by an anonymous RN
This first appeared in The Havok Journal on April 8, 2020.
I am an Emergency Department Registered Nurse in Boston and this is my humbling perspective on humility and humanity.
This isn’t like most other diseases…
This new strain of coronavirus, however it was formed, has really placed us as healthcare providers in a tough position. After years of military service, serving in a medical capacity, I feel somewhat calm as everyone around me in the Emergency department panics over “not being prepared” and not having proper personal protective equipment. I work 40-plus hours a week, not because I’m required to, but because I want to. I love the chaos the emergency department brings; COVID-19 creates an all-out crisis.
I look around at my fellow nurses and see the concern and deep, blank stares on their faces while I try to make light of things and smile, jokingly stating “this must be your first time being unprepared, huh?” and they return a stern look of seriousness as I grin and let out a slight laugh. I think back to my time in the military and realize this isn’t my first, second, third… time being unprepared for a seriously dire situation. During the invasion of Iraq, troops were seen advancing into the heart of Baghdad in open-top, open-door Humvees, wearing old, mismatched flak jackets and Kevlar helmets. Truth is, we will never fully be prepared for anything, and that is how life goes.
One month ago, I didn’t think much of it, during my time in the military I had been faced with the risk of swine flu, H1N1, MERS-CoV, Ebola, and of course the ever-so-famous Anthrax. If you had told me the country would be on lockdown, personal protective equipment would disappear along with toilet paper, and the rate of the ‘greatest generation’ and baby boomer hospitalizations would fill my department and align the hallways I wouldn’t believe you. I think, like most Americans, I felt comfortable in my U.S. protective bubble and the oceans-width between our first-world lifestyle and the overpopulated, mismanaged, poverty-stricken country of China.
After graduating from nursing school I began working in the Emergency Department which is a rare occurrence, but given my military and trauma experience, I believe I was granted a pass as a new nurse. Six weeks ago, day-to-day department activities were the usual norm, working a twelve-hour weekend shift with my common patient assignments: stabilizing a young man who had overdosed on heroin in the code room, taking report on an adorable, frail ‘Nana’ who had fallen, hit the backside of her head and is on the blood thinner: Coumadin, all while attempting to advocate for my patient with an unknown cause for change in mental status whose currently urinating on the floor at the same time as “Code Stroke” comes overhead, estimated time of arrival 5-minutes.
It was manageable, with an outstanding emergency nursing team and leadership, just a normal day in the ED for our nursing team. We had the Naloxone and ventilation for the young man who had overdosed, we had the laboratory work and Vitamin K reversal agent for the bleeding Nana, we had the spinal tap and subsequent antibiotics for the man whose mental status reflected that of meningitis and we had the CT-scan within the twenty-minute timeframe and Alteplase to administer shortly after for the ischemic stroke patient. It seems chaotic to the average individual, terrifying to the families and friends of these patients but to us, we have the knowledge, the support, the skill, and tools needed to do our job, and we do it well.
To us, it is controlled chaos.
Even in military-grade traumas, motor vehicle accidents, stabbings, gunshot wounds, we are prepared. Sure, some of us have our weaknesses and strengths which makes our team mentality and functionality extremely successful. My personal weakness is the frail Nanas and Papas, they pull on my heartstrings and my military mentality and tough exterior go out the door. For a very influential period in my life, my grandparents raised me, they supported me during my schooling, impacting my nursing career greatly, so I may have some mirroring transference underlying! On the contrary, some of my fellow nurses seem to shy away from the gushing blood and exposed bones whereas I run to it.
A couple of weeks ago, when a man used a table-saw and accidentally took 90% of his first-four fingers off of his hand, along with the wood he was cutting, I was the go-to nurse. I began to remove the plastic shopping bag he had used to contain his fingers. I asked a fellow nurse, “I thought they banned plastic bags in the city?” as if nothing was different from the usual chain of events and afterward walking out to the department cleaning my hands of blood and mentioning to my co-workers “that room smells like pennies”, referencing the iron content in our blood. Four weeks ago, I would have told you we were prepared for the worst that could potentially walk into the department.
A week later, I had gotten a patient, a middle-aged man, otherwise healthy who had recently come home from a business trip in China complaining of shortness of breath and chills. One of the doctors had mentioned “maybe it’s that new virus coming from Asia”, at this point, no one knew the term ‘COVID’, nor was the future pandemic on anyone’s radar. The man ended up having bilateral pulmonary embolisms, blood clots in both lungs marked up to prolonged travel with minimal leg movement. Over the next few weeks, I’d see this man again, and again. My first experience with novel coronavirus-19, and to the best of my knowledge he is currently ventilated and on life-support.
I volunteered to be one of the first nurses in the department to assess a potential COVID-patient. I and one other nurse put on our personal protective equipment, from head-to-toe dawned with an N-95 respirator mask and a surgical mask on top of that, two pairs of gloves that we had grabbed from the neatly organized, fully-stocked cart outside of the negative pressure treatment room. We entered the room, conducted our (then) two swabs, one in the nares and the other in the throat, and did our full assessment, minimizing personal contact with the patient. I can remember seeing the fear in her eyes, the sadness that her recent leisure trip to Italy may be the culprit behind her daughter’s illnesses. The situation became worse by the day, week-by-week, guidelines changing, prolonged COVID-test wait times, a drastic increase in patient visits for COVID-19 testing went up while the supply of gloves and masks decreased.
