A NIGHT SHIFT

While the city sleeps, a team of nurses cares for the sickest of the sick in the Northeast Baptist Hospital COVID-19 ICU. For nurses, the night shift is long stretches of quiet punctuated by crisis. We spent two nights alongside them.

larms were blaring in the COVID-19 intensive care unit. A patient suddenly had awakened in the dark. A breathing tube was threaded down her throat.

It was a few minutes before 1 a.m., and her sedatives had worn off. In her room, behind a wall of windows and a closed glass door, she twisted against the wrist restraint that kept her from dislodging the tube. She bit down on the tube and tried to lift her arm.

If she pulled out the tube, she could die.

Her nurse, Frank Salinas, hurried to her door. He needed to enter the room to calm her down.

But first, he had to put on a yellow fabric gown, blue gloves, goggles, a respirator — the PPE, or personal protective equipment, that has become the indispensable uniform of medical personnel during the coronavirus pandemic.

It took Salinas nearly three minutes to suit up.

As the patient struggled, the ICU charge nurse, Sam Beckett, stood on his toes outside the room, waving to her.

“It’s OK. It’s all right,” he said through the glass door. “Hold on. Hold on.”

Once at the patient’s bedside, Salinas tried to soothe her, but he had to raise his voice to be heard through his respirator. In the hall, where her IV stand was stationed, Beckett increased her sedatives to put her back to sleep.

That night, four nurses and a respiratory therapist were caring for five patients, all but one of whom were breathing with the support of

a mechanical ventilator. It was a rare slow shift in the 12-bed coronavirus ICU at Northeast Baptist Hospital. Some patients had been there for weeks, others just a few days.

Ever since the pandemic hit San Antonio in March, the overnight team members have done their best to help the sickest coronavirus patients make it to morning. From 7 p.m. to 7 a.m., they see patient after patient stricken by the same terrible and perplexing disease, constricted by the same limited options for treatment. With doctors available by phone but not present, they rely more on each other. They are the lifeline for worried family members; and when a patient is dying, they’re the only ones allowed in the room.

Their jobs have been fundamentally changed by the coronavirus. They put on and remove protective gear seven or eight times per shift. Their faces are hidden behind masks, and a layer of glass or protective gear always separates them from those under their care.

“If she pulls out her endotracheal tube, you can’t run in there. You’ve got to put your PPE on. If her heart stops, you’ve got to put your PPE on,” Beckett said.

As Beckett started his shift that night in May, he had his temperature checked outside the emergency room before making his way to the second floor of Northeast Baptist. He oversees the night operations of the hospital’s two intensive care units — one for COVID patients, the other for everyone else.

At the nurses’ station on the non-COVID side, he was briefed by the day charge nurse. Every bed in the unit was taken, but the coronavirus ward was less than half full.

When the virus first began spreading in San Antonio, Northeast Baptist had been flooded with COVID-19 patients. Now, the staff had learned to live with the virus, and the hospital was transitioning back to normal operations, as were other area hospitals. By June, COVID-19 would have sent a total of 500 people from across the city to hospitals. More than 200 of the patients needed intensive care.

Another nurse, Charla Price, pulled out her phone to show Beckett a video that was circulating among the ICU staff.

“I got it yesterday,” she said, hitting play.

In the video, a coronavirus patient they had treated stood on the sidewalk. There were birds chirping, a blue sky overhead.

“Just wanted to let y’all know that I’m capable of walking very slowly, but I’m getting there,” the middle-aged man said to the camera. “Thank you so much for saving my life. From what I hear, there were some scary moments, but thank you again for what y’all did for me.”

In the ICU, they saw patients in desperate states. Many still were on ventilators when they left the hospital, bound for a long-term care facility. They rarely heard from them again.

Here was a man who had managed to make it through. He was smiling, looking and sounding healthy.

“That is mind-blowing,” Beckett said to Price, thinking back to how sick the patient once was. “I would have bet everything I had that that wouldn’t happen.”

Beckett pushed past a pair of double doors into the COVID unit.

It was quiet. The glass doors to all the rooms were closed to prevent the airborne virus from drifting into the hallways.

