Most of my nursing experience has taken place in acute care settings. I left hospital nursing in 2022, and have been in long-term care ever since. Overall, I’ve been a nurse for 8 years, working in healthcare for over 12, and I forgot the word “antecubital” yesterday. Not only did I forget it, but I forgot that there was even a word to describe that area of the body. I contented myself with “inner elbow” for my note and moved on.
I am trying to remind myself that when you stop working with IVs, there’s not a lot of reason to remember the word to describe anybody’s antecubital area, but still… Once I recalled the word, it was like an area of my brain suddenly lit up, and memories of a part of me that hadn’t existed moments earlier was suddenly reactivated. I was shaken. I’m very humbled right now, because I feel like I had a VERY SMALL glimpse into what it must feel like to have Alzheimer’s.
It might not be that my residents are struggling to remember things all the time, but more that they’re constantly forced to confront the fact that they have forgotten things they don’t even remember forgetting. I feel like there’s a greater loss than I had assumed.
For example, if you’re trying to come up with a word and it’s right on the tip of your tongue, you at least have the reassurance that there IS a word and it DOES EXIST and you used to KNOW it and you CAN know it again. But what if somebody introduced themselves to you one day and you suddenly remembered that they are your daughter… that you have a daughter… that you forgot your daughter. And you suddenly remember the day they were born and it becomes fuzzy as they get older in your memory but you know there MUST be memories from birth until now that are gone. You were fine a moment ago, not knowing you had a daughter. But now…
You’d be constantly mourning the loss of your life with every spark of a memory. Would you resent being confronted with the truth? Or grateful to have that spark reignite for a moment? Would you start to remember but it’s too overwhelming to accept so you turn away and choose to avoid the triggers, becoming upset and acting out until those strangers (your family) stop coming around anymore. They tell themselves it’s okay because you don’t remember anyway. You tell yourself it hurts too much to remember so they should stay away.
Just musing on a Saturday, feeling very humbled to have the brain that I have, knowing how delicate of an organ it is based on how quickly it can turn against you.
We are nearing two years into this pandemic. The miraculous answer to ending the tragedy (a vaccine!) was quickly developed and made freely available to the public at the end of 2020, and yet one year later we are enlisting the aide of the National Guard because our healthcare workforce is collapsing from the endless onslaught of unvaccinated incubators of the more virulent Delta variant.
New, more surprising complications of the prolonged pandemic arise daily. PPE is in ample supply currently. We have enough ventilators. However, we are constantly running out of essential medications (such as fentanyl, propofol, cisatricurium, and norepinephrine) that are routinely poured into our sedated, ventilated, paralyzed, and proned COVID patients in ICUs across the country. Supply chain interruptions of specialized tubing for central lines and suction canisters cause hasty substitutions or policies of reuse that have unknown implications of hospital-acquired infection rates.
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Our patients are younger during this wave. They are not as often the old and frail with organs already failing. This time my average COVID patient is an unvaccinated person in their 40’s-60’s who don’t have any diagnosed health problems beyond obesity. Non-smokers. Working men and women with families to support. These patients get just as sick, but they last longer. They linger in the ICU, lungs scarred and yet fragile, unable to wean off the ventilator. They get a tracheotomy so they can have more time on the vent to maybe improve. After a month in the ICU their muscles have wasted and they can barely hold their head up. Their kidneys have suffered the onslaught of systemic inflammation, hallmark of the Delta variant, and are now reliant on dialysis. They will never return to work. They will require oxygen for the rest of their lives. Their families will face the financial burden of enormous medical bills and lost wages.
Remember, the vaccine is FREE, SAFE, and EFFECTIVE.
I wonder sometimes if I’m living in a different reality. Patients are always surprised when they end up in the ICU. They regret not getting vaccinated. They struggle more and more to breathe. They ask, fear in their eyes, if they are going to get worse. I encourage them to call their loved ones because once they need to be intubated there is no telling when will be the next time they speak to their family again, if ever. And every one of them is shocked that it’s happening to them. In my job, I see a lot of anguish, delirium, depression, anxiety, and regret. I also see hope, determination, and acceptance. Those encouraging moments have become so rare now that COVID is 90% of my ICU.
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Please take a moment to read the linked article. I also summarize it below, but it’s worth reading.
