I’ve always known the intensive care unit (ICU) was where I belonged. I like the intensity and I’ve always taken pride in making what must be the worst and scariest days for patients and their families at least a little bit more tolerable. But I feel like I’m unable to do that now, even though I’ve been amazed and impressed by the resilience, creativity, and determination of my colleagues as we face this virus.
On a typical day in a COVID ICU you come in and pick up your personal protective equipment (PPE). That might be one N95 for the day, one face shield, one surgical mask, one cap. Some places were rationing gowns, but we have gowns and gloves outside every room. It’s one-time use in the room and then you take it off.
Next I look to see my assignment, and at the peak of this pandemic that was usually three patients. Normally ICU ratios are one nurse to one or two patients, depending on how sick they are. That may not sound like a lot but when a patient is very ill, every minute of a 12-hour shift is taken up with something. Trying to do that for three patients is daunting.
Normally in ICU the first thing I do after getting report is assess my patients from head to toe. I check their skin, do a neuro assessment, listen to their heart, look at their rhythm, do an EKG, check pulses, look at my lines, check my monitor, go through everything in the room, make sure everything is safe and there’s nothing wrong, and get a baseline for the shift.
Caring for COVID patients has required us to change how we approach things. We’re trying to bundle care to limit PPE use and exposure, so before going in a room I organize my day, and once the team has rounded and I get a plan from the doctors, I put on my PPE: a gown, two or three pairs of gloves, a scrub cap, a face shield, and an n95 mask. Then I go in. I do my assessments, check equipment, give morning meds, do any dressing changes, check a point of care lab if necessary, and make sure they’re clean. Most of my patients are sedated and require a breathing tube and a ventilator. If their oxygen levels are still low sometimes it’s medically necessary to paralyze them to let the ventilator work.
Sometimes we’re also proning patients [rotating them to lie on their stomachs]. When you lie on your back, you’re lying on parts of your lungs. Lying on your stomach can open up those parts and help you breathe. It can take six to eight people to physically flip patients onto their stomach with a breathing tube and all the ICU equipment.
When something is going wrong in one of my rooms, my first response is to run into the room. In the past, if a patient had MRSA or something that required PPE, my thought wasn’t always to protect myself first. If I could get a gown on and not tie it in the back, I’d probably just throw it on and run in. And that’s just not an option here. If my patient desats [oxygen levels drop], I still have to put on a gown and tie it, put on gloves, a face shield, and a mask to run into that room. It might take 90 seconds. But when you’re used to running into that room the minute you hear or see anything, 90 seconds feels like a lifetime.
Because there is no family allowed, it falls on the nurses, physician assistants, nurse practitioners and doctors to communicate with families. We’re using video platforms to let families see and talk to patients. You have families calling four, five, six times a day sometimes. I put myself in their shoes and I know I would be losing my mind. I would want to know everything that was happening. It’s a very different experience to hear about it than to see your loved one lying in a bed with a breathing tube in, unable to talk, face swollen and bruised, with tubes. I feel for these families, but there are times when I just don’t have 30 minutes to FaceTime with one patient’s family while I have two others who are crashing. I think that’s honestly been one of the hardest things. There has to be some way we can make it easier for patients and families to communicate with the team without stretching resources so thin.
Watching the news and talking to families, I’ve encountered the sentiment that health care providers are giving up or that we’re not doing everything we can for patients. When you’re not there and you don’t see it, it’s hard to understand the difference between “we’re doing everything we can and it’s not working,” and “we’re giving up.” We don’t ever give up. But there sometimes comes a point when everything we’re doing is getting us nowhere. I think it’s very important that everyone takes a few seconds to think about what quality of life means to them. What quality of life would you be OK with?
For me, the most horrifying part is that the patients who land in the ICU and stay in the ICU are not walking out. A few get better enough to go to a long-term acute care facility or leave the ICU trached [with a breathing tube]. That’s not to say there aren’t mild cases who are doing fine, but the outcomes for these very sick patients are grim. I’ve taken care of patients whose kidneys have failed and come back, but their lungs—even if everything else is fine, the damage this virus is doing to people’s lungs goes beyond an acute illness. Weeks later we still can’t wean a patient off a ventilator. Their lungs are just so damaged.
I don’t want to be dark, and I don’t think losing hope is the right attitude, because we are continuing to fight. But we should also be learning from this pandemic. Every day that I walk onto the COVID ICU I go in with the understanding that my peers and I are going to do everything in our power to help, but sometimes it’s just not enough. Even as the rate of infection in the U.S. slows down, we’re not going back to “normal” at the hospitals but rather finding a new normal. We have to respect this. Early on when things were starting to get bad, before we hit the peak, people just did not seem to care. The parks have been packed. And I know it’s nice out, but there will be other nice days. I feel like it’s gotten better to a point. But we have to take this very, very seriously.