Behind the doors, patients lay motionless, hooked up to ventilators. Their ventilator settings are scrawled on their windows in dry erase marker — one reads, 20 380 +8 40%. Extended tubing snakes across rooms and through cracks in the sliding doors to IV poles in the hall. The arrangement limits nurses’ exposures, allowing them to administer medications without having to enter the room each time.

The long tubes can be like a “bird’s nest,” Beckett said. Sometimes it takes a team to figure out which tube is carrying which drug. Nurses and respiratory therapists duck under them as they work in the rooms.

Walking through the unit with a clipboard, Beckett checked on all the patients and jotted notes to indicate which were restrained by wrist braces and large ankle cuffs.

With COVID patients, such precautions are essential. If a patient yanked out a breathing tube, nurses wouldn’t be able to pump air by hand, a procedure known as rescue breathing, until the patient could be reintubated. Doing so would spray particles of virus into the air, putting health care workers at a high risk of infection.

He passed the room of a patient lying stomach-down on the bed. Hospitals have been using the technique, called proning, to help relieve pressure on the lungs of COVID patients who don’t respond well to a ventilator. These patients require a higher level of care and their own nurse.

Other rooms on the unit sat empty, not yet cleaned since their last occupants had left. An urgently needed room could be turned around in a few hours — staffers wait one hour after it is empty before starting to sanitize and another four before bringing in a new patient. When there are rooms to spare, leaving one vacant is itself a form of decontamination. The longer it sits, the higher the likelihood that the virus will die off without finding a new host.

Beckett walked over to one of the nurses finishing his shift. A doctor had told the nurse to call the family of a patient who was doing poorly. He might die, the nurse said. Family members were coming to the hospital that evening to say goodbye.

It is the only time visitors are allowed in the COVID unit.

About 6:30 p.m., Beckett entered the staff lounge for a meeting with the nurses working that night.

They trickled in and took seats around a long oval table. Many were dressed in royal blue, but those working with COVID patients wore powder blue surgical scrubs.

Some of the nurses volunteer to staff the COVID unit, where they work three nights straight and are off the rest of the week. Others can’t care for those patients, due to pregnancy or health conditions that made them vulnerable to complications, should they become infected.

So far, the hospital had been lucky. None of the ICU staff had fallen ill from the virus.

The conversation turned to the patient whose family was coming in.

“I thought he was doing so well last week. But he just, over a period of days …” one nurse said, punctuating the sentence with the sound of a deflating balloon.

“That’s how it goes,” Beckett said.

“I know, it’s terrible. That’s what I try to tell people. It’s like when it happens, it’s like that.” The nurse snapped his fingers.

A phone alarm went off, signaling the start of their shift.

“Everybody good on PPE?”

Beckett asked as the group dispersed.

Outside the lounge, Beckett was approached by Margaret Kirby, the hospital’s staff chaplain. The COVID patient’s family would be there soon, she said.

“This will be through the glass?” he asked.

“Yes.”

After briefly visiting with the ER staff, Beckett went back upstairs to the COVID unit, minutes before the patient’s family was expected to arrive.

As a supervisor, he wanted to be a second set of eyes while they were there. Entering the unit and seeing their loved ones in such a state is jarring to families, who sometimes lash out in anger at the staff.

This illness is not something they could have planned for, and they have not been there to witness all the efforts to save the patient. In one instance, a person had accused a doctor of not caring about a family member.

Kirby, 49, had done this before. Too many times. By now, she knew what to do. Downstairs, she prepared the family members for what they were about to see.

Cautiously, the patient’s wife and children approached the glass door of his room. A sob escaped from behind his daughter’s face mask. Her mother put an arm around her shoulders.

This moment always was difficult. Not being able to touch their loved one. Being separated by a pane of glass.

Kirby stood back. During the pandemic, she had been forced to adjust her approach. Her training at Northeast Baptist in 2009, and the decade of hospital and hospice chaplaincy that followed, had taught her the importance of consoling families with a hug, a squeeze of the hand. Now, her job was to help families grieve from a distance. She had chairs ready, in case they were overwhelmed by emotion.

