Coronavirus (Covid-19) in the I.C.U.: The experience of an intensive care nurse in Illinois

Filed Under: Costs

Continuing our series of interviews with doctors and other medical personnel in the era of Covid-19: A recently graduated nurse in the ICU of an Illinois hospital told us about her experience.  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?

ICU Nurse
Outside of the nursing world, it’s kind of surprised me how many people just straight up don’t believe in [Covid]. There’s a lot of backlash on social media. People think it’s a big hoax or that it’s not as bad as it seems, because the one person they know that had it wasn’t that bad. Even when I try to talk to some of them, they just don’t want to believe it. That kind of surprised me because I see the darkest deepest parts of it. It’s kind of shocking to me that people could still be in disbelief.

Within the hospital itself, [I’ve been surprised by] how much resilience everyone has and their adaptability to things that are changing all the time. Every day when I go into my shifts rules and regulations are changing, and everyone just kind of picks it up and rolls with it. First, we started off with limiting the number of staff that go into patients’ rooms, [and were] reusing N95s, and now we have respirators; how we turn the patients [has changed], which ones we put in the prone position and which ones we don’t and all that – all those regulations change every day as new evidence rolls in.

“Our first Covid patient rolled in and all the rules got thrown out the window”

Phoebe Pinder
Are you working directly with Covid patients?

ICU Nurse
Oh, every day. I’m in an I.C.U., so we have 10 beds. I think last week or the week before, was the first time since this whole thing started that we had our first non-Covid patient. So we’ve pretty much been a straight-up Covid I.C.U.

Phoebe Pinder
Have you been working there since Covid started?

ICU Nurse
Yeah, I started my position at the end of February, and then I think it was like three weeks later all the lockdowns started happening. So it was pretty much right from the get-go. I got two days of non-Covid orientation and then our first Covid patient rolled in and all the rules got thrown out the window; we had to learn new roles right away.

Phoebe Pinder
How have the patients been handling it for the most part?

ICU Nurse
A lot of our patients are intubated and sedated, because it’s not comfortable having a tube down your throat. Everyone who is intubated and on a ventilator, we keep them calm and comfortable with a variety of sedation medications. So they’re not really able to verbalize how they’re doing — it’s more about how their vital signs are changing and their electrolytes and labs, and just the subtle things that we as nurses have to notice.

Now we’re letting more of the physician go into the rooms, but when this all started and we were conserving PPE because we didn’t know what kind of shipments we would be getting in, we weren’t letting the doctors go into the rooms. At one point in time, I was the only person allowed to go into my patients’ rooms. Everything that the doctor was doing – prescribing interventions, meds, etc. – was based off of my assessment. It was kind of scary, but it sure made me realize I need to be very, very precise and be a huge advocate for my patients in that sense because they couldn’t do it themselves.

In the ICU I have the sickest of the sick. I sometimes have patients on BiPAP, or a heated high flow nasal cannula, which is called a vapotherm, but most of the time they’re intubated and sedated.

Some of [the patients] handle it, okay. A lot of them have not been, which is kind of the norm for this right now. A lot of our patients do end up passing away or get transferred out to larger hospitals for higher acuity care. But the ones that do make it, they’re tough. They’re tough people. It’s hard when there’s this infection that just takes over your whole body and you can’t breathe, you can’t move, you can’t do anything without your oxygen just tanking.

But we’ve had some success stories, patients get discharged, even out of the ICU. They do get lonely in there when they can’t have their family and friends come and visit them. The nurse can’t be in there 24/7 – we have to protect ourselves too and limit our exposure. But [the patients] are tough.

Phoebe Pinder
Do you guys have total PPE that you have to wear when you go in to work?

ICU Nurse
Yeah, I have my own cloth hairnet now instead of the throwaway surgical ones. There’s been donations made. I have one of those that I wear the entire shift, and then every time I go into the room I put another hairnet on top of it so that I could throw that one away. I put on at least two or three pairs of gloves with my gown and little shoe coverings, little booties.

