In­side a COVID-19 in­ten­sive care unit

In the global hot spot of Ari­zona, a Tuc­son hospi­tal strug­gles to save its largest-ever num­ber of crit­i­cally ill pa­tients.

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TUC­SON, Ariz. – As one of the city’s largest hos­pi­tals bat­tles to save its largest-ever num­ber of crit­i­cally ill pa­tients, its COVID-19 in­ten­sive care unit is eerily quiet.

The only sounds are the beeps of ma­chines and the shuf­fle of staff in pro­tec­tive gear en­ter­ing and ex­it­ing rooms of peo­ple who lie se­dated, eyes closed, with mul­ti­ple tubes com­ing out of their mouths.

The hall­ways, pa­tient rooms and the COVID-19 op­er­a­tions cen­ter at Tuc­son Med­i­cal Cen­ter pro­vide an in­side look at what hos­pi­tals strug­gle with around the state: not enough ICU beds, a high­erthan-usual num­ber of sick em­ploy­ees, in­tense staffing chal­lenges and frus­trat­ing de­lays in COVID-19 test­ing.

Months into the fight against COVID-19, there’s no end in sight.

The si­lence masks a life-and-death strug­gle, as well as ten­sion and des­per­a­tion. As health care work­ers gear up to bat­tle a mer­cu­rial disease in­side those rooms, de­bates on mask-wear­ing and so­cial dis­tanc­ing con­tinue out­side. So do de­bates on how ag­gres­sive Gov. Doug Ducey’s poli­cies should be to try to slow the virus’s spread in a global hot spot.

The most re­cent spike in cases at TMC be­gan in early June, when the hospi­tal got 20 COVID-19 pa­tients within 10 days from Santa Cruz County. That was about two weeks af­ter Ducey’s stay-ath­ome ex­ec­u­tive or­der ex­pired and about a week af­ter re­ports of Me­mo­rial Day week­end rev­elry.

“We opened up too fast,” said Judy Rich, the hospi­tal’s CEO and a reg­is­tered

“What was dis­ap­point­ing was af­ter we knew we were get­ting into a surge sit­u­a­tion, the gov­er­nor was still say­ing we were OK . ... We knew we were not.” Judy Rich, Tuc­son Med­i­cal Cen­ter’s CEO and a reg­is­tered nurse

nurse. “We in the health care com­mu­nity were sur­prised, I think, at the speed with which ev­ery­thing opened up – the bars, the restau­rants, the hair sa­lons. It was all at once. There was no phas­ing here.”

Last week, Tuc­son Med­i­cal Cen­ter had 75 pa­tients with COVID-19. Twen­tyeight of those pa­tients were in the ICU, 25 of them on ven­ti­la­tors.

“We never ex­pected that we would be at these kind of num­bers in July,” Rich said. “We have ex­panded our ICU by more than 50% . ... I think we’re all adding as many beds as we can pos­si­bly push the sys­tem to add.”

At this time of year, the av­er­age daily cen­sus in the ICU is typ­i­cally 18 pa­tients, said Mimi Coom­ler, the hospi­tal’s chief op­er­at­ing of­fi­cer and a reg­is­tered nurse.

Right now, the ICU has 41 pa­tients. COVID-19 pa­tients take in­creased man­power and stay for long pe­ri­ods of time. The record is 59 days.

“Staffing, which was not a prob­lem in March and April and May ... is now the No. 1 is­sue. We are all be­ing asked to open beds that we would not have staffed,” Rich said.

The hospi­tal, which has 4,500 em­ploy­ees, is deal­ing with an un­prece­dented num­ber of work­ers who are sick or in quar­an­tine. Last Wed­nes­day, 66 peo­ple across the or­ga­ni­za­tion called in sick be­cause they’d ei­ther tested pos­i­tive or had symp­toms.

The staff is ex­hausted.

