Coronavirus (Covid-19) in the E.R.: A New York emergency room nurse’s experience

Filed Under: Costs

- photo by Camilo Jimenez

Continuing our series of interviews with doctors and other medical personnel in the era of Covid-19: A nurse in the emergency room of a busy New York hospital told us about her experience, speaking on condition of anonymity.  Here’s a transcript of our conversation, lightly edited for length and clarity.

 

Phoebe Pinder (CHC)
What has surprised you most about the Covid era, both in your nursing role and outside it as well?

E.R. Nurse
What surprised me the most was the lack of resources that we had. Maybe this sounds ignorant, but I thought to myself, we’re not gonna run out of things, there’s no way we’re gonna run out of things. And sure enough, we ran out of ventilators. We ran out of the high-flow oxygen setups; we ran out of gowns and masks. I was reusing masks, using one for maybe even three weeks worth of shifts – that’s 11 or 12 shifts.

You’re used to, if somebody needs to be on a ventilator, you and the doctor quite literally just put them on the ventilator, and you’re not used to having to decide who would be the best candidate because of the lack of resources. That was really upsetting and very shocking at first.

Outside of the nursing world, what has surprised me the most is that some people really do not care about Covid, or they don’t take it seriously. I’ve seen that less and less in New York, but from watching the news and [seeing] how other states did not shelter in place or shut down the state appropriately….I’m still disappointed, because [in those states], people are now going to suffer because their state cared more about keeping the economy open, which is really upsetting to see.

PP
Have you had any instances where you’ve had to explain to people the need for precautions like wearing a mask?

E.R. Nurse
I think people get tired of wearing the mask. They usually come in wearing it, but then I notice they’ll pull it down or have it below their chin while they’re waiting around in the hospital. So you have to gently say, “please wear your mask, it actually is safer for you, as well as all these other patients.” Once people are in the hospital, they are mostly compliant, and I would imagine [that’s] because they’re uncomfortable maybe being around each other.

Limited Covid Testing for Patients and Staff

PP
So you work in the Emergency Room. Are you testing everyone who comes in?

E.R. Nurse
Unfortunately, we are not testing everyone who comes in. My hospital doesn’t have the resources to do that. We test people who come in for Covid-specific symptoms. If they come in for a fever, shortness of breath, body chills, or really bad body aches, they go to a designated, assigned area.

We group people together based on their symptoms to try and keep people with non-Covid symptoms separate in another area. Then we test the people with Covid symptoms. They do the nose swab, and then there’s several blood tests that we send off. But unfortunately, not every patient who comes in [gets tested]. If you come in for abdominal pain, you’re not going to get a Covid test.

PP
Are they testing the staff at all?

E.R. Nurse
Originally, staff was only able to get a test if they had a fever. Back in March they thought that the Hallmark sign of Covid was to have a fever, even though some people had different signs and symptoms without having a fever. It really hits everybody differently. But back then, you used to only be able to get a test if you had a fever.

Then they were testing employees if they had any symptoms, but you couldn’t go to employee health and request a test if you had no symptoms. They wouldn’t let you do that. Now, they’ve shifted towards the antibody testing, because that’s become more readily available. All employees are able to get antibody testing, should they choose to.

PP
Do you know any of your co-workers who tested positive, either for antibodies or active infection?

E.R. Nurse
Quite a lot of coworkers actually were out sick for extended, maybe two- or three-week leaves because they tested positive. We were caring for really critical patients, but unfortunately, I think the reusing of masks, the ill-fitting masks, and the improper P.P.E. contributed to [so many staff members getting sick].

In my department we had quite a lot of nurses out at the same time. Most of them who tested positive for the nasal swab and then were out [have now] gotten the antibody test and tested positive for antibodies.

Horribly Understaffed: ‘It’s so unsafe’

PP
Did you guys have a lot of Covid patients come into the emergency room?

E.R. Nurse
Oh, yes. Back in March and April we had a massive amount of people coming in mostly for Covid symptoms. There was one night I got to work at 7pm and the census was 155! That’s Covid and non-Covid combined, but [there were] 155 people in the emergency room, which is really high. We only had 15 nurses on staff. Understaffing is a very big problem.

