Anchorage intensive care nurse Melina Mack felt like she was living in a different reality from the rest of the city as March began.
Outside Providence Alaska Medical Center, Anchorage went about its business as normal, largely unaware that life might soon drastically change. But inside, Mack and other staff were ramping up their readiness as the new coronavirus spread around the world. The hospital had been testing people for COVID-19 for about a week when the first positive case was detected in Anchorage.
The uncertainty was scary as she worried about how many sick people were headed her way.
“I was reading about Italy and all of these places, and (Anchorage) hadn’t shut down yet,” Mack said.
Others felt similarly unsettled about the working conditions reported elsewhere.
“I stopped watching the news,” nurse Aimee Jordt recalled recently. Jordt’s medical unit at Providence often tended to patients recovering from surgery. But by mid-March, Providence had converted one of its three halls to care solely for COVID-19 patients.
“Everything is changing constantly,” Jordt remembered thinking.
Two months later, health care workers here have seen a decrease in cases, and credit Alaska’s hunkering down, distancing, masking and washing. Now, businesses are reopening and restrictions are loosening. But the pandemic’s end is not yet in sight, and gains here may prove hard to sustain in a state that has limited capacity to handle a large patient surge.
“We have been fortunate … the great majority of our population still hasn’t been exposed,” said Dr. Michael Bernstein, regional chief medical officer for Providence Alaska. “If we stop doing everything now, if we stop social distancing, we stop hand washing, wearing masks, I can guarantee you we would have another wave, and it would be bigger than what we experienced.”
Jordt and Mack recently sat outside Providence to talk about what patient care during the pandemic has been like for them so far.
Jordt shared her experiences with this message for the public: “We need you to do your part, so we can do ours.”
The early days of the pandemic felt like waiting for a tsunami after an earthquake, Jordt said. No one knew when it would arrive or how destructive the wave would be. She feared for her own health, too, a concern deepened by a shortage of personal protective equipment nationwide.
“Our whole careers we’ve been told PPE is one-time use,” she said.
Jordt, 29, grew up in the Southeast Alaska town of Craig and studied nursing at UAA. She works both in direct patient care and as a “charge nurse,” the nurse who oversees other nurses on that day’s shift, on 4 North, a medical-surgical unit on the fourth floor. Since mid-March, 4 North has been home of the “COVID hallway,” 12 rooms reserved for patients who have either tested positive for COVID-19 or those who have symptoms but are awaiting test results.
Rapid testing, now an option in the Providence emergency room, has changed the COVID hallway. Now, COVID-19 can be ruled out in hours for hospitalized patients, and negative patients are directed elsewhere from the emergency room. But for weeks, when test results took several days to come back, patients admitted with COVID-19-like symptoms were treated as positive until proven otherwise.
So far, the COVID hallway hasn’t operated at full capacity, but it came close in the pre-rapid-testing days. On the busiest days, there were just two open beds.
COVID hallway patients can have no visitors, and are not permitted to leave their single-bed, one-chair rooms. Most are alert and oriented, and healthy enough to be bored and lonely, Jordt said. Some followed coronavirus news and some avoided it. All seemed to appreciate the human connection when masked and face-shielded nurses walked in the room.
“Every patient that I’ve taken care of has been unbelievably kind, very thankful,” Jordt said.
She could tell when rule-out patients were scared as they waited for test results. “Being able to tell people, ‘Hey, you’re negative,’ it’s like you told them they don’t have cancer,” Jordt said.
Others tested positive, and the sound of coughing was common in the COVID hallway. Nurses “clustered” care to get as much done as they could each time they entered the room to limit the number of times they needed to don PPE. In the room, Jordt said nursing work could include checking vital signs and blood sugar, giving medication, assisting with hygiene and bringing in food trays.
For COVID-19-positive and rule-out patients, checking oxygen saturation levels is key, she said. Some wore a pulse oximeter finger probe 24 hours a day.
