I’ve been an ICU nurse for ten years. I’ve worked in many specialties including pulmonary infectious disease, cardiac and trauma. I’ve taken care of the sickest flu patients requiring full cardiopulmonary support. Now I am working in COVID ICU. This is not for the weak.
Part 1 – Mobilizing for COVID-19
I left a full-time bedside nursing job in 2019 to enter academia full time. This was a natural progression in my career, and a welcome challenge. I work clinically occasionally, but now the majority of my energy is in the classroom rather than the bedside. Then COVID-19 happened. It seemed to start with the flip of a switch and progressed rapidly. I receive daily phone calls, emails and text messages begging any and all ICU nurses to please come help. COVID-19 progresses rapidly with many patients requiring ICU resources, including mechanical ventilation, vasoactive support and continuous dialysis. Each of these skills takes many weeks to months of training for the nurse to be sufficient in managing. The hospitals simply don’t have enough help.
I answered the call, not knowing what I was answering. Since this started, I’ve worked in three COVID ICUs. Each hospital handles the challenge a little differently with the same end-goal in mind: To keep staff safe and to save patients.
Hospitals structure ICU units by specialty. A neuro ICU nurse and a cardiac ICU nurse are not the same. A nurse may require 12 weeks of training for one specialty and six months of training for another. It is highly specialized, requiring astute assessment skills, adept technical skills, and what one of my favorite mentors used to call “nurse spidey senses.” Patient condition changes rapidly, by the minute or second. Things can go downhill fast. Brain death by hypoxia only takes four minutes. This need for constant assessment and management makes the ICU environment a very precarious one in ideal circumstances. Nurses don’t care for more than one to two patients at a time because it’s impossible to manage more than that safely.
When COVID-19 arrived, hospitals restructured ICUs and created COVID ICUs to protect non-infected patients. A select group of nurses care for the COVID-19 patients and the rest are funneled to other ICUs. Our ICUs are full. Some hospitals have opened more ICUs in environments not built for ICUs. To staff them, some hospitals are “cross training” non-ICU nurses to the environment. They get a handful of shadow shifts and then they go to work in their new environment. Hospitals are begging for ICU nurse help. I know many ICU colleagues who have returned to the bedside to help. Some deployed to New York City. I feel heavy that I couldn’t deploy to New York. I’m looking at how I can prepare to deploy when round two of COVID-19 happens next year.
COVID ICU units are amazing. The hospitals I have worked in activated fast to protect their staff. COVID-19 is considered airborne isolation, because the virus can remain in the air for a significant period of time after it has been aerosolized. There is a huge risk of aerosolization in the ICU because of intubation. Many of these patients require intubation, or a breathing tube placed down their trachea. This tube is attached to a ventilator which mechanically assists the patient’s breathing. The tube acts as a conduit between the patient’s lungs and the environment. With each breath, if not attached to the ventilator, virus is expelled into the atmosphere like a volcano. Many staff deaths in New York City have been emergency room providers assisting with intubation, because of the frequency and volume they were exposed to viral load. Now that we know about this danger, more safeguards are in place for intubation, including specialized teams, additional PPE, and clear boxes placed over the patient to block aerosolization once the tube is placed. It’s haunting that we know so little about this virus that our trial and error includes death of our front-line staff.
We have experience with airborne isolation with tuberculosis. Most ICUs have a handful of negative pressure rooms with anterooms attached. Staff put on PPE in the anteroom and enter the negative pressure room from a special door. This keeps the air in the room (which may contain an infectious agent, like tuberculosis) from entering the rest of the unit. We don’t have enough negative pressure rooms for COVID-19, so hospitals mobilized very quickly to create them. Hospitals placed special filters in each room to make every room in COVID ICU a negative pressure room. Some hospitals made the entire unit negative pressure, which necessitated staff use respiratory PPE (a PAPR or N-95) the entire time they are on the unit. This means staff need to leave the unit, perform an intricate doffing procedure and walk down several hallways if they just want to take a sip of coffee. It’s laborious, but necessary for safety. Hospitals I have worked in trained “safety officers” to stay on the unit and watch staff don and doff (put on and take off) PPE. They stop and correct staff if they are at risk of having a PPE failure. This is necessary for our safety, and I am very grateful.