Flagstaff, Ariz. (AP) - In the intensive care unit, nurses and doctors are valued for their ability to take quick and decisive action with every patient who needs the highest level of care for their critical condition.
However, nurses and doctors, now on the front lines of COVID-19, have had to restructure every action and routine of both their work and personal lives because of the virus. Over the past three months, healthcare strategies based on federal recommendations have been in nearly constant flux, the supplies medical workers once treated as disposable are now valued like gold and morale has often hit severe lows as ventilators arrived broken and the numbers of deaths continued to rise.
Flagstaff Medical Center is considered a top-tier trauma hospital in northern Arizona, meaning it’s the first place critical care patients are sent north of Phoenix. Northern Arizona Healthcare, through its two hospitals in Flagstaff and the Verde Valley, serves a region with 700,000 residents, multiple sovereign Native American nations and millions of tourists every year.
Because of how widely the novel coronavirus spread throughout communities, the hospital stopped all elective surgeries and its critical pediatric care to dedicate four intensive care units solely to COVID-19 patients.
While Flagstaff has had hundreds of cases, the neighboring Navajo Nation has had thousands of cases across its communities.
At its peak, the Flagstaff hospital had about 40 critical patients at one time spread between the four intensive care units, according to Joel Terriquez, an infectious disease doctor.
The Arizona Daily Sun was able to interview three Northern Arizona Healthcare nurses over video. The nurses discussed the hardships of daily life, detailing the past three months of working on the front lines of the coronavirus pandemic.
Danielle Rust, a critical care nurse, has been charged with working in the intensive care units, fashioned and specialized to quarantine and treat people with COVID-19. On her unit, Rust is just one nurse on a small team, each trusted to make quick and precise decisions each shift to keep their vulnerable patients alive.
Rust said around the time of the first positive coronavirus case in northern Arizona, she knew the hospital’s game plan, and she knew the federal recommendations. Still, she felt nervous about the unknown.
Soon after the city of Flagstaff ordered its bars and restaurants to shut down on March 17, the coronavirus began its community spread and cases at the Flagstaff hospital surged.
Rust said the hospital had anywhere from one to four COVID-19 patients in its intensive care unit in mid-March. At the time, she said some felt this would be the pandemic’s peak.
That illusion was shattered when a spike in cases on the Navajo Nation indicated a large outbreak and many of the reservation’s critical cases were diverted to Flagstaff’s intensive care. In one day, 17 critical patients were flown to the Flagstaff hospital, according to chief quality officer John Mougin.
Rust said she remembers watching the lead physician assess the first patient brought into the hospital. She has seen people being admitted for care dozens of times before. But when the doctor turned around to look at her, she knew the coronavirus pandemic would be unlike anything the hospital, her coworkers or northern Arizona had ever seen.
“I saw it in the provider’s eyes - the urgency - that we need to get these patients intubated now,” Rust said, as she wiped tears from her eyes.
“We didn’t know how long this was going to last,” she added. “And how hard it would be.”
Many of the patients flown in that day, unable to breathe for themselves, were eventually intubated - a process that involves inserting a plastic tube down the windpipe. At the time, it was the recommended way to treat patients.
The stands holding IV bags have become an essential part of western medicine’s tool for care. But in the coronavirus intensive care containment unit - “COVID land,” as Rust calls it - the IV drips are placed outside of the patient’s room, on the other side of the door. When the unit is full of patients, the stands line the hallways.
A long line connects the drip to the patient fighting for their lives on the other side.
This is one of the many steps doctors and nurses have taken to reduce the chance of COVID-19 spreading to hospital personnel, patients or the community at large.
Routines and protocols change often at the hospital, in the name of remaining as clean and efficient as possible. Doctors base procedures on ever-changing and sometimes conflicting recommendations from the Centers for Disease Control and Prevention, the Arizona Department of Health and Human Services, and academic studies.
One protocol the hospital instituted early on was maintaining a clean area before entering the unit that doctors called a “donning and doffing zone.”
The zone was constructed to ensure every medical worker could put on and take off their protective gear safely while protecting the hospital from the spread of disease. One medical worker is stationed in the zone to watch people put on and take off their personal protective equipment correctly.
Nurses must wear their normal scrubs as a base, a full-body plastic suit up to their neck, and a head covering with a fan that creates negative pressure in the helmet to keep air moving. Rust said getting all the gear on can take up to 20 minutes.
The fans are loud, but despite them the suits remain hot, the nurses explained. Due to how long it takes to put on and take off the protective suits, nurses are also forced to forgo things like visits to the toilet for at least three hours. At most, nurses have spent up to six hours in the suit, according to Amy Nunemaker, a critical care nurse working on the COVID-19 unit. Nurses and doctors also have to account for dehydration by drinking more water before donning the suit.
“It’s physically exhausting. It just changes your whole outlook and routine. … In the beginning, I felt like I was preparing for battle coming into work,” Rust said. “It felt like I was leaving home and going into a war zone.”
One often-heard complaint from patients before COVID-19 is how often people - nurses, doctors, family, physical therapists, cleaners, nutritionists, janitors - enter their rooms and prevent patients from resting.
But in the containment unit, there are no visits. Patients are all alone.
One patient’s story has continued to inspire nurses to remain strong during times of low morale.
The patient was a woman brought to their unit in the beginning of April. She held out against the coronavirus for 46 days and was the first patient medical workers avoided ventilating for as long as possible, Nunemaker said.
Because COVID-19 is a respiratory illness that manifests in symptoms including coughing and shortness of breath, ventilation was recommended early on in the crisis as one of the first steps to take in patient care.
