BEHIND THE WALLS
“You deal with death every day . ... You want life to go back to normal but you can’t.” Morgan Prescott Valleywise Health Medical Center ICU nurse who estimates she has cared for about 30 COVID-19 patients since mid-November who have died
The small, slender man in the COVID-19 intensive care bed was thrashing, opening and closing his eyes, and at one point broke the mask helping to push pressurized air into his lungs.
He was one of the exceptions, a patient who might make it out of this unit alive.
The man, in his 60s, was hospitalized in a converted pediatric emergency department at Valleywise Health Medical Center in Phoenix. He was one of 11 people being cared for in a 12-bed ground-floor ICU on Jan. 14, nearly all of them patients of color and representative of the neighborhood around the hospital, 2601 E. Roosevelt St.
Unlike every other patient in the unit on Jan. 14, the man was not at
tached to a mechanical ventilator, which requires a tube to be inserted into the windpipe in a process called intubation. He had just been extubated — had his ventilator tube removed — and instead was connected to a machine known as BiPap, which stands for bilevel positive airway pressure, delivered through a face mask.
As of Feb. 4, 573 patients with suspected and confirmed COVID-19 were on ventilators in Arizona hospitals, a 71% increase from the number on ventilators on Thanksgiving Day, and 43% lower than the number of COVID-19 patients on ventilators at the peak of Arizona’s January surge.
These are the patients who require the most specialized staff, and the longest hospital stays and, more often than not, they have the most heartbreaking outcomes.
Extubation was a good sign for the Valleywise patient. Most COVID-19 patients who are hooked up to ventilators don’t ever get off of them, Valleywise providers say. They are the patients who linger, then die.
“I feel like patients with severe COVID illness don’t do well. Once they get to the ICU, the outcomes are usually poor,” Valleywise charge nurse Jennifer Granger said.
While Arizonans getting immunized with the COVID-19 vaccine and political leaders are touting a close end to the pandemic, patients at Valleywise Health Medical Center and other hospitals across the state are spending weeks hooked up to mechanical ventilators with little chance for survival. If another surge of illness happens, the number of COVID-19 patients on ventilators — the sickest of the sick — likely will rise again.
Valleywise ICU nurse Morgan Prescott has been taking care of COVID-19 patients since February 2020, and has since seen only one or two patients successfully get off of ventilators.
“You deal with death every day,” said Prescott, who estimates she’s cared for about 30 COVID-19 patients since midNovember who have died. “I definitely have days when I cry on my way to work and cry on the way home . ... Or you are getting dressed in your scrubs in the morning and you just cry because you are tired, you are emotional. You want life to go back to normal but you can’t.”
It seems to Prescott as though the latest surge is worsening.
“Our numbers are going up every day. ... More patients, less beds,” she said.
‘Stable’ can mean ‘no improvement’
Any COVID-19 patient who ends up in the ICU is contacted by someone from the Valleywise palliative care team, which since the summer surge has included a full-time social worker.
Families sometimes believe that hearing their loved one is in stable condition is good, but it can also mean no improvement.
“Once we see them on the ventilators, we’re seeing weeks of kind of a slow, gradual decline and then not really much improvement,” said palliative care nurse practitioner Jill Krmpotic, whose team works in a partnership with Hospice of the Valley. “I am doing more hospice care right now. It’s hard, but it’s needed.”
Krmpotic says she tries to touch base with families multiple times per week and she uses direct language, like “we feel like the patient is going to die” rather than less clear descriptors such as “stable.”
What families don’t always realize, Krmpotic said, is that the stories they read about in the news, where patients have been on a ventilator for months only to recover, or whose lives are saved by a lung transplant or an external lung machine called ECMO — extracorporeal membrane oxygenation — those stories are exceptions, Krmpotic said.
“Those cases are very, very unusual,” Krmpotic said. “I think that families, unfortunately, are kind of banking on those stories, rather than the majority of what we’re seeing, and it’s incredibly sad.”
