UK HealthCare: Voices from the Front Lines — Medicine Intensive Care Units (MICUs)
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 two 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. 18, 2021) — UK HealthCare nurse Kendall Pfister has a vivid memory from one of the previous surges of COVID-19: a middle-aged patient whose heart simply … stopped.
Shortly after the patient arrived in one of the medicine intensive care units (MICUs), Pfister says he was placed on dialysis, sedated, medically paralyzed and proned. When she returned to work two days later, she saw he was already maxed out on three powerful medications used to keep the heart going: epinephrine, norepinenephrine and vasopressin.
“One should be enough, right?” Pfister says. “But if you needed that many, we’re in trouble.”
During that same shift, the patient’s vitals began declining so rapidly that there was nothing the medical team could do. He died on his stomach, too unstable for the team to even turn over.
“All of these medicines (and machines) meant to keep you alive maxed out at the ultimate doses, and it’s still not enough,” Pfister says, incredulous. “It happened so fast. (The ventilator) was still running after his heart hit zero.”
Though treatment options for COVID-19 have improved since the novel coronavirus first appeared in 2019, there’s no “magic bullet” guaranteed to cure the disease. Experimental monoclonal antibody therapies have shown promise for preventing severe COVID-19 in people who have recently tested positive or been exposed. However, administering these prophylactic treatments takes a tremendous amount of resources, and they’re not easily accessible for many patients, particularly those who live in rural areas.
From the patient perspective, the overall treatment regimen for severe COVID-19 doesn’t look much different than it did last year: increasing levels of oxygen leading to a ventilator, proning, steroids, blood pressure and other heart medications, and antiviral medications. In the most extreme cases, patients may be given extracorporeal membrane oxygenation, known as ECMO.
Clinical pharmacist Melissa Thompson-Bastin works in the MICU in pulmonary critical care. She sits on UK HealthCare’s COVID-19 subcommittee, which meets regularly to make decisions about which drugs and therapies UK will offer patients. The committee is constantly reviewing the latest literature about which drugs appear to be more or less effective against COVID-19 so the medical team can adjust its treatment protocols.
“Every month, there’s just a ton of stuff to review to make sure we’re keeping up with the best evidence,” Thompson-Bastin says. “It’s like drinking out of a fire hose.”
Ultimately, 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.
“The vaccine is the only drug that really works for COVID,” Thompson-Bastin says. “If you come into my ICU, we’re going to give you these other drugs that don’t work as well, but it’s all we have.”
With the current standard of care for severe COVID-19, many patients still die. Those who survive the ICU face a long, grueling road to recovery. In 2013, UK HealthCare launched an ICU Recovery Clinic — at that time, it was just the third such clinic in the nation. The multidisciplinary team of health care providers in the clinic helps patients work through the extensive ongoing care they need after a serious illness.
Prior to COVID-19, the ICU Recovery Clinic saw three to four new patients each month. Now, the staff are seeing anywhere from 12 to 20 new patients per month — many of them younger and struggling to navigate their “new normal” in the aftermath of COVID.
“Their brains don’t work, their bodies don’t work, they have all these new medicines and they all have PTSD,” says Ashley Montgomery-Yates, M.D., a critical care physician and UK HealthCare’s chief medical officer for inpatient and emergency services. “I don’t think people understand that — they think you go to the hospital, you get COVID, you get better. But that’s not how this works. A lot of these deficits are recoverable, but it takes a year to get you better.”
‘It’s sad to see so much taken from these people’
Most adult COVID patients are assigned to the 9th and 10th floors of UK Chandler Hospital Pavilion A, the home of its multiple MICUs. During the latest surge, the average age of hospitalized COVID patients has trended dramatically downward. Walk through the hallways of these floors now, and you’ll pass room after room of young and middle-aged adults — people in their 20s, 30s, 40s, 50s. Many only had minor, everyday health issues, like asthma or high blood pressure.
