Six weeks isn’t much time to prepare for a pandemic. Dr. Julie Trivedi saw it coming in January, or at least that’s when she noticed a rise in reports of strange respiratory illnesses in China. Trivedi is the medical director of infection prevention at UT Southwestern Medical Center, which operates the William P. Clements Jr. University Hospital. She started emailing a few administrators about what she’d found. By February, she was sending daily updates to more than 70 people within the institution.
There were cases of COVID-19 in Germany and Italy and Japan. It was spreading rapidly across Europe and Asia. Considering North Texas’ travel patterns, our region’s medical providers were already behind, through no fault of their own. It was a matter of when, not if. And of how severe, based on what elected officials were willing to do to limit social interactions. Dr. Daniel Podolsky, the medical center’s president, began informing business leaders and public health officials of what his research experts were seeing in the models. He was introducing what Dr. Trish Perl, Trivedi’s boss, refers to as “non-pharmacologic interventions.” Things like travel restrictions, possible business closures, physical distancing from others. The measures that are now as familiar as breakfast.
Inside the walls of the medical center, the staff was doing a different calculus. They would be providing care to a highly contagious population of patients who could not be exposed to others being treated for more common ailments. Intake and visitation policies changed quickly. A surge plan was developed, including the possibility of shifting some services out of the hospital where COVID-19 patients would be treated. Protective equipment was cataloged, more stringent processes defined. The emergency department was split so that confirmed and potential COVID-19 patients were isolated. Everyone who walked into the hospital had to wear a mask and get his temperature taken.
Perl assembled an in-house COVID-19 modeling team, and UT Southwestern became the regional leader in forecasting the future caseload. It climbed ever upward, another ascent for every loosened public policy. At press time, one day after the Fourth of July holiday, the medical center’s models anticipated a 50 percent increase in hospitalizations by July 16. That would mean more than 1,700 COVID-19 patients in Dallas and Tarrant county hospitals, pushing them to the limits of their capabilities.
All the while, the adversary was still not fully understood.
“If you said it was planned, everybody would know you were lying,” says Perl, the chief of infectious diseases at UT Southwestern.
Clements is one of the jewels of the Southwestern Medical District. The $800 million facility opened in 2014, about eight months before Parkland’s new hospital began seeing patients down the street. UT Southwestern staffs both teaching hospitals. The architecture at Clements—major investments in technology, airflow, and infection control—has made it somewhat easier to create an environment where COVID-19 can be treated.
It is also one of the world’s most respected research centers, meaning its patients—and Parkland’s—are eligible for clinical trials. Remdesivir, an old Ebola medication, has been tested here. In July, UT Southwestern announced that its scientists had a promising lead on repurposing a pneumonia drug called Atovaquone, which early experiments showed could disrupt an enzyme that is key to the coronavirus’s replication. When it comes time, they will have the patient population to test it.
Six weeks isn’t much time to prepare for a pandemic.
About a third of those hospitalized for COVID-19 qualify for these experimental drugs, Perl says. And anyone with breathing problems is now eligible to be treated with remdesivir. During a staff call in July, Podolsky announced that there were 145 research projects underway, everything from “basic efforts to understand how it infects cells and cell damage” to “new and novel approaches to therapeutics in clinical trials.”
Parkland has treated more patients than any hospital in North Texas, it being the county’s public hospital. But Clements has two dedicated COVID-19 wards that are populated with patients who sometimes have more complex cases, patients who have cancer or who have had transplants.
Beds for less-ill patients are on the 12th floor, while the ICU operates on the eighth. The total patient number at a given time has peaked at 61, about a third of the volume seen at the larger Parkland. Still, nurses work 12- and 13-hour shifts, monitoring patients whose vitals are so weak that even a small drop in oxygenation is cause for alarm. Providers spend up to four hours in ICU rooms with unconscious patients who need constant attention.
“These patients, when they get sick, it happens quickly,” says nurse Simon Platt. “You have to be prepared and ready to act.”
The 12-story hospital is shaped like a W, making it easier to partition floors and create smaller units with their own negative-pressure airflow. Some providers carry iPhones. HDTVs hang on the walls in each patient room, each equipped with an app called BlueJeans that one nurse called “FaceTime on steroids.” Families of some patients are connected 24 hours a day, even while they sleep. They can buzz the nurses themselves if they feel their loved one is uncomfortable.
The caregivers begin their days by donning their personal protective equipment. They wear two pairs of gloves and a gown. A hair covering called a bouffant goes over their heads. They pull light blue plastic coverings over their shoes. They choose between an N95 mask with a face shield or a powered air-purifying respirator (PAPR, pronounced “papper”) that looks like a scuba mask with a tube hooked up to a battery. It blows purified air into the wearer’s face. Which you wear is a matter of preference.
“What I care about is you know how to wear whatever it is you’re wearing,” Perl says. “A lot of the errors that occurred in the past with Ebola and SARS, it was not that the PPE failed, even though everyone wants to make you think that it was because they weren’t wearing an N95 mask or they didn’t have this or that. It was all about those errors we made when we were taking the stuff off that was contaminated.”
After doffing the PPE, caregivers put their N95 masks in a paper bag so they can be sterilized each night and used elsewhere in the hospital. Perl says the supply chain for PPE is 15 to 18 months behind the demand; what can be reused is. UT Southwestern provides scrubs so that none of the contaminants leave the hospital. The doctors and nurses are in this gear for most of their shifts, except during breaks for food and water. Caregivers said they undress in their garages or their driveways and rush to the shower afterward. The hospital offers to pay for hotel rooms for anyone needing to isolate from their families.