“As of Tuesday, there were 1,382 Minnesotans hospitalized with COVID-19 and only 47 staffed ICU beds were available in the entire state.”
There is a ranked list of 100 US counties based on number of COVID cases compared to population size. Of the 100 worst counties on the list, MN claims 25 of them.
The current national average is 26 COVID cases per 100,000 people. Anything above 10 per 100K is considered “high levels of community transmission.”
SWMN area is particularly hard hit right now. Dodge County (located between Mankato and Rochester on the map) is #3 in the country at 173 cases per 100,000 people. Goodhue County (between Red Wing and Rochester) is #9 with 148 cases per 100,000 people. Wabasha County (between Rochester and Winona) is #30 in the nation with 112 cases per 100,000. Scott County (between Belle Plaine, New Prague and up to Chaska) is #69 in the USA with 98 per 100,000. And Blue Earth County is now #89; the current rate is 93 cases per 100,000 people.
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When people find out that I work in the ICU, everyone’s first question is: “do you have any patients that are vaccinated?” Anecdotally, almost every one of my COVID patients are unvaccinated. The ones that are fully vaccinated and yet still get deathly ill are rare, and are always sad cases; chronic conditions impaired their immune system and so their greatest protection would have been to have everyone surrounding them vaccinated and properly masked. They did everything they were supposed to do but then they ran into the wrong person. For those who like hard facts, however,
“according to the MMA, 70% of COVID-19 hospitalizations in Minnesota are unvaccinated.”
There’s a new tragedy popping up in the ICU: people who did everything they were supposed to. They quarantined and masked for over a year. They got the vaccine and celebrated surviving a pandemic. Yet, somehow, the virus found its way in and they are now dying.
My patient and her husband both got the vaccine. She had already fought lung cancer and lived past doctors expectations by several years. Getting the vaccine signaled the end of a year of worry and precautions, constantly taking care to protect themselves knowing the novel virus would be a death sentence. They rejoiced at having cheated death yet again.
She arches restlessly in the bed, clear mask covering eyes, nose, and mouth. The pressure of life-sustaining oxygen being pumped into her in an attempt to give just a little more time for family to say goodbye. She lost half a lung to cancer already. The remaining tissues inflamed and scarred, barely able to exchange oxygen and carbon dioxide despite the force of the pressure aimed to keep delicate alveoli open. A halo of peach fuzz covers her pale head gripped by the straps of the mask. “She was so happy that her hair was finally growing back,” her daughter muses softly from across the bed. Both children share stories and songs, desperate to feel normal despite the reality of their mother’s eminent death ever present in the room.
Yesterday, my patient’s husband arrived to see her and say goodbye. Recovering from COVID himself, he arrived dressed in a spotted hospital gown with an oxygen tank trailing behind him. His nurse wheeled his chair closer to the bed so he could hold his wife’s hand. He called her name softly. There was no response. Though her eyelids fluttered open occasionally, his wife was no longer aware of her surroundings and so he resigned to simply sit next to her for hours. From time to time he would pat her hand and gently call her name, but getting no meaningful response he simply sat and watched her labored breathing, his tired eyes taking in the image of his wife losing the battle that he was fighting still.
Her husband has said his goodbyes and today the children are here. “I’ve never seen anyone die,” her son comments, unprompted. He attempts conversation, unsure what to ask. The patient is restless and delirious. I’ve given all the medications I can and tried to make her comfortable in the bed. Out of ideas, I finally rest my purple-gloved hand on her forehead and gently stroke it, as a mother would caress her child. The desperate gasping slows and my patient’s panicked expression shifts to a blissful one as her eyes gently close. As I continue my ministrations, grateful for an intervention that works, her son queries behind me: “You must see people die all the time. Do you ever get like PTSD from it? Like nightmares?"
Do I have PTSD? Do I have nightmares? Can I ever forget the faces of every panicked, gasping, patient who took their last keening breaths under my care? Can I sleep soundly at night while mentally flipping through the catalog of faces, monitors, phone calls, beeps, cries, shouts, the menagerie of images of sedated, intubated, paralyzed bodies needing turning, cleaning, treatments, assessments, having the same conversations over and over with families trying to understand that their loved one will not survive while we continue to “do everything” to prolong their life despite no chance of meaningful recovery?
As I continue softly smoothing my patient’s tense brow, watching her eyelids flutter closed as she slips further away... I know this, too, will be burned into my memory.
