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‘Tough’ times for health care workers

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    Charge nurse Karen Bonoyer, center, talks with physical therapist Patrice Conard, right, and RN Dessa Rogers, second from right, in Gifford Medical Center's inpatient unit as LNA William Turinetti, left, makes a phone call in Randolph, Vt., on Thursday, Dec. 23, 2021. Even with Vermont's high vaccination rate, "we're still getting some very sick people in here," she said. While caring for their current patients and preparing to give a monoclonal antibody treatment on Thursday, the staff was trying to schedule a second antibody treatment for an outpatient being sent from Dartmouth-Hitchcock Medical Center. (Valley News - James M. Patterson) Copyright Valley News. May not be reprinted or used online without permission. Send requests to permission@vnews.com. valley news photographs — James M. Patterson

  • Felisters Ngoma, a registered nurse, works in the wing of Gifford Medical Center's inpatient unit that houses the hospital's two negative pressure rooms that are set aside for COVID-19 patients and are where monoclonal antibody treatments are normally given to outpatients with less severe COVID-19 symptoms. With both rooms occupied on Thursday afternoon, staff set up another room, without the benefit of isolated ventilation, to administer the antibodies to a patient. (Valley News - James M. Patterson) Copyright Valley News. May not be reprinted or used online without permission. Send requests to permission@vnews.com. James M. Patterson

  • Without the added protection of negative pressure ventilation, a room in Gifford Medical Center’s inpatient unit is set up for a scheduled monoclonal antibody treatment infusion for an outpatient with less severe COVID-19 symptoms on Thursday, Dec. 23, 2021. The preparation, infusion and required observation time can tie up a staff member for up to three hours. Gifford is receiving referrals for the treatments from several other hospitals. (Valley News - James M. Patterson) Copyright Valley News. May not be reprinted or used online without permission. Send requests to permission@vnews.com. James M. Patterson

Valley News Staff Writer
Published: 12/25/2021 10:27:09 PM
Modified: 12/25/2021 10:26:42 PM

SPRINGFIELD, Vt. — Dr. Marvin Malek, a hospitalist at Springfield Hospital, tries not to smile.

“Usually I try to put patients at ease by saying something funny,” he said in a recent interview. “Now I have to make sure I don’t laugh.”

He tries to keep a flat expression so as not to disturb the fit of his N95 mask, which filters most, but not all, airborne particles. Protecting himself from COVID-19 is one of the many things on Malek’s mind as the 69-year-old physician cares for patients amid the largest surge of COVID-19 the Upper Valley has seen since the pandemic began two years ago.

Health officials in both Vermont and New Hampshire expect that cases and hospitalizations are likely to increase even more in the coming weeks following holiday gatherings and due to the increasing presence of omicron, a more infectious variant of the virus that causes COVID-19. Deaths also continue to mount, with the highest rate of death among those who are not vaccinated. Last week, New Hampshire announced its first pediatric death due to COVID-19.

The ongoing COVID-19 pandemic, and the associated worsening of a shortage of health care workers and critical care beds is placing additional demands on health care workers in the Upper Valley at a time when they are already worn out from having worked and lived in a pandemic for nearly two years.

“It is really tough, definitely,” Trevor Swan, nursing director of the emergency department at New London Hospital, said in a recent phone interview.

The job of managing nursing staff in the emergency department of the 25-bed critical access hospital has become 24/7, he said.

“It’s nothing for me to get phone calls at midnight; 1 a.m.,” he said.

‘Domino effect’

Amid the surge, which is currently affecting much of the U.S., President Joe Biden last week announced he would be sending medical personal and FEMA teams to areas hard hit by the winter surge, including Vermont and New Hampshire, with the aim of expanding hospital bed capacity.

One such team is on site at Springfield Hospital helping with pediatric vaccination clinics and preparing to open a new COVID-19 treatment clinic, the hospital announced last week. The team is slated to stay through Jan. 15.

New Hampshire also has activated the National Guard, which is providing some staff to help out with tasks such as food service and clerical work. While these efforts may relieve some of the strain on Upper Valley hospitals, health care workers are still under extreme pressure.

Mt. Ascutney Hospital and Health Center declined FEMA resources offered to the help with a monoclonal antibody clinic on Christmas Day because the hospital lacked the staff to operate the clinic, said Dr. Joseph Perras, Mt. Ascutney’s CEO.

