To provide a glimpse of the concerted effort being mounted at St. Louis hospitals to fight the coronavirus, the Post-Dispatch talked with three health care workers on the front lines: emergency physician Dr. Dave Tan, intensive care nurse Micah Toombs, and nurse manager Gil Gonzales. The three shared details from a recent shift at work during these historic few days.
Emergency physician Dr. David Tan decides to leave without breakfast, nervous the heavy rain might make him late for his 7 a.m. shift.
He slips out of his quiet house in St. Charles County while his wife and four children are sleeping.
At the beginning of the pandemic, when cases of disease caused by the coronavirus started making their way into his emergency department at Barnes-Jewish Hospital, Tan couldn’t shake a sense of worry and anxiety during his morning commutes.
No one knew what to expect. Staff wondered if their preparations would be enough, if they would be able to save as many lives as possible, if their gear would protect them and their families.
Dealing with unpredictable and critical cases is in an emergency doctors’ DNA, but the coronavirus is unlike anything Tan has seen in his 23 years as a doctor. Its symptoms can be insidious. It’s different in how it’s a threat to his own health and that of his family.
Tan, 49, has relied on the support he gets from co-workers in his weekly videoconferences as well as the “good nights” and promises of prayers from his family before he heads early to bed.
During his morning commute this gloomy Saturday, Tan feels more settled and assured. The night before, the department chair talked about the hospital’s promising numbers: a flattening number of admissions, the ability to do more diagnostic tests, strategies to handle more patients just in case.
“We have met every challenge with expertise and compassion,” the leader told the group meeting on Zoom. “There might be some light at the end of the tunnel.”
All the mathematical models had pointed to that Saturday — April 25 — as the day the St. Louis area would reach its peak hospitalizations for COVID-19. The models predicted between 600 and 700 people would be in the hospital.
That’s what Dr. Alex Garza had been warning about during his daily briefings as head of the task force that represents the major St. Louis area health care systems: BJC HealthCare, Mercy, SSM Health and St. Luke’s Hospital.
“Peak,” however, is not the best term, Garza said. He described the increasing number as more like cresting a gradual hill. One must look at the average of fluctuating numbers across several days.
The week started Monday, April 20, with 757 hospitalizations, the highest so far and 60% higher than at the beginning of April. The number averaged around 700 until the weekend, when it hovered at 652.
‘I am strong’
At her oldest son’s apartment in south St. Louis, Micah Toombs gets ready for her Saturday shift taking care of the sickest COVID-19 patients at SSM Health St. Mary’s Hospital in Richmond Heights. She pulls on a pair of yoga pants and a T-shirt.
Clean scrubs are waiting for her at the hospital.
Toombs, 48, normally splits her time between the apartment and her home in Potosi — where she lives with her youngest daughter and husband — to save on driving when she has to work.
She hasn’t been home or seen her family in six weeks, however, since she started working five 12-hour shifts in a row and feared infecting them. Her son, furloughed from his job at a movie theater chain, left the apartment and returned to Potosi.
Toombs worked at a small hospital in Potosi before coming to St. Mary’s 17 years ago. She worked for two years before moving to the intensive care unit. It was so scary at first, she questioned her career choice. The nurses in charge encouraged her.
She is fulfilling her oath as a nurse to devote herself to those in her care. This is what she is trained to do. This is what she’s here for.
As she prepares breakfast — two hard-boiled eggs, medium well — she does her daily 5-minute meditation. An app on her phone leads her through breathing and affirmations.
“I am healthy. I am excited for the day,” she says, sitting on her couch, with her palms open to the universe. “I am strong. I am courageous.”
‘Armor of God’
The alarm goes off at 4:45 a.m. on Monday. Gil Gonzales, 46, rouses his three Chihuahuas and checks to see if his 71-year-old mom, who has Parkinson’s, is up.
His mom’s sister died over the weekend, so their conversation over breakfast is focused on family and how she can’t fly to El Paso, Texas, for the funeral.
As he sits on a stool at the counter, she pulls out a small glass bottle of anointing oil that has been prayed over.
