A Little Rant And Some Failures

[JBMmom]

There are some days that are easier than others with this pandemic. I feel like I'm becoming that friend/family member that just can't "get over it". I know others here are having similar pandemic experiences, so I'm just venting.

We've been tripled in the ICU for weeks, it's exhausting and concerning for patient care and outcomes. I was transferred to the PACU last night to cover three intubated patients being held there and it was the first shift in weeks that I actually got out on time. In many ways it was nice because I was not in charge and no one needed any help. It was just me and my three patients, and another float nurse came by every couple hours to help with turns and baths. But I also caught myself in a judgmental mood for a while. We had an overdose patient who was COVID positive last month. After over 40 days on the vent, he was trached and last night he was in PACU. Looks like he's going to make it. This patient will be arrested on domestic violence charges if he ever leaves the hospital (or long term care rehab), and he has made so many choices over the years that have hurt others- including some of the staff that admitted him last month. COVID has robbed us of some truly wonderful people. Right now there's a father of six who probably won't make it, a couple weeks ago we lost a former police officer with two young kids, the list goes on and on. Of all the people to get the miracle everyone is praying for, it's this guy. I did my best to provide the appropriate care, but I admit I found myself avoiding him when he was calling me over for the 40th time to explain why he's in the hospital and why he can't get up and leave. 

The other night I had a young man in his 30s maxed on high flow with a nonrebreather over it. He was hypoxic and intermittently confused. He would remove his oxygen and then drop his sats, even into the 60s. I went in and out all night, at least 3-5 times an hour. I didn't make other staff do it, except once or twice when I was in the room with one of my two other patients. Everyone else just wanted to intubate him to stop the alarms from going off. Not getting a blood gas, not trying medication, they just wanted to intubate. I realize that hypoxia and confusion are potentially appropriate indicators for intubation, but when he had the high flow on, he would sat at 98% when positioned on his stomach or over on his side. I told them that I refused to intubate him just to have another patient die on me. I wanted to give him a chance on the high flow. Well, the oncoming nurse decided before we were even done with report that "I'm not listening to that all day, he's buying a tube". I was so annoyed. We don't intubate for staff convenience! (or at least we shouldn't) I saw last night he's on the vent and proned now.

Are other places keeping people on high flow or BiPAP for extended periods? Are we waiting so long that people are exhausted and that's why they die? We've had people on those for as long as two weeks before intubating to try to get them through with self-proning and positioning.  Are any places still intubating somewhat early on, and are those outcomes better? I'm SICK of everyone dying. 

Last week I had a prone patient and when we went in to turn her head, her oxygen levels dropped and weren't recovering. She was already on 100% and it didn't help to try and bag her. I called the daughter and held the phone up so she could talk to mom and say goodbye. Until then we had been wondering why we had this very ill woman with many comorbidities on the vent and proned. We knew it was futile, why was the family doing this to her?! Well, it turns out the daughter was being discharged from a short term rehab facility three days later and just wanted to see her mom. So I felt like an *** for being judgmental. I really try not to be but lately it seems to be creeping in more, personal failures. Maybe just a sign I need a break.

Anyway, thanks for reading and letting me get that off my chest into the cyberworld. I know we've all had it rough lately, hoping that you all stay healthy and well. Take care of yourselves.  

[0.9%NormalSarah, BSN, RN]

@JBMmom I totally feel you. None of these are personal failures. I have felt the same way so many times over the last 2 years, I’m tired and feel judgmental at times as well. In the emergent intubation I was so focused on getting everything done that I forgot to make sure my patient spoke to his wife one last time, he had done so an hour before but I felt incredibly guilty that I didn’t offer it once more. And of course he never spoke to her again because we lost him. Even with my other patients I feel I’m not doing as much for them because I’m so inundated with work to do that I’m in and out quickly. I feel like a failure, too, but I try to remember it’s not my fault that it’s just hard and there’s too much to do, it’s impossible. It’s helpful to know others feel this same way. 

I went to dinner with my husband last night and we were talking to a nice couple sitting next to us while we waited for our table, and the topic got on what we all do, and when I said I’m a nurse and they asked where, I said ICU and they just both asked me how I’m doing. I honestly almost started crying because I can’t really sugar coat what’s happening, and I’m not one to do that anyway. Anywho, you’re not failing, and you’re wonderful for sharing how you feel because it helps others like me who feel the same way. We are in this together, even when so many of us have to step away from the bedside and get into other important areas of nursing. I hope I can keep going for now for my career goals, but boy am I hating it sometimes.

[JBMmom, MSN, NP]

7 hours ago, 0.9%NormalSarah said:

I hope I can keep going for now for my career goals, but boy am I hating it sometimes.

Thank you for sharing. You're right that sometimes we just get focused on what NEEDS to be done and we can't get to some of the things that we wish we could do. Yes, we are all in this together, I hope that things go well for you with your future career goals!

[Music in My Heart]

Just to throw this out there...

I'm not sure that this guy's case was necessarily just about "staff convenience." If a patient requires that much intervention in order to tolerate/accept the intervention then staffing and acuity levels could easily dictate that he be intubated to assure stable PaO2. If there were even a sitter but we all know how rare those are.

It's not at all clear to me how a nurse with 2 other patients could manage the time to go through the donning/doffing q15 minutes to get the guy's HFNC back on while still providing adequate care for their other patients. And each time his HFNC comes off, he desats yet again.

Honestly, it sounds like barring adequate staff to single him, or maybe double with a soft player, intubation might have been the best of the crappy choices available.

Hard to say without being in your shoes and on your floor but it doesn't sound grossly inappropriate to my ears.

[JBMmom, MSN, NP]

3 hours ago, Music in My Heart said:

Hard to say without being in your shoes and on your floor but it doesn't sound grossly inappropriate to my ears.

