Julie Hurlburt started a recent 12-hour nursing shift at Mercy Hospital's intensive care unit with a hopeful goal — to keep her COVID-19 patient alive long enough for his daughter to fly into town and see him.

But 10 minutes into her shift, the patient was dead.

Hurlburt, an intensive care nurse for the past 21 years, has cared for her share of the 3,500 people in Minnesota who have died from COVID-19. Each loss is difficult, but this one really stung.

"Some days I feel like I can deal with this," Hurlburt said. "Some days I have to step off the unit and cry and come back and deal with it."

Heartbreak and loss are realities in the "red zone," the ICU wing designated at Mercy for critically ill COVID-19 patients. The unit name stems from the red tape on the floor that marks where strict infection prevention protocols start. Step across the line and people must wear gowns, masks and gloves at all times to minimize the chance of catching or spreading the novel coronavirus that causes COVID-19.

Mercy has been busy amid the pandemic's surge, treating more than 100 patients admitted with COVID-19 on recent days. The Coon Rapids hospital is a nexus of critical care to the north metro and east-central Minnesota, and is part of the Allina Health system that has seen an 85% rise in COVID-19 admissions since Nov. 1.

At one point on Friday, Mercy had no open beds, and 10 patients needing inpatient care were waiting in its emergency department for openings. The red tape that had cordoned off eight ICU rooms for the most severe COVID-19 cases last week was pulled up and extended down the hall to protect 12 rooms this week.

"It's so challenging to be fighting to keep these people alive," said Dr. Matthew Klee, Mercy's ICU medical director.

Hospitals have improved outcomes over the course of the pandemic, according to a review by the Minnesota Department of Health of 6,736 COVID-19 patients who completed hospital care.

The death rate is 10% — down from 15% in May when the health department reviewed outcomes of the first 1,104 hospital cases. However, the data underscore the risk for the 27% of patients admitted to ICUs and the 14% who were placed on ventilators because of difficulty breathing and plummeting blood oxygen levels. Of 961 patients placed on ventilators, 37% died.

"I really thought we would have more effective therapies by now," Klee said.

Earlier this summer, donor plasma from patients who recovered from COVID-19 was used aggressively. Shortly after it received emergency use authorization from the U.S. Food and Drug Administration in August, though, data emerged that questioned its broad benefits.

Mercy critical care doctors have started reserving that only for patients with weak immune systems or on immunosuppressive drugs.

"With so many of these interventions," Klee said, "its been very difficult to see if they are really making a difference."

Blood clots are sources of complications for critically ill COVID-19 patients, who all receive at least low-level doses of blood-thinner drugs at Mercy to prevent those risks. The timing of larger, therapeutic doses for COVID-19 patients varies by hospital — with overuse carrying the risk of bleeding and complications.

Hennepin County Medical Center was an early user of the steroid dexamethasone to combat the immune system's sometimes fatal overreaction to infection, and its hunch was verified by a British study showing that the drug reduced COVID-19 mortality.

The steroid is perhaps the most surefire option ICUs have right now, said Dr. James Leatherman, an HCMC critical care physician.

"Other than the steroids, it's all about just basic ICU management," he said. "I've often wondered if places like New York that just got overwhelmed, if that might have had something to do with their worse outcomes early on."

Donning the gear

Health officials said this underscores the need to protect caregivers from infections themselves by slowing the spread of the virus, because the availability of doctors and nurses with critical care training is what makes a difference.

Mercy's "red zone" is designed so that doctors and nurses don't have to change in and out of protective gear so much. One downside of constantly wearing masks and respirator helmets is the muffled speech, which forces caregivers to speak loudly and repeatedly to be heard.

"Did you check on that heparin drip?" nurse Nicole Melich hollered to a colleague.

After a blank stare and brief pause, the nurse replied, "Oh, I know what you were saying!"

The upside is that nurses can quickly respond and enter rooms of patients without having to don new protective garb.

In only the first few hours of a recent shift, Hurlburt had already helped a doctor place a chest tube in her patient, adjusted her medications, checked her blood sugar eight times, and flipped her from her stomach to her back.

Rotating patients from their stomachs to their backs has made a difference, preventing secretions from clogging on one side of the lungs. The surface area of the lungs is larger in back, so turning people on their stomachs also reduces pressure on that side of the organ and increases oxygen flow. But the process is intensive, requiring at least six nurses or caregivers to do it safely.

One day last week, the "red zone" staff was rotating patients in six of the eight rooms. Despite the intense care, three of them died.

"Our limit in the ICU is two patients for one nurse," said Mercy ICU nurse Kyle Fondie, "but a lot of these patients are sick enough that they need a nurse for themselves. It's hard to explain how sick these people are [to others] who can't see them."

Age and race are factors. The death rate is 24% for Minnesotans 75 or older who are hospitalized with the infectious disease, according to the state health review data. Among 72 American Indians hospitalized for COVID-19, 21 (or 29%) died.

Obesity is a risk for more severe COVID-19 as well, and was found in 36% of Minnesotans with COVID-19 admitted to hospitals. The state's overall adult obesity rate is 30%.

'A long haul'

Length of stay for COVID-19 has shortened overall, according to state health figures, from nine days in the spring to six days in the fall. ICU stays in particular have declined from 15 days to 11 days. However, ICU doctors said they have learned that patience is required with some of the more severe cases.

Dr. Nicole Roeder of M Health Fairview recalled one COVID-19 patient who was on a ventilator for 90 days, and on paralyzing drugs for most of that time, before recovering.

"This is kind of a long haul rather than a sprint," she said.

Hospitals have responded by deferring non-urgent surgeries that might require ICU recoveries to maintain beds for COVID-19 patients.

The number of ICU beds in Minnesota filled with non-COVID patients has decreased from 1,009 on Aug. 1 to 766 last week, while the number filled with COVID-19 patients has increased from 64 to 387.

Hospitalizations throughout the pandemic have increased two to four weeks after lab-confirmed infections have increased.

Infection numbers have started to decline in the past few days in Minnesota, though, and hospital leaders said they are hopeful that will continue and be followed by declining hospitalizations next month.

"These patients are difficult to manage," Klee said. "It takes a lot of expertise."

This is the third in a series on Minnesota hospitals' response to the surging COVID-19 pandemic.

Correction: Mercy Hospital ICU nurse Kyle Fondie said the ICU's limit is two patients to one nurse. Previous versions of this article quoted Fondie incorrectly.