A look inside Billings Clinic’s overflowing intensive care unit

BILLINGS, Mont. – Nurses fill the hospital room to turn a patient from the stomach to the back. The ventilator that forces air in is most effective when he’s on his stomach, so he’s in this position most hours of the day, sedated and paralyzed by medication.

Lying on his stomach all these hours produced sores on his face, and a nurse dabbed the sores. The dark lesions are insignificant given her current condition, but she continues in the same manner, quietly, soothingly, seeming to whisper to him as she works.

The man has been a patient at the Billings Clinic for almost a month, most of the time in the hospital’s intensive care unit. He is among other patients, room after room, with the same sinister tubes inserted down his throat. They have covid-19 – the vast majority are not vaccinated against the virus, according to the hospital. Visitors are generally not allowed in these rooms, but the man’s mother comes almost daily to look through a glass window for the 15 minutes allowed.

It all happened on Friday. He was dead at 24 on Sunday morning.

The hospital morgue cart arrived at the ICU – as is often the case nowadays – then the room was sterilized, another patient took the man’s place and the cycle began again . Last week, 14 people died from covid here, the state’s largest hospital.

“I feel a little hopeless,” said Christy Baxter, director of intensive care at the hospital.

The situation has been playing out in hospitals nationwide since 2020. But now Montana is a national hotspot for covid infections, recording the largest percentage increase in new cases in the past seven days. The state announced 1,209 new cases on Friday, and Yellowstone County, home to the Billings Clinic, is suffering the worst. As of last week, the county had 2,329 active cases, more than the next two counties combined.

What is different from the first scenes of the pandemic is the public response. Not so long ago, cheers of community support could be heard from the hospital parking lot. Now the tensions are so high that the Billings Clinic is printing signs in its hallways asking that staff members not be abused.

The intensive care unit here can accommodate 28 patients, but last Friday was operating at 160% of capacity, Baxter said. To deal with the overflow, nurses are providing care elsewhere beyond their training, as covid patients fill other parts of the hospital. In the hall of the emergency department, rooms approximately 6 feet by 6 feet were fashioned with makeshift plastic walls. Ten members of the Montana Army National Guard arrived last week to help out in whatever way they can. Hospital staff volunteer to sit with dying patients. The beds line the hallways.

“The problem is, we are running out of hallways,” said Brad Von Bergen, hospital emergency manager.

The hospital has announced that it may soon be implementing “standards of crisis care,” which essentially means it will ration its equipment, staff and medications, giving preference to those it needs. can most likely save, regardless of vaccination status. It’s an ugly system, abhorred by those who will use it, with tiebreakers in place to decide who potentially lives and dies. Other Montana hospitals have taken similar action.

An overcrowded hospital also means that a person, say, a person injured in a car crash in rural eastern Montana and requiring advanced hospitalization will not be able to get that care at the Billings Clinic.

“We are at the point where we are not confident in the future that we can continue to meet the needs of all patients,” said Dr. Nathan Allen, medical ethicist at the Billings Clinic and its director of the medical department of emergency. “And it’s heartbreaking.”

“No one wants to be in a position where we might have to ration healthcare and potentially take a ventilator away from a patient who would likely die and give it to another,” said Dr Scott Ellner, CEO of the hospital. “Are we there?” I would say we are very close.

To some extent, this rationing is already underway. A patient still hospitalized here with covid could have benefited from a machine, known as the ECMO machine, needed to keep his heart and lungs functioning. However, the operation of this machine requires at least a nurse, 24 hours a day, usually for two to three weeks. Typically, this would be an effort of last resort for the most critical patients. Even with this care, the prognosis for the middle-aged man would be grim. Without it, Baxter said, he will surely die.

“The reality is I can’t staff this,” Baxter said. “Are you giving this optimal care to one patient or are you giving excellent care to five? “

The Billings Clinic would hire over 100 more nurses if it could. The staff shortage is not unique to this hospital; it’s nationwide, which means the help needed isn’t coming anytime soon. Baxter tells the story of a young nurse who resigned, claiming he was tired of lying to patients he knew were going to die.

“Patients look at you with that fear in their eyes and say, ‘Am I going to do this? ”, Said Baxter. “You want to encourage them not to give up hope, but you also know the chances of survival are going to be slim.”

Recently, a patient’s last wish was for his preschooler to come and sit with him, to see him one last time. This would generally not be allowed, but an exception was made with hospital staff draping the child in oversized protective clothing, goggles and an N95 mask. Thereafter, the nurse and the doctor sobbed with the patient.

“The moral distress associated with working in healthcare is extremely high for many people right now,” Allen said.

Intensifying this, he said, patients or their loved ones mistreat doctors and nurses. Threats have sometimes necessitated police intervention. The garish insults and blasphemies are daily. A patient threw his own feces at a doctor. Some, even when faced with an intubation tube, wonder about the need to be vaccinated or the effectiveness of the prescribed medication.

Emergency doctor Dr Sara Nyquist said a patient asked her if she was a Republican or a Democrat.

“I said, ‘I’m your doctor,’ she recalls. “You wonder how we got here.”

Ellner, the clinic’s CEO, said he didn’t understand what had happened to civility. “There is a part of society that wants to pretend that the covid wave is not really happening,” he said. “But it is our everyday reality.”

Jennifer Tafelmeyer, a nurse in the hospital’s cardiovascular unit, said the best part of her job before the pandemic was to help patients improve, walk them around the halls, talk about diet and exercise, and possibly escort them to the front door. It hasn’t happened for a long time.

“We just don’t get the wins,” she said.

As she was telling the story, she paused to wipe away a tear. Moments before, she had learned that one of the patients on this floor was not to survive the night.

Allen predicted that the Billings Clinic had yet to experience the worst of the recent spike in infections.

“We are still seeing an increasing number of community cases,” he said. “And we know that hospitalizations lag behind new diagnoses. Unfortunately, it can absolutely be worse than where it is. “

In the meantime, he said, he expects the doctors and nurses here to rally as they did, taking comfort in words of thanks from many patients and gestures like a father bringing pizza. to the emergency department as a sign of appreciation for the care provided to her child.

“The hardest things have been the big things,” Allen said, “and the most inspiring things have been the little things.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism on health issues. Along with policy analysis and polls, KHN is one of the three main operational programs of the KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization that provides information on health issues to the nation.