Do I have PTSD? “It’s been a hard year,” I reply finally, choosing instead to focus my attention on this woman who grows more relaxed under my hand’s repetitive strokes.
She still lingers at the end of my shift, teetering between death and life with each uneven breath. As I introduce her children to the next nurse taking over care, I am struck by the incongruity occurring. I am invested in this patient and family. I have been on a difficult journey with them for two days now. But it is not MY journey.
This is a day that will change all of their lives. They have cancelled plans, plane tickets, and are living moment to moment following each ragged breath of their mother. “I had her for 60 years,” her daughter remarks. “I only had 50,” her son complains, with a smile.
I am a central part of this story, facilitating this process of death, guiding the family through uncharted waters and providing comfort. Yet I do not belong here. I am merely dipping in and out in the background. I am replaceable by the next nurse. When I go home, my part in their story will end.
But it doesn’t end for me. My eyes are on the road home, but I’m wondering if she is still hanging on. I am brushing my teeth yet also hoping her son will give up his lighthearted facade when he is finally confronted with the end. I am climbing into bed, worried if the medications I gave actually helped as much as they could. Could I have done something differently? Death is so final. I can’t go back and do it differently. Why am I thinking about it at all? My job is done now.
The job is done, then why does she linger? Her face becomes mist, shifting and twisting into hundreds of faces, each with a name and a story. I take a piece of each of them with me. I carry them. But I am not a part of their story.
The vaccine may have saved a life... and almost ended another’s.
When my patient was admitted, direct transfer from a smaller hospital, I assumed the worst. The story was all too familiar: white male, 70’s, cardiac and pulmonary history, Mr. “R” presented to the ER with shortness of breath and hypoxia. His oxygen needs had advanced to BiPAP and so he needed an urgent transfer an hour away to my ICU.
The only thing different about this patient’s history, is that he had received both doses of the COVID vaccine. Exposure happened shortly after the second dose and so he had not yet built up the necessary immunity. Mr. “R” had dismissed his initial symptoms as side effects of the shot, but eventually tested positive when his worsening symptoms prompted him to seek medical help.
When his BiPAP need became only CPAP that night, I was cautiously optimistic. I overheard the admitting provider tell my patient, “getting the shot may have saved your life.” Mr. “R” slept soundly that night. No rapid respirations, no sudden desaturations, and no constant coughing. He had no fever and no DVT’s. CT showed bilateral opacities consistent with COVID pneumonia, but his lungs sounded clear, if diminished. What was going on? Mr. “R” wasn’t behaving like the hundreds of COVID patients that have rolled through this hospital over the last year. A glimmer of hope began to grow in the back of my mind. I ignored it, so as not to scare it away.
I floated to other units for the next few shifts, so I hoped Mr. “R” would continue to improve and move out of the ICU while I was away. Days later, I peeked into his room and was disappointed to see a familiar sight: Mr. “R” was intubated and proned. “They all turn out this way,” I told myself. What did I expect?
But just as before, his trajectory skewed differently than expected. He only needed a small amount of supplemental oxygen through the ventilator, and he was tolerating a respiration rate that was about half the rate that the traditional COVID patient wanted to breathe. His numbers looked good when he was returned to his back, so there was no need to prone or paralyze him again. His sedation medication needs were minuscule compared to the famously “sedation-resistant” COVID patients I was used to. The doctor told Mr. “R’s” family not to worry about him needing a trach, because their loved one would likely be extubated within a few days, if not sooner.
Was all this thanks to the vaccine? Is this what I can expect for my COVID patients going forward? I began to hope again, the light shining brighter as I finally acknowledged the glimmer from before.
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A new admit rolls in to the unit. Not my patient, but as usual it’s all hands on deck. “Post-code” is all I hear as the bed rattles to a stop. A flurry of PPE, screens, cords, and tubing, various alarms and beeps, and people dashing across the unit for supplies, as everyone works together to stabilize the patient, get labs and imaging, and begin the critical cooling process to protect brain and cardiac function. As activity dies down, I learn more details of his arrest and resuscitation. Something perks my attention. “He had just gotten his second COVID shot,” his nurse tells me. “He got it earlier today. His wife figured he was just having side effects.”
My thoughts race. Could the vaccine have had something to do with this patient’s heart stopping? Has this happened before? Will I be seeing other patients with similar stories and outcomes? Which vaccine did he get? Pfizer? Moderna? Could it be completely unrelated? What if this happened to my loved ones?
