Intensive care units are somewhat like business hotels in that they have a constant turnover of patients. They were not intended for extended stays, like hotels with kitchenettes. But this spring, that changed dramatically.
COVID-19 patients are landing in intensive care for as long as 28 days or more. Before the pandemic, a typical ICU stay usually lasted three to four days.
This is placing intense pressure on medical professionals and exacerbating staffing shortage issues at hospitals, especially those in border regions.
"It's nothing like we've prepared for -- this is not something I grew up with and trained for in ICU medicine," says Dr. Dennis Amundson, medical director of the ICU at Scripps Mercy Hospital in Chula Vista, California. "These are critically ill people who need tremendous amounts of rehab. We're dealing with long-term ramifications that are unusual."
Amundson has overseen care for some 80 patients with COVID-19 at a hospital that's just 7 miles from the U.S.-Mexico border in San Diego County.
A pulmonologist who served in the U.S Navy for 38 years, including multiple deployments to Vietnam and Afghanistan, he is no stranger to intense battlefield conditions. He used to lead an ICU aboard a ship, and has accompanied Joint Special Operations Command troops on missions. He finds what's happening now very similar to the battlefield.
"I was with field teams and JSOC, and in that environment we tend to plan but go in knowing the plans could completely change once you're in," he recalls. "I feel the same thing with this pandemic now, as we deal with a tricky, unpredictable virus."
Amundson, who is 70, came out of a nine-year retirement after he left the Navy to spearhead the ICU three years ago in Chula Vista, a border city that's home to a significant number of underserved minorities. Many of them have little or no access to quality health care, so they're often not in the best health when they come in to be seen and many have chronic conditions.
"I feel like we're making a difference with our patients and their families. It's a good way for me to end my career in medicine," says Amundson, explaining why he chose to return to medicine, and to this particular area. "I grew up in a small town in Iowa, and it seems much more like a family down here."
With the current extended hospitalizations, he and his team are getting to know both the patients and their families really well, something that didn't happen before.
When San Diego County shut down in March, many local Mexican Americans lost their jobs and went to stay with family south of the border in Tijuana. But when they caught the virus, some becoming quite ill, they returned stateside seeking treatment.
Among the most ill are people with chronic underlying conditions -- diabetes, kidney disease, hypertension -- which complicates COVID-19.
"Initially, the average age of our patients was in their 50s, but the ones that stayed and didn't get better were older, in their 60s and 70s," he says.
His ICU unit has 24 beds placed in isolation rooms, all of them being used to treat COVID-19 patients now. He and two other physicians and two nurse practitioners cover the day shifts, supplemented by per diem or temporary physicians at night. The unit also has 90 nurses.
The Chula Vista hospital is one of five Scripps hospitals, but it has half of the health system's patients being treated for the virus. Staffing has been a challenge, especially with some colleagues reducing their hours, and Amundson and his team have been stretched thin. Workers and equipment from sister hospitals have been brought in to fill the gaps.
Like several other hospitals in the San Diego area, his unit did accept critically ill patients who were transferred from hard-hit Imperial County, a rural border region two hours east of San Diego.
"We started to see an uptick in cases from Brawley and El Centro and when they reached out to us, we filled all our beds, then we referred them to hospitals up north," he says.
His typical day starts around 5:30 a.m., when he arrives to take over from the night shift staff. He does rounds -- visiting patients to determine their condition and coordinate a care plan -- and notes who needs the most immediate help, then tag teams with a nurse practitioner. One person stays outside the isolation units in case of emergency elsewhere on the floor, so they can respond quickly without having to worry about decontaminating themselves.
Amundson draws on his military deployment experience -- and a more recent trip to Liberia to help out during the Ebola outbreak -- to be strategic in how his team copes with treating high-risk, contagious patients. This helps bring anxiety levels down.
"We put everything we need to go into a room in a clear plastic bag so we can quickly find it," Amundson says. "As the SEALs say, we doff and don. We know exactly where our gear is, we put it on carefully but we also know how to do it quickly."
When he enters a patient's room now, he pauses to think of everything that needs to be done and tries to get it done without leaving the room.
Typically, ICU doctors would intubate a patient and leave, but now he stays in the room for up to two hours, putting in a catheter line if needed, so lab technicians don't have to enter the room and nurses can draw blood, which reduces the number of people who step inside the isolation room and limits their exposure. Once he put these measures in place at his hospital, other hospitals in the Scripps system picked up these tips and are now changing their procedures.
In the afternoons he meets with pharmacy staff and others, and ends his shift changing out lines of tubing for patients, before decontaminating and heading home.
The father of six hasn't seen any of his children in person since the pandemic began. "We usually get together often, but now we just do Zoom every Sunday. It's been hard to stay in isolation and not see them," he admits.
Initially, Amundson and the other clinicians did shifts of seven days on, seven days off, but realized their efficiency dropped after four days due to exhaustion. Now he switches to a night shift midway, so there's better work-life balance.
Like many other hospitals, he has been preparing for a surge, which he expects will happen if the uptick in cases continues.
He is very concerned about how weak recovering COVID-19 patients are and the tremendous amount of rehabilitation they will need before life returns to normal for them. Many of them suffer strokes, tremors, lung scarring and heart damage.
"There's really no place for them to go, when they transition from the ICU and need rehab, especially in the border (region)," he worries. "What we need is post-ICU facilities to help patients become functional again."
But he is grateful to the community, which has reached out to ask how it can help.
"The war brings out the best of people and the worst of people," Amundson says. "It's not a sprint, it's a marathon now. It's not a battle but a war. God willing we will have a vaccine that's durable. Right now the virus is kind of winning and we just have to hunker down and hold the battlefield and get ready for a longer war."