Hospital heroes

What life is like on the front lines of the pandemic

While the rest of us sheltered at home to buy them time, pitching in where we could, and maybe taking part in salutes to them every evening at 7, frontline medical workers have been putting their health on the line to fight a highly communicable disease. BOSS spoke with three of them who have different specialties and from different parts of the US to get a sense of what life has been like inside hospitals. Dr. Christopher Barrios is a pulmonary disease and critical care specialist at Saint Louis University Hospital. Dr. Naveen Kukreja is an anesthesiologist and ICU doctor at the University of Colorado Anschutz Medical Campus in Denver. “Claudia” is an emergency room nurse in the Boston area, one of the hardest hit metropolitan areas. BOSS granted her anonymity for fear of retribution for speaking out.

Diagnosis

One of the trickiest things about COVID-19 has been recognizing the symptoms. In some people, it presents as a classic respiratory illness called Acute Respiratory Distress Syndrome (ARDS), Barrios said.

“But we have had people test positive that did not have any respiratory symptoms. I’ve had people come in with abdominal complaints, get a CT scan of their belly—which usually catches the lower lung fields—and have the lower lungs be abnormal, and they test positive for COVID-19,” he said.

In other cases, patients have presented to the hospital with diabetic ketoacidosis (DKA) without respiratory symptoms and tested positive for COVID-19. Typically, people with diabetes presenting in DKA have a pre-disposing factor such as infection or medication non-compliance that causes their blood sugar to become elevated.

“If you can’t really find a reason for DKA, you start to wonder, ‘Is there something else?’” he said. “What we are seeing is that the diagnosis of COVID-19 is sometimes difficult to make because its presentation can be variable.”

If you’re one of those who thought—or still thinks—COVID-19 is just the flu, you’re not alone. Claudia even thought so initially.

“When it first started, I was on that bandwagon of, ‘It’s probably going to be just like the flu. It isn’t going to be that big of a deal,’” she said. “But then when we actually saw these patients come in, it’s like nothing I’ve ever seen.”

Usually if someone is not getting enough oxygen, you can tell right away. The person is panicked, sweating, can’t speak in full sentences, has a high heart rate. When COVID-19 patients began coming into the hospital, Claudia said, a woman in her late 30s came in.

“I’m just thinking someone who is short of breath obviously looks short of breath. I’m thinking, ‘She looks fine.’”

The woman got off the stretcher, walked into a room in the ER, and set herself on the bed.

“I put her on the monitor and her oxygen is at 70%. A normal oxygen saturation is 95-100. You want it above 90 ideally. She didn’t look like she was struggling to breathe, but when you stop and you look at her, you realize she’s breathing at 45 breaths a minute,” Claudia said, noting that 12-18 breaths per minute is a normal range. “We’ve had to learn a different way. They just don’t look like someone that is very sick off the bat, and they’re the sickest patients we have.”

The woman died in the ICU.

Treatment & Recovery

To make sure their patients are getting enough oxygen to their organs, hospital professionals often intubate them to support their breathing. They’ve found that in certain cases of COVID-19, early intubation may not be necessary.

Instead, Claudia said, they’ve been giving them as much supplemental oxygen as possible. They’ll give patients who can breathe on their own a nasal cannula—a breathing tube with extensions that go in the nostrils—and a non-rebreather facemask and flip them on their stomachs.

Kukreja said that after initially intubating most COVID patients whose oxygenation was deteriorating, they started to trial a different approach. “We started saying, ‘Wait a minute, we’re accumulating a lot of intubated patients really fast.’ It actually got to the point where we were testing our ventilator supply,” he said. “Then we started asking patients to prone themselves before resorting to ventilation because the reason it works, it would still work even if you weren’t on a ventilator. A lot of patients who did that were able to avoid intubation. It’s unclear if the prone positioning helped. This strategy needs to be appropriately studied, but it didn’t seem to hurt.”

