The pandemic in the ICU: An Intensive Care Unit under siege in the time of novel coronavirus
On March 15, a 50-year-old man who’d been feverish and coughing for the previous 10 days arrived at Providence Little Company of Mary Medical Center’s emergency department. His wife dropped him off at the entrance and by the time she’d parked, hospital workers had already taken the ailing man inside.
Doctors were on the lookout for novel coronavirus cases, but as yet had little idea what exactly they were looking for. At that point, there were only 69 confirmed COVID-19 cases in LA County. Most were people who’d recently traveled abroad or had been in close contact with somebody who had. This patient, whose name was Ramon Zuniga, fit neither criteria.
He was admitted to the regular hospital unit for treatment with antibiotics and oxygen. Zuniga had no underlying medical conditions, and so when his condition rapidly worsened, it caught everyone’s attention.
What was happening to him wasn’t usual. His ability to breathe was drastically deteriorating. Within 24 hours, he was transferred to the ICU and put on a ventilator. Doctors had tested Zuniga for COVID-19 the day he arrived. On March 16, the results came back from the LA County Department of Public Health. He had tested positive for the virus.
Dr. Anita Sircar remembers holding the report in her hands and taking a long look.
“This was it,” Sircar said. “It was here. And we proved it was here in our hospital. And now we were going to have to learn how to be COVID doctors and nurses in real-time. There was no more time to prepare. It was here.”
The siege begins
On March 8, Kathy Welch, an ICU charge nurse at Providence Little Company of Mary, ran in the Los Angeles Marathon. More than 27,000 people from 78 different countries participated. A month later, Welch remembered the marathon as if it had occurred in another decade.
“You know, that was the last large scale outdoor event,” she said. “I wonder how many people got infected from that?”
Welch was about to embark on a marathon of an entirely different sort, a global medical emergency that would, over and over again, fill her ICU with patients infected by a virus a ten-thousandth of a millimeter in diameter, capable of mortally attacking a human body in wildly unpredictable and seemingly malicious ways. Welch and her colleagues at the 28-bed ICU unit at Little Company of Mary were accustomed to unpredictability and to extremes — heart attacks, strokes, and all the worst accidents that befall human lives — but what they were about to experience was beyond anything they could have imagined.
Registered nurse Lindsey Burrell remembers seeing the novel coronavirus as an enlarging blip on the radar in January, February, and early March. The medical center had begun staffing and equipment preparations, but they’d seemed like “what ifs” for a worst-case scenario, Burrell said. On March 16, the day Zuniga’s test came back positive, LA County issued its Safer At Home order. By the time Governor Gavin Newsom issued a Stay at Home order for the entire state, on March 19, Burrell began to grasp the enormity of what was happening.
“It really struck me, ‘Okay this is much bigger than we had anticipated,’ even though we watched the news the last couple of months prior to that,” Burrell recalled. “It became apparent this was going to affect us more than any of us thought. I thought this was just going to be the run-of-the-mill virus, kind of like the flu, N1H1…you know, see a little bit of it, and it will be okay. I thought a lot of the disaster planning was just a worst-case scenario. But I had no idea ‘til pretty much a week later that this virus is not only much bigger than all of us, and much bigger than anything we’d ever seen, but it was very different.”
More and more cases began arriving in the ICU. By the last week of March, the ICU was in full-blown pandemic mode. Early that week, highly symptomatic patients were admitted, but the backlog in testing meant some results would delay confirmation of COVID-19 for up to a week. At the same time, the Center for Disease Control (CDC) guidelines for those eligible for tests kept changing, as did its guidelines for Personal Protection Equipment (PPE). This increased unpredictability within every ICU.
“Patients are sitting there and we’re assuming that they’re COVID, but then the criteria had to be met to be able to test them per CDC guidelines,” Burrell said. “So there is confusion on should we wear PPE, should we not wear PPE? Some had these symptoms, or they knew someone who traveled overseas, so then they were at heightened risk and we swabbed them…Then there was a whole handful of these patients who were symptomatic who didn’t meet the criteria and then suddenly it was like, ‘Oh, okay. Well, how do we protect ourselves?’”
