Fatigue, Fear and Frustration 

If you talk to healthcare providers treating COVID-19 patients at St. Joseph Hospital in Eureka, the linchpin in Humboldt County's pandemic response, they all have a story to tell about when the reality of their challenge hit home.

For Kristen Beddow, the charge nurse in St. Joseph's emergency room, it was losing a patient. Beddow grew up in Ferndale and decided she wanted to become a nurse after taking an emergency medical technician class as a senior in high school led her to a job at City Ambulance. She says she loves "organizing chaos" and "being there for people in their hard moments," making the ER a perfect fit.

"The first time COVID really scared me was when I saw someone going from talking and asking us to adjust their pillows to dying, just within hours," Beddow says, her voice trailing off over the phone. She explains that some COVID patients come in looking fine, but their conditions can deteriorate very quickly and unexpectedly, necessitating a kind of hypervigilance from providers. "You just never know."

For Paul Shen, a hospitalist who treats COVID-19 patients in St. Joseph Hospital's intensive care unit, it was also losing a patient — which was the moment the cumulative toll, the fatigue of providing a different level of emotional support for his patients, hit him. Shen, who gave up a lucrative tech industry career to pursue a medical degree and a masters in public health, describes caring for patients in the middle of a pandemic as "why we got into medicine ... our calling." But the doctor says the necessary practice of isolating COVID-19 patients, not allowing friends or family visits, and providers' having to don multiple layers of personal protective equipment — gowns, gloves, respirators and face shields — just to treat them adds barriers, making care harder to render and moments of human connection simultaneously more important and more difficult to achieve.

"When it comes to having someone's hand to hold or a patient feeling they are a human being because of a personal contact, sometimes you're it," Shen says. "The fatigue is facing patients, especially when they're not doing well. These patients are isolated. They're scared. You're their primary support."

Shen says the case that comes back to him in quiet moments is one of the last patients he had who died. Shen works 7 a.m. to 7 p.m. shifts 14-days at a time, so he essentially spends half the month living at the hospital and the other half trying to recover and recharge. He was wrapping up a 14-day stretch in the ICU and stopped to say goodbye to a patient he'd been treating for 11 or 12 days and had become fond of — joking with him every morning and listening to the man talk about how he looked forward to getting back to his antique shop.

"I was ending my shift and I remember going to him and saying, 'I want to wish you the best. You've been a wonderful patient to take care of,'" Shen recalls. "And he said, 'Well, you're kind of my best friend in here.' If I count the human contacts he had, I don't think that's entirely off base, either."

The following day, the man was intubated and put on a ventilator. Shen says he re-read the man's obituary to prepare for his interview with the Journal.

"The need to provide that kind of support, in addition to the medicine itself, for me is an honor but also requires an expenditure of emotional energy I don't generally give to other cases," Shen says.

For Mario Monte, a staff nurse in St. Joseph's ICU who decided nursing was his calling after working as a caregiver for a small long-term care facility in Santa Rosa, the moment isn't singular but chillingly played on a loop in the ICU. Most COVID-19 patients, he says, are transferred from the hospital's respiratory unit when their blood-oxygen levels start to plummet and they need more acute care and consistent monitoring. They're scared, Monte says, and greeted in the ICU by staff cloaked in face masks and shields.

"We see the patient come in and they literally ask you, 'Do you think I'm going to die?'" Monte says. "It's a very hard to answer that question. But the patients I've worked with who are COVID-positive, that's the first question that they ask me, 'Do you think I'm going to make it through this?' ... It's hard to make promises when you know it's really variable. I just tell them what the current status of their health is."

Over the past two weeks, as local COVID-19 infection rates reached unprecedented levels and fears grew that the surge long feared is now arriving amid a perfect storm of pandemic fatigue, cold weather and holiday gatherings, the Journal interviewed a host of caregivers at St. Joseph Hospital. They spoke about their fears and anxieties, their exhaustion and their resolve. And they spoke of the growing dismay of standing frayed but poised to meet unspeakable challenges as a portion of the community continues to disregard public health officials' orders.

"There's a lot of frustration," says Beddow. "I have trouble expressing how frustrating it is that there are people who don't want to take the simple precautions that can help. That's how it spreads, because everyone says, 'I'm just going to do this one little thing. It's just this one thing.'"