Intellectually I knew that, even if it were an adverse reaction to the vaccine, the mortality rate of the vaccine is significantly lower than COVID-19 itself and so it should not be a reason to avoid getting vaccinated. I knew this. Objectively. As a nurse.
But as a spouse, and a daughter, and a granddaughter... it gave me pause. Despite my scientific brain telling me “correlation is not causation,” I felt myself hesitate. Maybe I should wait to have my spouse vaccinated... I should find out which manufacturer produced his shot... maybe this is happening a lot and it’s not reported as an adverse effect?
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Now, sitting in my car after a long few shifts, I am able to write and process and gain perspective.
How easily our emotions take over. It’s been a long pandemic. I forgive myself for wavering. I must remember to be kind to myself. We’ve been through a lot as healthcare providers. It’s okay to have hope for the future and it’s also okay to be nervous. We are writing the playbook as it happens. So give in to that glimmer, even when it seems hope is lost.
The other day I called and spoke to your son who was blindsided by your re-hospitalization. He explained that you had recently “beat COVID” and were just now starting to get back to “normal”.
What people fail to understand is that COVID damages the heart. It is insidious. While your lungs seem to be improving over months of recovery, the virus has long since invaded your organs, injured your heart muscle and nerves. You have been feeling better. “I beat this,” you think. That’s what they all think.
I promise your son that I will call with any updates and reassure him that you’re in good hands. I hang up the phone and notice you are becoming more restless and disoriented.
Suddenly, you can’t breathe. Your lungs are filling with fluid because your damaged heart can’t pump blood effectively and you begin to drown. Cardiogenic shock. Flash pulmonary edema. The terror in a person’s eyes as they gasp “I can’t catch my breath...” is burned into my memory over and over. There’s actually a diagnostic term for this symptom: “a sense of impending doom.” Once you witness it, you never forget it.
Your face is now purple. You’re restlessly tossing and turning in the bed, trying to sit up, to get up, to take everything off in an attempt to find air. And we apologize as we hold you down firmly, bruising your frail skin, as we try intervention after intervention to save your life. We try everything to avoid putting you on a ventilator. But nothing is working. Your tired body is in a shock state. Your blood pressure plummets and vessels clamp down to preserve blood flow to essential organs. Your skin becomes cold and mottled. We add medication after medication to help your heart squeeze harder, keep your blood pressure up high enough to perfuse kidneys, lungs, and brain.
Writhing and twitching restlessly, your body is fighting our interventions without realizing it. I try to give pain medications and sedation medications but your blood pressure continues to drop so I have to stop. For 3 hours straight, we work to stabilize your respiratory status until you are finally intubated and on a breathing machine.
It’s now 7 hours into my shift and someone takes over for me so I can grab a bite to eat. The cafeteria is closed by this time so my lunch consists of an energy drink. I rejoice in the 30 minute break from my N95 pressing into my skin. When I return, we spend another 4 hours at your bedside, keeping you alive with every tiny adjustment.
When I spoke with your son that morning, I told him though your situation was tenuous, you were awake and talking and looking good. He was reassured. When I called your son back that evening, I had to explain that you were now on a breathing machine, asleep, paralyzed with medications, and I had no more medications to give to keep your blood pressure up. “But you said he was fine this morning...” he stammers.
Yes. That is what COVID does. It does not rest. And neither can we.
I am a Registered Nurse stationed in the ICU, trying my hand at writing for catharsis, and am bringing you all along for the ride. I hope you find my insights informative and relatable. Names and details have been changed to protect patient privacy.
In times of “fake news,” when even basic science is called into question, I believe in the importance of frontline healthcare workers joining the narrative. Hospital social media policies and HIPAA laws have largely discouraged nurses and providers from publicly sharing their experiences. The “information void” this created has been filled with half-truths, conspiracy theories, and political rhetoric. Knowledge is power; it is our responsibility as nurses to empower people through education and advocacy.
Empathy is the virtue that can save us all. We wear masks in public to protect others more than ourselves. We agree to stay at home and make sacrifices because we understand the bigger picture. We all miss our loved ones. We can relate to the loneliness of the nursing home residents unable to hug their families, to the fear of learning someone you know has been infected, and to the hopelessness and frustration of watching numbers rise and communities locked down. Sharing our stories will make the difference in how our world is shaped by this pandemic. How will History record this event? As a time of division, or a time of unity?
