Madison hospitals deal with uncertainty during COVID crisis

MADISON, Wis. — Monitors beep and intravenous poles line the hallway on an eight-bed wing in UW Hospital's ever-expanding COVID-19 unit.

Tubes deliver high-powered oxygen to patients who can barely breathe, many of whom were healthy just days ago. Before entering the rooms, nurses don gowns, gloves and hood-like respirators. No patient visitors are allowed.

Until recently, the hospital had four wings for coronavirus patients. To meet growing demand, it added another wing. Late last month, it designated another. Even that wasn't enough, so a seventh wing opened Friday.

As of Friday, 57 COVID-19 patients were at the hospital, including 16 in intensive care, quadruple the volume from six weeks earlier. If Wisconsin's coronavirus surge doesn't turn around, the hospital may soon have to place infected patients in pre-op waiting areas or operating rooms, said Dr. Jeff Pothof, chief quality officer for UW Health.

"Every time we go to the next thing, it becomes less ideal space," Pothof said. "I wish I had a rosy feeling that things are going to get better here shortly, but I don't know that we have anything in place to say this gets better before it gets worse."

Wisconsin this month is reporting an average of 5,500 new COVID-19 cases each day, more than eight times the rate from early September, when the state became one of the nation's coronavirus hotspots. Most people who get infected don't require hospital care, but those who do have sent hospitalizations soaring to 1,860 coronavirus patients statewide as of Nov. 8, up from 275 in early September.

Deaths from COVID-19 keep mounting, too, with a total of 2,312 around the state and a daily average of 38, nearly triple the peaks from early in the pandemic, when treatments weren't as plentiful and hospitals weren't as prepared.

Some will recover and go home. Others will recuperate in nursing homes or rehab facilities, where they could face lingering complications. Still others will deteriorate, requiring ventilation and intensive care for weeks or months. Some of them will die.

There's no telling who will meet which fate.

"It is still a challenge to predict who is going to get better and who is going to worse," said Dr. Andrew Braun, a UW pulmonologist and critical care specialist who treats coronavirus patients.

"They're just a normal Joe off the street, and then two days later they're paralyzed and laying on their stomach, not breathing well," nurse Ainsley Billesbach said of some patients.

"I would just hope that people would be taking it more seriously," said Billesbach, who has been caring for COVID-19 patients since March. "We're eight, nine months into this, and we have the maximum patients we can handle right now."

To enter a patient room, doctors, nurses and therapists must wear gowns and gloves, plus N-95 masks and face shields or devices called powered, air-purifying respirators, or PAPRs, with hoses through which filtered air is pumped.

Nurses typically care for two patients, adjusting medications and oxygen levels, turning patients when needed, giving them baths and helping them eat and go to the bathroom. Nurse educators who normally would teach patients about topics such as wound care aren't allowed in COVID-19 patient rooms, so the regular nurses do that too.

Whenever nurses go from one room to another, they must change gowns and gloves and clean their face shields or PAPRs.

To minimize the time with patients, nurses put monitors and IV poles, normally kept in rooms, in the hallway so they can check them without entering. The unusually cluttered, noisy hallway becomes a juxtaposition signaling efficiency.

As much as finding space for patients is a challenge, staffing is a greater concern — in part because some workers have been infected with COVID-19 or exposed to it, often away from the job, so they can't come in. UW is looking at asking retirees to return and using doctors and nurses at outpatient clinics who previously worked in intensive care, Pothof said.

"They're not staffed for people who have a lot of mobility needs, and that's what we're starting to run into," Pothof said.

Madison's two other general hospitals are facing similar situations.

SSM Health St. Mary's Hospital, which had 35 COVID-19 patients as of Nov. 6, including three in intensive care, opened a second space to treat them a week ago and may need to expand the footprint again, said Dr. Amy Franta, regional chief medical officer for SSM Health. The hospital has sent one patient to the surge facility in West Allis, Franta said.

UnityPoint Health-Meriter had 54 COVID-19 patients as of Nov. 6, including 16 in intensive care, and has been admitting 10 to 12 infected patients each day, said Nathan Bubenzer, manager of emergency preparedness. It has three areas for coronavirus patients, but may need to reschedule more procedures for other patients to accommodate those with COVID-19, Bubenzer said.

The hospital, which hasn't sent any patients to the West Allis facility, has turned to nurse staffing agencies for help, but they're having a hard time keeping up, too, he said.

Most receive remdesivir, an antiviral drug approved last month for COVID-19 patients, said Braun, the critical care doctor. Many get dexamethasone, a steroid that has shown promise against coronavirus symptoms, or convalescent plasma, an infusion of antibodies from recovered patients, he said.

Some take an experimental "antibody cocktail," developed by Regeneron Pharmaceuticals, through a clinical trial. Many are flipped on their stomachs, especially if they go to intensive care, to help them breathe. That way fluid doesn't pool as much and the heart doesn't push on the lungs.

The biggest challenge in treating COVID-19 patients isn't choosing which treatments to offer, Braun said. It's the no visitor policy. Doctors and patients, if they're able, can talk by phone or video with family. But with rare exceptions, loved ones can't come to the bedside.

A big part of medicine is communicating a patient's condition with families, to help them make difficult decisions, Braun said.

"It's hard to express the degree of illness to someone's family members without them actually seeing it in person," he said.