“We were in unchartered territory,” Welch said.
Then there was the issue of the symptoms themselves, and the unique trajectory of their impact on each patient.
“Their symptoms were unlike anything we had seen,” Burrell said. “They would do fine for a few days — and this still applies — maybe they’d be on a little bit of oxygen support. Some had these weird fevers, some didn’t have fevers, and then they would have a chest X-ray and then no more than 10 to 12 hours later they would tank — you know, go on full oxygen support, gasping for air, coughing uncontrollably, severe fever, body aches and then would end up emergently intubated.”
Welch remembers witnessing the disconnect between public perception of the nature of COVID-19 and what she and her colleagues were seeing in the ICU.
“At first, on the news, when it was coming out, it was, ‘Oh it’s affecting older people and other people with underlying health conditions more rapidly, the younger people aren’t getting affected,’” Welch said. “Well, that’s not true.”
What they were seeing in the ICU as more COVID-19 cases were treated was increasingly baffling.
“It was over a period of time we were learning,” Welch said. “What struck me and most of my colleagues was that we don’t know what we don’t know. It was a very humbling experience, but we realized that we just don’t know, so we are going into this not necessarily blind but we are going into this — we don’t know what we are up against. And that was unsettling for a lot of people. Some people in the news were like ‘Oh this is just like the flu. Why don’t they talk about how many people we lose every year to the flu?’ And it was like, ‘No. This is different. This is not just the flu.’ This is something we are seeing that hits young people, older people, middle-aged people. And then, as it’s gone on, you’ve got perfectly healthy people with no pre-existing health conditions die within days of contracting it.”
COVID-19 wasn’t like the flu and it wasn’t like any other virus anyone had ever seen. Dr. Sircar, who is an infectious disease specialist, spent the last two decades of her life studying and treating viruses. But even she had to begin again with the novel coronavirus.
“One of the things people have to understand is that this virus is only three months old,” Dr. Sircar said. “So the understanding of this virus is all happening in real-time as we try to treat this virus. All of us doctors and nurses and scientists and public health responders are working on this at the same time we are learning about this virus. So that makes it even more challenging.”
The overwhelming public perception of COVID-19 is that it is a disease of the respiratory tract. And while respiratory problems are one of the disease’s most prevalent impacts, COVID-19 has revealed itself, over time, as much more complex than just viral pneumonia. COVID-19 can cause kidney failure and blood clots that block the flow of blood to the heart or brain. While the novel coronavirus has shown itself particularly adept at attaching to the cells of the respiratory tract, it can also act on the cells of the liver and other organs; significantly, this invasion sometimes happens without being detected, both because the virus’s incubation period is up to 14 days and because COVID-19 can be present without symptoms. In some cases, the virus is even able to move within a body without provoking an immune response. Then, when the immune system is finally engaged, it goes into hyperdrive and the patient crashes. This complexity in how COVID-19 “presents” results in uncertainty from each patient to the next.
“We usually have an idea of what to anticipate,” Dr. Sircar said. “We can say this is probably going to be 72 hours on the ventilator, this is how I’m going to do the antibiotics, this is how I’m going to taper off the medicine. I’m going to get them discharged, and they’ll probably go to rehab for a few days. It’s very formulaic, and you can tell by your patient: ‘Oh this is a 28-year-old. They are going to go home in seven days.’ ‘This is a 70-year-old; they are going to go home in two weeks.’ You know this because you do it over and over and over again. With this infection, with this virus, it’s a moving target. We have no idea how it’s going to land. And so we have to brace ourselves for which turn it’s going to take next.”
Burrell was likewise struck by how quickly those turns occurred with COVID-19.
“These patients who were in their forties and fifties, some with no past medical history, were turning and knocking on death’s door, quite literally, within minutes of being intubated,” Burrell said. “I can’t emphasize enough that it was unlike anything I’d ever seen before. That’s when things really changed, at the end of March. It has drastically impacted our lives since then.”
A doctor’s story
Dr. Sircar found herself in the middle of a pandemic in her hometown after a career spent chasing infectious diseases around the world.