“With the rapid spread of omicron in the state, and the known lack of efficacy of available monoclonal antibodies against omicron, we have requested FEMA personnel to help staff vaccine booster clinics in January,” Perras said in a Wednesday email. “We are awaiting their response to this request.”

Due to staffing issues, New London Hospital has had to limit the number of inpatient beds that are open for patients to as few as 16 at a time, Swan said. In turn, that means that patients who otherwise would be admitted to the hospital from the emergency room sometimes have to spend the night in the ED, he said. That ties up beds in the emergency department for other people who are seeking emergency care.

It’s “kind of a domino effect,” Swan said.

In normal times, New London aims to get people in and out of the emergency department in about half an hour. These days, however, patients are sometimes waiting two hours.

“That is a drastic change for us,” he said.

The wait for critical care beds can be even longer, with some patients having to travel to Rhode Island or New York to find a bed with the appropriate level of care. Sometimes no such bed can be found as hospitalizations across the Northeast also are seeing high numbers of patients with COVID-19.

“Nobody has beds anymore,” he said. It’s a “rarity if we find a bed outside of New Hampshire that can take a critical care patient.”

As a result, Swan said New London and other small hospitals are preparing to hold more seriously ill patients in their facilities, as models estimate the number of patients hospitalized with COVID-19 in New Hampshire could balloon from a peak of nearly 500 earlier this month to as many as 700 in mid-January.

As it is, New London Hospital’s emergency department, which has three trauma beds and five exam rooms, has at times had as many as six patients with COVID-19.

Caring for a patient with COVID is more difficult and time-consuming than caring for patients with other ailments, Swan said. Nurses have to garb up with protective gear before entering a room where a COVID-19 patient is being treated. Then they go in and try to get as much done as possible in one visit, check on the patient’s oxygen levels and make sure they have the medication they need, so as to avoid gowning up multiple times.

Doing all this takes a nurse off the floor, away from other patients, for as many as 45 minutes. That leaves one other nurse and just one or two physicians to care for the remaining patients, he said. Nurses are spread very thin.

“They really are tired,” he said.

In an effort to open up additional beds on the inpatient side, New London is competing with many other hospitals for traveling nurses, Swan said. Speaking in mid-December, Swan said he hoped that three new traveling nurses would help the inpatient side to open more beds. But, he said all it takes is one nurse calling out due to illness or other issue to trigger bed reductions once again.

We are “starting to see staff come down with COVID,” he said. “Then you have them out for 10 days.”

Burnout

Caring for patients with COVID-19 also is straining resources at Dartmouth-Hitchcock Medical Center, which like New London Hospital is a member of the Dartmouth-Hitchcock Health system.

Some patients at DHMC, the state’s only academic medical center, are so sick that a ventilator isn’t doing enough to get oxygen into their bodies. In such cases, patients are sometimes put on an extracorporeal membrane oxygenation, or ECMO, machine, which serves as an artificial lung by taking blood from the body, oxygenating it and removing carbon dioxide, before returning it to the patient.

Patients on ECMO are deeply sedated and require that someone attend to them at all times. They can be on the machine for anywhere from 10 days to months, said Brian Heybyrne, a DHMC respiratory therapist. Patients on ECMO are so dependent on the machine that they can have a heart attack within 90 seconds if there’s a problem with the machine.

It’s “important to point out how resource intense these therapies are,” he said.

Patients who are very sick with COVID also benefit by being moved into a prone position, which requires that they be turned over from their back to their stomach. That can take five people working together to avoid detaching important lines.

It’s “extremely risky,” Heybyrne said.

As with patients on ECMO, patients in a prone position need to be continuously monitored for safety, he said.

The growing workload takes its toll on hospital workers, Heybyrne said.

“We were burnt out last year,” Heybyrne said. “Now we’re just numb going through the process.”

There have been some staff departures amid the pandemic workload.

“Anybody who was eligible for retirement has retired,” he said.

Heybyrne said one of DHMC’s early ECMO patients has recovered and gone home. The patient occasionally sends along an update. Because patients on ECMO have a high rate of death, “it doesn’t always turn out great.”

