The call came in on Thursday afternoon. It was happening again.
A patient from outside Casper was being put on comfort care. Her parents were driving six hours to the Wyoming Medical Center to be with their dying child. But it wasn’t clear whether they would be allowed to sit with her at the end. Visitation is not allowed at the hospital; the risk of infection is too great.
Dr. Andy Dunn gets these calls nearly every day now. Sometimes more than once. The hope of recovery is slim for these patients, and the focus becomes making them comfortable for what may very well be their final moments.
“I guess we can go into sadness,” said Dunn, the chief of staff at Wyoming Medical Center, the state’s largest hospital. If there is a front line against the virus in Wyoming, it might be found here, in a sprawling campus in the center of Casper. “It’s still a huge amount of sadness...But (also) feelings of, ‘What are we going to do?’ Then there’s a sense of, ‘How long is this going to last? How much more?’”
COVID-19 is killing more people in Natrona County and across Wyoming. The state escaped the trauma of early virus surges in New York and Washington. But now, Wyoming has the fourth-highest death rate in the nation over the last seven days. Thirty-five Wyoming residents died from COVID-19 in the first week of November (35), almost the number of deaths in July, August and September combined (37).
The volume of COVID-19 deaths recorded in the last nine months already exceeds the number of annual highway deaths in Wyoming for every year for at least the last five. 30 per 100,000 people have now died in Wyoming from the virus, double the state’s already record-setting average suicide rate.
And death is not the only permanent outcome of COVID-19, doctors have said. Young people are developing chronic heart and lung conditions they may have for the rest of their lives. Others have trouble finding words or remembering recent events.
Health officials recently warned Gov. Mark Gordon the state could be heading for 3,000 new COVID-19 cases a day, and 2% of those cases could need hospitalization. That would mean 60 new hospitalized patients a day. Sixty-four of the state’s 219 COVID-19 patients Friday were being treated at the Wyoming Medical Center, the most of any hospital in the state.
Those working at Casper’s hospital say an influx of that degree would be crippling.
Before and now
Saturday was Dunn’s 21st straight day walking into Wyoming Medical Center. He’s spent the month watching beds fill and patients grow sicker.
He has an easy time categorizing things before and things now.
The hospital just looks different. Before the most recent surge in COVID-19 cases, virus patients were in a certain area of the hospital. Now they’ve filed half the facility.
The cardiac unit has been moved, and COVID-19 patients now take two hospital floors, plus a separate intensive care unit and catastrophic unit. It’s different for patients, too. Doctors, nurses, housekeeping staff, everyone is dressed in layer after layer of protective gear.
“They get to see our eyes, and that’s pretty much all they get to see,” Amanda Messmer, a patient advocate at the hospital, said.
Patients are scared. They’re more vulnerable. And they’re alone. Families far away or just down the street aren’t able to see their loved ones in the hospital. Visitation has been indefinitely suspended amid the surge, the hospital announced in late October.
“When you’re dealing with someone who’s bypass dependent, so they don’t have a breathing tube but they have like a Darth Vader mask attached, blowing air into them every couple seconds in a really loud aggressive manner,” Dunn explained. “You can’t hear the TV, they’re looking around for some comfort and you know you can’t stay in the room very long because of the viral load, even though you’re geared up.”
The Darth Vader mask Dunn is describing is a noninvasive ventilator that doesn’t force a tube down a patient’s throat, but provides near constant, intense oxygen therapy. Dunn said a high number of his patients are using such machines. Fighting for each breath.
Messmer, the patient advocate, is responsible for giving these patients some comfort. No one envies her work. Doctors have told her as much. She’s the hand-holder, the comforter, the connection-maker. And she is often the one who sits with patients as they die.
And she, too, can easily separate past and present. Before the surge and now.
“I feel like I’ve said goodbye to more patients recently than I did when I worked at the nursing home,” she said.
Her afternoons lately have been full with video calls between patients and their loved ones. She gets to the sicker patients first, to make sure they get to see their family in case they take a turn.
“I feel like there’s not enough of me to go around. I can’t be in all of my rooms all of the time,” she said. “Some days I have left very ugly crying.”
Before COVID-19, Messmer would see between six and 10 patients a day. Now, she cares for up to 45.
She’s been a patient advocate at the hospital for eight years, and has worked in various jobs there for 15. Before that, she was a certified nursing assistant at a nursing home. She’s used to the stress of aiding patients through what she described as “probably the scariest time of their life.”
But this virus is different. Patients come in and instead of getting better in three days, they might deteriorate drastically before getting better. Or they might not get better at all.
“Sometimes it feels like you’re on this rubber band,” she said. “The patient is fine, then you get snapped back and they are not fine.”
“All of a sudden they’re gone”
Dr. Tim Olson can tell when his patients are getting worse. He can see it on their faces.
“There’s a look of dread and fear in people’s eyes,” he said. Patients trying to catch their breath like a sprinter after a race.
A virus patient’s oxygen needs can serve as a good indicator for their condition. If their oxygen levels fall despite receiving oxygen, Olson knows they’re getting worse.
Olson is a hospitalist who has worked at the medical center since 2014. He’s treated thousands of patients, he said. But the pandemic is unlike anything he’s faced in his career.