It’s time for the people at the front lines to make their collective voices louder. We have been spoken over long enough.
I cried at work today for the first time during this pandemic.
I have fought for many patients to survive COVID. Proned, paralyzed, unproned, suctioned, titrating drips, checking labs, in and out of these rooms, carefully prying eyes open to shine a light and wonder if they are looking back at me. I chat with them as I turn their bodies, adjust their limbs to avoid sores, tell them to fight and to breathe well. Some days they seem to rally a bit. No real improvement but no decline either. We grow hopeful, despite experience telling us it is likely futile.
Families want to see them. Some have been avoiding it until now because “they wouldn’t want to be seen like that”, but the realization eventually hits that their loved one will likely never come home. As an entire familia gathers around a computer screen to see their father/husband/grandpa unconscious in the hospital bed before them, tubes from every corner, they began to plead with him: “You have to come home. We need you. I’ve never seen you back down from a fight. You have more to do. Your grandkids miss you. Come home soon. We want to see you for Xmas...” The little ones begin to cry, not understanding why their grandpa is not awake and ready to reassure them. Someone begins to pray “La Palabra de Dios es vivo, El Señor salvate, todo es posible con la fe...”
Suddenly, the cardiac monitor grows blurry and my eyes sting. My nose runs beneath my mask. My face is hot and my chest tightens. I wasn’t prepared to be affected today. I had built up barriers of professionalism. “It’s my job. I have to stay strong because they depend on me.” But today my thoughts drifted to my partner and HIS familia. I imagined his father’s voice over speakerphone and his grandmother crying “mijo, tenga fuerza” and our child staring at his Papa through a tablet screen. The fears I had bottled up since the start of the pandemic came rushing forward and I realized just how terrified I truly am that COVID-19 will invade my home and my family and tear my loved ones from me with ruthless agonizing despair.
I mutter an excuse as I disappear to sob in the bathroom. I allow myself all of 2 minutes to fall apart before I wipe my eyes, blow my nose, adjust my N95, and return to the ICU to continue the fight.
2 minutes. It took me 9 months to have 2 minutes to break down and then return.
This pandemic will have lasting effects, there’s no doubt. Economic & physical burdens can be addressed with stimulus checks and vaccines. But psychologically and emotionally your healthcare workers are breaking. Who will put us back together? Who will help the helpers?
“[...] one of the worst fears of the pandemic—that hospitals would become overwhelmed, leading to needless deaths—is happening now. [...] This is such a searingly ugly idea that it is worth repeating: Americans are likely dying of COVID-19 now who would have survived had they gotten September’s level of medical care.”
A new statistic shows that health-care workers are running out of space to treat COVID-19 patients.
It’s here folks. I’ve seen it. And yet I’m STILL listening to people talk about having parties and hanging out with people outside of work and extended families. STILL. ಠ_ಠ We were all advised of the sacrifices necessary to avoid this outcome and yet...
It’s not just COVID. This affects anyone who has a medical need. Clinics are closing in order to divert staff to hospitals. As a result, thousands of patients across the country risk falling through the cracks without their needed checkups to maintain chronic conditions such as heart failure, diabetes, hypertension, and COPD. Inevitably those people will become more acutely ill, requiring a trip to emergency room. For example: CHF exacerbation, hypertensive crisis, DKA or HHS, and acute respiratory failure are some of the most common reasons for hospital admission and are all considered “acute-on-chronic” problems.
This time, however, if you need to be admitted, we may not have a bed for you. Neither will any hospital for hundreds of miles. If you’re lucky, you might be transferred to another hospital after hours of waiting in the emergency department. Or, you might be sent home after being stabilized with instructions to just come back if you get worse again.
How about planned surgeries to replace hips and knees, or to remove cancerous tumors? What will be the complications from delaying those procedures? Oncology patients who have a dangerous reaction after starting a new chemotherapy treatment? They are already severely immunocompromised. Can they wait in a bed in a hallway? I’ve cared for oncology patients who are routinely admitted to the hospital every two weeks in order to receive an 8-10 hour chemotherapy infusion. If those patients can’t be guaranteed a bed and a chemo nurse every two weeks for 6 cycles, how will that impact their treatment plan?
