The critically ill patients in Parkland’s Covid-19 Tactical Care Unit couldn’t wear masks even if they wanted to. They each have a plastic tube jammed down their throats, straight to their lungs. The other end of each tube coils like a translucent snake, tethering the inert form in the bed to a gleaming machine — and, with luck, to life.
It’s eerily quiet on this long, open ward and the 30 patients on ventilators seem frozen in place. They’re unconscious, sedated with powerful drugs, in part to prevent them from ripping out the lines that are keeping them alive.
Not one would hesitate for a nanosecond to trade the invasive plastic tubes for the masks that we, breathing free on the outside, get to wear.
Not the 52-year-old man in one bed or his 77-year-old mother a few beds down. Not the man who went on a ventilator on this Friday night or the one who has been on a machine for more than two months.
In this low-ceilinged space, crammed full of a maze of medical equipment, the two rows of beds stretch farther than you want to look.
Many of the intubated patients lie on their stomachs to make breathing easier. On one man’s back lie a rosary, a cross and a prayer card, placed there by the staff at the family’s request. On another is a pocket prayer shawl with the words “May you be reminded of God’s unending love for you.”
Death stalks the rows of beds as surely as the legion of caregivers struggling to fend it off. They navigate around dialysis machines and IV poles buried in drips, tubes and electronic equipment. Often they are running out of options for lungs that have failed to respond day after day.
The eyes of the world are on Texas right now for all the wrong reasons — as the state sets one shameful record after another for coronavirus cases and hospitalisations. But the 300 women and men working inside Parkland’s “red box” — the nickname given to the brightly painted Tactical Care Unit and its spillover wards on floors 14 and 16 — are too busy, and too tired, to see beyond the next patient.
Dr Matt Leveno, the Tactical Care Unit’s medical director, paused for a long time Saturday when asked how much worse things were than two weeks ago.
“I have not done anything other than take care of critically ill Covid patients since the end of February, and I’m just resigned that this is what I’m going to be doing all day for the foreseeable future,” he said.
“The plan right now is just to run, run, run, run, run — until you just can’t. So I’m just going to go as fast as I can and do as much as I can until I can’t do it anymore.”
Leveno talked to me at the bedside of a 45-year-old man who has been on a ventilator for two weeks despite maximum breathing therapy. His kidneys are failing.
“There’s simply nothing more that I can do,” Leveno said. “I don’t think he’s going to survive, whether it’s today or tomorrow.”
The patient in the next bed was a 60-year-old man admitted April 26 and put on a ventilator two days later. Nurse Joe Krais, who normally works in Parkland’s ICU burn unit but has been with the Covid team since March, has been his caregiver for weeks.
“You develop a relationship with even an unconscious patient and you get emotionally attached,” Krais said. “Right now, we’re taking it day by day and sometimes hour by hour as far as him doing better or worse.”
Krais also pointed to the swelling numbers of the last two weeks. “Is it affecting us? Yes. With the toll, the workload, it’s a challenge.”
The conversations, even as Leveno and his team made their rounds with the most critical patients, were hushed. The quiet was broken only by the putt-putt-putting of hand-held vibrating treatments on patients’ chests, occasional ventilator alarms — and the coughs.
Each time I walked the ward, a nurse or respiratory therapist was at nearly each bed, double-checking the digitally controlled medication drips, adjusting the ventilator, smoothing a pillow or turning a patient.
One seriously ill man, not on a ventilator but aided by two extra oxygen sources, laboured mightily to breathe. His belly contracted sharply in rapid bursts while his face contorted in pain.
That’s “air hunger,” Samantha Rowley, senior vice president of nursing and surgical services, told me as a nurse checked on the patient. “That’s a lot of work for the body to handle.”
As the Parkland executive responsible for the Covid-19 unit, Rowley seems to be everywhere on the ward to make sure everyone has what they need.
“This has been the worst week,” Rowley said on the last Saturday in June. “It’s been rough. It can be hard to come back when you lose two people in a day. But we have to.”
She said Parkland is lucky to have had a staff that can flex from other departments to the Covid unit, but she’s unsure how long that is sustainable. The hospital is taking in more coronavirus patients — and they are sicker when they arrive than they were in the past.
She and her team are feeling increasingly anxious about doing their job in a way that is safe for the patients and the Parkland team.