‘Fewer peo­ple are dy­ing’

Out­side the hospi­tal’s chapel is a wall of hearts, rep­re­sent­ing the peo­ple who sur­vived COVID-19. There are 130 card­board hearts on the wall, and hospi­tal of­fi­cials said there are 30 to add.

An ICU nurse talked about mak­ing a sim­i­lar wall of hearts just for the COVID-19 ICU pa­tients.

“I think we are learn­ing how to take care of them bet­ter. We are short­en­ing our length of stay in the (COVID) ICU,” Rich said. “More peo­ple are sur­viv­ing a re­ally ter­ri­ble course in the ICU . ... Fewer peo­ple are dy­ing here, with­out a doubt.”

In­side one of the hospi­tal’s two COVID-19 ICU units, it was dif­fi­cult to see who was mak­ing progress and who wasn’t.

In one room, a pa­tient on a ven­ti­la­tor was ly­ing still on her stom­ach – a med­i­cal ther­apy called pron­ing.

“It takes a team of about six or seven peo­ple, in­clud­ing res­pi­ra­tory ther­a­pists, to safely roll the pa­tient onto their stom­ach. We have a lot of tubes and lines that we work re­ally hard not to dis­lodge,” clin­i­cal nurse spe­cial­ist Angie Muzzy said. “They are at very high risk for in­jury to their eye, to their skin. … So we have to be very dili­gent about pre­vent­ing in­jury to them.”

Pron­ing im­proves COVID-19 pa­tients’ oxy­gena­tion, Muzzy said. When pa­tients lie on their front, the blood sup­ply can get to the clearer parts of the lungs, she ex­plained.

“They stay on their stom­ach for 16 hours, and ev­ery two, you tilt them just a lit­tle bit,” she said. “Some­times within the first 20 min­utes, you watch a per­son whose oxy­gen lev­els were 88%, barely 90%, and sud­denly they will be 95% to 100%. It’s phe­nom­e­nal. We know it helps sig­nif­i­cantly; it’s just la­bor-in­ten­sive.”

A COVID-19 ICU pa­tient who had been taken off a ven­ti­la­tor was about to be dis­charged from the hospi­tal to go home. An­other pa­tient had just been dis­charged to a lower level of care.

The ICU unit, be­hind doors with red signs on them that say “STOP,” is for the sick­est of COVID-19 pa­tients.

The pa­tients, in their own rooms be­hind glass, are each con­nected to a catheter and to a med­i­ca­tion IV, and they wear spe­cial­ized leg braces to pre­vent blood clots. One man, who ap­peared to be in his late 60s or early 70s, had three tubes com­ing out of his mouth – a feed­ing tube, a suc­tion tube and the tube for the ven­ti­la­tor.

The man was sur­rounded by pil­lows and tilted to his left side. He must be turned ev­ery two hours to main­tain his skin in­tegrity, since he’s not mov­ing around on his own, Coom­ler said.

In ad­di­tion to ven­ti­la­tion, oxy­gen and pron­ing, doctors pre­scribe the an­tivi­ral remde­sivir and dex­am­etha­sone, a steroid, to treat COVID-19 pa­tients. Some­times blood thin­ners are used if the pa­tient has clot­ting com­pli­ca­tions. They also use con­va­les­cent plasma from re­cov­ered COVID-19 pa­tients.

COVID-19 more like TB than flu

The iso­la­tion needed for a COVID-19 pa­tient is sim­i­lar to treat­ing a pa­tient for tu­ber­cu­lo­sis, Coom­ler said.

“Here we treat ev­ery COVID pa­tient like they could give it to some­one else,” Rich said. “The con­ta­gious­ness of COVID is ex­po­nen­tially so much greater than the flu. We don’t iso­late peo­ple when they get the flu.”

In the emer­gency depart­ment, staff mem­bers at­tend­ing to a pa­tient wore head-to-toe protection, in­clud­ing gog­gles and masks (an N95 cov­ered by a reg­u­lar med­i­cal mask for a few peo­ple). One staff mem­ber wore an ad­vanced res­pi­ra­tory protection sys­tem that looked like a hel­met with a plas­tic face shield.

