Hardly able to breathe, Barbara Ritter told her nurses to do whatever it took to save her from covid-19 -- even if it meant using a ventilator.
"I don't care what you have to do to get me well, but get me well so I can go home to my daughter," Ritter recalls saying. "Even if I have to be vented, whatever you have to do, get me well."
Ritter, 52, of Ola barely remembers falling asleep, but she remembers the confusion when she awoke after a week on a ventilator at Conway Regional Hospital.
Ritter was fortunate.
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Of the 562 coronavirus patients who have required ventilator treatment in Arkansas, Ritter belongs to the half that made it off. So far, 277 Arkansans with covid-19 have died while on the machines, according to figures released by the state Department of Health last week.
Tracking ventilator use by covid-19 patients allows state officials to gauge the severity and extent of the virus as well as keep tabs on health care inventory to ensure sufficient resources remain available should there be a surge in need, a state Health Department official said Friday.
"We do track usage and availability, and to this point have had enough resources," Health Department spokesman Gavin Lesnick said. "As of this morning, we showed 330 patients in the state on ventilators, 90 of which were covid-19 patients. We have a total of 1,056 ventilators owned or rented in the state, so that leaves 726 available."
The beginning of the pandemic saw the nation scrambling to manufacture and purchase ventilators to meet the projected need. Car manufacturers such as Ford and General Motors as well as other manufacturers inked $3 billion government contracts to build the life-saving machines.
Last week, the U.S. Department of Health and Human Services announced that the national stockpile had reached its capacity with nearly 120,000 machines available for deployment to the states in need. The Trump administration canceled some of its remaining orders for ventilator production.
Hospitals in Arkansas, once fearful of a ventilator shortage, now say their own stockpiles are more than sufficient to meet the current need.
Jacob Stover, chief administrative officer and associate vice chancellor for clinical finance at the University of Arkansas for Medical Sciences, said the academic medical center has more than enough ventilators, and it is even returning some machines that were rented in anticipation of the predicted surge of covid-19 patients.
UAMS has treated 41 covid-19 patients on ventilators to date, Stover said.
"During the covid time frame we have sought many different suppliers, some traditional, some not traditional," Stover said. "We generally try to work through our existing GPO [general purchase order] arrangements first."
Likewise, Baptist Health has 127 ventilators across its health care system from various suppliers, said Dr. Eddie Phillips, chief medical officer for Baptist Health. The hospital system also has the ability to create additional ventilators by converting anesthesia and other breathing assistance machines if needed.
"We have less than half as many patients, 13, on the ventilator with covid-19 across the Baptist Health system now as compared to the peak of 29 two weeks ago," Phillips said.
HOW IT WORKS
A ventilator is a machine that breathes for a patient who has lost the ability to breathe on his own because of injury or illness -- such as covid-19, which attacks the respiratory system.
The machine includes two tubes. One pushes oxygen-heavy air into the lungs; the other removes -- or exhales -- carbon dioxide from the body.
Patients are sedated, then intubated, meaning a tube is placed down their throats past the gag reflex.
Ventilator use is a last resort for covid-19 patients, said Jeff Halbert, lead respiratory director at the University of Arkansas for Medical Sciences.
Out of the state's 861 cumulative deaths from covid-19, those who died while on a ventilator account for over 32%.
"They're used by patients that can no longer sustain their own respiratory drive," Halbert said. "The ventilator doesn't heal anybody. It's a mechanism to sustain life until we can resolve the issues that caused the need in the first place."
Halbert joined the UAMS team in February, just right before the pandemic hit. He hardly had a chance to acclimate to the new job before facing critical questions like: Are there enough ventilators? And, is there enough protective equipment?
As the state's only Trauma 1 facility, UAMS was more prepared than most with about 85 ventilators in stock.
"About 13 of our vents were supposed to be trade-ins for new ventilators," Halbert said. "We went ahead and kept them, then purchased 13 new ones."
Previous ventilation use averaged between 18-22 each day, but that has increased to about 30 per day for UAMS, Halbert said.
"We had to create covid units and noncovid units," Halbert said. "There was a lot of maneuvering and we have to constantly come up with different strategies."
Staffing is also an issue when it comes to caring for covid-19 patients requiring ventilator use.
"UAMS has struggled with recruitment because of the nursing shortages. We have employed outside contracted staff and also internally trained other staff to manage and plan for surge level impact," Stover said.
MIRACLE PATIENT
Normally, the decision to place a patient on a ventilator is an emergency, with no opportunity to ask the patient's preference, Halbert said.
"A lot of times when people get to that point, they're no longer able to communicate," Halbert said. "We rely on the patient's advance directive, if they have one in place."
An advance directive is a pre-written statement of a person's wishes regarding medical treatment in the event they are unable to communicate to health care providers. Some directives forbid life-sustaining measures -- such as ventilator use -- to be taken.
For Ritter there was no question.
