The first thing they felt was scared.

Nurses at Maui Memorial Medical Center knew they were facing a battle with COVID-19, the deadly virus that was already ravaging communities on the mainland, and the news was horrifying. Emergency rooms and ICUs in New York and other hot spots were overwhelmed; staff struggled to manage the flow of cases; and fatalities were so frequent that hospitals brought in refrigerated trucks to hold the bodies.

Fortunately, things never reached that level on Maui. The Wailuku hospital cared for 21 patients, beginning with the first COVID-positive case April 1. As of Thursday all of Maui County had experienced 118 cases, with six deaths.

Still, the staff at the island’s lone acute-care hospital dealt with the reality of this bewildering novel coronavirus every time a new patient arrived, each requiring individualized and concentrated nursing and each a potential source of lethal infection.

To handle the influx of patients, the hospital set up additional “warm” isolation units and instituted processes recommended by the Centers for Disease Control and Prevention to reduce risk, isolate symptomatic patients and protect health care personnel.

As they worked to set up those processes, Maui Memorial itself became the center of a cluster that began in mid-March, possibly beginning with a single COVID-positive employee. The cluster, which eventually infected 14 patients and 38 health care workers — including two cases connected to travel and two involving community transmission — was declared “closed” by the state Department of Health last week after two incubation periods of 14 days had passed without a new case. The last onset of illness was April 21.

Tough as it has been to care for COVID-19 patients, the hardest part has been seeing what the patients and their families go through, according to COVID unit nurse Stephanie Roberts. Multiple phone calls a day to family and occasional FaceTime connections “still don’t equal being here,” she said.

Some patients suffered from confusion, waking up to find themselves in a strange place with tubes everywhere and no family to hold their hand or be their advocate. For one hard-of-hearing patient who relied on lip reading, the necessary masks made the situation even more difficult.

On Monday, with no new COVID-19–positive admissions for more than two weeks, no one on a ventilator for the past 30 days and only a single coronavirus patient at Maui Memorial, nurses working in the last of the hospital’s COVID units could wind down a bit and reflect on their first bout with the global pandemic.

The pandemic’s arrival at Maui Memorial, which is operated by Maui Health, an affiliate of Kaiser Permanente, was particularly stressful in the beginning, before protocols and workflows were set up to handle this new and highly infectious disease, said Intensive Care Unit nurse Amy Noor. As medical professionals everywhere learned more, “a lot of information was coming at you from a lot of different places” regarding the ways the virus could spread, the use of personal protective equipment and how to deal with the multiple levels of care needed on a single unit.

Seeing what was going on elsewhere helped the local staff to learn what to expect, said Roberts, a nurse in the Maui South medical unit who moved to the COVID unit set up in the Wailuku Tower ICU. Forewarning was helpful, but “it was exhausting to learn everything, because everything is so new.”

Roberts moved to the new unit along with her regular supervisor, nurse manager Jolynn Constantino, who led the setup of one of four new units to treat positive or suspected cases after existing negative-air-pressure isolation rooms, which help prevent airborne diseases from escaping the room and infecting others, filled up. Constantino continues to manage Maui South along with the hospital’s last- remaining COVID ward.

“Jolynn did an excellent job,” said ICU nurse Matthew Johnson. Calm and helpful, “she got that place into shape real quick.”

Constantino said it felt like she was on the phone or living at the hospital for several weeks running. “I was home but still working,” trying to keep up with what was happening here and elsewhere, worried about her patients and staff. Constantino was born and raised on Maui, and “this is my community, my hospital. My family lives here. I wanted to make sure we were doing things right for our community and families.”

The unit the team set up resembles those seen on mainland newscasts, with IV poles and ventilator controls outside glass-fronted rooms so nurses can adjust the equipment and keep an eye on patients while minimizing the frequency with which they have to enter the room.

Each visit to the bedside requires a complex “don and doff” process: As one nurse stands watch, another puts on a gown, mask, hair covering and face shield; the process is reversed upon exiting the room. The witness is there to ensure that no detail is forgotten that might result in contamination. A nurse uses a new set of personal protective equipment each time, along with several pairs of gloves and hand sanitizer between steps.

“Everything now takes more time. It is exhausting,” Noor said. “There’s a lot to think about.”

After a 12-hour shift, it’s a relief to take off the tight N95 mask, slip out of hospital-supplied scrubs and head for a hot shower.

Some have kept their distance from members of their own households, sleeping on the couch or retreating to a hotel room provided by the “Hotels for Heroes” program. Like the rest of the community, they stay put during their time off, with social lives on hold.

Having weathered the first wave of the pandemic, hospital staffs are thinking ahead to the possible second wave many experts are predicting. That last COVID unit will stay in place, ready for any additional patients. The nurses said they are grateful for the support they received, both from their team members and from the community, during the first wave of COVID-19 infections.

People have brought food — poke bowls, plate lunches, chocolate — offered to donate PPE and expressed their appreciation. Others donated to the Maui Health Foundation, which allowed the foundation to support restaurants by purchasing meals for hospital staff. Gestures of gratitude included last week’s air drop of 144,000 plumeria flowers, representing the island’s population, by Blue Hawaiian Helicopters.

And while the public is saying “mahalo” to nurses and other essential workers, “I want to tell the public thank you for helping us help their family and neighbors by staying home,” Johnson said. The community’s adherence to the rules of infection control has helped “flatten the curve” and avoided overwhelming the hospital.

“It cuts the numbers down so we can treat other stuff,” from broken limbs to heart attacks, he said. “By staying home, you’re allowing me to take care of those other issues.”