Nobody was terribly optimistic about Rick Huggins making it out of intensive care at Bethesda Hospital alive — not after weeks hooked up to a ventilator due to a severe COVID-19 respiratory illness.

So when the 51-year-old Eden Prairie man was wheeled out of the ICU to a recovery room a week ago, doctors, nurses and others lined the hall to congratulate him and fist-bump one another for the COVID-19 survival story.

"You have to celebrate the wins," said Dr. Andrew Olson, who treats patients at Bethesda.

As the one of the nation's first and only hospitals to focus solely on COVID-19, Bethesda has seen its share of death. Twenty of the first 130 COVID-19 deaths in Minnesota hospitals were at Bethesda. But the St. Paul hospital also has seen joy and recovery, as social distancing in Minnesota has delayed the peak of the pandemic and given doctors more knowledge with which to confront an infectious disease that didn't surface until late last year.

Learning from peers on the coasts who saw earlier surges in cases, doctors at Bethesda and multiple Minnesota hospitals said they have maximized the effectiveness of critical care strategies while awaiting a vaccine or drug therapy. At the same time, they have been stunned at how COVID-19 differs from other common respiratory illnesses — causing digestive problems, heart complications and even strokes.

"On one level it is simple," said Dr. Chris Kapsner, who directs emergency care at Abbott Northwestern Hospital in Minneapolis. "On another level, it's morphing into this super scary beast."

Minnesota hospitals have managed so far but are wary of COVID-19's second act, when social distancing restrictions ease and infections predictably increase. The number of hospitalized COVID-19 patients in the state doubled from 240 on April 22 to 476 on Saturday, and the number of ICU patients increased from 107 to 180 in the same 17-day time frame.

Minnesota leaders are haunted by images from Italy of patients dying when hospitals were full. That nightmare scenario compelled Gov. Tim Walz to issue a statewide stay-at-home order through May 18, allowing hospitals time to add thousands more beds.

"I cannot have a single person who needs an ICU bed or, God forbid, a ventilator, not get that," he said in late April.

Bethesda embodies the do-whatever-is-possible spirit that has emerged in the COVID-19 fight. Built in phases over the past century and eyed for closure last year, the dated 90-bed facility has windowless doors to many patient rooms and a dumbwaiter for lab samples rather than a pneumatic tube.

Its staff is hodgepodge — including doctors and nurses who left other hospitals to respond to the pandemic, and travel nurses from as far away as Mississippi.

"We learn how each other works," said Angie Whitley, a Bethesda ICU nurse manager.

Caregivers help one another in putting on disposable gloves and gowns before entering patient rooms, and cleaning and donning face shields.

On Thursday, eight caregivers entered one ICU room to wrap a patient in a blanket and rotate him from his belly to his back. Research has shown that more prone time helps COVID-19 patients by preventing clots in the lungs and improving oxygen flow.

After hours facing down, the patient's head was swollen, so the team elevated the bed so he could sit up and recover.

"It's not going to make the front page in most papers, but the mainstay of care to these patients is just really good supportive care," Olson said.

Managing oxygen flow

While as many as 80% of people with COVID-19 have mild or no symptoms, the virus can cause shocking fluid buildup in the lungs and decreased oxygen flow into the bloodstream.

Aggressive oxygen management has become a staple for Twin Cities hospitals — with the use of less-intensive nebulizers and oxygen cannulas early on before turning to ventilators if needed.

Doctors were caught off guard at first by "happy hypoxia" cases of patients who looked normal despite severely low blood oxygen saturation, or O2, levels, Kapsner said.

"Normally when we see someone with O2 stats in the 70s and 80s, this is very disturbing," he said. "They're usually gasping or in respiratory distress."

A New York study in April found only 12% of COVID-19 patients survived after being placed on ventilation, but Minnesota doctors said their results have been better — partly because they haven't run out of beds or resources at any point in the pandemic.

At North Memorial Health Hospital in Robbinsdale, more than half of patients are surviving placement on ventilators, said Dr. Deanna Diebold, a critical care intensivist treating COVID-19 patients. "We have seen nowhere near that kind of mortality."

Doctors have learned to be judicious with ventilation settings so patients aren't overwhelmed by blasts of air, and with fluid levels because excessive moisture in the lungs can be problematic, she said.

While caregivers interact more with patients via iPads and other devices, they still spend time at the bedsides — even when patients are in comas, she said.

"Patients can hear us on some levels," Diebold said. "So we don't want the human touch factor to go away."

Marking success

Huggins figures he was infected while visiting family in Ohio, and then suffered a fever that topped out at 105 degrees. His father-in-law also suffered COVID-19 around the same time and then a stroke, but is recovering as well.

An avid cyclist who has crossed Ohio on four rides, Huggins was shocked that he was hit so hard. He doesn't remember much about his time in Bethesda's ICU but will always remember the send-off.

"They were excited to see me survive," he said. "It was very emotional."

As he was discharged Friday and moved to a rehabilitation facility — 30 pounds lighter than when he entered the hospital on March 26 — Huggins pressed a hotel bell to mark his departure, and the Beatles' "Here Comes the Sun" played over the loudspeaker.

Both are now traditions when patients leave. Health unit coordinator Alex Leal said he found the bell in the drawer of an old rehab unit at Bethesda and figured it would be a nice way to mark success. Roughly 100 COVID-19 patients have been discharged so far from Bethesda.

