BRIDGETON — It’s 6:45 a.m., time when the nursing staff for DePaul Hospital’s two intensive care units start their 12- to 14-hour days with a huddle.
They used to sit together inside a break room for the updates. Now, the couple dozen staff members line the wide hallway to the operating rooms and open the large double doors at the end so a strong breeze washes over them.
The week’s already off to a running start. Just one room is open in each unit, leaders announce, and there are three people in the emergency room waiting for intensive care beds.
The huddle lets out a soft and exasperated “Oh.”
“It’s going to be a busy day, but we will manage,” said Jennifer Dawson, the charge nurse for the 18-room north unit, where the patients are the sickest. They are all on ventilators and nearly all have COVID-19 or are waiting for test results.
To free up space, Dawson and Sarah Griffin, the charge nurse on the 20-room south unit, will have to figure out how to move the pieces around in a hospital puzzle that has increasingly less wiggle room.
Who might be ready to move out of intensive care? Do they have COVID-19 and require a “negative pressure” room where the air is not shared with other areas? Do other floors have the space and staff to take them?
At the same time, patients are more than just their medical charts. With no-visitor policies in place once again, nurses and doctors must act as surrogate comfort and support systems. They must communicate even more with families.
“We just ask for flexibility,” Griffin said. “I know I ask this every time, but things are changing constantly. About every five minutes, they change. So, I truly appreciate everything you guys are doing. Ask for help if you need it.”
Hospitals in the St. Louis metropolitan area and across Missouri have joined many parts of the country in reporting record numbers of hospitalizations for COVID-19. Missouri also is facing record levels of new cases, with nearly 25,000 positive test results in the week leading up to Thanksgiving. And holidays have historically brought surges.
Based on current trends, models predict St. Louis-area hospitals will run out of ICU beds around the first week of December — and afterward will only get worse.
To brace for the impact, the hospitals are postponing surgeries and planning how the Missouri National Guard can help. They are considering erecting a field hospital but are unsure how to staff it. Temporary staffing agencies are overwhelmed with demands across the country.
Their most grim task is developing crisis guidelines for clinicians to follow if they have to choose which patients can and can’t be helped.
DePaul, one of eight local SSM Health hospitals, is among the hardest hit by the pandemic in the St. Louis area. Situated in Bridgeton, it serves some of the most vulnerable ZIP codes in north St. Louis County — where many of the region’s working poor reside. Many are essential workers such as bus drivers, teachers, janitors, nurses and clerks.
The Post-Dispatch spent Monday morning inside DePaul to provide a glimpse into how hospitals are dealing with what will be the worst weeks of the coronavirus pandemic.
As the nurses stand in the huddle clutching their coffee mugs and water bottles, leaders go over reminders: Connect patients and families through Zoom videoconferencing. Welcome any floating or temporary staff. Immediately notify the intensive care physicians of any safety concerns.
And sometime during the day, just pause.
“Turn to someone next you and say thank you,” said nurse manager Angelo Lavalle. “Everybody has stuff going on outside the hospital. Take a minute to recognize each other. Just try to remember why we do this, and we’ll get through this together.”
An empty room
In the corner of the north unit, intensive care nurse Jenna Medwick is supposed to be ending her night shift.
Today, however, she’s staying late. One of her patients, in his late 40s, died in the early morning hours. He had come to the hospital in early October, suffering from vascular disease that had gone untreated. He later tested positive for COVID-19, which landed him in the ICU with multiple organ failure.
The patient’s spouse was allowed to stand outside the floor-to-ceiling glass door to his room when he died. Medwick explained what was happening, answered questions. They talked about what he was like, what he liked to do.
Medwick started working as a nurse in January, just a couple months before the pandemic hit. “There’s been a lot of loss, but I learned a lot,” she said. “It’s been humbling.”
After walking the spouse back to the lobby, Medwick prepared the remains for transport to the morgue. She finished paperwork and taped it to the door.
After the room was empty, a housekeeper arrived with two large carts of cleaning equipment and trash bags. She sanitized every inch of the floor, bed, monitors, equipment and electrical cords. She threw away the bedding and disposable curtains.
So much death
Nurse Riccia Robinson is also staying well into the morning after her night shift in the north unit. A new patient was assigned to her at 6 a.m. It had been an exhausting night. Her other patient’s blood pressure suddenly dropped dangerously low as she was trying help resuscitate yet another patient on the unit.
