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Tales from the Frontline

It is hard to explain what I have seen and done these past few weeks, but I am going to try my best to give you insight that comes with working in a hospital in the hardest hit borough of the epicenter of this pandemic. Like the vast majority, I was naive to how intensely COVID-19 was going to hit this city. Looking back, I don’t know how because I can no longer imagine living in a world where COVID is not the center of our lives. 

I was a pediatric intensive care nurse (RN) for five years in a children’s hospital in the Bronx before I became a nurse practitioner (NP) in an oncology hospital in Manhattan. I guess pediatric intensive care is my calling because it is still my subspeciality now as an NP. The past seven weeks have simultaneously felt like a whirlwind and a lifetime. I have been working six nights a week at two jobs, totaling a little over 70 hours per week. I’m not bragging, or complaining. I wouldn’t have it any other way. Critical care is my calling, and while I have been doing it for a while, nothing could prepare me for what I saw this spring. 

With COVID hitting the Bronx hard, I knew I had to do my part for the borough I was raised in. At the start of the pandemic, I began picking up shifts whichever nights I wasn’t at my primary job in Manhattan. My pediatric intensive care unit (PICU) in the Bronx had unofficially been turned into an adult COVID ICU with patients ranging from a few months old to their mid-40s, all critically ill with COVID. I remember my first night back and a colleague explaining the process of donning personal protective equipment (PPE), taking it off, and cleaning it so that it could be reused. I had never had to reuse PPE before, but the entire city had a mass shortage. We were even running out of the sanitizing wipes to clean the PPE. We would cut a wipe in half, use it, store it in a plastic specimen bag and reuse the wipe until it ran dry. 

The unit looked like a war zone. There was equipment everywhere. Supplies everywhere. IV pumps and ventilator monitors were outside the rooms so staff had to expose themselves as little as possible. However, we still spent hours each night in COVID rooms because the patients were, and still are, in a condition so tenuous that they require frequent interventions. And while the rate of new diagnoses and admissions may have declined, some of these patients continue to be intubated on very high ventilator settings.

Being a pediatric intensive care unit, most of our staff had only ever cared for children. However, in the space of a two-week span in March, the majority of our patients were over 30. Our infant floor of the children’s hospital was turned into an adult step-down unit. Since the rooms usually contain cribs, we did not have enough hospital beds to put patients in. We started using these trolley contraptions that could have possibly been hospital beds in the 1970s, when the average American was much smaller. I don’t know where they had been living the past 40+ years, but they had to suffice. Our hospital auditorium was also turned into a step-down COVID unit, separating patients by curtains and pulling medical providers from various units and clinics to staff it. We ran out of the typical ventilators we use and began to use older transport ventilators. These, too, had to suffice.

We had and continue to have some of the sickest COVID patients in the city. Unfortunately, we saw death too frequently. I can promise that we gave those patients everything we had. Days to weeks of medical interventions with maximum ventilator settings, antiviral therapy, vasopressors, continuous dialysis, repositioning, suctioning – just to name a few – could not change the outcome for many. Adult patients died without loved ones nearby, as visiting policies had to be revoked by NYC hospitals to decrease community transmission of the virus. I spent the last few minutes of some of these patients’ lives with them. We made them as comfortable as humanly possible, but I know me or my colleagues, being with them did not suffice when it should have been loved ones. Pediatric patients are allowed a parent at the bedside, and I have heard the wails of these parents echo through the halls when they lose their children. No matter where we are in the unit, we stop what we are doing but avoid eye contact with each other – probably because it feels like another failure. Then we pick up where we left off because we have to keep going. Too many lives are at stake.

There were nights during March and April that “code blue” and “rapid response” seemed to be announced over the PA system every five minutes. We were running to medical emergencies from room to room in the PICU and various floors of the children’s hospital with paper bags of PPE in hand. There were not enough staff for the high acuity of patients we were seeing. No hospital in NYC had adequate staffing for the inflow of sick patients that came through its doors. 

The camaraderie was strong in our unit in the Bronx, as it was throughout the NYC medical community. We took our assignments and rolled with the punches. We have gotten into a routine of sorts for taking care of these very sick, and often, obese adult patients. Every night at 10 p.m., we form “proning teams.” We layer on our PPE and seven of us go from room to room to turn intubated patients from their backs (supine) to their stomachs (prone). Preliminary research has shown that proning COVID patients, who require high ventilator settings due to their acute respiratory distress syndrome (ARDS), can lead to better ventilation and, therefore, oxygenation. However, there are no mechanical lifts, so this repositioning is all done manually. The majority of these patients weigh 250 to 350 pounds, but we have it down to a science. One person manages the airway, to make sure the endotracheal tube does not move, while three people are on each side of the patient to turn. It sounds fairly rudimentary but, I can assure you, it’s a complex process. We see many critical events after repositioning because these patients are so unstable. Their oxygenation, heart rates, and blood pressures can drastically change, and we need all hands on deck. In addition, due to their copious secretions, their endotracheal tubes are difficult to secure and a movement of just a few centimeters can cause a cardiopulmonary arrest.

Under no circumstances are we allowed to go into a patient room without PPE on. Donning PPE at baseline is a process and, during an emergency, feels like an eternity. When a code bell goes off, our response has always been to run towards it. In the past few weeks, I have found myself running a few steps but quickly backtracking because I forgot my brown paper bag of PPE. We race to put on the PPE to get into the room as soon as possible. Hospital policies are ever changing as we try to figure out the science behind this new virus. Does performing CPR without an endotracheal tube aerosolize the virus and increase spread? What’s the best way to ventilate patients using noninvasive measures without, again, aerosolizing the virus? The focus continues to be on how we can best care for our patients without increasing the spread of disease. This dual focus has decreased staff risk and the prevalence of new COVID diagnoses among healthcare workers. It also means there are labeled bags everywhere of PPE everywhere. I forgot to put my bag of PPE away after my last shift, and I am already dreading the treasure hunt that is going to ensue trying to find it.

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We finish our shifts exhausted and I walk or run the two miles back to my apartment so as not to contaminate a bus or uber. I strip at the door and put my scrubs deep in my hamper before I shower. Then I lysol wipe down all the surfaces I touched pre-shower. It may sound like overkill, but I am so worried about spreading the virus. Recently, surgical caps were donated to us and that has made a huge difference because it means that I no longer need to wash my hair after every shift. They, too, can be peeled off and washed. A few mornings, I’ve iced my face to prevent bruising from the N95 masks. They are not meant to be worn for hours at a time and they are definitely not meant to be wiped down and reused until they fall apart. I’ve considered after business school creating an N95 that is semi-comfortable to wear, but I digress. These are relatively mundane problems to be having during this health crisis.

Sitting down to write this article has forced me to think about and attempt to process some of the things I have seen and experienced these past two months. I worry about the burnout and PTSD that will emerge for healthcare workers after all of this is over. Even scarier, I don’t know when this will be over. I am grateful to live in a state where the leadership and people are more focused on citizens’ health than the economy. I read about protests in other states and it astounds me that anyone can think this is fake propaganda. If they saw what so many frontline workers have seen, they would know this is no hoax. 

This is a devastated battlefield in a war with no end in sight.

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