It was mid-February when Humboldt County confirmed its first COVID-19 case, which, according to the New York Times, was the first case confirmed in rural America and just the 13th in the nation. Beddow says she recalls being in the emergency room when the call came in from someone saying they'd returned from traveling in China and were experiencing flu-like symptoms. She said the consensus among staff was that it was unlikely to be COVID-19 but that the person should come to have a sample taken that could be sent to the U.S. Centers for Disease Control to be tested. They took all possible precautions but were still shocked when the test came back positive — COVID-19 had arrived in Humboldt County.

"That's when it was like, 'OK, this can actually happen here,'" Beddow recalls.

To hear providers tell it, the ensuing 10 months have felt like trying to sprint a marathon. The first task was figuring out how to effectively treat this new disease in a manner that was safe for providers and other patients.

St. Joseph Health CEO Roberta Luskin-Hawk, who in addition to being a physician has a background as an infectious disease doctor and researched HIV under National Institute of Allergy and Infectious Diseases Director Anthony Fauci, says she was on daily calls from across the health system in February and March about treatment protocols, infection prevention and how to find personal protective equipment amid a shortage and global demand. But the situation was evolving rapidly.

Kelsey McCulloch, a Humboldt native who got into nursing because she likes the human connection — "I like people," she says — and serves as St. Joseph's nursing manager of emergency services, says it was a constant struggle to keep up with the torrent of information, all of it coming from the front lines of providers scrambling to treat a new disease.

"We'd see almost hourly changes in information about symptom presentations and what to watch for and who's at risk," she says. "We were making signs and laminating signs to educate staff and then two hours later something would change. It was very stressful."

Shen says he and other providers spent copious amounts of time talking to colleagues in more heavily impacted areas of the country and reading publications out of Wuhan, China, about the disease, trying to learn how the disease impacts patients and effective interventions.

Beddow says it's hard to overstate the stress of that period.

"Information was changing daily," she says. "I remember the first few weeks, I didn't go home to my kids. I stayed somewhere else until we could kind of get a handle on making sure we had proper protocol and equipment."

And as the charge nurse at the ER, Beddow had to find the balance of making sure staff had the equipment needed to stay safe while also conserving it to meet whatever demand arose with uncertain supply chains, calling it "just a really challenging role."

Meanwhile, the stories coming out of New York and Italy about scores frontline healthcare workers becoming exposed, falling ill and dying were pervasive and inescapable for anyone working in a hospital at the time.

"It definitely increased my anxiety," says Karis Hassler, the ICU nurse manager at St. Joseph. "It increased a lot of people's anxiety."

Luskin-Hawk says St. Joseph benefited from being part of a 51-hospital system, which was able to leverage significant purchasing power to secure large amounts of personal protective equipment and lean on hosts of experts to compile and disseminate the latest information.

"When there was a new clinical protocol, I'd know," she says.

Even now, while providers say St. Joseph has "enough" PPE, there still isn't as much as people would like. Even today, equipment remains on backorder, Beddow says, adding that providers have become PPE connoisseurs amid a patchwork of inventory, knowing which face masks fit comfortably and which pinch the ears.

Over the course of some months, Luskin-Hawk says the hospital implemented its current protocol, under which COVID care is provided in its emergency room, a new respiratory area and the intensive care unit. The goal of the Respiratory Care area, she says, is to make sure COVID-19 patients are isolated in negative pressure rooms with providers who develop expertise in using PPE and care of these patients.

Luskin-Hawk says COVID-19 patients are generally cared for in the hospital's 11-bed respiratory care area — which can flex to 32 beds if needed — and those whose conditions are deteriorating are moved to a negative pressure isolation rooms within the ICU. The emergency department also has negative pressure rooms , so patients suspected of having the virus or who are likely to need an aerosol-generating procedure can be kept isolated.

By June, McCulloch says things began to settle. There were fewer day-to-day changes, guidelines had solidified and PPE supplies had become a bit more stable.

"We felt secure at that point," she says.

Individual providers say they also adopted their own habits and protocols in an effort to keep their private homes and loved ones safe. Monte, the ICU staff nurse, says he goes directly into his garage when he gets home, changes into a fresh set of clothes before entering the house and then goes straight to the shower. McCulloch uses hospital-issued scrubs at work and showers before heading home, then leaves her shoes in a box on her front porch. Shen says he now uses only his own equipment, which he never lets out of his sight, and always makes sure he has alcohol pads in one pocket of his coat and hand sanitizer in the other, and he always changes clothes before entering his home.

