A fire engine wailed its siren up Cotton Avenue and disappeared behind the El Paso Long Term Acute Care hospital.
A man at the front desk held his hand up to a visitor: "Please wait outside. A COVID patient is being transferred."
Upstairs on the third floor, in an office outside the COVID-19 wing, nurse Valerie Scott updated a co-worker on the patient being rushed by the fire department to an emergency room. She wore black scrubs and spoke from behind a black surgical mask.
The supplemental oxygen wasn't helping. The man couldn't breathe.
"I don't think he is coming back," she said, worried.
725 people have died of COVID-19 in El Paso since March 23 -- the day the county reported the first death tied to the novel coronavirus, according to El Paso Times. Grandparents, parents, siblings and one teenager have died; retired people, working people and teachers have died. Nurses have died.
The bed belonging to the man who left Scott's hospital in distress would be occupied again that evening. The waitlist for her 15 dedicated COVID-19 beds had swelled overnight from 22 to 32 patients.
Across the city, more than 1,000 people per day are testing positive and the city's major hospitals are overrun with severely ill and dying El Pasoans. Hundreds of health care workers have flown into El Paso to pick up shifts from exhausted doctors and nurses and to staff tent hospitals erected in parking lots. The refrigerators of six morgue trailers hummed, keeping the bodies cold.
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The El Paso Long Term Acute Care hospital, physician-owned and licensed for 33 beds, is pitching in as it can.
"They tried to talk to the family," Scott told her co-worker, who manages the relationship with acute-care hospitals, about the COVID-19 patient transferred out. "Basically, at this point, it would be better to give him comfort measures… Here there was nothing more we could do."
She had reason to worry: When doctors have ordered an emergency room transfer of a COVID-19 patient, it meant things had taken a turn for the worse and the patient rarely survived.
The co-worker cursed under her breath.
In the city outside, beyond the hospital's pale pink stucco walls, El Pasoans went about their day, most in face masks but with few other precautions. People shopped at Target and Walmart and shopping centers. Bars-turned-restaurants kept dining rooms open to guests. A fight between city and county leaders and businesses over restrictions on daily life lumbered through the court system.
The relentless war against a deadly, invisible enemy was out of sight to all but those working its front lines.
The El Paso Long Term Acute Care hospital faces southeast, soaking up morning light, built as it was in 1925 for tuberculosis patients when sunlight was the only cure for another disease that eats away at the lungs and suffocates those who succumb to it.
The COVID-19 wing occupies half of the hospital's third floor.
Inside, the narrow hallway is cluttered with shelves and rolling cabinets filled with personal protective equipment and tray tables of PPE outside each patient's door: beige gowns, blue booties, blue gloves, blue N95 masks and heavy-duty face shields. The florescent light is softer than at a newer hospital.
Scott, a licensed vocational nurse and the hospital's clinical coordinator, opened the wing in May. It took three months to make the bed space, acquire the PPE during a time of extreme scarcity and determine protocol for patient care and provider safety, she said.
The hospital is taking on COVID-19 in addition to its usual patients, people who have suffered wounds, trauma or who have spent weeks in intensive care and need a step-down facility, a place to recover before rehabilitation or going home. Scott cared for one of the survivors of the Aug. 3, 2019, Walmart shooting.
When the ward was ready, she held a staff meeting.
Who would be willing to work the COVID floor?
"No hands went up," she said. "Everybody was scared."
She and hospital Chief Executive Skylier Blake, who is a registered nurse, decided they would work the unit themselves.
"I am part of administration. If I am asking other people to do it, I didn't feel comfortable telling people `will you volunteer' without doing it myself," she said. "I am a nurse first, and I love what I do. At that point, I hadn't seen an actual COVID patient -- just what you hear from other nurses and physicians. Everybody looked tired and overwhelmed. I just wanted to do my part."
She and Blake set an example. The week before the ward opened five others volunteered.
Several were so scared to go home to their families -- terrified of exposing their partners, children or parents -- that the hospital paid for hotel rooms for nearly a month.
