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TUCSON, Ariz. – As one of the city's largest hospitals battles to save its largest-ever number of critically ill patients, its COVID-19 intensive care unit is eerily quiet.
The only sounds are the beeps of machines and the shuffle of staff in protective gear entering and exiting rooms of people who lie sedated, eyes closed, with multiple tubes coming out of their mouths.
These patients at Tucson Medical Center are different from those who fell ill with COVID-19 in the early days of the pandemic. Those first cases were mostly patients in their 70s and 80s coming from nursing homes and assisted living facilities. Patients now arrive from the community at large, including younger, working-age people.
There are no get-well cards in the patient rooms, no balloons, no flowers and no visitors. There's no indication of who the patients might be aside from a few details – a pair of fuzzy, bright yellow socks on one man and french braids in one woman's hair.
The hallways, patient rooms and the COVID-19 operations center at Tucson Medical Center provide an inside look at what hospitals struggle with around the state: not enough ICU beds, a higher-than-usual number of sick employees, intense staffing challenges and frustrating delays in COVID-19 testing.
Months into the fight against COVID-19, there's no end in sight.
US coronavirus map: Tracking the outbreak
The silence masks a life-and-death struggle, as well as tension and desperation. As health care workers gear up to battle a mercurial disease inside those rooms, debates on mask-wearing and social distancing continue outside. So do debates on how aggressive Gov. Doug Ducey's policies should be to try to slow the virus's spread in a global hot spot.
The most recent spike in cases at TMC began in early June, when the hospital got 20 COVID-19 patients within 10 days from Santa Cruz County. That was about two weeks after Ducey's stay-at-home executive order expired and about a week after reports of Memorial Day weekend revelry.
"We opened up too fast," said Judy Rich, the hospital's CEO and a registered nurse. "We in the health care community were surprised, I think, at the speed with which everything opened up – the bars, the restaurants, the hair salons. It was all at once. There was no phasing here."
Last week, Tucson Medical Center had 75 patients with COVID-19. Twenty-eight of those patients were in the ICU, 25 of them on ventilators.
"We never expected that we would be at these kind of numbers in July," Rich said. "We have expanded our ICU by more than 50%. ... I think we're all adding as many beds as we can possibly push the system to add."
At this time of year, the average daily census in the ICU is typically 18 patients, said Mimi Coomler, the hospital's chief operating officer and a registered nurse.
Right now, the ICU has 41 patients.
COVID-19 is not taking up the most beds in the hospital; a total of 428 patients were in TMC on Wednesday. But the COVID-19 patients take increased manpower and stay for long periods of time. The record is 59 days.
"Staffing, which was not a problem in March and April and May ... is now the No. 1 issue. We are all being asked to open beds that we would not have staffed," Rich said.
The hospital, which has 4,500 employees, is dealing with an unprecedented number of workers who are sick or in quarantine. Last Wednesday, 66 people across the organization called in sick because they'd either tested positive or had symptoms.
Coomler said, "We've never had this many people out for the length of time that they need to be out of work because of an illness."
Hospitals are accustomed to being busy during flu season, but COVID-19 is different because of how sick some of the patients become, hospital officials said.
The staff is exhausted.
They've seen this level of patients before, but not this level of need.
Inside the ICU: 'Fewer people are dying'
Outside the hospital's chapel is a wall of hearts, representing the people who survived COVID-19. There are 130 cardboard hearts on the wall, and hospital officials said there are 30 to add.
An ICU nurse talked about making a similar wall of hearts just for the COVID-19 ICU patients.
"I think we are learning how to take care of them better. We are shortening our length of stay in the (COVID) ICU," Rich said. "More people are surviving a really terrible course in the ICU. ... Fewer people are dying here, without a doubt."
Inside one of the hospital's two COVID-19 ICU units on Wednesday, it was difficult to see who was making progress and who wasn't.
In one room, a patient on a ventilator was lying still on her stomach – a medical therapy called proning.
"It takes a team of about six or seven people, including respiratory therapists, to safely roll the patient onto their stomach. We have a lot of tubes and lines that we work really hard not to dislodge," clinical nurse specialist Angie Muzzy said. "They are at very high risk for injury to their eye, to their skin. … So we have to be very diligent about preventing injury to them."
Proning improves COVID-19 patients' oxygenation, Muzzy said. When patients lie on their front, the blood supply can get to the clearer parts of the lungs, she explained.
"They stay on their stomach for 16 hours, and every two, you tilt them just a little bit," she said. "Sometimes within the first 20 minutes, you watch a person whose oxygen levels were 88%, barely 90%, and suddenly they will be 95% to 100%. It's phenomenal. We know it helps significantly; it's just labor-intensive."
