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Captain James A. Lovell Federal Health Care Center
FHCC ICU preps for COVID-19
By Public Affairs Specialist Jayna Legg
Tuesday, October 27, 2020They could see it coming. They didn’t know it at the time, but the Lovell Federal Health Care Center ICU doctors, nurses and other clinicians had about six weeks until they received their first COVID-19 patient.
When the deadly virus arrived, the FHCC ICU team was ready.
“We learned a lot about what was happening in China, Italy and South Korea,” said Dr. Raúl Gazmuri, section chief of Critical Care and ICU director. “Everybody was issuing guidelines. We took advantage of that time.”
Looking back to the challenging spring of 2020, Gazmuri said the good news story he tells about the ICU’s response to COVID-19 is one of “successful teamwork, preparation, learning about the disease as we went along, and saving lives.”
Between March 1 and July 1, of 82 COVID-19 patients admitted to acute inpatient medicine (without advanced directives that would have limited care), 21 came to the ICU. All recovered but one. The patient who died was extremely ill with other factors involved, Gazmuri said.
The lifesaving team included many: the ER, anesthesia, cardiology, pharmacy, infectious disease personnel, and especially respiratory therapists. “Respiratory therapists were instrumental as we moved forward and developed new protocols,” Gazmuri said.
FHCC Chief Medical Executive Dr. Frank Maldonado agreed that teamwork was key to the ICU’s favorable patient outcomes. But perhaps most notably, Maldonado said the ICU team understands how severe illness can affect the body.
“The knowledge of the critical care team regarding body physiology – or how the body works normally, how it responds to severe illness and how does illness affect the body – is critical for having a positive outcome with this disease, that and good bedside care,” he said.
He added that the ICU team, under normal circumstances, “is very academic. We have a very highly motivated and well-trained and well-read team that works very well together.”
More negative pressure rooms, new protocols
In addition to the team reading as much COVID-19 research as possible, physical steps had to be taken in the ICU. The number of negative pressure rooms was doubled to eight, thanks to the efforts of the FHCC Engineering team. Negative air pressure rooms are used to isolate patients and prevent airborne diseases from escaping.
New protocols had to be created for a long list of procedures, from when and how best to intubate a COVID-19 patient to how to provide CPR to a patient suspected of having the virus – all while minimizing the risk to staff.
When the team learned about the benefits of “proning,” RN Mylene Apigo, clinical nurse leader in the ICU, took the lead to develop a protocol and form a Proning Team. She said the team practiced on manikins, and on themselves when necessary.
Proning is the process of turning patients from their backs onto their stomachs so they are lying face down. The patient may or may not be intubated (have a breathing tube inserted). The position allows better expansion in parts of the lungs, and therefore may help with oxygenation.
Gazmuri and Apigo agreed that, for staff, fear was one of the biggest foes in the beginning.
“There were a lot of uncertainties in the beginning and so much information coming from so many places,” Apigo said.
Nurses, doctors and other staff members had to fully understand how Personal Protective Equipment works. Some providers were bringing their own plastic shields and other outside PPE to work. “We had to make sure we were following CDC (Centers for Disease Control) and Infection Control guidelines,” Gazmuri said. “Some ideas people felt strongly about but they weren’t part of the recommendations.”
“After about two or three weeks, everyone relaxed, and the fear faded away when they realized, ‘we know how to provide the care and protect ourselves,’” he said.
Teams trained in new procedures
Initially, proning patients was a “big enterprise,” Gazmuri said, because the patient is connected to many lines, and once they are turned, they have to remain that way for 12 hours. “It is a very elaborate process,” he said. “We had never done it before.”
Intubation, too, is a more complex process with COVID-19 patients, because of the need to minimize the number of health care workers at the bedside in a negative pressure room. The ICU’s new protocol calls for a respiratory therapist and nurse to be present in the room, and a runner to be positioned outside.
