VA Northeast Ohio Healthcare System
COVID-19 Clinical Response
March 15, 2020 is a date doctors and nurses at the Louis Stokes Cleveland VA Medical Center will remember forever. That was the day a global pandemic arrived on their doorstep when an elderly man with dementia tested positive for COVID-19.
“Even though you know it’s coming and you’re developing treatment algorithms and infection control protocols, I think a small part of you hopes that it’s not going to come to your hospital,” said Dr. Usha Stiefel, Chief of Infectious Diseases.
At first, said Dr. Charles LoPresti, section chief of acute care medicine, physicians looked for fevers, for chills, for typical upper respiratory symptoms, such as coughs or shortness of breath. But they soon found that positive patients could also present with just headaches or nausea/vomiting.
In the beginning, LoPresti said, doctors didn’t know much about the disease, but they did know COVID patients could deteriorate rapidly.
“I don’t know how many times I’ve had a patient about to be discharged when they crashed and ended up in the ICU,” said Dr. Sarah Augustine, Associate Chief of Medicine Service.
The Medical Intensive Care Unit was initially reserved for COVID patients. Patients who weren’t quite as sick, or who had started to get better, went to the Progressive Care Unit.
“It was extremely stressful,” said Holly Robinson, PCU nurse manager, but “our nursing kicked in. We’re going to take care of the patients.”
Amid a nationwide personal protection equipment shortage, the Cleveland VA was lucky. It had extra powered air purifying respirators (PAPRs) on hand.
“We were asked to conserve, [but] we never felt that we did not have enough” said Lisa Neelon, MICU nurse manager. “My goal was to make sure the staff felt safe.”
Everyone was afraid to bring COVID home – Robinson slept in a different room from her immunocompromised husband – so the hospital provided scrubs medical staff could change into at work and showers they could use before going home. No one from either the MICU or the PCU became infected with COVID at the hospital.
After almost a year, doctors and nurses have learned how to treat the virus, and the death rate has gone down. Veterans no longer go on ventilators right away; it’s too hard to take them off, said Augustine. Instead, patients receive high-flow oxygen first. Similarly, drugs initially touted as lifesavers were soon discarded as ineffective and potentially harmful. They’ve been replaced by the steroid dexamethasone and the antiviral remdesivir. Most patients also receive blood thinners.
Nurses have learned to check lab results that normally wouldn’t matter for respiratory illnesses, said Robinson,
and they quickly discovered that a normal pulse oximeter reading of, say, 98 percent, wasn’t necessarily accurate. Veterans’ oxygen levels might really be 66 percent. “That’s not something that you’re presented with in nursing school.”
Practitioners from throughout the Cleveland VA and other, nearby institutions – the Cleveland Clinic, University Hospital, MetroHealth – would call and text each other at all hours to pass on such odd results.
“We all became a lot closer – physically distanced, but mentally closer – to our colleagues,” said Stiefel. “We were all in constant contact. There was obviously very minimal data.” Studies were released early, before peer review, so physicians could learn from each other in real time.
One problem still proved nearly impossible to solve: “Patients who are alert feel trapped,” said Robinson. “We’ve had delirium set in” after months of isolation.
Nurses, social workers and clinical psychologists might read texts from a Veteran’s children. They might show a patient family photos. They might set up a tablet for video chats.
However, “it is not the same,” said Augustine. “I’m not sure it’s possible to realize how awful the isolation is. Worse is having to withdraw support when you haven’t been able to visit your loved one. It’s devastating.” (The Cleveland VA recently began allowing 15-minute terminal visitations for COVID positive patients with appropriate PPE.)
When patients do recover, “it is a wonderful feeling,” said Neelon. “When we sent our sickest patient out it was just a beautiful moment.”
Those happy moments have sustained frontline workers for the past year. They’re important because, even with vaccines, COVID isn’t disappearing anytime soon, said LoPresti.“This was an all-hands-on-deck response, and we needed everybody,” he said. “I could not be happier with the willingness that I saw from everybody in terms of being flexible with rapidly changing protocols and uncertainty and personal anxiety around health so many stressors, so many reasons to not do your job well. The VA just shined through.”