ALL QUIET ON THE WESTERN FRONT
By Vincent Lyn
From a COVID-19 ICU Nurse in NYC working on the front lines who wants to remain anonymous.
I am a Covid ICU nurse in New York City, and yesterday, like many other days lately, I couldn’t fix my patient. Sure, that happens all the time in the ICU. It definitely wasn’t the first time. It certainly won’t be the last. What makes this patient noteworthy? A few things actually. He was infected with Covid-19, and he lost his battle with Covid-19. He was only 23 years old.
I was destroyed by his clinical course in a way that has only happened a few times in my nursing career. It wasn’t his presentation. I’ve seen that before. It wasn’t his complications. I’ve seen that too.
It was the grief. It was his parents. The grief I witnessed yesterday was grief that I haven’t allowed myself to recognize since this runaway train got rolling here in early March. I could sense it. It was lingering in the periphery of my mind, but yesterday something in me gave way, and that grief rushed in.
I think I was struck by a lot of emotions and realities yesterday. Emotions that have been brewing for weeks and realities that I have been stifling in order to do my job effectively. My therapist tells me weekly via Facetime that it’s impossible to process trauma when the trauma is still occurring. It just keeps building.
I get home from work, take my trusty companion Apollo immediately out to pee, he’s been home for 14 hours at a time. I have to keep my dog walker safe. No one can come into my apartment.
I’ve already been very sick from my work exposure, and I’m heavily exposed every day that I work since I returned after being 72 hours afebrile, the new standard for healthcare workers. That was after a week of running a fever of 104 even with Tylenol around the clock, but thankfully without respiratory symptoms. I was lucky.
Like every other healthcare worker on the planet right now, I strip inside the door, throw all the scrubs in the wash, bleach wipe all of my every day carry supplies, shoes and work bag stay at the bottom of the stairs.
You see, there’s a descending level of Covid-19 contamination as you ascend the stairs just inside my apartment door. Workbag and shoes stay at the bottom. Dog walking shoes next step up, then dog leash, then running shoes.
I dodge my excited and doofy German shepherd, who is bringing me every toy he has to play with, and I go and scald myself for 20 minutes in a hot shower. Washing off the germs, metaphorically washing off the weight of the day.
We play fetch after the shower. Once he’s tired, I lay on the floor with him, holding him tight, until I’m ready to get up and eat, but sometimes I just go straight to bed, awakening frequently to the echoing sounds of alarms in our minds, horrific nightmares that plague our resting hours. We awaken tired and anxious. Then, we do it all again.
Quite honestly, I’m so tired of the death. With three days off from what has been two months of literal hell on earth as a Covid-19 ICU nurse in NYC, I’m having an evening glass of wine, and munching on the twizzlers my dear aunt sent me from Upstate NY, while my dog is bouncing off the walls because I still don’t have the energy to run every day with him.
Is it the residual effects of the virus? Is it just general exhaustion from working three days in a row? Regardless, the thoughts are finally bleeding out of my mind and into a medium that I’m not sure could possibly convey the reality of this experience.
There’s been a significant change in how we approach the critically ill Covid-19 infected patients on a number of different levels over the last two months. We’re learning about the virus. We’re following trends and patterns. We are researching as we are treating.
The reality is, the people who get sick later in this pandemic will have a better chance for survival. Yet, every day working feels like Groundhog Day. All of the patients have developed the same issues. This 23-year-old kid walked around for a week silently hypoxic and silently dying. By the time he got to us, it was already far too late.
First pneumonia and then Acute Respiratory Distress Syndrome (ARDS), that’s essentially lung failure. Then kidney failure from global hypoxia and the medications we were giving in the beginning, desperately trying to find something that works. Then learning that it doesn’t work, it’s doing more harm than good in the critical care Covid-19 population.
Dialysis for the kidneys. They are so sick that your normal three-times weekly dialysis schedule is too harsh on their body. They’re too unstable. So, we, the ICU nurses, run the dialysis slowly and continuously.
They are all obstructing their bowels from the ever-changing array of medications, as we ran out of some medications completely during our surge. We had to substitute alternatives, narcotics, sedatives, and paralytics, medications we’re heavily sedating and treating their pain with, in an effort to help them tolerate barbaric ventilator settings.
Barbaric ventilator settings while lying them on their bellies because their lungs are so damaged that we have to flip them onto their bellies in an effort to perfuse the functioning lung tissue and ventilate the damaged lungs.
Lungs that are perfused with blood that doesn’t even have adequate oxygen carrying capacity because of how this virus attacks.
Blood that clots, and bleeds, and clots, and bleeds. Everything in their bodies is deranged. Treat the clots with continuous anticoagulation. Stop the anticoagulation when they bleed.
GI bleeds, brain bleeds, pulmonary embolism, strokes.
Restart the anticoagulation when they clot their continuous or intermittent dialysis filters, rendering them unusable, because we’re trying not to let them die slowly from renal failure. We are constantly making impossible treatment decisions in the critical care pandemic population.
A lot of people have asked me what it’s like here. I truly don’t have adequate descriptors in my vocabulary try as I might, so I’ll defer to the metaphor of fire.
