Shifting roles and responsibilities
During the COVID-19 pandemic, my role and responsibilities quickly shifted from caring for only adult oncology patients, to medical patients, to ICU patients on ventilators. The challenges of learning how to care for these patients also provided an opportunity to experience a type of nursing I probably would have never experienced otherwise.
In some of our first days as a COVID-19 ICU floor, I cared for two patients with COVID ARDS. Both of these patients had similar comorbidities: DM, HTN, HLD. One pt was in his eighties, and one was in his fifties. The patients with ARDS in our COVID ICU were very similar in terms of treatment approaches, sedation cocktails, vent settings, and pressor requirements. Having patients with very different backgrounds, but the same reason for ICU admission, reinforced the learning points for me.
Every patient was approached systematically
Their sedation and RASS scores were first. Dilaudid (until supplies grew thin, then switched to Fentanyl), Propofol (tubing changes every 12 hours!), Versed, Ketamine, Dex (a new kind) in some combination. Then came their recent gases, P:F ratio, vent settings, plan for prone vs supine, length of intubation. Then hemodynamics: pressor requirements (do they “like” the Vaso?, do they try to die on you when you change out a stick of Levo?), telemetry review, many patients with QT prolongation, CRP, Ferritin (numbers I’m familiar with, but no CAR-T cells in sight), clotting issues. GI/GU: tubes, tubes, and more tubes. What’s their tube feeding formula and rate goal? Does their Flexiseal leak? Do we have any bags today or do we need to become a mechanical engineer to empty the bag in the toilet? Is the skin intact? Do they have swelling and DTIs from proning? Do you have the cute infant gel pillows in the room?
You worked so hard for twelve hours, documenting every drip, vital sign, vent setting (if they didn’t flow into Epic), you did mouthcare and repositioning every 2 hours and worried every time you interacted with the patient’s mouth, thinking of the constant viral shedding. You spent so long setting up the ipad just right so you could see your patients’ waveforms on the monitor, then the IV pole got bumped by someone quickly going by to empty the trashcan- probably holding their breath while they did it.
You wanted to be a good nurse ...
... and, you wanted to take the time to really wash your patient’s matted hair, but you also counted the hours the N95 had already been on your face, and you started to think about retaining your own CO2, and how thirsty you were, and did you pee today? I hope I have a really good seal on my face. Will the patient even survive this? The next hour is approaching…we need to do our hourly documenting. It’s time for another full head to toe assessment. And, this nurse likes you to document a RASS score hourly. Will this nurse trust me to draw the ABG on my own? I’ve done it a bunch of times now.
This partnership is amazing. This nurse trusts me. I can manage a patient with an ET tube. Lunch is being delivered today. The kids in the neighborhood drew chalk messages of hope and thankfulness for healthcare workers. A patient graduated from the ICU and moved to the yellow side. A patient is walking in the hall! My patient… that patient from the beginning, that patient who was proned 4 times, that patient who was extubated, then had to be re-intubated, then had to be trached and PEG’d…he sat up in the chair and Zoomed with his grandchild, while on room air.
This is pandemic nursing. This is Lunder 9.