UK HealthCare: 'Voices from the Front Lines' — Kentucky Children’s Hospital/Labor & Delivery

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 the fourth and final chapter 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. (Nov. 3, 2021) — In the early days of the pandemic, there seemed to be the slightest of silver linings — children were mostly spared from the worst complications of COVID-19. Infection rates in children were low, and most who contracted the virus were asymptomatic or developed only mild symptoms, such as coughing or congestion.

“In the first go-round (of COVID-19), we were very prepared,” says Abby Holmes, clinical nurse expert in Kentucky Children’s Hospital’s pediatric intensive care unit (PICU). “But when the first wave didn’t really affect kids, we just got back in our routine of taking care of normal day-to-day ICU patients.”

But when the delta variant of COVID-19 began rapidly spreading across the country, everything changed. Not only did SARS-CoV-2 become much more contagious, it was causing more severe complications in younger and younger people, including a sizable number of patients under the age of 18. While most adult COVID patients are taken to the medicine intensive care units (MICUs) on the ninth and 10th floors of Chandler Hospital Pavilion A, children under the age of 18 with COVID are brought up to the acute care or ICU units in Kentucky Children’s Hospital (KCH).

Since July 30, KCH has seen a sixfold increase in pediatric patients with severe COVID compared to the prior 16 months of the pandemic. Patients in KCH have ranged in age from premature newborns — born to COVID-positive moms — up to young, college-age adults. Not only are there more young inpatients, but the ones who come in now are far more ill than the children treated by the team prior to this surge. At one point during the surge, seven of the 16 beds in the PICU were filled with severely ill COVID patients.

“With the delta variant, we’ve had sicker kids this time around,” says pediatric nurse Jenna Shanks. “We’ve had more (very sick kids) than I’ve seen in the three-and-a-half years that I’ve been here, even with non-COVID-related issues.”

Treatment for these young patients often focuses on respiratory support. Some may get by with supplemental oxygen from a nasal cannula or a BiPAP or CPAP mask. Others have needed a ventilator, proning or even extracorporeal membrane oxygenation (ECMO) to support their lungs — a stark contrast to the earlier waves of the pandemic.

“With the intubated kids, we are seeing ventilator settings we’ve never seen before, just because their lungs were so sick,” Holmes said. “That was a little intimidating and scary — even for us — to look at a ventilator and see some of those numbers.”

Children who come to KCH with COVID are allowed to have one parent or guardian stay with them, but that person must remain in isolation with their child to prevent the spread of the virus. This means the parent is completely reliant on the health care staff for all their needs, as they are not allowed to leave their child’s room.

“They rely on us to bring them everything, whether it be an extra blanket or something to eat or drink,” Shanks says. “We tell them that we’ll be in there as much as we can be, but unfortunately it’s not enough — and if you need anything, hit the call light and let me know.”

But treating COVID patients is not easy, and the time needed to don/doff personal protective equipment before seeing each patient adds up. As one of only two children’s hospitals in the state, KCH has always been extremely busy, even prior to COVID. But the extra resources it takes to care for COVID patients makes it extremely difficult on an already busy staff.

“When they ask for something, you definitely try to do it, especially in these rooms where they can’t come out,” Shanks says. “And I want to give them something before they even ask, because I know how hard it is for parents to ask for things. My heart just breaks because there’s times where I go home and I realize I forgot to give them something as simple as a juice box.”

In addition to the influx of COVID-positive children, the pediatric units have also been overwhelmed with an increase in other illnesses like RSV (respiratory syncytial virus) and bronchiolitis. Normally, “respiratory season” begins around October, but this year, it came early. After more than a year of limited contact with other kids, these infectious diseases increased dramatically this summer as children resumed most in-person activities.

