Aside from everyone wearing face masks, life within Erlanger hospital is starting to more closely resemble a time before the novel coronavirus brought Chattanooga health care systems to their knees, forcing them to pivot nearly all their energy toward preparing for a COVID-19 surge and conserving valuable resources for only the most essential services.
Several pedestrians converge at the entrance to the main corridor that leads from the medical mall lobby to the main hospital. Doctors clad in scrubs hurry down the hall to their next procedure. A pair of food service workers laugh together as they push a cart carrying supplies.
Outside, it's a warm and sunny day in late February. More Chattanoogans are venturing into the world, discovering their "new normal." In the coming weeks, public health officials will give those who are fully vaccinated the go-ahead to reunite with their friends and loved ones.
More than 1,600 doses of lifesaving COVID-19 vaccine - a scientific breakthrough that was only theoretical a year ago and the key to ending the coronavirus pandemic - will be administered in Hamilton County that day.
But tucked away in a far corner of the hospital - down the corridor, up four stories and at the end of a long hallway - ongoing reminders remain of why the masks, the social distancing and the vaccines have been so badly needed, of what they are protecting against.
Occupational therapist Cori Cohen asks a critically ill coronavirus patient to make a simple hand gesture.
"Can you give me a thumbs up?" Cohen asks.
The patient slowly raises his right hand, but his thumb doesn't move. Cohen congratulates his effort.
"Can you lift your left arm?" she says.
He tries but instead gasps for air and breaks out into a coughing fit. She comforts him and begins to move around the bed, stretching his arms and then tilting the bed farther back, then up and back to a neutral position.
After about 15 minutes of therapy, she approaches the door and begins the tedious task of removing the layers of personal protective equipment designed to prevent exposure to the highly contagious coronavirus.
The robe and first layer of gloves are disposed of in the room, which is engineered to keep the air pressure inside lower than the outside so that contaminated particles don't flow out when the door is opened. Just outside the door, another trash can waits to receive the remaining gear. After each step of the process, she coats her hands with sanitizer.
A line of red tape marks the boundary between the room and the "safe" zone where the care team is waiting to discuss the patient's progress.
"How's he doing?" physician assistant Mia Malin asks.
"He's doing OK, still a little sleepy. I think we're reaching the end of his tolerance," Cohen says.
The team, led by critical care specialist Dr. Jigme Sethi, decides to reduce the patient's sedatives a bit with hopes his drowsiness improves, but finding the right balance of drugs for each patient is a delicate matter. They must monitor him closely through the window to his room, watching for changes in his breathing pattern or signs of delirium.
Much has changed in the year since COVID-19 - the disease caused by the coronavirus - was first detected in Hamilton County. Yet for the sickest coronavirus patients and the medical professionals tasked with caring for them, several constants remain.
Coronavirus patients require more intense care than others, and their condition can deteriorate rapidly with little warning.
Though providers better understand how to treat and manage the disease, a drug that can effectively and reliably cure COVID-19 doesn't exist.
Patients that need invasive, mechanical ventilation to support their breathing - such as the person Cohen was treating - often don't survive.
"The rules changed with COVID. There was no manual, there were no guidelines, there was only learning," Cohen said. "Before, if a patient wasn't breathing quite so well, we would have said, 'Oh, no, we're not going to do anything. We're going to let them rest.' Whereas now, we're trying to work on getting them to do something to make themselves feel better, so that maybe their [oxygen] saturations improve, maybe their alertness improves."
Hospitalized COVID-19 patients are still hidden from the public, including their own family members, because the risk of infection is too great. Perhaps that will change once vaccines become widespread, better treatments emerge and the pandemic is controlled. But for the foreseeable future, the devastating effects of the disease remain largely a mystery.
Ashley Bradford, a critical care nurse at Parkridge Medical Center, said it's impossible to understand the gravity of the disease without seeing it firsthand.
"People that have not worked in a COVID ICU just don't know," she said. "I just didn't know how bad it was, how hard it was, the fear that came with it."
Combined, Chattanooga's three hospitals - Erlanger, Parkridge and CHI Memorial - have treated nearly 7,000 coronavirus patients from across the region since the pandemic began, according to hospital spokespeople. Of those patients, 593 didn't make it out alive, leaving behind families who will never get to experience the long-awaited reunion.
"So when people start talking about mask mandates going away and getting life back to normal and things like that, they really just don't know what COVID is capable of," Bradford said.
Fellow Parkridge nurse Kaetlyn Schaff echoed Bradford's sentiments.
"I've always worked in an ICU, and I've seen death - that wasn't a surprise for me when I went through school. But seeing this much death so consistently, it's not easy to deal with," Schaff said.
Andrea Gilliam, a critical care nurse in Erlanger's COVID-19 ICU, has watched the pandemic unfold since the beginning. She helped treat the hospital's first coronavirus patient in March 2020 and said she thought she was handling the stress fine until January, when she experienced a "mental break" as local hospitals were grappling with the post-holiday surge.
