Recovery remains tightrope between hope and despair
Experience fighting the virus improves outcomes for many of the critically ill, but it’s still a battle for everyone involved
SAN JOSE >> In the Emergency Department at East San Jose’s Regional Medical Center, beds spill into the corridors. The waiting room is nearly full and, as the second wave of the coronavirus pandemic surges, so is the COVID-19 ward on the second floor.
In the intensive care unit during Thanksgiving week, patient after patient in glass- walled rooms lay sedated, thick ventilator tubes running down their throats — a grim scene at the Bay Area’s hardest hit hospital. And perhaps nobody better represents the balancing act of heartbreak and hope more than Juan Flores.
Earlier this past week, in the last room in the back corner of ICU East, the 68-year- old patient in a bright yellow hospital gown was sitting up and looking through the glass. He had no ventilator, just an oxygen tube
connected to his nose. With a surprising grin, he waved.
At that moment, Juan Flores was thankful. By Thanksgiving Day, when his oxygen levels plummeted, he too was intubated.
Hospitalizations are surging in the Bay Area, forcing new restrictions and mandatory quarantines on Saturday in a desperate act to keep the infected from overwhelming hospitals.
But doctors and nurses have learned so much since the first surge of the pandemic hit in the spring that patients are faring better than the ones who ended up here when the pandemic began. Steroids that doctors had been reluctant to use are now proven to work. The antiviral Remdesivir is readily available. And for many patients, less in
‘With the advances in ... understanding of the disease, the length of stay for these patients is less.’
— Dr. Paul Silka,
Regional Medical Center’s head of the Emergency Department
trusive BIPAP machines and high-flow nasal cannulas are pushing enough air through the nose to open the lungs, keeping them off ventilators and out of the ICU.
Flores “came in ver y sick” two weeks ago with heart problems and diabetes.
“Had he come in March or April, he would have been intubated on Day 1,” said Dr. Kashif Hassan, a critical care specialist who is in charge of Flores’ care. “We are more experienced now.”
Last spring, Regional Hospital was ground zero for the pandemic across the Bay Area, peaking at 67 coronavirus patients a day in April. By June, the numbers were down to single digits. Now, though, they’re back up to nearly 60 a day. About 10 new cases arrive each day in the Emergency Department — so many at times that ICU doctors are called in to help.
At the pandemic’s onset, “it was so doom and gloom and crash and burn,” said nurse Liz Thurstone, who works in the second floor COVID-19 ward. During the first wave, she remembers routinely rushing to “three Code Blues before 10 a.m.” to try to resuscitate patients. Now, “there’s an element of fatigue, but we’re in a much better place in treating patients.”
Families of COVID-19 patients are still not allowed to visit their relatives. But one afternoon last week, before Flores was intubated,
Dr. Hassan wheeled an ipad on a pole to Flores’ bedside. His 40-year- old son, Israel, was on FaceTime, asking how he was feeling.
“Eight. On a scale of one to 10, eight,” Juan replied in Spanish, saying that after 10 days in the ICU, he was feeling better every day.
What happened to the Flores family is typical of how, especially in the heavily Latinx and Asian community of East San Jose, the virus is spreading. Three generations of Flores family live together in a three- bedroom, one- bath house in East San Jose, including Israel and his wife and three children.
Israel, who works as a supervisor for a painting contractor and moves among job sites every day, was the first in the family to test positive for the coronavirus in mid- October. He holed up in his bedroom, and his wife, Esther, and mother, Theresa, left meals outside his door. Everyone sanitized the bathroom every time they used it. But within a few days, as his wife and children got sick, Israel sent his parents to a hotel for a week. It was too late. They got sick, too. Juan, long- retired from his assembly line job at an electronics factory, felt the worst. He struggled with a sore throat, fever and body aches.
In touch with doctors, Juan tried to recover at home. But after two weeks, his breathing worsened and he became so weak, he doesn’t remember the ambulance taking him to the hospital. His blood glucose level soared.
“Watching the news, I’ve seen what a lot of people go through,” his son, Israel, said. “They go into the hospital and they don’t come out. I didn’t want to lose my parent.”
His second day in the ICU, Juan told his son, “We’ll see what God has for me. If I don’t come out of this, take care of everybody.”
Early in the pandemic, most of the patients coming into Regional and other hospitals were the elderly and frail, often from nursing homes where the crisis was hitting hard. Many ended up adding to the soaring death toll that now exceeds a quarter-million people across the country.
Now, though, “I can’t tell you the last time I saw a patient from a nursing home presenting signs of COVID,” a good indication that those patients are better protected now, said Dr. Paul Silka, Regional’s head of the Emergency Department.
Instead, patients coming through his department, either through the filled- up ambulance bay or the waiting room and tents outside, tend to be younger. They are often essential workers in their 20s and 30s with other health issues like diabetes, obesity or heart problems that make them sicker. But because they are younger, they tend to recover sooner and better than the elderly. Patients, well aware now of the severity of the virus, are also coming in sooner, and are less likely to be admitted directly to the ICU.
“In no way is there overconfidence, but we’ve done this before,” Silka said. “We’re at the stage of keeping up, and with the advances in our understanding of the disease, the length of stay for these patients is less and we’re seeing better outcomes.”
A Reg iona l spoke s - woman said it was difficult to see a clear downward trend in death rates over the nine months treating COVID-19 patients. But a study by HCA Healthcare, Regional’s parent company, found that death rates dropped from March to August at three New York hospitals, from 25.6% to 17.6%, after accounting for increasingly younger patients.
The median length of hospital stay was down from seven days in April to six in September.
Some of the improvements can be found on Regional’s second- floor COVID-19 ward, where patients routinely receive the steroid Dexamethasone to reduce inflammation in the lungs and get earlier access to less-intrusive breathing treatments.
“We’re trying to keep them afloat up here, so they don’t have to be intubated in the ICU,” Thurstone said. They don’t succeed every time — last weekend four patients were transferred down to the ICU. But for nurses who have been working the long months of the pandemic, donning and doffing protective gowns, masks and gloves each time they see a patient, “it’s gratifying to see people turn the corner,” she said.
In the early days, when lucky patients recovered and were finally released, hospital staff would line the hallways as the wheelchairs of survivors passed and, like at hospitals across the country, played the Beatles’ “Here Comes The Sun.” It was a triumphant hymn after beating the long odds against a deadly enemy.
At Regional, they don’t really play it anymore. With so many patients going home, the novelty seems to have worn off. And that’s not a bad thing, nurse Thurstone said. Maybe, she said, “it’s a sign of victory and progress.”
Until Thursday, it looked like Juan Flores was making progress, too.
His doctor, Hassan, said he was making “baby steps in the right direction.“
On Monday, with Hassan at his bedside, Flores was able to show his gratitude and choked up.
“Muchas gracias,” he said, then spoke in English, “T hank you ver y much, Doctor.”
But after more than eight months of battling the coronavirus, doctors know how things can turn quickly in the wrong direction. Now intubated, Flores hasn’t been able to speak since Thanksgiving, balancing, delicately, between heartbreak and hope.