It’s a quiet Friday morning in the COVID-19 intensive care unit at Baptist Memorial Hospital in East Memphis, and a doctor and nurse are looking at a couple of chest X-rays. 

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One of the X-rays has a noticeable black spot on the upper left lung, but in this situation, the black spot isn’t the problem but a lack of one. 

That spot of black is noticeable because it’s surrounded by a cotton-y field of white, cloudy signs of pneumonia from COVID-19. 

This X-ray is from Saturday, April 4. Next to it is one taken that morning, April 10, which shows substantially less white and more healthy expanses of black. 

The patient in question, an African American woman in her 50s, is in a depressurized ICU room only a few feet away, and represents a first for Memphis medicine, twice-over. 

The Daily Memphian got exclusive access to Baptist’s COVID-19 units to see how the staff is dealing with this epidemic on a daily basis. As cases in Memphis rise, they have reconfigured parts of the hospital to meet the specific demands of the virus, found ways to preserve crucial resources for the surge ahead, and are deploying both groundbreaking and controversial treatments in an attempt to buy critical patients needed time and save lives. 

The doctor examining those chest X-rays is John Craig, a cardiovascular surgeon and director of Baptist’s ECMO program. An ECMO machine (Extracorporeal Membrane Oxygenation) is a rolling bedside device used for patients dealing with heart or lung failure. Where a ventilator replicates lung function by pushing air in and out of a patient’s lungs, an ECMO machine pulls blood out of a patient’s body, oxygenates the blood and returns it. It functions, in this case, as a kind of artificial lung outside the body. 

Baptist is the only hospital in the Mid-South with an adult ECMO program and this is the first patient with the novel coronavirus in the Mid-South to receive the treatment. There have been positive reports of ECMO use for COVID patients in China and, a few days earlier, a report surfaced out of Chicago that a medical team from Northwestern University had used ECMO to save the life of a COVID patient. Doctors at Baptist are hoping for a similar result. 

A few minutes later, layered in personal protective equipment (PPE), Craig is joined by Dr. Stephen Threlkeld, co-director of Baptist’s infectious disease program, to visit the patient. 

While Craig checks the ECMO machine, Threlkeld examines the patient directly, pulling up the sheet to look at her feet. 

“The feet are the farthest thing from the heart,” explains Threlkeld, who was part of the team that treated the first COVID patient in Memphis, a little more than a month ago. “The feet are nice and warm, there’s good blood flow, good color, not too much swelling. That’s the hardest place for the heart to take care of. So that’s an important window into how you’re doing from a vascular standpoint. She looks good.”

This patient had been at the hospital for a week before moving to the ICU. 

“That’s a pretty typical time frame,” Craig says. “Sometimes people do fairly well for a week or so and that’s usually when the deterioration happens. That was exactly the course here.”

“It’s one of the peculiarities of this particular infection,” Threlkeld says. 

The patient first began receiving ECMO treatment on Tuesday, March 31. The X-ray showing the island of healthy black amid an ocean of infected white was from five days into the treatment. Four days later, her lungs had cleared up enough to clamp the ECMO, halting the blood recirculation. (The patient remained on a ventilator.) 

And the next day, on Thursday, this patient became another Mid-South COVID first: The first to receive plasma antibody treatments from a donor who had recovered from the disease. 

Craig and Threlkeld both say she would have died without ECMO treatment. It’s not the ECMO, exactly, that’s healing her lungs. Her own immune system is doing that, but without ECMO, she wouldn’t have had the chance. 

“It will buy you time,” Craig says. “It’s kind of weird for us. We put people on a heart/lung machine to fix things. To do coronary bypass or fix a valve. In this case, you put them on a heart/lung machine and then you let them do their own repair, which is fascinating to watch. It shows how much the human body is capable of if you can give it a chance.”

The idea with plasma antibody treatments is also to help the patient’s immune system fight the disease. 

“In recovery, you have several branches of the immune system go on the attack,” Threlkeld says. “The antibody branch is one we can more easily transfer to someone else. The antibodies (from a recovered person), by their molecular nature, will more easily stick to the virus and allow the other arms of the immune system to pick up the virus and get rid of it.” 

While the patient remains in critical condition, the ECMO treatment seems to have pulled her from the brink and has her headed in a positive direction. It’s too soon to gauge the impact of the plasma treatments. But the hope is full recovery.

“That’s the goal,” Craig says. “That’s what we’re going for.” 

Why this patient for these treatments? An uncertain combination of need and potential for impact: With ECMO, in particular, which patients are sick enough to need it but also viable enough that it could help them survive?

