‏When COVID-19 invaded our nursing home

I suspect that there are members of the public who, even today, still believe that the dangers of COVID-19 have been exaggerated. This reminds me of the story of several blind people asked to describe an elephant. The participant who touched a leg formed a different impression from the one who felt the elephant’s trunk, which differed from the one who touched an ear. The moral of the story is that, even when a person’s description is accurate, an individual perspective will not always precisely depict a phenomenon in its entirety. If we apply this metaphor to COVID-19: those who are healthy and don’t personally know of anyone who fell ill from the virus may well have a different perspective from those who caught the virus but were asymptomatic; while anyone who was hospitalized or knows of someone who became seriously ill or died of the virus or its complications will see things very differently again.

Until recently, my own perspective on COVID-19 was formulated primarily through following the media, reading first person reports from journalists or medical personnel, and consulting medical papers on the subject. This indirect exposure led me to take the potential dangers of the virus seriously from very early on supporting imposition of draconian measures designed to do everything possible to prevent COVID penetration. My naïve and simplistic view was that, so long as we strictly maintained this policy, the nursing home would remain COVID free. Indeed, this approach proved effective for months — until two weeks ago.

Unfortunately, at the time of writing, several health workers, together with 15 of the 35 residents, have been stricken with COVID-19, and we shall not be surprised if more prove positive with further testing.  One resident has sadly died.

The diagnosis was established as follows: a day after her last shift, after feeling unwell with what she and her doctor presumed was an ordinary sore throat, one of our health workers nonetheless went for COVID testing and, to her surprise, was found to be positive. She had been meticulously careful both about using protective equipment at work and about taking precautions at home. Even in retrospect, she has no idea how she became infected nor how she passed on the disease. I have recently come to the conclusion that, while the virus typically spreads from close unsafe contact between two people, when the community rate of infection is sufficiently high, as it is now, or the viral load is too high as it could be in an infected nursing home, it somehow finds other means of spreading. This theory was reinforced a few days later, when our administrator, who has no physical contact whatsoever with either workers or residents and is punctilious in following COVID-19 precautions, likewise came down with the virus. Her only “fault” was that she had been spending long hours at the nursing home. Other nursing homes, too, have reported similar unexplained patterns of spread. Our local experience parallels what is going on country wide and in fact worldwide with continued extensive spread of the virus even in instances where precautionary measures have been taken.

Upon receiving her results, we automatically went into lockdown. Two residents who had fever that day were put into room isolation, and that same evening we obtained a special in-house test that revealed one of them to be positive. Both were referred to hospital. This was the first time that one of our residents had tested positive for COVID-19. We were at a new and dangerous inflection point.

For the past few months, through coordination with the Ministry of Health and its affiliates, a team had been coming to our nursing home to routinely test our health workers and residents. In addition, we also have an emergency testing contingency option which we utilized after our health worker tested positive. While we had often received results within 24 hours, because of lab backlog it took two days before we received the results. We were devastated to learn that five additional residents were COVID positive.

When a resident becomes COVID positive, nursing home function undergoes a dramatic transformation. Firstly, residents who have tested positive need to be completely separated from those who have not.  Secondly, all nursing home workers must at once don special COVID-19 disposable overalls that are cumbersome and uncomfortable to wear. These measures are improvisations, as our nursing home is not authorized to deal with COVID-19 patients on a regular basis.

The fact that all five positive residents were largely asymptomatic was encouraging, but we were nonetheless required to transfer them all out.

Asymptomatic residents were removed to special nursing homes with COVID wards. Those who developed symptoms such as fever, cough or decreased oxygen saturation were transferred to hospital. A ministry affiliate took charge of the process, arranging for ambulance transport and deciding who would go where. Unfortunately, the transportation team itself was overwhelmed by parallel outbreaks elsewhere and became so backlogged that we waited for an undesirable day and a half before they arrived. Despite our immediate isolation precautions, these two delays, awaiting test results and transfer, offered the virus further opportunity to incubate and continue spreading within the nursing home.

Our leadership triumvirate found itself with innumerable tasks at hand. Our administrator was responsible for overseeing the transfer out of COVID-19-positive residents, which happened to take place on a weekend. That same day, another special ministry team arrived to vaccinate our remaining residents and health workers. Despite the outbreak, we were determined to Pfizer-vaccinate our residents at the first possible opportunity. Finally, though we had not yet received our previous COVID test results, we had ordered repeat testing to identify possible additional cases among the residents. In sum, three major events converged on a single weekend day: group testing for COVID, vaccinations and the transfer out of COVID-19-positive residents.

Our head nurse embarked upon room changes, moving and separating COVID-positive from COVID-negative residents. She also had to ensure that our health workers knew exactly how to wear the new COVID-19 protective gear and that they were following the latest stricter hygienic protocols. At the same time, it was vital that she show understanding and support for the nurses and their aides as they assumed additional burdens and experienced new tensions and fears.