Beckett had been watching from across the unit. He walked over to the family members. In a hushed voice, he explained what the numbers displayed on the patient’s screen meant and answered their questions about his medical care. He knew they needed to see him with their own eyes to understand how serious his condition was. It was something that couldn’t be conveyed over the phone.

The patient’s nurse, Evelyn Menking, was inside the room. She would be the conduit for the family to communicate with the patient.

For several minutes, Menking and Kirby fiddled with smartphones and two-way radios. Finally, they were ready.

Menking held up a phone as a priest read a prayer over a video call. With oil on her finger, she traced the cross on the patient’s hands and forehead. The audio was broadcast to the family out in the hallway using the radios.

Around them, the other nurses on the unit went about their work. One began donning protective gear at the door of an adjacent room.

After the prayer, the family members took turns talking to their loved one over another video call. One after the other, they told him they loved him.

“We want you to rest in peace and keep an eye on us, wherever you are,” his wife said, her voice wavering. “I love you.”

“He heard us,” his daughter said. “I know he heard us.”

His wife placed one hand, then the other, on the glass. She put her head against her hands and sobbed.

It was as close as she could get.

After the family left, Kirby turned to Menking and Salinas. She thanked them for their work. She hoped they were wrong, that the patient would rebound. It had happened before.

“We’re praying he makes through the night,” Kirby said.

Menking, one of the youngest nurses in the ICU, had done this before, too. With each patient, it felt like a balancing act of how much to invest emotionally. So many were at risk of dying, and what few treatments were available didn’t work for everyone.

It was hard to watch family members in pain. Being in the room during such moments felt like an enormous privilege and an intrusion. But the patients she remembered the most were those who were alone at the end.

The pandemic had been emotionally taxing for others on staff, too.

In the early weeks, when little was known about how to treat the illness, nurses only could watch, helplessly, as patients deteriorated.

Family members would call three, four, five times a day. Often, there wasn’t much to report. Once patients became critically ill, their condition would stagnate until a sudden change, for better or worse. Many were hospitalized for weeks, some for more than a month.

For Beckett, 35, the pandemic affected most of his family. His father is a vascular surgeon, and his brother, also a nurse, traveled to New York to help with the coronavirus surge there. At its peak, hundreds of people were dying every day, and some had to be buried in a potter’s field.

Beckett’s brother seemed reluctant to share much about what he saw, aside from recounting one exchange he had with hospital administrators. When his brother asked what would happen if he became infected, he was told to put on a hospital-grade mask and fly home, because “you don’t want to die in New York.”

Heartrending scenes had played out at Northeast Baptist, too. During one busy week, back when both sides of the ICU and two other units were solely devoted to COVID patients, Beckett had seen a nurse stop in his tracks as he passed a patient’s room before quickly turning away.

Beckett found him in the break room, crying. The nurse usually worked at another hospital, and this was his first shift helping with the influx of coronavirus patients. He told Beckett he knew one of the patients — she also was a nurse, and she had become like a second mother to him after he immigrated to America. He hadn’t known she was hospitalized.

She later died.

Even after treating dozens of COVID patients, this was the case that stuck with Beckett, the one that brought a lump to his throat. He didn’t know her, but it felt more personal. Like losing one of their own.

In a negative pressure room that prevents the virus from escaping, a patient sat up and swung his legs over the side of his bed. His movement triggered an alarm.

The patient’s nurse, Simon Denton, rushed over, worried the man would try to get up on his own. He was too weak and unsteady. Denton threw on his protective equipment.

“If he falls on the floor, he stays on the floor,” Denton said. “If we get sick, we’re no good to take care of them.”

With N95 masks scarce, Denton, like most of the nursing staff, had purchased his own respirator. The exterior could be disinfected with bleach wipes, and it had filters that lasted for about six months.

His fellow nurses joked that they had just begun to understand his thick British accent, but now his speech was nearly impossible to discern through the respirator. When Salinas wore his own respirator, he said it made him sound like Darth Vader.