“During the first surge, we saw people who were either elderly or severely immunocompromised, which was still sad and terrifying,” says nurse Corie Roberts. “But now, you’re having people come in who are younger than you — I mean, I’m 29 years old. When you have a patient coming in who is 22, 23 years old with COVID and you know how it plays out, it’s terrifying and heartbreaking. It’s sad to see so much taken from these people.”
“There doesn’t seem to be any pattern to these patients,” says nurse Betsy Anderson, who has worked in the MICU for eight of her 21 years at UK. “The only pattern here that I’m seeing is that most of the people we have are unvaccinated.”
In the earlier days of the pandemic, patients’ health tended to decline gradually, with symptoms worsening over the course of weeks. Now, with the delta variant, the decline into requiring dramatic, life-saving care happens quickly.
“A lot of them get sick very fast,” says Hassan Yousaf, M.D., a fellow working in the MICU. “They’ll come in on day one, then day two they’re already on the ventilator.”
The MICUs are something of a “catch-all” for seriously ill adult patients. While the cardiology, trauma and surgical services have their own ICUs, most anything else that needs very advanced care comes to a MICU: complications from diabetes, other severe respiratory illnesses, cancer, liver failure, sepsis, and much more.
When MICU beds are filled with COVID patients, that leaves fewer resources for people battling these other severe illnesses. And “resources” encompasses much more than having an ICU room — it includes having proper staffing to take care of that patient, medical supplies like tubing and masks, and even medications.
“Everyone is used to being able to walk into the hospital and get the care they need at any point in time,” says MICU clinical pharmacist Samantha Gauthier. “But now we’re utilizing every resource that we can to help those patients … resources are much more limited than people think they are.”
For example, it takes at least seven health care providers to prone a patient with COVID-19. Proning, or placing a patient on their stomach, can improve function in both the heart and lungs of patients who are experiencing respiratory distress. Proned COVID-19 patients are frequently on ventilators, often unconscious, and are frequently hooked up to myriad other tubes and machines — all of which require careful monitoring as the patients are being flipped. To be more efficient, a “proning team” makes rounds in the MICUs, flipping patients on a schedule.
But before any provider can step into a COVID-positive room, safety comes first: they must don their personal protective equipment (PPE), which includes a gown, gloves, eye protection and N-95 masks. Just prepping to go into a room can take several minutes, and the process must be repeated by doffing (removing) the used PPE and replacing it with fresh protection before the provider can attend the next patient.
“It’s not easy to take care of a COVID patient,” says Yousaf, who notes that he may see up to 20 patients on a shift. “If you’re spending just five or 10 minutes donning and doffing, that takes away a lot of time out of your day.”
Health care staff have come up with quick fixes and creative ways to make COVID care just a little simpler. Monitors and pumps are kept in the hallway outside of the room — the multiple IV tubes fanning out and snaking around the door to the patient, held aloft with hooks that are usually meant to hold catheter bags in place. Ventilators are now positioned so that respiratory therapists can see them from the hallways; telehealth cameras are positioned to focus on vital signs monitors, with the feed playing back on a screen at the nurse’s desk. Medical team members write notes on the clear glass doors with dry-erase markers so the rest of the staff can see updates without going inside.
Taking advantage of telehealth technologies has been crucial for the staff. In spring of 2020, UK HealthCare launched its Enhanced Care through Advanced Technology Intensive Care Unit (eCAT ICU), a virtual command center staffed with ICU nurses located off-campus. The eCAT ICU staff can teleconference directly into patients’ rooms, providing an additional set of eyes for monitoring patients and assisting the on-site staff with other duties, like charting and signing off on medications. They also set up virtual visits between patients and families.
“I can hit that (eCAT ICU) button and say, ‘Hey, can you keep an eye on this patient while I go to the next one?’” says Jennifer Alonso, a MICU nurse who works night shift. “They do frequent checks on us. If a patient isn’t doing well, we can alert them to keep a closer eye on them.”
