In New York City, ambulances queued up outside the entrance to an emergency room. Passengers waited, some for five hours, to be triaged. They sat in the lobby hours more before seeing a doctor.
Calvin Sun – a freelance ER physician who said he’s worked 18 shifts at 10 hospitals in recent weeks – said it was easier for him to leave the ER from one door and reenter through another rather than weave between the tightly packed beds of coughing, sick people. Many more filled a hallway, sometimes for three days, until a bed or ventilator was available upstairs. Some died waiting.
Sun said nurses he knew to be unflinching told him they were terrified for their lives. Some used days-old face masks and wore garbage bags as gowns. When the hospitals ran out of hairnets and surgical caps, Sun wrapped a scarf around his head. When a gown did not have long enough sleeves, a co-worker wrapped tape around his arms.
Sun, who has worked in New York emergency rooms since earning his medical degree five years ago, assessed the growing list of patients – all reported COVID-19 symptoms. He felt like every care decision he made was between a bad choice and a worse one.
“I was crying for the future,” Sun said. “I felt like nothing I was doing was beating back the tides.”
USA TODAY spoke with 36 health care workers from coast to coast to capture a snapshot of what life is like for them amid a pandemic that’s raging in some cities and still creeping into others.
Health workers in places with fewer confirmed cases said they count their supplies, answer fearful questions on social media and anxiously read news reports about colleagues elsewhere who are swamped with patients desperate for care.
And they hope.
In Rapid City, South Dakota, Dr. Nancy Babbitt stewed on the reports of chaos out of New York medical centers as she rode her bike to work. She alternated between anger and sadness as she pedaled by neighbors ignoring public health recommendations to avoid contact as they hugged friends or let their kids play at the neighbor’s house.
Babbitt knows it is only a matter of time before her own town is in crisis.
“Everything tells us, all the data we can see tells us, no place in the United States will be spared,” she said. “We have that information. And it’s hard to see people going about their daily lives in a state of denial or fear.”
In the cities overwhelmed with critical patients, doctors and nurses fear for their safety while choosing which patients to keep alive and which to let die. Some killed by COVID-19 have been their colleagues.
Hope has given way to determination and exhaustion.
Despite shortages of safety equipment and the medical tools to do their jobs, health workers showed up for work and made do with creative workarounds.
Those unfamiliar with intensive care and infectious disease procedures report going through condensed training on how to operate ventilators, intubate patients and safely don protective equipment – if such equipment is available. They’ve made makeshift surgical masks out of sanitary pads or by stapling rubber bands to slip-on shoe covers. Some hospitals bulk-ordered rain ponchos because medical gowns are on back order.
They’ve relied on community volunteers who sewed fabric masks that are not ideal but better than nothing. High school teachers with 3D printers manufactured washable devices that can be fitted with a piece of a N95 filter, allowing hospitals to stretch their limited supply.
A nurse – a friend of a friend who had seen Sun's Instagram post that he had extra N95 masks to share – came by his house to pick up some. She told Sun two of her co-workers had died from COVID-19.
Sun said goodbye, closed the door and picked up his phone to continue talking with a reporter.
“Oh my God,” he said. “One of the nurses that died was a patient I intubated at a different hospital a week and a half ago.”
A few hours later, he was asked to cover another ER shift. He went in.
'They’re afraid they’re going to die at work'
John Coleman, a pulmonary and critical care specialist at Chicago’s Northwestern Memorial Hospital, has seen the number of COVID-19 cases increase each day.
“We’ve had to go from one ICU to two ICUs to three ICUs,” Coleman said. “Now we have a mix of people who are getting sick acutely and requiring high levels of support and ventilation.”
Doctors, nurses and technicians train one another in their respective roles to minimize exposure to the coronavirus and limit the use of supplies.
“Usually everyone in the team goes into the room, but our approach is, whoever’s going into the room will do all three jobs,” Coleman said.
Tricia Rae Pendergrast, a med student at Northwestern’s Feinberg School of Medicine works with GetMePPE, a nationwide effort to find and distribute protective equipment to health care workers who are jeopardizing their own well-being.
“I have colleagues in their 20s setting up wills and sending their banking information to their spouse because they’re afraid they’re going to die at work and won’t be able to make those preparations,” she said.
Dr. David Thimons has been at the center of the largest COVID-19 outbreak in Beaver County, Pennsylvania.
He cares for 450 people at Brighton Rehabilitation and Wellness Center. In one week, 41 patients tested positive, three of whom died. Six employees also tested positive.
For days, Thimons has worked from early in the morning to late at night, evaluating the latest techniques and literature on anything that could help his aging residents battle COVID-19. When talking about patients he worried would not survive, Thimons sounded exhausted and defeated, but his tone grew hopeful as he described those beginning to show signs of recovery.
