“And starting this weekend, at least one Toronto-area hospital will begin training physician volunteers so they can help critical care nurses in the ICU, as a way to immediately add more staff to keep up with a flood of severely ill COVID-19 patients.”
I had to laugh about this one. The medical residents, aka “baby doctors,” barely know how to do anything. I’ve had to teach doctors how to place an IV line, how to reduce a prolapsed rectum, how to talk to patients about death. And there’s no way they’ve ever considered giving IV antibiotics or other medications. Talk about chaos in the ICU.
I couldn’t find the original news article. See video report on Global News
This week’s meme from inside my brain… If you’re old enough to remember the movie Gladiator, you’re welcome lol
Well, I think this week finally broke me. The state of California is removing the stay at home orders in the Bay Area, as they project 25% ICU bed availability in the coming weeks. I just want to know WHAT ICUS HAVE BEDS???? Because its not us. We don’t have any. Any time a patient leave, we replace them immediately with another patient from the emergency department, from another unit on our hospital, from another hospital in our system. Our nurses are getting pulled to go take care of ICU patients in random places all throughout the hospital as we wait for the ICU rooms to be available, but we’re already short staffed. So, we’re basically screwed. Plus, the patients are sick. We’re talking multiple code blue events in the ICU per shift, multiple deaths, overtime in the high single digits. And that’s not great, because research shows that shift workers in the 12th through 16th hours of their shifts have the mental capacities of someone who is legally drunk.
So, the nurses are the equivalent of crabby, sleep deprived, hangry drunks. It is a nasty atmosphere sometimes. A lot depends on the mood of the head doctor (the Intensivist) and the Charge Nurses. The nurses need a lot of emotional support. That leaves a charge nurse like me–who seeks to be supportive emotionally and intellectually as well as an upbeat and positive force in the unit but also suffers from being an empath (as well as her own depression)–in a really hard spot. I can get drained. I have the support of wonderful friends and a great therapist, and it takes me a long time, but I get drained.
And last night, I found myself outside the hospital, sitting on the ground a homeless person has probably slept on, letting the cement cool my legs, crying and smoking a cigarette at 4:45 in the morning. This was not my most glorious nursing moment. It was dark and painful. But those tears needed to come out so I could finish report on well over 30 patients and prepare for what I expected to be the oncoming shift’s foul mood leftover from yesterday’s day shift.
So here I am, after a not-sufficient amount of sleep, trying to process some of last night’s feelings. Being a nurse is exquisitely difficult some days. In addition to all the pressures I’ve already mentioned above, we had a traumatic patient admit that ended after what was essentially a five hour code blue. Another nurse and I pushed ACLS (advanced cardiac life support) drugs regularly, gave units and units of blood products in a massive transfusion, started the patient on CRRT (continuous renal replacement therapy, ie dialysis), maxed him out on ALL the cardiac meds you can imagine. After doing everything we could at least twice, more likely four times, a discussion with the family led us to make the patient comfortable with some morphine. The previous five hours had been filled with such pain and chaos–blinding lights and shouting. I put on some soul music. Don’t ask how I choose what music to pick for patients, but the second “Sitting on the Dock of the Bay” started playing, our patient just seemed more alert but relaxed. I sang to him, held his hand, and told him it was ok now and that we’d take care of his pain. He died while “Ain’t No Sunshine” by Bill Withers played. And that’s not what that song is about at all, but maybe it should be. Maybe its a better song that way.
Here’s a Spotify playlist I started for end of life music. I’ll keep adding to it, but I put this two songs on it for a start, in case you need a listen…
Trauma is something that nurses just accumulate, and its hard to release it. Moments like last night’s sidewalk meltdown are bound to happen for me, as I absorb and process all the emotions of the ICU. Would I change my life if it could be less traumatic? Would I change jobs? I’m not sure. I’m starting to consider the idea that I can’t just continue to accumulate trauma and other people’s emotions. I’m just not sure I would love my job as much if I couldn’t help patients at the end of their lives.
Both of my covid tests came back negative. I feel more confident that there were two negative results, but I was still sick for a little more than a week all told–so I’m baffled. I don’t think it was the flu, but it’s possible. Could have been a cold, I guess–just one of those old-fashioned pre-covid coronaviruses? Luckily, I’m starting to feel better because the ICU is busy and I keep getting calls to come in extra. We planned ahead for the winter & holidays by hiring dozens of traveling nurses and new staff, but we’re still short staffed, unfortunately.
