At overrun ICU, COVID patients spill into hallways, but ‘we are running out of hallways’

Nurses at Billings Clinic in Montana prepare to turn a patient from his stomach to his back in the hospital’s intensive care unit. | Provided

BILLINGS, Mont. — Nurses fill the hospital room to turn a patient onto his back. The ventilator forcing air into his lungs is most effective when he’s on his stomach, so he’s in that position most of the day, sedated, paralyzed by drugs.

Lying on his stomach all those hours has produced sores on his face, and a nurse dabs at the wounds.

The man has been a patient at Billings Clinic for nearly a month, most of that time in intensive care. He is among room after room of COVID-19 patients — the vast majority unvaccinated against the virus, the hospital says.

Visitors generally aren’t permitted, but his mother came to gaze through a window for the allowed 15 minutes.

This happened on a Friday. By Sunday, he was dead, at 24.

The hospital’s morgue cart arrived at the ICU — as it frequently does these days — then the room was sterilized, another patient took the man’s place, and the cycle began again. In a week, 14 people have died of COVID here at Montana’s largest hospital.

“I do feel a little hopeless,” said Christy Baxter, the hospital’s director of critical care.

Montana is a national hot spot for the coronavirus. Yellowstone County, home to Billings Clinic, is seeing the worst of it, with more cases than the next two counties combined.

The ICU has space for 28 patients but on a recent day was operating at 160% capacity, Baxter said. To handle the overflow, nurses must provide care beyond their training as COVID patients fill other parts of the hospital. In the lobby of the emergency department, rooms roughly six feet by six feet have been fashioned with makeshift plastic walls. Ten members of the Montana Army National Guard arrived a week ago to help in any way they can. Hospital staffers volunteer to sit with dying patients. Beds line hallways.

“The problem is we are running out of hallways,” said Brad Von Bergen, the hospital’s emergency department manager

The hospital announced it might soon implement “crisis standards of care,” which means it would ration equipment, staff and medicine, giving preference to those deemed most likely to be able to be saved, regardless of vaccination status. It’s an ugly system, abhorred by those who would wield it, with tiebreakers in place to decide potentially who lives and who dies. Other hospitals in Montana have taken similar steps.

Christy Baxter (far right), director of critical care at Billings Clinic, meets with nurses in the hospital’s cardiopulmonary unit, which houses overflow patients from the ICU.

An overcrowded hospital also means that a person ― say, one injured in a car crash in rural eastern Montana and needing advanced hospitalization ― won’t be able to get that care at Billings Clinic.

“We are at the point where we are not confident going forward that we can continue to meet all patients’ needs,” said Dr. Nathan Allen, the medical ethicist for Billings Clinic and department chair for emergency medicine. “And that’s heartbreaking.”

“Nobody wants to be in a position where we may have to ration health care and potentially remove a ventilator from one patient who would likely die and give it to another,” said Dr. Scott Ellner, the hospital’s CEO. “Are we there? I would say we are very close.”

To some extent, rationing is already happening. A patient still hospitalized with COVID might have benefited from an ECMO machine needed to keep his heart and lungs functioning. Operating that machine, though, requires at least one nurse around the clock, usually for two to three weeks. Typically, it would be a last-ditch effort for the most critical of patients. Even then, the prognosis for the middle-aged man would be poor. Without it, Baxter said, he assuredly will die.

“The reality is I can’t staff that,” Baxter said. “Do you give that optimal care to one patient? Or do you give great care to five?”

Billings Clinic would hire more than 100 more nurses if it could. The staffing shortage isn’t unique. It’s nationwide, meaning help isn’t arriving anytime soon. Baxter tells the story of a young nurse who quit, saying he had grown tired of lying to patients he knew would die.

“The patients look at you with that fear in their eyes and say, ‘Am I going to make it?’ ” Baxter said. “You want to encourage them to not give up hope. But you also know the chances of survival are going to be slim.”

Recently, a patient with a preschool-age child made a dying wish to see the child one last time. Such a visit typically wouldn’t be allowed, but an exception was made, with staffers draping the child in oversized protective clothing, goggles and an N95 mask. Afterward, the nurse and doctor sobbed with the patient.

“The moral distress of working in health care is, for many, many people, extremely high right now,” Allen said.

Intensifying that, he said, are patients or their loved ones mistreating doctors and nurses. On occasion, threats have required a police response. Screaming, profanity-laden insults are a daily occurrence. One patient threw his own feces at a doctor. Some, sick enough to have been intubated, still question the need to be vaccinated or the effectiveness of the medicine prescribed.

Dr. Sara Nyquist, an emergency medicine physician, said she has been asked by a patient if she is a Republican or a Democrat.

“I said, ‘I am your doctor,’ ” Nyquist said. “You do wonder how we got here.”

Ellner, the clinic’s CEO, said he doesn’t understand what happened to civility.

“There is a part of the society that wants to pretend that the COVID surge isn’t really happening,” he said. “But this is our reality every single day.”

Billings Clinic emergency department manager Brad Von Bergen and Dr. Jaimee Belsky discuss how they might create additional patient space in a hallway. The hospital’s intensive care unit was operating at 160% capacity that day. “The problem is we are running out of hallways,” Von Bergen said.

Jennifer Tafelmeyer, a cardiovascular nurse, said the best part of her job before the pandemic was helping patients improve, walking them down hallways, talking about diet and exercise, eventually escorting them to the front door. That hasn’t happened in a long time.

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

She wiped away a tear, having just learned one of the patients in her unit wasn’t expected to survive the night.

It probably will get worse, Allen said.

“We are still seeing growing numbers in community cases,” he said. “And we know hospitalizations lag behind new diagnoses. Unfortunately, it can absolutely get worse than where it is at.”

Still, he expects the doctors and nurses will rally, taking comfort from words of thanks from many patients and gestures like a father bringing pizza to the emergency department as a show of appreciation for the care his child got.

“The most difficult 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.