The cruelty of COVID-19 is in the details, in how the patients are kept away from loved ones, treated by nurses and doctors who are so bundled up in protective equipment that only their eyes are visible. One man told a nurse that his experience made him feel like he was in a zoo, people peering at him through glass. The patients struggle for air. They need what’s known as “proning,” the act of being turned onto their bellies to give oxygen a better chance at reaching the blood. Those patients often have lines inserted into their veins that provide medication. There’s a line for the bladder, a line for the nose, sometimes rectal tubes. The nurses have to make sure all that stays put during the turn. Some patients are hospitalized for over a month, breathing tubes snaking down their throats.
The ICU nurses meet unconscious victims, piecing together details of who they are through distanced conversations with family members. The nurses in the regular unit keep watch over blood oxygen levels. If they change, the ICU is alerted so they can prepare to take on a new patient if need be.
Then there are the symptoms. The common ones—cough, fever, difficulty breathing—are expected. But there are also cardiovascular issues. There can be blood clots. Clements doctors have found abnormal liver function in about a third of their patients. Diagnostics are key: they watch inflammatory markers through lab work and catch clots in ultrasounds. The infectious disease doctors run the show, provide therapies through the clinical trials, and make sure the disease doesn’t spread to caregivers or other patients. The COVID-19 patients might be intubated, but their care is still an active process.
The cruelty of COVID-19 is in the details, in how the patients are kept away from loved ones, treated by nurses and doctors who are so bundled up in protective equipment that only their eyes are visible.
This is a complex disease requiring a multidisciplinary approach. Hematologists treat the vascular problems. Cardiologists take care of the clotting. Some patients require neurologists. Pulmonologists ventilate the patients. It is not just, as Perl puts it, “the weird and the wonderful” that get attention from all over the hospital.
“It’s a fascinating disease,” Perl says. “The fact that they get blood clots is weird. If you’d ask me, do people who have infections get blood clots? I’d say no. But there are different manifestations of this disease.”
Nurses perform most of the hands-on care, dressed like they’re cleaning up a chemical spill. Normally they’d go into patient rooms three to four times an hour. Now that’s reduced to three to four times a shift. Patient notes get written on glass with marker: the day and time the patient was proned, whether he has been given convalescent plasma, oxygen levels. Nurses can’t distance physically. Nursing is tactile. They provide reassurance and comfort. And now they’re hidden behind layers of plastic.
Nurse Daniel Luterman tapes to his gown a photo of himself with his 13-month-old daughter before entering the patient’s room. “It allows them to know there’s a person behind this mask and that I’m in there to care for them,” he says.
Nurse Neeley Borden uses physical touch to reassure her patients on the eighth floor. “I try to get close to them so they can see my eyes,” she says. “I want them to feel my hand in theirs to let them know I’m there.”
Assistant nurse manager Amy John stands outside a window with her mask off to allow the patient to see her before she goes in. “So it doesn’t feel like such a stranger is taking care of them,” she says.
Assistant nurse manager K. SheRon Ellis works in the ICU, where many of her patients are intubated. She applies that attention to the family members, using the BlueJeans software to make sure they see their loved one. “Being able to see them, being able to see the nurses, being able to watch the care that is being provided is a very significant thing,” she says. “We use the family members as a connect point until we get the patients to a point where we can connect with them directly.”
Some, of course, do not reach that point. Perl says that Parkland and Clements have “very, very low mortality” rates, but UT Southwestern declined to provide specific data. However, when death does come, the nurses are the family’s guides. Perhaps the disease’s cruelest effect is that it isolates the sickest from their loved ones. There are no visitors here; the goodbyes happen through a screen, oftentimes to a patient who is not awake.
“Their family members, they become my family,” Luterman says. “I know what it’s like to lose someone in my immediate family, and that’s what a nurse’s job is to do—care for everyone.”
Because a patient’s vitals can drop so rapidly, death is always a possibility—particularly in people who have been intubated for weeks. A ventilator outside a room is usually a bad sign. Luterman finally got a long weekend not long ago and came back to that scene outside the room that had housed one of the hospital’s sickest patients. He’d cared for her through her whole ICU stay, talking to her daughter each day. She wasn’t conscious, but the nurse felt he knew her. Now he was sure she was gone. He composed himself enough to peek his head in. She was sitting up, chatting with her daughter through the screen.
“Before that shift was over, I transferred her up to 12, out of the ICU,” Luterman says. “Having that feeling, that is one of the best feelings you can have as a nurse. Taking somebody who you’re not sure if they’re gonna make it, then knowing they’re gonna be just fine.”
All the nurses have stories like that. And they all have others that don’t end so brightly. They will have more. As this story went to print, Dallas County added a record 7,771 cases over the past week. On June 9, 257 people were hospitalized for COVID-19 in Dallas County. By July 9, that number was up to 699, an increase of 172 percent.
As the numbers climb, the nurses and doctors at Clements will put on their masks and their gloves and their gowns and prepare for another day just like the one before it. They will introduce themselves to new patients through the glass, pointing to photos of themselves without a mask. And they’ll hope, with their care, that it’s the start of one of the good stories.