There’s a suit and head gear, de­signed for treat­ing Ebola pa­tients, that’s used to in­tu­bate pa­tients with con­firmed and sus­pected COVID-19, said Dang Huynh, as­sis­tant med­i­cal di­rec­tor of the TMC emer­gency depart­ment.

Often it’s the emer­gency room staff who first see the COVID-19 pa­tients who can’t breathe and in­tu­bate them. A tube is in­serted into pa­tients’ air­ways, so they can be con­nected to a ven­ti­la­tor.

Who are the pa­tients?

COVID-19 pa­tients tend to be in their 50s and 60s, hospi­tal of­fi­cials said.

In April and May, TMC’s COVID-19 pa­tients skewed older, typ­i­cally 75 years or older, Rich said.

“We had a lot of hot spots in nurs­ing homes here,” she said. “But that seems to be un­der con­trol. We get maybe one or two a day.”

Younger pa­tients who end up in the

ICU often have un­der­ly­ing health con­di­tions such as di­a­betes, hy­per­ten­sion or obe­sity, Muzzy said.

“We have peo­ple with a va­ri­ety of dif­fer­ent ill­nesses. Maybe they al­ready have re­nal fail­ure, and the virus just over­whelms them and they have no wig­gle room to bounce back,” she said.

About 80% of peo­ple who con­tract COVID-19 will get bet­ter on their own. For those who get sick, the ill­ness is dev­as­tat­ing, caus­ing not just lung prob­lems but car­dio­vas­cu­lar is­sues and a host of lin­ger­ing chal­lenges, from con­fu­sion to breath­less­ness and fa­tigue.

TMC has treated mul­ti­ple pa­tients from hard-hit Santa Cruz County near the U.S.-Mex­i­can bor­der, which has the high­est rate of COVID-19 cases in the state.

It has treated pa­tients from Yuma County and the White Moun­tain Apache Tribe, two other ar­eas with spikes in COVID-19 cases.

What ‘surge’ mode looks like

Tuc­son Med­i­cal Cen­ter has been in what’s known as “surge” mode since the first week of June, us­ing beds and staff above nor­mal ca­pac­ity.

Coom­ler said, “Our chal­lenge is, how do we sus­tain that? How do we sus­tain our staff, our nurses, our res­pi­ra­tory ther­a­pists and our doctors know­ing that this isn’t go­ing to just be for a week or two?”

What once was a smooth hospi­tal rou­tine has been up­ended. More time is needed to put on and take off pro­tec­tive gear, and more time is needed to take calls from pa­tients’ fam­i­lies who need up­dates.

Is­sues with test­ing and test re­sults con­tinue.

Pa­tients miss the visi­tors. The staff misses the visi­tors, too.

A fed­eral Dis­as­ter Med­i­cal As­sis­tance Team set up headquarte­rs in a hospi­tal con­fer­ence room.

Nurses are asked to work four 12hour shifts per week in­stead of three.

The hospi­tal has added ICU beds as fast as pos­si­ble since cases be­gan to in­crease.

The hospi­tal is ready to go up to 45 ICU pa­tients. That has re­quired adding staff, pulling in physi­cians and nurses from other ar­eas of the hospi­tal, us­ing health care providers sent from a fed­eral dis­as­ter as­sis­tance team and bring­ing in travel nurses for the ICU.

COVID-19 rooms, whether in­side our out­side the ICU, have been up­graded with large tun­nel-like tubes that protrude out the back of the hospi­tal rooms to cre­ate a neg­a­tive-pres­sure en­vi­ron­ment for max­i­mum in­fec­tion con­trol.

The hospi­tal had 33 neg­a­tive pres­sure rooms be­fore the pan­demic and up­graded rooms to add 100, said Richard Parker, di­rec­tor of fa­cil­i­ties and con­struc­tion at TMC.