Denton, 44, was not fazed by the protective equipment required to work with COVID patients. He’d undergone training for handling chemicals during his time as a diesel mechanic in the British army and later in the U.S. as a military contractor. After a back injury, he’d embarked on a new career in nursing, joining the staff at Northeast Baptist in 2016.

The nurses store their equipment in large paper bags, which some have decorated. One depicts a hand-drawn skull and crossbones, flames and a banner reading “COVID-19.” On his, Salinas had written, “Frank’s COVID killing magical paper bag. As seen on TV!!! Works just like magic!”

Salinas, 40, became a nurse after working in hospitals for years as a monitor technician, assisting with electrocardiograms. He longed to make a difference in the lives of patients. When he joined the ICU staff, he could do just that. It is the place of last resort.

There, he found his sense of humor was more important than ever. His intent wasn’t to come across as insensitive. It was a way of coping with the difficult environment so he could keep coming back every day.

At a computer, Beckett clicked through the charts of patients coming through the ER who had been classified as PUIs — persons under investigation for COVID-19. If any of those patients tested positive and began to go downhill, they could be transferred to the unit. It was Beckett’s job to know a patient was headed his way before he was told about it.

Beckett read through the symptoms and medical histories of the patients. None seemed like a classic case of COVID-19. Then again, he had encountered plenty of surprises.

But as the night progressed, negative results came back for one patient after another.

“0 for 8,” Beckett said to Salinas after 4 a.m. Three hours to go.

A half-hour later, Salinas stood in a patient’s room, against the window, and held his arms up. On the other side, Lisa Nguyen, a respiratory therapist, traced his outline on the glass in black marker. It looked like an underwater diver, with a mask and goggles.

Beckett walked over to the room and cracked the door so Salinas could hear him.

“Do your job,” he said, eliciting laughs across the unit.

Salinas emerged from the room and glanced at the drawing.

“You’re very good with a pen,” he said. “That’s awesome.”

By all accounts, this was a good night for the nursing staff members. The shift had been largely uneventful, with no admissions, emergency codes or deaths.

These were the kinds of nights they hoped for.

The following week, after Memorial Day weekend, the pace was frenetic.

The COVID ICU was full — there were 12 patients, seven more than on that slow night. Five people had been admitted over the last two shifts. All but two were on ventilators.

Screens above the nurses’ station displayed how long the patients had been hospitalized: Four days, two days, one day, 22 hours, 13 hours, one hour.

Tonight, there was no point in monitoring possible ER admissions. Any new patient would have to be transferred elsewhere. Every bed also was taken in the lower-level COVID unit, which handled patients who weren’t as sick. If someone there began to deteriorate, Beckett could take them on. But he would be across the hospital, without access to rescue supplies and unable to perform his charge nurse duties.

“If one of those goes south, I don’t have anywhere to put them,” he said.

In Beckett’s mind, the crush of patients had to be related to the reopening of businesses. Over the holiday weekend, his friends had invited him out to the Comal River. He had declined, but he’d seen pictures of the scene on Instagram. It had been packed.

“I’m already hot and sweaty,” nurse Adam Alvarado said, less than an hour into his shift.

A harried day side nurse, Marisela Martinez, sat at a computer nearby, an hour after she was supposed to clock out. A new patient had come in just before the shift change, and she still had work to do before she could go home.

“What’s up, Mari?” Denton asked her just before 8 p.m.

“This is bad,” she answered. “This is not even Memorial weekend.”

“It’s not,” Salinas said.

“Wait till two weeks after Memorial weekend,” Martinez said, mentioning gatherings she’d seen on social media.

“It’s going to be bad.”

As Martinez prepared to leave at 8:40 p.m., nearly two hours after the end of her shift, she turned to Salinas, who was taking over for her. The patient wasn’t doing well.

“Frank, you need to call the family. Just in case,” she said.

“I’ll do it now.”

Forks of lightning flashed through the windows, and thunder rumbled overhead. Rain began to lash at the glass.

Salinas called, but there was no answer. He left a voicemail.

He hates these calls. The families always ask if the patient is going to get better. He tells them to be ready to come to the hospital. Just in case.