“There are people in their golden years, they just want to spend time with their families, their grandchildren, their wives,” he said. “And all of a sudden they’re gone.”
Those calls are the ones that leave Olson in shame. Knowing things might have been different. Thinking, “this person didn’t do anything to deserve a death by drowning in their own lung fluid.”
Doctors have more options to treat COVID-19 patients than they did in March and April. They’ve learned better what to do and when. Medications like dexamethasone and remdesivir, which treated President Donald Trump, have helped keep the mortality rate lower than it was in the spring. And doctors have learned to save ventilators as a last resort, because “when we ventilate patients, the mortality increases.”
But Dunn said on the whole, there’s not much they can do for patients who don’t show signs of improvement.
“We get calls through the night when the oxygen requirement goes up,” he explained. “Before, when the oxygen requirement goes up there’s immediate action to be done. It’s like oh my gosh, OK, let’s do X, Y, Z, and let’s do this, and let’s do this...”
“But with this, there isn’t X, Y and Z to do. When I get that call in the middle of the night that the oxygen requirement has gone from 5 liters to 8 liters, That’s like, ‘OK, here we go.’”
“It’s a sobering feeling, because as a doctor, as a health care person in general, you’re trained to fix people and to get improvements,” he said.
Each week, a larger fraction of the hospital’s patients are there because of COVID-19. As of Saturday, the hospital was caring for 64 virus patients. On Oct. 1, there were 14 such patients.
Not only are there more patients, but they’re staying longer, too. Before the pandemic, even someone who came to the hospital incredibly sick would in most cases be well enough to leave within three or four days, Olson, Dunn and Messmer all said.
But now, people can be in the hospital for weeks.
“COVID patients are in the hospital for a very long time,” Olson said. “And that consumes a lot of hospital resources.”
Dr. David Wheeler, a neurologist at WMC and president of the Wyoming Medical Society, said the state is experiencing the worst case scenario warned about in the spring. He used New York City as an example, saying the intensity of that city’s first surge is close to the present reality in Wyoming’s hospitals.
“We’re so much worse off than we were six months ago,” he said.
The hospital staff are overwhelmed. Everyone is working more than 40 hours a week, most between 60 and 80 hours. Nurses and coming in on their off days to fill in for colleagues. Doctors are taking on additional duties.
“We’re trying to bring in travelling nurses but so is every other hospital in the country,” he said, adding that more people are testing positive or having to quarantine than are being replaced.
“The influx of additional personnel is not keeping up with the outflux,” he said.
The worry is that hospitalizations and deaths have yet to catch up to the steep acceleration of cases, and statistically there’s little reason to expect they won’t, Wheeler said. When this happens, non-virus related mortality may also increase if people can’t access the hospital for heart attacks, car accident injuries or other emergency traumas.
He said he envisions a scenario where more people die at home because an ambulance can’t reach them because of an untenable volume of calls. Otherwise they can’t get a bed in the hospital and die before space is available.
“I am pessimistic that unless people change their behavior there’s a very high likelihood we’re going to run out of hospital resources,” he said. “And that’s going to be catastrophic.”
Dunn runs an outpatient respiratory clinic, which he started in March to treat residents with COVID-19 symptoms.
That clinic is seeing a lot more patients—just the latest indicator for what may be on the horizon. When it was established in March, the clinic treated 100 patients a day, if that. The most was 158.
Now, they’re consistently seeing more than 200 patients a day on average, and recently topped 300 for the first time.
What’s more, the people coming to the clinic are sicker than those who came in the spring. Dunn admitted two patients out of the respiratory clinic Thursday “because they were that sick.” Others have been given oxygen at home.
“What’s becoming taxing is the fear and the feeling there’s no end in sight,” Olson said.
Escalating infections and hospitalizations spurred local leaders in the majority of Wyoming counties to take action last week. Natrona County Health Officer Dr. Mark Dowell signed a county health order Wednesday mandating masks in most public places, and health officials are hoping the measure will help save lives and businesses. Similar orders have been passed in 14 other counties and the Wind River Reservation.
Wheeler estimated with 100% mask compliance in the community, the virus would “peter out” in a matter of weeks.
Gov. Gordon, too, recently announced new restrictions on indoor and outdoor gatherings. The new measures limit indoor gatherings to 25 people and outdoor to 250. The announcement, made Friday afternoon, comes as Wyoming now ranks second in the county for the rate of new COVID-19 cases reported in the last week.
Dunn said he hopes residents rally around the mask order and unite against the pain caused by the virus. He wants residents to avoid Thanksgiving gatherings and “be boring.”
But there is another action that people can take to help the community, the hospital staff say.
Empathy for the people fighting the virus. Empathy for the most vulnerable among us.
Messmer spends most of her day in head-to-toe protective equipment. She has sat in hospital rooms while patients have deeply personal, end-of-life conversations with their wives and children.
She doesn’t quite understand those who resist face masks and social distancing. Those who are skeptical of the virus’ increasingly grim toll.
“I want to tell these people they need to come follow us around for a day,” Messmer said. “They need to see what their skepticism is doing.”
Follow health and education reporter Morgan Hughes on Twitter @m0rgan_hughes