I’ve decided to share my unique perspective as an ICU RN in order to lift the veil somewhat and allow you all to grasp the reality of the situation.
🩺A typical Full Code COVID patient in the ICU, in my experience:
•A tube is in their mouth, extending down into their trachea, where it is held in place by a balloon to prevent air leaks. This tube is their lifeline and so it is secured to a device which is adhered to their cheeks to prevent dislodgment. The tube is connected to a machine at the side of the bed which forces air into the lungs at a set pressure, volume, and rate. We use a wand with suction to clean out their mouths every two hours. If needed, we occasionally thread a smaller tube through their endotracheal tube in order to suction out the gunk that makes you cough so it won’t clog up the breathing tube. If we switch modes to allow the patient to control their breathing, COVID patients will try to breathe 30-40 times a minute (normal rate is 12-20). They will also try to take deep breaths and cough. COVID makes tissue in the lungs so fragile that inflating them with high volumes and pressure will cause damage and scarring. We can’t let these patients breathe the way they want to breathe or else they will destroy their lungs and die.
•All of this is uncomfortable for the patient and so they are sedated. Medications to make them sleepy and to prevent agitation are given through continuous IV infusions. These medications also drop the patient’s blood pressure and so they also receive continuous IV infusions of medications called “pressors” which raise blood pressure. These “drips” are titrated up and down constantly by nurses to keep the patient sleepy enough to breathe with the vent, while also maintaining enough blood pressure to perfuse their vital organs.
•These pressor medications are very caustic and can burn and scar peripheral veins, so the doctor will place a central line. This is a long tube that’s threaded into a vein in the neck to almost reach the heart. In order to closely and accurately monitor blood pressures, we will use another long tube that’s inserted into an artery (either wrist or groin). That line continuously measures the average arterial pressure and nurses adjust those pressors based on that number.
•When your body is very sick it has trouble self-regulating to achieve homeostasis. Your kidneys are one of the first organs to suffer damage when you are very sick. Healthy kidneys help regulate blood pressure, electrolytes, and the acid-base balance of your blood. In the ICU we have to regulate all of that for you. We draw blood to check labs frequently, sometimes hourly, to monitor: how well you are getting oxygen in, how well you are breathing carbon dioxide out, how well your body is managing your acid-base balance, your electrolyte levels which will cause cardiac arrhythmias and even brain swelling if they are too high or low or if they change too quickly, blood clotting factors, level of waste products in your blood, etc. The nurse is constantly drawing these labs, reading the results, and giving medications or making ventilator adjustments to correct imbalances.
•Because the patient is asleep and has a tube in their mouth, they are unable to eat or drink anything. We put another tube in the mouth with the vent tubing, but this one goes down the esophagus and into the stomach. We then attach it to suction to remove gastric contents, use a syringe to administer medications, or hook it to a pump with a bag of liquid nutrients called “tube feeding” that will slowly trickle in just enough fluid (20 mL/hr) to ensure your gastrointestinal tract stays active and you have enough calories to meet your basal metabolic needs (the amount of calories your body burns by lying in bed).
•Because you aren’t eating or drinking or moving and the sedation medications are making your bowels sleepy, we give you laxatives to keep you pooping. Since your diet consists of a bag of liquid calories, it comes out of you much the same way. So we even have a tube for that, called a rectal tube (or “fecal containment device”) that’s held in place by a balloon in your butt and your poop just runs into a bag.
•It’s important for us to monitor how much urine your kidneys produce each hour. In order to be as accurate as possible, we insert a tube into your urethra which is held in place by a balloon in your bladder. Urine runs continuously into a bag where it can be assessed and measured.
•We monitor the heart via 5 wires stuck to the chest that give us a continuous visual representation of the electrical activity of your heart. COVID damages cardiac tissue and so arrhythmias and cardiac ectopy are common. If your heart beats too fast it can’t fill with enough blood to maintain your blood pressure, so sometimes we need to add even more continuous IV medications that prevent the heart from galloping off or doing too funky of a beat too often. The heart can sometimes be so damaged that it can’t squeeze effectively either, so we use other IV drips to help the heart beat and prevent it from giving up entirely.
