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The Beginning of a Pandemic
By late January, Dr. Sam Dominguez sensed the world was about to change. The professor of infectious diseases at the University of Colorado School of Medicine had spent his entire career studying emerging pathogens such as SARS, and the news coming out of China at the time, about a novel coronavirus with a high human-to-human transmission rate, led him to believe a pandemic was possible. “It seemed like there was a tidal wave coming,” says Dominguez, who is also a pediatric infectious disease specialist at Children’s Hospital Colorado, “and medical facilities needed to gear up.”
That prognostication proved correct. By March 5, Colorado had its first confirmed case of COVID-19. Come the end of that month, as state and local officials ordered the rest of us to stay home to slow the spread of the virus, Centennial State hospitals were overrun with infected patients—many of them dealing with severe respiratory issues that required them to be on ventilators for more than a month.
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The initial onslaught was unlike anything most health care workers had experienced in their careers, and the pervasive lack of knowledge about and understanding of the disease caused an all-consuming sense of uncertainty and anxiety. Proximity to the virus made many fear they’d become infected themselves and potentially pass the virus along to a family member. “There was just so much unknown at the beginning of this whole thing,” says Dr. Frank Lansville, the director of the Medical Center of Aurora’s emergency department. Still, nurses, doctors, and hospital employees of all sorts continued to provide care to those suffering most. General care nurses took on roles in the ICU; medical facilities shared resources and information about treatment possibilities in ways they hadn’t before; and everyone adapted to wearing much more personal protective equipment (PPE).
The sacrifices made by those frontline workers helped get Colorado to a place where public life was able to return, albeit in a modified form, by June. By mid-July, however, the number of positive cases, as well as hospitalizations, had already started to increase again—a signal that medical facilities would likely have to return to crisis mode. “The virus is not going away,” Dominguez says.
To highlight the challenges these medical professionals dealt with throughout the spring and early summer, we gathered some of their stories. Collectively, they describe what it was like to work in a hospital during a once-in-a-century global pandemic.
Early Days in the Emergency Room
Dr. Frank Lansville has lived through a number of stressful, traumatic situations during his 25-year career, including caring for victims of the Aurora theater shooting in 2012. The first days of COVID-19, however, felt more protracted and uncertain than anything the director of the Medical Center of Aurora’s emergency department had ever experienced. In his own words, Lansville details the anxiety associated with that period.
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“In the first few weeks of dealing with COVID-19, I remember a specific elderly woman who came in saying she didn’t feel well. Her husband had already been admitted with COVID-19, but she looked decent despite having the virus. She said to me, I just don’t want to die from this. All of my clinical knowledge suggested she would be OK. So, I told her that. She ended up dying three days later.
That was a wake-up call. The woman had moved through the ER, and once she was in the hospital they did everything they could for her with breathing devices. That still wasn’t enough. I started realizing how little we can do as doctors to fight this disease. Most of the treatment is supportive. We can use some antivirals, and we eventually started giving folks some blood products, but it’s not like there is a specific medication that works wonders.
We’ve only been seeing the patients in the worst respiratory condition, though. Early on, a lot of folks with mild symptoms were coming to the ER. We didn’t have a lot of tests, and we were keeping the ones we did have to confirm people staying at the hospital were positive. We had to tell so many people, Yeah, you likely have it, but you have to go home. They would look at you and say, Are you kidding me? There’s nothing you can do? There was only room for the sickest patients. We added an app called Vivify Health so that we could follow up. Having an outlet where they could ask questions helped them feel better.
The doctors have fear as well—this is the first time in our careers where we’re constantly at risk too. The mentality of an ER doc is to charge into the room. We still have a sense of urgency with what we do. But we have to spend more time pausing. Do I have PPE? Can I interact with this patient from a distance? We have to assume everyone who comes in has the virus—even if it was because of a car accident. That change in mentality has come because we want to limit exposure to the disease for ourselves and others. We need our frontline health care people to keep working.”