Muzzy was in good spirits on Wednesday. A COVID-19 ICU patient who had been taken off a ventilator the day before was about to be discharged from the hospital to go home. Another patient had just been discharged to a lower level of care.
The ICU unit, behind doors with red signs on them that say "STOP," is for the sickest of COVID-19 patients.
The patients, in their own rooms behind glass, are each connected to a catheter and to a medication IV, and they wear specialized leg braces to prevent blood clots. One man, who appeared to be in his late 60s or early 70s, had three tubes coming out of his mouth – a feeding tube, a suction tube and the tube for the ventilator.
The man was surrounded by pillows and tilted to his left side. He must be turned every two hours to maintain his skin integrity, since he's not moving around on his own, Coomler said.
In addition to ventilation, oxygen and proning, doctors prescribe the antiviral remdesivir and dexamethasone, a steroid, to treat COVID-19 patients. Sometimes blood thinners are used if the patient has clotting complications. They also use convalescent plasma from recovered COVID-19 patients.
COVID-19 more like TB than the flu
The isolation needed for a COVID-19 patient is similar to treating a patient for tuberculosis, Coomler said.
Hospital staff members treat everyone with symptoms as if they have COVID-19 until it's certain they don't.
"Here we treat every COVID patient like they could give it to someone else," Rich said. "The contagiousness of COVID is exponentially so much greater than the flu. We don't isolate people when they get the flu."
In the emergency department, staff members attending to a patient who was coding on Wednesday wore head-to-toe protection, including goggles and masks (an N95 covered by a regular medical mask for a few people). One staff member wore an advanced respiratory protection system that looked like a helmet with a plastic face shield.
There's an entire suit and head gear, designed for treating Ebola patients, that's used to intubate patients with confirmed and suspected COVID-19, said Dang Huynh, assistant medical director of the TMC emergency department.
Often it's the emergency room staff who first see the COVID-19 patients who can't breathe and intubate them. A tube is inserted into patients' airways, so they can be connected to a ventilator.
Who are the patients?
COVID-19 patients tend to be in their 50s and 60s, hospital officials said. TMC has one patient in the 30s in the ICU and another in the 40s.
In April and May, TMC's COVID-19 patients skewed older, typically 75 years or older, Rich said.
"We had a lot of hot spots in nursing homes here," she said. "But that seems to be under control. We get maybe one or two a day."
Younger patients who end up in the ICU often have underlying health conditions such as diabetes, hypertension or obesity, Muzzy said.
"We have people with a variety of different illnesses. Maybe they already have renal failure, and the virus just overwhelms them and they have no wiggle room to bounce back," she said.
About 80% of people who contract COVID-19 will get better on their own. For those who get sick, the illness is devastating, causing not just lung problems but cardiovascular issues and a host of lingering challenges, from confusion to breathlessness and fatigue.
TMC has treated multiple patients from hard-hit Santa Cruz County near the U.S.-Mexican border, which has the highest rate of COVID-19 cases in the state.
It has treated patients from Yuma County and the White Mountain Apache Tribe, two other areas with spikes in COVID-19 cases.
What 'surge' mode looks like
Tucson Medical Center has been in what's known as "surge" mode since the first week of June, using beds and staff above normal capacity.
Coomler said, "Our challenge is, how do we sustain that? How do we sustain our staff, our nurses, our respiratory therapists and our doctors knowing that this isn't going to just be for a week or two?"
What once was a smooth hospital routine has been upended. More time is needed to put on and take off protective gear, and more time is needed to take calls from patients' families who need updates.
Issues with testing and test results continue.
Patients miss the visitors. The staff misses the visitors, too.
A federal Disaster Medical Assistance Team set up headquarters in a hospital conference room.
Nurses are asked to work four 12-hour shifts per week instead of three.
The hospital has added ICU beds as fast as possible since cases began to increase.
The hospital is ready to go up to 45 ICU patients. That has required adding staff, pulling in physicians and nurses from other areas of the hospital, using health care providers sent from a federal disaster assistance team and bringing in travel nurses for the ICU.
COVID-19 rooms, whether inside our outside the ICU, have been upgraded with large tunnel-like tubes that protrude out the back of the hospital rooms to create a negative-pressure environment for maximum infection control.
The hospital had 33 negative pressure rooms before the pandemic and upgraded rooms to add 100, said Richard Parker, director of facilities and construction at TMC.
Parker upgraded six rooms on Wednesday and was scheduled to upgrade 10 more to keep pace with patient need.
The negative pressure pulls the air out of the room, filters it and sends it outside. That keeps whatever that patient has in the room instead of letting it get out into the corridor where it could endanger the staff and anyone else walking through the unit.