PP
Wow. What has that been like?

E.R. Nurse
That was pretty awful. The thing with Covid is that people crash so quickly. Somebody can look okay, and their oxygen saturation could be okay on the monitor, and then literally within minutes they can decompensate and go downhill. For these kinds of patients, you have to be really on top of what’s going on, and when we have so little staff caring for multiple unstable patients at once it’s honestly doing a disservice to the patients.

It was really unsafe to be managing several intubated patients at once per nurse, but we had no choice because we had such little staff. That was because a lot of co-workers were out sick, and they weren’t able to get replacements.

Eventually they got travel nurses in and the travel nurses were really helpful, but unfortunately, they did come a little late. They came around late April, when things were starting to get a little better and our staff was starting to come back. We ended up having an excess of staff. I appreciate that the travelers came, but unfortunately, we really did need them earlier when the staffing was a big issue.

PP
Did you have any patients that you thought might have been able to receive better care or might have been able to make it if you didn’t have such a shortage?

E.R. Nurse
Yeah, I did have several. I’ll give you an example, because this still haunts me to this day. I came on shift with my partner in the area to take report, and there’s like eight or nine critical patients for the two of us. One of the doctors said, “if you take care of anybody first, please take care of this man because he needs a CAT scan and he needs several medications.” So I go over to the patient and I’m working on him, and then I see his heart rate dropping.

When you see somebody’s heart rate dropping like that, it means they’re probably gonna code on you, and you don’t have much time. I told the doctor. Eventually the patient coded, and he was really, really sick. We coded him, but he looked terrible and honestly, he ended up not making it.

But because of how rushed everything was and how everything was going downhill, the patient next to him, the doctor was like, “we have to intubate this patient right now.” So literally, we just threw a sheet over this man’s body and pushed his bed to the side so we could start working on the other patient.

In the moment, I was like, okay, yeah, this man passed, now this other person is gonna go downhill, I have to help them. But then I thought about it. I was like, that’s somebody’s dad. That’s somebody’s dad that I tried to help but couldn’t, but then I just pushed the bed to the side. It’s just a body laying there. I felt so, so bad about that. Even though we really tried to help him, it didn’t feel like we gave him much dignity. I would not want that to be my father. I think about it from time to time, because that really bothered me.

PP
I’m so sorry you had to go through that. For the most part, how are patients handling it?

E.R. Nurse
Back during the peak, people were not handling it well. They were really scared, which is totally understandable. You go to approach a patient just to say, “you may have Corona,” and people would get really upset right off the bat. Now I think that things have died down and less people are requiring intubation. People are just walking in saying, “oh, I have a cough,” and they’re more stable. People are still anxious, but I think they are handling it better.

I wonder if maybe that’s because businesses are starting to open up, so people feel like if they get Covid it could be less severe, which is not necessarily true. But I have just noticed that shift now that things have started to die down a little bit. If we do have some patients, they’ve taken the news pretty well that they may have Covid. That could just be their personalities. But back when this did first happen, maybe because it was so new, people were freaking out when you suggested that.

changes over time

PP
Could you talk a little bit about what things were like at the beginning, when this all first started, versus the peak, versus now? How have things changed?

E.R. Nurse
When this first started, I definitely did not imagine it was going to be the way it was when we hit our peak. When this first started, we tried to prepare the E.R. by having one designated area for Covid patients. We call it Area B. We figured oh, we can have this area just for Covid patients, so we can try and contain them. Then as it started to get worse and worse with higher numbers and people coming in more critical, one area was certainly not enough. So we had to have multiple designated areas of the whole E.R., and they were split into Covid non-critical – people who came in and their vitals presented more stable in triage – and Covid critical. Those were people who came in really short of breath, vitals not good, probably would need intubation or high flow oxygen. They were sent to the critical area.

We tried to move all of our adult non- Covid patients into pediatrics along with the children, which was really hard, because the pediatric E.R. is so small. But we didn’t want to keep adults who were coming in with non-Covid symptoms in a large area with these Covid patients.

