COVID: I'm ready to leave the hospital until the end of the pandemic guilt

[CardiTeleRN]

Hello!

I am considering leaving the hospital until the end of the pandemic. Not necessarily because of the ill patients. Mostly because of the politics. I understand that there is a shortage of staff for COVID units. My issue is, the hospital I work for is constantly creating new COVID units for patients that are asymptomatic. I've learned these hospitals are getting additional funding from the relief programs put in place by the government. The hospitals gain additional funding if the patients are placed on vents as well. I've noticed MDs and rr therapists are forcing us to place them on vents even if they do not meet the criteria.....

I am becoming extremely overwhelmed and am sick of what I am seeing. I hate how the system is taking advantage of these extremely difficult and emotional taxing times...I don't want to be a part of this anymore.

Am I wrong?

[GS ED RN, MSN, RN]

I am NOT playing devil's advocate - but is it possible that these patients are placed on vents to avoid difficult intubation in setting of COVID-19 Infection - my understanding from working in ED and briefly in COVID-ICU is that due to the high risk aerosolization during intubation - they prefer to intubate under ideal circumstances - controlled setting as much as possible --- not while the patient has been in resp arrest for a while and is on verge of coding and things just get plain old messy --- also as the nurse yes we care for ventilated pts... but we arent the ones actually intubating ... so what do u mean by "being forced to place pt on the vent" without breaching HIPAA can you provide an example of what you are seeing -- is the patient who has been on hi-flow 100% for days and proning  without improvement to o2 sats/labs/ABG/mental status being intubated??? or is someone who is alert, on nasal cannula but COVID+ being wrongly intubated??

[EllaBella1, BSN]

I don't mean this to be rude, but do you even care for intubated patients? Your username includes 'tele', so I assume you are a cardiac tele RN, not one that works in ICU. 

The truth here is that unless you routinely care for vented patients, or have extensive experience with managing critical ARDS patients, there is no way for you to truly understand when we look to intubate a patient. With COVID patients we see patients routinely with PF ratios that are absolute crap. A year ago a patient with a PF ratio of 75 would have been in a rotoprone bed, intubated and paralyzed without question. Now we see patients with PF ratios less than 100 sitting on 100% CPAP with high peep for DAYS. The problem with this is these patients are having complications. I can't even tell you how many patients I have had this year with pneumos or pneumomediastinum. I have personally had several patients on 100% cpap on 12-15 of peep who have developed pneumomediastinum recently, who might have an SPO2 in the high 90s at the time, but we intubate them. Why? Because we know the crashing and needing chest tubes is right around the corner. To someone who doesn't see the full picture it might look like we are intubating someone who is 'doing OK' and doesn't need it. Or another example, someone in ARDS whose CO2 is rising on each ABG. If they are a full code and bipap/cpap isn't helping drop their CO2, they are getting intubated, even if they have an SPO2 of 99 on the monitor. 

All I'm saying is there is a LOT more to who gets intubated and who doesn't than you might think, and there are many reasons for medical necessity for intubation aside from the obvious low SPO2 and airway protection. I can promise you though, physicians, critical care nurses, and RTs are not out looking to intubate people for money. 

[herring_RN, ASN, BSN]

This is from last April. It begins, "Covid pneumonia initially causes a form of oxygen deprivation we call “silent hypoxia” — “silent” because of its insidious, hard-to-detect nature." (It would be detected by pulse ox or ABGs.)

The Infection That’s Silently Killing Coronavirus Patients: This is what I learned during 10 days of treating Covid pneumonia at Bellevue Hospital.

https://www.nytimes.com/2020/04/20/opinion/Sunday/coronavirus-testing-pneumonia.html 

[avado, BSN]

I am quite aware of ARDS and YES I have done vents but when the family member has "Hope" that resting the lungs will help their mother who has severe CHF?  IS a poor message! I knew she would be dead in no time flat.

We are suppose to be the advocates for the patient and the family especially when they are not allowed at the bedside. Please have that sincere talk regards to wishes and status. Yes, no-one perfect.

Now reading all the remarks attacking experience or now "causing conspiracy" due show why nurses do leave the field. Nothing new.