•When we’ve done all we can do and the patient is still not improving, we will try “proning” and/or paralyzing. Medically paralyzing involves giving a continuous IV drip that stops muscles from being able to contract. This removes the extra oxygen demand of muscles, maximizing the oxygen that the COVID-damaged lungs can process. We need to give the least amount of paralytic medication necessary to prevent long-term complications. We are able to check the degree of paralysis by attaching electrodes to the patients face or wrist, sending electrical pulses (like a bark collar does), and then counting the muscle twitches. Paralytics also affect the body’s ability to create tears, so we need to pry open your eyes to administer eye gel regularly.
•Putting a patient in a prone position (on your stomach) helps by increasing blood flow to different areas of the lungs. It takes 5+ people to roll a patient VERY CAREFULLY onto their stomach without pulling out any of their tubes or lines. These are very sick patients and sometimes the movement can be too much of a strain on their heart and lungs. It’s a delicate, time consuming process. Patients remain proned for 16 hours, then returned to their back for a few hours. We may repeat the process again several times over the next 2-3 days, depending on if it is helping or not.
So how does this COVID patient get out of the ICU? Rarely, a patient improves enough to be awake and off sedation with the vent settings allowing breathing at the patient’s own rate. If the patient continues to improve, they are extubated (breathing tube out) and moved to a progressive care unit in the hospital to continue recovery. Unfortunately, the patient will often return to the ICU after only a day or two in the PCU. They deteriorate again because of all those COVID complications: heart damage, clotting (in lungs, legs, brain, etc), worsening pneumonia, etc. They can also develop complications that occur just from being hospitalized, such as: MRSA, cDiff, ventilator-associated pneumonia, bloodstream infection from the central line, UTI from the urinary catheter, peripheral limb ischemia from high doses of pressors, delirium (confusion/hallucinations), or injury related to falling.
•If the patient is still requiring mechanical ventilation after about 10 days, the next step is to have a surgeon create an opening in the neck called a tracheostomy so the ventilator can be attached through the hole in their neck. This way they can have long term ventilator support while continuing to attempt treatment. These patients are then transferred to a long-term acute care hospital where they will have to survive months of therapy to try to optimize their quality of life. After their prolonged hospitalization they will need to learn to breathe on their own again, swallow again, walk again, and learn how to take care of themselves as much as possible again. If they survive all of that then the patient will next move to a rehab center or nursing home. By this point, many do not survive due to new complications, the stress of prolonged sickness and comorbidities, or because the patient and family decided to pursue comfort cares instead.
🩺Some real talk here because knowledge is power:
I encourage EVERYONE (regardless of age or current health status) to fill out a Healthcare Advanced Directive, and choose who will make medical decisions in the event you are incapacitated. Consider your wishes NOW, and make sure you also know what your parents, grandparents, and spouse want. If your family member is hospitalized with COVID-19 and becomes so sick that even BiPAP is not helping, the doctor will ask you to make a decision between invasive mechanical ventilation (and everything that I described above) or “comfort cares.”
The specifics of “comfort cares” is individualized, but it essentially focuses the plan of care to acknowledge the patient’s decision that their quality of life is more important than extending it artificially without reasonable chance of recovery. The doctor prescribes medications to ease anxiety, and pain and the patient eventually passes away naturally without aggressive measures like a breathing tube or chest compressions. Families can be present with their loved one via telephone or Zoom video, though visitor restrictions may be eased for end-of-life patients, depending on the facility.
If you already have existing health complications (comorbidities) that make your chance of recovery from cardiac or respiratory arrest unlikely, you are able to let the doctor know from the beginning whether you are okay with CPR and a breathing tube, or if your wish is to make your code status DNR/DNI. DNR means that if your heart stops beating, you don’t want us to do chest compressions or shock your heart to try to restart it again. DNI means that if you can’t breathe on your own, you don’t want a breathing tube in your throat with a machine to breathe for you. You can choose one or the other, or both. You can also change your mind at any time, revoke your code status, and be considered a Full Code again. Full Code that means that we do everything medically possible to keep you alive, including breaking ribs during CPR, and putting a tube down your throat.
It’s important to not only have in mind what your own wishes are, but to discuss with your loved ones about their wishes. Very often, patients are either unconscious or too sick to communicate clearly and so the doctor will ask the next-of-kin or Healthcare Proxy to make the decision. Don’t make that emotional moment be the first time you think about it. And don’t put your loved ones in that position either. Have a conversation, put it in writing, and free them from the burden of that decision.
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