From 4 North, COVID-19-positive patients can be moved to COVID-19 beds reserved on the intermediate care or intensive care units.
Those who improve go home. On multiple occasions, staff have lined the corridor to applaud as a patient heads for the exit. “We’ve had quite a few discharges, and it’s super exciting,” she said. “You gotta take your wins when you have them.”
But sometimes, 4 North nurses observed that patients have increasing trouble recovering from simple tasks, like getting up to go to the bathroom. For some, oxygen saturation levels drop and an increased flow of supplemental oxygen doesn’t help. Physicians have ordered those patients to be transferred to the intensive care unit two floors below.
Melina Mack, who grew up in San Diego and also studied nursing at UAA, says her job with COVID-19 patients in the ICU is often to get them to do things they feel too sick to do. “You have to kind of kick their butts a little bit, honestly,” she said.
The section of the ICU that had been reserved for heart patients on the hospital’s second floor is now strictly for COVID-19-positive patients in need of critical care. The area, which has seven beds, is across the hall from the main 28-bed ICU (which also has three beds reserved for COVID-19 care). A separate Intermediate Care Unit has 10 COVID-19-specific beds.
Staff call the transformed cardiac ICU “COVID Island” now, a reference to its rounded nurses’ station among a semi-circle of patient rooms. From early to mid-April, its beds were nearly full most days, said Mack, who has worked there regularly since the coronavirus crisis began. At the time, there was no rapid testing available to quickly know who was COVID-19-positive.
Patients who need care there are typically breathing fast, 30 to 40 breaths per minute, Mack said. That rate can spike to 50 for some who try simple tasks like brushing teeth and combing hair. Generally, they are too sick to talk, out of breath after speaking just a couple words, she said.
“These people have no reserves,” Mack said.
There’s one nurse for every two patients on COVID Island. The team, which includes two doctors and an advanced nurse practitioner, works to keep a bad situation from getting worse. Mack’s role is different there from what she had been used to during her three years in ICU nursing.
“It’s really changed nursing practice, with those patients, and it makes you a lot busier,” she said.
To limit the number of people coming into the space, Mack now must draw blood and do housekeeping tasks that others might have done. Personal protection takes considerable time, also.
The routine each time she leave a patient’s room: Remove the outer of the two pairs of gloves she wore in the room, sanitize the ones she’s still wearing, remove her face shield or powered air purifying respirator and place it into the “dirty” bin, sanitize her gloved hands again, remove the gown, remove the gloves, wash hands, put on new gloves, then clean every inch of the shield or PAPR, remove gloves, and wash hands again.
“Now, it’s like a 10-minute process to even get ready to go into the room, and then it’s a 10-minute process to leave the room and to wash my hands and (go) on to the next patient,” Mack said.
The team has benefited from the COVID-19 care lessons learned Outside, such as the effect of positioning a patient chest-down. That’s now a common COVID-19 care technique in the Providence ICU.
“It’s amazing. You can watch someone’s oxygenation go from like 80% to 90 or 95 (percent),” Mack said. “We know now, let’s get them on their bellies sooner and we know to try to keep them off the vent.”
That’s where the tough love comes into play. Mack said she explains the situation bluntly to patients who balk at the uncomfortable position or avoid the breathing measurement device she asks them to breathe into. She explains that COVID-19 patients who need breathing tubes face difficult odds of survival.
“We need to do everything we can,” Mack said she tells them.
Many, but not all, patients who get sick enough from the coronavirus to need ICU-level care, are older or have underlying health conditions. Mack said she has seen enough patients to know that no one is immune. Mack, 28, has treated several patients who were nearly her age or younger.
“They were sick enough to be in the ICU, and they were walking a very fine line between needing intubation,” she said.
Few ICU-level coronavirus patients have been intubated so far at Providence, she said. Mack said their first COVID-19 patient who needed a ventilator was successfully removed from it. That outcome provided a morale boost for the staff. Another nurse told Mack about the conversation she had when that patient emerged from sedation.
