Dr. Yanina Purim-Shem-Tov shoulders a lot as she helps lead the emergency department at Rush University Medical Center amid the coronavirus crisis.
The grueling 70-hour workweeks. An ever-evolving understanding of COVID-19. Her husband moving into the guest room to reduce the chance of a possible transmission.
Purim-Shem-Tov accepts it all with an unflustered shrug, confident in the knowledge that her department — the entire hospital, really — was built for this exact moment.
“If I seem calm, it’s because we are ready,” she said. “Everybody has their own anxiety level, absolutely. But here at Rush, we are extremely prepared.”
With the number of coronavirus cases predicted to peak in Chicago as soon as Saturday, Rush will serve as the city’s bellwether hospital. If Rush reaches capacity during the surge, it will be an indication of trouble.
“There are other hospitals across the city that have been able to step up in this time of need and assist in caring for the sickest patients,” said Suzet McKinney, CEO and executive director of the Illinois Medical District and a former deputy commissioner at the Chicago Department of Public Health. “But if Rush becomes overwhelmed, it’s a bad sign. If Rush is overwhelmed, so are many, many other places not just in the city, but in the state.”
Preparations began nearly two decades ago, after the 9/11 attacks led hospitals and first responders to rethink the definition of a mass casualty. While Chicago had Level-1 trauma centers to handle gun violence, burn victims and car accidents, the city seemed less equipped to deal with bioterrorism or a pandemic.
In 2012, Rush filled the void with a distinctive butterfly-shaped building along the Eisenhower Expressway. Every room at the groundbreaking hospital can be outfitted with an ICU bed, and even the soaring Brennan Pavilion was designed to become a low-grade emergency department if needed.
That forethought has landed Rush on the front lines of the region’s fight against the coronavirus. According to the hospital, its intensive care unit has roughly 25% of all COVID-19 patients on ventilators statewide. And 1 of every 20 people hospitalized because of the virus in Illinois is being treated there.
Many of the patients have been transferred to Rush from local hospitals that didn’t have the ability to care for them, said Dr. Paul Casey, the hospital’s acting chief medical officer. Some of those hospitals sent ventilators along with their patients to help Rush cope with the onslaught.
“We have been pretty aggressive in making sure we’re there to support those hospitals and those patients,” Casey said. “So we are seeing a lot of people in our critical care area.”
On Tuesday, the medical center allowed a Tribune reporter and photographer inside its emergency department and intensive care units. The latter has expanded by 50% as the number of COVID-19 cases statewide has climbed to more than 15,000.
Unlike the chaotic scenes playing out in images from hospitals in New York and Italy, the Rush corridors were calm and the staff seemingly calmer. Neither visitors nor staff are allowed to congregate, so some parts of the medical center have a quiet, empty feel that belies the sense of urgency with which everyone works.
Still, the fight against the virus is evident. The 14-story building smells of newly wiped countertops and hand sanitizer. Most employees move about with extraordinarily dry-looking hands, as if testifying to the incompatibility of constant hand-washing and Chicago’s chilly spring weather.
Anyone who comes into the medical complex first must have their temperature taken and grab a surgical mask. Those with fevers — including employees — are not allowed to enter. Staff members showing signs of illness are placed on paid furlough until their conditions improve, Rush spokesman Tobin Klinger said.
He declined to confirm how many employees have been diagnosed with the coronavirus. Purim-Shem-Tov said “a couple” emergency department nurses have contracted the virus, but no attending physicians have tested positive thus far.
Doctors and nurses interviewed by the Tribune expressed satisfaction with the level of personal protective equipment available, though, in some cases, they aren’t wearing brands they’re accustomed to because of national shortages. The hospital has stocked its inventory in keeping with a predictive modeling tool that weds data about the virus’s spread with the staff’s PPE burn rate.
“Things are calm here because all these little pieces are in place,” said Dr. Mark Yoder, medical director of the hospital’s medical intensive care unit. “We see how it works and it’s working well.”
The hospital had its first COVID-19 patient test positive March 4, but it was already prepared for such an eventuality. Rush was among the first Chicago hospitals to designate beds for infected patients and among the first to envision the surge and plan accordingly, said Dr. Allison Arwady, commissioner of the Chicago Public Health Department.
“They don’t just do it for their hospital, they make that knowledge widely available for some of the smaller hospitals that need to be thinking about surge,” said Arwady, whose office speaks with Rush and other area hospitals each day. “They’re excellent partners for us.”
Rush’s COVID-19 response is overseen by a command center, a group of roughly 90 people from the hospital’s various departments. Twice a day, there are hourlong video conferences in which the group goes over the current coronavirus caseload, shares the latest research and reviews the Chicago area’s projected infection rates, among other things.
The sessions — part medical symposium, part brainstorming session — began in February, a week before the medical center had its first patient test positive. As employees sit in conference rooms scattered throughout the sprawling hospital complex to maintain social distancing, Rush officials repeatedly ask what they should be doing today, tomorrow and into the foreseeable future.
The answer, so far, has been a lot.
During the past three weeks, the medical center has refashioned its ambulance bay into a triage center for suspected coronavirus patients and shifted floor plans to turn the neonatal intensive care and endoscopy units into ICU rooms for COVID-19 patients. Under normal circumstances, the planning, construction and consensus-building for these projects would take years to complete.
Rush got them done in three weeks.
“We say that we’re built for this (pandemic) from the facilities standpoint, but we’re also built for it from a team standpoint,” Casey said. “Everyone is willing to stand up to the challenge and do what needs to be done.”
One of the biggest transformations has been in the emergency department, where patients enter through a specified door and are required to put on a surgical mask before approaching the front desk. Anyone exhibiting coronaviruslike symptoms — cough, sore throat, fever — is immediately sent to the COVID-19 triage center.
