The soundtrack of patient care on the second floor of a Methodist Hospital area still labeled “pediatric intensive care unit” comes from the ear-numbing sound of air-scrubbing systems hastily installed in each room.
Patients and caregivers raise their voices to hear one another over the powerful motors that clean and draw air out through massive air ducts running in the newly established COVID-19 intensive care unit day and night.
But because the scrubbers work to protect health care workers from the patients they are trying to save, helping to stop a contagious disease from spreading, they also clear the way for doctors, nurses, and therapists to give better bedside care.
“Initially we were seeing these people not like patients – we were treating them like people that could hurt us,” said Adam Sahyouni, a nurse manager overseeing the unit since its start in March. “We still take the enhanced precautions seriously, but if we need to go in every 15 minutes, we’re going in every 15 minutes.” That means wearing protective gowns, face shields, gloves, and caps.
“Now we’re not rushing,” he said. “We treat them the same level of excellent care that they would get if they were not a COVID patient. And that’s just been a big shift.”
Being able to spend more time in close proximity to their patients is a great relief to Sahyouni and others on the team. It’s one example of how, almost four months into battling the coronavirus pandemic, treatment is evolving even as frontline health care professionals cope with a sharp rise in the number of hospitalizations.
In San Antonio, the number of people hospitalized with COVID-19 has more than doubled in a week. On Sunday, Metro Health reported 406 people are currently hospitalized, with 133 in intensive care and 64 on ventilators. “These are trends we should be concerned about,” Mayor Ron Nirenberg said.
On a recent morning, Methodist Hospital in the South Texas Medical Center was treating a dozen patients, one in each “negative pressure” room of this retrofitted COVID-19 unit that looks much like any ICU. The center of activity was a nurse’s station, surrounded by patient rooms with sliding glass doors that allow caregivers to visually monitor their patients, some of whom rest in hospital beds while others sit in reclining chairs. Tray tables, IV poles, and other equipment line the corridor.
Unlike other ICUs, however, the entire team wears surgical scrubs they can change out of at the end of a shift before going home, and the many doctors, nurses, and therapists who work in the unit spend several minutes helping one another don yellow paper gowns and disposable gloves before entering a patient’s room. Masks are a given.
When the sliding doors open, the drumming and whirring noise from the air scrubbers flows into the hallway. On each door, in black marker, are notes about a patient’s status – but also heartfelt, hand-drawn posters left by patients’ family members, who aren’t permitted in the unit.
Staffed with hospital workers who volunteered to help treat COVID-19 patients, the unit is one of three isolated and off-limits areas at Methodist set up in response to the coronavirus pandemic, when it became clear many patients would need acute care. Personnel are tested if they experience symptoms, but none has become infected with the virus, Sahyouni said.
With a background in cardiovascular ICUs, Sahyouni has been working with Methodist’s COVID-19 patients since the hospital first opened a unit at one of its ambulatory surgery hospitals. He moved with the unit when it was relocated to the main hospital at the Medical Center.
In the few short months that Sahyouni said have felt very long, the team has cared for more than 200 COVID-19 patients. Staffers call him “Colonel Covid.”
But when asked how many of those patients have died, he said he prefers to count the “wins” – those who’ve recovered and walked out – than the losses, he said. Locally, 97 people have died.
One of those who recovered was a woman in her 30s named Esther who had been receiving treatment for over a month. When it was feared she might die, nurses created a Tik Tok video of them dancing to the music of her favorite band and played it for her. The video drew over a million views, and Esther improved.
“I really attribute her recovery to the nurses and everybody that did not give up on her,” Sahyouni said.
With some patients spending weeks in the hospital, loneliness and hopelessness can set in. The staff helps patients by connecting them to family via Facetime and by going the extra mile when they can. Sahyouni has a photo on his phone of a nurse giving one patient a pedicure.
“It’s hard on the nurses, it’s hard on the family members, and it’s hard on the patients that can’t see their family,” Sahyouni said. “We try and reach out to them as often as possible.” The doctors have a board in their office that has contact numbers and names of patients’ family members, and they reach out to them at least once a day.
