By Kevin Jones
Photos by John Partipilo
If you’re a member of the team caring for patients in the COVID-19 unit at Vanderbilt University Medical Center’s Adult Hospital, you get to work via skybridge, crossing from the main building to the Medical Center East North Tower.
Some days you might pause and take a breath, just for a second, at the skybridge’s big windows, soaking up the vista of the Nashville skyline. Because from that point on—as you pass through a security checkpoint and two sets of locked doors, and step onto a floor where most people aren’t allowed—the walls can feel like they’re closing in.
Crossing that skybridge is how Lisa Flemmons, MSN’08, begins her 14-hour shifts on the U-shaped eighth floor of Medical Center East—“MCE8”—the hospital’s 37-bed COVID unit. Flemmons leads a team of fellow nurse practitioners who, along with registered nurses and attending physicians, manage care in the floor’s ICU. When the first critical patient arrived last March, Flemmons was at his bedside. (He survived.) She and her team have been on the job ever since.
“These are the sickest patients I’ve ever taken care of,” says Flemmons, who began working in critical care in 2007. “Every single patient is as sick as their neighbor, and you feel pulled in every direction. You’re worried about all of them, all the time. Working here means having the sickest patients in the hospital all in one place. It’s intense.”
Alumni like Flemmons—from Vanderbilt’s schools of nursing, medicine, management and more—have been at the center of the Adult Hospital’s response to COVID. Interviewed in November, as COVID infections were skyrocketing nationwide, Flemmons and several other alumni reported feeling weary after eight months of life ruled by the realities of the coronavirus—on top of an election that turned the public health crisis into a political Rorschach test.
But they also acknowledged the effectiveness of strategies they implemented in the pandemic’s earliest days. They expressed gratitude for Vanderbilt’s collaborative culture and a resolve to keep providing care that, even as vicious as COVID can be, was saving lives.
“DON’T STRAY FROM THE THINGS YOU KNOW”
Last January, the accelerating spread of SARS-CoV-2 made it apparent that VUAH’s two-bed Contagious Disease Response Unit, created for the rare victim of Ebola or other more-isolated emerging pathogen, would not suffice if Nashville were to be hit hard. So administrators began planning for a major outbreak, starting with two central questions: Who would care for infected patients, and where?
To answer the first question, the hospital tapped Flemmons and her team of nurse practitioners from the medical ICU, where they had pioneered the hospital’s use of NPs to manage critically ill patients and were experts in caring for people with pulmonary disease—including Acute Respiratory Distress Syndrome (ARDS), a type of lung damage caused by several illnesses and often seen in COVID patients. The team also was versed in treatment with extracorporeal membrane oxygenation (ECMO), a sort of dialysis for the lungs used to oxygenate the blood of people with severe respiratory disease.
Flemmons’ team was initially hesitant to leave the medical ICU to staff the front lines against a highly contagious, largely unknown disease—“It was like, well, OK, I guess we’re doing this,” recalls NP Susan Hellervik, MSN’09—but Flemmons soon joined other hospital staff in sizing up MCE8, which at the time housed recovering patients from the hospital’s other ICUs.
“We literally went room by room and said, ‘OK, we need these cords, these monitors and these machines to run blood gases,” Flemmons recalls. “We spent a couple of days trying to identify how we were going to convert the rooms into ICU rooms.”
The team learned to don and doff personal protective equipment every time they entered and exited a patient’s room. They mastered the use of PAPRS, respirators that blow filtered air into space-helmet-like hoods. Designated “dofficers” ensured that their colleagues didn’t inadvertently spread infection as they got in and out of gear. Associate Hospital Epidemiologist Dr. Bryan Harris, BS’05, MD’09, MPH’16, oversaw the training. He says the responsibility weighed heavily.
“There was nothing that mattered more to me than making sure staff were safe,” Harris says. “These were my friends.”
All in all, MCE8 came together quickly, with the hospital bypassing its usual deliberative, meeting-heavy process and with medical staff across departments volunteering to help however they could. In a matter of weeks, the floor was transformed into VUAH’s self-contained COVID unit, where all admitted patients with the virus would be treated—including “incidental” patients, who’d been admitted for other reasons but tested positive. Not all patients would need intensive care, but any of the rooms could be quickly converted to an ICU room as necessary.
Faced with an illness about which medicine had more questions than answers, the hospital put its faith in the care Flemmons and her team had provided for years.
“Early on, when people were doing things that were not evidence-based and throwing a lot of drugs at this, my mentors told me, ‘You know how to practice critical care, and you’ve been taking care of ARDS patients for years. So don’t stray from the things you know.’ That was reassuring for my team,” Flemmons says.
Even if aspects of it were familiar, COVID packed surprises—like patients with dangerously low oxygen levels who somehow weren’t fighting for breath or turning blue.
“Normally, we’d be rushing to intubate those patients and get them on a ventilator,” explains Flemmons, “but with COVID, they’re looking at you saying, ‘I’m fine, why are you so excited?’ And you’re saying, ‘But you’re not fine! Put your oxygen back on!’”
PREPARING FOR A MARATHON
VUAH and Clinics Chief of Staff Dr. Shubhada Jagasia, MMHC’12, says the hospital had positive outcomes from several moves made early on, including a COVID mortality rate for hospitalized cases that, as of mid-November, was 10.3 percent compared with 34 percent statewide.
“We said, ‘This is likely not going to be a sprint, but a marathon, so let’s set this up well,’” explains Jagasia, who notes that her master of management in health care from the Owen Graduate School of Management, along with her M.D., has helped her lead during a pandemic rife with unknowns.