Sircar, whose father was an orthopedic surgeon in Torrance, completed her MD and Masters in Public Health with a specialty in Tropical Medicine and Hygiene at the prestigious St. George’s University Medical School. She completed an infectious disease fellowship at UCLA-Cedars Sinai and in 2005 began her career with Doctors Without Borders. Over the next decade, she was a part of several outbreak response teams in Suriname, Bangladesh, and throughout Africa.
“I was in Guinea for the Ebola response, I was in Angola for a yellow fever outbreak,” Sircar said. “Before that, I was with Doctors Without Borders in South Sudan in a refugee camp where there was a malaria and acute waterborne diarrhea outbreak in women and children refugees in South Sudan.”
Sircar was drawn to infectious diseases as means of practicing what she describes as a “portable specialty” that would allow her to travel all over the world and not be confined to the medical environments of First World countries.
“For example, a cardiologist would need a cath lab, or a nephrologist needs a dialysis unit or a pulmonologist needs ventilators to do what they do,” she said. “But infection disease specialists, all we really need is our stethoscopes and our wits about us and we can go into any country in the world and do what it is we do.”
Sircar was attracted to investigating neglected tropical diseases, parasitic infections, malaria, and cholera, all of which mostly occur in the developing world.
“These are infections that are easily treatable and easily preventable if the infrastructure of public health is done efficiently and correctly,” she said. “And so when you think about infectious diseases, people don’t have to die from them. You could have vaccines that can prevent overwhelming disease, and you have antibiotics that can treat people, and they get better. So as a med student or as an intern, when I would see cases come in with really bad pneumonia and the chest X-ray looks terrible and then we give them antibiotics and seven days later the chest X-ray is clear and they look better and they went home to their families and they lived their life — that was winning the lottery for me. That was the best feeling, for people to get better and go on. And so I was like, okay, I can do this.”
Like most of those drawn to the field of public health, Sircar also saw it as a way to make the biggest impact, the best way to truly serve.
“There is no ‘I’ in public health,” she said. “There is an I, but I always say it’s after ‘U’, so it’s everybody else. It’s the whole community that you are trying to protect all in one blow. And for me the other sort of crazy thing about infectious diseases is that it will always for the rest of my life be sort of a worthy adversary. Because most specialists are specialists in one organ system — just the eyes, just the heart, just the lungs. Infectious diseases are every system all the time, parasites, viruses, bacteria — you never know what’s going to come in through the door, and it always surprises you. You have to be sort of a systemic doctor.”
Sircar had reached the pinnacle of public health in serving with the CDC, which she joined in 2015 specifically to be part of the Ebola response.
“Because that was a rare neglected tropical disease that hardly got any attention, and as an infectious disease doctor I studied it but I never got to see a case until I actually went to West Africa,” Sircar said. “To see people get the right vaccines and the right antibiotics at the right time and watch their lives be saved is everything that any doctor would ever want to see happen.”
Sircar only returned home last year because her father had passed away and she felt it was her duty to look after her mother. She was serving as a consultant when the novel coronavirus arrived in the United States. She’d been tracking the virus since the outbreak in China appeared in the news in early January. By February, in the middle of the influenza season, she was already suspecting some of her patients could be infected with the novel coronavirus.
“I was thinking, ‘Could what we are seeing be a mixture of both? Or is it too early to say there is anything like community transmission?’” she recalled.
By February 29, after cases were confirmed in Washington state, she knew the virus was coming here.
“It is more a question of when it will come and not if it will come,” Sircar told Easy Reader at the time. “But this is not a reason for alarm, but a call for preparedness.”
Less than a month later the pandemic had turned American life upside down. After decades of traveling around the globe in order to treat outbreaks, Sircar was facing the biggest adversary in medical history while living with her mother in Palos Verdes.
“My mom was like, ‘Were you so bored? Did you make this pandemic happen?’ How did this pandemic follow you?’” Sircar said.
Ironically, she was forced to move out of her family home. Her mother is 75 and takes arthritis medication that weakens her immune system.