Barrios explained that prone ventilation, the practice of flipping intubated patients with ARDS on their stomachs, leads to more homogenous aeration of the lungs in ARDS thus improving gas exchange. That technique has been studied since the 1970s. “What is different about our current situation is that we are asking awake, non-intubated patients with COVID-19 to lay on their stomachs as a way to improve gas exchange and oxygenation,” he said. “This practice should be studied in a large randomized controlled trial, but anecdotally it seems to help some patients with severe respiratory symptoms and COVID-19.”

For those patients who do recover, the immediate aftermath depends on how sick they were to begin with. Some are doing pretty well after they leave the ICU, Barrios said, though they might require supplemental oxygen for some time after leaving the hospital.

“For the people that present with acute respiratory distress syndrome due to COVID-19 and are intubated for a prolonged period that we say have critical illness, those people have a much longer post-hospital course to undergo,” he said. “They have to have rehab, a lot of times they’re not going to be able to go home right after hospitalization, they’ll have to go to a rehab facility, undergo physical therapy.”

UC Anschutz’s Department of Infectious Disease was able to get some patients enrolled in a number of drug trials. Among the drug treatments tested depending on the patient have been the Interleukin-6 inhibitor sarilumab (commonly used to combat inflammation) and remdesivir. The Department of Pulmonology in conjunction with the Department of Emergency Medicine was able to enroll some patients in a trial looking at the efficacy of hydroxychloroquine. What he sees most often used now are remdesivir and convalescent serum, made from the plasma of patients who have recovered. At this time, however, there is no conclusive data regarding the optimal therapeutic approach to treating COVID-19.

Isolating the Virus

Because of how contagious the novel coronavirus is, hospitals are cautious about protecting staff and other patients. Barrios and his fellow attending physicians rotated seven days in the ICU and seven days out of the hospital during the height of the pandemic in St. Louis. On the days he works from home, Barrios has video telemedicine visits with patients. If he suspects they have COVID-19 and instructs them to go the ER, he calls the ER and infection control to alert them. Staffers at the ER meet the patient outside, put a mask on the patient, and escort them in via a special entrance. The patient will be placed in a negative pressure area that keeps air inside from flowing out to where other ER patients are, and tested for COVID-19.

SLU hospital set off two ICU floors for COVID patients only. Once patients are deemed negative, they move to another ICU floor. On the COVID floors, rather than doing rounds bedside with residents, some attending physicians have opted to do table rounds with the team and later examine the patients themselves decked out in personal protective equipment (PPE).

Claudia said there are only two entrances open at her hospital. Patients with appointments in clinics go through the main entrance and have their temperatures checked and must wear a mask. Visitors are not allowed. Patients who can walk to the triage entrance first go to a tent outside the ER. If their oxygen levels, blood pressure, and heart rate are OK, they go to an office that has been converted into a triage unit. There they are tested by swab and treated as long as they’re stable. If they’re not stable, they go straight from the tent to the ER without stopping, in order to prevent the spread of infection. For non-COVID emergencies, patients are cleared and sit in the waiting room until they can be seen.

Kukreja said at the crest of the wave in Denver, his hospital had five surge teams treating about a dozen patients each. They have since reduced that to three teams covering up to 16 patients each. Test results that used to take days now take a few hours. Operating rooms are opening up for non-emergency and elective surgeries.

Protecting Staff

For frontline personnel, PPE is extremely important. Barrios has his own reusable P100 mask with ventilators on either side. If he’s on a COVID floor, he also wears goggles and a face shield that the doctors share and clean.

“When I go into the patient’s room, I also have to wear the gown and gloves, shoe covers, hair net. In between rooms I take off the gown, gloves, that kind of thing and throw that away, but the rest of the stuff I keep with me,” he said.

Residents and fellows who receive new patients after-hours when an attending is not in the hospital have appropriate equipment, Barrios said, praising the preparation by the ICU director and assistant director. That St. Louis was not as hard hit as other places such as Chicago and New York City has helped.

Though ski resorts in Colorado were an early hot spot, Denver itself had seen fewer than 5,000 confirmed cases and fewer than 300 deaths as of May 20. Kukreja said the university was able to facilitate some personnel to purchase PPE they personally wanted above and beyond what is already being provided.