“It was the first time in three days that I smiled,” he said.
The home front
Every day when Cleveland, Mississippi, nurse Brittany McCreary arrives at Bolivar Medical Center for her shift, she changes her clothes, puts them in a paper bag and puts on her scrubs. After work, she changes back into her clothes, puts her scrubs in the paper bag and rolls up the top. Once home, she takes off her shoes outside the house then dumps her scrubs directly in the washing machine. Finally, she takes a shower before touching her kids.
“I don’t think they fully understand,” McCreary said.
Health workers said family support and little moments of “normal life” have been critical to managing unusually high levels of stress.
On Sunday, McCreary planned an alternative birthday party for her daughter, who turned 9: a scavenger hunt around the city with clues leading to presents. They were surprised by family friends who devised their own celebration.
About 10 cars rolled past their house in a birthday parade with appropriate social distancing. Parents honked horns while children held up signs for McCreary’s daughter and tossed candy.
“It’s a birthday she will never forget,” McCreary said. “It was awesome.”
Safety protocols mean nurses and doctors have to deny their patients similar interactions with friends or family that could be comforting. No visitors. No exceptions.
Sometimes hospital staff can help patients use video chat to stay connected with loved ones. The dynamics can be tense. Distraught family members have screamed at nurses who denied them entry to a hospital. A few tried to run past screeners and had to be removed by security.
After turning away husbands and wives and daughters and sons, health workers have watched patients die alone. Nurse Kellie Gross said that’s been the most heartbreaking part of the crisis for her.
“Every time a code is called overhead, my stomach drops,” said Gross, who works at Long Island Jewish Medical Center.
Sometimes, health workers know the people who die.
On March 30, the Rev. Tim Russell, a pastor at Second Presbyterian Church in Memphis, Tennessee, died of complications from COVID-19 after nearly two weeks of hospital care. His care team included members of his church.
“Tim was a good friend to many people and a resource for this community,” said Steve Threlkeld, co-director of Baptist Memorial Hospital-Memphis' infectious disease prevention program. “He will be sorely missed.”
Albuquerque, New Mexico, progressive care nurse Pamela Mount is a planner and problem solver, not a worrier. In her spare time, she crafts wooden boxes with drawers based on friends’ favorite songs: a cowboy boot for the country music lover and a bright, whimsical one for the Pink fanatic.
In the past few days, Mount has taken the safety glasses from her workshop to use at work – a poor substitute for protective medical gear.
Mount said she feels prepared and well-trained for the fight ahead. Still, she worries about her 84-year-old mother, for whom she is a caregiver, and her husband, who has a health condition that puts him at high risk for severe COVID-19 symptoms. Mount admits that if either were to contract the disease and need hospitalization, neither would receive a ventilator if they were in short supply. She knows someone else would be more likely to survive.
Instead of cutting back her available hours at work to protect her family, Mount has volunteered to work extra shifts. She is looking for a relative to take on primary caregiving duties for her mother and reviewing how to minimize the risk of bringing an infectious disease home from work.
“When I chose to be a nurse 37 years ago, that was part of my commitment. It means I get put in the way of harm,” she said. “I feel very strongly that I want to support this community. I want to be able to go to work and do everything I can in order to help people through this crazy, insane period.”
It turns out Mount won’t be going to work anytime soon. She received a call from work telling her to isolate for two weeks because one of her nurse co-workers tested positive.
“I really hope she’s OK. I don’t have any symptoms,” Mount said, still trying to figure out how to minimize contact with family at home. “I think it’s the spirit of the universe telling me … to be quiet and maybe run my bandsaw.”
Up north, another nurse grappled with a positive test.
After caring for about 20 COVID-19 patients at the University of Illinois Hospital, Daniel Ortiz, 29, learned he had been infected.
“It’s a roller coaster of emotions, and it’s difficult to put it into words,” he said. “It’s like we’re flying an airplane as we’re building it in the air, knowing that it’s going to crash into a circus.”
Dozens of other nurses at the Chicago hospital tested positive for the virus, and Ortiz said it’s causing staffing shortages.
“The hospital is hectic. It’s chaos. You can’t even imagine what’s going on,” he said. “You get to the hospital, and half of your staff isn’t there anymore. They’re either calling in sick, or they’re worried they’re going to bring it home to their kids or family.”
Ortiz lives in a Chicago apartment complex with his wife and parents. His parents live in a unit upstairs, and he lives in a unit with his wife below. He hasn’t seen his parents in a month, and he and his wife sleep in different rooms.
“I haven’t really hugged and kissed my wife the way I want to," Ortiz said. "When we talk, I have a mask on. It’s like I’m in the hospital.”
