It was the morning of Sept. 16, and Idaho had just hit “crisis standards," a point of last resort for health care. Hospitals had so many patients with COVID-19, the state gave them permission to downgrade medical care for everyone. That could mean discharging patients faster than usual, or it could mean the unthinkable: choosing who gets an intensive care bed or oxygen.
But the hospital was calm, and so was the man in the cowboy hat. He placed his worn Bible on the front desk and leaned in for a temperature check. He wasn't at Saint Al's because he was sick, he told the woman screening him for a visitor pass. He was there to minister to a patient being taken off a ventilator. He picked up his Bible and headed for the elevator.
A few hours later, a few floors up in the ICU, another patient called his family over Zoom. He said what might be his last goodbye, as doctors, nurses and a respiratory therapist got him ready for intubation.
Since the fourth surge began, the Idaho Capital Sun has interviewed dozens of Idaho health care workers about what they've seen on the front lines of the war with COVID-19.
The Sun confirmed their employment but allowed some of them to speak anonymously — so they could speak freely and because the events now happening in Idaho hospitals are so similar as to be virtually interchangeable.
No health care worker revealed any patient's identity or private medical information.
Things are 'different' in the ER, but patients still get care
It was the weekend before Labor Day. As an ICU doctor and a member of Idaho's crisis standards committee, Dr. Rebecca Legg wasn't on vacation. She was waiting for a phone call.
“I've lived with this, now, for a year and a half," Legg said in an interview that weekend. “How are we going to do this?"
Not only was Legg treating COVID-19 patients for Saint Alphonsus Health System, she spent the pandemic immersed in ethical quandaries. She helped to write Idaho's framework for health care providers to use when a catastrophe forces them to make life-or-death choices.
That framework would guide Idaho through “crisis standards of care."
On Labor Day, Legg and the rest of Idaho's 33-member crisis standards committee got the call: Coeur d'Alene's Kootenai Health needed permission to ratchet down the quality of its medical care. It was so overloaded that hospital staff turned a classroom into a medical unit.
With the committee's recommendation, Idaho Health and Welfare Director Dave Jeppesen on Sept. 6 activated crisis standards for North Idaho.
Idaho's largest health system made its own request the following week, and Jeppesen on Sept. 16 expanded “crisis standards" to the entire state. Then, he experienced the crisis firsthand.
“My mom had a stroke Thursday morning, just a few hours after crisis standards of care was activated statewide," Jeppesen said during a press briefing this week. “Not only was it stressful that my mom had a stroke, there was added worry about the availability of health care when she went to the ER."
Jeppesen fought back tears and his voice quavered as he recounted the day.
“Things were different in the ER," he said. “There were other patients receiving care in the waiting room. My mom fell when she had her stroke, and there was a concern that she had broken bones. X-rays were done in a non-traditional X-ray area, with a longer wait than usual. Fortunately, she did not break any bones. Normally, a person in her condition would be held overnight for observation. Because of crisis standards of care, after she was stable, she was discharged later the same day from the ER."
Jeppesen said the emergency room team was “amazing" and “caring, empathetic and positive" even under intense pressure. He said his mother is recovering at home, with family as a de-facto nursing team.
Jeppesen pleaded with Idahoans — repeating words he's used for months. This time, his chin trembled as he spoke:
“We are so lucky to have such talented health care professionals in Idaho. And those same dedicated health care professionals across the state need our help. They need the unvaccinated to please consider choosing to get vaccinated. The vaccines work, they are safe and effective. And they need all of us to please wear a mask indoors and in crowded outdoor spaces."
Idahoans peddle misinformation, people get sick
Idaho's coronavirus cases, hospitalizations and deaths have risen for weeks. The daily body count has been in the double digits for a month. Idaho has now recorded more than 2,700 COVID-19 related deaths — about 490 since Aug. 1 alone.
Still, Idaho's vaccination rate remains stuck at well under half the population, the lowest rate in the U.S.
Interviews with doctors and nurses suggest Idaho is stuck in a perfect storm of distrust that is sending people to their deaths.
The pandemic was a growth opportunity for the cottage industry of health misinformation, including some local doctors, unlicensed practitioners and ideological groups who have spread unsupported claims about COVID-19 and vaccines.