"I don't let any of the clothing that entered the hospital touch anything in my house," he says.

There's an inherent stress in that level of day-to-day awareness, providers say, with most adding they live in constant fear of becoming a vector who infects the people they love most.

"We became very vigilant," says Hassler, the ICU nurse manager at St. Joseph, whose family moved to Humboldt County when she was little because her father wanted to raise his kids in a small community with a university. Hassler considers all that has changed since February and pauses.

"This year's been so long," she says.

On the best days, under the best conditions, working in a hospital and caring for ill people simply isn't for everyone.

"What we do here in the ICU is hard," Hassler says. "We're taking care of an extremely vulnerable population at the worst times of their lives, both for the patient and their loved ones."

COVID-19, providers say, has made it incalculably harder, primarily for three reasons.

First, the PPE protocols — while entirely necessary — are constant and exhausting. Providers have to don gloves, gowns, masks, face shields and sometimes capper hoods before entering an infected patient's room — which they estimate can take anywhere from 90 seconds to three minutes. Then, when leaving the room, they need to doff, or remove their protective gear and sanitize in a ritualized, meticulous way, which can take another three to five minutes. Combined, the ritual adds as much as eight minutes to each encounter with a COVID-19 patient, whether it be bringing them a glass of water, an extra blanket or something much more substantial.

Beddow says this forces providers to try to cluster care, doing as many things as possible when entering a patients' room. But ER nurses are staffed at a nurse-to-every-four-patients ratio, so if a nurse spends an hour in a patient's room, that's an hour where colleagues need to cover their other three patients.

The need for such extensive PPE also makes it harder for providers to have those human moments with patients that they believe are integral to quality care. Those moments amount to one of the more rewarding aspects of the job.

"It really has presented that human connection that a lot of us thrive on — you're kind of yelling through a face shield and a respirator," McCulloch says, adding that she wants patients to know she's smiling at them under that respirator even if they can't see it. Everything is a little more difficult now. Every single aspect of it."

Compounding those challenges is the prohibition on visitors, which leaves providers as not only patients' physical caretakers but also their primary emotional supports and their connection to the outside world.

"That's a huge barrier," Hassler says. "It's completely understandable why it needs to happen but it's devastating to not only patients and their family members, but also to the ICU staff and these nurses and caregivers who are having to bridge the gap of these loved ones as far as being at the bedside and present with family members. Patients do better when surrounded by their loved ones."

Shen says the added layer of communicating with family members outside the hospital's walls is challenging, saying he believes there's been "a loss of social trust in providers" and that, to a degree he hasn't experienced with other ailments, some families respond to his condition updates with denial. But even without that, he said the disappointment in their voices can linger.

And layered on top of these changed conditions and their added layers of stress for providers, there's also the fact that COVID-19 is a dynamic disease unlike anything they've seen before. Beddow says the many symptoms associated with the disease — everything from respiratory distress to stomach problems and headaches — make it challenging to quickly identify and treat. But the most alarming aspect, she says, is how quickly some patients grow very ill — some will come in and look "fine" only to unexpectedly take a sharp turn for the worse. McCulloch agrees that the rate at which some patients decline is alarming.

"A lot of our more serious cases have really surprised us with how fast they became very, very ill," McCulloch says

Hassler adds that while so much of COVID media coverage is about deaths, it's already clear less than a year into the pandemic that some of those who survive the illness face long-term impacts.

"COVID-19 has been life-altering for many people," she says. "For some, it's just a temporary discomfort. But you don't know which one you're going to be. You don't know which one your best friend is going to be, which one your loved one is going to be, which one your child is going to be. ... There are people who are now having dialysis three times a week and it's not just old people. It's young people as well who are now on the donor list for kidneys because of the effects of COVID-19."

And underlying all the challenges of caring for COVID-19 patients is the lurking feeling that things will get worse before they improve. The fear is palpable.

"There is the fear from my community, my patients, my coworkers, my family that just leads to a day-to-day anxiety," Beddow says.

