Angela Smith, an intensive care nurse at Maine Medical Center’s COVID-19 unit, said she will always remember the fear. The fear of the unknown at the beginning of the COVID-19 pandemic, the fear in the eyes of patients who contract the disease, and the fear they express as they gasp for what may be their last breaths.

“The fear is ever-present,” said Smith, 50. “Many patients will say to me, ‘Am I going to die?’ I usually say, ‘Not on my watch.’ But I may be lying sometimes.”

More than 1,000 patients have been treated at Maine hospitals for COVID-19 since the pandemic began. While treatments have improved and mortality rates for COVID-19 inpatients have gone down, hospitals are still the setting for an often grueling battle for survival. Every step of the way, doctors, nurses and other staff help patients, working long hours and endangering themselves by being in contact with people who are positive for COVID-19. And when patients die, hospital staff grieve for the victims and their families.

The Portland Press Herald/Maine Sunday Telegram interviewed four nurses and a doctor on the front lines of the pandemic, to hear their stories of what it’s like to care for the patients who have been treated in Maine hospitals for COVID-19. They described seeing patients die while family members talk to them on a Zoom call, the loneliness of COVID-19 patients in isolation, and the value of supportive co-workers amid all the suffering and stress.

Smith works at the Scarborough Surgery Center and volunteered to pick up extra shifts – one to three each week – in the COVID-19 unit at Maine Med.

Smith said although her primary job is at the surgery center, she felt compelled to help because she has a long background in intensive care nursing, and wanted to help the hospital during the pandemic. Smith said with the nursing shortage nationally and in Maine, she knew her services would be needed in intensive care.

“I’ve always been a helper,” Smith said. “It’s just something I felt like I had to do. I could literally work seven days a week if I wanted to.”

Smith said when patients arrive at the hospital, they fear death, and if they are gasping, have an immediate fear of not being able to breathe.

“It’s terrifying. We take our ability to breathe for granted, we do it 15-20 times a minute without thinking about it,” she said. When patients die, it takes an emotional toll on everyone – families, nurses, doctors and hospital staff.

“I treat every patient as if they were my family member,” Smith said, pausing. “It’s a soul crusher when things don’t turn out well.”

For Chantal Bauder, a nurse at Maine Med’s COVID-19 intensive care unit, comforting patients is a significant part of the job, but the staff is stretched thin as the hospital has gotten busier from the fall and winter spike in cases.

Bauder said nurses are picking up as many as three extra shifts a week to have enough staff to care for patients during the surge, with some nurses routinely putting in 60-hour weeks. Bauder said she couldn’t put a number on it, but deaths are more frequent than during the summer.

“There comes a time where you just can’t give the patient enough oxygen,” Bauder said. “That’s when you have to be there for them, when family isn’t there for them. Hold their hand.”

Many COVID-19 deaths occur in a hospital, and as of Saturday, 358 Maine people had died of COVID-19 since March. The Maine Center for Disease Control and Prevention said it did not have data available on how many of the deaths occurred in a hospital.

In a study of three New York hospitals published in October in the Journal of Hospital Medicine, death rates declined from 25.6 percent of all hospitalized COVID-19 patients in March to 7.6 percent of patients in August, as hospitals improved treatments and more medications became available.

But there still is no cure, and COVID-19 remains lethal, approximately five times deadlier than influenza among hospitalized patients, according to the U.S. Centers for Disease Control and Prevention. Vaccines are starting to become available – and front-line health care workers are among the first to be immunized – but the vaccines will not be widely available for months.

In Maine, as of Saturday, 1,091 people had been hospitalized since the pandemic began, with 188 currently hospitalized. While there’s no hard-and-fast number of how much worse the pandemic can get before patients overwhelm hospital capacity, Maine’s trajectory is worrisome, public health experts have said, with average case counts skyrocketing from about 30 per day in October to more than 500 per day.

In some patients, the disease can progress at an alarmingly fast rate, said David Rogers, a nurse who worked in Maine Med’s COVID-19 unit from April to June.

“You can see it in their eyes, the fear,” Rogers said. “I cannot imagine going from a normal day, then coughing like you have a cold and then a few days later being on a ventilator.”

And then there’s the isolation. Patients must fight COVID-19 alone in their hospital room.

To keep hospitals safe from an outbreak, rules forbid most visitation, except in end-of-life situations. With nurses and doctors having to gear up in protective clothing every time they enter a COVID-19 patient’s room, in-patient visits are fewer and the length of each visit is shorter, said Dr. Al Teng, chief of critical care at Central Maine Medical Center in Lewiston.

Teng said sometimes patients fall unconscious before dying with no one in their room.

“We are often the last people the patients see before they die, and sometimes that means they are seeing us from the other side of a glass door,” Teng said.