“A lot of us bought reusable P100 masks. They filter more than N95 masks. That really took a lot of the PPE questions off the table,” he said. “If I go into a patient’s room, I put on my own personal one that I bought.” Otherwise he wears an N95 mask that is exposed to UV light after each shift and reuses it a few times. “We were cautious about how (PPE) was distributed. But I never once ran into a situation where I needed something PPE-wise and did not have it.”

While noting that her hospital has been more fortunate than some others, Claudia said PPE has been an issue. She gets one N95 mask—designed for one-time use—per 12-hour shift. When intubating, swabbing, or putting patients on breathing apparatus, the ER staff will put a surgical mask over the N95 mask because those activities can send the virus airborne and onto the PPE. They ran out of shoe coverings. They ran out of gowns, so they have taken to wearing makeshift gowns made from nylon. While they applaud the effort on the donors’ part, the reusable gowns aren’t the most comfortable.

“They’re really cumbersome, They’re gigantic. They just don’t really fit well. It’s like having six trash bags on you at once. It’s just so hot,” she said.

Wearing an N95 for so long makes a mark on their faces. “When you’re using it over and over again, the elastic becomes really stretched out, so we’ve been tying our elastics into knots. By doing that, you’re pulling your mask much tighter and closer to your face and you’re getting a lot of breakdown and red, raw noses.”

‘It’s Still Going On’

Barrios said on May 5 that Missouri had seen a downward trend in deaths, and so plans were being made to restart other medical procedures at his hospital. “I think it’ll probably happen in phases,” he said. “What happens is you stop doing elective surgeries and then those elective surgeries start to become urgent. So I think those are the ones that’ll be started up first.”

Since then, however, that downward trend has gone up. He said as things open back up, the hospital staff expect another peak in June, though they hope not as high as the first wave. He recommends that people remember we are still in a pandemic, and even as places open up to stay 6 feet apart, avoid crowded places, and wear a mask in public.

“It’s still going on,” he said. “It’s not OK for life to go back to normal. It won’t be back to normal for quite a while.

“The reason we did this is that if we didn’t, the spread would have been such that it would have overwhelmed the healthcare system. We already saw some overwhelming of the healthcare system in New York and in Italy and Spain. It’s not something you want to see all throughout the country or the world. There are people dying because COVID is a deadly disease and we don’t have any good treatment for it yet, but what you really don’t want is people also dying because hospitals lacked healthcare resources.”

Kukreja doesn’t want to speculate, but he is optimistic that any uptick in cases as states reopen will not be worse than the initial surge. “Human behavior has changed,” he said. “If you walk outside, if you go the grocery store, if you go to pump gas, people are behaving differently.”

How You Can Help

Because COVID-19 has affected communities differently, Claudia understands that it can be hard to see the benefits of shelter at home orders and continued social distancing as restrictions ease. Not only have different parts of the country had a worse time, but poorer communities suffer more than well-off ones.

“Your actions have consequences for other people who maybe have pre-existing medical conditions—or even don’t—and could catch something that you don’t realize you have,” she said. “No one wants this. Trust me, I want everything to go back to normal. I want everything to go back to the way it was, but it’s just not going to happen right now. I think if people just follow directions and do what they’re supposed to, we could stay on top of this thing a lot easier. Wash your hands. Keep your hands off your face. If you’re sick or symptomatic, stay home, do not go out. If you feel like you can’t manage your symptoms at home, then go to the emergency room.”

Kukreja agreed that simple steps can make a big difference. “If you’re sick, stay home. If you’re feeling ill, stay home. If you’ve had recent sick contacts or you know somebody with COVID, get tested and consider self-isolating if it’s appropriate,” he said. “Otherwise, if you’re feeling well and you don’t have any reason to believe you were exposed or infected, wear a mask in public, wash your hands frequently, try to avoid crowded areas, and maintain your social distancing.”

As Mattel has recognized with its new line of action figures, these frontline hospital workers are the heroes of the COVID-19 pandemic. But there are things everyone can do to respect their contributions and ensure shutdowns don’t return. Yes, things are reopening and we hope the worst is over, but the coronavirus is still dangerous. We’re not out of the woods yet.