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APRIL 08, 2020 -- Nothing in her nearly 30-year nursing career prepared Gina for what she's gone through in the past few weeks — not even the dawn of the HIV epidemic, when the fear of AIDS prompted most healthcare providers to back away.
COVID-19, she says, is different. "I'm terrified."
Gina (a pseudonym) worries about how much worse things at her hospital will become. Mentally and emotionally exhausted, she tamps down her panic while at work. But when she gets home, she can cry in the shower without anyone hearing. "I don't want anyone to know what it's doing to me," she said.
Gina is a long-time critical care nurse working in a 200-plus bed community hospital that's part of a multi-hospital system in the northeastern United States. She spoke with Medscape Medical News on condition of anonymity and asked that her hospital not be identified.
With little warning, the hospital's 12-bed intensive care unit (ICU) grew to 28 beds. It now houses 21 COVID-19 patients on mechanical ventilators.
To ramp up nurse staffing, what used to be taught in a 3-month clinical training program was condensed into an 8-hour crash course in critical care nursing.
Overnight, step-down nurses became ICU nurses who are expected to take care of the hospital's sickest patients. Some had been nurses for less than a year.
As an experienced ICU nurse, Gina is assigned to three COVID-19 patients, a patient load that's likely to increase as the crisis worsens. It's physically demanding work. "I'm lucky if I get to pee once in a 12-hour shift," she said.
Patients with COVID-19 are intubated, paralyzed, and sedated. They receive central venous catheters, arterial lines, nasogastric tubes, and urinary catheters. Most are on one or more vasopressor drips. Oxygenation, pulmonary function, and cardiovascular status are continuously monitored. The nurse titrates and adjusts drug infusions in response to changes in these parameters, drawing labs periodically to monitor a host of other body functions.
The newly trained nurses need a lot of support. They are still learning about mechanical ventilation strategies, endotracheal tubes, neuromuscular blockade, sedation, pronation, and the hemodynamic consequences of COVID-19 and its treatment. Gina spends a lot of time teaching, advising, and reassuring them, as well as stepping in to help when their patients aren't doing well.
"Every time I come out of one of the isolation rooms, the less experienced nurses are waiting with questions. Blood pressure is dropping, what do I do? Patient desatting, what do I do? The monitors are beeping. They are panicking. I help them assess their patients, and I troubleshoot the equipment. I teach them how the meds work, how to document, what's important, what to focus on.
"We are all on a learning curve," she admitted. "I'm seeing things I've never seen before. I'm putting patients on 16–18 cm of PEEP, which I've never done before. With COVID, we are always trying new things. These patients are sicker. They don't sedate as easily as other ventilated patients; they awaken very quickly. It's hard to explain to the newer nurses how unusual this all is and why we are having problems keeping them stable."
But she appreciates every one of the nurses working there, even if they don't have much experience. "I always tell them, 'Thank you for coming, just keep coming, you are not alone. If your patient crashes, we will be there with you.' "
Taking Personal Risks
Hospitals across the country are reporting shortages of personal protective equipment (PPE), and Gina's hospital is no exception. She's been given a single N95 mask that which must be used "until it falls apart." At the end of each shift, she places her used mask in an envelope for UV sterilization before using it again on her next shift. Early on, the nurses were left to cobble together their own face shields and order their own goggles online.
To reduce their exposure risk, nurses try to combine patient care tasks to minimize the number of times they must enter the room. They have to don and doff PPE carefully, following a specific protocol, to avoid contaminating themselves or their PPE during the process. The early shortcut of positioning IV pumps outside of rooms to avoid having to enter the room every time an infusion needs to be titrated was stymied when they ran out of extension tubing. Just talking about it nearly brings Gina to tears.
Adding to the burden of care is the discomfort of spending hours at a time in an isolation room in full PPE: one or more gowns or coveralls, head coverings, masks, goggles, gloves, shoe covers, and face shields. "It's hard to hear, and unbearably hot. I can feel the sweat pouring down my back," explained Gina, "and I'm getting light-headed."
Gina works the night shift, which isn't staffed as well as during daytime hours. During days, 10 nurses work in the ICU, but only seven or eight are scheduled at night to care for the same number of patients. "We were already short-staffed before this started," she added.