“Do you have any idea what’s going on in the world? Do you know what coronavirus is? Does that mean anything to you?” the nurse told Mack that she asked. “Don’t even worry about it. Just know that you’re a little miracle.”
Not everyone has been so fortunate. Providence does not disclose the number of COVID-19-related deaths that have occurred there, but Mack said the no-visitors policy for COVID-19 patients has made such situations more difficult for families who would otherwise want to be at a dying patient’s side. In normal times, that part of the job is a point of pride for Mack.
“Someone being able to die comfortably, and with the support of their family, and everyone agreeing and knowing that we’re making them as comfortable as possible, is what’s really special to me,” she said.
Now, nurses operate FaceTime video calling to connect with families in such situations, something Mack has experienced, she said.
“It’s hard, because you can’t read body language as well, and you can’t look someone in the eye. You can feel the emotion behind the screen, and it can be really sad,” Mack said. “It’s like desperation on the other side. They just want to be with their loved one.”
Though a patient may be unresponsive, Mack talks to the patient. “It’s lots of telling patients, even if they can’t understand, 'Your family would be here if they could. They want to be here,’” Mack said.
Mack’s experience has meant caring for dying patients is not new for her, but it doesn’t ever get easy, she said. “I notice the days that are harder than others, and I have my routine,” Mack said. “(It’s) not too often, but there are shifts where you just go home and cry your eyes out.”
COVID-19 victories are hard-won in the ICU. Patients are sometimes on oxygen for a week, frustrated by the lack of progress. On the good days, patients improve enough to get sent back upstairs to the COVID hallway where they can continue to recover. Those days are the reward, she said.
“That’s why we’re nurses, I feel like. It feels so good when people get better,” Mack said.
Mack hopes that one day she’ll look back on this time and feel she did her best for her patients, that she managed her stress and trusted her co-workers. It’s a big job right now, but it’s rewarding.
“There’s something so surreal about walking into a COVID-positive patient’s room and being like, ‘The only thing that separates me from this virus, that has literally shut down the entire world, and that we know nothing about, is my personal protective equipment,' ” Mack said.
“It is the job we signed up for ... but just that reality is just crazy to me,” she said. “I got to help people get better.”
Bernstein, the Providence chief medical officer, said, “Our staff has been healthy. No one in the first couple months of care acquired COVID while caring for patients that had it.”
Mack and Jordt say the community support matters. Families and community members thank them, they said, and there’s been a lot of free food.
“At one point a couple weeks ago, we were like, ‘OK, no more Krispy Kremes,’” Jordt said.
Both nurses say the whole story of how Alaska confronts the coronavirus has yet to unfold. The COVID hallway had a run of several days with no patients recently. Mack said there has been a gradual decrease in patients on COVID Island too. Some days they also have none.
Things have improved. For now.
But they worry the public, few of whom have direct experience with a coronavirus-sickened person, may be lulled into complacency or mistakenly conclude that the trouble is over. As businesses reopen, both nurses are concerned about an uptick in COVID-19-positive patients.
Ten Alaskans with COVID-19 have died since the pandemic began, but more than 75,400 people have died nationwide as of May 9, according to the Centers for Disease Control and Prevention. On that day, the U.S. had nearly 29,000 new positive cases than the previous day.
“You don’t want to live in fear, but there needs to be a healthy amount of fear to keep people cautious,” Mack said. “We’re still Alaska. We have the potential to be easily overwhelmed.”
On a sunny spring morning, the two women walked toward a hospital entrance dressed in scrubs and wearing masks. Their temperatures were checked at the door before they started another day. Both expect COVID-19 patient care will be a primary job duty for the foreseeable future.
Jordt said she has heard chatter in the community that the pandemic is a hoax. She sometimes wishes she could take a video at work to show people who have trouble understanding the struggles of COVID-19.
“I just keep my mouth shut and I just keep on walking,” Jordt said.
“People don’t want to believe it until it’s their loved ones,” Mack said.
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