Editor’s note: Jackie Christianson is a Pine City High School graduate who currently lives in Wisconsin. She is a nurse practitioner with ICU and ER experience. At the end of March, she flew to New York City to work with patients as the COVID-19 pandemic peaked in that city and overwhelmed its health system. She wrote about her experiences in her blog at https://sites.google.com/nursesinternational.org/projects/our-stories/nurses-stories?authuser=0. These are excerpts from her writings.
March 25: My flight from Madison to LaGuardia had two passengers, including me. The NYC roads were similarly silent, like we had entered the city in an alternate dimension. The cab driver told me I was his first customer all day.
I arrived at the hospital and reported to the emergency department. I learned that I’ll be the first nurse practitioner ever to work in the department, and that I will be in the current busiest hospital in the city. Presently they are at “surge capacity,” which means it’s all but standing room only. The normal capacity of the department is 60-70 beds, and there are currently about twice as many patients as beds, despite efforts to discharge and divert patients. Most of the patients are seated in a chair or, if they’re unlucky enough to need one, a cot in the hallway. The rooms are reserved for the least fortunate people: patients who need respiratory support, heart monitors, or invasive procedures. Patients are all assumed to be COVID-19 positive. If they didn’t come to the emergency department (ED) with it, chances are good they’ll leave with it.
Tomorrow I flip to night shift and head to the tent ED, the hospital’s temporary solution to admit and treat even more patients.
March 28: The situation is still severe, despite having only about 70-100 patients in the department over the past two days. You can still barely navigate the ED hallways for all the patients in beds or chairs occupying the hallway. Diagnostic and treatment procedures that normally take 2-3 hours in totality are taking 8+ hours due to the delay in order completion.
I caught a few patients with oxygen tanks that had run out or who were showing signs of deterioration and needed their oxygen turned up or blood pressure management. Hopefully that work helped a few people stay off the ventilators. Internal medicine and other ED providers have told me that most people who deteriorate to the point where they need a ventilator usually die. I believe them based on what I have seen in the past three days.
I arrived a little early to my shift, just as they were starting CPR on a patient. Most codes take immense resources on the best of days, and there are usually five or six team members participating when CPR is in progress, but the patient who went into cardiac arrest was a COVID patient, so they limited the team to three (an RN, an MD, and a respiratory therapist). Resuscitation efforts are light under current circumstances – perhaps 15-20 minutes instead of the 45-60 minute average. We can’t reasonably justify taking away that many resources from so many other ill patients to run a code, especially since only about 15% of people who have CPR done get a pulse back and maintain it for 24 hours. The hospitalist told me around 5 a.m. that they had attempted resuscitation on seven patients since night shift started. They’ve reached the point where they’re so busy trying to resuscitate people that they’re almost at a standstill with their living patients.
March 30: The last two days have been brutal. The raw number of patients in the department has improved a bit, but the sickest patients are still in our department and we’ve had many deteriorate over the past few days. I’ve lost track of the number of patients we’ve placed on ventilators, and many who have been on ventilators for a few days are deteriorating and dying despite escalating support. Yesterday we had 1,000 total COVID-confirmed deaths in the United States. We don’t test people post-mortem unless they have an autopsy, so I’m sure those numbers under-represent the total deaths by a significant margin. We’ve had at least three patients tonight arrive via EMS and simply be declared dead on arrival; they weren’t tested and likely won’t count toward the official COVID-19 count, even though odds were good they had it.
I’ve had to both order and place restraints on many patients because some are becoming confused and agitated. Sustained low oxygen levels, even when they aren’t low enough to be deadly, have a negative effect on brain function.
The department is at the point where I, the person who’s been here for all of four days, am medically managing critically ill patients who are unstable or newly intubated. I haven’t yet done an intubation myself, but … I’ve done almost every other skill I’m qualified to do in the critical care setting, from jugular IVs (in the neck) to ordering continuous infusions of blood pressure support and sedative medications. I guess I haven’t drilled into a bone for IV access yet, but that also strikes me as a likely possibility in the coming week. I’ve been extremely grateful I’ve maintained these skills over the years and that my medical practice is fluent enough that the stress-haze I’m in isn’t impairing the care I can provide.
April 2: Everyone keeps sending me messages and affirmations and telling me I’m a hero for coming here, but I feel more like I’m prolonging the inevitable for most of the people I see.