When we hit our peak we began to run out of ventilators. We got a donation of ventilators from Cuomo, and I remember one of the respiratory therapists told me – I’m not sure if it is true or not – that they were the ventilators that were used during 9/11.

As the numbers in our E.R. got higher and higher and higher, we started running out of supplies. [Staff was] trying to select who they thought would be a good candidate for high flow oxygen and sending people to different floors based on whether they thought they would have a chance, which sounds so awful.

I remember one night we were intubating a patient, and the doctor looked to the other doctor and said, “what floor do you think I should assign him to?” The other doctor said, “well, anybody who has a chance, who they think is going to survive, is going to the I.C.U.” My heart just dropped because I realized my three other patients were going to regular floors. And just that feeling to know like, oh my gosh, they don’t think they’re gonna make it… it was eye opening and it was really rough.

Now, “post Covid,” we’re back to one designated area for Covid patients. More people are walking well, so they walk in and their oxygen saturation is still very good. They’re usually not short of breath; they have more mild symptoms, and they are able to go to one area. All of our cases of non-Covid have spiked up again, like people coming in for more regular issues. Patients who come in more frequently who we used to see a lot [before Covid] and then we stopped seeing, they’ve come back.

PP
What do you think will be the long-lasting changes due to Covid – in the E.R. or just in general?

E.R. Nurse
I wonder if it’ll continue to change how we triage people. Pre-Covid, people would come in and, let’s say they say, “I have a fever” or whatever, that would be fine, we just assign them to a regular area. But I wonder now, the longer [Covid] is around, if somebody comes in with a respiratory and/or Covid symptom, if we’ll keep that designated area, and if all those people will still go to one area. I wonder how long that will happen for.

I think things in society in general, like in New York City…I think things are going to be very different for a long time. I think a lot of people think things are going to go back to normal very quickly; I kind of get that sense from my non-nursing friends. They’re very excited that things are opening up. But I don’t think that things are really going to go back to normal. I think that things are going to take quite a while.

I was supposed to go to a concert in July, and it got rescheduled for October 2021. That is understandable, but I thought to myself, I couldn’t even imagine going to Madison Square Garden right now and being in a concert with thousands of people. I just think that’s going to change.

I think things will be different and it’ll be very strange for a while. That’s, I guess, the unforeseeable future. I don’t know how long that’ll happen for. I think it’s going to take a very long time for things to go back to the way it was. That’s just my opinion.

PP
What do you think is going to be particularly challenging for people to deal with?

E.R. Nurse
I think maybe accepting that things will take a while to go back to normal. I’m also a little worried because, now that things have gotten a bit more lax, it seems as if people have also gotten more lax. I see more people going out without masks. A friend sent me a video of people who were all lined up in New York City, I think to go get dinner — it looked like a restaurant was open for outside eating, or drinks, I’m not sure. It was just a massive line of people, and most of them looked like they weren’t wearing a mask or distancing. They were bunched together, just big groups of people hanging out.

We are worried that there’s going to be a second surge in New York. Several doctors think it may not be as severe, which I’m really hoping because to go through what we went through again…it was horrible. I am worried about that, and I think that that’s going to be surprising and hard for people if we do end up having to shelter in place again.

Daily life during covid-19

PP
I’d imagine that every day is kind of different, but could you generally try to describe what an average day is like for you?

E.R. Nurse
Yeah, I can try. I’ll take my shift the other night because I was in the Covid designated area. I’ll come clock in at 6:45pm. At 7:00 we do a huddle, led by our nurse manager, who tells us about any updates that we have to the emergency room, any new policies we have in place, anything that they want to share, and if anybody has any concerns, they can share them.

Then we will receive our assignments for the night. Every night that you are there, you are switched to a different area; everybody rotates through the areas, so you usually do not get the same assignment two shifts in a row. I’ll go to my area and I’ll take endorsement from the nurses who are going home. We try and split the patients evenly. I’ll take the handoff from one of the nurses, and then he or she will show me each patient.