“Generally speaking, the ICUs are calmer (in the summer),” says Chelsea Kindel, a pediatric respiratory therapist at KCH. “But we never got a break this summer. The adult providers have not had a break, either. We’re exhausted. I work with some amazing, selfless hardworking coworkers, and to be honest, I don’t think that I would be standing here if it wasn’t for them.”

Prior to the arrival of the delta variant, KCH staff treated very few actual COVID-positive patients, but they did see several cases of multisystem inflammatory syndrome in children, known as MIS-C. This rare but serious condition causes inflammation in various organs of the body.

Though the exact causes of MIS-C are unknown, it occurs in children who have had a COVID infection, even if that infection was mild. MIS-C can resemble sepsis, or even a severe COVID infection, and it typically shows up six to eight weeks following an initial COVID infection. With so many more pediatric COVID patients coming in late this summer, Holmes says the staff is preparing for a potential increase in MIS-C patients, possibly beginning in the coming weeks.

“We're still waiting around for that spike and that secondary inflammatory response, and a lot of those kids previously ended up at the ICU,” Holmes says. “I am fearful of what's going to happen in the winter, because those are our busier respiratory months. Then we're putting COVID and MIS-C on top of it and on top of an already very busy hospital with staff that is emotionally and physically drained.”

‘‘Devastating’ is really the only word’

Severe COVID-19 has also been on the rise in another specific high-risk population — pregnant women. The Centers for Disease Control and Prevention lists pregnancy as a high-risk factor for developing complications from the disease. In fact, pregnant women are three times more likely to end up in an ICU due to severe COVID-19 compared to non-pregnant women.

Some COVID-positive pregnant women are able to be treated in one of six negative-pressure rooms in the UK Birthing Center inside Chandler Hospital, as long as their disease hasn’t advanced too far. But the sickest moms-to-be are taken to a MICU for more advanced care, including ventilators, or to the cardiovascular intensive care unit (CVICU) if they need ECMO.

Contracting COVID-19 is dangerous not only for the mom, but also for her unborn child — UK HealthCare has seen a sizable increase in the number of premature deliveries that have been necessitated by the mother having severe COVID-19.

“The baby is being oxygenated by the mom,” says UK labor and delivery nurse Colleen Honey. “So if mom isn’t have a good exchange of oxygen, then the baby’s not having a good exchange of oxygen. We don’t want to deliver these babies early, but sometimes we have to.”

In the worst cases, babies have been delivered prematurely to try to save the life of both patients. UK’s Birthing Center has converted one of its three operating suites into a COVID-only suite to handle these emergent situations for patients on that floor.

However, for the extremely ill COVID patients in the MICU, there have been times when the mom has been too unstable to move into an operating room on another floor, and the staff have had to perform emergency bedside C-sections.

“We attend any high-risk delivery so we can be there if the baby needs help with resuscitation,” says Alicia Chenail-Friend, a physician assistant in the neonatal intensive care unit (NICU). “Now we are often getting called up to the adult ICU floors, which are a long way from the NICU, just to be there at the bedside of the mom. So if mom doesn’t do well, they’ll do a C-section and then we’re there to be able to take care of the baby.”

After the C-section, moms remain isolated in their negative-pressure rooms, where they will hopefully recover — many pregnant COVID patients’ oxygen levels improve quickly after giving birth. Meanwhile, the premature babies are whisked away to KCH’s NICU, which is equipped to handle the special needs of these delicate, fragile newborns.

Occasionally, babies born to COVID-positive mothers will also have COVID, known as vertical transmission. However, the real issue for these patients is their prematurity — especially for babies who have been delivered extremely early.

“A lot of these babies (born in the second trimester) can have breathing issues or developmental issues,” says Mandy Brasher, M.D., a fellow in the NICU. “They’re at risk for having bleeding in their brain, and they’re at risk for intestinal complications as well.”

When mom is COVID-positive and her newborn is not doing well, they must remain separated in their respective ICUs — a heartbreaking but necessary decision that ensures both patients can get the care they need.