Methodist is at the forefront locally of COVID-19 treatment using extracorporeal membrane oxygenation, or ECMO, which pumps a person’s blood through tubes to an artificial lung for oxygenation and returns it to the bloodstream, bypassing the lungs and allowing them to recover.
Dr. Jeffrey DellaVolpe, a critical care medicine specialist who oversees the ECMO program at Methodist’s COVID-19 unit, said that in cases where the lungs are no longer able to oxygenate the patient’s blood sufficiently, ECMO can be a life-saving strategy.
ECMO is not only improving mortality rates, it’s sparing the patient from the often-harmful effects of ventilator use. Patients on ECMO are able to remain awake and mobile, eat food, interact with others, and even some can venture outdoors in select cases, which contributes to a better recovery and fewer complications.
DellaVolpe has used the treatment with 27 patients so far. The only other hospital in the San Antonio area employing ECMO for COVID-19 treatment is the San Antonio Military Medical Center, he said.
As the pandemic has swept across the country, doctors and researchers have grasped at treatment options, relying on their interpretations of limited scientific data and their own experience, he said.
“Anyone who calls themself an expert is ill-informed,” said DellaVolpe. “We’re all trying to assemble and interpret the data and studies and experience we have. Our practice has evolved a lot in the last couple of months.”
Methodist is also participating in clinical trials for the drug Remdesivir and for plasmapheresis, a process that helps clean the blood, as well as using convalescent plasma and ECMO. But the limitations of those trials mean not every patient qualifies, and drug shortages remain a problem. Patients are not put on ECMO until doctors have an “exit strategy” planned for how and when they will come off the machine.
Now that doctors are beginning to understand COVID-19 better, “there’s really a lot of hope associated with treating the disease,” DellaVolpe said. But having enough staff available to care for the rising number of coronavirus patients is a concern, he said.
“We are staying afloat because of the staff – they are carrying a heavy load,” he said.
Several patients currently in Methodist’s COVID-19 ICU are no longer positive for the virus, including one man who has been on ECMO for over 60 days. However, they are still battling life-threatening infections and COVID-19’s effects on the cardiovascular system.
“One of the challenges that we’re having with COVID is to be able to make sure the blood stays anticoagulated – thin enough,” said Mark Gonzalez, the unit’s nursing director. “Patients are forming clots as part of the disease process. We’ve got normally healthy individuals with no comorbidities that are having massive strokes, just because they have a massive blood clot or heart ischemia blockages.”
That’s one aspect of the disease, he said, that makes it different from influenza. “This is definitely not the flu,” Gonzalez said.
Until recently, San Antonio’s hospitalization numbers during the pandemic had remained low relative to some parts of the country, giving local medical professionals and hospitals lead time to prepare, said Dr. Charles Burch, director of the COVID-19 ICU since it was activated.
But treating patients with the virus has been a steep learning curve. “The whole world is learning how to treat this,” he said.
Now a recent second surge of hospitalizations has forced Methodist to increase its capacity to 60 beds and purchase new negative pressure machines for every room on an expanded telemetry unit where critical care patients are admitted.
“We’ve been able to stay ahead of capacity issues, but it takes a lot of planning,” said Burch, who meets daily with hospital administrators to assess what’s happening locally with cases and how many patients are showing up in the hospital’s emergency room with worsening COVID-19 symptoms.
The hospital also has established a COVID-19 discharge clinic for survivors, Burch said. The clinic provides mental health care for those dealing with the trauma of a long hospitalization, as well as follow-up medical care.
“We have a flu season every year, and people can get severe lung failure from influenza [but] almost all of those fully recover,” he said. “We’re seeing these [COVID-19] patients in our office after they’ve recovered and we do testing of lung capacity, and even the ones that seem fully recovered, their lung capacity hasn’t returned to normal yet.”
It’s still early of course, so it may normalize, Burch added, but many in the health care world are concerned about possible permanent damage left by the virus.
“The unknown is what to expect,” he said.