You're right, all I did was stave off the inevitable. And really I probably made it more about me than him which wasn't right either. I just didn't want to take this kind, scared, young man and put him on the ventilator in the middle of the night. At least by getting him through to day shift he was able to talk with his family before it happened, because who knows if he'll speak with them ever again. 

Both of my other patients were intubated and proned. So providing appropriate care for the three of them together wasn't ideal under any circumstances, but I was able to get to his room most of the times myself. Obviously sometimes other staff members responded when I was busy. 

I appreciate your response and admit that I was largely venting. It seems like most people that make their way down to the ICU on high flow end up intubated anyway. Just how things are going these days.

[MunoRN, RN]

The "early intubation" idea at the beginning didn't seem to last long, mainly due to data out of NYC that showed this was likely doing more harm than good.

But we still intubate, at some point there aren't other options, although typically at that point any plan of attack is going to be futile, once a patient needs a vent they are probably better off with palliative care.  

It used to be there would be discussions about the optimum timing to intubate a particular patient, although now that often leads to a discussion that the timing in the end changes nothing.

I haven't seen many people who end up on the maxed out HFNC/NRB combo not end up needing to get to tubed, or eventually recover to any meaningful degree, what usually tips the scales to decide to intubate is either elevated CO2 levels or instability with the HFNC/NRB combo including when they take it off.  60's isn't all that bad though with them off, 30's or 40's isn't uncommon, and prior to Covid I had never thought it was possible to have a single-digit pleth (with an excellent waveform).

[Music in My Heart]

1 hour ago, JBMmom said:

I appreciate your response and admit that I was largely venting.

Said venting among people who really get it... and who else besides us actually does... is vital... about the only thing that let's me walk back in the door.

 

Quote

It seems like most people that make their way down to the ICU on high flow end up intubated anyway.

Depending on the facility where I clock in, I'm either an ED nurse or a Rapid Response nurse... and just over the last 3 shifts have taken three HFNC folks to the units only for them to be tubed a few hours later.

I'm getting a little tired of this "omicron is less virulent" message that's propagating. Sure, it is... but its contagiousness is so much higher that the absolute numbers are staggering... we've shattered our own record from 18 months ago...

Good for you for keeping your heart in the game! ❤️

[Music in My Heart]

20 minutes ago, MunoRN said:

60's isn't all that bad though with them off, 30's or 40's isn't uncommon, and prior to Covid I had never thought it was possible to have a single-digit pleth...

I wonder what kind of morbidity these folks end up living with (those who do, that is) directly attributable to the profound and prolonged hypoxemia.

Meanwhile, I'm lining up to get my 5th dose of mRNA vax in a couple weeks.

[MunoRN, RN]

54 minutes ago, Music in My Heart said:

I wonder what kind of morbidity these folks end up living with (those who do, that is) directly attributable to the profound and prolonged hypoxemia.

Meanwhile, I'm lining up to get my 5th dose of mRNA vax in a couple weeks.

Separate from the frequent strokes, cardiomyopathy, renal and hepatic failure these patients often end up with to varying degrees, the issue they all have is severe pulmonary fibrosis.  

This is due tissue remodeling and scarring that results from a severe, prolonged inflammatory process, essentially chronic ARDS 

The chronic lung dysfunction is pretty bad but we've been finding that even worse than that is the lungs are left with no defense system.  We've had multiple patients who we considered to be our few "wins" come back with untreatable lung necrosis, usually fungal infections that cause a lung or lungs to literally disintegrate.  The last one was a mom of two toddlers who miraculously got discharged after severe Covid, only to come back a few weeks later and decline rapidly and expire.

[JBMmom, MSN, NP]

17 hours ago, Music in My Heart said:

I'm getting a little tired of this "omicron is less virulent" message that's propagating.

I know. We're wondering whether some of these sicker patients are still delta patients because most were sick back at the end of December when our region was not totally omicron. But at this point, I don't care what variant, I don't care about the vaccination status, I'm just sick of the deaths.

16 hours ago, MunoRN said:

We've had multiple patients who we considered to be our few "wins" come back with untreatable lung necrosis, usually fungal infections that cause a lung or lungs to literally disintegrate.  The last one was a mom of two toddlers who miraculously got discharged after severe Covid, only to come back a few weeks later and decline rapidly and expire.

We've had only rare "wins" with people either being discharged after extubation or trached and pegged and then discharged. The pulmonologists that are our intensivist group said they are seeing so many former covid patients in their hospitals with severe ongoing lung issues. How heartbreaking for all of you to have the successful patient die. These are the things that just get to be defeating. 

[2BS Nurse, BSN]

Although it probably wouldn't make a difference, I wish every unvaccinated person was forced to read your story. ☹️ Please don't beat yourselves up ICU nurses. You're doing the jobs the rest of us are terrified to do. If you only had crystal balls. ?

[pinkdoves, BSN]

awh my heart goes out to you! this sounds like a very stressful situation!

[Myruby]

I am not an ICU NP, but I find myself much, much, shorter with patients.  I glare at people in the supermarket who wear their masks below their noses, just want to be alone a lot after shifts.  I have 2 jobs for a total of 30 hours per week and am considering quitting one of them.  Last week at our monoclonal infusion center, we saw mainly unvaccinated patients. I've sent some right on to the ER as they were too sick to qualify (too late) Seeing a patient saunter into our very small unit with his mask under his nose almost made me lose it. All our pts are covid +, we all wear full PPE.  I told him to pull it up or leave, that none of us have covid and are trying not to get it..  Not the most therapeutic interaction of my career but to be honest, it was the best I could do in the calmest tone of voice that I could muster at that particular moment.