FINAL GOODBYES

Bauder said typically when a patient is near the end of life, one family member is permitted to visit for one hour, dressed in protective gear. Sometime later, hospital staff will remove the mechanical ventilator’s breathing tube and arrange for a Zoom call with more family members in the final minutes before death. It’s hard to know whether the patient can hear or understand what is being said.

“We hear fathers, mothers, sons, daughters, husbands and wives say their final goodbyes,” Bauder said. “They usually are apologizing that they can’t be there in person at the end.”

Bauder said for nurses, “it’s been a long year” and each death is difficult.

“There’s nothing (nurses) can say to each other to make it better. When it happens, we acknowledge the sadness and we are all there for each other. And then we have to get ready for the next COVID patient,” she said.

Smith said the cumulative effect of seeing the suffering of COVID-19 patients is draining.

“Every single death takes a little piece of me,” she said. “How do you care enough but not so much that you burn out? But we are all in this together, and I think we will make it through.”

Smith said she does what she can to comfort the patients, and they can connect with family members by phone or over Zoom.

“I tell the patients that we are going to get them feeling better. Reassurance is a huge part of what we do. We reassure them that they are not alone,” she said.

COMMUNICATION PROBLEMS

One of the hurdles nurses and doctors must overcome, Teng said, is how difficult it is to communicate with patients while wearing full protective gear, including the Powered Air Purifying Respirator, or PAPR. The respirators make noise, the room’s air systems make a “humming” sound and patients who are short of breath can’t speak up.

“It’s difficult to hear them and understand what they are saying,” said Rogers, the nurse. “The air is constantly blowing around in your mask. I write things down on paper sometimes.”

Teng said “when you’re in the room wearing the PPE, it’s hot and uncomfortable. You have physical stress on top of the emotional stress.”

But he said there can’t be any shortcuts, to keep health care workers safe. More than 2,400 health care workers have tested positive for COVID-19 since the pandemic began, according to the Maine CDC.

Jessica Pernal, a nurse with Maine Med’s COVID-19 intensive care unit, said that with the time it takes to put on and remove protective gear, “you can’t just pop in and out of a room like you used to. Every part of the day has to be planned.”

“The patients are frightened and don’t know what’s going on a lot of the time,” Pernal said. “Sometimes I feel like we kind of lose that nursing touch.”

And hospitals are much busier in Maine than earlier in the pandemic. Hospitalizations are now about 10-15 times higher than during the summer. Another doubling or tripling of cases would strain hospital systems. In other states, such as California and South Dakota, the volume of COVID-19 patients has swamped hospitals to the breaking point. Some hospitals in other states have put some patients in gift shop areas to wait, or sent patients out-of-state for care.

‘A CRUSHING LONELINESS’

Smith, who is single, said she has stayed away from family members who live nearby, worried that she would accidentally transmit the virus to them or that they would give it to her and she would unknowingly bring it to the hospital.

“It’s a crushing loneliness, and it’s difficult to put into words,” Smith said. Watching television, news about the virus is ever-present, making it nearly impossible to get a mental break from the coronavirus.

Smith canceled plans for a tropical vacation to celebrate her 50th birthday in December, and mostly she spends time with her dog, Twilight, a German shepherd mix. She misses seeing her daughter, grandchildren and mother.

“I figure there’s no getting away from COVID, so you might as well go to work,” she said.

Teng said he worries about the emotional well-being of health care workers who are feeling “pandemic fatigue” just like everyone else, at the same time that a surge in cases is happening and months before vaccines will have an impact. The Lewiston area has been especially hard hit with skyrocketing COVID-19 cases, and the hospital now treats about 10-12 patients per day, about double what it was in summer and early fall.

“For the first time in at least 25 years I missed the large Thanksgiving we do in Boston, with 30-40 people there,” Teng said. “We canceled it this year, and it was painful, and I felt sad and disconnected. But it was the right thing to do.”

He said part of what the staff is seeing at Central Maine Medical Center is “people who attended some of the same Thanksgiving gatherings coming to the hospital with COVID-19.”

MOMENTS OF JOY

Bauder said despite the hardships, there are moments of joy, like when some patients leave the ICU to go to an intermediate care area. If they continue to improve, those patients may leave the hospital a few days later.

“Our hope is that we are sending them out of the ICU to eventually leave the hospital,” Bauder said. “When we wheel patients out they are giving thumbs up, and for many it’s the first time they’ve left their room in days or weeks. They graduated from the ICU and they’re moving up in the world. It’s a happy moment.”

When COVID-19 patients are discharged from Maine Med, the intensive care staff will later receive cards, artwork and handwritten letters from former patients and their family members.

“They have absolute gratitude for all of us and everything we are doing,” Bauder said. “To get cards and messages from a family whose dad, husband or wife has come home, that’s a huge reason why we are picking up extra shifts. We come into work every day, hopeful.”