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— Clinical

It began with seven tea kettles

Frontline staff at UC San Diego Health recollect the first days of the pandemic, a time marked by fear, uncertainty and endless acts of kindness

By Michelle Brubaker, Jackie Carr and Jeanna Vazquez

On a cold morning in February, seven stainless steel electric tea kettles, filled with hot water, are delivered to patients’ rooms at UC San Diego Health Medical Center in Hillcrest. The tea kettles are not typical, but neither are the times.

The COVID-19 pandemic had begun in earnest, and the kettles represented an early act of comfort and humanity in a time that would soon demand an outpouring of both.

On February 5, 2020, UC San Diego Health activated the organization’s Hospital Command Center (HCC), the central location where in-house experts gather to develop and implement a response to an emergent and urgent situation. In this case, it was the growing crisis surrounding the novel coronavirus, SARS-CoV-2, then rapidly spreading in Wuhan, China.

Five days later, UC San Diego Health received its first patient with diagnosed COVID-19, an evacuee from Wuhan, who had previously been airlifted to and quarantined at Marine Corps Air Station (MCAS). The patient was officially the 13th case of COVID-19 in the United States and would soon be followed by others from MCAS.

They arrived via ambulance, escorted by law enforcement vehicles and greeted by medical staff, security officers and officials from the Centers for Disease Control (CDC), all wearing masks, face shields, gloves and other personal protective equipment (PPE).

Seven new tea kettles were purchased, filled with hot water and served with sides of lemon and ginger to the first patients from Wuhan.

There were more questions than answers

The virus was largely unknown, as was the plan of treatment. There were more questions than answers.

“One question raised in the HCC was ‘Does anyone here speak Mandarin?’” recalled Lily Angelocci, transformational health care lead coach at UC San Diego Health. “From there, I spent the next two weeks at the bedside of the patients in our intensive care unit, helping to meet their physical and emotional needs.”

Four evacuees were eventually transferred from MCAS to UC San Diego Health for care. Most spoke little or no English. Translators were found.

Angelocci was always nearby, intent on addressing their physical needs or easing their emotional concerns. It wasn’t yet clear who was infected with the SARS-CoV-2 virus and who was not, but all of the patients were far away from home, away from loved ones and afraid of a disease no one yet understood.

“At the time, we had to wait days to receive test results from the CDC in Atlanta to confirm if the patients from Wuhan were actually positive with the virus,” said Angelocci. Two were.

“What initially struck me was the delicate humanity of the situation,” said Francesca Torriani, MD, program director of Infection Prevention and Clinical Epidemiology at UC San Diego Health. “In the patients’ faces, I could simultaneously see fear and gratitude: fear of rejection and gratitude for us accepting and welcoming them.

“Can you imagine being evacuated from Wuhan on a windowless airplane, not knowing if you had the virus, or if you would live or die; of being targeted because of bringing a new disease into a country? My heart went out to them.”

Even with the language barrier, the patients’ concerns and fears soon became apparent.

Comfort Food

“We realized that they were not eating,” said Jill Martin, director of food and nutritional services at UC San Diego Health. “We needed to devise a plan to make sure these patients were fed and felt supported. Our role is not just to provide food on a tray. Providing healthy meals is a significant part of the recovery process. That was our main priority.”

Many of the patients could not digest certain foods being offered.
With assistance from Angelocci, Martin’s team visited specialty grocery stores to purchase more familiar fare. It brought patients and staff closer together. “One of our chefs, Bo-Kai Liao, speaks Mandarin and was integral in those early days, making sure there was a strong line of communication. He would call the patients in their rooms several times a day, find out about their food preferences and customize their meals,” said Martin.
Favorites were wonton soup, egg and seaweed soup, congee (a type of rice porridge), spicy Mapo tofu and a Taiwanese basil omelet.

Meals were served using only disposable materials, to reduce the risk of virus transmission. Some foods, such as meats, were cut into bite-sized portions in the kitchen before delivery.

“We are all human, but different things comfort and heal us,” said Martin.

“We found a balance of caring for these patients while still following all the safety measures.”

Normally, loved ones are in the rooms to help with the meals, but that was not the case for these patients. Sometimes, patients were too weak to cut their own food, so we did that for them to make sure we were doing everything we could to help them eat and heal.”

The seven tea kettles were part of that process.

“In Chinese tradition, they do not drink cold or room temperature water, only hot water. In talking with the patients, we realized they were being served cold water,” said Angelocci.Tea kettles were purchased. Patients soon received their water hot, served with sides of lemon and ginger. Patient Experience staff added to the efforts, delivering floral arrangements to brighten up rooms and power cords, chargers and coloring books to help patients stay connected to the outside world and pass the time.

“We always teach our staff one word: the Japanese term, ‘gemba’,” said Angelocci.

“It means ‘the place where value is created.’ In practical terms,” said Angelocci, “it means to ‘see, show respect, and ask why.’ It meant the world to patients and staff.”

“We needed to devise a plan to make sure these patients were fed and felt supported. Our role is not just to provide food on a tray. Providing healthy meals is a significant part of the recovery process. That was our main priority.”