Every night after a 12-hour shift that could sometimes stretch to 14 hours, Scott, 35, would video call her husband and daughters, ages 10 and one. The little one couldn't comprehend why she could only see Mommy on a screen.
"A lot of people say, `You are a nurse. You signed up for that.' With COVID, the difference is, it's so ugly," she said. "We've taken care of tuberculosis patients and patients with other contagious diseases but nothing ever like this. I signed up for it, but my family didn't. Nobody wants to take that home to their kids, their partner, their parents. It's really, really overwhelming."
Scott described what it's like to work the COVID-19 floor day in, day out:
"At every patient's door, you take your gloves off and sanitize your hands. Then you take off your face shield and sanitize your hands. Then you pull the mask off without touching the mask. You sanitize your hands again. You put new gloves on and then take off your gown. You sanitize your hands. Then you put your other mask on (the one for outside the room) then wash your hands with soap and water.
I've never in my life experienced something like this. It's crazy. It's hard and it's tiring. It's exhausting.
Everybody is tired. You have marks on your face from the mask. You take your PPE off and two minutes later you have to put it all on again. It takes so long to make rounds. That is what people don't understand. The care they are getting. when you have so many people and you have nurses taking care of more patients than they should have to.
There's times. we've had a few patients pass and it's exhausting. It's hard. You have these people -- you know they are passing and you have to tell their family over the phone. You form a bond with patients. They are like your family. It's just more emotional. It's really hard.
The drive home is horrible. You go through your whole day. Was my mask on right? Did I do everything I needed to do? You go through everything, every detail. You do rounds on four patients and you have to think -- did I turn them? Did I make sure he had water? There are times when I would be at the end of the shift, thinking, where is my face shield? Did I touch that? You go back through every step. That drive home is horrible.
Once you get home, you walk in the door. There are so many steps. You take off your clothes. You take off your shoes. Before I can greet my kids or say hi to my partner, you have to run upstairs and take a shower. My kids think, `Mom didn't even want to give me a hug.'
You had a rough day. You have those bad days and you try not to take that home but it's really hard.
Even more so now."
Scott worked the COVID-19 ward for four months straight, until other nurses stepped up. Now she works the unit as needed and the hospital manages the wing with 15 dedicated nurses and nurse assistants and six respiratory therapists. Everybody is working overtime.
In Scott's office, which she shares with Blake, the complex daily calculations of admissions and discharges from the COVID-19 and non-COVID-19 wards cover a wall-sized white board in dry erase marker. Blake calls it a strategic board. Scott calls it something else.
"That is part of why we have that anxiety board," she said, explaining the logistics of managing the COVID-19 unit with limited staff and the need to isolate certain patients. "We have to make sure we don't put somebody in a room sharing a bathroom with somebody else."
Hospital space is extremely tight. Blake and Scott nodded to the board and explained how the pandemic makes it impossible to double-up rooms the way they normally would.
"My hospital license is for 33 beds," Blake said. "But some patients have to be isolated and we lose beds in double rooms. It's hard to get to 33. Our highest census we have hit so far is 24. Right now we have more COVID then non-COVID."
The hospital is applying for permission to allocate some licensed beds to the empty second floor, he said.
"What people don't realize is that these patients that you are seeing, they take two, four, even up to eight weeks to go through an entire process," Blake added. "If the acute care settings were backlogged then (in June), where do you think we're going to be now? We had patients then who had been intubated for 55 days and still spent 33 days with us."
Nearly every line on the white board, each representing a bed, was marked with a patient's name.
Five days later, Scott had good news.
The COVID-19 patient transferred out was stable and would be back in a few days, she said.
"A lot of these patients feel like they are drowning," she said. "They can't catch their breath. The doctors here were worried enough about his respiratory rate that they wanted to send him out. I was worried. The ones that get bad enough that they get sent out, most of them haven't made it."
"I'm very glad he is going to come back," she said.
The patient would be delicate, still needing supplemental oxygen, she said.
But it was a battle won. One life saved.