“And I’m seeing all the high-risk, sickest patients all day long, so I thought that is the perfect storm for really bad complications. So I moved out into an apartment,” Sircar said. “I only get to see her once a week, from the driveway, get her groceries and make sure she’s got food in the fridge. It’s just temporary but it’s challenging.”
Sircar has worked every day since March 28. When she isn’t treating patients, she’s on the phone with colleagues around the world, trying to learn what is working, or reading journals and news stories about the novel coronavirus.
“It snuck into our community without us even knowing,” she said. “And now it has put us all on sort of the 911 of medical emergencies for doctors. This is us changing the game. This is us finding new ways of treating, of detecting, of solving this problem in real-time, as it is happening. And that is very, very challenging.”
On March 17, Ramon Zuniga was “intubated,” or placed on a ventilator, by Dr. Alex Hakim, the ICU’s supervising doctor. Shortly thereafter he would slide into a coma. His prognosis wasn’t good. Studies have shown that more than half of all COVID-19 patients who go on a ventilator die. In New York City, estimates indicate 80 percent of patients put on ventilators have died.
“We all thought he was going to not make it,” Sircar said.
Over the next 19 days, Zuniga would remain on the ventilator, and the scene around him in the ICU would grow increasingly intense. The first COVID-19 death at Providence Little Company of Mary occurred on March 24. At one point in early April, all 28 beds in the ICU were full.
“We were out of ventilators and we were thinking, okay, what strategies are we going to do now?” Sircar said. “Are we going to get ventilators out of the ICU and bring them to the floors? Get additional ventilators and put them on floors that aren’t ICU rooms?”
The entire operation of the medical center had changed. Visitors were no longer allowed. Tents were set up outside the Emergency Department to separate those with COVID-19 symptoms. The hospital had readied itself for a possible surge of the sort that had hit Washington state, where Providence is headquartered; lessons were already being applied. Many surgeons who specialize in elective surgeries were no longer coming to work. Such surgeries had all been postponed. Additional Personal Protective Equipment was acquired for all staff. After earlier uncertainties with CDC guidelines, everyone was wearing PPE. But even that came with its own uncertainties. Welch recalled a report from the medical journal Lancet, which circulated in early April, indicating novel coronavirus was capable of living on the surface of a mask for up to seven days.
“It was devastating news to us because we’re thinking, ‘Oh man, we’re screwed,’ because you have your mask on and it gets in the way sometimes because you’re breathing into it over a 12 hour or 13-hour shift and it falls down and we adjust it,” Welch said. “And we are not rubbing our eyes or putting our hands to our face, but if you don’t wash your hands right away and then if you touch your phone — because we are getting calls all day — and then the phone goes up to your ear…. You just really have to be OCD, which, you know, we are. And that’s a good thing.”
Every move every moment of every day includes a calculation of risk for everyone working in the ICU, both while they are at work and when they go home. These calculations range from how a patient is “turned” on a bed — a periodic process to prevent skin degradation — to regularly wiping down every screen with alcohol, to the increasingly elaborate process of dressing.
“It is a process. You’ve got to take alcohol wipes to wipe off my pens, my badge, sanitizing wipes to wipe off my shoes,” Welch said. “We have hairnets. We’ve got booties. Then we take our scrub tops off first, and that’s contaminated, so we do it with gloves on.”
Everyone wears not only the standard N-95 mask but a mask over that as well as a face shield, gloves, and a protective body-length gown over everything. No skin should be exposed. Most also have scrubs they wear home and then a process of social distancing and showering occurs once they are there. Burrell, who has two small children, has had to train them to keep their social distance until she has completed her self-cleaning routine — and this is after a 13 hour day.
Perhaps the most fraught calculations are going in and out of patient’s rooms.
“It used to be you’d go in and out of the room multiple times,” Burrell said. “With these patients, you need to strategically think about what you need to accomplish and what you need to bring. Because once you are in there, you are in there — you are not going in and out. You shouldn’t be opening the door because you need to be careful not to spread COVID outside the unit.”
About 100 people work in the ICU, with 16 nurses per shift. The coronavirus outbreak has tested their physical and mental endurance.