The social worker on the palliative care team has added a bereavement component to their work that can include help with hospice resources, funeral assistance and grief counseling, Krmpotic said. Palliative care is typically chronic disease management to improve quality of life. But during COVID-19, the team’s work has increasingly comprised end-of-life counseling for both families and Valleywise staff.
When it’s clear patients aren’t going to get better, some families may opt for “comfort care,” where medical providers turn off the ventilator, take out the breathing tube and give the patients whatever makes them comfortable. The palliative care team also works with translators for the many Spanishspeaking families whose loved ones are at Valleywise, and with a chaplain.
Arizona led rest of nation in new cases, hospitalizations
On Jan. 15, at the peak of its second surge, Arizona was leading the nation for its rate of new COVID-19 cases, for new COVID-19 deaths, and its rate of hospitalizations, according to analyses from the Centers for Disease Control and Prevention and The COVID Tracking Project. The state eclipsed 11,000 known deaths from COVID-19 during the week of Jan. 15, less than seven days after it passed the 10,000 case mark. The state as of Saturday exceeded 14,000 known COVID-19 deaths.
At Valleywise and other hospitals across Arizona, staff says the latest surge has felt longer than the first one, which may be because there are more patients — more COVID-19 patients than there were in the summer, but also more patients overall, because the winter season typically brings more people to the state and results in a busier health care system.
“We’re all worried that we’re maybe hitting a plateau here,” Valleywise chief medical officer Dr. Michael White said Jan. 14. “We’re not seeing big increases day over day, but everyone is kind of staying at this high plateau. I think ultimately it will be longer (than the summer surge).”
A majority of the patients who talk about where they may have been exposed attended family gatherings, including holiday dinners, Valleywise nurse manager Regina Villa said.
She hopes that members of the public can understand that making sacrifices for a little longer, including avoiding getting together with friends and family, will help keep the hospitals from being overwhelmed, and it will also help save lives.
“It’s too much. It’s not just us. It’s every hospital in the whole Valley,” Villa said. “We have way more patients now than we did in the summer.”
Most people who become infected with the SARS-CoV-2 virus, or new coronavirus, that causes COVID-19 don’t get very sick, and most of the ones who do get sick and are hospitalized don’t end up dying. Of the 1,702 COVID-19 patients who had been hospitalized at Valleywise between the beginning of the pandemic and Jan. 14, 202 of them, or nearly 12%, have died.
They may not be a majority, but it’s those who get sickest who we all need to protect, Villa said.
Often, they are people with underlying health conditions, and being over 65 puts patients are higher risk. But Villa stressed that otherwise young and healthy people can become extremely ill. It’s impossible to predict, but infection can be prevented, she said.
Most of the hospitalized COVID-19 patients at Valleywise right now seem to be in their 50s and 60s, Villa said, but there’s a range. A 30-year-old patient with COVID-19 died Jan. 13, she said.
“We have a 24-year-old right now,” said Granger, the charge nurse who was overseeing the 12-bed ground-floor COVID-19 ICU where the patient was extubated. “I find it really frustrating when people say they (the patients) are all older, that they all have comorbidities. ... The problem is, it’s unpredictable. While it’s true for most of them, it’s not true for all of them, and you don’t know which one that’s going to be.”
Granger, who has been working five 12-hour shifts per week, is frustrated by people who use the age or underlying health conditions of COVID-19 patients as evidence to dismiss the virus’s severity. Advanced age and preexisting conditions do not make any patient less valuable than another, she said.
“They all deserve the care,” she said.
They don’t have the luxury of working from home
Right now, there’s not an exponential growth in cases or hospitalizations in Arizona, and indicators point to a declining in the latest surge.
But there are new variant strains of the new coronavirus that appear to be more contagious, and the percent of positive COVID-19 test results in the state remains above the desired benchmark. On Friday, more than 1,600 Arizonans visited hospital emergency rooms in the state for suspected and confirmed COVID-19.
Valleywise is a so-called safety-net hospital, which means it aims to care for underserved populations, including people who are uninsured and underinsured. Sixty percent of its patients are covered by the state’s Medicaid program, which is known as the Arizona Health Care Cost Containment System and is a government health insurance program for low-income people.