— Jill Martin

Kevin Kwak, MD,
was among the first doctors to see and treat patients from Wuhan, China.

Counceling Patients

The unpredictable nature of COVID-19 first struck Kevin Kwak, MD, a hospitalist at UC San Diego Health, when he walked into the room of a 30-something patient with the disease.

When I had seen the patient earlier in the day, he seemed stable overall. He did have some shortness of breath, but he was able to communicate. Later that evening, he was on six to seven liters of oxygen,” said Kwak.

“Seeing a patient decline like that in only about 12 hours was eye-opening. He did have some co-morbidities, but that moment stands out as when I truly realized how serious this virus is, and that it does not discriminate.”

Kwak was among the first health care workers on the scene when patients from Wuhan were admitted to a dedicated, isolated COVID-19 unit at UC San Diego Medical Center in Hillcrest.
The unit was the product of multiple departments collaborating, and was staffed by physicians and nurses who volunteered to care for the patients.

“I remember that night vividly,” said Kwak. “I was asked if I would be willing to take care of the patients coming from MCAS because we were not sure of the associated risks. I am relatively young. I am healthy. I live alone. I quickly answered yes. It was definitely something I wanted to do.”

“There were so many uncertainties at that time, but we were all incredibly focused while collaborating, coordinating and communicating.”

— Kevin Kwak, MD

Collaboration, Communication, Coordination

He said most of the Wuhan patients’ symptoms were mild, but he spent considerable time trying to alleviate their uneasiness.

“As physicians, we were still learning about the trajectory of the virus. We were trying to address the patients’ questions, even though we didn’t know all the answers. The main questions were: Am I going to be okay? When will I be able to go home? I could only tell them with confidence that we were working around the clock to provide the highest quality of care. We were gathering as much information as possible and adapting.”

All of the Wuhan patients were discharged a week or so after admittance to continue their recoveries with family and friends. By then, however, COVID-19 cases were appearing among local residents. At Hillcrest and Jacobs Medical Center in La Jolla, long-term COVID-19 units were set up for patients from the San Diego community.

“Back in February 2020, all we knew about the virus was that it was respiratory, but we weren’t sure how it was being transmitted,” said Dante Segundo, RN, MSN, nurse manager at UC San Diego Health.

The rising number of local cases prompted massive organizational changes.

“We transitioned from a relatively contained situation with the patients from Wuhan to one that was now affecting the community at large. Our entire hospital system had to pivot.”

Processes, from testing and treatment plans to managing huge volumes of lab work, were refined daily, often spurred by evolving CDC guidelines.

“We were all learning about the swab tests, waiting three to four days for test results (from the CDC in Atlanta) and understanding what PPE we should be wearing,” said Kwak. “There were so many uncertainties at that time, but we were all incredibly focused while collaborating, coordinating and communicating.”

It Takes a Medical Center

Conquering COVID-19 required a team effort, from university researchers to practicing physicians, nurses and the staff that keep hospitals functioning.

I must give credit to the pulmonary critical care group for the daily care and management of the patients. I saw how their team, under the leadership of Dr. Jess Mandel, fine-tuned the treatments and turned the care of patients with COVID-19 into an art,” said Torriani.

“Based on their observations, they developed strategies for steroid use, ventilation management and other necessary lifesaving interventions that were eventually taught to other hospitals in the United States and Mexico.”

In the beginning, only physicians and nurses were permitted inside rooms with COVID-19 patients. It was a matter of prudence and safety, but it also “provided the opportunity to work closely together, which strengthened our working relationship during such a stressful moment in time,” said Segundo.

“It was all hands on deck,” added Kwak. “We were all in the same boat, learning about this disease together. We were supporting each other and had a deep understanding of what we were all going

through and feeling. We were holding each other up through all of the exhaustion. We became like family during this time, and those strong relationships remain.”

COVID-19 changed work streams throughout the hospital. It impacted the hospital’s Environmental Services Department (EVS), who needed to assess and revise cleaning and disinfection protocols.

It Was All Hands On Deck

There was a steep learning curve when the first patients arrived from MCAS Miramar, and initially Environmental Services (EVS) staff did not clean the rooms when patients were to avoid any unintentional contraction of the virus. Instead, nursing staff kept patient rooms clean; EVS crews prepared rooms before and after patients were admitted or discharged. When community spread surged in April 2020, EVS teams transitioned to cleaning rooms with patients to better support over-taxed nurses and doctors.

Throughout the pandemic, Segundo said the tripartite mission of UC San Diego Health — outstanding patient care, groundbreaking research and inspired teaching — was tested, but rose to the challenge.

“As an academic medical center, we had patient care, research and education all happening in one space at the same time. That idea of lifelong learning was an everyday normality for our unit,” Segundo said. “I’m most proud of our resilience. We found ways to be joyful, caring and critical thinkers all at the same time.”

“It was all-hands-on-deck. We were all in the same boat, learning about this disease together. We were supporting each other and had a deep understanding of what we were all going through and feeling.”

— Kevin Kwak, MD

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