With the recent surge in COVID-19, the beds are quickly filling in the intensive care units at Brooke Army Medical Center, a sprawling military hospital and Level I Trauma Center in the heart of San Antonio.

Many patients are on ventilators or hooked by myriad tubes and wires to a heart-lung bypass machine as they battle a virus that has so far claimed over 145,000 lives in the U.S. alone. In the trenches beside them are the frontline healthcare workers – technicians, nurses, physicians – the last line of defense for the most critically ill patients.

“Dealing with the virus on and off duty, the (personal protective equipment), the long shifts … to be honest, it takes a toll on the staff,” said Lt. Col. Trisha Bielski, Chief, Critical Care Nursing Services. “I couldn’t be prouder of my team and the job they’ve done in incredibly challenging circumstances.”

Bielski oversees hundreds of critical care nurses working in BAMC’s four dedicated COVID ICUs. This day, her attention is focused on 3S, an inpatient ward that’s been transformed from a cardiac unit to a COVID-dedicated ICU reserved for some of the city’s most critically ill patients. Her nurses are tending to several patients on ventilators along with six patients on extracorporeal membrane oxygenation, or ECMO, a heart-lung bypass treatment for patients unresponsive to a ventilator or less invasive measures.

Over the past few weeks, BAMC has taken on additional civilian trauma patients and doubled its ECMO capacity to try to absorb some of the most critically ill community members with COVID-19 and ease the burden on other hospitals, Bielski explained. While BAMC primarily cares for military beneficiaries, a special secretarial designee status enables the hospital to accept civilian ECMO patients and trauma patients, as part of its Level I Trauma mission, in coordination with the city.

A unit transformed

In recent months, COVID and the expanded ECMO mission have transformed 3S from a bustling inpatient ward into an equipment-laden area devoid of the chatter of family and friends. The nurses’ colorful scrubs are now concealed by gowns, their faces obscured by masks and face shields. Technicians stand by patient doors with a clipboard, meticulously ticking off boxes on a checklist, ensuring everyone who enters or exits a room is properly donning and doffing PPE. With safety on the line, mistakes aren’t an option when it comes to PPE.

“We continually train our staff on PPE wear and stress the importance of all safety measures,” Bielski noted. “It takes time but it’s effective and, I hope, reassuring for our staff who are understandably nervous about contracting the virus.”

While beneficial to the healthcare system, the trauma and ECMO mission expansions have generated a need for additional nurses and technicians to increase BAMC’s bed capacity. In some cases, Bielski is able to borrow nursing support from the U.S. Army Institute of Surgical Research Burn Center, which is housed in BAMC, or from outpatient clinics and other wards. However, manpower is a limited pool, particularly as deployments, humanitarian missions and community-based support requirements draw military personnel away from BAMC, which has many personnel deployed overseas and stateside.

“We’ve been very stretched,” Bielski said. “We are constantly assessing our staffing models to ensure we can manage our patient census while ensuring the safest care.”

For the nurses pulled from other work areas, it’s often an adjustment to shift from a clinic to an ICU, especially one such as 3S that requires such a high level of patient care.  

“One of the biggest challenges is working with staff I have never before worked with,” said Army Capt. Amanda Crow, ICU Clinical Staff Nurse and Charge Nurse. “Despite this challenge, I have been continually impressed by the professionalism and hard work of the providers and nurses I have just met. Everyone has been very supportive and helpful to one another during this trying time.”

Taking down barriers

Communication is key, particularly when donning PPE for hours at a time. “It’s draining to wear PPE over a 12-hour shift, but more importantly, it creates challenges in communication, whether to your peers or with our patients,” said Army Sgt. 1st Class Jeremiah Canter, Critical Care Nursing Service Noncommissioned Officer in Charge.

Face masks create a barrier of sorts between staff and patient, an unfortunate hindrance to communication in an environment where human contact is already severely limited. Aside from the staff, a BAMC-supplied tablet is often a patient’s only link to the outside world and loved ones.

“It’s heartbreaking that our patients who are so critically ill can’t have the comfort of their family members at the bedside at this time,” Bielski said.

The nurses do their best to fill the void with technology, an avenue that has proven vital for patient communication and morale. Crow recalled caring for an elderly patient battling COVID and other conditions. With all medical interventions exhausted, the family made the difficult decision to move toward end-of-life care. Crow quickly coordinated a group video chat with the patient’s spouse, children and grandchildren prior to withdrawal of care.

“The family was able to talk to their loved one, see her face, pray for her, sing to her, and let her know how much she meant to them,” Crow recalled. “It was a very moving experience, and I am grateful I was able to facilitate it.

“I would like to think that having that time with family brought her comfort in her final hours and gave her family closure,” she said.

The staff strives to create these personal connections on a daily basis, Canter noted. “We do the best we can to make them comfortable. We talk to them when we are bedside and try to arrange virtual chats. It really lightens their spirits at a tough time. Even when they aren’t able to speak, you can see their faces light up.”

Moments of comfort

For the ICU staff, these video chats spur thoughts of their own families throughout the day. At the end of a long shift, Canter is grateful to head home to his three children visiting for the summer from Georgia. He’s meticulous about changing out of his uniform in his garage before entering the house. Even as he fights exhaustion, Canter takes time to play cards or board games with his kids before he heads to bed.

“We talk about my job. They know what I do, and they aren’t scared about it,” he said. “They know it’s a possibility I could get it and people die from it, but I tell them not to be scared. Just respect it and do the right thing and you’ll be ok.”

Crow’s family lives in Pittsburgh, but frequent video chats bring her comfort in the evenings. “As with most families of healthcare providers during this time, my family does worry,” she said. “Several of my immediate family members are nurses, so we are able to allay each other’s fears knowing that we take any and all necessary precautions in both our personal and professional lives.”

Even as she juggles staffing and critical care duties, Bielski knows she’s asking a lot from her staff, and often worries she’s not thanking her team enough. “My team has been living and breathing this every day for months,” she said. “I’m so proud of what they do on a daily basis. They are truly making a difference in supporting our community.”

For Crow, this is exactly what she signed up for. She was inspired to become a nurse after seeing how nurses supported her father, who was ill, and her family when growing up. After joining the Army, she became even more determined to become a nurse after her older brother was injured in an IED blast while deployed and spent months recovering from a traumatic brain injury at Walter Reed National Military Medical Center. “I was inspired by the care he received and wanted to pay it forward to other families.”

COVID-19 or not, Crow never looked back on her decision to become a nurse. “This is a strenuous time to be working in healthcare, and we are all facing unprecedented challenges,” she said. “That being said, I am grateful to be supporting my community during these trying times. I take pride in knowing that I am taking care of members in my local community, and I hope that my efforts can make a positive impact in the care of others.”

“I feel as a critical care section, we are the COVID response team,” Canter added. “It’s us against COVID, and we have too much at stake to lose.”