Shortly before 9 p.m., Salinas entered a patient’s room. It wasn’t long before he was back at the door, rapping at the glass to get Beckett’s attention. Something was wrong.

The patient’s left eye was swollen, as if from a punch to the face. Air from the ventilator was escaping into the patient’s face, neck and torso.

Salinas was joined by Nguyen, the respiratory therapist. Outside, Beckett was on the phone with the electronic ICU, which helped monitor critical patients overnight using cameras in their rooms. The staffers in the room couldn’t communicate well through their respirators.

“This looks pretty bad,” Beckett said.

Outside, the storm was worsening. There was another loud clap of thunder.

Within minutes, a technician was rolling an X-ray machine into

the unit and donning protective gear outside the patient’s room.

“Look at all that air,” Nguyen said when the scan appeared on a screen.

Outside, another nurse handed Salinas a phone.

“Hey Frank, it’s EICU. They’re making changes.”

Nguyen went back into the room, dialing down the pressure settings on the ventilator. If it helped, the patient would remain that way for the night. Otherwise, a doctor could be called in.

A half-hour later, the patient seemed to be doing better. Salinas stood at the door, watching Nguyen work inside. She drew a vial of blood for tests.

He often had a smile on his face, but now he was serious.

The clock ticked past 11 p.m. It still was early.

Alvarado prepared to transfuse a unit of convalescent plasma into a patient. Drawn from someone who had recovered from the virus, the plasma contains antibodies to combat the virus.

“200 cc’s of the juice of life,” he said, before hanging the plastic bag on the IV stand.

Across the unit, a clear liquid was seeping out from under a door and into the hall, an apparent leak from a dialysis machine. Three nurses began mopping up the mess with towels, a task made more difficult by the maze of wires and tubes extending from the patient’s bed.

Two doors down, Nguyen was assisting Denton and another nurse as they moved a patient to a new mattress to help prevent the formation of pressure ulcers. They rolled the old bed outside the room, placing a sheet of paper on top of it.

“DO NOT TOUCH,” the handmade sign warned. “CONTAMINATED!”

Tonight, there wasn’t a moment to spare in the unit.

To Denton, it seemed that in the world outside the hospital, people were “out in force,” many without face masks. With bars and businesses opening back up, he’d observed an uptick in auto traffic over the holiday weekend, crowds at the rivers. There was talk of reopening water and theme parks.

By mid-June, close to 150 people would be hospitalized for coronavirus in San Antonio, including almost 60 in ICUs, reaching the highest daily totals yet. In just a week, Bexar County would see more than 1,000 new cases, a worrying trend that officials called a second wave. Across Texas, hospitalizations would surpass 2,100.

People didn’t seem to be taking the virus seriously, Denton thought. They were acting as if the pandemic was over.

For the nurses, there was no end in sight.

Photos by Bob Owen / Staff photographer Nurse Monique Capps hands a mouth-moistening sponge tip to a COVID-19 patient at Northeast Baptist Hospital.

Charge nurse Sam Beckett, who oversees night operations in the Northeast Baptist ICU, takes a brief break.

Photos by Bob Owen / Staff photographer Nurse Evelyn Menking, left, works on a COVID-19 patient in the Northeast Baptist ICU while overnight charge nurse Sam Beckett watches through a window.

Nurse Frank Salinas, left, gets assistance from nurse Marisela Martinez. Nurses often will help from out in the hallway.

Photos by Bob Owen / Staff photographer Nurse Raymond Garcia tends to a coronavirus patient. When the virus first began spreading in the city, Northeast Baptist was treating COVID-19 and little else.

Frank Salinas, an ICU nurse at Northeast Baptist Hospital, administers an injection to a COVID-19 patient.

After moving a COVID-19 patient to a new mattress, hospital staffers place a sign on the old one as a warning that it still needs to be disinfected.

Nurse Raymond Garcia removes his stethoscope as he checks on a COVID-19 patient. Staffers must wear personal protective gear while working with the patients.

Nurse Evelyn Menking, wearing a respirator and face shield, pulls on a protective gown.