We used to have N95 masks, but the hospital just got us respirators that actually let us breathe better. We can exhale our CO2 without retaining it all. I’ve been using that one for the past week and that’s been great. And a face shield; we each have our own designated face shield as well. So there’s lot of gear to put on every time we go into the room.

Phoebe Pinder
How are the doctors feeling about not being able to see the patients in person?

ICU Nurse
Luckily for us, in general, our doctors really work well with our nursing staff and trust our judgments. They do go look in the windows so that they can see an overview of what’s going on with the patient, but you know, it’s hard when they can’t listen to [the patient’s] lungs on their own. So they are just really pertinent about asking us to notify them of any and all kinds of changes. There’s a lot of lab work that they look at instead and x-rays and things like that to determine patient condition along with the nursing assessment.

The only doctor that really insists on going in the rooms every day is the infectious disease doctor, which makes sense – he kind of needs to see all the patients on his own. But as for the rest of them, they’re really good about working with us as a team and listening to our judgment. They haven’t really complained. I mean, we can’t really have 800 doctors going into every single room every day. That’s a lot of a lot of PPE for a 20-second assessment.

Temperature checks, but tests only for symptomatic people

Phoebe Pinder
Are they testing the staff for Covid?

ICU Nurse
They’re only testing staff who present with symptoms. Every day when I show up for my shift there is a temperature check person who makes sure that we don’t have a fever. We also have to fill out a webform that goes back to the CDC to show that we don’t have a fever, shortness of breath or coughing before we show up for a shift.

It’s done before the shift, so if it’s a day I’m not working, I don’t have to fill it out. But it has to be done within two hours of me showing up for work. They check that and then they check my temperature again at the door and if I have symptoms then they’d send me down to the tent outside the E.R. [for nasal swab testing]. But I haven’t had any.

Phoebe Pinder
Have any of your co-workers gotten sick with Covid?

ICU Nurse
Not in my direct unit. I think there’s been one nurse in the whole hospital. We’re a pretty small hospital to begin with. We only have 143 beds total, and only 10 in the I.C.U. I think only one nurse has tested positive, and obviously was sent home.

Daily Life During COVID-19

Phoebe Pinder
What has changed most for you personally during the Covid era? Work, home life, etc.?

ICU Nurse
For work, it’s really been prioritizing my plan for the night — trying to cluster care as much as possible. In normal circumstances, I can walk in and out of the room as many times as I need to like, “oh, I forgot to bring a pillowcase. Let me just go grab one really quick.” But when I’m in a Covid room all dressed up, I can’t just leave and get more stuff.

I really need to plan ahead of time, “okay, I have meds due at 9 o’clock and I have meds due at 10 o’clock.” I have to figure out a time where I can just do all of my medicine together so I don’t have to go into the room two separate times. It’s really changing that sense of prioritization for me. I can spend a long time in the room at once, but then I don’t have to go back for four more hours unless there’s a change in my patient’s condition, which is a little different than what I was used to before.

For home life… Illinois was really tough on the lockdowns. We’re slowly, slowly reopening. We just got to the point of having outdoor seating with social distancing at restaurants, whereas I know other states have been opening up more quickly. I think I saw we have had some of the slowest growth [of cases] so something about that is working.

But it’s hard to stay home and not see my family and friends, even though I get to go to work. I still get a little stir crazy; I like things like going out for pizza, and it’s hard not to be able to do that. I’ve been quarantining with [my boyfriend] at his parent’s house because they have a separate basement, so it’s kind of turned into our little mini apartment. His dad has heart problems and my mom has lung problems, so I’m trying not to stay too close to either one of them just in case.

Planning, planning, planning

Phoebe Pinder
I know it’s probably different every day, but do you want to briefly describe what an average day is like for you?

ICU Nurse
I work the night shift, 7 p.m. to 7:30 a.m. When I show up for my shift, we do a little huddle where we talk about what patients we have in the unit, just so everyone’s aware what everyone’s code status is — who’s a full code versus Do Not Resuscitate; what kind of major drips we have going on. If somebody’s on vasopressors to help out with their blood pressure, or different medications for their heart rate, if they have a really slow or really fast heart rate, those are kinds of things that the whole unit needs to know a little bit about.