“I mean truly, I have never run around so many hours of my life,” said Burrell, who is keeping a video diary for the television news program 20/20. “I joke that if I had one of those Fitbits or whatever that tracks your movement, I probably walked or ran ten miles yesterday….I’m literally moving non-stop. I don’t sit down. Like, what is sitting down? And if you ask any nurse what day it is, nobody knows. We lose track.”
“Sometimes you get home, and you’re like, ‘Gosh, I didn’t even go to the bathroom all day,” Welch said.
Workers in the ICU also carefully look after one another.
“For instance, when one of the nurses needs help with her patient, somebody else will go, ‘I’ll do that. I’ll go in. You’ve got kids at home,’” Welch said. “It’s done very matter of factly, very professionally. I work with a stellar group of people. I can’t tell you how proud I am. And I’ve been there 23 years now.”
Welch came to nursing relatively late in her professional life, going back to school in her 30s after first having a career in banking.
“I needed to get into a profession in which people cared about each other, and one in which you were helping others,” said Welch, who as charge nurse is the “air traffic controller” of the ICU. “Nursing was it.”
Burrell’s mother, Julie Baker, has been a nurse for 47 years and works in the ICU. Growing up, Burrell swore she would never be a nurse. She studied to be a lawyer, but then took time off to take care of a neighbor who was dying, going through hospice at home.
“The last few days, while she was still awake and talking, we spent almost all day together talking,” Burrell recalled. “The day before she passed away, she looked at me and she said, ‘You know, you are in the wrong profession. You need to be a nurse. You are missing your calling.’ She passed away at 2 p.m. the next day, and I sat and thought about it and I came to the conclusion, yes, I do need to be a nurse.”
“It wasn’t about medicine that was healing her, because it wasn’t — we all knew she was going to pass. But to know that the time spent with her and talking with her, that the emotional support was what truly healed her soul and her heart and her mind before passing, that was what ultimately made me believe being a nurse was about more than just medicine. It’s about the emotional healing and being able to help a person at the most vulnerable time of their life.”
A week later Burrell began looking at nursing programs. She inquired at Mount Saint Mary’s University, who said the deadline was that day. She applied and graduated at the top of her class. Now she works alongside her mother, who still works in the ICU at the Little Company of Mary. And now she is putting her gift for emotional support to use in ways she never could have expected.
Burrell is known as the patients’ cheerleader on the ICU, jumping up and down and waving at them from outside their rooms to help keep their spirits up. But she and the other nurses have also taken on a more somber role. Eleven people have died of COVID-19 in the ICU since the pandemic arrived. Their families are not allowed in the ICU, so the nurses are the people who tend to these people until the very end.
“Patients are dying alone without family members and they’re not just older patients,” Burrell said. “Some are in their forties, and they have kids, and we are FaceTiming and doing phone calls, sometimes even as a loved one takes their last breath. And that, to me, has been the hardest part of this entire battle. Because no matter how challenging any other virus or disease has ever been and how it’s affected the world, we really have never been faced with this idea of a patient dying in a room by themselves, alone, with the exception of a nurse. Usually, we have family there and they hold their hand. That doesn’t happen anymore, and that has been the biggest challenge for us.”
Little Company of Mary Chief Executive Garry Olney said the pandemic has brought out the best in the medical center’s entire team.
“This crisis has brought our teams closer together than they have ever been before,” Olney said. “I think the most challenging aspect is for these patients to be without their families and loved ones at the bedside for extended periods of time. But every caregiver who steps in that room takes on that challenge and becomes the encourager and the go-between for those families. It is really amazing and inspiring to see…Never before has the term Healthcare Hero been more appropriate than now.”
The nurses have taken to saving the EKG strip, the rhythm strip of the patient’s last heartbeats, printing it out, and writing notes on it for the families.
“We can mail it to the family, or we just put it inside of a glass jar to make it known that even during COVID, you know we treated their loved one like they were our family,” Burrell said. “And we were there with them.”
Some days during the last six weeks in the ICU at the Little Company of Mary have been almost unendurable. At one point, an MRI technician who worked elsewhere in the medical center tested positive for COVID-19 and ended up on a ventilator, depressing group morale until he unexpectedly recovered. At another point, a mother and daughter both arrived in the ICU and the mother eventually died. A husband and wife died within 24 hours of each other.
