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Early COVID- Frustration and Sadness

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As the COVID pandemic extended into the first few months, how people were reacting to the situation started to impact the patients that were being admitted. This impacted families and staff in many different ways and started to bring troubling aspects of our own thoughts and judgments into play.

Specializes in Long term care; med-surg; critical care. Has 9 years experience.

Sometimes Our Patient's Life Choices are Hard to Understand

Early COVID- Frustration and Sadness

A few months into the pandemic, we had a patient admitted directly to the ICU from the ED. She was in her late 80s, and her story quickly went through the unit because we were honestly at a loss for how this could have happened.

For many of us in the northeast, life came to a standstill the weekend of March 15, 2020. My children came home for an intended two-week break from school and then didn't return for six months. Our roads were deserted, driving to work for night shift I sometimes didn't see another car on my 20-mile commute.

My family didn't leave the house for months. I went to work, stopped at the grocery store and went home, that was it. Almost everyone else I knew lived a similar hermit-like lifestyle. We missed birthdays, anniversaries, none of the kids had graduations or saw their friends. But we also had a low rate of COVID infection in our state and were relatively lucky. Up to this point, almost all of the patients we saw had what seemed to be unavoidable exposures to COVID. Our local Walmarts, unfortunately, became a hot transmission spot. People still needed to shop and the essential workers had to work. Many of our initial patients in ICU were impacted in this way.

Grandma, however, appeared to have been living a somewhat carefree lifestyle. Within the few weeks before her admission, she had flown down south for a grandchild's graduation, then flown to another southern state for a family wedding before flying north of us to a family reunion and then returning home. It was unclear where among her three large gatherings and six plane rides she had contracted COVID, or how many people she may have exposed in the process. And I can't lie, some of us were a little mad.

Here we were trying to do what we could to minimize the risk we posed to others as healthcare workers, some of us even stayed in hotels for weeks to minimize exposing our own family members. And many of our communities were dealing with the challenges of people in isolation to try and keep people safe. How could this woman and her family have done this?! Didn't she realize she was old and at high risk for serious illness?! Didn't her family realize that as much as they would like to have grandma at that graduation or wedding, she might not celebrate future events if she made those trips?! It was the first, but not the last, COVID experience where the patient seemed far more culpable for their situation. 

But that's life. In those early days, working in the ICU and being mostly cut off from social interactions, we didn't see the people that had a mild case and never came to the hospital. We didn't even see the people that were admitted to med-surg for a couple days of support and then went home. We saw the people that came to ICU, and died. Our view of this pandemic was totally different so it was hard for us to view the world as others saw it.

None of us would have gotten on a plane for any amount of money, and most of us are relatively young and healthy. Then again, in the ICU most patients share some level of responsibility for their current situation. We rarely have a healthy patient who was hit by a bus or the like. We have people that smoke, drink, are non-compliant with their diabetes or hypertension treatment, etc.

It's not our job to judge what gets a person there, it's our job to treat them once they're there. Some days that's harder than others and I admit to days where I fail. Where I just want to shake a patient and tell them if they don't get their life together they'll die, as so many others have done over the years. At first, COVID seemed different, a sneaky ninja that attacked unsuspecting people trying their best to stay away. But then, as people returned to their normal ways of life, more and more cases that appeared avoidable, came to us.

Grandma had a typical course of stay in our unit. We encouraged her to lie prone as much as she could tolerate, but she said it was uncomfortable and would only last a few minutes before either repositioning herself or ringing for someone to assist her. She was intubated within a day of admission, the family was made well aware that the prognosis was grim given her age and comorbidities. They were adamant that she would want to be a full code, she was strong and a fighter and if anyone could survive this, it was grandma. She was clearly a woman that was in overall decent shape for her age. She was still driving a car, she didn't walk with a walker or a cane, she arrived with her bag of makeup and hair products among her belongings. I'm always amazed when anyone brings such items to the hospital, as if illness does not preclude their desire to remain as put together as they normally would be. Then again, I only own chapstick myself, never really finding the effort of beauty products to be worth my time. 

The last evening of grandma's life I arrived to take report and she was on increasing pressor support. Maxed on levophed and vasopressin, we were quickly titrating up her neo-synephrine. The pulmonologist called for a quick update during my report and I asked whether we would consider starting the epinephrine infusion as our final line of support, with the added bonus that when the eventual code happened, we could minimize the nurses needed in the room if epi was already running. Since we wouldn't be needing anything else as a push med, she thought that was a good idea, so after report I hung the epi.

It was about three hours into the shift when pressor support was maxed and her blood pressures started dropping. I did call the family and let them know that it was unlikely that she would make it through the night, the doctor had already explained that her body may stop responding to the pressors, did they want to reconsider her code status so we wouldn't have to do CPR and risk additional injury. No, they insisted she would remain a full code and we should do everything possible. 

We had an informal policy related to these codes by this time. There would be one nurse, one tech and one RT in the room. The patient wouldn't be manually bagged, because that requires opening the circuit, there's a manual option on the ventilator that I admit I don't fully understand because I don't see that side of the code. The nurse and the tech would alternate for the 20 minutes of CPR before it would be called.