At its peak on Dec. 31, 252 patients were hospitalized in the county. The peak for ICU hospitalizations came on Jan. 8. At the time, 65 patients in the county were in intensive care.
"I think I cried every day for three weeks straight. I had to see a therapist because of it. I had to go see my doctor about medication," Gilliam said. "The mental toll it took on me to see people the same age as me and have to put them in body bags, have to call their kids and husbands and say they're not gonna make it, knowing that they have children that are like the same age as my own kids."
COVID-19's impact is not exclusive to the ICU.
Hospital patients who don't require intensive care are kept on a separate floor, but unlike the ICU, those rooms don't have windows that allow the nurses to monitor patients. Doors must be kept closed due to risk of air contamination, so patients spend most of their day in isolation.
Depression in COVID-19 patients is a serious issue, said Ashley Engen, a clinical staff leader nurse on Erlanger's COVID-19 floor.
"We used to go into the room any time we wanted to, with our patients before, and now we only go in at designated times," she said. "Sometimes the best thing we can do is say, 'I'm sorry, I'm here for you,' but it's through [personal protective equipment], it's through gloves and a shield, and we have muffled voices."
While on one hand the layers of personal protective equipment and closed doors make patients and providers feel disconnected, Engen said the experience creates a strong bond between nurses and their patients.
"We spend 12 hours a day trying to keep them out of the ICU, keep them oxygenated, keep them well, and we get attached to their family members, because you're the connecting person between them," she said.
Even in a year's time, the disease is not well understood.
"It doesn't behave like anything we've known before. You do everything you're supposed to do, and the patient does everything right, and for some reason they don't make it. I think that's been the hardest thing," Engen said.
In the COVID-19 ICU, Dr. Sethi said the team is constantly monitoring machines, oxygen levels and blood pressure, which can change minute by minute.
"You can't afford to step away from the room for too long without the need to have to be called back urgently. Other critically sick patients tend to be unstable, but not to the extent of these patients," he said.
On that February day, each patient in the ICU had different oxygen and pressure needs. Some were on a "high flow" oxygen machine known as a Vapotherm, another wore a new "hood" device, which resembles an astronaut's helmet to deliver oxygen and air pressure.
The hood is less invasive than a traditional ventilator, which requires intubation, and therefore more comfortable. Patients need less sedation and are able to eat using a straw through a small window on the side. However, Sethi said that patient may need to be changed to a ventilator if his status does not improve.
"It's been a long illness for him, and he hasn't shown signs of getting better," Sethi said. "He hasn't gotten significantly worse, but it's always a worry when the healing doesn't occur. Because then the question is, 'What next?''
A new set of lung X-rays taken that day also show no signs of improvement, which means it's looking more and more likely that the patient will need to be intubated.
"But that kind of mechanical ventilation has its own issues. High pressures on the ventilators damage the lungs, and often they don't heal," he said. "If the lungs don't heal, then they can't live on a ventilator, especially at the high pressures and high amount of oxygen that we give them. That's when they start doing poorly and other organs fail."
Cohen will soon don another set of protective gear in order to enter that patient's room and conduct therapy with hopes his condition will improve. It could make the difference between him needing to go on a ventilator or getting to keep the hood.
"All the patient has to be doing to be appropriate for therapy is be somewhat stable and be able to interact in some way with their environment, and that doesn't mean follow commands," she said. "Sometimes that means they can open their eyes and they can attend to me for like 10 minutes at a time or five minutes, but those are things that I can work on - slowly starting to get them to interact more with their environment, be able to participate in their care."
Sethi and the other doctors who oversee the COVID-19 ICU rotate through the unit once every four weeks. February was his first time back since the winter surge.
"I think when I was here last time, the total numbers were well above 100 in the hospital, and the ICU was full. Now it's just a fraction of that," he said. "They're still very sick, but they don't seem to be as critically ill and as sick as they were before."
He's keeping an eye on the new variants but is cautiously optimistic the worst days are behind them.
"I anticipated that the disease would spread even faster. So this is a positive thing to see that the community has responded, the vaccinations are happening. And the numbers are dropping off, which is entirely unexpected. Even last month in January, I wouldn't have expected the dramatic decline that we've seen," he said.
Though the pandemic has taken its toll, staff say getting to see patients recover and go home is worth it.
On the regular coronavirus floor, 49-year-old patient Taft Butcher is about to be discharged after a week in the hospital. He still has trouble breathing and gets winded when he talks.
"I'm just ready to be home with my family and friends, just have some interaction with people," Butcher said, saying messages and calls from loved ones kept him going throughout his stay.
"If you do have a family member or friend here, talk to them, send them a text. It means the world, especially in this isolation. It's hard to fathom - you can have all the friends in the world, but you can't see anybody, you can't reach out, you can't touch them," he said, as his nurse, Engen, prepared to wheel him out.
"That's the most rewarding thing, especially with COVID," she said. "The most incredible thing I've seen is when patients come in with everything stacked against them - all the comorbidities and everything - and they get better."
Contact Elizabeth Fite at [email protected] or follow her on Twitter @ecfite.