I’ve gotten numerous questions about personal protective equipment, so here’s a long and short of what I’m doing to protect myself. When I am ready to go to work, the last thing I do is put my scrubs on before I leave the hotel room. I bike to work in my scrubs and put on my N95 and face shield from the previous day before I enter the hospital. I do sometimes replace it with a fresh N95, depending on the state of the one brought, and I wear a surgical mask over the N95 to reduce the likelihood of soiling it. When I go into patient rooms, I wear gloves and a gown, though I sometimes skip that step when seeing hallway patients in a non-contained area to preserve our supplies. At the end of my shift, I remove the face shield and N95. I bike back to the hotel without a mask, then as soon as I am in the door of my hotel room, the scrubs come off and are left next to the door, to reduce contamination of my hotel room. I usually shower after this as well, but if I’m too exhausted, I just wash my hands, arms, face, neck, and chest before proceeding to bed.
I don’t have any symptoms, other than a sore throat from dehydration on shift. I’m 29 and healthy, so I’m highly unlikely to become seriously ill and, based on the statistics published by countries like South Korea that can be bothered to test extensively, I’m extremely likely to be an asymptomatic carrier. Many nurses and doctors I know from back in the Midwest have told me they’re only getting a surgical mask for confirmed cases, or nothing for patients who haven’t had a confirmed positive test.
I wonder how many nurses will die a preventable death from COVID. Numerous coworkers here, where protection is required for every patient regardless of test status, have tested positive. A few are on ventilators or in intensive care as I write this.
On a more positive note, I learned today that at 7 every evening, the community around this hospital gives everyone working for the hospital a standing ovation. People driving by turned up their music, people yelled out their apartment windows, and passersby joined in. I hadn’t noticed the signs around the block or heard it previously, but another staff member told me it’s been going on daily for at least a few days.
April 5: I finally developed a pressure sore on the bridge of my nose. It’s from where my mask is fitted to my face, and I’m surprised it took this long. I found a dressing that will cover it, but it will likely reduce how effective the mask is. I’m wearing the dressing anyway, but I’ve almost certainly already been exposed during all of the resuscitations. At least this way I’ll have a smaller wound on my face to go with my disease exposure.
It’s still chaos here, but the chaos is far more controlled. The USS Comfort, the naval ship that has been in port and ready for patients since Monday, finally started taking COVID patients on Wednesday.
I had assumed the trucks behind the hospital were food trucks for patient meals or something hospital supply-related. I learned today they’re outfitted with coolers for all the dead bodies. There are so many dead that the funeral homes are full and the city morgue is over capacity. They must have filled the first trailer, because the second one showed up over a week ago. NYC had over 700 confirmed dead from COVID on April 8th alone, and I guess they’ve got to go somewhere.
We’re commonly seeing patients with COVID who have blood clots in various places (mostly lungs and brains). Apparently a huge number of patients have had blood clots in the lungs found on autopsy. We’ve seen more than a few patients with a (normally) extremely rare condition called DIC. It starts as an uncontrolled cascade of blood clots form throughout the body, which cause their own life-threatening problems that can obstruct circulation to the lungs. Eventually, if the blood clots themselves don’t kill the patient, the body runs out of material to make blood clots with and starts to hemorrhage because it can’t heal micro-tears in the vessels like it normally can. I’ve only seen DIC two times in my career other than my time treating COVID patients.
Tonight we ran out of endotracheal tubes. We have put so many people on ventilators that we only have small and XL size intubation tubes. If your airway is the size of a bratwurst, you’re in good shape, but for anyone who’s even close to average, we just don’t have the right size. They’ve been using the too-big and too-small tubes anyway because it’s better than nothing, but I never even considered the possibility of running out of those tubes because they’re so damn common. The OR, on a normal day, probably uses 50-100 of them. Why the hell are we running out of such a commonly used supply? We’ve run out of BiPAP machines, too, so that tool is no longer an option to keep people off the vent. The endotracheal tube issue will likely be fixed during the day shift, but there isn’t a good BiPAP alternative. We have a jury-rigged CPAP machine made from a CPAP mask, a certain type of manual bag ventilator with a special valve, and two high-flow oxygen connections. It’s a good temporary solution, but it’s only a matter of time until we run out of those supplies, too. I wonder if running out of oxygen supplies in the hospital is possible?
I ended my last shift in this stretch of 11 shifts in a row with a wake-up resuscitation one hour before the end of shift.
When I return to the hospital – if I return to the same hospital-they’re offering everyone the COVID antibody test. I’ll definitely get it done the day I return; if I have antibodies, that means I can start the clock and 14 days post-test, I shouldn’t be contagious and have a degree of immunity, which will make me feel much safer about returning home.