As the automated blood pressure readings dropped I garbed up and went in. There was a Youtube station of instrumental inspirational music that I found to be calming and played for many patients overnight. I left the harsh overhead lights off but did turn on the smaller under cabinet lights so I could see clearly about the room. At about 70s systolic I was surprised I could still palpate a radial at all, and there was a clear carotid pulse, mostly due to the 10 mcg/min of epinephrine infusing. But grandma's eyes already had the milky look of someone who had long since looked out and registered anything around her. I told her I had just spoken with ______, and that everyone at home was thinking of her and loved her, and then I apologized for the fact that I was going to have to do CPR when her heart stopped and we would do our best to not cause her any pain. 

We didn't hit the code button for these codes, everyone knew the plan. I hit the nurse call light when I lost a palpable pulse and that meant I would be starting compressions, so the RT and tech should come in. A coworker called the on-call MD to head down so it would be official. The 20 minutes of CPR was sad, and ineffective, as we knew it would be. I was glad that I didn't hear the crunch of ribs as I so often have, I'm sure my depth was slightly less than 2 inches, but it seemed the appropriate level of intervention. 

As I got her washed and transferred to the morgue I admit I once again had some feelings of anger. I almost wanted the family to look at the pictures of grandma at the graduation, the wedding, and the reunion, and feel a sense of guilt for encouraging her to make those trips that could have ended her life. But then I realized, if she had stayed home and missed those events, but taken an essential trip to walmart, or the gas station and still contracted COVID, then the family wouldn't even have those pictures. Grandma lived her life as she wanted to, and while I'm sure she didn't anticipate that those trips would end her life, she made her life choices in the best way for her. 

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3 Comment(s)

jive turkey

Specializes in A variety. Has 9 years experience.

7 hours ago, JBMmom said:
 

As I got her washed and transferred to the morgue I admit I once again had some feelings of anger. I almost wanted the family to look at the pictures of grandma at the graduation, the wedding, and the reunion, and feel a sense of guilt for encouraging her to make those trips that could have ended her life. But then I realized, if she had stayed home and missed those events, but taken an essential trip to walmart, or the gas station and still contracted COVID, then the family wouldn't even have those pictures. Grandma lived her life as she wanted to, and while I'm sure she didn't anticipate that those trips would end her life, she made her life choices in the best way for her. 

This is a valuable lesson for everyone bearing animosity towards patients.  Thank you for sharing.

JBMmom, MSN, NP

Specializes in Long term care; med-surg; critical care. Has 9 years experience.

2 hours ago, jive turkey said:

This is a valuable lesson for everyone bearing animosity towards patients.

I don't know that what I see being expressed is what I would call animosity for the most part. I think it's frustration and weariness. As I've mentioned, I don't see people that are asymptomatic (that I know of), or mildly sick, the COVID patients I see in my work mostly die. And they've ranged in age from their 30s to their 90s, some without any real known comorbidities. So, from my perspective, NOT getting the vaccine seems far riskier than it does to many others that haven't seen the same things. Even the worst side effect I've seen attributed to the vaccine by someone I know personally, is FAR better than what I've seen of the people that either haven't survived or will have a very prolonged recovery. And there are nurses at risk in caring for these patients. I just read about a nurse who had conquered cancer but her immune system was compromised, so she contracted it and died. That's where people get angry, because it was potentially a preventable situation that caused her death. 

But in writing that post, I did have to admit to where my own judgments can sneak into my job, and not just related to COVID. Sometimes what we do is frustrating because people will always make bad decisions. This has just truly pushed people to their limits for so many reasons. Thanks for your response. 

jive turkey

Specializes in A variety. Has 9 years experience.

1 hour ago, JBMmom said:

I don't know that what I see being expressed is what I would call animosity for the most part. I think it's frustration and weariness. As I've mentioned, I don't see people that are asymptomatic (that I know of), or mildly sick, the COVID patients I see in my work mostly die. And they've ranged in age from their 30s to their 90s, some without any real known comorbidities. So, from my perspective, NOT getting the vaccine seems far riskier than it does to many others that haven't seen the same things. Even the worst side effect I've seen attributed to the vaccine by someone I know personally, is FAR better than what I've seen of the people that either haven't survived or will have a very prolonged recovery. And there are nurses at risk in caring for these patients. I just read about a nurse who had conquered cancer but her immune system was compromised, so she contracted it and died. That's where people get angry, because it was potentially a preventable situation that caused her death. 

But in writing that post, I did have to admit to where my own judgments can sneak into my job, and not just related to COVID. Sometimes what we do is frustrating because people will always make bad decisions. This has just truly pushed people to their limits for so many reasons. Thanks for your response. 

I hear you.  I would never discount what you and other CCRNs witness.  If not animosity on your part it definitely exists among us in regards to patients and their lifestyle choices.  

What you see is the reality of how dangerous this disease can be.  That has to be recognized and responded to. There's no denying that.  We are fortunate that the tragedies in the ICU aren't reflective of every patient and everyone in society.  

I imagine police and correctional officers experience similar frustrations being at the epicenter of crime and having frequent encounters with criminals.  While what they see does not reflect society as a whole, we appreciate their efforts to end crime and increase awareness much as we do with those of us on the front lines in regards to protecting everyone from COVID. 

 

I think it was noble and respectable of you to catch what your were feeling and consider a diferent perspective. Many  can't or don't.