Speaking of staffing, there was an article in the LA Timesexplaining ICU capacity and why it is so important to use as a metric for “shutting down” California. The Bay Area is currently at 17.8% capacity (slightly about the 15% cutoff for mandatory stay-at-home orders), but according to the article, 36 million Californians are living in areas where the ICU capacity has dropped below 15%.
The bottom line when ICU capacity is so severely limited–and I’m going to give it to you straight as a nurse in one of the best ICUs in the Bay Area– is that the only beds left are often beds at small, less busy hospitals. Yes, a bed may be an ICU bed–but the are not all created equal. You see, there are different types of hospitals. General hospitals provide basic emergency services but may need to transfer patients for higher levels of care. Trauma hospitals is where people are taken when involved in an accident with immediate life-threatening injuries and a full surgical team is always available. A tertiary care center is where patients are sent for specialty care at the highest levels. Doctors, nurses, and other staff at these hospitals that perform more complicated surgeries and regularly care for sicker patients and will be more skilled. They simply have more experience, and may also be involved in research studies–thus giving them access to drugs or treatments earlier than other hospitals.
So in a rural area, you may go to the local general hospital, be diagnosed with covid and admitted. But if you decompensate in a small rural ICU, you may find that the ICUs at tertiary care centers where you need to go for specialty care are no longer accepting patients because they are full–or, and this is more likely–they do not have enough staff.
At my hospital, we are lucky because the charge nurses guard the staffing with their lives. They never let the nurses be forced to take more patients than is safe, even if that means that a nurse is only caring for one patient. But no all hospitals are so lucky. In California, ICU nurses can take care of up to 2 patients at a time. In other states, 3 patients is the norm. I cannot even manage taking care of my sick covid patients AND two other sick patients as well.
Stay home if possible. Otherwise, be safe out there & please wear a mask.
Among the other fantastic treats I received: a homemade pumpkin chocolate chip muffin and pizza from one of our patients who just left the hospital after his heart transplant.
After being off for 5 days, however, I was pretty terrified that I would find a hospital overrun with covid and bursting at the seams with patients. And we do have a pretty full house… but amazingly, our covid numbers haven’t skyrocketed. House-wide we have only 29 total, 6 of whom are “cured,” and 2 are waiting for results. There are NO cases in the ICU currently.
This is definitely better than I had hoped for and expected, given the terrible news I’ve been hearing lately. Perhaps the hard work of London Breed, mayor of San Francisco, and Gavin Newsom, governor of California, is paying off in reducing covid infections and hospitalizations!
Also, one last thing to be so happy about this extra shift.
Labeling iStat cartridges with 2021 because next year is ALMOST HERE which means 2020 is done. GOOD RIDDANCE!
On NPR, you can listen to this 4 minute interview from an ICU nurse on the frontlines as she discusses patient regrets, masks, and surviving the pandemic with Audie Cornish on All Things Considered.
Mobley describes this very common experience:
“A lot of times before they’re intubated — which means put on a ventilator because they can’t breathe on their own — when they’re still struggling to breathe, and they’re saying, ‘Well, I didn’t know COVID was real, and I wish I’d worn a mask.’ And then it’s already too late,” she tells NPR’s All Things Considered. “You can see the regret, as they’re struggling to breathe and it’s finally hitting them that this is real. It makes me very sad.”
Last week, everyone was still happy for the overtime and could see the $$$ in the missed meal breaks. Everyone was chipping in, picking up extra and actually in buoyant spirits (if that can ever be said about ICU nurses).
I actually texted this image stolen from Pinterest to a colleague in my happy and helpful bliss last week… perhaps it was delirium?
For my first few shifts this week, though, the nurses were just not feeling like doing as much OT. I can’t blame them. Our patients are incredibly sick. Our job is incredibly hard both physically and emotionally. There just isn’t as much support available as there should be even if people volunteer to work OT because nurses on overtime just aren’t working their best.
Also, it makes me sad to say, but the patients aren’t getting the best then either. As nurses we want to be THE BEST we can be for our patients, especially in the ICU, but when you’re working hours 12 through 16.5, you can’t always give your best. It’s sorta like the Rolling Stones’ song, loosely “translated” to this scenario: you can’t always give what you want, but you give at least what patients need.
On a happier note, though, I ended my week with a fully staffed night shift that gave report to a fully staffed day shift! First time in 3 weeks.