But as doctors and researchers learned more about the virus, early ventilation was shown to be associated with a high mortality rate.
So nurses had to find another way to help the patient breathe, all the while still unable to touch or get close to the patient to speak with them. This woman was the first patient they helped breathe easier by using a technique called “proning,” Nunemaker said.
Nunemaker, who has worked as a nurse for 20 years, would knock on a window between herself and the patient to get her attention, then communicate using hand signals. She signaled to the patient to flip onto her side or stomach, which lets gravity do the work of creating more space in the chest cavity for easier breathing.
When the woman changed her position correctly, she and nurses celebrated by by high-fiving through the window and pumping their fists as they smiled; a moment of joy between a woman isolated in a fight of her life and a healthcare worker dressed in a protective suit.
“After a couple of days, her respiratory status declined rapidly. I was with her the day we admitted her. I was with her the day she declined,” Nunemaker said.
Despite their new technique, the woman had to be placed on a ventilator as her condition continued to worsen. The nurses were unsure if she was going to make it.
“I held the phone to her while she talked to her family and told them goodbye,” Nunemaker said.
But the patient made it through the night, and continued to fight.
“I am happy to say that last week - 46 days later - we got to transfer her to Phoenix to the long-term care facility,” Nunemaker said. “She got to Zoom with her family, and wave goodbye to them before she was flown down to Phoenix. That woman had us working for 46 days.”
“All 46 days,” Rust chimed in.
“It was not an easy 46 days,” Nunemaker said, her surgical mask unable to hide her smile. “It was touch-and-go the entire time and I will never forget her. She is a positive case that I have to remember and hold close to my heart.”
An unforeseen consequence of the pandemic is the way it has interrupted medical workers’ home lives.
Like when Nunemaker’s husband asked her to grab some milk after work, she told him she wouldn’t do it.
Despite their specialized training in proper hygiene, medical workers have heard stories about a Flagstaff medical worker who was confronted before coming into work while wearing their scrubs in public. Nunemaker and Rust, who both used to run errands before or after work, said after hearing the story they would never wear scrubs in public again.
“I could not handle people being mean to me,” Nunmaker said. “I wouldn’t survive that.”
Early on, Nunemaker placed a bucket of bleach outside of her home and every night after work she places her shoes in it as one precaution of many to prevent any germs from entering her home. Many medical workers now shower when they leave the hospital, the two nurses said, and shower again as soon as they get home.
Nurses and doctors have both had the conversation about whether they should even stay with their families during the coronavirus. Among other things, not living at home would leave the medical workers without their support system during one this stressful time. Nunemaker and Rust’s families both decided they should stay, but isolate if they felt the risk increased.
“I have two little kids, I have a 5-year-old and a 2-year-old. Just the thought of not being able to go home….” Rust said, her voice cracking as her thought trailed off. “But (my husband) said - he was very supportive - he said, ‘No, we need you here. We need Mom here.’”
Many other medical workers have already isolated themselves in hotel rooms, campers or shelters away from home to avoid any chance of spreading the virus to family. Both Rust and Nunemaker explained that it’s a personal decision based on what steps one is willing to take and how safe that person is fully knowing the risks.
While relying on their immediate families for support, the two said they have isolated themselves from other family members, friends and their normal habits.
Given the traumatic nature of their jobs, self care is taught as a part of the curriculum at nursing schools. Nurses need to find a way to vent their stress and remain happy as a way to handle the trauma involved in their profession. Some nurses are revitalized through friends, the outdoors, family or hobbies.
The coronavirus, however, has taken many of their self-care rituals.
For example, no amount of support will calm Rust’s fears about possibly spreading the coronavirus to her parents. Her children, who were often babysat by her parents, have not seen their grandparents for months.
Nunemaker said live music and music festivals are her therapy, and she can feel its effects.
“I know when my self-care is working, I can put my shoulders down, I can smile and move through the emotions that I have had from my job,” she said.
Nunemaker had tickets for 28 concerts and live shows, all of which have been canceled because of restrictions on social gatherings. She has been unable to spend time with her friends beyond Zoom calls, and has been unable to meet her best friend’s newborn child.
As a result, Nunemaker has been forced to find new outlets for her stress. One day, she made herself put on a dress and wear earrings to go out and buy plants to decorate her home. She also made a point to wear her wedding ring, something she cannot wear at work in the COVID unit.
“The self-care thing has been probably the most challenging part of this, because we do need that,” Nunemaker said. “We also work a lot of extra shifts; each week we’re working one to two extra shifts.”
Despite the stories they’ve heard about people in the community confronting doctors and nurses, the nurses said the majority of the community has been kind.
Medical workers have built a wall of thank you cards in the hospital; they have seen cars flashing hazard lights from the church gatherings in the hospital parking lot; they felt moved by the donations of food, masks and gowns, and lotions for their dried and cracked hands; and they have heard the people howling in thanks from their home at night. People have shown their thanks, and all of it has meant so much, the nurses said.
Tyffany Laurano stepped into her new role as the chief nursing officer in November before the pandemic. She has not been on the front line, but has been a close observer of the work Flagstaff’s nurses have done.
Laurano said being able to call herself a nurse after witnessing what Nunemaker, Rust and the other nurses have done every single day has filled her with pride she’ll hold on to for the rest of her life. Laurano said what appreciation she has been able to share never feels like enough to pay back the daily sacrifice nurses put themselves and their families through to care for total strangers.
“I think it’s actually so amazingly true: Nursing - what we have been able to accomplish as a force - is the most beautiful, amazing thing I’ve ever witnessed,” Laurano said.
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