Medical providers at Valleywise say their patient base includes a large number of working-age people with jobs that do not allow them the luxury of working from home. Many don’t have paid leave if they take time off work for illness. They bag groceries, clean houses, deliver food, cook food and wait tables in restaurants. Often, they are living in homes with multiple generations under one roof.
“It’s easy for some people to take off for a month or two and have financial resources. A lot of people in this area live paycheck to paycheck,” said Dr. Frank LoVecchio, a Valleywise emergency room and public health physician.
“Because people live paycheck to paycheck, they have to go to work. And it’s pretty obvious that when one of them goes to work, the breadwinner, that they might work in a store, catch it and bring it home to the family. That has been happening since Day One in our general area.”
Burn specialists now taking care of COVID-19 patients
Arizona cases began increasing in November and surged following Thanksgiving and the Christmas holiday season, which fueled the existing spike in both cases and hospitalizations, creating what some have referred to as a surge within a surge. Two weeks after New Year’s Day, case numbers remained high, though they have since started to fall.
Hospitalizations typically lag positive cases by about two weeks. Deaths are the last number to rise.
Valleywise has Arizona’s only nationally verified burn center. But even specialized burn doctors were caring for COVID-19 patients during the height of the second wave of illness.
Burn surgeon Dr. Michael Peck was not tapped for COVID-19 duty during the summer surge, but he began helping in mid-January. Also helping with COVID-19 patients were a physician’s assistant from the burn unit and some surgical residents, who would normally be working in operating rooms.
“I don’t do this normally for a living. I’m doing it now because they need an intensivist to help take care of these patients, but this is not typically what I do,” Peck said on Jan. 14. “This is happening not only throughout the hospital here, but throughout the city. It’s a problem ... It’s not physical beds, it’s people. We’re running out of nurses, we’re running out of doctors to take care of these people. We’re being stretched.”
Nothing is business as usual at Valleywise.
In the emergency department, it’s “all COVID all the time,” LoVecchio said in the midst of January’s surge. Forty patients were in the Valleywise emergency department on Jan. 14, and 25 to 30 of them were either confirmed or suspected as COVID-19 positive, he said. Twelve patients in the emergency department, some of them with COVID-19, were sick enough to need admission to the hospital but were waiting for inpatient beds to open up.
Overall, the patients coming into the emergency department with COVID-19 are sicker than those who came in during the summer. Patients have become more savvy about the illness, and aren’t coming to the hospitals when they have mild symptoms.
“Back in the summer, half of the patients I saw, for lack of a better term, were worried well,” LoVecchio said. “They were worried, wanted reassurance that they weren’t going to die. Now patients are very educated. They know about quarantine, separating themselves from their family.”
ER doctor braced to ration care
LoVecchio was ready for the latest surge to worsen, and he was bracing himself in case state standards for rationing care were implemented, which to date they have not.
“I want to have a positive attitude, but I don’t see it getting better anytime soon,” he said. “There’s a time when the beds are going to be totally full . ... Now the prize is for all of us to get vaccinated. That is where I see the end coming, but do I think it’s going to be a bad next month? Absolutely.”
The man who was taken off his ventilator was one of a total 79 patients with suspected and confirmed COVID-19 in the central Phoenix hospital on Jan. 14, and one of 27 COVID-19 patients in the hospital requiring ICU care.
A bed was open because one patient in the unit died the previous night.
The patient who was extubated Jan. 14 was to remain in the ICU under observation. In some cases, patients are extubated and then don’t do well and need to go back on the ventilator, White explained.
“It’s not immediately extubate, transfer out,” he said.
Granger recalled talking to the man 10 days previously, before she intubated him. Seeing him get off the ventilator was a hopeful development.
The thrashing was not unusual, nor was breaking the BiPap mask. Patients are heavily sedated while they are on ventilators, and the medications can make them confused and delirious.
Myriad challenges still face patients post-COVID-19, particularly if they’ve been on a ventilator.
Still, extubation means that maybe one day this patient will be able to go home.
And that would be exceptional. “He is definitely making progress,” Granger said.