The Importance of Respiratory Therapists
Respiratory therapists have found a new level of recognition while managing patients on ventilators during the COVID-19 pandemic.
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For most of her career, Monika Charyga believed people didn’t fully understand her job. The 28-year-old would mention that she was a respiratory therapist at St. Anthony Hospital in Lakewood, and someone would guess that she examined people’s lung capacities or gave out inhalers. “I’d tell them that’s partly true,” she says. “But people never realized that we work in every area of the hospital—the ER, the ICU, the NICU. And we aren’t just doing routine stuff. We play a big role in emergency situations.”
Since COVID-19 infiltrated the United States, however, the importance of respiratory therapists—specifically, during challenging procedures—has been on full display, and confusion about the job itself disappeared pretty quickly. The virus unleashes some its most devastating effects on people’s lungs, and thousands of Americans have been put on ventilators in order to survive. Respiratory therapists are essential when hooking patients up to the machines, and they manage people while they’re on them. Those tasks also put the airway experts in dangerously close proximity to the virus.
By early March, outbreaks in countries like Italy had shown the world that ventilators would be crucial in the fight against the novel coronavirus. American hospitals like Swedish Medical Center in Englewood prepared accordingly. “We were looking at each individual floor, trying to figure out how many oxygen outlets we had,” says Lindsay Bowman, a respiratory therapist at Swedish. Charyga says similar arrangements were being made at St. Anthony while they worked to locate every ventilator possible. The preparation was necessary: As people were admitted, many—especially elderly patients—saw their oxygen levels crash quickly. Normally, St. Anthony would have about 15 to 20 patients on ventilators. That number reached closer to 40 by mid-April.
The process to get people on those machines is known as intubation, and it’s not always an easy procedure under normal circumstances. When it comes to COVID-19, a doctor and a respiratory therapist typically decide to put someone on a ventilator when secretions in the lungs hinder airflow enough to leave a person in danger of becoming hypoxic (lacking enough oxygen to sustain bodily functions). There are limited ways to make the process easier beforehand. “We have a mask we can use to pump up a patient’s oxygen a little bit,” Charyga says. “But with COVID-19 patients, we can’t do that. It involves squeezing a bag that goes through their nose and mouth and gets the virus all over the room.”
Intubation itself is also an aerosol-generating procedure, which means it causes respiratory droplets to be dispersed. To limit exposure to those droplets, health care workers are taking extra precautions during the procedure. The intervention used to last about 45 minutes; it now runs up to two hours. “It takes more of a mental and emotional toll,” Bowman says.
The amount of time patients are spending on ventilators has also increased. Some are having the machines pump oxygen into, and remove carbon dioxide from, their lungs for more than a month; four days had been a typical time frame before COVID-19. But when people do successfully get taken off the device, it’s worthy of a celebration. “One patient started singing,” Charyga says. “He had a tube in his throat for a long time, so it was raspy. But it was so joyful. I’ll never forget it.”
Frontline Workers Explain How They Adapted
As the official number of Coloradans infected with COVID-19 continued to rise, hospital ecosystems were thrown into flux. Protocols were adjusted daily. Portions of buildings were transformed. And nearly everyone’s role changed in some manner. We asked four frontline workers to describe how they adapted.