But the updates from the former patient “reminds us why we’re doing it,” he said.

Frustration

In addition to fatigue, health care workers also are feeling frustrated that many people continue to refuse to be vaccinated against COVID-19 and won’t wear a mask in public places.

Dr. Bill Palmer, a hospitalist at Mt. Ascutney Hospital and Health Center in Windsor, said he recently stopped at a Windsor gas station, but had to leave because no one else inside the store had a mask on.

“Basically, I was furious,” said Palmer, who also is the New Hampshire chapter governor of the American College of Physicians.

Palmer said the group has tried to lobby Gov. Chris Sununu to encourage him to enact a statewide mask mandate.

He said he supports mask requirements in public places and employers’ vaccine mandates, both of which Sununu opposes.

“I think the thing is what it boils down to: People need to do something,” Palmer said. They “can’t go around with no vaccine, no mask.”

Palmer said he wishes that people who are going about their business without a vaccine and without a mask would think about the hospital staff who are pulling extra shifts to care for the sick.

Palmer said he’s uncertain how many of those who have not yet been vaccinated are strongly opposed to the vaccines and how many simply haven’t gotten around to getting the shots. He’s seen some of the latter in the hospital at times.

“I’m hoping there are enough of those people it’ll make a difference,” he said.

The current surge, which is being driven largely by those who are unvaccinated, is hitting the Twin States hard, in part, because it comes amid a health care workforce shortage that pre-dated the pandemic and affects all areas of the industry.

In addition to struggling to meet the needs of COVID-19 patients, hospitals also are continuing to struggle to find inpatient beds for people experiencing mental health crises, and to find beds at nursing homes and rehabilitation facilities once patients are no longer in need of hospital-level care.

Prior to COVID-19, Malek said he would get a no when seeking to transfer a patient to DHMC 30% of the time. Now it’s 80% of the time, he said.

On the DHMC side, Heybyrne said they have gotten transfer requests from as far as Texas, Florida and the Dakotas.

“We didn’t have a bed for them,” Heybyrne said. “That’s telling me that if you’re looking to transfer someone thousands of miles away, that’s desperation.”

Matt Bouteiller, a certified physician assistant in the emergency department at Gifford Medical Center in Randolph, said the inability to transfer patients means that in some cases patients aren’t able to get the care they need in the time they need it. A heart attack patient who arrives in Gifford’s emergency department typically needs to be transferred to a catheterization laboratory within a short period of time, but that isn’t always possible these days, he said.

That results in providers taking a different approach to treating the patient that is “proven not to be as good for the patient,” he said.

After an experience like that, Bouteiller said, “you get the feeling that you didn’t give great care.”

Amid the stress and burnout of the pandemic, the future of the health care workforce in the Twin States remains in doubt.

Palmer, who is 65, has already scaled back his clinical work as he had planned to before the pandemic.

While Mt. Ascutney has some young, energetic providers, Palmer said he worries that the additional stress of the pandemic will burn them out early.

“I don’t want them to go: I’ve got to get out of medicine,” he said.

Pulling together

In the face of burnout, fatigue and frustration, Upper Valley health care workers say that their co-workers are key to their resiliency in these difficult times.

“We have a great group of people in our department that work as a team,” said Alexa Swift, a DHMC respiratory therapist. “That’s what gets us through every day.”

They check in on each other and cover shifts when others are sick. They give each other breaks when they are the ones sitting with a patient on an ECMO machine, she said.

Nurses in New London also cover for each other when someone is out, said Swan, the director of nursing in New London Hospital’s ED.

In addition to giving to each other, hospital employees are finding hope by giving to the community. They are donating items to the Turning Points Network, the Sullivan County nonprofit that serves survivors of domestic and sexual violence. Workers in the emergency department are purchasing gifts for five children they’ve “adopted” from Turning Point’s shelter, Swan said.

When he spoke earlier this month, he said the staff breakroom was “jam-packed with items for these families.”

“This is their way of celebrating,” he said of the hospital staff.

Even as Upper Valley health care workers seek space and staff to cover the anticipated additional surge of COVID-19 patients in January, Swan said he hasn’t lost his optimism for the future: “I’m crossing my fingers for 2022.”

Nora Doyle-Burr can be reached at ndoyleburr@vnews.com or 603-727-3213.


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