“There are some people where the need is extremely high but the benefit of ECMO might be really low, because they’re unlikely to survive even with it,” Threlkeld says. “Trying to figure out who’s really going to benefit is the tricky part. We’ll figure that out over the next few months in more detail.” 

The calm before the surge? 

If you’ve been absorbing a lot of national media coverage over the past month, the description of a quiet morning at a COVID unit might seem odd. 

You might picture a frantic scene, with patients overwhelming hospital resources, both rooms and PPE. 

That’s not what’s happening at Baptist-Memphis, at least not yet. And, if things go as well as they reasonably can, hopefully not ever. 

“It’s fair to say that we are pathological optimists, but we don’t know (how bad it will get). Dr. Fauci said it well: the virus decides these things,” Threlkeld says, speaking of Anthony Fauci, the government’s top infectious disease expert. “But we also have our say,” Threlkeld adds, alluding to both medical preparation and community actions such as social distancing. 

On this Friday morning, there are 25 confirmed COVID patients at the hospital, 11 in the ICU (six of those on ventilators) and another 14 in regular beds. This number has gone up, but slowly so far. Two days earlier, there were 20 COVID patients, with 10 in the ICU. The day before it was 22 and 11. 

“It’s been quite stable over the past several days, which is encouraging,” Threlkeld says.

Baptist has 38 ICU beds available in this COVID unit, with more than 80 ICU beds in the East Memphis building, not counting those dedicated to transplant units.

Between the preparation and the surge lies a surplus, even if a temporary one.

This COVID intensive care unit was previously devoted to cardiac patients. Some who would have been here have been relocated to other parts of the hospital, but some, as in other areas, would have been elective procedures now delayed. 

“When you remove elective procedures, the total number of beds in use goes way down. So there’s an innately large surplus of beds you can use for COVID if necessary,” Threlkeld says.

In addition to fewer patients in the hospital at the moment, there are also fewer visitors, and none in the COVID unit. 

“The isolation factor for patients is a difficult one,” Threlkeld says. “There are really no visitors.” 

Doctors and nurses also find ways to limit room trips without reducing care. 

Telemedicine, a buzzword of the pandemic, is sometimes used in-hospital. 

“If Dr. Threlkeld goes to check on a patient and wants to come back just to tell them something, he doesn’t have to dress out. He can call into the room on telemedicine,” says Dana Dye, VP/administrator and CEO of Baptist-Memphis. “It’s a way to keep from burning through PPE.”

Given the infectious nature of the virus, extreme caution is used in patient interactions. Gowns, gloves, foot coverings, masks and other headgear (such as face shields) are deployed for each interaction. The process of putting on and taking off PPE is exacting and often a group effort. (It becomes even trickier when a 6-foot-3 reporter with size 13 shoes, one unaccustomed to such endeavors, is added to the mix.)

N95 masks and shields are sanitized for reuse, but the gowns and gloves are disposed of after each use.

One method to limit this process has been setting up IV stations outside of rooms. If you’ve been hospitalized or visited those who are, you’ve noticed how frequently nurses enter rooms to make adjustments to medication and treatment. Not here.

“These are usually in the room with the patient but we put extension tubing on all of the IV tubing,” says Kristin Quinn, nurse manager of the COVID ICU, demonstrating the out-of-room station. “If these alarm or go empty we can switch them from out there without having to put on all of the PPE to go into the room every time.”

Quinn recently asked her night nurse how many room trips the set-up saved him in a shift. The answer was 12.

“That’s 12 gowns (saved), 12 times he didn’t have to get in and out of his mask,” Quinn said.

“It’s really important to save our personal protective equipment and this is a great way to do it,” Dye says. “Kristin and her staff really spearheaded that. They are what I call the ‘Memphis MacGyvers.’”

This kind of problem-solving in the face of the unconventional challenges posed by the novel coronavirus can be seen all around the unit. 

Using HEPA filters, the hospital converted 106 rooms – ICU and regular rooms – into negative-pressure rooms for COVID patients. The Centers for Disease Control, in its recommendations for COVID treatment in health care settings, calls these “Airborne Infection Isolation Rooms.” Negative pressure is used to contain airborne contaminants.

In one currently open ICU room, you can see that a window has been removed and covered in plywood, with a hole for filtered air to be pumped out of the room (and out of the building). 

“In this situation, because of airflow issues, we like to have people in negative-pressure rooms, because being on a ventilator, putting a tube down the trachea, will necessarily lead to some increased spray of secretions, aerosolization. That can be an increased risk to health-care workers, so we like to do those things in negative-pressure,” Threlkeld says.

This was trickier for operating rooms, where positive-pressure environments are typically most needed. But Baptist built an operating room specifically for COVID patients. 