I always go to the patients’ bedsides to make sure I know what they look like and they know who I am, and I can talk to them and introduce myself. Then, I’ll take stock of what the patients need – for example, if they need a medication or if they need bloodwork – based on who is the sickest or who seems like time is of the essence for them, I do those orders first. I prioritize it based on issue and based on the patients.

So in the Covid area, for example, let’s say one patient needs an antibiotic, but then another patient comes in and they’re wheezing in their lungs. I would always attend to [the wheezing patient] first, because that can become a more advanced, very severe issue. I would give the medication for the wheezing first, then give the other thing. It’s a lot about prioritization, and you start to kind of be able to recognize who is sicker, who needs attention first.

As people keep coming in, you and your partners rotate through who gets the next patient. When I get a brand new patient I go talk to them. We start an I.V., we get labs, usually we’ll hang some fluids or give medications if the doctor thinks it’s appropriate. Then based on the lab results or any medications they need, throughout the night we just keep re-evaluating them.

It’s a little different from nursing on the floor. Nursing on the floor, I think, is a little more set. They have set medications and set orders. In the E.R. it’s like everything is kind of emerging at once. You treat each problem accordingly until you end up sending [the patient] upstairs.

PP
How did your family feel about you working with Covid patients?

E.R. Nurse
They were very anxious, and they still are. I try to just sort of avoid them, because I live at home with my family. My parents are older – they’re in their 60s, and my mom is immunocompromised. She was particularly frightened.

So… I would take off all my clothes outside. Literally, I would go around to the back of my house, take off all of my clothes, go inside, and dump them immediately in the laundry. I’d go upstairs, I’d shower, and then… I wasn’t even using the stove; I wasn’t using my kitchen, because [my parents] were so scared of it. I kind of just stayed in my room, unless I had to go to work. There was no real way for me to avoid them, but I tried my best to limit the surfaces I touched and my interactions with them.

PP
Are you still taking all those precautions, or have you been able to relax a little bit?

E.R. Nurse
It’s definitely relaxed, but I still haven’t seen a lot of my family. I haven’t even given my mom a hug. It sounds like such a small thing, but to think of that for three months! It’s strange to live in the same house. But things have relaxed more. I’ve been cooking. I still take off all my clothes though, when I come home. That’s the first thing I do, and I throw them in the wash so I don’t have to walk through the house in them, and they don’t have to touch anything. That I still have continued to do.

reflections

PP
What do you think has been the most challenging for you to deal with during all this?

E.R. Nurse
I think the lack of staff for sure. Because…we were trying our hardest, but we were not giving the safest quality of care, and also we were so rundown. All of us were really rundown, and trying to care for multiple, multiple patients at once.

It is next to impossible to care for several patients at the same time, especially if a lot of them are starting to go downhill and decompensate. I think that was the biggest issue. Then second was lack of resources. But from a nursing perspective, the staffing was just…that was the worst.

PP
Do you think this whole experience has changed you in any way?

E.R. Nurse
Yeah. I always try to be empathetic to people, but I think, because we saw so many people suffering…I try to be nice to people no matter what, but now that Covid has happened, I try to be really empathetic. Even if, let’s say, someone says “oh, I’m short of breath,” but their oxygen saturation is still really good, I recognize that it can still be really scary for them. Instead of just being like, “oh, well it’s okay because your saturation’s good,” instead of kind of brushing them off, I recognize that it can be really scary for people and I try to empathize more.

We were really stretched so thin for taking care of patients. I try to give everybody the care that I’d want my mom or my dad to get if they went into the hospital. I’d want people to treat them with respect, so I try to do that for the people who come into our hospital. I feel like maybe there’s a heightened sense of that, just because this was so traumatizing for patients and so traumatizing for us.

PP
Is there anything that you want people to know as an emergency room nurse?

E.R. Nurse
I guess I just want people to know that this is really serious. I know a lot of people took it seriously, but they also didn’t see the things that we saw. So for people who think maybe, “oh, it doesn’t affect me because I’m a young person,” or, “oh, it’s not as severe as everyone saying…”

I even see people online saying “the hospital staff is lying.” We’re not lying. This is a really, really scary and severe thing. So I just want everyone to know: please take this seriously, and try and stay safe.