As she was rushed in an ambulance on Aug. 14 to Conway Regional Hospital's Covid Care Unit, Ritter gasped for air from lungs compromised with double pneumonia and told the health care workers to do whatever was necessary to save her life.
"I hardly remember, but told them to go ahead because I was exhausted from coughing so much," she said. "I can't hardly explain how sick I was."
Ritter believes she was exposed to the virus at the Western Yell County Medical Clinic, a satellite clinic of Chambers Memorial Hospital in Havana, where she works as an admissions clerk and screened patients for covid-19 symptoms.
Even though she is a Type 2 diabetic, Ritter said she is healthy and active.
Since retiring after more than 26 years as a pastor at Cross Connect Outreach Center in Danville, Ritter is a three-time Arkansas Game and Fish Master Angler. She gardens and delivers her harvest and other supplies to the elderly in her community free of charge, and is a master seamstress. She plays the piano, guitar and drums and is frequently remodeling her home on her own, building out kitchen cabinets and adding rooms.
"She has more talent in her pinkie than I have in my whole body," said Charity Keener, 42, who was adopted by Ritter at 16. The pair have been inseparable ever since and currently live together outside of Ola.
Ritter said she had been diligent about wearing an N95 mask and using hand sanitizer, but was still fearful of contracting the virus.
"There were many times I had to pray and get hold of myself because the truth is you never knew who was coming in and with what," Ritter said.
Ritter was deep into a home remodeling project when she developed a runny nose. She didn't think anything of it, but on Aug. 5, she developed a cough.
By the next day, the cough had worsened and a sore throat was added to her symptoms.
By the weekend, she tested positive for covid-19.
"I know now, since having gone through what I did, one of the worst things is to be afraid of covid. I had to deal with it myself," Ritter said. "When I read the text where I was positive, I immediately started thinking fearful thoughts like: 'How bad am I going to get? Am I going to be another statistic?' and 'What stat will I fall in?'"
As her condition worsened, Ritter was first hospitalized at Chambers Memorial Hospital in Danville, before being transferred and immediately placed on a ventilator and a feeding tube at Conway Regional Hospital.
Keener, who later tested positive for covid-19, said it was heart-rending to not to see her mother during this time.
"I called those poor CCU nurses at Conway at least once, and often twice, per shift," Keener said. "Each new nurse was given a brief bio of mom. They were also given messages to give to her even though she was sedated."
Ritter said she barely remembers going to sleep after being sedated and then woke up a week later.
"You talk about confusion, this girl was confused," said Ritter, adding that she was surprised to find herself with a "perfect" pedicure when she awoke, provided by one of the nurses.
Health care workers at Conway Regional flooded Ritter with attention throughout her stay, with one employee singing to her and others praying with her at bedside.
Halbert said weaning a patient from a ventilator can be a long process. The patient is assessed daily to see if the ventilator levels can be reduced.
"They then move on to a spontaneous breathing trial, where we put the machine on the minimal setting to help them breathe on their own," Halbert said.
For Ritter, the process was quick and relatively painless, she said.
"Thousands of people were praying and contacting us, checking on us both. I have never in my life seen people come together as so many have with this," Ritter said. "The hospital staff cheered me on and was so proud that I came off vent and was doing so well. They literally stood in the hallway, lined up looking at this miracle lady."
THE UPSHOT
The long-term impact of ventilator treatment can be daunting, depending on how long the patient had to be intubated, Halbert said.
"You can have a little bit of anatomical trouble. Intubating a patient and putting an airway in can sometimes be very difficult," he said. "Also, you're putting an artificial airway through your vocal chords that are used to closing. You can sometimes experience upper airway, anatomical trouble. Being very sick, you will have complications. Covid-19 can also produce some lung scarring."
In some cases of long-term use, the patient can have a diminished neurological capacity, Halbert added.
Ritter, who was released from the hospital on Aug. 25, was weaned off supplemental oxygen last week. She has to take updraft treatments and use inhalers at home to strengthen and to clear mucus from her lungs.
"I'm so weak I can't walk across the floor without getting out of breath," she said, adding that the doctors told her that her lungs "won't even start to feel normal" until at least four weeks and it will take time to return to full strength.
Ritter is unable to work and is currently on unpaid medical leave. Keener -- who was injured in an automobile accident several years ago and was placed on disability after numerous surgeries -- said the financial loss is the mother and daughter's greatest struggle now.
Friends immediately stepped forward to help, even setting up a fundraising campaign to help the mother and daughter duo.
"One day mom had a steady income. The next day she's sick with something she caught while doing her job," Keener said. "Now we have no idea when or if she'll be able to work again. We are told it will be a very long time. I was home with virtually no funds while my mom was on the ventilator. If not for friends bringing groceries and supplies, I don't know how I would have made it. We all know that isn't a long-term solution."
Ritter said she is not worried about the future.
"I had a team of thousands praying and God working through the medical team at Conway. And here I am today," she said. "My life was saved and I will spend it helping others and spreading the gospel as I have done over 30 years."