“Those are the days you are just flattened,” Dr. Sircar said. “Why? Why does it have to come to this? What more could I have done?”
After two weeks on a ventilator, only the faintest glimmer of hope remained for the recovery of Ramon Zuniga. Dr. Hakim and Dr. Sircar were encouraged that he hadn’t suffered any organ failure and appeared cognizant enough to be able to follow some simple commands, meaning his brain hadn’t shut down. Their approach had been to be as patient as possible.
“He was not getting better, but he was not getting worse,” Sircar said. “That was a little glimmer of hope.”
Because he was an early case, the doctors hadn’t tried the use of mild steroids, which at the outset was believed to be too dangerous from what anecdotal evidence had been gathered. But as doctors throughout the global medical community shared treatment success stories, it had begun to emerge that sometimes small doses of steroids helped.
“We didn’t start him on steroids because that was the general thinking at the time,” Sircar said. “It wasn’t until at the very end where we were like, ‘We need to get him off the ventilator. Let’s just challenge him with steroids. We don’t have anything else to lose here. Let’s just see if this flies.’”
So on April 5, they took Zuniga off the ventilator — known as “extubating” — for the first time. He was able to breathe, on his own, while still a machine that gave him fresh oxygen.
“The first couple of days we tried, he was on it for two hours,” Sircar said. “And then the next day I walked by and I was like, ‘How long has he been on the breathing transfer?’ ‘Oh, he’s been like this for about six hours.’ And the next day it was nine hours and I was like, ‘Gosh, he’s doing this! He’s got this will to do this.”
Finally, they took him off the ventilator entirely.
“He had a little bit of fuzzy memory, obviously. He didn’t have all the details but he came back to himself very quickly,” Sircar said. “One of the things that is usually helpful and reorienting for a person after they come out…is if they see a familiar face, like one of their family members. He didn’t have that, so the nurses quickly helped him get on FaceTime and called his family so he could hear his wife and kids. And that helped orient him….and we kept doing that every day until he just called his family more and more and he just came back to being himself.”
Zuniga was discharged on Easter Sunday. ICU staff were overjoyed as they watched him reunite with his family at the hospital entrance.
“COVID might be a dark and scary storm, but you will never crack the foundation here at Providence, because we will win,” Burrell said. “And victories like this keep us going, and keep us strong. For each and every one of us, and it didn’t matter what line of medicine you work in that hospital, it was a victory.”
A larger sense of victory also emerged as April wore on and the ICU, though still busy, remained at far less than full capacity.
“Right now it’s sort of a slow trickle, where we’ll have 15 beds full for three days, we’ll get six or 10 patients out of ICU, and then later we’ll start filling them up again,” Sircar said. “This is exactly the pace we need so that we’re not overrun, where we have 28 patients on a ventilator for two weeks and nothing else to offer anybody else who comes through…This is what the whole point of flattening the curve means, giving us enough time for medical resources to be available and for the physicians and nurses not to burn out.”
Sircar said that perhaps the two biggest misperceptions about the novel coronavirus pandemic is the oft-stated sentiment that healthcare workers represent the frontline of the battle against the virus and that the flattening of the curve meant the war was won. The day she was interviewed, 61 people died of COVID-19 in LA County. Even so, a growing clamor was demanding loosening social distancing restrictions.
“I know there’s a lot of discussion about opening up…but we have to do this slowly,” Sircar said. “I understand the frustration of being confined but it’s really, really important what people are doing. I always say, the doctors here, we are not the frontline. The community out there, they are the frontline. By just staying at home and doing nothing, they are doing more than we are here…Social distancing is really the only way for us to buy time. Because everything comes to an end, even pandemics. All pandemics end. What we don’t want is for this to end with a high body count.”
“We have 28 ventilators in the current ICU, with a surge capacity to fit 22 more non-ICU beds with ventilators if needed,” she said. “All we need is there to be one big party where 30 people get sick at the same time, and two of those people don’t make it. So for me, the community is the frontline. We are the last defense.”
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