In this chapter, I am going to discuss my nursing experiences with the COVID-19 pandemic. While there has been an endless barrage of information on this subject, I don’t feel that there has been that much from the perspective of someone who has actually been in the frontlines this whole time, that of an ICU nurse. Most books written are by doctors who only spend a few minutes with their patients and make it sound like they are the ones who actually are taking care of them. When in actuality, it is the much maligned nurses who do the vast majority of the thankless work surrounding patient care and only get a fraction of the compensation. While it is true that CNA’s are involved in patient care as well, they are not part of the care with ICU patients which is where most of the serious action has taken place with the COVID-19 patients in this pandemic. If an infected patient is fortunate enough not to require a transfer to the ICU, they usually have full recoveries. It is those patients unfortunate enough to reach the ICU, whom don’t do so well. For even if they survive, many suffer from long term symptoms of the infection. Which is something that is just being discovered by the medical profession but has been observed by nurses for quite some time. It may sound like I am a little bitter, well, I am. I have seen more people die in the last 20 odd months than I have in the rest of my career. Thanks to politics and infighting with the corporate elite those numbers are not radically changing. I am sure that you have heard about all these percentages on how many people survive COVID, over 98% do, well, that is no consolation for the ICU nurse when our survival rate is less than 10% for those patients. While I don’t have the actual numbers, I fear that it is way less than that. During the peak time of the pandemic, I have seen as many as five people die in one night. To give you a better perspective of this, my unit had less than 30 patients in it at the time.
I am sure that you hear about all the drugs and treatment modalities that are out there, well, it doesn’t do the patient any good if they are not being utilized or started soon enough. What I am seeing is the same old pattern of treatments for these patients while their symptoms gradually progress until they just up and die. I am sure it is also very frustrating for the doctors as well. I know that their hands are being tied. This is where I need to be careful because I have a license to protect and my livelihood as well. Since I am not a doctor, I am not privy to information or the discussions that take place with them. I am not sure if they have certain guidelines they have to follow or not. If they do, they need to change them, The current crop of treatment plans involves drying out the patient to such an extent that the patient’s blood pressure suffers and eventually so does their kidneys. Many eventually have to be put on continuous dialysis treatments or CRRT. This loyalty to this treatment modality causes the patient’s condition to take an up and down path, I feel unnecessarily so. But who am I? I just spend 12 hours a day taking care of these patients. I am just a lowly nurse who also happens to use a stethoscope. Well, enough of the self pity, it is just frustration because we did not go into nursing to see people die.
I am sure that you have heard a lot of nonsense going around about the vaccine. Well, I am a pro vaccine person. That is, it should only be given under certain circumstances. I believe that it should never be mandated. If we, as citizens were kept in the loop and were given information that we could truly trust, I think that things would be a lot better. I am a highly trained nurse with over 11 years of critical care experience alone and I feel like I can’t trust the information out there. I also am a blogger of sorts who has devoted an inordinate amount time studying and writing about the pandemic and I am having a really hard time finding accurate information. It has come down to power and money and nothing else. I have researched Dr. Fauci and Dr. Birx extensively. I feel that they are at the bottom of this misinformation campaign. If you go back and look at their history you will find out that they were at the core of all the HIV/AIDS panic back in the 1980s. If you want more information, simply go to my blog, common-sense-in-america.com and look up two categories: COVID-19 and Healthcare and Dr. Fauci. You will find countless articles covering this subject. Dr. Fauci is a power hungry little troll who is responsible for hundreds of thousands of people’s deaths worldwide. I firmly believe it is his arrogance and his godlike complex that are at the core of our current pandemic. But regardless of all the propaganda and misinformation out there, the vast majority of the patients that progress to the ICU are the ones who are not vaccinated. So despite what all the media is saying on either side, this is the unvarnished truth. You can do with it what you will. One more thing, with the Delta variant the age of our ICU COVID patients is getting younger and younger. People in their 50s and even 40s are getting deathly sick. No longer do they even need a slew of comorbidities to earn them an ICU bed. Even those that do survive their ICU stay, many have long term ill effects.
