EMERGENCY DEPARTMENT, KENT HOSPITAL — The other day, a colleague of Dr. Laura Forman, Kent Hospital’s chief of emergency medicine, turned to her and said: “I’m pretty sure this is the apocalypse.”
“Yeah, I’m pretty sure it is,” Forman responded.
“Well what do we do?” the colleague said.
“I think we just keep working,” Forman said.
The colleague agreed, and turned back to his computer.
And so that’s what Forman was doing the Wednesday before Christmas: She kept working. Things weren’t so bad, by apocalypse standards. The waiting room wasn’t full, yet. Every bed in the 43-bed emergency department was spoken for, but only one person was being seen in the hallway. They did not have to intubate any teenagers the same age as Forman’s 18-year-old daughter this day. Over the intercom, an announcement: A Christmas pie sale was going on in the cafeteria. The cafeteria has not yet been transformed into a room for COVID patients. It hasn’t come to that — yet.
“Babies are being born,” Forman said as the announcement blared. “Pies are being sold.”
But pretty good in December 2021 is pretty bad for the life of anyone else who has worked in medicine in 21st century America.
“I’ve worked in refugee camps that were less stressful,” Forman said, standing against a wall with arms crossed by the respiratory care unit. “We don’t have kids dying of malnutrition — that was horrible. But this is a sustained level of trauma and chaos that’s as bad as we’ve ever seen. It’s certainly unprecedented in this country in the last century.”
The Boston Globe on Wednesday went inside Kent Hospital in Warwick, part of Care New England, to get a sense of what a health care system in crisis looks like.
It looks like staff who are exhausted and frustrated, declining to even ask COVID-19 patients whether they’re vaccinated or unvaccinated, because usually the sickest patients are unvaccinated and usually it makes the staff angry. It looks like patients, some in their 30s or 40s or 50s, with ventilator tubes snaking into their mouths and their wrists tied to their bed so they don’t try to tear them out from their throats. It looks like room after room of patients sleeping fitfully with oxygen tubes strung across their upper lip and into their nose. One patient’s cough was so painful that he simultaneously cried out in pain.
This might not be the literal apocalypse, but for many people it is the end of the world: A colleague recently told Forman that she struggled with trying to find a place to move the body of a person who had died of COVID-19 to make room for another patient. The morgue was full. They have brought in a refrigerated trailer to help with the overflow. That drastic measure was an indelible sign of the pandemic in New York in the spring of 2020. Nearly two years later, it is here in Warwick, Rhode Island.
“Most of these folks have COVID,” Forman said as we walked through one hallway of the emergency department.
Even though COVID hospitalizations in Rhode Island are roughly half their peak from last year thanks to widely available vaccines, the hospitals are not able to handle what might have previously been just an ordinary pre-pandemic day of flus and ankle sprains. The Omicron variant of the virus that causes COVID-19 may turn out to be milder, or at least milder in people who are vaccinated or previously infected. That would be a godsend, but hospitals are already struggling mightily under the pressure of the Delta strain and increased non-COVID volume.
“The pandemic has shown us every single fault line of health care,” Forman said, “and boy, are there a lot of them.”
Rhode Island’s health care system broke gradually, and then suddenly: A system that relied on just-in-time logistics and always-near-capacity hospitals has proved incapable of dealing with two years of pandemic strain. Nurses and other professionals have left for better paying jobs, or left the profession altogether, opting out of a traumatic system.
Like other hospitals, Kent has had to hire temporary staff, pay out a lot of overtime, and shift and shuffle existing staff. Roles blur. At one point during the tour Wednesday, Forman, who is the chief of emergency medicine, stepped in to answer the phone, the job of a unit secretary, a job she had decades ago. The strain can be immense: Sometimes that means a 20-hour shift, four hours of sleep, and then another shift. It’s a recipe for burnout.
The system was pushed to the brink, and pushed some more, and pushed some more. A room that was once used to give families bad news is now a COVID patient room. A tent outside can handle an extra 10 people. Some patients wait in their cars to be seen, rather than pack a crowded waiting room. It wasn’t crowded Wednesday, but that would surely soon change. Community spread is like wildfire. What comes next? Kent Hospital is preparing for a difficult January.
“I feel like we don’t have the resources to stretch much further,” said Sherri Sprague, Kent Hospital’s associate chief nursing officer for ambulatory services. “We’re kind of out of ideas.”
