I AM STANDING OUTSIDE my infected patient's room and the noise in the hall is relentless. Alarms beep, nurses and physicians talk in loud groups, a custodian buffs the floors, and a housekeeper shakes out a wastebasket. Nurses hear the “symphony” of healthcare all day long. The sounds mostly went unnoticed before the pandemic, but not anymore.
My patient, Mr. Smith,∗ is being treated for COVID-19. He is endotracheally intubated and on a mechanical ventilator. He is receiving multiple I.V. medications, including vasopressors, sedatives, and anticoagulants.
The medications are on an I.V. pole outside his room. This is the first way that nursing care during the pandemic is different from nursing care before it: The extra-long I.V. tubings are “snaked” into the room, taped to the floor, and labeled with the names of the medications. They are labeled again, closer to the central venous access device in a neck vein. These medications often require rapid dosage adjustment, so having the medications outside his room enables me to make changes without donning my personal protective equipment (PPE). I review Mr. Smith's medications before I enter his room.
Battling a ‘monster’
It's time to go in to assess Mr. Smith. First, I gather my PPE and perform hand hygiene. I take off my “clean” surgical mask and place it in a brown paper bag, the kind that would ordinarily hold a peanut butter and jelly sandwich. That was before this coronavirus. These days, paper bags make me cringe.
Next, I put on my isolation gown, making sure it's carefully tied around my neck and waist. I then reach for my N95 mask. Putting this on is a project because, due to equipment shortages, we must reuse the mask repeatedly. It rests in a little plastic container. I put the entire container to my face, carefully avoiding the outside of the mask. I then pull the straps around my hair, which is covered in a scrub cap. One strap is placed on the crown of my head (top strap) and one on the base of my neck (bottom strap).
After my N95 mask is secured, I put another surgical mask over it. This mask is considered the “dirty” mask, used to protect the precious N95. Then I put on my plastic face shield. Then I put on my gloves, which cover the cuffs of my gown.1 Finally I'm ready.
I open the door to Mr. Smith's room and close it after me. The quiet inside is deafening. I hear the rhythmic “breathing” sounds of the ventilator, but that's it. The contrast with the chorus of sounds outside the room is striking. I am on my own in here and doing battle with the “COVID monster.”
I start my nursing assessment, telling Mr. Smith, “I'm your nurse. My name is Lisa, and I'm going to take care of you today.” There is no indication that he knows I am here. I make sure the ventilator settings are as they should be. I check his vital signs and auscultate his heart, lung, and bowel sounds. I assess his lower extremity neurovascular status and check the urine output from his indwelling urinary catheter. I then confirm correct placement of his feeding tube.
I turn and reposition Mr. Smith and inspect his skin, concerned about the risk of pressure injuries. I apply lotion to his skin, avoiding vigorous massage over bony prominences, and perform passive range of motion exercises. All the while, I talk to him. “Today is Tuesday. It's the middle of March. It's cold today. Did you hear that crazy wind last night? I don't think spring is ever going to come.”
He sounds “junky,” nursing vernacular for airway secretions. I must suction his airway. I tell him, “Mr. Smith, this is going to make you feel uncomfortable, but I have to get that gunk out of your windpipe.” Tears leak from his eyes; maybe it's a reflex, maybe it was that painful. There is no way to know. I continue my monologue. “The governor says we're on lockdown for the next 6 weeks; can you believe it? I guess the silver lining is that there's no traffic on the way in to work. What did you do for work?” He does not respond; he is sedated, unresponsive.
I spend at least an hour in Mr. Smith's room doing the things nurses do—assessment, planning, intervention, and evaluation, making mental notes about what to document. We are supposed to limit our exposure to the virus, and I know I am exceeding that limit. Mr. Smith looks comfortable, so I prepare to exit the room. I am dripping with sweat and dying to remove my PPE. I carefully remove my gloves and gown and dispose of them.
Once outside the room, I wash my hands, put on clean gloves, and remove my face shield. I clean the face shield with an alcohol wipe and hang it outside the room to dry. Then I remove my “dirty” surgical mask, wipe it down, and hang it. I reach for the plastic container and hold it up to my N95 mask. I remove the elastic straps from my neck and head and deposit the mask in the container. Then I remove my gloves and perform hand hygiene again.1 Finally, I put on my “clean” surgical mask and exit the area.
Leaving the room is like entering another planet. The noise returns and someone tells me that I am getting a call. It is Mr. Smith's wife, wanting to know how he is. I have nothing good to report, but I do not want to take away hope. I focus on his stable vital signs and say that he is tolerating his tube feeding. He is producing urine, so his kidneys are okay. She cries, and so do I. We plan a video call for 1400 that day so she can see her husband and talk to him.
Meanwhile, the physicians make their rounds. They ask me what is going on with Mr. Smith; we review his medical record. Not a single physician goes into Mr. Smith's room, which I cannot help resenting. They are solely relying on my nursing assessment and document my assessment findings in their progress notes.
Mr. Smith is not my only patient with COVID-19—I repeat the same process for Mr. Jones, whose condition is about the same. I work inside his room, enclosed by a glass door, while the physicians stand outside the glass, knock on the panes, and shout instructions to me. I feel like I'm in a zoo exhibit. I have never felt more alone. The only thing that keeps me focused is knowing that I am providing care to Mr. Smith and Mr. Jones as if each were someone I loved. So, I keep going.
So do my nursing colleagues. I have worked with many of these men and women for over 35 years, and never have I been more impressed by the quiet courage they bring to the bedside. When we have time to think about it, we cry.
The shift goes on and on. One nurse needs to “prone” her patient. Prone positioning is supposed to improve oxygenation, but sometimes it works and sometimes it doesn't. Regardless, it is a 30-minute process that takes four to six staff members to accomplish, thereby reducing the number of available staff in the rest of the unit.
Another nurse loses a patient. On one shift we ran out of body bags; that was a bad, bad day. All we could talk about was what we were going to drink when we got home. Wine, beer, scotch, tequila—the only thing we wanted was something to make us numb.
A new normal
Ultimately, the physician had to inform Mr. Smith's family that the decision had been made to terminally extubate him; the physicians had determined there was no hope for meaningful recovery. On his final day, I give him morphine to keep him comfortable. The respiratory therapist shuts off the ventilator and the physician removes the endotracheal tube. Mrs. Smith and her children watch via my phone and say goodbye to their husband and father. They talk to him until he dies, singing a family favorite song: “You are my sunshine, my only sunshine...”
We lost another soul. And that is now our “new normal,” a term I personally detest. Nurses are never going to be the same again. Everything we learn in nursing school is about support and comfort; COVID-19 took that away. We are supposed to minimize our own risk of infection by limiting the time we spend with our patients. Families are not allowed to come into the hospital. The isolation is stark. Imagine dying surrounded by people gowned, gloved, masked, and holding a cell phone in a hazard bag. What could be more terrifying?
When it's time to leave the hospital, I change out of my contaminated scrubs and put on “clean” scrubs. I pull into my garage and wipe everything with the bleach wipes that I keep in my car. My husband leaves a bathrobe in the garage for me. I change out of my clothes, put on my bathrobe, and immediately throw both my “clean” and “dirty” scrubs into the washing machine. I go upstairs and take the hottest shower I can stand. I lean my head against the tile of the shower wall. I cry.
After a glass of wine (maybe two), I go to bed. I listen to a meditation tape. I pray for the people who died alone and for the families who could not be there.
In the morning, I get up and do it all over again. So does every other nurse I know. That is what we do. This is our new normal, and COVID-19 is our new reality.