I have seen a rate of nurse burnout that I have never experienced before. I actually think that we are experiencing PTSD (Post Traumatic Distress Disorder). I have recently joined this number. I just recently tendered my resignation in an effort to keep my sanity and to also prevent any safety issue with my patients. My patient’s safety is of the utmost importance to me and I could not live with myself if I did something to jeopardize their safety or health. So I am taking the next couple of months off so that I can get some much needed rest and re-think my career options. Nursing has become a job for young people. The 12-hour shifts are becoming more and more difficult to manage. I used to work four and five days a week but ever since the pandemic entered the picture, I have been barely tolerating my three 12-hour shifts a week. I feel that I have aged 10 years in the last 20 months.
I have decided to discuss in this chapter what a generic and typical patient goes through right up to their death. First of all, once the patient is found to be positive, their whole life changes. They are now isolated from their family. The family can’t even see them through windows in the door of their room. I think that this is carrying things a little too far. However, we do allow phone calls and we can set up zoom calls with them if they are unable to do so themselves. When I went into nursing school, I was told during a class on end of life, that the hearing is the last sense to go even after the sense of smell. So, we were told that it is very important that we watch what we say around our patients because they may actually be able to hear us talking. So, even if they are intubated and sedated, we allow the zoom calls in the hopes that the voices of their loved ones give them some solace. The patient is also isolated in the kind of care they are now receiving. They now only see people in protective gear with masks, respirators and face shields. Their care by necessity has become highly impersonal and lacks the humanity of the human touch. Touch that is not through protective gear but with skin on skin contact. People are social creatures and need this contact, why else do we use solitary confinement in our prisons as a form of punishment?
I have listed below some of the symptoms that a positive patient can experience.
Symptoms may appear 2-14 days after exposure to the virus. People with these symptoms may have COVID-19:
-Fever or chills
-Shortness of breath or difficulty breathing
-Muscle or body aches
-New loss of taste or smell
-Congestion or runny nose
-Nausea or vomiting
Look for emergency warning signs for COVID-19. If someone is showing any of these signs, seek emergency medical care immediately:
-Persistent pain or pressure in the chest
-Inability to wake or stay awake
-Pale, gray, or blue-colored skin, lips, or nail beds, depending on skin tone
The main symptom that causes the nurse concern in our patients is their breathing difficulties. This is obviously the most critical symptom that we have to control. Patients will experience progressively greater and greater shortness of breath. They will get to a point where the act of eating is too much for them. During this time they are already receiving the various treatments that are allowed in their respective states. We start them on a simple nasal cannula and we gradually increase their flow rate till it reaches 6 liters. Then we have to switch to usually a non-rebreather mask, then by this time they have been usually transferred to the IMC. Soon the mask is no longer sufficient and they require a Hi-Flo nasal cannula which provides more aggressive support with a much greater flow of oxygen. Sometimes they require both a mask and the Hi-Flo cannula. If the patient can tolerate it we place them on continuous CPAP (Continuous Positive Airway Pressure). By this time, the patient requires assistance to do the simplest tasks even taking sips of water. Eating solid foods has long since become but a memory. If they are lucky, they may be able to tolerate a protein drink but the increased work of sucking the viscous fluid through the straw may be too much work for them. It is typically at this stage that they get upgraded to the ICU.
Once they are at the ICU which is the vast majority of them, it is their final destination. After a few days, some may take a little longer but they eventually all succumb to the call of the ventilator and the endless flow of aggressive IV therapy that this entails. Each new drip (gtt) we add brings with it additional issues that we have to monitor for. The patient on the artificial breathing machine needs sedation to keep them calm enough so that they can tolerate it. They are no longer aware of their surroundings which is usually for the best. Because now they have tubes in most of their orifices, one to feed them, one to collect their urine and another one to collect the all too frequent diarrhea that arises due to the tube feeding that they will soon start receiving.