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“I began working at Presbyterian/St. Luke’s about a month before COVID-19 showed up. When everything started, I wondered if it was worth keeping the job. I was scared I would take COVID-19 home to my family members. But I thought about it more and realized the community needed me. This is where I belong. It doesn’t matter that I am in housekeeping; I can help people as much as a nurse. Sometimes that’s by cleaning more thoroughly, and sometimes it’s with a simple smile.” —Nhamen Yilma, environmental services employee at Presbyterian/St. Luke’s Medical Center
“It was tough talking with patients’ family members and friends over the phone, because we weren’t allowing visitors. It’s one thing to say, Yeah, they are stable, doing OK in there. And it’s another thing to see it. You hear the pain in people’s voices when you have to tell them that someone is on oxygen or a ventilator. We started using an iPad to FaceTime some folks, but it’s not the same.”—Jordan Swartz, ICU nurse at Sky Ridge Medical Center
“We do most testing with an oral swab or a blood draw. The COVID-19 test is a nasopharyngeal swab, which requires you to really go into the nasal cavity. You do it with a little flexible wire that’s about six to seven inches long and has a very small Q-tip on the end. Once it’s in there you have to rotate the swab for five to 10 seconds. It’s uncomfortable for the patient, and nurses were uncomfortable knowing they were making someone feel that way. No one said they didn’t want to do it, but we had to provide some education on it, so we weren’t getting false results.”—Charlene Lopez, infection prevention manager at Sky Ridge Medical Center
“We have to wear an N95 mask for every call we go out on. Typically, I am trying to see if I can smell blood, alcohol, things like that, but that is inhibited by the mask. I also don’t usually hesitate before jumping right in. That’s what the job demands. Now, if we see someone and they are conscious, we ask them a couple of questions before approaching. Do you have a bad cough? What about a fever? If someone is unconscious, then we try to clear out the people around them. You do the best you can knowing that you’re likely going to be exposed to COVID-19.”—Joy Stephens, paramedic at Denver Health
An OB-GYN Finds New Purpose
Throughout the spring, certain sectors of the health care system came to a halt—both so resources could be used to care for COVID-19 patients and to keep the virus from spreading. But some procedures not directly related to treating the disease, such as childbirth, couldn’t stop. Dr. Rania Khan, chair of Littleton Adventist Hospital’s OB-GYN department, told 5280 how working in labor and delivery helped her overcome a personal loss.
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“At the end of February, I, myself, was about 27 weeks pregnant. I experienced some complications, and the baby’s heart stopped beating. I ended up losing the child. Testing was done to see if the fetal loss had anything to do with the new coronavirus, but it doesn’t appear it did.
I was supposed to take a lot of time off, but I decided to come back to work after about 14 days. It had a lot to do with COVID-19. I wanted to be present and felt like the department needed some direction. When I returned, I was really nervous I wouldn’t be able to relate to patients. I have been active in administrative roles for the past three to five years, and I was considering options where I could stick to that type of work. After talking with our mental health support lead, I determined it would be helpful to still interact with mothers.
Once I did, there was a camaraderie I’ve never felt before. Often, everyone is concerned with things happening around the birth, like whether they got a baby shower or how many people or candles they can have in the room. I felt like patients were way more focused on how to keep both the mom and baby healthy. Everyone was concerned with the most important aspects of childbirth.
Obviously, parents are really worried. One of the largest studies of pregnant patients was just published, and we aren’t seeing any birth defects related to COVID-19. At Centura facilities, we also haven’t seen any true cases of vertical transmission, which happens when a potentially sick mom passes the disease on to the baby. There have actually been some positive side effects: Typically, newborns lose about five to 15 percent of their weight in the first 48 hours of life. It hasn’t been that drastic recently. That may be related to less visitors and more time for maternal-fetal bonding.
Our world would certainly be better if COVID-19 never happened, but the silver linings do exist. For me, I got to think about something else besides my fetal loss. And overall, the focus on safety has been a welcome change.”
A Race to Produce Convalescent Plasma
The Blood Donor Center at Children’s Hospital Colorado was the third facility in the country to begin collecting convalescent plasma, which is used in one of the few COVID-19 treatments that has shown promise. Dr. Kyle Annen, the hospital’s medical director of transfusion services, broke down the steps needed to get the first sample ready in less than 12 hours.
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Receive Desperate Request
“We are one of the few hospitals in the state with a blood bank attached, but on March 31, I told the senior manager of transfusion, I’m not sure we should be pursuing convalescent plasma. I don’t know if we’re going to have a significant need in the pediatric population. An hour later, I got a call from a colleague over at UCHealth University of Colorado Hospital. She had a patient who was intubated, critically ill, and COVID-19 positive. The family was insisting on convalescent plasma, and she asked if we could help. We said we would.”
