As we endure the spread of the viral plague COVID-19, we fall into two groups. In what might be called the civilian group, we are for the most part staying distant, trying to avoid virus-filled droplets — perhaps even an exchange of air — that can make us very sick, even kill us. We’re walking and talking — unless foolhardy — 6 feet from one another, and trying to stay home.
Then there is the other group, those whose jobs require them to touch and tend the most severely afflicted, trying, with no proven medicine, to make them well. In Arkansas, more than 250 of them have become infected themselves, some in the course of their work taking care of people whose disease is still lurking unannounced, some from inadequate protective wear. As of April 20, one in three were nurses and one in five were certified nursing assistants, licensed health care workers or unlicensed health care workers. Nearly one in 10 were doctors.
It takes mental, physical and emotional strength to tend to patients in critical care. It also takes a measure of courage when those patients have been infected by a virus about which little is known except that it is highly transmissible. It comes with loneliness, as caregivers separate from family to protect them from what may have been picked up in the hospital.
“Right now, I kind of equate it to, if this was a war and I was a soldier,” Elizabeth Sullivan, a registered nurse for 12 years at the University of Arkansas for Medical Sciences, said. “This is what I would be doing.”
Sullivan, 39, is clinical services manager for an intensive care unit but is on the front lines, seeing patients sequestered in the COVID-19 unit because, she said, she would never ask her staff to do what she would not.
In an early April interview, Sullivan described the patients she sees in the all-RN-staffed E4 Medical Neurology Unit, for people with strokes, brain bleeds and other medical needs, including those on mechanical ventilation.
“When [COVID-19 patients] come in, they truly are struggling to breathe,” she said, and intubation is usually necessary. Before the medical team puts a patient on a ventilator, they explain what will happen and try to get a sense of who their patients are. “We try to talk to them, ask them, ‘Tell us your story,’ ” Sullivan said. The nurses explain that they want to be able to help their families as well as the patient, to establish a bond. “We let them know we are doing everything we can,” Sullivan said. “There is a lot of fear. The patients are coming in asking for help.”
Because the risk of transmission of the virus is so high, family members cannot visit the ICU, even if the patient is at death’s door. But there is communication: Nurses and attending physicians call and take calls. “They can ask questions and still participate in the plan of care,” Sullivan said.
The patients may be heavily sedated, unable to communicate, but family members are able to see them: UAMS provided iPads to nurses caring for COVID-19 patients, so families could connect by FaceTime.
The 2014 outbreak of the terrible virus Ebola, which included infections in the U.S., introduced to the nonmedical world the substantial gear medical personnel had to wear to keep from being infected with the hemorrhagic disease. UAMS’ emergency room doctors demonstrated for the press the moon-suit protocol for health care providers: an N95 respirator mask (equipped with a with breathing valve), a plastic face shield, head wrap, gloves, Tyvek suit, surgical gown. The virus never materialized in Arkansas, so the sight of medical providers suited up like astronauts to guard against death remained academic rather than real.
The N95 mask, plastic face shield, headwrap, gown and gloves are back in the time of coronavirus, personal protective equipment that even the layman now knows as PPE. Health care providers coming into contact with COVID-19 patients must wear the uncomfortable gear to protect others and stay healthy themselves, and must change the gear every time their procedures bring them into contact with their patients’ body fluids. Sullivan estimated that the “burn rate” — how much of the disposable gear is tossed — adds up to, on average, six to 10 gowns, six to 10 N95 masks and 20 pairs of gloves a day per person. The lack of such PPE has been an urgent issue nationwide, as the federal government has left the states to fend for themselves in what has been a highly competitive rush for supplies. It was not until April 12, more than a month into the virus’ appearance in Arkansas, that a substantial amount of state-procured PPE — mostly gowns and gloves — arrived, around 15 percent of the PPE that the state is spending $75 million on.
Sullivan said personnel in the ICU have been “getting everything we need for every patient” and there are hourly checks to make sure they’re not short of PPE in the ICU. UAMS has not yet had to resort to sterilizing and reusing masks, as has been the case in New York. “I feel so safe coming into work,” she said.
Nine of the 28 beds in UAMS’ E4 unit are in negative pressure rooms, outfitted to keep air from inside circulating out and into the rest of the ICU. “We have not had to fill them all,” Sullivan said; only five COVID-19 patients were in ICU as of April 22. The beds serve not just COVID-19 patients, but, in the interest of safety, persons displaying symptoms of COVID-19 who have been tested but are still awaiting results. If their tests come back negative, they are moved out.
UAMS had six COVID-19 positive patients who were not in ICU as of April 22, and 17 suspected cases. The hospital’s surge strategy, which included altering the rooms on the ninth floor of the Central Hospital into negative pressure rooms and plans to take over operating rooms, can provide a total of 247 beds strictly for COVID-19 patients should the need arise.
Before she heads to work at 7 a.m. for her 12-hour shift, Sullivan is screened, as is everyone, medical and nonmedical alike, who enters buildings on the UAMS campus. Her temperature is taken and questions are asked about her exposure and travel. The PPE provided to ICU staff allows them to answer “no” to the question about direct contact with a person known to have COVID, though they have certainly been closer than most people.