“That’s why you find operating rooms in the center cores of hospitals,” Dye says. “But these (COVID) patients need to be in a negative-pressure environment.” 

“Dana spearheaded that,” says Threlkeld. “And we’ve already had an urgent appendectomy (of a COVID patient).”

“We were able to do her surgery safely, for her and everyone else. She’s done very well and I think she’s gone home now,” Dye says. “I had someone say, you do constant pressure because the patient could get a wound infection. With a COVID patient, that’s the least of their worries.” 

Known unknowns

The 25 positive COVID patients at Baptist on Friday understates the situation some.

There were also 54 in-hospital patients awaiting tests, many of whom may end up having the flu or strep throat or other unrelated illnesses. And there were 638 Baptist patients at home waiting for results, most of whom, even if positive, will not be hospitalized. 

“Being in the hospital and getting a COVID test are independent things,” says Threlkeld, noting that “80 percent or more” of people who test positive do not require hospitalization. 

What gets you hospitalized? 

“With some variation, as we learn more and more about the disease, the same things that get you hospitalized for other things. You’re unstable in any way,” Threlkeld says. “Increasing shortness of breath, high continued fevers, the kind of things that make us concerned you might deteriorate.

“After five to seven days, an illness that’s annoying but not dangerous can then go over the falls and you get quite ill quickly. We’ve had to move people to the ICU after seeing them in the morning and their oxygenation was OK and by the late afternoon it was clearly different. But you’re in the hospital because you’re sick. And it might not be COVID.”

The regular floor treating COVID patients at Baptist was more bustling than the ICU, but nothing close to frantic. There were more nurses roaming the hall, with more PPE (apparently due to more frequent room visits) along with a distribution of lunches. Patients include one married couple, which given how the virus is spread through close interaction, is not unusual, according to Threlkeld. 

This regular floor – or step-down unit – is something of a way station. Some patients will end up in ICU and some will happily head home. Some are presumed COVID positives waiting confirmation. 

At one point, a “transport” call goes out over the intercom. 

“There’s a certain elevator that they go down and we’re able to clear the hallways so visitors and others are not nearby,” Dye says.

Transport might be for patients moving to the ICU. It could also be for discharge, as this one was.

There’s fluidity between COVID/non-COVID and hospitalized/non-hospitalized, which are separate but overlapping distinctions. 

One partial illustration of that comes from Threlkeld’s morning consultation with pulmonary radiologist Dr. Rob Optican. 

In addition to patient check-ins in both the ICU and regular units, this has become part of Threlkeld’s daily COVID routine. 

“When this first started to ramp up, we began to look with Rob at every person pending or positive to get a feel for what we were looking at,” Threlkeld says. “What kind of things can be predictive on their chest X-ray before the test comes back? When you put the clinical picture of people with their X-rays, they don’t always go together.”

These consultations sometimes happen in person, but given access to technology, could happen with Optican at a different hospital site or even at home. On this day, Optican is calling in from the Imaging Center at Wolf River Boulevard.

After discussing the patient who had received ECMO treatment, Threlkeld and Optican look over images from two patients with much in common but a crucial divergence. 

Both are men over 60 who are past heart transplant recipients. One wasn’t initially considered a likely COVID case, but had a positive test. One had been exposed to a confirmed positive family member and seemed a likely COVID case, but has tested negative. 

The first man, the positive test, “was treading water for a week, then went over the falls, clinically,” Threlkeld says. 

“Back on March 20, he looked like a heart failure patient. On April 5th, he still looks like heart failure. On the 8th, he’s much fluffier … more compatible with what we’ve been seeing with the COVID infections, and it’s fairly extensive,” says Optican, noting that the patient has stabilized the past couple of days. 

This is a patient with whom Threlkeld has used hydroxychloroquine, the unproven-for-COVID treatment that has shown some positive indicators in lab settings and that became controversial via repeated mentions at President Trump’s press briefings. 

“We have not given it a lot, but we give it to the people with the highest risk and the most to gain,” Threlkeld says. “Massachusetts General and other large academic institutions, they still recommend considering it. We do not know how effective it is. I’ve certainly given it to people that it didn’t help. But those are all anecdotes.

“Fauci said this: We need large controlled trials. But in someone who has a big chance of getting sicker and dying, if you can control the downside, it’s probably reasonably safe to give that drug. … We may find out in a year that hydroxychloroquine was utterly useless.” 

As for the other man:

“He’s had a negative test, but has gotten worse. Same trajectory,” Threlkeld says. “Symptoms are unclear. It could be a lot of different things. We don’t know that he’s positive yet. We just know that he got sicker.”