Then we take report from the day shift. In the I.C.U. we are one to one or one to two, so the most patients I’ll ever have is two. Something that would be a one to one would be like a cardiac arrest patient, because there’s a lot involved. So the day nurses will tell me about the patient, they’ll give me a rundown of their assessment — what kinds of doctors and medications they have, and if there’s anything special I need to do for the night, like make sure you hold this medication or make sure you draw this lab at midnight or something like that.

If it’s a non-Covid room, we can walk into the room and say hi to the patient, just so they can see who’s leaving and who’s coming in. If it’s a Covid room, we kind of wave from the window so that we don’t have to dress up just to say hi.

Then I’ll take about a half hour to go over my doctor’s orders, to make sure everything is set, things that I need to do, labs that I need to draw. I’ll write down what times I have to give my medications – usually it’s like 9pm, 12 to 1, 5 a.m., 6 a.m., something like that. Then I’ll start to prioritize my plan for the night as if it was going to go perfectly.

In the ICU we do full assessments every four hours, so I’ll plan my 8 o’clock, 12 o’clock and 4 o’clock, around my medications and other things like that. If we have a C.N.A. or a tech helping us, we’ll plan our bed baths, and other kinds of things they can help us with. If the patient needs a blood sugar check or something, then the tech can help me get that so that I know if I need to give insulin. I’ll help out my fellow nurses with things that they might have going on and prepare for all of that to get thrown out the window at any given point in time.

Phoebe Pinder
So you really just play it as it goes?

ICU Nurse
You kind of have to. You never know who’s going to show up in the emergency room and who needs to be admitted to the ICU. Whenever there’s a rapid response called on a patient on the floor who might be deteriorating, then we have to go assess the patient ourselves and see if they need to have more interventions or if they need to come to the I.C.U. for more critical care.

We have a computer system that shows us every single patient in the hospital so we can see who’s most likely to crash and come over. We can watch that and kind of prepare; if we have a bed open we can get the bed ready, versus if we’re full, can we downgrade somebody and kick them out in case somebody is crashing? So it’s all kind of just playing it as it goes. Everything’s constantly changing.

Changes Over Time

Phoebe Pinder
Could you talk about what things were like for you at the beginning of COVID versus the peak versus now?

ICU Nurse
Throughout this whole time, there’s so much that’s still unknown, and we’re learning a lot, but in the very beginning, I think everyone was really on edge. Nobody wanted to go into the rooms at all because we didn’t know how it was really transmitted and we were just trying to protect ourselves. Right when it started, I was still in orientation, so I was with another nurse who was my preceptor. Our very, very first Covid patient, I controlled everything from the outside of the room and she controlled everything from the inside so that we both didn’t have to go into the rooms.

Within a couple of weeks, we actually took all of the medication drips machines, IV pumps and put them outside the room. Normally they’re inside the room, but every time they start beeping [we have to check], and we have drips that we have to change the rate every 10-15 minutes depending on the patient’s response. That was a lot of hassle to go into the room, get all dressed up just to change the rate. So we got extensions and put all the drips outside the room so you can control that without having to get all your P.P.E.

We got to be really good at turning our patients prone. Research was showing that that’s better for lung expansion because Covid takes over the lungs completely. So [the prone position] tries to help open up the lungs and get more airflow going through. The first time we proned a patient we had to watch YouTube tutorials. It took us 45 minutes to do it and it took like 10 people, but lately we’ve been doing it with one respiratory therapist and three nurses, and it takes about three minutes. We have a system, we flip them over, and we’re good to go.

Now we kind of know what we’re doing, we have a flow for all those treatments. Respiratory has a flow for all of their treatments and we work really closely with them. I’ve learned a lot more about ventilators than I thought I would ever learn in my lifetime, because a lot of times I’m already in the room, so respiratory will just knock on the window and ask me to adjust one of the vent settings so that they don’t have to get dressed up and come in there with me. If it’s easy enough, you know, turning their oxygen from 60% to 50%, I can do that really easily and it saves them a trip from coming inside the room.