“We have a bag for everything needed for intubation, and we developed a specific approach,” Gazmuri said. “We agreed to temporarily paralyze the patient to avoid generation of aerosol, to minimize risk to providers, so we included it in our intubation protocol.”
Trained teams were ready to intubate patients at night if necessary, during the height of the pandemic in the spring. To avoid having a crisis with a COVID-19 patient elsewhere in the hospital, ICU staff closely monitored reports of COVID-19 patients who were admitted to the FHCC Medical-Surgical floor, before they were sick enough to be transferred to the ICU.
Patients with COVID-19 pneumonia may deteriorate quickly and need to be monitored closely, Gazmuri said, so it’s best to get them to the ICU early on.
The ICU incorporated a “Work of Breathing Scale” into a tool called the Rapid Response System, to recognize early on an increase in how hard a patient works to breathe. Gazmuri explained that as a patient gets sicker, the patient’s lungs get stiffer, and then the patient breathes faster, using other muscles. Generally, Gazmuri said, “hospitals don’t monitor ‘the work of breathing’ like we do here.”
FHCC had an advantage. The Work of Breathing Scale was developed, and its clinical use was demonstrated at the FHCC about five years ago. On a scale of 1-7, the patient’s breathing is rated. “We learned those who didn’t need intubation rarely and only transiently exceeded 4,” Gazmuri said. “We learned that at 5, they needed intubation. We submitted that for publication, and in July of this year it was accepted as a Research Letter in Critical Care.”
By paying close attention to a patient’s breathing, intubation can be avoided in many cases, Gazmuri said.
He remembered one of the ICU’s early COVID-19 patients. “He had a terrible CT scan of the lungs. He was in Med-Surg. I went there, and he was talking to me. As soon as his cough went away each time, he was OK.”
The patient was soon rushed to the ICU. He needed oxygen to help him breathe but he wasn’t intubated. “We learned that most patients need oxygen and non-invasive ways of helping their lungs, without intubating,” Gazmuri said.
Fewer patients intubated
Gazmuri estimated that 80 percent of the COVID-19 patients admitted to the ICU were not intubated, “and they did well. The three patients who were intubated were extremely sick.”
The ICU stocked up on high-flow nasal cannulas – devices that help with breathing by supplying up to 100 percent oxygen, at higher flows than the usual oxygen cannulas. In many cases, this meant the patient didn’t have to be intubated.
Intubating fewer patients had another benefit. “The fact that we didn’t have to intubate most of them enabled our team to concentrate on the sickest patients and provide care that probably saved their lives,” Gazmuri said.
The ICU nurses prepared for battle, as well. They held an ICU skills fair early in June and reviewed all the new protocols and SOPs. “All those intubation concerns, proning concerns, all were reviewed,” Apigo said.
“So right now, we are much more confident we are capable of applying our protocols and taking care of all COVID-19 patients,” she said.
All the FHCC nurses and many other nurses temporarily assigned to the FHCC had to meld into a round-the-clock force, fighting COVID-19 not only in the ICU but on the Medical-Surgical floor and in the ER.
“During this COVID-19 season, the majority of the nurses, not only in the ICU, had to work with other nurses from other departments, like GI and PACU (post-anesthesia care unit),” Apigo said. “There were so many nurses coming in being trained to be ICU nurses, so there was a lot of comradery between nurses.
“The walls that were there before, they’ve crumbled because now we were all in the same boat,” she continued. “It was, ‘Hey, we were afraid, but we have to take care of our patients.’ That is carrying over to this day, even though we’ve gone back to our spaces.”
Communication with the ICU team and other health care workers in the hospital was key. The ICU held regular shift change huddles. Apigo and Gazmuri used the huddles to give updates on new protocols and developments in COVID-19 treatments.
A 24-hour tele-conference phone line was set up in the ICU training room to allow for constant collaboration. Additionally, interdisciplinary rounds were held on Thursdays, to bring in staff from other areas, such as dietitians. The only subject for Tuesday resident doctor conferences was COVID-19, and nurses and other ICU providers regularly participated.