With her trembling hand, she rubs some on the back of his neck in the shape of a cross. “I love you, mijo,” she says, using the Spanish term for my son. “I send you with the armor of God.”
It has become their morning ritual.
Just after 6 a.m., Gonzales gets in his car and backs out of the garage of their Tower Grove South home. She watches through a large window in the door. Gonzales waves to her as the garage door closes.
In the employee parking garage at Barnes-Jewish, he fills out a checklist on his phone for employees, marking “no” to questions about symptoms of the coronavirus. After he crosses a sky bridge that connects the garage to the medical campus, an employee reviews his checklist and takes his temperature. He gets a yellow dot for his nametag, showing he’s been approved to work.
The second Gonzales steps off the elevator to the ninth floor, he begins rapid-fire greetings to every nurse he sees getting off the night shift. He makes sure to say each of their names before heading to a 20-bed COVID intensive care unit — the fifth and last created by the hospital.
Maybe say goodbyes
Tan, when he arrives at Barnes-Jewish, heads to the resident lounge, and changes into black scrubs and sneakers.
Before entering the emergency department, he finds his name on a bag holding his N95 mask, a tight-fitting mask capable of blocking 95% of the very small particles transmitted in the air by coughs, sneezes and medical procedures.
The masks are meant for one-time use, but hospitals have had to figure out how to decontaminate masks for reuse because of demand. Barnes-Jewish tested a hydrogen peroxide vapor procedure. Staff can reuse their own mask up to 20 times or throw it out if it no longer fits.
Tan makes sure his is snug and puts on goggles. He’ll wear a mask his entire shift.
Every patient admitted to the hospital with COVID-19 comes through the department. Tan is one of 11 doctors working.
They’ve seen far fewer overall patients during the pandemic, because people are fearful to come in. Doctors worry that means people may be putting off care until it’s too late.
In the first four hours of his shift, Tan cares for nine new patients. Two fear they have COVID-19. Both are in their 50s and African American.
One man complains of mild symptoms — sore throat, mild cough, no fever. Tan senses the man’s anxiety. He tells Tan he’s worried about the person he lives with, someone with multiple risky medical conditions.
Tan orders a test. In the past, the man’s mild symptoms and lack of exposure would not have qualified him for a test. But the hospital’s testing ability has increased.
Tan tells him to continue social distancing at home, even if the results end up negative. Wear a mask, wash hands often and clean surfaces. “For safety’s sake, act like you are infected,” Tan tells him.
Another patient’s condition is more serious. Her oxygen levels are low. Her chest X-ray shows abnormalities in both her lungs. He orders a test and admits her to the intensive care unit.
Before she’s sent upstairs, there is something else Tan must consider. Because no visitors are allowed in the hospital, he needs to determine if she is sick enough to call her loved ones and maybe say her goodbyes.
If a patient is likely to quickly need a ventilator, a machine that helps people breathe through a tube inserted in the windpipe, the patient will be sedated. He or she may never wake up.
Tan has practiced what to say in that moment: “You are very sick and need intensive care. Sometimes, patients will get worse very quickly, and because it’s not possible to predict who will deteriorate quickly, we’d like to offer you an opportunity to speak with your family, to give them an update and share with them what could happen. Would you like to do that?”
It’s difficult, but it’s the right thing to do, Tan says. Patients appreciate the opportunity.
Fortunately, Tan’s patient responds well to supplemental oxygen. He dodges the tough question.
‘We belong together’
Toombs arrives 20 minutes early for her 7 a.m. shift. With it being her first shift after being off two days, she feels energized. She changes into her hospital-washed teal scrubs and dons shoe coverings. She picks up her N95 mask, decontaminated with germicidal ultraviolet light.
She’s assigned a patient and told the next one admitted will be hers as well. The woman, in her 60s, has been in intensive care for almost a month. She’s on a ventilator and sedated.
Toombs hits the ground running. COVID patients in the ICU require constant monitoring. Their oxygen, blood pressure, blood sugar and sedation levels fluctuate. Multiple intravenous lines of medications must be continually adjusted to keep everything in balance. Frequent blood draws are necessary. Vital signs can change in a moment.
