UK HealthCare: Voices from the Front Lines — Cardiovascular Intensive Care Unit (CVICU)

We joined hospital staff for a few days in September 2021 to document the reality of treating COVID-19 patients across the hospital system. This is chapter three in our ongoing series, “UK HealthCare: Voices from the Front Lines,” highlighting stories and perspectives from our front-line workers who have been caring for our sickest COVID-19 patients since March 2020. For more from this series, visit https://ukhealthcare.uky.edu/covid-19/voices.

LEXINGTON, Ky. (Oct. 25, 2021) — Up on the eighth floor of University of Kentucky Albert B. Chandler Hospital Pavilion A, critical care nurse Charles Elliott stands just inside a patient’s room, carefully untangling and organizing multiple sets of IV tubing. The door is open and the September sun is beaming through the window, washing the room with soft light. It’s a sharp contrast to the dark reality happening inside: a young patient barely clings to life despite every possible therapy thrown his way.

This patient came in with COVID-19, but was hospitalized so long ago that he no longer has an active COVID infection. Like every other COVID patient currently on this floor, he is unvaccinated.

"By the time they get here, (the damage) is already done," Elliott says. "We’re just playing catch-up now and trying to give them the best shot we can."

The patient is on eight different medications, some to manage vital functions, some to keep him sedated and immobile. His ventilator is maxed out; he’s been proned. And he was brought to this floor for the very highest level of life support just to give him a chance at survival: extracorporeal membrane oxygenation, commonly known as ECMO.

With his lungs too damaged to properly oxygenate his blood — even with the ventilator working as hard as it can — additional mechanical assistance is needed. Tubes filled with dark red blood, nearly the size of a garden hose, peek out from under his blankets. They curl and wind down to a specialized machine adjacent to the bed.

Elliott squats down, pointing to a diamond-shaped device attached to the machine — the oxygenator, an artificial lung that functions like the real thing by adding oxygen to the blood. This patient has already depleted four of these devices, and his machine is running on the highest blood flow settings possible.

“He wasn’t doing well yesterday,” Elliott says, his voice growing quiet. “Now we wait.”

‘It’s a 50/50 shot at best’

ECMO is a therapy that gives the heart and/or lungs a chance to heal while a machine does the work for them. It’s most often used for patients who become critically ill from a disease or trauma that has ravaged the heart or lungs; many of these patients end up needing ECMO as a bridge that keeps them alive while their organs recover or while they await an organ transplant. During the pandemic, ECMO use has increased dramatically as more COVID patients experience severe lung damage from the disease.

“ECMO is kind of like science fiction for people who have no background in it,” says Aaron Harris, an ECMO specialist who has worked at UK HealthCare for more than eight years. “The way that it works with your physiology is a game changer. It offers an opportunity for people when there is no other option.”

ECMO involves placing large, thumb-sized cannulas in the neck and in the groin. Depending on where the cannulas are inserted (in an artery or vein), the system can do the work of the heart, lungs, or both. The machine takes the blood out of the body, adds oxygen and removes carbon dioxide, then returns the blood back to the body. This allows a patient’s lungs to “rest,” hopefully healing to the point where the organs can once again function without assistance.

However, ECMO isn’t the only thing keeping these patients alive. Most are also on ventilators, the machine forcing air into their lungs to help further boost their oxygen levels. Many are on dialysis because their kidneys have failed — a common consequence of heart and lung failure. They’re on feeding tubes for nutrition; catheters for body waste elimination. And that doesn’t even include the long list of IV medications that flow through the long tubing from pumps kept outside the door: painkillers, paralytics, insulin, blood pressure medications, and more.

Even with all these medical interventions, the CVICU team have seen a need to add in yet another option on top of all these modalities to help extremely sick COVID patients — proning.

“Sometimes we have to prone an ECMO patient, which is very dangerous,” says Carissa Smith, critical care nurse in the CVICU. “We didn’t think we could get more life support than ECMO and a ventilator, but then we started turning patients over. It’s definitely a last resort. It’s scary for everyone involved, but if it helps them, we’ll try it.”

Patients on ECMO and/or ventilators are usually sedated and paralyzed. While most people may assume this is done purely to prevent pain or discomfort, it’s also for physiological reasons — for example, a patient who shivers is using more oxygen.