Throughout the worst weeks, the ICU team monitored COVID-19 treatments that were working and recommended based on the experiences at other hospitals. Every time there was a pharmaceutical intervention shown to have promise in treating COVID-19, such as the drug Remdesivir, FHCC adopted it as well.
“It was total teamwork,” Gazmuri said. “No decision was made alone … everyone learned things new to that person. I learned a lot, about N95 (respirators) and ventilators. That knowledge crosses our usual boundaries. Whatever we learn is applicable to our patients.”
Maldonado agreed. “The knowledge they obtained was shared with the medical floor,” he said. “They actually provided a lot of educational activities that were transmitted to doctors outside the ICU to continue the good care of patients.”
Vietnam veteran battles COVID-19 in ICU
After more than two months fighting COVID-19 in the FHCC ICU, Vietnam veteran Orlando Richardson was weak, but slowly regaining his strength.
The former Army paratrooper had nothing but praise for the ICU team he credits with saving his life.
“I’ve received excellent care,” said Richardson, who was still wobbly as he stood with some assistance and sat in a wheelchair in the ICU on an early summer morning. “I was half dead when I got here.”
His memory of his first days in the ICU is hazy. He remembers calling a friend from his “close combat” support group to bring him to the FHCC. He couldn’t walk at that point he was so sick.
Just two days before, the retired postal carrier went to the store to do some shopping. “I was in a mask,” he remembered. “Someone who wasn’t wearing a mask coughed on me … two days later I was so weak I had to crawl to the bathroom.”
Richardson, from Chicago, has participated in PTSD support groups and at the FHCC and also goes to the Evanston Vet Center for services. He was afraid to go to the hospital, “because I didn’t want to get sick. And I thought ‘If I do get that sick, I’m probably going to die.’”
He said he was in excellent shape before COVID-19 “ambushed” him. “I don’t know where this came from or I would have went the other way.”
Richardson required a tracheostomy and was on a ventilator for 40 days.
Gazmuri said of the more than 20 COVID-19 cases the ICU had treated to date, Richardson was the toughest patient.
“You were so sick,” he said, addressing Richardson. “You were maxed out with oxygen on the ventilator.”
The next step in treatment would have been putting Richardson on an ECMO (extracorporeal membrane oxygenation) machine, Gazmuri said, something FHCC doesn’t have. “We started knocking on doors of every hospital,” but ECMO machines at first were only used with patients 40 and under; then the age limit was upped to 65. Richardson is 73.
Fortunately, Richardson didn’t go on the ECMO and stayed at the FHCC, gradually improving enough to get off the ventilator, remove the tracheostomy, get out of bed and walk around his room.
“As a paratrooper, they programmed something in us called drive,” he said proudly. “If there’s an opportunity, I’m going to take it. I’m going to beat it.”
Richardson is most looking forward to hanging out with his five grandchildren again. “I love to run around with them, especially the 4-year-old,” he said. During his illness, ICU staff helped him video chat with his grandchildren from his hospital bed.
‘Your life is a miracle’
Richardson said he was feeling much more optimistic, after his two months in the FHCC ICU. “I’m getting back to almost normal.”
He credited his faith, and the health care professionals at the FHCC, with his recovery.
“I would not be here. I believe in God - and the wisdom he bestowed on these scientists,” he said, comfortably interacting with a group of smiling ICU nurses, providers and resident doctors gathered for a photo with him. After so many weeks, Richardson knew his caretakers well.
Third-year medical resident Dr. Nyembezi Dhliway, part of Richardson’s treatment team, told him, “Your life is a miracle.”
Instead of a second chance, Richardson said, “I’ve been given three or four chances.” His first “second chance” was surviving 1967-68 on the battlefield in Vietnam. “In combat, bullets would be whizzing by my head. I could hear them.”
He hopes that sharing his recovery experience will inspire “someone,” especially veterans fighting COVID-19.
Richardson was discharged from the FHCC in August and transferred to a rehabilitation facility, where his family reported he was doing well.