At night, the ICU nurses also have to cover the hospital's rapid response team (RRT), meaning that a nurse must leave the ICU when the RRT is called to another part of the hospital. One night, when two RRTs were called at the same time, Gina was left to watch 12 intubated COVID-19 patients by herself.
Although there are no physicians in the ICU on nights or weekends, intensivist coverage is available via telemedicine. The ICU rooms are equipped with cameras and "e-alert" buttons. If the nurse needs to speak with the physician or has an urgent situation, pressing this button instantly brings an intensivist to the room's video conferencing screen. The remote clinician can see the patient and has access to all of the monitoring data and the electronic record, enabling real-time communication and order entry.
Running Out of ... Everything
The equipment shortages that were predicted nationally are already happening in Gina's ICU. "We ran out of vents a week ago. Every vent is in use -- even the six new ones we got from the stockpile. Someone has to die before they can bring up another COVID patient.
This is survival mode. "Our new norm is, what do we have to do without today? What are we out of now? What's worse today than yesterday? It's disheartening. People are cracking. Nurses are having a hard time," she said.
"We are preparing for co-venting; how will I take care of four patients at once? That's my fear right now. It takes five people to safely turn a patient prone. I'm terrified that we won't have enough staff, that we are going to run out of everything and we'll have to decide who lives and who dies. Now we are focused on DNRs, but as vents get scarcer, we are going to be talking about comfort care."
Watching Patients Die Alone
The absence of family members at the bedside of a dying patient is a stark difference from business as usual in the ICU. Comforting devastated family members is nearly impossible ? no taking of a hand, touching a shoulder, offering a hug after delivering bad news.
"I call each family before the end of my shift," said Gina. "I dread calling when the patient has been doing poorly. The family is crying on the phone. All you can tell them is that we will keep trying."
Gina became emotional as she described a COVID-19 patient she took care of recently. "He was only 53 years old, and he was made a DNR. His kidneys were failing and he needed dialysis." Her voice broke and she began to sob. "I'm looking at people who shouldn't be dying. They have an 11-year-old son. They can't come in. I'm afraid he's going to get worse and he's not going to make it. I didn't want to provide false reassurance, so I told his wife, 'We'll see how he is in the morning when we do his labs.' We have to use an iPad for FaceTime, just so they can see dad's face with all the tubes, before he dies."
The other night, three COVID-19 patients died on one shift, and Gina knows that many more are going to follow. "The first patients who came in a couple of weeks ago are still on ventilators — we can't get them off. Their lungs are shot, their kidneys have failed. DNRs are common now, to avoid having to do CPR, which is useless. Why break their ribs when it won't make any difference?"
Despite the grim prognosis, Gina tries to remain hopeful. "I don't know if they can hear me, but I talk to my patients anyway. I tell them that their family misses them, that they called to find out how they are doing, that their family loves them and wants them to get better."
It's What I Signed Up For
"When this all started, I thought that as a community hospital, maybe we wouldn't be hit as hard. It wouldn't be as stressful. I was wrong."
Still, she would never walk away.
"I knew going into this career that I could be exposed to something. It's part of what I signed up for many years ago.
So far, only one of her coworkers — a respiratory therapist — has tested positive for the new coronavirus. "It terrifies me, but would I stop doing what I'm doing? No. Who's going to do it? This could be my mom, my dad, my loved one. Someone has to care for them."
Despite her best efforts, Gina still feels that she's not doing enough. "To be able to keep going, I have to forgive myself that I'm not going to be the ICU nurse I was before COVID. It's not possible. I can't physically be in the room like I used to be. I do the best I can with what I have. I keep my patients as clean and comfortable as I can. It's about setting priorities and focusing on what is absolutely mandatory, and trying to forgive yourself for not being able to do everything."
Gina has a night off coming up, but she volunteered for an extra half shift to provide an extra pair of hands, just to help her coworkers. "They are drowning," she said. "I've never seen anything like this. Sometimes I throw up in the car before I go in to work. I just hope I have the strength to make it through this. But if no one is there to take care of them, what's the alternative?"
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