We all have former colleagues or friends or family who are working in areas where the wave crashed already," McCulloch says. "There's just this anticipation of not if but when for us."

That COVID-19 wave hasn't crashed on Humboldt County yet but there's reason to believe it's cresting. As the Journal went to press, the county had already confirmed more than 400 new cases through the first 15 days of December, with four COVID-19 related deaths reported over the span of six days. At St. Joseph Hospital, providers say the emergency room is already overwhelmed, though not yet with COVID-19 patients.

While winter months generally see an increase in hospitalizations, with the onsets of flu season and the stresses of the holidays, this year has been different.

"We're dealing with more critical patients than I think any of us have ever seen, like every day. Just a lot of sick patients — sicker than we've ever seen," says Beddow. "We've been overwhelmed with incredibly sick patients because they were afraid of getting COVID so they stayed at home or didn't see their doctor or didn't come in."

Hassler says it's important for people to remember with all this talk of ICU capacity that St. Joseph's ICU is "often full" in non-pandemic times with trauma, cardiac and neurological patients. Even a small influx of COVID-19 patients can make it tremendously challenging for providers to get everyone the care they need.

Beddow notes, in addition, the hospital currently has patients awaiting transfers out of the area for specialized care that St. Joseph can't provide. But hospitals throughout the state have extremely limited capacity in the face of COVID-19 case surges. They don't have the open beds to accept transfer patients, so some end up staying at St. Joseph "much longer than we'd like them to."

The pandemic and associated stresses and isolation have also had "devastating" mental health impacts on the community, providers say.

"The emergency room has seen an incredible increase of people coming to us in acute emotional distress," McCulloch says. "We're seeing these patients repeatedly who have lost hope on a regular basis. That really wears on your ability to maintain hope. And some of their manifestation of emotional distress is in anger and violence. While we still treat those patients with the dignity and kindness they deserve, it's been very intense."

Amid it all, healthcare workers face many of the same pandemic-related stresses as everyone else and find many of the things they once turned to for self-care are no longer possible.

"Honestly, it's been incredibly difficult," says Beddow. "Especially people who have children at home are struggling to find respite or an scape from the stress of life right now, as it is for everybody. I've seen the anxiety and the burnout in the department go through the roof and a lot of people want to get out just because of that stress every day and not being able to find an outlet."

Hassler says she worries about "compassion fatigue" with her staff. While they all signed up to take care of sick patients, it "can still be traumatic and devastating," and they are simply not used to "experiencing so much loss." Luskin-Hawk concedes that the situation has been "emotionally wearing" and staff are already exhausted.

"What we've asked of people is truly extraordinary," she says. "Work in healthcare is challenging on a normal day without a pandemic but these are truly extraordinary times."

She says the hospital has tried to redouble efforts to make sure employees get the psychological and social support they need, saying the system has even put together a wellness app that allows employees to self-assess their mental state and determine if they might need to talk to someone. Everyone interviewed for this story says they worry about their colleagues.

They also feel the worst is yet to come.

"It's really scary," Monte says. "But when it's demanded of us, if the situation comes, I'm sure we're all ready to step up. But you can only go on for so long. ... When there may be a surge, we're going to stretch people thin. We're going to tire our nurses out. We're going to tire our techs out. We're going to tire everyone else out and, at some point, we're just not going to be able to provide the care we're supposed to provide."

A number of people interviewed for this story say they are uneasy about sharing their feelings publicly but want to give the community a glimpse into their reality and some insight into the very real challenges already facing the local healthcare system. They are largely exhausted and frustrated but still determined to provide quality care. They also recognize they alone can't flatten the curve or prevent the worst of the surge yet to come. That's in the community's hands.

"There are certain faces of patients that just stay with you forever. The ability to allow it not to haunt one's self — it can be very difficult," Hassler says, her voice trailing off into quiet sobs into the phone.

"And," she continues after a moment, "that's why I wear a mask and I wash my hands and we don't even visit our family members. Because families should be together."

Editor's note: This story was updated from a previous version to correct inaccurate information initially provided to the Journal regarding how COVID-19 patients are separated from other patients at St. Joseph Hospital.

Thadeus Greenson (he/him) is the Journal's news editor. Reach him at 442-1400, extension 321, or thad@northcoastjournal.com. Follow him on Twitter @thadeusgreenson.