The neg­a­tive pres­sure pulls the air out of the room, fil­ters it and sends it out­side. That keeps what­ever that pa­tient has in the room in­stead of let­ting it get out into the cor­ri­dor where it could en­dan­ger the staff and any­one else walk­ing through the unit.

“It’s also an iso­lated ex­haust. It makes sure that we don’t re­cir­cu­late the air from the rooms we just made neg­a­tive with other pa­tient rooms,” Parker said.

Parker said his staff con­stantly checks rooms for me­chan­i­cal prob­lems.

“I have guys that will go through ev­ery one of those and in­spect to make sure the fan is still run­ning, that the duct work is still in­tact. The sun is pretty bru­tal, so we want to make sure the duct work is in­tact, and we seal any leaks with it,” he said. “We also go through on the in­side. We have a lit­tle puffer smoke test, and we put that at the door and make sure the room is truly neg­a­tive. If it’s not, then ob­vi­ously, we’ve got a prob­lem some­place. Just set­ting it up was a big task, and main­tain­ing it to make sure we’re pro­tect­ing ev­ery­one in the build­ing, that’s an­other big task.”

The hospi­tal makes some ex­cep­tions to the no-visi­tor rule, but that’s dif­fi­cult in the ICU, Rich said.

“We try to stay con­nected to the fam­ily. We’ve got sto­ries of our nurses on the front line, with fam­i­lies out­side the window, hold­ing the hand of a pa­tient who is dy­ing,” Rich said.

The hospi­tal is one story, so some fam­i­lies are able to see their loved ones via window vis­its. Last Wed­nes­day, in the midafter­noon heat, a mid­dle-age man and two young adults stood un­der a ra­mada near the win­dows of the COVID-19 unit, wear­ing flu­o­res­cent green visi­tor stick­ers. The young man in the group was cry­ing.

Surge line used ‘con­stantly’

Hos­pi­tals across the state, in­clud­ing TMC, use a surge line that was cre­ated by the Ari­zona Depart­ment of Health Services.

It is a 24/7 statewide phone line for hos­pi­tals and other providers to call when they have a COVID-19 pa­tient who needs a level of care they can’t pro­vide. An elec­tronic sys­tem lo­cates avail­able beds and ap­pro­pri­ate care, evenly dis­tribut­ing the pa­tients, so no one sys­tem or hospi­tal is over­whelmed by pa­tients.

“We didn’t know what the surge line was un­til we ac­cepted 20 pa­tients from Holy Cross in June. Fi­nally one day, we started push­ing back and say­ing, ‘Why isn’t any­one else tak­ing these pa­tients?’ ” Rich said. “That was in one of our weekly calls, and ev­ery­one started say­ing, ‘We’ve got to use the surge line.’ ”

Caron­delet Holy Cross Hospi­tal is in hard-hit Santa Cruz County.

“As much as we’ve been dis­ap­pointed with the state’s re­sponse, they did a re­ally good thing when they opened up the surge line,” Rich said. “A lot of states didn’t do that . ... We are us­ing the surge line con­stantly.”

From June 28 to July 4, TMC ac­cepted 25 pa­tients from the surge line, took a to­tal of 40 calls and trans­ferred seven pa­tients to other fa­cil­i­ties. The hospi­tal had to de­cline 12 pa­tients for ICU care from surge line calls.

“These are very ur­gent calls,” Rich said. “They are call­ing and say­ing, ‘I’ve got some­body in my ED (emer­gency depart­ment), we just in­tu­bated them. They are crash­ing, and I need to get them into an in­ten­sive care unit.’ ”

As of last Wed­nes­day, there were 181 ICU beds avail­able statewide out of 1,672 to­tal.

‘Take good care of them’

Rich did not wel­come Ducey’s news brief­ing June 11 claim­ing that Ari­zona hos­pi­tals had ad­e­quate ca­pac­ity.

