Pandemic: The Beginning

JBMmom, MSN, NP

The Early Days

I have to preface anything about my experience during the pandemic by saying that I was lucky. I live in the northeast and we didn't suffer nearly the overwhelming patient load and deaths that so many dealt with elsewhere in the United States. My heart goes out to nurses, techs, and RTs that had unmanageable patient assignments and dealt with constant death and the inability to provide care as they would have wanted. We had our share of challenges but we were able to work through them. Also, in my hospital, I think the nurses that stepped up the most were on our med-surg floor.

COVID Numbers Climb

For the first seven months or so of the pandemic, all COVID patients in our hospital were either on the med-surg floor or in the ICU. The other four floors were deemed "clean floors" until November of 2020 when the numbers were too high to keep them in the 40 beds available on those two units. The med-surg nurses, at times, had higher acuity patients than even our PCU floor. Prior to the pandemic, for example, I think high-flow nasal cannula was only on that floor maybe once a month, and we're talking 25 liters 40% range at most. Suddenly they had patients maxed on high flow, with non-rebreathers over, and potentially decompensating, but they rose to the challenge and absolutely kicked butt. And, while other nurses in our hospital were all over facebook whining about their patient exposures and challenges they were facing, those med-surg nurses just put their big kid pants on day after day and got it done.

The First Patient & Treatment

So, back to the beginning. Our first patient was admitted the second week of March, 2020. I wrote about his eventual death at the end of the month in a previous post, it will probably always stick with me because I was the one holding his hand when he died. At the time the current treatment plan was to intubate patients once they required more than 5 liters of oxygen by nasal cannula. Our ICU has only one true negative pressure room, and there were concerns about whether this might be an airborne transmission, so some industrial-sized filters were installed in our rooms. Plywood was put up in the windows, blocking out all of the natural light, and filters and filtration systems were installed. The fabric tubing made it look like so many used car lots where the giant inflatable tube man was being vented outside our windows. It also made a constant inhuman drone in the rooms. For patients that weren't on ventilators it meant it was too loud to hear a TV, or talk on a phone, or even have a conversation between short breaths. They were trapped in a constant hum, and every few hours a nurse would come in and attempt to communicate while giving medications. People got a catheter just because we weren't supposed to go in the room more often than absolutely necessary and we couldn't risk having people that were so short of breath they could barely talk, spilling urinals or trying to get out of bed to a commode.

There was a definite feeling of fear. A buddy had to watch you garb up and then doff to make sure you didn't bring anything out with you. Of course, being not real negative pressure rooms, we doffed PPE right in the room, less than three feet from the patient in the bed, so if it truly were an airborne transmission, 100% of the staff and patients on the unit would have gotten the virus, and quickly. We didn't have shields at first, those came along later. Just the gowns, gloves and N95. The N95 was put in a paper bag with your name on it and taped to the wall for your shift. They were to be reused until "visibly soiled" and for a while we had to put our name on a list when requesting a new one, to make sure no one was asking for an exorbitant amount of PPE. I got "lucky" and ended up intubating three of the next patients that were put on ventilators.

Intubation

My first COVID intubation was a pleasant gentleman, 80 years old, and he had just retired from his job three weeks earlier at the urging of his family, because of the chance of him contracting COVID. Ironically, his wife first contracted it in a local Walmart according to the family, and the rest of the family tested positive as well. He had a great sense of humor, he arrived from the ED on 4 liters of oxygen by nasal cannula. His family had dropped him off only a few hours earlier and he walked into the ED on his own because they couldn't come in with him. Within a few hours, I was at 5 liters and he was maintaining in the mid-80s. At the time that was the trigger to intubate.

