The sound of hundreds of beeping machines is more muffled than usual in the immaculate hallways of the intensive care unit at UC San Diego Medical Center, Hillcrest. Each of the 13 doors that lead to patients is closed, an extra measure of precaution to help prevent the spread of COVID-19. The ICU at Hillcrest is shaped like a U. Nurses fan out along the bended line, so they can hear the muted calls of the ventilators keeping their patients alive. Everyone sits up just a little straighter.
Shannon Cotton is standing outside the room of her patient, fully donned in protective gear. She and a respiratory therapist are watching through the glass door, as an emergency doctor works on the man inside. During normal times, they would be inside helping. These are not normal times. Because the procedure produces aerosol and potentially droplets of fluid – which could transmit the novel coronavirus – the doctor told them to stand outside the door and only come in if they were needed.
There are other reasons to limit patient contact, too. No one knows if hospitals will have enough supplies to get through the coming surge of COVID-19 patients. At this moment, for instance, the Hillcrest ICU doesn’t have any face shields. Cotton is wearing eye goggles – which she must wash, sanitize and reuse – even though a shield would give more protection. (Last week, county public health officials said they received a shipment of protective equipment from the national strategic stockpile, which accounted for around 30 percent of what they asked for.)
“We’re scared,” said Cotton, when I spoke to her for the first time on March 22, the 16th day of San Diego’s outbreak. A few days later, the ICU was full of COVID patients. “All we keep hearing is, ‘The surge is coming, the surge is coming.’ But to be honest, it feels like the surge is happening right now.”
Public health officials currently estimate that San Diego could hit its peak number of cases in five weeks. Current projections show the number of patients who need to be hospitalized may surpass the number of beds available. Through extreme social distancing measures, officials hope they can buy themselves enough time to increase hospital bed capacity and get critical medical equipment to frontline workers like Cotton.
Cotton’s patient makes it through the procedure without needing her assistance, so she stays outside the room. It is a victory, but also a loss. COVID-19 patients receive only the most limited contact. Except in extreme circumstances, they are not allowed visitors at Hillcrest or any other hospitals in San Diego. Nurses, like Cotton, are their only tangible connection to the living world.
Cotton, who is tall and energetic, wears her hair in a ponytail that bounces as she walks. She talks to her patients a lot – she calls herself a “chatterbox” – whether they can speak or not. Patients who are intubated, like the man she’s treating and many COVID-19 patients, can’t talk. She speaks to his family several times a day on the phone and then reports back to him.
“I’ll mention the family member’s name that’s calling and hold his hand and wake him up a little. His eyes will kind of flutter open and I’ll repeat it again and tell him what the family member said. You can see him smiling even through the breathing tube. He’ll squeeze my hand back,” she said.
But every time she enters the room, she has to make a difficult choice about how long she will stay. The more surfaces she touches, the longer she hangs around, she puts herself – and her husband and children – at risk.
“I want to be able to be close to my patients, talk to them, spend time with them, but then you are also thinking, ‘Wow, the longer I spend in this room, the higher the risk I could get COVID-19,’” she said.
Witnessing the rapid changes in COVID-19 patients is jarring, Cotton said. Many come into the ICU still walking around. They are on oxygen, but haven’t been intubated. Once a patient has received a certain amount of oxygen without improvement they are sent to the ICU in anticipation of a crash. Patients come in with shortness of breath and a cough and rapidly deteriorate into “really bad respiratory distress,” Cotton said.
“Imagine breathing through a straw and the anxiety you might feel from not being able to catch your breath,” she said.
Nurses like Cotton will increase a patient’s oxygen as much as they can. Next, they have to intubate, a procedure that involves sliding a tube down a patient’s throat and into their airway. The tube is connected to a ventilator, which helps the patient breath. As of last week, there were roughly 300 available ventilators in San Diego, according to the Union-Tribune. But New York City is running low on ventilators and some hospitals have resorted to sharing them between patients, according to the New York Times.
On her way out, Cotton briefs the nurse who is taking over her patient. She’ll be off the next day, but says she will text him to get an update on the man who has been in her care.
“It’s really heart-wrenching to end your shift and wonder … You’re driving home wondering will the patient make it until the morning,” she said. Cotton wakes up and texts the nurse. She waits for the three dots to show up on her iPhone screen so that she knows he is responding. Their patient made it through the night.
Two days later, she is back at work and caring for the same patient. His situation is much the same. She washes his hair and shaves his face – anything to “help him feel normal,” she said. Nurses, she said, tend to believe in the power of therapeutic touch and hand-holding. Often nurses can depend on family members to help lend patients this type of emotional support. But for COVID-19 patients, only nurses can provide it. The nursing assistants usually responsible for cleaning are not even allowed in the room.
Another day goes by and then Cotton is back in the ICU, working as the “charge” nurse, coordinating nursing operations for the entire unit. The mood has eased up, slightly. Her patient is still there, but showing small signs of improvement. The stock of supplies seems to have increased. Nurses have face shields again and the hospital has announced it will hand out surgical masks to anyone who comes inside. Also, it’s Sunday. The normal cadre of administrators is at home. The nurses, for the most part, have the ICU to themselves.
Two walk by, making the rounds. One pulls out her phone and blasts MC Hammer’s “Can’t Touch This” – as an ironic ode to everyone’s new life. They check in to see if patients need to be turned or if the other nurses need anything. Both of them dance their way through the corridors. Their dancing is awful, thinks Cotton, but she and everyone else can’t help but laugh, and be pulled into the moment. One patient smirks and moves her shoulders from side to side behind the glass door.
“For a minute, it was just like the normal ICU,” Cotton said.