As we witnessed the media instill fear into the general population, our department became so overwhelmed that a majority of asymptomatic potential COVID-patients would be tested outside in a makeshift-military style testing site, whereas the symptomatic patients, experiencing shortness of breath, hypoxia and elevated fevers would come into the main department for treatment. As the days went by, I saw fewer traumas and saw more elderly, more immunocompromised patients.
It became the norm, walking into the department one morning and having one patient who had passed from acute respiratory distress within hours of onset, whose pale, cold-body was waiting to be transferred to the morgue. My other two patients included a middle-aged woman being placed on a BiPAP breathing machine awaiting transport to the Intensive Care Unit and the other, a younger woman, needing a repeat D-Dimer test because of her shortness of breath and previous lab work depicted pulmonary embolisms: blood clots in her lungs. After-the-fact we found out that both women had tested positive for COVID-19.
Last week, we ran out of the COVID-19 test kits. The few we received were being rationed for those being admitted to the intensive care unit, the rest would be “presumed positive” and treated for COVID-19. Our presumed positives had become overwhelming, our admission floors are full, we have dedicated units for COVID-19. Our Intensive care units are full, our ventilators are all in use. At the start of this week, as the majority of companies are laying off employees due to the statewide quarantine and business shutdowns, we are only seeing some of the most critical patients in the Emergency Room.
The progression of COVID-19 is fast, too fast. A 60-something-year-old woman within the last 48-hours of writing this came into the department at 07:30 am, trouble breathing, within minutes progressed to hypoxia, her oxygen saturation was 81%, her heart was racing, she needed to be intubated. “CODE BLUE TO THE ER, CODE BLUE TO THE ER, CODE BLUE TO THE ER”. Respiratory came with their ventilators, the nursing staff jumped in to help, all of us in our masks, gowns, gloves as this woman’s clinical presentation is that of COVID-19. EKG leads on, lines placed, medications given. Another nurse and I worked on stabilizing this patient for five hours, her heart rate would skyrocket, her blood pressure would drop, Norepinephrine in, blood pressure would jump, and she would fight the respirator.
It was the ultimate chemistry experiment. Vasopressors, sedatives, opioid-analgesics…etc. looking through our medications offered by the ICU doctor: Dobutamine, Fentanyl, Propofol, Levophed, as we are titrating the dosages, the patient’s eyes slightly open, she attempts to pull her tube out, increase propofol and give a bolus: all occurring within minutes. I am usually prepared for codes, but these aren’t your average codes. Her prognosis dropped significantly as it was an unsteady, narrowing pattern of events. None of us have ever seen anything like this before, someone as unstable as her with no medications seeming to correct the problem.
Working in a seemingly ICU-capacity as one of us needed to be bedside, but without ICU capabilities as we are in the emergency department – there are no ICU beds available. Her outlook didn’t look good, she was dusky, cool to the touch, her blood work was evident she was borderline septic. At 1:10 pm she went into bradycardia and subsequent PEA (pulseless electrical activity), the patient was a “full code” meaning we would do everything we could to bring her back. “One of Epi, begin compressions, place pads‘ ‘ and here I am trying to push life back into this woman. Resuscitation unsuccessful. She died from COVID-19-related complications resulting in acute respiratory distress syndrome. She wasn’t the first, and she won’t be the last.
The emotionally-taxing effect this novel infection has on myself and my fellow nurses isn’t something I expected. Every day, there is a new emotional dilemma and I find myself taking it home with me when I can go home. Being the mask-muffled voice that relays to the 55-year-old father of two that he isn’t pre-fusing oxygen and is stuck at 85% and if he isn’t assisted, intubated he might severely progress into respiratory distress. As he struggles to breathe and state his case, he grabs my hand, squeezes it, and begs “please don’t let me die”. Intubation complete.
Going to the next room only to find a sweet little lady, who is having a slight change in mental status, showing signs of rapid deterioration and sepsis, as she pleads with me not to leave her alone and that she is scared… having to call her only daughter and explain the situation, while the daughter’s voice cuts out and only a whimper can be heard as I tell her that her mother may not live past the next twenty-four hours. The request that she speak with her mother one last time as I go into the quarantined room fully-donned in protective equipment, I dial the number and place the phone to her mother’s ear, in attempt to protect her daughter she tells her she will be fine and they’ll be back to watch their usual television shows in no time, I can hear the daughter cry through the phone and say “I love you very much, mom”.
I think this is how the COVID-19 experience differs from my time in service.
I’ve never been on the receiving end. I’ve never been the witness or bystander to something so impactful. In war, you don’t think so much about how the impact of losing your own life may be. How mentally and emotionally heavy the loss may hold on to the ones you love and care about. Neither do my patients. I watch them push their pain through their eyes, crying and relaying their helplessness as their loved ones slowly decline and die right before my eyes.
As I try to push the medications and press the life back into their lungs and chest, I fail. I tell that family member who has placed all their trust and hope onto me, that I have tried everything I can to save their loved one, to save the woman who gave birth to them or the brother who was their best friend. My time in service has prepared me for everything I’ve faced thus far, but it hasn’t prepared me for this. This pandemic has been a humbling experience; absolute uncontrolled, unexpected chaos.
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