The patient, sitting on the side of her hospital bed, is one of the few awake in the pod. Many are in medically induced comas so their bodies won’t fight the blue-and-white tubes connecting them to the machines that breathe for them.
Their lungs are too damaged, too filled with fluid and infection, from COVID-19, the respiratory disease caused by the novel coronavirus that has sickened tens of thousands of Coloradans. So they lie unconscious as ventilators pump air in and out of their lungs.
Here in one of the three COVID pods at The Medical Center of Aurora, patients are sequestered behind glass doors and windows. Visitors are scarce. And even on calm days, such as this one in late May, the gravity of COVID-19 is ever-present.
The patient sitting up on her bed is working very hard to breathe on her own. Too hard. The team here will need to help, or she’ll continue to get worse.
So by mid-morning, a respiratory therapist arrives, carrying a red box full of supplies that draws the attention of Breanne Burley, the hospital’s director of critical care.
“Intubation time?” she asks.
In the intensive care unit of this Aurora hospital, many patients need ventilators — the breathing machines that have become a crucial tool in fighting the new strain of coronavirus that’s circling the globe. The decision to intubate a patient is not one that clinicians take lightly, as to do so means to sedate a person and insert a tube down their airway — all while never knowing when or even if they’ll wake up.
The number of patients on ventilators at the hospital peaked at 39 — all but four of whom had COVID-19 — a month ago. But on this day, the staff in the ICU are still caring for more than 20 patients sick with the respiratory illness, and most are on ventilators. It’s a stark reminder that even as Colorado’s coronavirus hospitalizations continue to decline and restaurants and parks reopen, the pandemic is not over.
The staffers working in this pod are still on the front lines, battling a disease for which there is no vaccine or cure. Since their first patient with COVID-19 arrived in early March, they have treated a total of 412 people with the coronavirus in the facility, learning how to work through the uncertainty of the pandemic.
In these past three months, hospital staffers have gained confidence in the treatments they deploy, but have watched even young, otherwise healthy patients struggle to survive. They themselves have weathered their first peak of the outbreak, yet worry about a potential second wave of infections as measures meant to stem the virus’ spread are relaxed.
“Most of us are concerned that there will be little peaks coming up as things open up and we don’t have the same level of social distancing and awareness of the virus,” says Dr. Chakradhar Kotaru, medical director of the ICU. “But it probably will not be as high as it was when the peak first hit.”
“Uncharted waters”
Amy Cooper put on a second pair of blue gloves, making sure there’s no gap between them and the sleeve of her protective gown. The nurse wears a respiratory mask donated to the pod. It’s just slightly more comfortable than the N95 masks her colleagues wear inside patient rooms
Cooper, who began her shift at 7 a.m., is part of the team of nurses, doctors and respiratory therapists preparing to place the patient on a ventilator. Today’s procedure is planned, unlike those a month ago when staff were having to quickly intubate COVID patients one after another.
“Do you need anything before I come in?” Cooper asks a coworker before joining her inside the patient’s room.
“Amy, I’m going to stay, too, and I can be a runner,” says Veronica Duffy, another nurse, as she moves to stand against the wall across from the room.
Once nurses and doctors enter a patient’s room in a COVID pod, they try not to leave until they are finished with their tasks because each time they exit they must change their personal protective gear. So Duffy is there, on watch, ready to grab anything her coworkers inside might need.
Placing a patient on a ventilator carries one of the highest risks of exposure for hospital workers because the intubation can aerosolize virus particles. Because of how easily the new coronavirus can spread, staffers sometimes use clear drapes that they place over patients like tents to act as shields while clinicians insert tubes through mouths and down airways.
“These are kind of uncharted waters,” Duffy says.
Those working in the ICU are used to caring for the hospital’s sickest patients. Yet in the past several months they’ve had to learn how COVID-19 affects people’s bodies and how to treat patients with the disease while responding to one of the most serious viral outbreaks in a century.
The lungs are often the first organs affected by COVID-19, which can cause potentially deadly illnesses such as pneumonia and acute respiratory distress syndrome, or ARDS. But in the months since the first case was confirmed in Colorado, doctors and nurses have discovered the disease doesn’t affect everyone — or all bodies — the same. Kidneys can fail. Blood clots that cause strokes and heart attacks can form. And in children, the virus appears to cause a rare multisystem inflammatory syndrome called MIS-C.
“A challenging part of COVID-19 is that we are still learning as we’re treating patients,” Kotaru says, adding, “It is a surprising disease because it’s not like a typical flu. So it does have other aspects to it that flu does not have.”
The hospital’s location in Aurora means that it’s in one of the state’s hotspots. Of Colorado’s 10 most populous counties, Arapahoe and Adams counties have among the highest cases per capita, with the former recording the highest death rate at 46.7 fatalities per 100,000 people, according to data from the state Department of Public Health and Environment.
In Colorado, more than 25,000 people have tested positive for the coronavirus and more than 1,100 have died from the disease, according to the agency
Many of the patients coming to the hospital, Kotaru says, have been Latino, a population that has not only become sick with the coronavirus at a disproportionately high rate but has also experienced more hospitalizations in some parts of the state.
In late March, as the number of patients increased, the Medical Center of Aurora converted two other areas of the facility into intensive care units to handle the overflow. The post-anesthesia care unit, or PACU, was transformed into negative air pressure rooms for coronavirus patients, while the catheterization lab was used for non-COVID patients. At its peak, there were 50 patients in the ICU, 42 of whom had the coronavirus.
Hospitalizations from the disease have declined statewide in recent weeks. At their highest point, in April, Colorado’s hospitals were treating 888 people for COVID-19. Last week, hospitalizations dropped below 350 individuals, according to the state health department.