Robinson talks with two day shift nurses who will take over for her. Her new patient was admitted from a nursing home and will likely not make it through the day.
The other patient has COVID-19 and has been in the hospital for three weeks. The nurses discuss a dizzying, long list of her medications and their amounts. They note the drugs she did and didn’t respond well to and what time they were given, trying to determine how best to keep her blood pressure stabilized.
They ask if the patient has any family. “She has a mother,” Robinson says. The patient is just 45 years old.
Robinson goes in the patient’s room one more time to make sure all her medications are stocked and ready. The day nurse, Heather Doherty, tells her, “Go home and get some sleep. I’ll see you tonight.”
Robinson still lingers, updating files on the computer. She was supposed to leave two hours ago.
“I’ve never seen so much death, so it’s hard,” she says. But it’s not as hard as what her patients’ families go through.
The charge nurse, Dawson, offers to notify the family of the new patient from the nursing home about his condition, but Robinson turns her down. “I don’t mind calling family, since I actually admitted him,” she says.
With an empty room and one open after it has been sanitized, Dawson is making arrangements to move in two of the three patients held in the emergency room. One of the three has COVID-19. The others are awaiting test results. Two had heart attacks, while the other’s blood pressure is dangerously low.
Another patient in the north unit no longer needs a ventilator to breathe. He can be extubated and moved to the one empty room in the 20-bed south unit.
But now the south unit has three patients waiting in the emergency room for a bed. Griffin, the south unit’s charge nurse, is trying to determine, as doctors do their rounds on her patients, which ones are well enough to move to other floors.
Dawson is thinking ahead about what will happen if more emergencies come in, or other patients on other floors take a turn for the worse.
“I will have no rooms. I will have to start doubling again,” she says. Fifteen out of 18 rooms on her unit can outfit two patients, if necessary. One room is already doubled up.
She begins figuring out who to double. It’s best if they are the same sex, diagnosed with COVID-19 around the same time and both stable or doing well.
“I’m going to have to do 7 and 14,” she says.
About an hour later, it happens. A fourth patient who had to be intubated in the emergency room is waiting for a bed in the north unit.
Dawson calls the nurse manager, Katie Eason.
“What are your thoughts about trying to double? I just don’t know if nursing-wise, that would help. It would just open rooms,” she asks.
Eason tells her she will try to bring in more staff for the night shift.
“Come on in. Come on in,” Dawson says. “We’ll get moving on this and go from there.”
While she’s talking, a woman answering the phones hands Dawson a note.
A family called wanting to know the last recorded weight of their loved one, which they need to know for cremation purposes. Dawson finds a computer on a nurse’s desk and looks up the record.
She makes a quick call to the family. “Sorry for your loss. Bye, bye.”
Morgue over capacity
A half dozen hospital leaders in charge of different areas, such as medical care, building operations and emergency services, space apart around a large wooden table. Others join in on a conference call.
Earlier this month, the incident command team began holding daily 9 a.m. meetings, much like they did during the first wave of the pandemic.
The team goes over the day’s dire numbers.
A record 108 patients who have COVID-19 or are suspected of having COVID-19 are currently in the hospital. The number had been in single digits over the summer after a high of 99 in the spring.
Twenty-six people were waiting in the emergency room before 7 a.m. for hospital beds.
Then there’s the hospital morgue, designed to hold four bodies until they go to funeral homes or the St. Louis crematorium, which helps store remains for the hospital, but is also full.
“So, over the weekend and again this morning, we have nine in the morgue right now. So we are over our limit of our capacity there,” one leader says. “Is it time to have the morgue trailer come back?”
Everyone agreed, yes. The 52-foot trailer outfitted to hold 28 bodies will arrive in 48 to 72 hours.
Vice President of Operations and Incident Commander Kelly Pearce assured everyone that in the meantime, remains are being handled respectfully with the refrigeration unit open to a common area and remains rotated to the coldest sections to maintain necessary temperatures.
They discuss other challenges.
The hospital needs more negative pressure rooms to handle patients with COVID-19.
More staff and ambulance crews are testing positive and can’t come to work.
An emergency process is being set up to honor out-of-state licenses for various medical personnel.
The emergency room is asking for plexiglass to be installed between patients in the waiting room.