They declare that health authorities who contradict their claims are lying and can't be trusted. So, many Idahoans follow their advice, reject the COVID-19 vaccine and ignore public health advice. And when they catch the coronavirus and end up hospitalized, these Idahoans argue with doctors and nurses, even as their organs fail and they can't breathe.
One of Legg's recent patients was an older woman with high blood pressure, diabetes and a suppressed immune system. She refused to go on a ventilator because she was convinced the hospital “would vaccinate her against her will," Legg said. The woman survived, but even as she left the hospital, she kept a tight grip on her belief that the vaccine “would be what killed her," Legg said.
Another patient, a middle-aged man, “just really fought against everything that we offered" to help him, Legg said.
He refused to be intubated until his heart was about to stop.
“Do you know the stress around trying to intubate a patient who was that desperate?" Legg said.
After he was on the ventilator, his family took up his battle.
“His family was just insistent that we were hurting him. And that what was going to save him was ivermectin," Legg said. “They threatened litigation against us. Ultimately, we allowed them to get a prescription for ivermectin and bring it in. And, of course, he died shortly afterwards anyway."
Dr. Jason Slade, a hospitalist at St. Luke's Nampa, recently had a patient for weeks who said he wasn't vaccinated because he was Christian and trusted God.
“God sends us a lot of miracles and things to use to deal with hard times. This may be a miracle God sent us," Slade said to the patient, who was unconvinced.
The man's health deteriorated. His lungs thickened and built up scar tissue. Oxygen couldn't make it through anymore. The damage probably would not heal, Slade told the man, who demanded the doctor talk to one of his family members about treatments.
The family member didn't know anything about the medications doctors were giving the man. Instead, she insisted they use “certain therapies" that don't work, Slade said.
When he asked what her role was in health care, she told him, “My role is a mom, and I've done my research, and I've talked with other medical professionals, and I know about your protocols, and I don't approve of them."
A few days later, the man's oxygen levels plummeted. Slade invited a family member to come to the hospital for what was likely to be a final visit.
“The whole family came down," Slade said. “I went out to explain to them (what was happening), and it was an unpleasant interaction. They had lots of accusations, demands."
The man eventually decided to go home with hospice care and died the day he went home, Slade said.
Slade, Legg and other health care providers are working overtime and witnessing death on a regular basis.
St. Luke's Health System averaged four COVID-19 deaths per day this month alone, St. Luke's Chief Physician Executive Dr. Jim Souza said Tuesday.
When patients and their families distrust health care workers, it adds to the emotional toll of these casualties.
“The health care system and health care workers, for all of our flaws — and we certainly have them — we still are here to help. We want you to live through an illness if you get it, we want you to survive," Legg said. “We just want to help. That's why we all went to medical school, that's why nurses went to nursing school."
'I wish everyone could see. … It's not a gentle death'
The front lines of the COVID-19 war are hidden from view. The worst parts of the pandemic are happening inside the hospital walls.
The Idaho doctors and practitioners who are fomenting distrust in public health do not work with COVID-19 patients in hospitals.
And the public cannot see what's happening because of privacy laws and visitor restrictions.
“People, when they hear the word epidemic or pandemic, I think in their mind they think of something like the bubonic plague. 'Bring out your dead!' and people dying in the street," Slade said. “We have evolved in our society that the level of (suffering in) this pandemic has been able to be suppressed. You aren't seeing this up close and personal because it concentrates in the hospitals. People that you personally know, they show up at the hospital, along with everyone else in the neighborhood. (And) we're at a spot where we're running out of physical space."
The Sun visited Saint Alphonsus hospital in Boise the day Idaho declared crisis standards. Health care workers expressed relief that journalists were inside the hospital.
Until recently, Idaho health care workers, families of COVID-19 patients and COVID-19 survivors were the only ones who could bear witness — and, often, people would accuse them of lying.
“I want them to come and see how sick these people are," said one local nurse. “For the patients that don't want to be intubated and we watch them decline, it is like a slow descent into madness."