[GS ED RN, MSN, RN]

On 11/29/2020 at 4:42 PM, Jack Peace said:

Let me ask you all this: for those of you who work in a hospital setting, are you testing for influenza as well as Covid with or without respiratory symptoms? 

at both my hospitals we test EVERYONE who is admitted - the swabs are rushed for laboring women/OR cases or people who are symptomatic and critically ill - this wasnt always the practice -before we only swabbed symptomatic admits - it must have changed at least a dozen times - people from high risk populations - undomiciled/nursing home/group home/dialysis etc. get one swab then a repeat swab 12 hours later - because apparently one false neg is possible - but two false negs hightly unlikely - great question - I am also curious to see other's peoples work rules regarding this 

[EllaBella1, BSN]

1 hour ago, avado said:

I am quite aware of ARDS and YES I have done vents but when the family member has "Hope" that resting the lungs will help their mother who has severe CHF?  IS a poor message! I knew she would be dead in no time flat.

We are suppose to be the advocates for the patient and the family especially when they are not allowed at the bedside. Please have that sincere talk regards to wishes and status. Yes, no-one perfect.

Now reading all the remarks attacking experience or now "causing conspiracy" due show why nurses do leave the field. Nothing new.

I wasn't responding to you. My post was in response to the OP. I didn't even read your post until I just went back and found it.  I agree with what you said, a family member should not have been told that, and the physician should have been upfront with them.

With regard to your comment about attacking experience- if that was in reference to my post, then you're mistaken. I wasn't attacking experience, I was simply stating that the OP doesn't seem to have the experience (based on their bio) to truly understand why we make decisions to vent some patients and not others. And I'm sorry, but it is a conspiracy to think that hospitals are venting covid patients for higher reimbursement. Not even going to argue that point. 

[MunoRN, RN]

10 hours ago, GS ED RN said:

I am NOT playing devil's advocate - but is it possible that these patients are placed on vents to avoid difficult intubation in setting of COVID-19 Infection - my understanding from working in ED and briefly in COVID-ICU is that due to the high risk aerosolization during intubation - they prefer to intubate under ideal circumstances - controlled setting as much as possible --- not while the patient has been in resp arrest for a while and is on verge of coding and things just get plain old messy --- also as the nurse yes we care for ventilated pts... but we arent the ones actually intubating ... so what do u mean by "being forced to place pt on the vent" without breaching HIPAA can you provide an example of what you are seeing -- is the patient who has been on hi-flow 100% for days and proning  without improvement to o2 sats/labs/ABG/mental status being intubated??? or is someone who is alert, on nasal cannula but COVID+ being wrongly intubated??

The "early intubation" rule was common at the beginning, then when the first analyzed data came out of New York it became pretty obvious that was doing more harm than good.  ie intubating Covid patients didn't appear to be commonly beneficial, and if anything was causing more deaths than it was preventing (most commonly due to VAP). 

There was a poorly supported belief at the beginning of the pandemic, which you'll still find in various places, that intubation carried a risk of producing aerosols beyond that of just 'regular' causes like talking, coughing, or just breathing.  But the source evidence doesn't actually support this theory.  But a result of that myth was the idea that if a patient is going to be intubated at some point no matter what, better to do it in a more controlled setting.  

There are certainly part of the country / cultural views where it's more common to see medically futile DNR patients still considered to be full code, I would guess that those same areas and cultures are those where you'll also find patients who are unlikely to benefit from intubation to get intubated regardless of the established futility of that intervention given their overall clinical picture.

[MaybeNia, ADN, RN]

Maybe they believe they're being proactive and trying to provide care early that they know will likely be imminent later.

Common theory: "If you wait until a patient goes bad to intubate, they probably won't come off the vent. If you watch the trends and intubate when the data is bad but patient is good, then you let the lungs rest while the body is not too tired to heal."

Also, they are possibly admitting  "asymptomatic" positive patients who have complicated medical histories, so that they're already where they can get immediate help if they need it. Also, consider that someone who "feels fine" may have labs/imaging that show a different story. 

I would whistle blow if you have solid, factual knowledge. I would ask questions and research more and try to learn if you're just looking from the outside in.