Dialysis patients with COVID-19 are ending up in the emergency room because they can’t make appointments at dialysis centers. Perhaps the National Guard can help with transportation.
“Hi Chuck, this is your favorite daughter,” says Tandra McWright, 50, on a Zoom videoconference with her mother in the north unit.
It’s her usual greeting, an ongoing joke she and her younger brother have with their mother, Charline Smith, 70.
It’s the first time McWright has seen her face since Nov. 4, when she took her mom to the emergency room for what she thought was a urinary tract infection. Smith had a stroke this summer, and McWright brought her to her Calverton Park home to care for her.
Smith’s temperature never went down, however. Her oxygen levels kept dropping until she could no longer get enough air on her own and needed a ventilator. McWright said she suspects her mom got COVID-19 while going to rehab.
Today, Smith is doing better. She’s wiggling her toes and fingers, nodding and opening her eyes. So her nurse, Ronnie Childs, coordinated the Zoom, holding an iPad to her face.
“Everyone is praying for you. I know you can feel the prayers,” McWright tells her. She and her brother are there with her, in spirit. Smith blinks in response.
McWright wants to call every 10 minutes and check on her mom, but she can sense the nurses are overwhelmed.
“I can’t imagine what it’s like there,” she said. “All this heaviness. How do you not take this home with you and go about your life and enjoy your evening?”
Richard Murphy’s heart
A patient who arrived at 6 a.m. from the nursing home is 74-year-old Richard Murphy, a Vietnam War veteran. His heart is failing.
Murphy’s nephew, Tyrone Murphy, and Tyrone’s wife, Vanessa, were allowed 15 minutes to say goodbye. They stood stoically outside his glass door, talking softly.
Tyrone Murphy said his uncle never recovered after getting COVID-19 in the spring while at Oakwood Estates Nursing and Rehab in Normandy. This is third family member he has lost to the virus.
As he leaves, he turns to the nurses nearby, including Medwick, who at this point has been working for over 15 hours.
“Thank you for everything you do,” he says. “I’m going to make sure I pray for y’all.”
It takes nearly three hours for a team that includes a doctor, respiratory therapist, pharmacist, dietician and nurses to make rounds on the patients in the north unit.
As they stand outside one COVID-19 patient’s room with rolling computer stands, Dr. Justin Grady needs to call the family, who has already called twice that morning asking for updates.
“Why the heart keeps stopping is because there’s so much damage to the lungs,” Grady explains. The lungs are “maxed out” on ventilator support.
The patient, in his 80s, has been on his stomach for several hours to help get oxygen to his lungs. They need to return him to his back, and he will likely have another cardiac arrest.
“There’s no amount of chest compressions in the world that can fix that,” he says. “If you do decide to take him off life support, one or two people can sit at the door as we take support off of him.”
The person on the other end of the phone is upset. Grady has to be firm.
“I can’t allow anyone next to him.”
The medical staff will wait until 1 p.m. to turn him, Grady assures the person, so all the family is available to make a decision on what to do.
Around 11:15 a.m., a 67-year-old heart attack patient is wheeled into the newly sanitized room. A team of nurses slides him onto the hospital bed. They hover over him, quickly attaching wires and tubes from head to toe.
Three patients who were holding in the ER for the north unit have now been moved in. One more is waiting. Dawson is still working to move one of her patients to the south unit and double up rooms.
“I’m just trying make more beds, so if they get nurses tonight, they have room to grow,” she says.
Other family members want to come say goodbye to Richard Murphy and are begging Dawson over the phone to bend the rules.
Then there’s a rapid response call to the seventh floor. Someone is in cardiac arrest and the charge nurses from the intensive care units must go assist. Dawson darts away.
This is all before noon.
With some surgeries postponed, nurses from the operating rooms have begun helping in the intensive care units as “taskers” — doing things like bathing patients, getting supplies and escorting family members. Those in management positions are even helping with patient care.
Physicians in other specialties are also doing what they can to take the load off intensive care doctors.
They’ve come close, but intensive care nurses have yet to institute “team-level nursing.” When assigned more than two patients, teams of nurses divide care by the tasks required rather than caring for the whole patient.
Dr. Ronen Dudaie, director of the intensive care unit, wonders what it will be like if the number of patients follows what the models predict, and all the rooms in the north unit are doubled up with patients.
“It will be survival mode at that point,” he says.