As hospitalizations decreased, the overflow rooms in the so-called cath lab closed on May 16 and those in the post-anesthesia unit followed three days later. Now, all critically ill patients are treated in the 38-bed ICU.
“Even though we had talks about where the next patients could go, I would say we were pretty close to reaching our capacity at that point,” Kotaru says. “More also from a staffing standpoint, rather than a treatment of patient standpoint.”
At the start of the outbreak, Colorado health officials warned of a potential surge in COVID-19 patients that could overwhelm hospitals by creating shortages in ventilators and personal protective equipment, or PPE, as it was already doing in hotspots such as New York City.
In such a scenario, it was feared many of the doctors, nurses and respiratory therapists trained to treat critically ill patients would become sick, with healthy workers left to face the difficult job of deciding which patients would receive life-saving care, such as treatment from a ventilator.
So far, staff at the Medical Center of Aurora have been spared from making those difficult ethical and moral decisions. They were able to get more ventilators from other hospitals, health systems and even schools. And during the peak, the workers say, they never faced the shortage in PPE that their colleagues struggled with in other corners of the country.
“I’m blown away by the number of us that have not gotten sick,” says Pike Quinn, one of the respiratory therapists on duty in the COVID pod. “A lot of us want to go see if we have antibodies.”
“It just feels like we’re trying to keep them alive”
In the patient’s room, Cooper explains how severely COVID-19 has damaged her lungs and why the clinicians must take such a serious next step in treatment. The patient, who will need to be sedated, is scared.
“I’m sorry,” one of the two nurses tells the patient, her voice muffled by the glass.
The pair are comforting the patient, Cooper recalls later, reassuring her that the team will watch over her.
“I find it pretty gratifying, to be honest, to know that I can be there to provide that support that someone needs” she says.
It’s tricky treating COVID-19 patients, Cooper says, because when they reach the point where they don’t have enough oxygen, they often don’t exhibit the restlessness, confusion and “air hungriness” that other hypoxic patients experience.
“And they don’t feel terrible, and that’s the strange thing,” Cooper says. “I can’t tell you how many times I’ve heard a patient say to me, ‘But I don’t feel like I need the oxygen. I feel OK.’ But your lungs just aren’t working well.”
Physicians try to determine when to safely place a person on a ventilator, knowing these patients can end up on the machines for weeks — and some may not survive. One example of this occurred early on in the pandemic, as physicians in Colorado’s mountain towns transported patients at risk of becoming critically ill to hospitals at lower elevations, hoping it would ease symptoms, and, just maybe, prevent the necessity of a ventilator.
On this day in May, 18 of the 23 patients with COVID-19 in the ICU are on ventilators. Normally, when treating patients with a ventilator, such as after a trauma or surgery, staff tries to take them off of the machines after two to three days. But with COVID-19, they’re finding people are on the machines for an average of nine days — and some even as long as 45 to 50 days.
Of the 91 COVID-19 patients that the Aurora hospital’s staff have placed on ventilators over the course of the outbreak, 72 have come off of the machines. Of those no longer on ventilators, 34 died and 38 survived.
“I just haven’t seen this many people this sick for (such) a long time,” says Quinn, the respiratory therapist. “Right now it just feels like we’re trying to keep them alive.”
He’s among the team of clinicians intubating the patient. Before he enters the room, Quinn dons a white respiratory hood, which has a blower that pushes air outward from his face to prevent virus particles from getting inside. These hoods are available to staffers unable to get a proper fit on their N95 masks.
Outside, Duffy, the nurse, keeps watch.
“Do you want the tent?” she asks about the drape occasionally used as a shield during intubation.
On the other side of the glass, Cooper shakes her head “no.” Not long after, a coworker gestures at Duffy. The team needs something.
“The Glidescope?” she asks before rushing to find the machine that will allow the clinicians to view the patient’s airway on a screen.
Duffy doesn’t find it in the ward, so she dashes off to another part of the hospital, telling those inside the room, “I’m going to have to go to the main pod.”
Once the machine is found and in the patient’s room, Duffy sanitizes her hands and returns to her spot against the wall, awaiting the next order. It doesn’t take long. Cooper presses her face to the glass and extends her fingers in the shape of an “L.”
Duffy takes off once more, this time in search of a sedative.
“The world has no idea what this looks like’
These days, visitors are rarely allowed in the ICU, a restriction put in place because of how easily the coronavirus spreads. They only come when clinicians need to make important decisions about care, such as end-of-life determinations. They’re so rare that when one staffer spots a pair on a recent day, he remarks, “It’s been so long since family visitation.”
With most families unable to visit the COVID-19 unit, the names and phone numbers of relatives are written on the glass outside patients’ rooms so staffers caring for them can easily call or FaceTime the patients’ loved ones.
It’s a difficult task, especially when a patient has spent weeks on a ventilator and nurses aren’t sure if they’ll survive.
“It’s so hard to convey just how concerned we are and what we’re seeing,” Cooper says, “because it’s just so off the wall that the world has no idea what this looks like for people.”
While the hospital has discharged 80% of all patients admitted with the new coronavirus, the staff recalls losing two to three patients day during last month’s peak. Once the hospital saw six patients with COVID-19 die in a single day.
“The ICU gets that percentage (of patients) that typically don’t make it,” says Burley, the director of critical care. “For the nurses taking care of these patients when they’re ventilated for weeks — that’s what makes it the hardest to continue to push through.”
More than an hour after the intubation began, Cooper emerges from the patient’s room and removes her respirator. Her face is red from marks left by the mask. She puts on a lighter, yellow surgical mask and wipes down the red box of supplies.
Behind her, the patient lies silently as the ventilator pushes air into her lungs, and a stillness overtakes the pod.
