At the Bedside with Covid-19 -Part 2: John

SafetyNurse1968, ADN, BSN, MSN, PhD

I used facebook to reach out to nurses working in hospitals in many places in the U.S. I’ve rounded all numbers to protect the identity of the nurses who agreed to be interviewed. I offered to pay all the nurses I interviewed for their time, but they all refused, so I’m making a donation to the American Nurses Foundation Coronavirus Response Fund in their honor. The fund focuses on:

Providing direct financial assistance to nurses (RNS SEE ELIGIBILITY HERE)
Supporting the mental health of nurses – today and in the future
Ensuring nurses everywhere have access to the latest science-based information to protect themselves, prevent infection, and care for those in need
Driving the national advocacy focused on nurses and patients

John works in an ICU in a large, urban hospital with 50 confirmed cases and only 4 deaths in a county of more than 300,000 people. In John’s state, there are 12,000 confirmed Covid-19 cases with 450 deaths. Their stay at home order occurred on March 30 and has been extended to June 10, 2020.

PPE situation

I asked John if he feels safe at work. His response was disturbing. “No, because they aren’t following protocols. I’ve worked in the ICU for almost 20 years. I love my job, and I’m passionate about educating staff on best practice, but I just got written up for trying to get my fellow coworkers to follow isolation protocols.”

“To take a Covid-19 patient off of isolation, you have to have 2 negative tests greater than 24 hours a part – and even then, if the patient is still febrile and symptomatic respiratory wise –they are to remain on isolation as if they have Covid unless the physician discontinues the isolation. But nurses are opening the door and taking away the isolation cart – they are deciding the patient is fine. My question is, who am I supposed to go to when I see a break in policy with covid and the supervisor has no idea what’s going on and it’s putting me and my patients at risk?

Another issue is how we deal with aerosolizing procedures. Any time you break into the vent line --Respiratory Therapists have to do that to change the filters in the vent --every time you open that circuit, the CDC says for 3 hours afterwards, anyone going into the room needs and N95 mask, but my hospital is doing 2 hours. I mean, technically, covid patients should be in negative isolation since it’s droplet, but limited rooms make that difficult.

For patients who are not vented, you used to need an N95 for any Bipap, cpap or vapotherm that was over 6 liters, but they just changed it to >20 liters. And it’s all about PPE.”

John says the hospital is assuring them that there is plenty of PPE. “They won’t give us numbers and they are asking us to recycle surgical masks, eye wear, N95, into a bag – But we don’t know the method. When will it happen? No information is being given.”

“I was one of those people wearing a mask prior to it being mandatory. People looked at me like I was nuts. Now it’s mandatory.”

To protect employees, John says they’ve closed down almost all entrances to the hospital, and no visitors are allowed. “The staff come through one entrance and there are screeners who take our temp with an infrared sensor, hand you a mask, and you sanitize your hands.

John describes three levels of masks. “The one you get at the door is the cheapest – for housekeepers – it’s a level 1 – much thinner. Level 2 is a true surgical mask.

Here’s the problem, people are walking from the parking area, getting on an elevator unmasked, not maintaining a 6 foot distance. These people are filling the elevators to get the mask, without wearing a mask! It’s insane.

The N95 are under lock up with a guard. The only way to get one is if you have a covid suspicious patient, and they count everything. There are five locations in the hospital where N95s can be obtained, all of them guarded by nurses or security guards.

If you have a patient on isolation, they bring you a PPE cart. If you run low on the cart, they bring you what you need.”

Reuse of N95s

“You have to reuse the N95s – they keep changing it. Right now I think it’s 1 per shift. There’s an egg crate container for your mask and it goes in a paper bag, but my concern is that the next time you have to reach in the bag you are contaminated. The bag must be thrown away after holding the mask. I’m using a Tupperware method to let mask dry out without contaminating myself.”

According to the CDC, extended use is preferred over reuse.

“A key consideration for safe extended use is that the respirator must maintain its fit and function. Workers in other industries routinely use N95 respirators for several hours uninterrupted. Experience in these settings indicates that respirators can function within their design specifications for 8 hours of continuous or intermittent use. There is no way of determining the maximum possible number of safe reuses for an N95 respirator. Hang used respirators in a designated storage area or keep them in a clean, breathable container such as a paper bag between uses.”