“What was dis­ap­point­ing was af­ter we knew we were get­ting into a surge sit­u­a­tion, the gov­er­nor was still say­ing we were OK . ... We knew we were not. We knew we were pre­par­ing for some pretty tough stuff to come,” she said. “That was the big­gest dis­ap­point­ment.”

Rich said she wrote a let­ter to Ducey, and the two spoke. The gov­er­nor asked what TMC needed, and she said that’s why the hospi­tal re­ceived help from a fed­eral Dis­as­ter Med­i­cal As­sis­tance Team, as well as med­i­cal per­son­nel from the Na­tional Dis­as­ter Med­i­cal Sys­tem Trauma and Crit­i­cal Care team.

The state plans to pay for health providers to work in hos­pi­tals that need them for six-week pe­ri­ods, and it will pro­vide fi­nan­cial in­cen­tives for hos­pi­tals to take acute COVID-19 pa­tients, Ari­zona Depart­ment of Health Services Di­rec­tor Cara Christ an­nounced.

On June 30, Christ de­clared that hos­pi­tals in the state could ac­ti­vate “cri­sis care stan­dards,” which guide the al­lo­ca­tion of scarce re­sources to pa­tients based on fac­tors such as their like­li­hood for sur­vival.

No care is be­ing ra­tioned at Tuc­son Med­i­cal Cen­ter, of­fi­cials said.

“We are so grate­ful to have a doc­u­ment that of­fers guid­ance that we have not had to em­ploy,” Coom­ler said. “At this point, we con­tinue to add re­sources in­stead of fig­ur­ing out how to ra­tion them.”

TMC needs more COVID-19 test­ing sup­plies and a faster turn­around for get­ting test re­sults, of­fi­cials said.

“We have had to ex­pend so many re­sources di­rectly be­cause we couldn’t rapid-test peo­ple,” Rich said. “The worse it gets in Ari­zona, the longer we’re wait­ing for re­sults. … We overuse re­sources to make sure we don’t miss any­thing.”

Rich wants peo­ple to know her staff mem­bers are ex­hausted, peo­ple are dy­ing and wear­ing a mask makes ev­ery­one safer.

“To get through this as a state, we have to marginal­ize the peo­ple who don’t be­lieve that it’s spread­ing, and we have to sup­port the peo­ple who do be­lieve that it’s spread­ing,” Rich said.

“The fu­ture of this disease is still so un­known to us that we have to act on what we know for sure,” she said. “What we know for sure is that masks are the No. 1 most im­por­tant thing we can do.”

She said her staff feels the pain of all the com­mu­nity mem­bers who have to bring loved ones to the hospi­tal yet can’t be with them.

“We’re go­ing to take good care of them,” Rich said. “We’re re­ally go­ing to be there for those fam­ily mem­bers and be there for those pa­tients.”

TUC­SON MED­I­CAL CEN­TER

PHO­TOS BY ANGELA PITTENGER/TUC­SON MED­I­CAL CEN­TER

It takes time for the staff at Tuc­son Med­i­cal Cen­ter in Tuc­son, Ariz., to put on and take off the pro­tec­tive gear needed to keep them and pa­tients safe.

Tuc­son Med­i­cal Cen­ter’s sick­est coro­n­avirus pa­tients are in the hospi­tal's ICU units.

At Tuc­son Med­i­cal Cen­ter in Tuc­son, Ariz., car­ing for pa­tients in the COVID-19 unit takes in­creased per­son­nel, and COVID-19 pa­tients’ stays are longer than those of oth­ers in the hospi­tal.

The neg­a­tive pres­sure equip­ment in COVID-19 pa­tient rooms at Tuc­son Med­i­cal Cen­ter pulls the air out of the room, fil­ters it and sends it out­side. This keeps pa­tients’ ill­nesses in their rooms in­stead of let­ting them get out.

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