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'I don't know where the end is': Inside the ICU at Saint Alphonsus

For the first time during the pandemic, Brian Holmes and photojournalist Kevin Eslinger visited the ICU at one of Idaho's largest and most impacted facilities.

BOISE, Idaho — Tens of thousands pass by Saint Alphonsus Regional Medical Center every day. Standing nine stories high, it's almost impossible to miss.

While it may be one of the largest buildings for miles, it's relatively simple for the outside world to ignore what's going on inside.

Crisis standards of care are in effect statewide, but Saint Alphonsus is one of the most impacted medical facilities in the state.

Beginning on the third floor, the main intensive care unit (ICU) holds 22 beds, the majority of which are filled with COVID-19 positive patients. 20 of those patients are intubated, breathing only by way of a machine.

These days, however, 22 ICU beds are not enough and the third floor is at full capacity.

In the unit next door to the main ICU is a 10-bed ICU, where every single patient is positive for COVID-19. Nine of those patients are currently on ventilators and some have been on them for weeks.

None of the ICU COVID-19 patients are vaccinated against the virus, according to the doctors at Saint Alphonsus.

Two floors below the main ICU in a separate section of Saint Alphonsus, a surgical recovery room has been turned into another ICU. The repurposed section holds eight more ICU beds, which staff expect will soon see their first critically ill patients.

Before a patient gets to the ICU, they are typically admitted to the emergency department. Being the only trauma center in the region, this area of the hospital can get busy without a pandemic.

"We've got all of our nursing and techs and two physicians and to PAs on right now to see patients," said Dr. Andrew Southard, the emergency medical director of Saint Alphonsus. "We just had a helicopter land, so it's starting to pick up."

Southard said the emergency department typically sees about 130 patients a day. On average, 13 of those patients are battling the coronavirus.

"Of the COVID patients that we see, probably 50-60% of them are getting admitted to the hospital right then," he explained.

With limited room, however, staff are left to determine where to put the sick patients.

"Before the COVID surge, we had a goal of 120 minutes until they were admitted to the floor. Most times, we were able to meet that [and] often times it would be within 60 minutes," Southard said. "On average, we're four to five hours at this point, on a good day. On a bad day, we're looking at 16 hours or so sometimes down here."

Like every other unit at Saint Alphonsus, the emergency department has had to create more space; what was once an area for equipment storage now holds six beds for COVID-19 patients.

This means the conference room became the storage room.

"Six months ago, this is where we did education and conferences, but we don't do that anymore in here," Southard said. 

Some Idahoans have long argued that the hospital should have been prepared for a surge in COVID-19 hospitalizations, but Southard said there is no way to prepare for something as dire as this pandemic.

"We train for disasters all the time," he explained. "We've trained for chemical disasters and biological warfare, but when you're talking about a sustained momentum of months or a year or a year and a half now, I don't think anyone can actually prepare for it."  

For the staff in the emergency department, the reaction mentally has been just as much of an adjustment as the repurposing of space.

"The ER is the most resistant place in the hospital," Southard said. "We're used to seeing bad things happen to good people, but I think what is the hardest thing right now is we're watching people get ill and die of a preventable disease."

Meanwhile, the ninth floor of Saint Alphonsus, which is normally dedicated to joint replacement and rehab, has been repurposed as a COVID-19 unit for overflow.

"Normally we wouldn't have beds in here, this is a gym for physical therapy," said Dr. Carolyn McFarlane.

The overflow space treated several COVID-19 patients earlier in the week, adding to the 32 patients already on the floor.

"Fortunately, we had some discharges, but unfortunately we had five deaths in our hospital here and so we have the space available today," McFarlane said. 

The ninth floor is not the only one that has been converted to treat COVID-19 patients; the fifth floor, which was originally an orthopedic floor, is now exclusively dedicated to COVID-19 care with 32 beds.

Despite having two dedicated floors and overflow rooms, the hospital is still struggling to keep up with increasing COVID-19 cases.

Idaho is already reporting record high COVID-19 hospitalizations, even higher than what was reported in December 2020. However, McFarlane said she is not surprised by this surge.

"We just cracked 40% vaccination rate for the state. Life is normal now, right? So people have pandemic fatigue. People are not masking, they're not distancing, they're enjoying all the jubilation that fall brings with football games, festivals, concerts, back to school, of course," she explained. "It saddens me because I see these as preventable deaths. We have an effective vaccine. I think there's a lot of misinformation out there regarding its safety and that does sadden me, but to take it personally? No, I don't because, at this point in time, the community needs us at our full capacity."

While McFarlane does not take vaccine hesitancy and pandemic fatigue personally, she knows the surge is taking a toll on all healthcare providers.

One of those providers is Cari Smith who, on this day, was in the middle of another 12-hour shift, something she said she will likely do for multiple days in a row.

"At the end of the third day, you're pretty fatigued physically, but the mental part is maybe the harder part because you have been that person standing in for family members," Smith said. "Sometimes being the last person a patient will see in their life before they pass away."

Smith can't count the times she has been that last person a patient will ever see in the last 18 months. 

"Yesterday I just wanted to yell because this could have potentially been avoided. This person had a lot of life left, did not have other health concerns," she explained. "It's funny how you're able to figure out how you're going to cope with that. You take your 60 seconds, you cry, you clean up your tears the best you can and then you go back in because you know that that family needs you to be there."

It is not uncommon for patients to die on the COVID-19 treatment floor without ever making it to the main ICU on the third floor. On this particular day, a Code Blue was called for a COVID-19 patient for the third time.

Code Blue refers to the critical status of a patient. Hospital staff can be called for a Code Blue if a patient is experiencing cardiac arrest, respiratory issues or a number of other medical emergencies.

When a Code Blue is called, staff from several units of Saint Alphonsus are called to assist the patient. For nearly half an hour, all of their attention is attuned to one room, working and hoping to bring someone back to life.

Doing this all day, every day for 18 months is an exhausting and emotional feat for all healthcare workers, but Dr. Meghan McInerney, the medical director of the ICU, said this is what the staff is trained for.

"It's not that the death doesn't affect us, right? We're not robots, we all tear up, go home and cry to our family members at various times," she said. "When you feel like you're doing this in the concept of the team, the idea that you're not alone doing this that helps a little as well. Because you saw, I wasn't alone in there. A bunch of people ran in to help."

For every Code Blue, countless staff members show up to try to save the patient.

"It's daunting and our team's struggling," McInerney said. "There's this moral distress that's happening amongst healthcare workers. All of us are feeling this extra weight of emotion and moral distress because so many of our patients are unvaccinated and dying because they chose not to get vaccinated."

Bluntly, McInerney said she does not see the light at the end of the tunnel.

"We'll do this Code Blue, we'll have to console a family member because their loved one died from COVID and then turn around and see that there's a big music festival downtown, large gatherings, and people are not wearing their masks," she explained. "And I get it. People feel like they want to keep living their lives and we're not asking for people to put everything on hold indefinitely. But I mean, we're in the biggest surge we've ever experienced. This is the first time that our state has declared crisis standards of care and many people are going about their lives as if there's nothing different going on."

At KTVB, we’re focusing our news coverage on the facts and not the fear around the virus. To see our full coverage, visit our coronavirus section, here: www.ktvb.com/coronavirus.

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