“(A patient) could be sedated but might be able to move their arm or shiver if they’re cold, and that’s going to increase oxygen consumption,” Smith says. “If we’re able to paralyze someone, we can optimize how much oxygen we’re able to give, and decrease how much oxygen their body is consuming, to the best of our ability.”

While ECMO can be a miracle therapy that brings someone back from the brink of death, it’s also not a guarantee for survival. National and international data shows that the chances of a COVID patient successfully coming off of ECMO hover at around 50%. And the longer a patient remains on ECMO, the less likely their chance for survival.

“Generally speaking, ECMO is supposed to be a short-term therapy,” Harris says. “If your other organ systems start having problems, the chance of being able to come off ECMO dramatically decreases. It’s a 50/50 shot at best.”

While some COVID patients at UK HealthCare may only spend a few days in the hospital, many are there for weeks or even months. At UK, the average COVID patient needing ECMO stays on the circuit for two to three weeks, though some have remained on the circuit much longer. Even if a patient survives and is taken off the machine, they may continue to remain in the hospital much longer while they are weaned off a ventilator. These prolonged lengths of stay present new problems for patients and their families, both physical and mental.

“Any time someone is in the hospital, they run the risk of getting something called ‘ICU delirium,’” says CVICU physical therapist Angela Henning. “Anyone who is in the hospital a week or longer has a much higher risk for that. Our patients with COVID are the highest of the high risk for ICU delirium and confusion.”

Physical and occupational therapists play an important role in both the medicine intensive care unit (MICU) and the CVICU, coming in daily to check on the patient’s mental state as well as their physical state. When patients are brought out of sedation, the therapists are there to see if they can tolerate being awake and to gently reorient them into the world with basic questions. Sometimes, Henning says, patients are too weak to even nod "yes" or "no."

After lying in a bed for weeks or months on end, paralyzed and sedated, COVID patients also experience extreme loss of strength and flexibility. Throughout their stay, the therapists go in to patient rooms and carefully "exercise" their joints to maintain as much mobility as possible. As patients gradually improve and wake up, the team focuses on helping them build back the strength to perform simple functional movements, like lifting a leg or even just sitting up in bed.

“You used to see movies from the 80s where people would be in comas for years on end, and then they just get up and walk out of the hospital,” Henning said. “That doesn’t happen. If you’re in bed for a month, the likelihood of you being able to get up, stand, and walk unassisted is very, very, very low.”

Nevertheless, seeing ECMO successfully give someone a second chance at life is incredibly rewarding and affirms what they do, the staff says.

“Seeing people that I’ve taken care of finally come off ECMO feels like a big triumph for them and their family,” Smith says. “They get a lot of hope from that.”

“I love when we work together really hard, and a person we’ve taken care of wakes up and can look us in the eye,” Harris says. “And they know that we have been doing everything we can to try to save their life.”

‘A lot of us are just sad’

In the earlier waves of the pandemic, COVID patients who required ECMO would remain on the 10th floor of UK Chandler Hospital in one of UK HealthCare’s MICUs. The CVICU’s mechanical circulatory support staff would move up to the 10th floor to care for these patients.

However, the sharp increase in COVID patients needing ECMO during this last wave necessitated a change to this system. The CVICU, usually home to patients with severe heart problems, began taking on all COVID patients requiring ECMO.

“We had to create a whole new team that deals just with the (COVID) ECMO patients specifically,” says CVICU critical care nurse Alexandra Malone. “We’re seeing more ECMOs than we have ever seen.”

Prior to the pandemic, the CVICU housed one to two patients requiring ECMO on average. That number increased to eight simultaneous patients during previous surges of COVID, Harris notes. But during the latest wave, the team found themselves continuously giving the therapy to 10 patients or more at any given time for weeks on end, physically maxing out the number of patients who could receive the therapy due to equipment and staffing restraints.

It still wasn’t enough — at the peak of the last surge, ECMO had a waitlist that rose to double digits. There is an extremely limited number of ECMO beds available in the state — only six Kentucky hospitals are registered with the Extracorporeal Life Support Organization to use ECMO for adult patients. UK HealthCare is one of the only medical centers that has the staff and expertise to provide this kind of complex care to a large number of patients for weeks and weeks.

And with the delta variant, the ages of people needing this extreme therapy became considerably younger.