"We needed to jazz it up and make it fun," he said of the discharge ceremony.

Some caregivers made sacrifices to go to Bethesda.

Laura Triplett figured it would be safe as a nurse to transfer to the COVID-19 hospital because her daughters had moved out and she couldn't infect them — until they moved back from Duluth and Mankato because of job losses amid the pandemic.

Now Triplett is sleeping in a camper outside their house in Inver Grove Heights.

"I'm more concerned about being at Walmart than my job," she said. "It was so busy, the line was so long and people were just on top of each other. It's amazing, you say, 'I work at the COVID hospital,' and everybody steps really far away from you."

Dr. Ben Trappey figured the risks would be lower at Bethesda than at his other hospital, because there is no confusion over who has COVID-19.

"You know that you have to take precautions for everyone," said Trappey, who is living in a hotel to avoid infecting his pregnant wife.

Short-term protection

Walz predicted that Minnesota might be the last state in which COVID-19 cases peak, but already more than 1,000 of its 1,244 ICU beds are occupied by patients with COVID-19 or other problems. Hospitals have a backup supply of 1,351 critical care beds that could be readied in 72 hours if COVID-19 cases surge.

"We've positioned ourselves about as best as we can," said Dr. John Hick, a Hennepin Healthcare emergency physician who has taken on a state hospital coordinating role. "Now just don't step on the gas too hard [on reducing social distancing)] because we can't fall behind on this virus."

Bethesda has opened only two of its three ICUs, but leaders of M Health Fairview believe it will be at capacity soon and are readying specialized COVID-19 medical and critical care units at St. Joseph's Hospital in St. Paul. If they fill up, too, the health system will add COVID-19 capacity at Southdale Hospital in Edina.

More than 1,270 health care providers have suffered COVID-19 infections, though only 103 were likely infected on their jobs.

Dr. Jon Cole got COVID-19 in early March after canceling a family vacation to avoid getting infected or spreading the virus. His wife got sick, too, though they had different symptoms. He couldn't taste an apple — with the loss of taste proving to be a hallmark symptom in many cases.

"I'm not used to breathing 24 times a minute and feeling short of breath just sitting on my couch," Cole said. "At its worst [for me], that is what it got to."

While it is an open question whether those who have had the virus can be reinfected, Cole said friends who have researched coronaviruses believe people at least have short-term protection after they recover. Cole said he has volunteered in his ER at HCMC to take on high-risk patients whose coughing fits increase the risk of them spreading the virus.

"I have offered to do that if anyone else feels uncomfortable," he said, "but I'm not under some delusion that I'm permanently immune."

Cole said he doesn't pretend that he understands all COVID-19 patients but can relate to their anxiety and give them coping strategies. That is important when considering that anxiety can exacerbate breathing problems, he added.

Sarah White suffered COVID-19 as well, probably while triaging patients at Unity Hospital's ER in Fridley. At the time, the policy by Allina Health had nurses moving among different triage sections of the ER with only surgical masks and not more protective N95s — which White said presented an unnecessary risk.

After three weeks in isolation, with her mom caring for her, White returned to work with her own N95 — a policy violation that caused conflict with her manager. Having had COVID-19 once, she wasn't risking it again.

"We would like to believe that [there is immunity], but we don't know," she said.

Supply concerns

Disputes have emerged at most hospitals as managers weigh the conservation of limited PPE supplies for a future surge of COVID-19 cases with the needs of doctors and nurses to protect themselves now.

Paper bags with caregivers' names clutter an entrance to one unit at Bethesda, containing normally single-use N95s that workers can reuse after they have sat for five days and any trace of virus has vanished.

Hennepin Healthcare faced a U.S. Occupational Safety and Health Administration complaint when it was briefly forced to use its last-ditch supply of N95s that were beyond their expiration dates and had to be rethreaded with new straps.

Nurses at United Hospital in St. Paul protested over the lack of scrubs to change into at work so they didn't get the virus on their clothes and bring it home.

Nurses have a right to be concerned, although scrubs technically aren't protective, said Sara Criger, president of Allina's United Hospital along with the Mercy and Unity hospital campuses. Instead of scrubs, the hospital provides pillow cases so workers can change before going home and put work clothes directly into their washing machines.

"Right now our staff and providers ... feel a huge amount of anxiety with the unknowns," she said.

Dr. Marc Martel and colleagues at HCMC created one solution — a translucent box with arm holes that can be placed over patients to limit the spread of germs if they cough while doctors perform aerosolizing procedures. Martel built the box himself and used PVC pipe to create a second device — a plastic hood to place over infected patients.

"I hate to say it, but Menards and Home Depot really supported this innovation," he said with a chuckle.

The University of Minnesota created a similar box and is developing one with an air filter on top to further limit the spread of infectious particles. Tests using a Glo Germ powder visually showed whether the box protected caregivers, said Dr. Gwenyth Fischer, director of the U's Pediatric Device Innovation Consortium. "We were able to see where those particles were flying around."

Caregivers also are devising ways to cope with the deaths — and the added tragedy that patients are alone when they die.

Mobile devices in patients' rooms at Bethesda are sometimes left on after deaths so relatives can spend moments with the victims, Triplett said. The Bethesda nurse prints out EKG readings of heartbeats from patients and places them in capsules along with condolence notes for families.

"I don't know what else I can give them," she said, "other than knowing that we were there [for their loved ones] and did the best that we could."