"It's also an isolated exhaust. It makes sure that we don't recirculate the air from the rooms we just made negative with other patient rooms," Parker said.
Parker said his staff constantly checks the rooms for mechanical problems.
"I have guys that will go through every one of those and inspect to make sure the fan is still running, that the duct work is still intact. The sun is pretty brutal, so we want to make sure the duct work is intact, and we seal any leaks with it," he said. "We also go through on the inside. We have a little puffer smoke test, and we put that at the door and make sure the room is truly negative. If it's not, then obviously, we've got a problem someplace. Just setting it up was a big task, and maintaining it to make sure we're protecting everyone in the building, that's another big task."
The hospital makes some exceptions to the no-visitor rule, but that's difficult in the ICU, Rich said.
"We try to stay connected to the family. We've got stories of our nurses on the front line, with families outside the window, holding the hand of a patient who is dying," Rich said.
The hospital is one story, so some families are able to see their loved ones via window visits. Last Wednesday, in the midafternoon heat, a middle-age man and two young adults stood under a ramada near the windows of the COVID-19 unit, wearing fluorescent green visitor stickers. The young man in the group was crying.
Surge line used 'constantly'
Hospitals across the state, including TMC, use a surge line that was created by the Arizona Department of Health Services.
It is a 24/7 statewide phone line for hospitals and other providers to call when they have a COVID-19 patient who needs a level of care they can't provide. An electronic system locates available beds and appropriate care, evenly distributing the patients, so no one system or hospital is overwhelmed by patients.
“We didn't know what the surge line was until we accepted 20 patients from Holy Cross in June. Finally one day, we started pushing back and saying, ‘Why isn't anyone else taking these patients?’ ” Rich said. “That was in one of our weekly calls, and everyone started saying, ‘We've got to use the surge line.’ ”
Carondelet Holy Cross Hospital is in hard-hit Santa Cruz County.
"As much as we've been disappointed with the state's response, they did a really good thing when they opened up the surge line," Rich said. "A lot of states didn't do that. ... We are using the surge line constantly."
From June 28 to July 4, TMC accepted 25 patients from the surge line, took a total of 40 calls and transferred seven patients to other facilities. The hospital had to decline 12 patients for ICU care from surge line calls.
“These are very urgent calls,” Rich said. “They are calling and saying, ‘I've got somebody in my ED (emergency department), we just intubated them. They are crashing, and I need to get them into an intensive care unit.’ ”
As of last Wednesday, there were 181 ICU beds available statewide out of 1,672 total.
'Take good care of them'
Rich did not welcome Ducey's news briefing June 11 claiming that Arizona hospitals had adequate capacity.
"What was disappointing was after we knew we were getting into a surge situation, the governor was still saying we were OK. ... We knew we were not. We knew we were preparing for some pretty tough stuff to come," she said. "That was the biggest disappointment."
Rich said she wrote a letter to Ducey, and the two spoke. The governor asked what TMC needed, and she said that's why the hospital received help from a federal Disaster Medical Assistance Team, as well as medical personnel from the National Disaster Medical System Trauma and Critical Care team.
The state plans to pay for health providers to work in hospitals that need them for six-week periods, and it will provide financial incentives for hospitals to take acute COVID-19 patients, Arizona Department of Health Services Director Cara Christ announced.
On June 30, Christ declared that hospitals in the state could activate "crisis care standards," which guide the allocation of scarce resources to patients based on factors such as their likelihood for survival.
No care is being rationed at Tucson Medical Center, officials said.
"We are so grateful to have a document that offers guidance that we have not had to employ," Coomler said. "At this point, we continue to add resources instead of figuring out how to ration them."
TMC needs more COVID-19 testing supplies and a faster turnaround for getting test results, officials said.
"We have had to expend so many resources directly because we couldn't rapid-test people," Rich said. "The worse it gets in Arizona, the longer we're waiting for results. … We overuse resources to make sure we don't miss anything."
Rich wants people to know her staff members are exhausted, people are dying and wearing a mask makes everyone safer.
"To get through this as a state, we have to marginalize the people who don't believe that it's spreading, and we have to support the people who do believe that it's spreading," Rich said.
"The future of this disease is still so unknown to us that we have to act on what we know for sure," she said. "What we know for sure is that masks are the No. 1 most important thing we can do."
She said her staff feels the pain of all the community members who have to bring loved ones to the hospital yet can't be with them.
"We're going to take good care of them," Rich said. "We're really going to be there for those family members and be there for those patients."
Follow Stephanie Innes on Twitter at: @stephanieinnes
This article originally appeared on Arizona Republic: Arizona coronavirus: Inside an ICU in global COVID-10 hot spot