The high-flow oxygen masks feel like “sticking your face out of a car window," the nurse said, and it makes it hard to eat. So the patients lose weight and “just shrink into nothing," she said.
“I wish everyone could see. I really think that if some 40-year-old guys had to come help me clean up the 40-year-old patients who are incontinent … and pooping themselves," that might persuade them to get vaccinated, she said.
“It's not a nice way to die. It's not a gentle death," she said. “It's not a good death. It's a lonely death. … But at this point, this is what people are choosing."
'I wish that I could tell those patients' families … they mattered'
The lack of space is one reason Idaho moved into crisis standards.
Saint Alphonsus in Boise recently turned a physical therapy gym into a COVID-19 overflow unit.
St. Luke's and other hospitals are doing ER triage in the waiting room.
“I've got three patients up in the (medical-surgical) unit" who are on maximum oxygen flow, Slade told the Sun in an early September interview. “They look like they're tired and they're failing. We're full. We had to kind of Tetris who can go into a lower level of care."
The doctors and nurses came up with a plan. They moved patients to the ICU, one at a time. “We intubated three people that night," he said. “The patient that I intubated last night, the only reason she had a bed and ventilator available was because the patient who had been in that bed, on that ventilator, died."
I don't think people realize that we are breaking. The whole system is on edge.
– Dr. Jason Slade, St. Luke's Nampa
One nurse in a Magic Valley hospital told the Sun that most shifts now end in tears. Even when she's away from work, she spends her time worrying about it.
Frontline worker in crisis? There is help
Idaho launched a dedicated, free hotline last year for frontline workers. It offers 24/7 crisis counseling and helps callers access short-term and longer term mental health care. Call 866-536-0239.
Another nurse who works in a local COVID-19 unit said the patients she cares for now “are incredibly, incredibly sick."
In normal times, the patients on her floor would be sent to the ICU, because that's where they really belong. But that's not always an option now.
“At the end of the day, if I've charted most everything, and they're alive, I'm happy. But nobody gets a bath every day," she said.
Some of the patients come to her floor after an ICU stay.
“They've got tubes in every orifice, literally every orifice. Some of these people are so sick and so weak, it is basic life-giving cares we are giving, it is not cares that we would like to give," she said. “These are brutal shifts."
Nurse managers have jumped in to help, which is rare, she said.
Her team starts each shifts looking for patients who might be ready for discharge, she said. Then, someone tells them the ER has dozens of people waiting, there are only three beds left in the hospital, “and the other hospitals are on divert. It's terrifying," she said. “How? How are we supposed to keep doing this?"
The nurse has lost many “really special" patients to COVID-19 over the past year and a half, she said. One sticks with her, an older man last year, who was worried about his dog. Would the dog's last memory of him be getting rolled into an ambulance? What would happen to his dog when he died?
She didn't know.
“I wish that I could tell those patients' families how much I've loved their family members, but it's HIPAA and all that," she said. “We get to write little cards and stuff. But how do you tell them almost a year later that you haven't forgotten their loved one, and that they mattered?"
What can you do to help?
Every health care worker the Sun interviewed said getting a COVID-19 vaccine is key. (And don't forget a flu shot.)
For people already vaccinated, there are other ways to help:
- If you have a medical emergency, go to the emergency room. The ER staff will help you. Don't be surprised if there is a long wait. Try to be patient and cooperative. “Don't yell. Don't throw things. Understand the overall situation — that things are not normal now," one nurse said.
- If you're already vaccinated, share your story with people close to you who aren't. Explain why you chose to get the vaccine, and what your experience has been. Listen to their concerns. Encourage them to talk with a trusted, qualified medical professional about the vaccine.
- Continue to wear masks, especially in public places.
- Avoid crowded indoor spaces. Avoid large gatherings.
- Get tested frequently for COVID-19, especially before spending time with at-risk friends and family members. If you can, buy over-the-counter rapid tests to use at home.
Idaho Capital Sun is part of States Newsroom, a network of news bureaus supported by grants and a coalition of donors as a 501c(3) public charity. Idaho Capital Sun maintains editorial independence. Contact Editor Christine Lords for questions: firstname.lastname@example.org. Follow Idaho Capital Sun on Facebook and Twitter.