 

 

The speed of deterioration

The world has learned about the coronavirus and the way COVID-19 attacks the body faster than any other new pathogen in modern history. But scientists have also learned just how much they have left to figure out.

Rick Lucas, a critical care nurse on the rapid response team at Ohio State University’s Wexner Medical Center, has learned just how little time it might take for someone to deteriorate.

When an inmate from a state prison was transferred to Lucas’s ward, he looked just a little bit off, just a little bit short of breath, breathing just a little faster than he should. Lucas watched in real time as the patient’s condition spiraled.

“Just in a few minutes, he went from needing a little bit of oxygen, two liters, which is pretty common in the hospital, to needing a non-rebreather,” Lucas said. 

The man was almost certain to end up on a ventilator, so Lucas called the anesthesiologist, who would administer the drugs to put him under so he could be intubated. The anesthesiologist couldn’t have been more than 100 yards away.

“Just in the minute or two it took anesthesia to get there, the patient was telling us he would rather die than wait any longer. And that whole thing unfolded over a 10- or 15-minute period,” he said.

Based on what Lucas had seen, the man had about a 1-in-5 chance of ever coming off the ventilator.

Across the nation, thousands of prison inmates have come down with the coronavirus. It is such a threat to those living in confined spaces, for whom social distancing is not an option, that some governors have ordered inmates released early. For those who remain behind bars, fear stalks them.

“They’ve been through so much trauma in what they’ve seen in the prisons, being in a cell with someone who isn’t getting taken to the hospital until they’re near death. They’re really terrified,” Lucas said. 

At the end of his nightly shift, Lucas changes into the pair of shoes he keeps in the trunk of his car. He meets his wife, a respiratory therapist also caring for COVID-19 patients, back home. Their children have been staying with Lucas’s parents for almost a month.

“We’re thankful to have technology to FaceTime and all of that, but it’s really hard on them,” he said. “We just don’t have a better way right now.”

 

 

A drumbeat of death

The Thursday afternoon that the first coronavirus case showed up at Howard Sandau’s hospital in Brooklyn, the entire team gathered around as they tried to resuscitate a man whose oxygen levels were plummeting. 

Ten days later, all 14 beds in the hospital’s intensive care unit were full of COVID-19 patients. They blocked off four more rooms as a new isolation unit, rooms that filled almost immediately. Another 10-bed ICU a few floors up was full, too.

Soon Sandau, an intensive care nurse for 14 years, found himself training colleagues to help handle the load.

“We started buddying up with each other, the nurses that were not ICU with the ICU nurses in order to give them a crash course in intensive care,” he said. “It was probably one of the most critical decisions that we made during this entire pandemic because we were able to very quickly create these new units, give training to new nurses.”

But soon, the hospital started running low on personal protective gear. Nurses were told to use their N95 masks until they were soiled.

“We conserved, and we conserved cautiously,” he said. Eventually his union, the American Federation of Teachers, spent $3 million in union dues to buy their own PPE for members across the country.

The days dragged on, the shifts seemingly endless, each one ending in exhaustion and alcohol wipes, cleaning the steering wheel in his car on the way home. But the crush of patients wasn’t letting up. 

“I’ve seen people die, but I’ve also had an amazing career of saving lives as well, from people coming into my ICU so critical that no one would ever expect them to survive and have them walk out of our unit,” Sandau said. “With COVID-19, it wasn’t happening for many, many weeks. We were losing patients. The patients on ventilators were not surviving. We had to prevent families of patients on ventilators from coming in to spend time with them.”

“When you’re used to maybe losing one person every couple weeks to three weeks even, and then you go into work and you lose five people in a 12-hour shift, that’s unbearable,” he said.

Even now, as the worst of the crisis passes, Sandau is preparing for the next wave. He cannot understand the people who are increasingly stepping outside, many of them without masks. He wants to tell young people who think they won’t experience the worst about the 26-year-old man with no underlying conditions who died.

“I hear out my door, out my windows, people clapping every night at 7 o’clock. In my mind, I’m wondering what that really means if we have people walking around with no face mask on and not social distancing,” he said. “It makes me feel appreciated and acknowledged, but when I see the same people walking around my neighborhood with no masks on, it’s like, really?”