If they survive the next two weeks on the ventilator, the family will find themselves at a crossroads either they will have to decide to withdraw life care or allow a surgeon to put a tracheostomy and a peg tube in their loved ones. During this time, their organs are becoming more and more damaged by the ravages of the virus. Micro blood clots continue to form despite anti-coagulation therapy and block off the microvasculature of the body which is in the brain, lungs, kidneys, and the liver. If the patient is lucky enough to get off the ventilator, the damage done to these organs is irreversible and leads to all the symptoms that an increasing number of patients are experiencing.
However, if they are not so lucky eventually the lungs start to collapse and require chest tubes to keep them inflated. During this time we are having to get more and more aggressive with the ventilator settings. Eventually the lungs become so damaged that nothing works any longer and they go into respiratory arrest and after 30 or so minutes of CPR their life ends. Remember that this is happening to younger and younger people. What an ignoble way to die!
Have I painted a vivid enough of a picture for you? So now you know what your loved one will experience and what your nursing relatives have been suffering through the last 20 odd months.
After thinking about this matter for the better part of the day, I decided to include one actual case after all because this was in fact a truly unique one for me. As a matter of fact, this may have been the case that finally pushed me a little too far. Maybe I had just lost too many patients and I could no longer just go on like it was just another day in the office. This was just one of those tragedies that may possibly have been avoided if our country was still the country of fair play and hope where anything is possible as long as you persevere. In most of the cases I have taken care of, I see them for a three to four day run and that is all. I don’t actually care for them throughout their whole COVID-19 progression. With this patient it was different. Thankfully, I was spared watching him leave this world because it happened on my day off. But the impact and sense of loss was still there. This patient’s story will be the last one included in Chapter 15. The death of this patient was one of the determining factors in my decision to leave my job as an ICU nurse in an acute hospital.
In the following portion of this chapter, I have included an account of the COVID-19 progression as per the perspective of a respiratory therapist. I just wanted to show you that I am not exaggerating what these patients are going through. This account was taken from the latimes.com website and was written by Karen Gallardo, a respiratory therapists at Community Memorial Hospital in Ventura.
I’m a respiratory therapist. With the fourth wave of the pandemic in full swing, fueled by the highly contagious Delta variant, the trajectory of the patients I see, from admission to critical care, is all too familiar. When they’re vaccinated, their COVID-19 infections most likely end after Stage 1. If only that were the case for everyone.
Get vaccinated. If you choose not to, here’s what to expect if you are hospitalized for a serious case of COVID-19.
Stage 1. You’ve had debilitating symptoms for a few days, but now it is so hard to breathe that you come to the emergency room. Your oxygen saturation level tells us you need help, a supplemental flow of 1 to 4 liters of oxygen per minute. We admit you and start you on antivirals, steroids, anticoagulants or monoclonal antibodies. You’ll spend several days in the hospital feeling run-down, but if we can wean you off the oxygen, you’ll get discharged. You survive.
Stage 2. It becomes harder and harder for you to breathe. “Like drowning,” many patients describe the feeling. The bronchodilator treatments we give you provide little relief. Your oxygen requirements increase significantly, from 4 liters to 15 liters to 40 liters per minute. Little things, like relieving yourself or sitting up in bed, become too difficult for you to do on your own. Your oxygen saturation rapidly declines when you move about. We transfer you to the intensive care unit.
Stage 3. You’re exhausted from hyperventilating to satisfy your body’s demand for air. We put you on noninvasive, “positive pressure” ventilation — a big, bulky face mask that must be Velcro’d tightly around your face so the machine can efficiently push pressure into your lungs to pop them open so you get enough of the oxygen it delivers.
Stage 4. Your breathing becomes even more labored. We can tell you’re severely fatigued. An arterial blood draw confirms that the oxygen content in your blood is critically low. We prepare to intubate you. If you’re able to and if there’s time, we will suggest that you call your loved ones. This might be the last time they’ll hear your voice.
We connect you to a ventilator. You are sedated and paralyzed, fed through a feeding tube, hooked to a Foley catheter and a rectal tube. We turn your limp body regularly, so you don’t develop pressure ulcers — bed sores. We bathe you and keep you clean. We flip you onto your stomach to allow for better oxygenation. We will try experimental therapeutics.