Find A Donor
“I started calling a few folks who had already asked if they could donate convalescent plasma to see if they met the requirements. At the time, the Food and Drug Administration (FDA) stipulated someone needed to have previously tested positive for COVID-19, have been symptom-free for 14 days, and then had a repeat test that said they were negative. I found a person willing to come in that day.”
Fast-Track The Process
“The donor came in and went to the drive-up testing site. We had to wait about three hours for the test, but it eventually came back negative, and we went to work collecting the product. The machines were already in place to do this. It is the same stuff we use to collect plasma on a regular basis. The blood is removed. It’s centrifuged so we can get just the part we want—in this case, the plasma. By 9 p.m. that night I had the first convalescent plasma product within 1,000 miles.”
Complete Final Steps
“Even though we had the plasma in hand, it still had to go through infectious disease testing, which is required by the FDA. That meant sending a tiny portion down to a lab in Texas, the closest location that does those appraisals. We got it on a plane, and they expedited the test. The patient got the plasma around 2 a.m. on April 1.”
[Editor’s note: The patient ended up recovering after 34 days on a ventilator.]
Expand The Operation
“The Blood Donor Center now has a whole setup to collect plasma from about 10 people a week, and we are sharing what we get with other hospitals. We’ve gotten a lot of positive signs about the effects, but ultimately, we still need a randomized control trial to know just how useful it is. Those are getting started across the country now.”
What Is Convalescent Plasma?
Plasma is the liquid part of your blood; it makes up about 55 percent of the red fluid coursing through your veins and is typically around 90 percent water. The other 45 percent of your blood includes red blood cells, white blood cells, and platelets. After your body fights off a dangerous pathogen—COVID-19, for example—the antibodies your body produced to defeat it stick around in your plasma. Blood donation centers across the country have been extracting plasma from people who have recovered (or convalesced) in order to transfuse the fluid into someone still fighting the disease. The hope is the antibodies created by the first person can aid the second person’s immune
system in the fight against the novel coronavirus.
How one doctor took on a new role: searching for people willing to donate convalescent plasma.
Dr. Keri Propst works as an anesthesiologist, but during the early stages of the pandemic, she also got to hone her detective skills. She became part of the Colorado COVID-19 Convalescent Plasma Project Consortium: a group of Centennial State health care groups, including Kaiser Permanente and SCL Health, and blood banks, like Vitalant, that have teamed up to both study the blood product and help get it to the sickest patients. Throughout April and May, Propst still spent some days sedating people before surgery at Saint Joseph Hospital, but she also tried to find people—mostly by sifting through files and calling folks—who’d recovered and were willing to donate the fluid. “I have been astounded by all these institutions working together,” Propst says, “as well as by how many people are donating. It makes me feel like we’re really all in this together.”
How One Institution Created Accurate Antibody Tests
Many of the initial COVID-19 antibody tests were inaccurate—but at least one Colorado organization spent extra time getting it right.
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Just days after Governor Jared Polis issued a statewide stay-at-home order, health department officials in Telluride and Aspen were already convinced they’d found the key to reopening. Because of the pandemic, the FDA had allowed commercial COVID-19 antibody tests to be rushed to market. Community members in both ski towns had purchased hundreds of the assessments, which they believed would tell them who had been exposed to the disease.
By late May, however, the Centers for Disease Control and Prevention warned that the current antibody tests were inaccurate up to half the time. “A lot of tests are detecting antibodies for other coronaviruses,” says Dr. Richard Zane, UCHealth’s chief innovation officer, “instead of ones for COVID-19.” That meant the assessments procured by Telluride and Aspen, as well as ones that many health clinics and hospitals had started using, were just causing confusion. As it turned out, researchers at UCHealth University of Colorado Hospital in Aurora had been working on a way to provide clarity.
Most antibody tests take a sample of a person’s blood and run it over a surface holding proteins found in COVID-19. If the patient has antibodies, they’ll bind with the proteins, creating a chemical reaction that indicates a positive result. In early April, Dr. Brian Harry, the medical director of clinical chemistry at University of Colorado Hospital, and his team decided they would grow the proteins used in such tests themselves so they could better ensure accuracy and have enough materials.