Dr. Steppe Mette, UAMS Health CEO, said the outbreak in New York has emphasized how crucial a high-functioning team of caregivers is to patients’ survival. “They need to be there for each other, function as a unit,” he said, and to know all the protocols. Difficult days dealing with “the unknown,” as Sullivan called it, has caused lots of tears, she said, but the comfort of a hug is forbidden. Elbow bumps, kicking each other’s feet and walkie-talkies that allow them to talk to one another when separated into patient rooms help keep up morale. “This is just so … this whole situation is nothing anyone thought we’d ever do when we signed up to be a nurse,” she said. “But I can tell you knowing that I get to do this with the co-workers that I have, it makes it so much better.”
Though some who are skeptical of how dangerous COVID-19 is — after all, 80 percent of people infected with the virus become only mildly ill, and some never show symptoms at all — have compared it to the flu, in critical care, it is nothing like the flu, Sullivan said.
Most of the patients coming into critical care have already tested positive. They’ve begun to get into trouble — that happens around week five into the infection, Sullivan said — and at that stage begin to “decompensate” with extraordinary rapidity into pneumonia. “They look like they might be doing well one minute and the next minute so sick they could go into cardiac arrest,” Mette said. Hence the need for early intubation for the very sick, Sullivan said; 90 percent of COVID-19 patients in her unit are on mechanical ventilators.
Patients on the vent may try to fight the machine, trying to take breaths when the ventilator is not. To synchronize their breathing with the machine, they’re sedated and then given a paralytic medicine that creates a coma-like state. Most are given blood pressure medication and some need what is called proning: That is, they’re placed on their stomachs to improve oxygen flow. That takes a “small army,” said Mette — nurses, physicians and respiratory therapists — to flip them on their bellies. “It helps expand their lungs and get those little alveoli to open so they can breathe,” Sullivan said. Proning is labor intensive: Patients can’t be left on their bellies, so the team must turn them back to front, over and over. Proning — and even small things like bathing — can reduce the COVID-19 patient’s oxygenation and blood pressure, so the team has to be vigilant.
“For flu, we don’t have to prone, and most flu patients don’t have to go on the vent. They don’t end up so sick, and they tolerate turns and bathing better,” Sullivan said.
A nurse in the COVID-19 unit is assigned as a don and doff officer (also known as the “dofficer,” Sullivan said) to make sure nurses remember to put on PPE before going into his or her patient’s room. “Sometimes your patient looks like they’re going to go bad, and as an ICU nurse it’s your natural inclination to just run in there” to the patient’s room, Sullivan said. “You can’t do that, or you’ll end up being the next patient.”
It takes about 30 seconds to put on the PPE. When a patient is trying to pull their tubes out or has managed to become disconnected from the breathing machine, that “feels like a long time,” Sullivan said. “Especially when it’s not what you’re used to doing.”
“This virus has really taken us all by surprise, I think, because there are so many things that we try that don’t help,” Sullivan said. “A lot of what we can do is just support them through that, knowing that you are doing all you can, but wishing you could do more.”
UAMS has treated one or two patients with hydroxychloroquine, the anti-malarial drug that President Trump is enamored of, Mette said, but “we’re hesitant because there’s no proof that it works. The evidence for it is slim, and it’s fraught with potential side effects.” The decision to provide any medication, Mette said, is made in discussion with the patient. “The physician must weigh the risks and potential benefits for each patient.”
Hydroxychloroquine is not for patients on life support, nor is it for patients with blood disorders, like sickle cell anemia. UAMS has also treated one patient with tocilizumab, a rheumatoid arthritis drug used to dampen what Mette said was the “exuberant inflammation” caused by the virus.
Using CPR on a COVID-19 patient — chest compressions cause the expulsion of droplets and the process is “risky business,” Mette said — is a challenge that is being discussed at hospitals across the country, and some are considering a do-not-resuscitate order regardless of a family’s desire. “If the likelihood of surviving CPR is remote, to nil, it becomes unethical to put health care workers at risk,” Mette said. And if care is futile, he said, why put patients through it? Mette said he hoped that UAMS would not be confronted with such a challenge.
The average stay for COVID-19 patients in critical care is about two to three weeks. Recovery time at home is “pretty considerable,” Sullivan said. “Their lungs are very very sick.”
As of April 22, UAMS had treated 34 patients and sent home 23. Three died. None who were released needed to be readmitted.
Medical personnel treating COVID-19 patients are quarantining themselves from family; isolating within the home is too risky. Some, Sullivan said, are staying in campers on their property so they can watch their children play in the yard.
“One of our nurses, he has twin girls and they’re like a year old, and he hasn’t seen them in three weeks,” Sullivan said. Mother and twins have gone through UAMS’ drive-through screening to bring him lunch. “He really struggles. It’s very emotional,” she said.
Still, she said, “morale is really high right now.” She’s not seeing any burnout. “It could be a possibility, but everybody is doing really really good.”
When Sullivan goes home, it’s to an empty house. Her husband and two children moved in March to a house on Lake Ouachita, near other family, and “they even took the dog,” she said. They stay in touch with “lots of FaceTiming,” she said: “They tell me every day how much they miss me, that they’re proud of me and that they love me.”
Sullivan’s son is a senior; he will have no graduation ceremony. Her daughter will have to celebrate her 14th birthday in April without her mother. “It’s hard, but it’s a short-term inconvenience for something that could save their life,” Sullivan said. She will stay away from family until the crisis is over.