One key decision: creating a single, dedicated COVID service line, rather than stitching together care from a patchwork of services and specialties. Another: centralizing decision-making at a COVID command center staffed by providers from across disciplines poised to quickly resolve emerging issues.
The hospital also standardized clinical treatment guidelines instead of leaving treatment to each provider’s discretion. Daily videoconference “huddles,” in which specialists consult on each patient’s case, further inform and personalize care.
“One of the striking things about this pandemic is that we’ve learned so much along the way,” says Dr. Tom Talbot, MD’96, MPH’03, the hospital’s chief epidemiologist. He points to the early assumption that asymptomatic spread of SARS-CoV-2, as with influenza, was unlikely. When data showed that people who weren’t sick could indeed infect others, the hospital had to turn on a dime and shift guidance for staff.
Talbot credits what he learned in Vanderbilt School of Medicine’s Master of Public Health program with helping him weed through the stacks of data, some of it published directly to social media without peer review, that have accompanied COVID: “You’re trying to understand the science while countering things that are out there that may be incorrect.”
“THEY DON’T HAVE ANYONE THERE”
One of the greatest challenges for the MCE8 team is the isolation patients endure because of strict infection-prevention protocols. Visitors weren’t allowed on the floor for the first several months of its operation, leaving patients without the lifeline of family, leaving medical staff without insight into patients that only a family member can provide, and leaving traumatized families without any way of knowing how their loved one was doing beyond a single daily phone call from providers.
“It places an emotional burden on all of us,” says NP Dan Ford, MSN’19. “You end up feeling closer to the patients who don’t do very well. You feel a responsibility to be connected to them because they don’t have anyone there.” When a patient dies, Ford says, “there’s no way it doesn’t eat part of your soul every single time.”
Over the summer, Flemmons and the ICU’s medical director, Dr. Todd Rice, MSCI’05, changed the visitation policy so that patients could have one visitor daily between 1 p.m. and 3 p.m. Visitors spend those hours in the hall outside their loved one’s room, in a chair pushed against the glass door, talking to them via iPad, sometimes even when the person in the room is sedated for days on end.
The staff on MCE8 can feel isolated too—disconnected from patients and families, sealed away from colleagues, frequently wrapped in PPE, unable to step out for fresh air or a cup of coffee because of the constant monitoring patients require. Staff spouses can’t drop by with meals like they did pre-COVID. Co-workers fearful of infection steer clear. Going home to family means persistent worry about infecting them. And seeking support often leaves staff struggling to describe physically and emotionally grueling work that someone who hasn’t experienced it can’t really grasp.
Says Hellervik, “People ask us how we’re doing, and we say, ‘Fine.’ Because what are you going to say? These have probably been the hardest months of any of our professional lives.”
Harris says command center staff, physically distanced from one another in a windowless basement room, aren’t immune from emotional stress, either, as they put in long hours month after month.
“There have been times each of us has been so overwhelmed that tears just appear,” he says. “I’m not a crier, but it has happened a couple of times, where you have a brief welling up of emotions, and you’re close enough to people that it’s OK to be vulnerable.”
April Kapu, MSN’05, DNP’13, associate chief nursing officer for advanced practice, oversees advanced practice nurses throughout the Vanderbilt system. She refers to a chart from the federal government mapping the phases of response that people and communities typically experience during a disaster; they’re not unlike psychiatrist Elizabeth Kübler-Ross’ stages of grief. On the chart, “heroic” and “honeymoon” phases are followed by a phase called “disillusionment.” Kapu says many of her colleagues are wrestling with that phase—and the risk of burnout—as case counts climb and as the initial outpouring of public gratitude for health care workers has waned.
“[Staff] are almost at the stage where they feel abandoned, forgotten. People are going on about their regular lives, but you’re still doing the same thing,” she says.
“At first, you felt like you were in the midst of war, and your country back home was rooting for you,” Harris says. “And now, you’re here, watching people die from a preventable illness, and then you go to the grocery store and people aren’t even wearing masks. It’s like they just don’t care at all.”
Amid the grief, the collaborative spirit among hospital staff has been a buoy.
“I’m full of gratitude for the support people have given us, especially our colleagues, who’ve really stepped up and helped my team, knowing we were struggling,” Flemmons says.
Talbot credits ongoing orchestration across departments, with, among other victories, enabling VUAH to be one of the first institutions in the nation to develop its own testing capability.
“There’s a culture here that is different than anywhere else,” Ford says. “It’s the attitude of how individuals treat each other and the mutual respect and support they give each other. That makes a big difference in the care of these patients.”
THE COMING WINTER
By mid-November, the near-term outlook from MCE8 was unsettling. Cases and hospitalizations were increasing at a record pace around the nation; in Tennessee, the daily average had jumped 55 percent in the month’s first 14 days.
In response to the growing number of patients, VUAH’s COVID unit expanded to an additional floor in the hospital and added clinicians to its teams, while Chief of Staff Jagasia was concerned about maintaining capacity to continue treating patients with COVID and those with non-COVID-related illnesses.
The promise of a vaccine glowed on the horizon, but in a nation receding under lockdown once more, a return to normalcy seemed a long way off.
Flemmons and her team were still making the trip across the skybridge, tired but determined. They had, she says, “prepared and planned and put a backup to a backup to a backup.”
“We’re all really nervous about winter,” she adds. “But we’re ready for it.”
Kevin Jones is a Seattle-based writer who writes for corporations, nonprofits and universities. His work often focuses on sustainability, corporate social responsibility and higher education.