Santa Barbara’s Head of ICU Battles COVID-19
Cottage Hospital’s Dr Robert Wright and His Team Stand on the Front Lines
by Nick Welsh | Published April 22, 2020
New realities beget new rituals, and, as is the case now, they’re often a matter of life and death. For example, when Dr. Robert Wright gets home from work these days, he immediately strips off his clothes and jumps in the shower for a final sanitizing scrub.
Wright — athletic, trim, and endowed with craggy man-mountain good looks — serves as medical director of Cottage Hospital’s Medical Intensive Care Unit (ICU). That’s where doctors stick ventilator tubes down the throats of COVID-19 patients whose lungs can no longer suck in enough oxygen to stay alive.
All this makes Wright — and his ICU team — the ultimate caregivers for the sickest of Santa Barbara’s sick.
To date, Santa Barbara has recorded more than 400 COVID positive cases, though the real number of infected residents — given the chronic shortage of test kits — is bound to be much higher.
For the time being, Wright said, social distancing is paying off. At any given time, Wright estimates he’s got 18 patients in one of Cottage’s three ICUs. Maybe half these patients require ventilator machines. Cottage now has 65 adult ICU beds, though Cottage has the capacity to ramp up to 150 if needed, Wright said. For the time being, Cottage has 55 ventilators that can serve adult and pediatric patients, plus 13 more for infants in the neonatal ward, which has 22 ICU beds of its own in addition to Cottage’s eight pediatric ICU beds. Thus far, that’s been more than enough.
Right now, Santa Barbara County residents — through enormous collective sacrifice — appear to be on track to flatten the curve, which means the number of residents sick enough to require hospitalization should remain well within the capacity of the county’s medical infrastructure. Only four patients have died; three reportedly suffered from underlying medical conditions. One was already receiving hospice care when the virus struck. This apparent success — coupled with the withering economic damage inflicted by the state’s strict shelter-in-place restrictions — is now, ironically, sparking public impatience.
Some argue Santa Barbara should declare victory and begin relaxing restrictions. The board of supervisors of Ventura and San Luis Obispo counties have made such declarations and have asked Governor Newsom for permission to begin. Newsom notified S.L.O. County that such actions would be premature. “We’ve been blessed. We’re not New York City,” Wright acknowledged. But he cautioned, “We haven’t seen the surge yet. If we ease up now, I worry about a spike in caseloads six weeks from now.”
The second wave of cases could prove more devastating than the first.
During the 1918 flu pandemic that killed 50 million people worldwide, Wright noted, it was the second wave that killed far more people than the first. “I really think we need to shelter in place longer,” he said. “But that’s just my personal opinion, not necessarily that of Cottage Hospital.”
Wright cited the spike of cases now erupting in Los Angeles County, just 90 miles away. “It’s getting a little hot down there,” he said. He also cited the explosion of cases coming out of the federal penitentiary in Lompoc — which now accounts for one-third of the county’s total caseload. County emergency planners worry the prison has the potential to become what’s known as a “Black Swan” event.
County officials say the prison is poised to install a pop-up hospital with an initial capacity of 22 beds on the prison grounds in “around two days.” But given the speed with which COVID spreads — throughout society and within a patient’s body — a whole lot can happen in “around two days.”
In the field of ICU medicine, Wright is regarded as a rock star, board certified in not just one medical specialty but four — a pulmonologist who for the past 40 years has treated people with heart and lung illnesses. Aside from his position at Cottage, Wright runs what had been a thriving private practice. One of the perverse ironies of the COVID scare is that office calls for a host of medical specialties has plummeted dramatically. Many nurses, frontline workers, and administrative staff are being laid off or furloughed. Sansum has furloughed hundreds.
Wright, who grew up in Ventura County, worked with AIDS patients at UCLA hospital in the early 1980s. COVID-19 is not as uniformly fatal as AIDS was; 81 percent of those infected with COVID-19 escape with only mild symptoms. But for the rest — disproportionately made up of people who are 65 and older, are overweight, or have diabetes, underlying heart or lung problems, or compromised immune systems — the stakes are life-and-death.