We are attempting to put out one fire, while three more are cropping up. Then we find out a week or two later that we unknowingly threw gasoline on one fire, because there’s still so much we don’t know about this virus.
Then suddenly there’s no water to fight the fire with. We’re running around holding ice cubes in an effort to put out an inferno. Oh yeah, and the entire time you’ve been in this burning building, you barely have what you need to protect yourself.
The protection you’re using, the guidelines governing that protection, evolved with the surge. A one-time use N95 facemask? That’s the prior standard, and after what we’ve been through, that’s honestly hysterical. As we were surging here, the CDC revised their guidelines, because the PPE shortage was so critical.
Use anything, they said. Use whatever you have for as long as you can, and improvise what you don’t have.
As we’re discussing medication and viral research, starting clinical trials, talking treatment options in morning rounds for your patient with the team of doctors and clinical pharmacists, suddenly, surprise! Your patient developed a mucous plug in his breathing tube.
Yes, that vital, precious tube that’s connected to the ventilator that’s breathing for them. It’s completely plugged. Blocked. No oxygen or carbon dioxide in or out. It’s a critical emergency.
Even with nebulizer treatments, once we finally had the closed-delivery systems we needed to administer these medications and keep ourselves safe, they’re still plugging. We cannot even routinely suction unless we absolutely have to because suctioning steals all of the positive pressure that’s keeping them alive from the ventilator circuit. One routine suction pass down the breathing tube could kill someone, or leave their body and vital organs hypoxic for hours after.
Well, now they’re plugged. We are then faced with a choice. Both choices place the respiratory therapists, nurses, and doctors at extremely high risk for aerosolized exposure.
We could exchange the breathing tube, but that could take too long, the patient may die in the 2–3 minutes we need to assemble the supplies and manpower needed, and it’s one of the highest-risk procedures for our providers that we could possibly carry out.
Or we could use the clamps that have been the best addition to my every day carry- nursing arsenal. You yell for help, you’re alone in the room. Your friends and coworkers, respiratory therapists, doctors, are all rushing to get their PPE on and get into the room to help.
You move around the room cluttered with machines and life sustaining therapies to set up what you need to stave off death. You move deliberately, and you move FAST. The patient is decompensating in the now-familiar and coordinated effort to intervene.
Attach the ambu breathing bag to wall oxygen. Turn it all the way up. Where’s the PEEP valve? God, someone go grab me the PEEP valve off the ambu bag in room 11 next door. We ran out of those a month ago, too. It’s all Covid-19 anyway, all of it is Covid-19. Risk cross-contamination or risk imminent death for your patient, risk extreme viral load exposure for you and your coworkers, and most certain death for your patient if you intervene without a PEEP valve.
You clamp the breathing tube, tight. The respiratory therapist shuts off the ventilator, because that side of the circuit can aerosolize and spray virus too if you leave it blasting air after you disconnect. Open the circuit. Respiratory therapy attaches the ambu bag. You unclamp. Bag, bag, bag. Clear the plug. The patient’s oxygen saturation is 23% with a PERFECT waveform. Their heart rate is slowing. Their blood pressure is tanking. Max all your drips, then watch and wait while this patient takes 3 hours to recover to a measly oxygen saturation of 82%, the best you’ll get from them all shift. These patients have no pulmonary reserve.
All of our choices to intervene in this situation risk our own health and safety. In the beginning we were more cautious with ourselves. We don’t want to get sick. We don’t want to be a patient in our own ICU. We’ve cared for our own staff in our ICUs. We don’t want to die. Now? I’ve already been sick. I am so, so tired of the constant death that is the ICU, that personally, I will do anything as long as I have my weeks old N95 and face shield on, just to keep someone alive.
I’ve realized that for many of these patients in the ICU, it won’t matter what I do. It won’t matter how hard I work, though I’ll still work like a crazy person all day, aggressively advocate for my patients in the same way.
My coworkers will go without meals, even though they’re being donated and delivered by people who love and support you. Generous people are helping to keep local restaurants afloat. We can always take the meal home for dinner, or I can devour a slice of pizza as I walk out to my truck parked on the pier, a walk I look forward to every day, because it gives me about eight minutes of silence. To process. To reflect.
I’ll chug a Gatorade when I start feeling lightheaded and I’m seeing stars, immediately after I just pushed an amp of bicarbonate on a patient and I know I have at least five minutes of a stable blood pressure to step out of the unit, take off my mask and actually breathe.
Every dedicated staff member is working tirelessly to help. The now-closed dental clinic staff has been trained to work in the respiratory lab to run our arterial blood gases, so that the absolutely incredible respiratory therapists who we so desperately need can take care of the patients with us.
Nurses in procedural areas that were closed have been repurposed to work as runners. To run for supplies while the primary nurse is in an isolation room trying to stabilize a patient without the supplies they need, runners to run for blood transfusions.
Physical therapists, occupational therapists, speech and language pathologists being repurposed to be part of the proning teams that helps the nurses turn patients onto their backs and bellies amidst a tangled web of critical lines and tubes, where one small error could mean death for the patient, and exposure for all staff.