In one corner of the MICU is another ingenious solution to a problem staff hadn’t dealt with prior to COVID: how to treat a patient who needs both a negative- and positive-pressure room. COVID patients are placed in negative-pressure rooms, designed for air to be sucked in and up through venting in the ceiling, which prevents potentially contaminated air from escaping into the hallway. But certain immunocompromised individuals need positive-pressure rooms to keep out airborne germs that could wreak havoc on their weakened immune systems.
The solution: take a dead-end hallway and build temporary negative-pressure antechambers that lead into the patient’s positive-pressure room. One antechamber remains functional, ready for future COVID patients who have this specific need.
“When we started this 19 months ago, nobody knew how to do this,” Montgomery-Yates says. “But it’s not that we’re necessarily doing anything different now, it’s that we have the resources, the equipment and the skill set to make these things feel a little more routine.”
‘We are tired of seeing people die every single day’
Just inside the main door to the MICU, a patient is taking her last breaths. She’s one of the many patients from the past year and a half who have been hospitalized for so long that the actual COVID infection is gone. There is nothing else the staff can do for her, and her family has made the heartbreaking decision to withdraw care.
She remains on the ventilator for now, the machine keeping her alive until her family can make it to the hospital. In the nurses’ station, a small electric candle flickers with a sign: "When this light is ON, please speak softly. Someone is saying goodbye." Most days now, it remains lit.
Being a witness to death never gets easier, but those who go into ICU care understand that it comes with the territory — most patients survive, but some do not. The level of devastation the staff have experienced on a daily basis throughout the pandemic — particularly during this latest surge — has steadily chipped away at their morale. MICU clinical pharmacist Samantha Gauthier works during the day and often as late as 11 p.m., her shift overlapping with both day and night shift health care staff.
“(We are) tired of seeing people die every single day, and it takes its toll on every single provider who takes care of patients,” she says. “There’s been days where there are four or five people dying at a time, and there’s nothing we can do.”
The highly infectious nature of COVID-19 means that when these patients are in isolation, no outside visitors are allowed due to the risk of exposure. Many families have had to say goodbye to their loved ones virtually, using the built-in telehealth monitors installed in every patient room.
But the staff is adamant — no patient dies alone. Respiratory therapist Kristina Oliver has been at the bedside of many COVID-positive patients as they’ve taken their last breaths.
“Sadness is something we deal with routinely, but unfortunately during COVID, it’s become very, very routine,” Oliver says. “Often, it’s just been a respiratory therapist and a nurse only in the room, and it’s surreal to be there and to know that you’re the last person to share in that person’s last moments. I can remember so many of their faces, so many of their names, and so many of their families on the TV screen … I don’t think I will ever forget.”
‘The sad part is, this was all preventable’
Yousaf is just one of the many providers who shared anecdotes about patients who realized, in hindsight, they should have gotten the vaccine.
“(I have treated) younger patients, anywhere between 30 to 60 years of age, and I would ask them if they’d been vaccinated or not,” Yousaf says. “And they would tell me they were not vaccinated, but that they want the vaccine right now. But it’s too late at that point. The sad part is, this was all preventable.”
“There’s so many people coming in who are unvaccinated,” Pfister says. “They’re young, maybe tentative (about getting the vaccine) because of misinformation out there. But then they ended up here, fighting for their life.”
Some patients may only spend a matter of days in in the MICU, while others may be there for months on end. The lucky ones who survive are weaned off a ventilator, discharged and begin their long journey toward recovery.
But for some patients, even a ventilator can’t provide enough mechanical assistance to help their lungs heal. Some COVID patients are taken to the cardiovascular ICU (CVICU) for a drastic procedure to try to save their lives: ECMO.
Next time: a visit to the cardiovascular intensive care unit (CVICU), where the medical team places COVID patients on extracorporeal membrane oxygenation, known as ECMO.
To register for a COVID-19 vaccine (first shot, second shot or booster shot if eligible), go to ukvaccine.org.
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