COVID-19 cripples the lungs with a searing efficiency, implanting itself into the hundreds of millions of tiny balloons that coat the lining of healthy lungs. Known as alveoli, they transfer oxygen from the lungs to the bloodstream and carbon dioxide from the bloodstream to the lungs. Without this transfer — which happens about 25,000 times a day — humans die of asphyxiation.
As the body fights the virus, the alveoli fill up like a wet sponge,” said Dr. Bryan Garber, a pulmonologist with Sansum. As the body grows more desperate for oxygen, its immune system launches a desperate counterattack, known as a “cytokine storm.” This storm can often prove fatal.
The most pressing challenge is keeping patients alive long enough so that their own immune systems can calm down and kick in. Roughly half of everyone who gets hospitalized gets placed into ICU, Wright said.
Once there, the patient is treated by a team composed of a pharmacist, a patient-care technician, a nurse, a respiratory therapist, and a doctor. “But the nurse does the bulk of the work,” Wright said. In New York City, one ICU nurse will have to care for five or six ICU patients. At Cottage, it’s usually one-to-one, or at most one nurse to two patients.
Because COVID-19 is so contagious — spreading via droplets that can remain infectious for three days depending on what surface they land on or up to three hours in aerosolized vapors that hover in the air — exceptional steps are required to make sure patients don’t infect their health-care workers. Although more than 50 health-care workers countywide have tested positive, Wright said no one working at Cottage ICUs has tested positive yet.
Typically, Wright said, it takes at least 10 minutes just to “gown up.” This entails goggles, a face shield, an N-95 respirator face mask, and a gown. The number of trips in and out of the ICU must be limited to reduce exposure. It’s not uncommon, Wright said, for nurses to spend five hours straight inside with their patients.
Gowning down — or “doffing” one’s protective gear — follows an elaborate protocol to minimize the chances of any contaminated droplets on the gear touching the person. Hands are washed. After exiting the ICU chamber, hands are washed again. Doctors, Wright acknowledged, were not so fastidious about hand hygiene before the virus. “We’ve learned to become very good soldiers in this effort,” he said.
At the beginning of each ICU shift, everyone has their temperature taken and answers questions relating to COVID-19 symptoms. One of those is diarrhea, which two weeks ago, Wright had experienced. “I called up [Cottage infectious disease specialist] Dr. [Lynn] Fitzgibbon and said, ‘I’ve got this little problem.’ She said I was going to have to be tested, so they pulled me out of the line,” he said.
It took Wright two days to get his results. He tested negative and was allowed back on the job. Since then, Cottage has developed a much speedier test in which results can be available within 15 minutes.
Oxygen doesn’t cure COVID-19; it merely buys patients time to rally their own immune systems. Getting that oxygen into the patient, however, ranges from mildly intrusive to invasive intervention that falls into the “heroic” category typically used only when the patient is on the precipice of death.
The most extreme example is known as ECMO (extracorporeal membrane oxygenation), an astonishing medical procedure by which the heart and lungs are bypassed completely, allowing a machine to pump oxygenated blood heated to the precisely correct temperature into your body instead.
Not quite so extreme — but still violently intrusive — is the ventilator itself. The patent must be sedated before the breathing tube can be inserted down the throat. Ventilated patients are often given paralytic drugs that prevent them from breathing on their own. If they were to breathe at a rate different than the one dictated by the ventilator, it could be lethal.
Patients need constant monitoring. If the pressure gets too high, the alveoli can pop. If undertaken too long, the muscles needed for independent breathing can become atrophied. That makes recovery harder. If the body goes into cytokine storm mode, there are medications — traditionally given to people struggling with rheumatoid arthritis — that can help. “You don’t want to intubate too soon,” said Wright. “But you don’t want to wait too long.”
Getting intubated hurts. “Most of these patients are anxious enough,” said Wright. “We don’t want them fighting us, so we medicate. If they’re fighting and spitting at you, that poses a serious risk.”
However fit — Wright gets up at 5 in the morning to go hiking with the likes of Dr. Fred Kass of the Cancer Center and Kurt Ransohoff, CEO of the Sansum Clinic — he is still in his sixties. That puts him squarely in one of the high-risk sub-groups. It’s a risk he weighs carefully. For example, Wright said he thought seriously of going to New York City to help. Ultimately, he thought better of the idea. “I was never in the military, but with COVID, you want to get into this fight. I really want to take care of these patients. I really do.”
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