Last month, on his day off, Ortiz developed a fever and headache. He woke up in the middle of the night in sweats. Ortiz called off work and was tested. The hospital had his results March 30, but he couldn’t get the results until the next day because the hospital’s employee health services was overloaded with calls. Ortiz went back to work a week later, seven days since the onset of his symptoms and after three days being fever-free.
“Ultimately, my goal was to get back to work,” he said. “Imagine how the patients in the bed are feeling, knowing they’re drowning? I’m not going to just hide at home and not take care of the people that need me.”
Around the country, hospitals with no or few cases describe planning efforts: how they will find extra staff if regular workers test positive and must be quarantined, how they plan to ration supplies and equipment and who will receive extra training so they always have someone available to intubate a patient or monitor a ventilator.
Despite all the preparations, Deb Snell said there is anxiety among her nursing colleagues in Burlington, Vermont.
“It’s the unknown, waiting to see what’s going to happen and how bad it’s going to get,” she said.
Babbitt, the family medicine doctor in South Dakota, volunteered to work shifts at hospitals if needed during an outbreak. The case count remains low, but she is exhausted by worry – both her own and the fears of friends and family.
“The unknown of how we keep our business going. The unknown of what people can and can’t do, and who they can and can’t be with. The unknown of what’s happening to people who are alone and isolated and don’t have a good social network,” she said.
Notifications ping on her phone more often these days. A text from a friend describing symptoms and asking whether to be tested. A Facebook comment from someone trying to make sense of public health orders. Babbitt is overwhelmed but feels a duty to help people however she can.
One recent night, Babbitt left work, delivered groceries to her 88-year-old mother and didn’t get home until 8 p.m. She had little time to unwind before a video chat with her elderly father-in-law in San Francisco, who described “worrisome physical symptoms.” She was on the phone with him, off and on, until around 2 a.m.
“Ultimately, we had to have a family member come over and call 911,” she said.
A few hours later, Babbitt was back at the office trying to figure out how to keep her business afloat when patient visits are down and insurance companies have reimbursed only a fraction of the actual cost for a telehealth visit.
“It’s a lot to process,” she said. “I try to stay centered and stay zen and have a big glass of wine every night.”
Rebecca Lauderdale, who practices internal medicine at a clinic in southern Mississippi, describes a similar anxiety waiting to know how the coronavirus will affect her rural community. She has a surreal sense that something much worse is about to arrive.
“We get a lot of hurricanes down here, and that’s what this feels like,” Lauderdale said, “that a hurricane is coming.”
The first cases
The night before his first rotation on the COVID-19 unit at Franklin, Tennessee’s Williamson Medical Center, Dr. Aaron Milstone was restless.
He intensely studied safety recommendations. He focused on the precise placement of protective gear – the bonnet on his head, the goggles on his face, the double gloves on his hands, the gown on his body and the booties on his feet. He analyzed over and over again the need for perfection when putting these items on and taking them off.
That’s what scared him most. If he did it wrong, he knew he could be responsible for spreading the disease.
"In 25 years of practicing medicine, I have never once shied away from anything," said Milstone, a former medical director of Vanderbilt University Medical Center’s lung transplant program who works in intensive care at Williamson Medical Center. "The AIDS epidemic or H1N1 in 2009, I never thought twice about catching something from a patient. With this, I felt like I was truly going into battle.”
On March 30, he began his first shift caring for the sickest patients – those on life support.
As he walked the unit's floor, he scrutinized the white boards on the wall, the ones detailing proper safety procedures. He examined the equipment, looking with a diligence he never had before. Then he prepared to see his patients.
"This is what I went into medicine to do," he thought. "I just need to forge ahead."
Tennessee's first COVID-19 case was diagnosed in Williamson County on March 4. More than a month later, the county is beginning to tally deaths.
Milstone's first case of the day was a woman in her 70s, one whose only major risk factor was her age. She was unresponsive when he checked on her.
"Do we tell the family there is some hope left?” Milstone thought. “Or that we've done everything possible?"
He reviewed her condition. She was no longer making urine. Multiple organs were failing. She was on life support.
He picked up the phone and called the patient's daughter.
"There's nothing I can do," he told her.
Many of those who die from COVID-19 die alone. Loved ones can see the body, but they can't touch it. Even after death, the virus keeps families apart.
When Milstone left the room, he paused, distraught and unsure whether he could carry on.
He looked down the stretch of hallway in front of him. Behind each door was another patient waiting alone.
Milstone walked to the next room. There was no time to mourn.
He had to fight for those who were left.
He had to save who he could.
Contributing: Dan D’Ambrosio, Brett Kelman, Corinne S. Kennedy, Rebekah L. Sanders and A. Drew Smith
This article originally appeared on USA TODAY: Health care workers manage COVID-19 chaos or prepare for it to hit