Nurse Describes What’s REALLY Going On In Hospitals During COVID-19

The following is a letter to the frum blog Matzav.

Dear Matzav,

I have been meaning to write this for weeks but, in addition to having my 5 kids at home due to coronavirus, I’ve also been working like crazy as an acute care nurse practitioner in an ICU dealing with many covid patients.

I want to just share a bit of what it’s like, because I see so many posts about opening up the country, about closet-minyanim, about people who just want life to return to normal. I want you to know that you should have a healthy fear of this virus, and if you are unlucky enough to face it daily, you would be extremely hesitant to go back to life as normal or to surreptitiously get around the restrictions that are in place to save lives. Your lives, and mine.

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This is not the flu. I’ve worked in critical care for 10 years and no flu season has ever come close to anything like this. Hospitals are maxed out, people deteriorate very fast, and mortality is high. It is not only the elderly and the immunocompromised getting sick. We had an otherwise healthy 21 year old patient who hung on the precipice for days before finally turning around. My ICU is very proud of ourselves for having a really impressive mortality rate of about 50%. Around the world, close to 70% of ICU covid patients are dying. I shake my head in disbelief. To be doing better than average, and still have half our patients die? And they are getting sick and dying in different ways than we have ever seen before.

The patients don’t believe me when I say they need to be intubated, and soon. Their blood oxygen levels are dropping to dangerous levels, in spite of maximum noninvasive support, and yet they often feel ok. They are scared of being intubated, and ask if we can avoid it, what they can do to push it off. I am scared for them too. I don’t want to tell them that this conversation we are having, it may very well be the last conversation they will ever have. I don’t want them to push off intubation, because then they will die for sure.

If we have a bit of time and if they have a bit of breath, I tell them to call their loved ones. Let their family hear their voices a bit. If it’s not the last time ever, it will be the last time for weeks, since covid patients have been requiring longer bouts of intubation than with other pathologies. They won’t hear, touch, or see a loved one for a long time. And maybe forever.

Will I die?, my patient asks me. I cannot tell him the truth, that more than half of covid patients who develop this extent of respiratory failure die. Not on my watch, I promise him, not while I’m here. That’s the best truth I can offer him. I won’t let him die tonight.

We call Anesthesia to intubate and they meticulously prepare everything outside of the room. They can’t forget to bring any item with them, because there will be no time to degown or go through the pantomimes of communicating with those outside the airborne protected room. At the same time, they mustn’t bring excess supplies, because everything that enters the contaminated room gets thrown out if unused.

It’s during the intubation process that my decision to have the patient intubated is confirmed correct, with no room for doubt. Had I been second-guessing that decision, I no longer do now. These patients have no respiratory reserve. Their oxygen levels drop dramatically, and often take a long, heart-stopping time to respond to full ventilatory support. I now wonder whether we should have intubated much earlier.

Though they are on the ventilator, we are not out of the woods. Blood pressure may be dropping and I need to insert a central line. The nurse puts in a nasogastric tube and a foley catheter. We order restraints so that all important lines and tubes remain where they should be. Can’t have them coming out, when it takes us so long to go in.

Every time a patient needs something, it’s a process. Mask on, faceshield on, gown on, gloves on. Check and recheck for a good N95 seal. And if we realize too late that we need something, it’s a song and dance communication game. Bang on the glass door and get someone’s attention. Scribble our request on the handheld whiteboards and hope those outside can find one to respond in kind. You can’t hear our shouts with the doors shut tightly and the massive air filters running loudly, and you can’t read our lips covered with masks. Rapid scribbles and pantomime have become the communication methods of choice.

The filter noise and the full body protective equipment make it difficult to communicate with the patients as well. We all look the same, save for our eyes. We shout to get our words heard. Patients are scared, which makes it even harder to comprehend the words they barely hear. It’s difficult enough for those patients who are not intubated. And for those patients that are intubated and deeply sedated, dramatically weakened and deconditioned, barely able to communicate their needs anyway? There is no family at the bedside to understand a subtle look or hand squeeze. The nurses struggle with their desire to nurture and care and comfort a patient, with the law of self-preservation that says get out of the room as soon as you can. You have a spouse and children at home, you cannot get them sick and you cannot die on them. And besides, you will be of no help to any patient if you become sick. And then there are your other patients as well, alarming, oxygen levels dropping, blood pressure fickle and meds to be given. But this patient needs you.

As a nurse practitioner, I am not in the room nearly as often as the bedside nurses. It makes me feel relieved, and also guilty. Sure, I get my time when we intubate, when a patient is decompensating, when I need to perform a procedure, to pronounce a death. But it’s less direct patient contact than it used to be and I feel guilty. I don’t go into the room to round every shift like I used to. I peer through the glass wall, and that will have to be enough. There is so much guilt everywhere now. We are doing all we can, but are we doing enough? We must protect ourselves so that we can continue to care for others, but have we neglected the basics of human touch and healing? When I do go in, I can’t help but apologize to the patients. To the deeply sedated patients, and to the dead bodies. I am so, so sorry. As I touch their shoulders, I am so, so sorry.

Somewhat later in the disease progression other organs and body systems start failing. A huge number of our patients go into renal failure, and need dialysis. Many are developing clotting disorders. Large strokes in young people. Perhaps microclots have been causing the hypoxia all along. We put our patients on larger doses of blood thinning medications to try to mitigate the clotting. But then some patients begin having bleeding problems and we have to stop the blood thinners. And in those patients whose lungs suffered enough of a hit, there is no lung recovery. After weeks on maximum oxygen on a ventilator, after proning and paralyzing, after administration of novel medications and plasma as part of clinical trials, after weeks of our effort, there is no improvement and blood oxygen levels remain low. There is no way their brains have survived this. And then we begin the discussions with families about withdrawing care. It is futile at this point. These are terrible conversations to have under any circumstance. But if family has not seen their sick loved one in weeks? To have these discussions and make these decisions miles away and weeks apart and hearts torn asunder!

Today I said goodbye to a patient who has been in our ICU for a month. He will not recover. After days of deterioration and discussion, his daughters have decided to let him go. I stood outside his door – not wanting to increase my exposure risk nor waste PPE on a nonessential entry into the room – and said goodbye. And I’m sorry. I’m so so sorry. A few tears that don’t escape my eyes. He will not be there when I get back.

Then I strip my scrubs and clean my belongings, change shoes before getting into my car, and go home to face my family and the world. The birds are chirping and the sun is shining and my friends and neighbors are all excited about life getting back to normal. And I can’t tell them everything I just lived and will be going back to.