Toombs talks to her patient through every step. “I’m checking your blood sugar,” she says. “I’m going to put a warm cloth on your face.” She holds her hand.
With no visitors, nurses make sure patients are not just surrounded by silence and the beeps of machines.
Toombs turns on a TV show or music first thing in the morning. Today it’s ’80s music. “I’m going to be singing whether you like it or not,” she jokes. Pat Benatar comes through the speakers. “We belong, we belong, we belong together,” Toombs belts.
She gives the family members a morning update. By now, they are familiar with the terminology and procedures. They understand Toombs can’t answer a lot of questions, that this new virus doesn’t come with the usual “this is what we can expect.”
Toombs’ patient is one of seven in the unit. A few weeks ago, the number was more than double. Her 12½-hour shifts extended to 14. With a strict two-patient-per-nurse limit, managing nurses were sometimes caring for patients.
Toombs would skip lunch, hating to ask someone to watch her patients. She found herself dehydrated, forgoing the time it takes to remove her mask and protective gear to take a drink.
Today, Toombs is able to heat up leftovers left by a nurse whose family owns a Chinese restaurant.
In the afternoon, she gives her patient a bath and brushes her teeth again. “This is like being at the dentist,” Toombs says. The patient’s hair was braided the day before.
When it was time for the afternoon update with the family, they asked Toombs if they could FaceTime her. Toombs had just moved the patient onto her side, which must be done every two hours, so Toombs propped up an iPad on a side table. “Take your time,” Toombs tells the family before stepping out.
They spent 30 minutes together in the video chat.
‘You are so brave’
Gonzales starts his day with a huddle for the staff he co-manages in two ICUs — one for COVID patients and the other for neurology patients recovering from things such as stroke, brain surgeries and seizures.
When the hospital decided it needed a fifth COVID ICU, his team was tasked with staffing it. They were allowed to volunteer. Many did. Their unit opened April 6.
The staff works two weeks in neurology, two weeks in the COVID unit, then back again.
During the huddle, Gonzales gives the staff a daily reminder.
“We are living through unprecedented times requiring resilience most of us have never had to tap,” he says. “Self-care and resilience go hand-in-hand. One of the most important acts of self-care is to be kind and compassionate with yourself.”
While nurses care for patients, it’s Gonzales’ job to care for the nurses.
“You are so brave for coming in every day,” he says to the staff. “Thank you, and thank you to your families for sharing you with us.”
Gonzales was a flight attendant before deciding to become a nurse nine years ago. The careers are similar in their strict culture of safety, constant troubleshooting, and need for congeniality and team work. You can never panic.
He and the staff caring for COVID patients head to the 10th floor and change into the unit’s assigned color of scrubs — blueberry. Each person has a job written on tape stuck to their backs — charge nurse, attending physician, runner.
“Runner” is new. Nurses try to bundle everything they need before going into a patient’s room, to minimize exposure and having to leave and put on a new gown. If a nurse needs something, she writes it on a piece of paper and holds it up to the window for a runner to get.
Intravenous poles holding bags of medication sit in the hallway rather than the bedside so they can be adjusted outside of rooms by the runner or a nurse.
Gonzales checks in with each nurse. One laments about having the sickest patient again. “You did so great last time,” Gonzales says. “We save our best nurses for our sickest patients.”
He meets with his director. They were expecting a surge, but numbers have been manageable, they say. It looks like the community did its fair share of work, too.
Gonzales also visits each of the unit’s 11 patients. About half can talk. He asks how their care has been.
One tells him, “My nurse, Anna, was an angel last night.”
Tan never ate breakfast. Around 1:45 p.m., he finally grabs a much-appreciated sandwich and chips donated by the nearby Re-Voaked sandwich shop.
An area set aside in the emergency department for low-risk patients suspected of having COVID-19 was busy, but Tan doesn’t care for any patients with suspicious symptoms the rest of his shift.
It feels more normal — patients with chest pain, injuries from car and motorcycle crashes and complications from other chronic conditions. It seems busier, like “before.”