Inside the ambulance bay, chairs are set up 6 feet away from each other with signs that say “clean” on the seats to indicate they’ve been sanitized since the last person sat there. Patients are called one-by-one into private screening areas or tents, where they go through a routine examination that includes their medical history and a check of vital signs.
Those deemed healthy enough to go home are ushered out through a side door with a recommendation to self-quarantine for 14 days. Those who need further care, typically people with difficulty breathing or oxygen rates lower than 95%, are taken out a different door. They exit onto a sidewalk covered with scaffolding and sheeting to protect the public from any droplets the patient may release.
A few yards away is Pod C, a section of the emergency department dedicated solely to possible COVID-19 cases. The spartan rooms are stripped of the typical carts and large medical equipment so the area can be cleaned more easily between patients.
Like the ambulance bay, the entire pod is a negative-pressure area where the ventilation system prevents airborne viruses from drifting to other parts of the medical center. In yet another example of prescience, the system was designed to prevent a deadly contagion from spreading inside the hospital’s walls.
On Tuesday morning, six of the pod’s 21 beds were occupied by patients suspected of contracting the virus. Each room has a sign on the door declaring PUI — Patient Under Investigation.
Purim-Shem-Tov, vice chair of the emergency department, said fewer people are coming in now, but the ones who do are much sicker. At the beginning of the pandemic, the emergency department typically admitted 1% of patients for critical care. Now the admission rate is about 30%.
In anticipation of more cases as the virus hits its predicted peak in Illinois, Rush turned its pavilion into a low-grade emergency room where patients with minor injuries such as ankle sprains and broken fingers can be sent. About two dozen individual recliners walled off by privacy screens already have been set up, though the hospital has not needed to use the area yet.
As part of the building’s architectural design by the Chicago office of Perkins and Will, medical gases and electrical access lines were built into the pavilion’s support columns and hidden so the casual observer wouldn’t notice.
Ten floors above, nurses in the ever-expanding intensive care units move quietly from room to room amid the syncopated rhythms of medial monitors. Dressed in face shields, surgical masks, gloves and surgical smocks, they check vital signs and relay telephone messages from family members. If the patients are well enough, the nurses often help them use FaceTime to the connect with friends and relatives.
The doors are supposed to be opened as little as possible, so doctors routinely check on their patients through windows if they don’t absolutely need to go inside. When they’re not inside a patient’s room, employees still must wear surgical masks, a medical center directive that makes the quiet conversations among hospital staff sound even more muted.
With the ICU admission rate outpacing its discharge rate, Rush continues to expand its critical care unit. Doctors from across the hospital — surgeons, nephrologists, anesthesiologists and residents of all specialties — have volunteered to help. The hospital has a finite number of ICU-qualified nurses, so officials are looking at ways to accommodate expansion without sacrificing critical nursing care.
The building’s total critical care bed capacity on the top five floors is 304, with additional capacity elsewhere in the hospital based on surge plans. There are two critical care units on the 10th floor, with a combined 55 beds.
The unit the Tribune visited had 28 beds, all designated for COVID-19 cases. On a normal day, about 30% of ICU patients at Rush require ventilators. On Tuesday, that number was around 80%.
If Chicago reaches the point where it needs to open the 3,000-bed field hospital at McCormick Place, the convention center could provide Rush some relief by accepting its low-risk patients. It will not, however, ease the demand for critical care at the West Side hospital.
Once patients are placed on ventilators, they typically remain on them for a week or two, creating a slow turnover time for the life-sustaining machines. With about 30 ventilators still in reserve as of earlier this week, Rush doctors said they felt confident about their ability to weather the predicted peak.
“We’re not unaccustomed to running 28 patients in a unit. That’s normal,” Yoder said. “It’s just that the patients are all, across the board, really sick. I think that’s what’s wearing on people.”
Throughout the hospital, there are signs of the pandemic’s emotional toll on the staff. Mental health workers walk through the various departments checking on employees, while wellness rooms in the ICU and emergency departments have essential oils and endless meals donated by restaurants in the Medical District and Little Italy neighborhoods.
A coffee shop in suburban Glenview brought pastries and coffee for doctors and nurses one day too. And handmade signs in front of the employee parking garage offer words of gratitude such as: “Not all heroes wear capes” and “We stay home for you.”
“Everyone who shows up right now, in a sense, is putting themselves on the front line and in danger,” Purim-Shem-Tov said. “We signed up for this, of course, but it’s nice to know people appreciate it.”
The employees practice self-care, as well. Yoder exercises, Purim-Shem-Tov binge-watched “Tiger King” on Netflix with her kids. At least one intensive care unit begins each day with group prayer or inspirational reading.
“We can’t do much outside of work, so I think it’s hard to really find that inner peace,” Yoder said. “But people are doing what they can.”
Karol Cordon can handle a lot that comes as a nurse at Rush these days.
The 12-hour shifts in the intensive care unit. The constant threat of infection. The meticulous decontamination process she goes through every night just so she can hug her three kids.
What tests her resolve is the way most of her patients with COVID-19 are dying — suddenly, and without family beside them.
Visitors are barred from the medical center during the pandemic. If they have enough time to get to there after a patient takes a turn for the worse, they can only watch helplessly from the other side of an ICU room door as those final breaths are taken. More often, though, patients go into cardiopulmonary arrest before relatives can even be called.
And so it falls to nurses like Cordon to comfort patients in their final moments, to hold their hands and relay messages of love that family members have asked to be delivered.
“We try to have a moment of silence for everyone,” Condon said. “But it’s hard. It’s the hardest part about this whole thing.”
Even at a hospital built specifically for this moment, the coronavirus can still be devastating.
sstclair@chicagotribune.com
Twitter @StacyStClair