To begin, Thomas Morrison, an associate professor of immunology and microbiology at the University of Colorado School of Medicine, identified the proteins present in the spikes jutting out of the virus and began growing versions of each at University of Colorado Hospital’s Cancer Center. Harry’s team then examined how they reacted to thousands of blood samples—including ones that didn’t contain COVID-19 and ones with antibodies for other coronaviruses. By mid-May, they’d created something they are confident is 99.6 percent accurate.
UCHealth has made those tests available to the general public, but Harry says we still have a lot to learn about COVID-19 antibodies: “People shouldn’t overinterpret results. We still aren’t sure if the antibodies provide immunity. The virus may mutate. If that happens, it doesn’t matter what the antibodies did to the old virus.”
What Does The Future Look Like For Hospitals?
Dr. Steven Brown felt like things were finally beginning to calm down in early May. The chief medical officer at Lutheran Medical Center was seeing fewer COVID-19 patients coming through the hospital’s doors. People were being taken off ventilators, having successfully fought off the disease. Even elective surgeries were returning in a limited capacity. That didn’t mean Brown could relax, though. He now had a new challenge: helping Lutheran return to something approaching normal operations with the threat of the novel coronavirus still imminent. The 68-year-old chatted with 5280 about that task, lessons learned from the disease’s initial outbreak, and the problems hospitals still face in the immediate future.
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5280: Is there anything you and your team figured out over the past few weeks that will make dealing with COVID-19 easier moving forward?
Dr. Steven Brown: There’s still a lot we don’t know about the disease. We’ve come to realize, though, that if you use PPE properly, it will protect you. We’ve had people going in and out of rooms with COVID-19 patients all the time, and very few nurses and doctors have gotten sick. When you are forced to use equipment and you realize it works, I think your level of anxiety drops down many levels. That knowledge will be especially important if we have a second wave. It’s also something that I hope can trickle into society at large. Masks work.
What does the financial situation look like for Lutheran?
When you’re not doing any elective surgeries, you’re losing a lot of your income. We certainly have had a financial shortfall. I think every hospital in America is experiencing the same thing. SCL Health received about $81 million in CARES Act funds since late April, but it still doesn’t cover what we lost.
[Editor’s note: SCL Health operates eight hospitals, including Lutheran, and more than 100 clinics throughout Colorado, Montana, and Kansas.]
We might be able to get back to even in the first half of next year. That being said, I am proud of the way our health care system responded to this situation. We knew we would be facing a bad fiscal challenge, but dealing with this disease remained the priority.
What are you most worried about as Lutheran tries to regain a sense of normalcy?
I think one of the biggest concerns is getting people to understand that if they think they’re having a serious health issue, fear of COVID-19 shouldn’t keep them away from the hospital. Nationally, the number of people coming to emergency rooms with heart attacks and strokes is way down. I think a lot of people are trying to tough it out at home. If you’re sick, if you’re having serious chest pain, or if you’re having symptoms of a stroke, you need to come to the emergency room. We know how to keep you safe.
During the pandemic’s first months, doctors and patients alike found out just how easy telemedicine was to use.
At one point during Colorado’s stay-at-home orders, Kaiser Permanente, a medical group with 29 offices throughout the state, saw its number of video telehealth visits go from around a dozen a day to several hundred. The spike began the same week primary care and specialty doctors shut down offices to limit the spread of the virus, which forced Kaiser to expand its already existing suite of telehealth options. It turns out that just about everyone is a fan: 93 percent of patients indicated they were satisfied with the attention they received during such visits, and Dr. Ari Melmed, medical director for Kaiser’s telehealth services, said many doctors were enjoying the work-from-home experience more than they anticipated. “Every field is figuring out that more can happen using technology than people thought,” Melmed says. “Health care is no exception. We will see more people going to the doctor this way going forward.”