“Either our community pulls together or we tip,” she said. “People either focus on the masking, the social distancing, the handwashing or things will get worse. Who knows what that looks like?”
I walked with Leveno part of that Saturday morning as he made his daily rounds of the most critical patients, conversations that included both nurses and respiratory therapists in the ward and staffers communicating through a Zoom meeting.
It was a drone of concerning reports: “Hospitalisation, day 27; ventilator, day 2.” “Overnight, a decreased urine output.” “Not a whole lot of headway with lungs.” “Watch this 200 blood pressure.”
Leveno observed a 73-year-old woman whom the medical team was trying to bring out of anaesthesia in order to remove her from the ventilator. “She’s doing very well,” he said. “And this would be the lady who I thought wouldn’t make it. But no, Covid is not like that.”
As we moved on, a nurse continued to comfort the tiny woman, whose eyes anxiously assessed the anonymous PPE-clad health workers.
What makes the coronavirus so challenging is its still-mysterious progression, Leveno said. A patient can have symptoms for many days before the situation becomes bad enough to require supplemental oxygen and hospitalisation.
“Then even with all the oxygen we can supply, the patient can’t do the work of breathing and ends up on mechanical ventilation,” Leveno said.
“It’s a waiting game: Is this a person who will turn the corner and get better or the patient who will be the next one we have to put on a ventilator?”
He said that even though he’s taken care of every critically ill Parkland Covid-19 patient since February — probably more than 100 — “I still can’t figure out who those patients, regardless of age, are going to be.”
“It’s very humbling,” he said.
Like Rowley, Leveno tries to stay clear of the politics of the coronavirus. But he acknowledged that it’s hard to watch when people aren’t doing things that are simple — wearing a mask or social distancing when possible.
“It’s different if you are the sole breadwinner for a household and have to take these risks for my family,” he said. “But ‘I don’t want to,’ ‘I don’t like it,’ that is more challenging for me to accept. It’s not a big sacrifice.”
The Tactical Care Unit provides 66 beds for the most critical patients; 58 of those beds were filled Saturday. The “red box” extensions, on floors 14 and 16, provide about 100 more, primarily for the least ill Covid-19 patients; 63 of those beds were in use.
While most of the Tactical Care Unit houses what would be classified in normal times as the ICU, some of the beds are designated for “progressive care” Covid-19 patients, meaning those who could flip, at a moment’s notice, into critical distress.
In one of these beds was a pregnant 23-year-old woman who, with fever and shortness of breath, had tested positive for the coronavirus. A plan was devised to ensure that the baby could be delivered safely in this ward, but after the child’s premature birth, the mother wound up on a ventilator for two weeks.
Leveno noted that the woman, who smiled repeatedly, had just come off the machine the day before my visit. “I don’t celebrate until they are back at the house, but I couldn’t be happier for her to be in this shape right now.”
Victor Salazar, 53, who had been in the progressive care unit for almost a week, spoke with me from his bed. “It’s been like hell” to have this disease,” he said. “It’s an ugly feeling to not be able to breathe.”
The Grand Prairie truck driver had to pause repeatedly as he talked; an alarm monitoring his oxygen level regularly blared to remind him that he needed to take a few deep breaths.
“I don’t wish this on nobody because it’s bad,” he said.
While the staff is learning more all the time about Covid-19, Rowley said the 12-hour “wave” that often accompanies the disease makes it unique in her years of nursing. “Even if a patient seems stable and improving … something happens in their body and you just cannot stop it from shutting down, organ by organ. When that cycle starts, it’s unstoppable.
“You feel helpless.”
And never more so than when Rowley escorts a family into a special “red box” room to see a loved one for probably the last time. When I checked in with her by phone late Saturday afternoon, she was in tears — having just been a part of two of those goodbyes.
At one bedside, an 18-year-old brought his high school diploma for his unconscious 45-year-old father to see. At the other, a mother begged her 32-year-old, “Fight, little one, fight.”
“It was just awful,” Rowley said. “We put our hearts and souls into this fight and we still can’t stop this tsunami from coming. It’s just killing us all.”
— The Dallas Morning News/TNS
ASSESSMENT: Led by Dr Matt Leveno, left, a team of healthcare workers assesses an intubated patient in the hospital.