As physician and medical director, I had the unenviable task of phoning the families of the COVID-19-positive residents, one after another, delivering the bad news and commiserating with them over their angst and further isolation that they and their loved ones would yet have to endure. I know all these family members well, some of them for several years. Their trust and grasp of the circumstances ameliorated my task. However, the absence of outrage did not mislead me. I fully appreciated that the experience they were undergoing was appalling.

At the same time, we also prepared an announcement to publicize in our family WhatsApp group. This had to be formulated in a manner suitable for both categories of families: those related to a resident who had tested COVID-positive and those related to one who had tested negative. It needed to provide enough information to allow the families to know what was going on, without breaching confidentiality or being unduly technical. Furthermore, it needed to be sent out quickly before false rumors could start spreading.

Once all that had been done, and the residents had been transferred, things at the nursing home itself calmed down a little. Nonetheless, because they were all our residents, we began contacting the various institutions to receive daily professional updates on the status of those who had been transferred. In addition, of course, each family made its own inquiries. In situations such as hospitals that were unwilling to provide telephone information to the referring physician or places that did not regularly answer the phone, I worked in cahoots with a family member: if they received an update, they would inform me, and if I managed to get news, I would inform them.

Regulations for family visits to the different locations varied. No one permitted a “regular” visit. Some allowed relatively close proximity, but only if the visitor were enveloped head to toe in COVID protection gear. Others offered viewing through a window. As anyone who has had a close relative hospitalized for COVID-19 knows only too well, visiting can be a Kafkaesque frustrating experience.

For the first few days, we were mainly concerned as to whether or not our infected residents would develop dangerous symptoms associated with COVID. Thankfully, in most instances, this did not happen. Another encouraging factor was the understanding that the longer these residents remained symptom-free, the less likely they were to develop COVID complications. When eventually deemed free of the disease, they would be permitted to return to our nursing home.

As COVID concerns declined, however, everyday nursing issues such as patients’ confusion, agitation and constipation surfaced and worsened. In many cases, a stubborn problem that had grudgingly been brought under control in our nursing home reemerged as some of this control was lost in the transfer out. Moreover, the established mechanism that enabled a family member to speak with a familiar health team representative who knew their parent well no longer existed. While far less serious than an imminent death threat, these ostensibly minor issues were nevertheless upsetting. After all, it was often problems such as these that had led the family to institutionalize their loved one in the first place.

From my standpoint, the sometimes-absurd vagaries of medical practice have played themselves out fully in recent days. For two days, for example, I conducted several difficult phone calls filled with anguish with three children of an elderly resident with COVID-19 who was deteriorating in hospital and appeared set upon an irreversible downhill course.  Between calls I received an emotional call from the daughter of one of our other residents.  While her mother had no COVID symptoms and was stable medically, she was very confused and agitated, and her only daughter, on phoning her, had found her unable to conduct a conversation. The daughter could not identify the problem nor and ascertain its severity. Because the daughter encountered difficulty reaching anyone on the ward, she telephoned me out of desperation. After I succeeded in reaching the nursing home and connected the daughter with her mother and a nurse, it turned out that the mother was upset because her socks had been mislaid. You could say that, depending on the case in hand, my repertoire extended from preparing family members for the worst possible outcome to commiserating with a daughter over her mother’s lost socks.

Throughout all this we continued with routine group testing every three days. Unfortunately, after the next test, five more residents were found to be positive. Although none had significant symptoms, all had to be transferred out, and the process described above had to be repeated. Again, I called all the families and delivered the bad news.

Between this test and the following one, some of the staff had also begun to feel unwell. One became COVID positive, and his condition deteriorated to the point that he required assessment in the ER. Thankfully, he improved and was sent to convalesce at home. We were concerned of course, about his welfare but also about being short-staffed, as yet another worker succumbed.

After each testing we continue to transfer out the newly diagnosed COVID-19 positive residents.

Our current situation is distressing: our COVID-positive administrator is in isolation; numerous staff members are at home with the virus; many of our residents are dispersed, leaving the nursing home almost half empty; every few days additional remaining residents are diagnosed as infected, and the resident who was fighting a battle for his life eventually succumbed. These are undoubtedly difficult times.

Until the onset of the COVID pandemic, coping with multiple patients because of a single event was beyond the purview and experience of most physicians, to say the very least. Unless they work in a hospital E.R., by and large community physicians are accustomed to handling individual cases: while they may perhaps deal with several cases at once, they are unused to orchestrating an event in which over a dozen patients are affected simultaneously.

Despite our present bleak situation, I am optimistic in the long run. We are a resilient, united and determined team.  COVID-19 is a time limited illness, and most people including the elderly should eventually recover completely from it and return even if it takes longer than we had hoped. Most of our residents are no longer in life threatening danger. While the viral invasion has not quite run it full course, we are likely way past the half-way mark. We have begun to move onto the next stage in that one positive COVID-19 resident has recovered and returned to our nursing home. Experience, interdisciplinary teamwork and sensitivity to communication are all essential for coping successfully with the situation. We very much hope that, as the benefits of vaccination begin to kick in, this type of nightmare will become a thing of the past.