“The people on ECMO during that first wave were older, in their 50s and 60s,” Harris says. “Now, it’s dramatically different. The age range of people needing ECMO is between 20 and 50 years old.”

“They’re all unvaccinated,” says Malone. “And that’s hard because they are so young, and most of them were normal and healthy before this … and they’re just not recovering as fast as we would like them to and we just don’t know what will happen to them after all this.”

During the prior wave of COVID, Henning says the teams would do a chart review of each ECMO patient, looking closely at the patient’s history to figure out what pre-existing conditions contributed to them becoming so sick — compounding factors like age, obesity, hypertension, diabetes. Now, younger adults are arriving with only minor health issues, if that.

“We’re seeing these young patients who only have maybe anxiety — not big underlying health conditions,” Henning says. “And the patients I work with here, if they survive COVID, they’ll have debilitating weakness, cognitive effects and disabilities that can last weeks, months, years — maybe a lifetime.”

All of this has put a tremendous strain on the CVICU staff. ECMO can be a risky therapy, and the care for these patients is hugely labor-intensive, as they must be monitored by dedicated and highly trained staff 24 hours a day for complications like blood clots, bleeding, stroke and infections. But when a patient has an active COVID infection, staff aren’t able to immediately run into the room to help if something goes wrong.

“It’s very difficult to see someone become rapidly sick, to the point of death,” Smith says. “And I’m out here putting on a hat, gown and gloves (and other PPE), but I want to be in there with them, trying to help.”

During this surge, as soon as one patient would come off ECMO — whether it was due to that person recovering or dying — the staff would immediately begin the process of bringing in the next patient from the waitlist, desperately trying to give someone else a chance to live. This nonstop cycle has been beyond fatiguing, says Kevin Hatton, M.D., Ph.D., chief of anesthesiology critical care medicine at UK HealthCare.

“Our staff has been phenomenal. Every time we’ve asked, they’ve given,” Hatton says. “For me, the problem is that we’ve asked, and asked, and asked. And they’ve given, and given, and given. Our staff is wonderful — but boy, are they exhausted.”

“A lot of us are just sad,” Henning says. “And the saddest thing is that it seems like people just don’t care — if you’re not in the hospital or a health care worker, it seems like people really just don’t care what’s going on.”

‘Please don’t become one of the patients in our units’

Caring for ECMO patients isn’t just physically demanding — it’s also emotionally draining as well. Because patients remain on the unit for so long, the staff becomes well acquainted with their families, developing relationships that can become heartbreaking when the patients don’t respond well to the therapy.

“It can be very draining to take care of these patients and to emotionally support their families,” Smith says. “I’ve had trying times with families on the phone, discussing the chances their loved one is going to make it through this — those can be scary numbers.”

“As a health care provider, you try to put up a wall and only allow people in so far,” Harris says. “But you can’t help but enter into some of that suffering these patients and the families are going through. I don’t think you could be a person and not let that affect you.”

The most disheartening aspect of the latest wave is that not only are COVID patients younger and otherwise healthier, but that their life-threatening situation could have likely been prevented with one simple step: vaccination. Recent ECMO patients have included young, strong men, pregnant women and even children, who are treated down in Kentucky Children’s Hospital.

The one common factor among them all? None of them were vaccinated.

“There are still so many people who are adamant about not getting vaccinated, but they’re not seeing how it’s affecting everyone here, and how we are all fighting for people to stay alive,” Malone says. “It’s unreal how many people are getting sick — and getting very, very sick.”

Collectively, the team agrees — they love the work they do, and will always do their best to help patients to help patients with severe COVID, vaccinated or not. But while ECMO can be a game-changing therapy for COVID patients, the best treatment is prevention: the Pfizer, Moderna and Johnson & Johnson vaccines have proven to be extremely effective at preventing severe illness and death from COVID-19.

“Take the chances that you have to protect yourself and protect your family — vaccination, masks, social distancing,” Hatton says. “Please don’t become one of the patients in our units. Please don’t let your family become a patient in our unit.”

Next time: a visit to Kentucky Children’s Hospital, where staff treat children with COVID as well as another specific type of patient — premature babies born to COVID-positive mothers.

To register for a COVID-19 vaccine (first shot, second shot or booster shot if eligible), go to ukvaccine.org.