This brings up the question of false-negative tests. 

“Every test can have a negative, and that can be because of several factors,” Threlkeld says. “It can be the sensitivity of the test, where every now and then one can read negative when they really have it. If you don’t get an adequate swab. If you’re not tearing up and uncomfortable after your swab for COVID-19, you haven’t been swabbed for COVID-19. So technique is important. If you’ve been using nasal washes right before someone swabs you, that could affect it.

“Either way, (doctors) still have to use clinical judgment and be on the aggressive side to try to keep people safe. If someone tested negative but you’re still worried about the clinical picture of that patient? We moved this person back to isolation because we just can’t be sure.”

“His CT (computed tomography) pattern was not what we’ve been seeing with COVID. It was very non-specific,” Optican said. “You see that pattern with just about any viral pneumonia and a lot of non-viral diseases. I’m not convinced radiographically that he’s got it. Clinically, it sounds like he does.” 

What’s next?

You could read this weekend of COVID-19 overwhelming hospitals in New York, of coronavirus patients packed in, bed to bed. 

An expected surge in Memphis remains a moving target, both horizontally (when will it peak?) and vertically (how bad will it get?). The most recent Health Department estimate cites late May to early June, a longer and lower wave. 

“I think there will be more cases, but there don’t have to be a lot more cases,” Threlkeld says. “It doesn’t have to be that way. And if we do our jobs well, it could be a substantial decrease from what we’ve seen in some other cities. If we have 10,000 deaths in Memphis and need MASH units to handle our situation, that’s a failure.” 

As cases creep up, the doctors, nurses and administrators at Baptist seem focused on providing current patients the best care possible, minding resources for the increases to come, preparing for the coming wave. 

“We told our staff and our leaders: What is normal today will not be normal tomorrow. And what we do today may not be what we do tomorrow,” Dye says. 

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The ECMO and plasma antibody treatments used for COVID at Baptist last week were each a first for the region, but certainly not a last. 

ECMO machines are more rare, more expensive and even more invasive and resource-intensive (in terms of materials and manpower) than ventilators. Craig says Baptist has a surge capacity of 14 to 18 but has never used more than eight at a time, and more typically one or two.

How to maximize the treatment’s impact for COVID patients is a topic of growing debate in the medical community.

“It’s a topic that we still need to learn more about,” Craig says. “You should probably be a bit more conservative in selecting patients. When people get to a phase of critical illness, the mortality rate is much higher than we see with many other problems. It’s a limited resource, so you have to be careful. The World Health Organization recommends ECMO for selected patients. The FDA has approved it. Knowing exactly when to use it? We won’t know that for several more months.” 

Plasma antibody treatments will presumably become more common as the treatment grows in availability. 

Plasma treatments have required Food and Drug Administration approval as well as qualified donors. Approval has meant a specific donor for a specific patient, but Threlkeld expects those requirements to be relaxed in the days and weeks ahead. 

As far as donors, in the current absence of serology tests, which would confirm if someone had previously had the virus, that means a confirmed positive test followed by a confirmed negative. 

“As we get more and more people who have recovered, we will hopefully have more of an army of people who can donate plasma locally. We hope to be ramping up very quickly to give it to more people,” Threlkeld says. 

Both treatments can hopefully save more higher-risk patients. 

“It’s too small to draw from our one institution, but the numbers nationally are very concerning,” says Threlkeld of the prospects for COVID patients at the ICU level. “People who are sick enough to make it to the ICU frequently do poorly. We hope that things like the ECMO and plasma transfusions that are just coming online will improve that number. We hope that as we bring more of these things online, we can decrease that number.” 

If ECMO and ventilators can buy time for patients, social distancing has bought time for the medical sector. 

“People talk about the models. There are scary models and less severe ones, but they don’t change what we’re doing. We have to prepare for the worst,” Threlkeld says. 

Along those lines, Dye says Baptist has put together a surge plan of its own. 

“What if 80 (ICU beds) is not enough? What if 100 is not enough? ICU is not a place. It’s a level of care,” Dye says. “How would we be able to manage critically ill patients outside the walls of a dedicated ICU? We’ve put that plan in place. We know what we would do and how we would manage it.”

An uncertain future is something the hospital has been planning for since treating the city’s first COVID patient in early March.

“One of the things I’m most proud of is that when Dr. Threlkeld, his team and others came together with the first identified patient, they said, this is the beginning, how do we prepare for the next however long? A very smart group of people came together and started making those plans early,” Dye says.

“How many ventilators do we have? Do we have enough PPE? How do we get more? How do we train the staff? We started from day one.”