“In a lot of situations when the mothers have COVID, we can’t allow them to come into the NICU where we have so many extremely ill and very delicate infants who would not survive contracting COVID,” Brasher says. “The social strain on both the infant and the parents has been incredibly severe.”

“You’re lucky if you have a COVID mom who is not super sick, she gets to keep the baby with her, and the baby does fine,” says Gina Barber, a neonatal nurse practitioner in the NICU. “But some of those babies get sick or need respiratory support. They come here, and it’s 10 days before either parent can come visit — they’re missing the first 10 days of their baby’s life.”

Tragically, some of the newborn patients born to COVID-positive moms have simply been too ill to survive. And although most mothers’ health improves after delivery, some have died before even getting the chance to hold their baby.

“We’ve had babies who were born because their mom is sick and they’re really premature, or who were just born really sick,” Chenail-Friend says. “And despite everything we’ve done, we’re not able to save them … ‘devastating’ is really the only word.”

“Seeing the situations that we have — where babies are separated from their mothers, and some mothers die without ever holding their babies — it’s just heartbreaking and something I would never wish on anyone,” Brasher says. “It’s so sad. It’s just so sad.”

‘You don’t ever want to see your kid lying in a hospital bed’

Encouraging COVID vaccinations in these specific populations — children and pregnant women — has become a priority for the providers, who are alarmed at the number of unvaccinated, extremely sick patients who have required extraordinary medical measures to survive these past few months. All of KCH’s pediatric patients have been unvaccinated, and nearly all of the most severe cases of COVID-19 have occurred in children over the age of 12 — meaning they were eligible for a shot. With the Pfizer-BioNtech vaccine now authorized for use by the Food and Drug Administration and endorsed by the CDC for children ages 5-11, KCH staff hope more parents will take the initiative to protect their kids.

“If people walked around the PICU, you would see that most of our COVID patients are ones that can't protect their own immune system — and even some of our kids have had no past medical history. They've never been sick a day in their life other than the common cold,” Holmes says. “What I would say to parents is that you don't ever want to see your kid lying in a hospital bed. And if there's one thing that you can do right now, it’s to get them vaccinated.”

For pregnant women, the staff understand that the decision to get vaccinated can be a tough one — when you’re responsible for the health of another human being, it’s reasonable to have some initial reservations about a new medication.

“The hesitancy that some of these moms have is because they’re pregnant and they’re scared, you know?” Honey says. “I think that we have to try to give them a little grace and acknowledge that, but also encourage them to get the facts and learn the risks of not getting vaccinated.”

“There’s a lot of misinformation, a lot of mistrust,” Barber says. “But the people who are taking care of you are medical professionals — we got into this to help people. Trust your doctor. Trust the people whose goal is that your health is good.”

Katie Vignes, M.D., is a current fellow in maternal-fetal medicine specializing in high-risk pregnancy, and she has helped care for pregnant women with COVID since the pandemic began — even as she herself was pregnant. At week 26 of her pregnancy, she chose to get vaccinated, a fact she regularly shares with many of the unvaccinated pregnant women she sees in clinic. Although she trusted the science and data behind the vaccine’s safety, it was caring for a close friend who had become dangerously ill while pregnant that truly solidified her choice.

“I remember caring for her as part of her care team and seeing her through FaceTime while she was in the ICU and seeing her struggle to breathe,” Vignes said. “Whenever I saw her struggling, I knew that I had to protect myself. I had to eliminate any chance that I would not be available for my children.” 

According to the CDC, roughly two of every three pregnant women are unvaccinated, a statistic the health care providers hope to change. For these moms, the safest option for their health — and that of their unborn child — is to get the vaccine.

“The sickest pregnant moms (who have lost babies) are young and healthy, otherwise, but they contract COVID and are unvaccinated,” Chenail-Friend says. “And it’s just devastating to know that if they had the chance to get a vaccine, their babies would be alive today.”