They try, nevertheless, to keep up the holiday cheer. Pies were being sold and babies were being born. Sprague was wearing a cheerful Rudolph the Red-nosed Reindeer COVID mask.
Other morale boosters from early in the pandemic are gone. At one point the hospital was playing the Beatles song “Good Day Sunshine” over the PA system every time a COVID-19 patient was discharged. That ended some time ago. Not as many people were going home as they’d like.
Nothing marks the occasion of someone’s trip in the other direction, as when a man in his 30s was wheeled past Forman and Sprague, a BiPAP machine helping him breathe.
It wasn’t enough help. He was headed from the emergency department to the intensive care unit one floor up.
INTENSIVE CARE UNIT, KENT HOSPITAL — Dr. Seth Koenig arrives at work around midday Wednesday, walking briskly through the main entrance and straight into the intensive care unit, where he puts his backpack under a desk and gets an update on a patient.
Are they any better?
Nurse practitioner Kiley Fair shakes her head no.
“Typical, progressive COVID disease,” Koenig said.
That is the way things often go in the intensive care unit, where the sickest of the sick are sent. On Wednesday, 13 out of 14 beds are filled; the 14th bed is kept open as a crash bed.
“How many (of the 13) are COVID?” Koenig, the chief of pulmonary, critical care and sleep medicine at Kent Hospital, asks his colleagues. “Seven?”
“Ten,” Fair responds.
Seven of those are on ventilators. The other three appear to be headed that way, including the man who had just been carted from the emergency department.
A year ago, this place was populated by grandparents. COVID-19 did and still does prey on the elderly and the most vulnerable, sparing children. Now it is attacking young adults, generally but not always unvaccinated. That’s at least in part, Koenig said, because older people have gotten vaccines and booster shots and are playing it safer.
“The woman who died there was 41,” Koenig said, pointing at one room. “The person who was in this room was 37 who died. The one I took out of there was 51. They’re young.”
It is hard to describe what it looks like in the intensive care unit, but once you do, it stays with you: patients lying in beds with tubes going into their gaping mouths, inert and helpless, with walls of monitors displaying generally grim news about their vitals. You can see them through the windows, but signs on the door warn of the precautions you have to take to draw near.
Even if they manage to get their oxygen levels up with invasive ventilation, which moves their chests up and down with oxygen from a machine, the battle is not over.
“We watch this spiral,” Koenig said. “So now the kidneys are going. We put them on dialysis, and then the blood pressure drops. And then we all know what’s going to happen. We know nine out of 10 of these people, in two weeks, we’re going to talk to their families, and they’re going to let the patient go.”
The ICU is brighter and quieter than the emergency department, shaped like a rectangle with rooms surrounding a central nurses’ station. There are other differences: Forman, the emergency doctor, said even sick unvaccinated COVID patients will often say they still won’t get vaccinated. By the time they get to the ICU, Koenig and his colleagues said, patients are full of regret, and wish they’d gotten their shot.
There are many stories about this, but some in particular stand out, like the husband and wife who were both in the ICU, both unvaccinated. The woman died. The man survived. When they brought him to her room, he threw himself on the floor and cried: Why didn’t we get vaccinated? And: Why her and not me?
A much smaller proportion of vaccinated people die, too. It’s confusing — not academically or analytically, but morally. COVID-19 is a serious disease, and no vaccine is perfect. Some of those who died had their primary series of vaccines, but not a booster. Some people get lung cancer even though they never smoked. But it is even more difficult for the staff to bear.
Koenig worked in New York during the spring 2020 surge there, carrying bodies to a refrigerated truck. What’s different in December 2021, and what’s so demoralizing, is that a vaccine is available now. Even if the world seems like it’s coming to an end, the Kent Hospital ICU is ready, from a staff and infrastructure perspective, for things to get worse.
“I don’t know if we’re ready for it emotionally,” Koenig said.
On a good week, about 10 percent of patients will come off a ventilator, Koenig and his colleagues said. They recall one patient who was on a video call with his young child as he prepared to go on a ventilator. The phone slipped from his hand as he lost consciousness. He did not survive.
By the time patients get to the ICU, the patients know these grim odds, and before the sedatives kick in they’ll say to the doctors and nurses: I’m going to die.
More often than not, they are right. It’s the sort of thing that makes Fair think that you can’t take any moment for granted. As a patient is going under, she will hold their hand and say: I’ll be here when you wake up.
“It’s the most human thing we can do,” Koenig said, “and nothing else really matters.”