He finishes around 3:45 p.m., 15 minutes after his shift is supposed to end. He goes to discard his dirty scrubs and take a shower, which he likes to do at work rather than home.
The shower is occupied, so Tan decides to jump on the computer. He looks up a patient he cared for a week ago and has been worried about. The man was a diabetic in his 60s and very sick with COVID-19.
Tan finds the name. His chart shows that a few hours ago he was weaned off high-flow oxygen and might be transferred out of the ICU tomorrow.
Tan smiles. It reminds him to stay hopeful about the patients they send to the ICU. To think about the many who will make it.
Doesn’t talk about it
Toombs never got a second patient. For the first time in weeks, she’s able to leave when her shift ends at 7:30 p.m.
“This is Brittany, she will take over for the night shift,” Toombs tells her patient. “I will see you in the morning.”
Toombs and her colleagues used to grab dinner or catch a movie after their shifts. It’s how they decompressed. At work, they tend not to talk much about tough moments and just focus on what they need to do.
Toombs has had two patients die during the pandemic. One was after two weeks of caring for her, trying everything possible.
The nurses get in their cars and head home. While in the car, Toombs makes her nightly call to her mom, who sewed a bunch of surgical hats that should be delivered soon.
She makes a weekly call to her worried 91-year-old grandmother. She calls home and catches her oldest son. They make fun of Toombs’ husband, furloughed from a winery, for spending six hours playing Pokeman Go. She talks to her daughter, 21, about picking out a veil. They are planning her wedding in October.
Toombs keeps the conversations light. She doesn’t want them to worry. She eats a banana for dinner as she talks.
As she heads to bed around 9:30 p.m., Toombs feels like they’ve gotten over a big hump. But she’s not complacent. She can’t shake her apprehension, like she’s waiting for the next shoe to drop.
One minute is like 15
As Gonzales finishes scheduling a videoconference between a patient and six family members for the next day, he hears a call for assistance. A patient’s oxygen level has dropped dangerously low.
He rushes to join a runner outside the room. The patient’s primary nurse suctions the ventilator tube and has them adjust the amount of sedation. The minute seems like 15 as they watch the levels increase.
At 3 p.m., Gonzales helps prone a patient, which involves flipping a patient onto his or her stomach to increase ventilation to the lungs.
The move requires six people. The provider at the patient’s head leads the team, making sure the tube in the trachea does not come loose, causing infectious air to fill the room. The leader barks out a series of orders done in concert as the team moves heart electrodes and protects intravenous lines.
“Who has the torso?” the leader commands. “Everyone have a good grip? Let’s pivot him onto his side. One, two, three.”
Under the protective gear, Gonzales feels the sides of his cheeks getting hot. Beads of sweat form at his brow. It takes about 20 minutes.
Once the patient is prone, they pause and watch the numbers on the machines to make sure he is OK, ready to flip him back if necessary.
After afternoon rounds, reviews of the day and preparations for the next, Gonzales checks in with his nurses again. “Thank you for your hard work,” he tells them. “Your impact has been tremendous.”
He leaves his blueberry scrubs and dresses in the navy ones he wore there. Around 6 p.m., he calls his mom to let her know he’s leaving so she can entice the dogs to her bedroom and shut the door.
When he pulls up to his house, he texts again to make sure she’s in the bedroom. He leaves his shoes outside, puts his clothes in a trash bag and heads straight to the shower.
They have dinner together, but apart. She’s in the dining room. He’s in the living room.
After talking all day, he retreats to his backyard, surrounded by only the birds chirping.
In the days after the projected peak, Garza, the hospitals’ task force leader, reports the average number of hospitalizations continues to flatten at just under 700. If models hold true, hospitals should start to see a taper over the next week or so.
“We are not headed downward yet,” Garza said, “but this plateau is encouraging.”
The downward trend depends on the rate of transmission of the virus in the community. The virus doesn’t go away, he stressed.
If social distancing guidelines are relaxed too soon, there will be second wave, he warns.
“The virus will spread and hit us harder than it has so far.”