I called his wife and daughter to give them an update and suggested that they facetime his cell so they could talk about things. No one in their family had even considered a ventilator, he walked into the ED for goodness sake, who could wrap their brain around that a few hours later?! They briefly discussed it and decided they would give it a go, I was in the room and he kept chatting with them. His wife and daughter appeared to have a very clear understanding of the gravity of the situation, the dismal ventilator success rates had already been in the news based on the situation in Italy, and he was a healthy gentleman but he was 80. Whether he didn't understand, didn't want to understand, or just wouldn't acknowledge anything all that serious was going on, he joked a bit during their facetime conversation and then said he would talk with them in a few days. I urged them to talk a little while longer, trying to tell them to say something meaningful without telling them to say goodbye. He once again said he would talk with them in a few days and hung up the phone.

Then I let him know that I would be leaving the room to get ready and the next time I saw him I would be accompanied by some doctors who looked like something out of ET and we would be giving him medicine to help him relax and sleep while the ventilator helped his lungs to heal. Or at least that was the goal. He sat quietly on the bed, maybe the facade he held for his family cracking just a little, and he asked whether I could just let him stand up and stretch his legs for a minute since he would probably get stiff laying down for a while. He stood up, paced back and forth a couple of times, and then said "okay, I'm all set". He got back in bed and I left the room to wait for anesthesia in their moon suits.

Back then the COVID patients all got a central line in their groin, so as not to expose the doctors to anything near the highly infectious end, and an arterial line, when they were intubated. We're a pretty low acuity ICU on the whole, so A lines aren't a standard intervention. The nurses were supposed to stay outside the room during intubation and that was the one and only time I complied with that plan. He was, by all measures, a pretty easy intubation and things seemed to be going along well. But then our angry, short, surgeon came to place the central line and he didn't appear to be well sedated. I was maxed on the sedation that I had available so I stepped away from the door and went over to the computer to get in touch with the doctor for new orders (we don't have MDs on the unit at night). I looked up a couple of minutes later and there's my patient, sitting straight up, trying to get his restrained hands onto the ET tube! I run towards the room yelling at him to stop. As I reach the door my work wife shoves me, nearly to the floor, yelling at me for my intent to go in and stop him from extubating himself without my PPE on. It wasn't the first time I was told "if something happens and they die, you don't risk your life to stop it". I guess the fact that I was told that more than once tells you my general approach to nursing, and maybe to life. I hastily threw on my PPE and ran in the room to find that my IV lines with the sedation were all running- directly into the bed. When the anesthesiologist placed the A line, somehow the IV was disconnected but I couldn't see that because it was on the opposite side of the bed. I reconnected, flushed, to confirm patency, and he settled back in. The surgeon was able to place the line and then the night was reduced to tasks. The weird thing with these patients was they would go from 5 liters nasal cannula, granted with sats less than 90%, to HIGH ventilator settings. We had people with PEEP of 20+ at times in order to keep them oxygenating.

Proning

He was proned towards the end of my shift, fortunately, he was a light gentleman and it wasn't too difficult. But sedation in those early days was hard, people seemed to take monumental doses to keep them sedated. Here was a man that barely took anything more than Tylenol in his life and in order to sedate him I had propofol, fentanyl, versed and ketamine, all at pretty high doses, before we started the nimbex drip. Initially, everyone we proned was paralyzed, fortunately, we moved away from that practice after a couple of months.

He was on the ventilator for about a week when we couldn't get him to oxygenate anymore. He had become hypotensive post-intubation and even when we weaned off propofol he still required pressor support. So his kidneys took a hit and then everything sort of failed at once.

Restricted Visitation

Because his family members were all COVID positive, they couldn't come to the hospital, even after they decided to make him CMO. His daughter would call every morning around 5 am and then again about 9 pm, thoughtfully stating she wanted to avoid our shift change and busy times. They never saw him again after the facetime call before he was intubated. We didn't think to ask families then if they wanted to see their loved ones on a ventilator. But maybe that's more closure than the black hole of nothingness and the words of strangers to give impersonal updates that so many families had in those first few months. Maybe just seeing that we bathed him every day, combed his hair, brushed his teeth, kept him on clean sheets, would have brought a little comfort. But they never even had that. I wasn't there when he was extubated, but my friend told me he never even took a breath on his own when the ventilator was removed.

So full of life, mourned by many, he was an early COVID casualty, and many more followed.