There’s a lot of different treatments that we’ve tried and started and stopped because of the emerging evidence. We were doing that hydroxychloroquine in the beginning, and then that was causing a lot of cardiac issues, so we stopped that, and now we’re doing the plasma. People who have had COVID can donate their plasma and we can get that into our patients and that’s potentially starting to show some help there.

Long-lasting changes at the hospital

Phoebe Pinder
What do you think will be the long lasting changes that are implemented at the hospital going forward?

ICU Nurse
I think probably new policies and procedures for doing, not necessarily Covid tests, but different tests in general. It used to be that we would do a nasal swab for every single patient for MRSA, and we’ve basically stopped doing that right now. I don’t know if they’ll bring that back for every single person or only patients that might need it.

I think people will be more conscientious about using PPE, even when, years down the line, this ends. If it’s a flu patient, you technically have to wear a gown and a surgical mask when you go in the room. In the past people would put one on, go in the room for two seconds just to check a temperature, and then leave. But I think people will keep some of the clustered care and try to do more than one thing at a time to not waste PPE, even though we’re not super short on it. I think some of those habits will stick.

Phoebe Pinder
You mentioned that you had your first non-Covid patient in a while recently. How do you keep the patients separate?

ICU Nurse
In the beginning, we only had two negative pressure rooms, which is where air from the room does not go back out into the central area – it gets pulled up and out of the room. That would be used for something like tuberculosis or chickenpox – things that are airborne. We had all of our I.C.U. rooms converted to negative pressure. The Covid patients are in negative pressure rooms and the doors are always closed so no air leaks back out into the central area.

Then what we try to do is, to the best of our ability – we have to worry about patient safety more than nurse preference – we try to make it so you’re not taking care of a Covid and a non-Covid at the same time. So, if you have a non-Covid patient, we try to make it so that you don’t go into Covid rooms. There’s not always the option to do so, but [we do it] as much as we can.

When you’re geared up properly with your P.P.E. there should be minimal to no risk of transmission. Also, all hospital staff wears a surgical mask at all times when you’re not wearing your N95 or respirator, so if I go into my non-Covid patient’s room, I still do have that layer of protection for me and for my patient

Phoebe Pinder
Going forward, do you think there’s anything that’s going to be particularly challenging for people to adjust to in the post-Covid world – be that practices at your hospital or things in everyday life?

ICU Nurse
I think what’s going to be hard is realizing that this is not going to be over and done with just because it’s summer and the weather is getting nice out and you know, you’re sick of it so you decide it’s done. I think this is going to last a while. We’ll have peaks and lows, but I don’t think it’s going to go away for probably a couple of years to be completely gone. I think it’s going to be hard, just in general, for people to keep practicing some level of safe social distancing and extra hand washing and being careful about who you’re around for the long haul.

People were willing to do it for the short term when it started, but just in my conversations, [I can tell] people are sick of it. I mean, I’m sick of it, but I think that’s going be what’s kind of difficult moving forward.

We still have to wear masks when we’re in stores or where we’re within six feet of other people. A couple of times I have seen people out with their masks down around their neck. I told them “hey, that’s not really helping you too much.” Some people respond and put it back up, others kind of give me a dirty look and walk away.

But I do remind my family to stay safe, wash their hands, wash the countertop — that’s like, the most used surface. Wash your hands before you touch food, wash your hands when you come in from grocery shopping, try to put your clothes in the washing machine, things like that.

Phoebe Pinder
Is there anything that you would like people to know as an ICU nurse during Covid?

ICU Nurse
I just want people to stay safe. Unfortunately, I’ve seen the worst of the worst of the worst, and I know how scary it can be. I know some people think that washing hands might not seem like a big deal, especially if you don’t see any kind of visible dirt or soil, but these things matter. Just stay safe.