Stage 5. Some patients survive Stage 4. Unfortunately, your oxygen levels and overall condition have not improved after several days on the ventilator. Your COVID-infested lungs need assistance and time to heal, something that an ECMO machine, which bypasses your lungs and oxygenates your blood, can provide. But alas, our community hospital doesn’t have that capability.
If you’re stable enough, you will get transferred to another hospital for that therapy. Otherwise, we’ll continue treating you as best we can. We’re understaffed and overwhelmed, but we’ll always give you the best care we can.
Stage 6. The pressure required to open your lungs is so high that air can leak into your chest cavity, so we insert tubes to clear it out. Your kidneys fail to filter the byproducts from the drugs we continuously give you. Despite diuretics, your entire body swells from fluid retention, and you require dialysis to help with your renal function.
The long hospital stay and your depressed immune system make you susceptible to infections. A chest X-ray shows fluid accumulating in your lung sacs. A blood clot may show up, too. We can’t prevent these complications at this point; we treat them as they present.
If your blood pressure drops critically, we will administer vasopressors to bring it up, but your heart may stop anyway. After several rounds of CPR, we’ll get your pulse and circulation back. But soon, your family will need to make a difficult decision.
Stage 7: After several meetings with the palliative care team, your family decides to withdraw care. We extubate you, turning off the breathing machinery. We set up a final FaceTime call with your loved ones. As we work in your room, we hear crying and loving goodbyes. We cry, too, and we hold your hand until your last natural breath.
I’ve been at this for 17 months now. It doesn’t get easier. My pandemic stories rarely end well.
Just a side note unlike many nurses I, with the exception of one instance did not pick up any overtime during the peak of the pandemic. I did so for the following reasons.
-Over the last fifteen years I have made over six figures a year. The more money I made, the more money I spent. While I got to do a lot of traveling and bought a lot of nice toys, financially, I was no better off. I was still in debt after all that time. When I talk to new nurses, I give them all the same advice, live within your means. Only pick up that fourth day to attain short term goals. Do not do it to live your daily life because if you do so, you will most assuredly get burned out. The vast majority of them are starting with nursing being their first career right out of high school and college. This means that if they stay in nursing their whole career, they will be in that field for possibly 50 years. That is a long time to be doing something, especially if you are locked into working overtime the vast majority of the time.
-A second reason for not picking up overtime was my health. I am not sure if the reader is medically inclined or is aware that the COVID-19 virus is unique in the respect that it seems to key in on several types of victims. It picks on people over 50. It picks on people that are obese. It picks on people that suffer from hypertension. It picks on people who are diabetics. It picks on people who suffer respiratory ailments. And finally, it picks on people with high blood levels of cholesterol and triglycerides. Of these factors that I have listed, I have four of them. Initially, people that met some or many of these criteria and became seriously infected mostly died. They seem to die no matter what the doctors did to treat them. Initially, there were no effective treatment modalities mainly because some of the likely treatments were blocked from being used. But regardless of the reasons for these failures, dead people cannot spend money and I valued my life more than a paycheck.
-The third reason I did not want to pick up extra hours was due to the difficulty of the work. I was just too physically and mentally exhausted after working my three days a week. For at least the first eight months of the pandemic, I took care of three positive COVID patients, most of who were on multiple intravenous medications and were on respiratory support. We were so busy that most of the shifts we worked we did not get breaks at all…there just was no time. I want you to remember that nurses and many other medical staff members work twelve-hour shifts. If you are used to working a five 8-hour a day week, think of adding four more hours to that shift and not getting time to catch your breath. We ate as we charted on our patients with even that time being interrupted by patient care issues.
-The fourth reason was that the more days you worked the more people you saw die. In one 24-hour period the hospital I worked in had eight patients die of COVID. That hospital had only 150 beds. That, by today’s standards is considered to be a fairly small hospital. In one night, five patients died on one of my shifts. Each of those patients had to be coded. A code typically takes almost a third of the staff off the floor to revive that patient. It also takes typically from 30 to 45 minutes. So, now the over-burdened nurses are having to watch even more patients as their co-workers futilely try to save these patient’s lives. Even if they are revived one or even two times, they will just code again until they can no longer be revived. This was our world for close to 18 months.