Testing kits

When asked how many test kits are available, John replied, “No one knows. There is rumor that our hospital isn’t testing anyone because they want to keep the perceived numbers down, make us look like a nice place to visit.”

Census

“Our hospital has only had 5 truly positive Covid tests, we’ve had 10 or so presumed positive, and a ton of PUIs (patients under investigation). We are waiting for test results for more than 100 people. But all of them are coming back negative. So we shut down the covid unit and sent most of the nurses home on pandemic pay.

There is no one to test, no one is coming in. Patients are coming in for open heart surgery, which is incredibly stressful to the body, and then are becoming covid symptomatic.

The tests we are doing can’t be accurate. If they don’t have covid then what do they have? I saw a patient with classic symptoms. She had thrown microemboli, she had bruises in her toes, but both tests were negative.

When they did a bronch – the bronch was positive. The nasal swabs aren’t getting it.

My question is, before doing a nasal swab, the patient is supposed to blow their nose, but you can’t do that on a vented patient. So maybe it’s not deep enough. We are seeing many patients with symptoms of covid who are testing negative. We have two other patients who we are pretty sure are covid positive, but they are not sending the bronch washes for testing.”

(A “bronch” is a bronchoscopy – a thin tube is passed through the nose or mouth into the throat and lungs. Common reasons for a bronch are to get a sample to send related to symptoms or something unusual seen on a chest X-ray, or to remove foreign bodies or other blockages from the airway.)

John went on to say, “A heart patient came in with a PO2 of 45 and after getting open heart surgery, covid symptoms appeared. He had two negative nasal swab tests. He was bronched but the sample wasn’t sent for covid testing. You’re supposed to send all samples for covid testing. Another patient was tested multiple times with the nasal swab and came up negative. Finally she was bronched and it was positive.”

Here’s a Youtube video from Mt. Sinai on how to do a proper Covid-19 test:

Proning

I asked John about proning patients. “Proning patients has been around for a long time – we used to do a lot of proning. Our staff are all young and none of them have proned, so last week we had two classes on how to prone.”

According to a review of literature conducted on April 11, 2020, Covid-19 can cause pulmonary edema, multi-organ failure, and acute respiratory distress syndrome (ARDS). The prevalence of ARDS among COVID-19 patients has been reported to be up to 17%. The prone position can be used as therapy for improving ventilation in these patients. “The main mechanisms of prone position in improvement of ARDS patients’ condition are affecting recruitment in dorsal lung regions, increasing end-expiratory lung volume, increasing chest wall elastane, decreasing alveolar shunt, and improving tidal volume. Patients remaining in lengthy prone position sessions leads to decrease in mortality of patients. However, correct selection of patients and applying the proper treatment protocol for prone positioning are key to its effectiveness.”

I had never seen this, so I asked John to describe it to me. Read this step-by-step article describing how to do it and what it looks like.

“It’s like sleeping on your stomach. With your left leg on a pillow, your head is turned the same direction as the left leg and the right arm is behind the patient with the patient’s right shoulder touching the bed and the hand is palm up. We also turn them the other direction. You aren’t completely flat. They do have proning tables, but they are so expensive. The biggest problem with proning is keeping the face and ears from breaking down from the weight.”

ECMO

Another therapy that John is excited about is extracorporeal membranous oxygenation (ECMO) “We started doing this 4 years ago as a last resort. You insert a massive canula into the jugular, or the femoral artery, you can even stick the canula into the heart. It pulls the blood to the machine, filters it to remove carbon dioxide, oxygenates it and returns it.”

John went to Emory to learn how to do it. “What I love about ECMO is that it is nurse driven. Most hospitals have perfusionists doing it, but here, we run them. It’s intense. You need 2 nurses to 1 patient. It totally works – saves lives.”

ECMO essentially replaces the function of the heart and lungs. It can be used for months to support patients until lung and/or heart function can be restored. For more information on ECMO, read What is ECMO?

All of these nurses are experiencing skin breakdown behind the ears, so if you know of where I can get them a behind the head ear loop holder, please comment!