Anesthesiologists and residents are managing airways and lines when carrying out these massive patient position changes. Surgical residents are all over the hospital just to put in the critical invasive lines we need in all of our patients.
The travel nurses who rushed into this burning building to help us are easing a healthcare system. The first travel nurse I met came all the way from Texas. Others terminated their steady employment to enlist with a travel agency to help us. Every day there are more travelers arriving.
A nurse from LA came to me after she found out I was part of the home staff, in my home unit, where this all first started in my hospital what feels like a lifetime ago, and said, “I came here for you. For all of the nurses. Because I couldn’t imagine working the way you guys were working for how long you were working like that”. During our surge and peak in the ICU, we were 1:3 ratios with three patients who normally would be a 1:1 assignment. And they were all trying to die at the same time. We were having to choose which patients we were rushing to because we couldn’t help them all at the same time.
The overhead pages for emergencies throughout the hospital rang out and echoed endlessly. Every minute, another rapid response call. Another anesthesia page for an intubation. Another cardiopulmonary arrest. A hospital bursting at the seams with death. Refrigerated trailers being filled.
First it was our normal white body bags. Then orange disaster bags. Then blue tarp bags. We ran out of those too. Now, black bags.
The heartbreakingly unique part of this pandemic is that these patients are so alone. We are here, but they are suffering alone, with no familiar face or voice. They are dying alone, surrounded by strangers crying into their own masks, trying not to let our precious N95 get wet, trying not to touch our faces with contaminated hands.
Their families are home, waiting for the phone call with their daily update. Some of their loved ones are also sick and quarantined at home.
Can you even IMAGINE? Your husband or wife, mother or father. Sibling. Your child. You drop your loved one off at the emergency department entrance, and you never, ever see them alive again.
Families are home, getting phone calls every day that they’re getting worse. Or maybe they’re getting better. Unfortunately, the ICU in what has quickly become the global epicenter for this pandemic is not a happy place. We are mostly purgatory where I work, so this snapshot may be more morbid than most.
These people are saying goodbye to their loved ones, while they’re still walking and talking, and then maybe a week or two later, they’re just gone. It’s like they disappeared into thin air.
That level of grief is absolutely astounding to me, and that’s coming from a person who knows grief. I held my young husband’s hand when his heart stopped beating. I was there. That grief changes you immeasurably.
But this grief? This pandemic grief? It’s inconceivable. These families will suffer horribly, every day for the rest of their lives. They might not even be able to bury their loved one. God, if they can’t afford a funeral with an economic shutdown their loved one will be buried in a mass grave on Hart Island with thousands of others like them. What grave will they have to visit on birthdays and holidays?
Yesterday, I was preparing for a bedside endoscopy procedure to secure a catastrophic GI bleed in this 23-year-old patient.
It was a bleed that required a massive transfusion protocol where the blood bank releases coolers of uncross matched O negative blood in an emergency, an overhead page that, ironically, I heard as I was getting into the elevator to head to the fourth floor for my shift yesterday morning; a massive transfusion protocol that I found out I would own as a primary nurse, as I desperately squeezed liters of IV fluids into this patient until we got the cooler full of blood products, and then pumped this patient full of units of blood until we could intervene with endoscopy.
Before the procedure, I stopped everything I was doing that wasn’t life sustaining. I stopped gathering supplies to start and assist with the procedure.
I told the doctors that I would not do a required “time-out” procedure until I got my phone out, and I Facetimed this kid’s mom because I didn’t think he would survive the bedside procedure.
She cried. She wailed. She begged her son to open his eyes, to breathe. She begged me to help her. Ayudame. Ayudame. She begged me to help him. She sang to him. She told him he was strong. She told him how much she loved him. I listened to her heart breaking in real time while she talked to her son, while she saw his swollen face, her baby boy, dying before her eyes through a phone.
Later in the day, after the procedure, his mom and dad came to the hospital. He survived the securement of the bleed, but he was still getting worse no matter what we did. He’s going to die. And against policy, we fought to get them up to see their son.
We found them masks and gowns that we’re still rationing in the hospital, and we let his parents see him, hold him. We let them be with their son.
Like every other nurse would do in the ICU here, I bounced around the room, moving mom from one side of the bed to the other and back again, so I could do what I needed to do, setting up my continuous dialysis machine, with the ONE filter that supply sent up for my use to initiate dialysis therapy. This spaceship-like machine, finicky as all hell, and I had one shot to prime this machine successfully to start dialysis therapy to try to slowly correct the metabolic acidosis that was just ONE of the problems that was killing him as his systolic blood pressure lingered in the 70s, despite maxing all of my blood pressure mediations.
Continuous dialysis started. You press start and hold your breath. You’re not removing any fluid, just filtering the blood, but even the tiniest of fluid shifts in this patient could kill him. But you have no choice.
His vital signs started to look concerning. I could feel the dread in the pit of my stomach, this was going south very quickly. Another nurse and the patient’s father had to physically drag this mother out of the room so we could fill the room with the brains and eyes and hands that would keep this boy alive for another hour.
She wailed in the hallway. Nurses in the next unit down the hall heard her cries through two sets of closed fire doors. We worked furiously to stabilize him for the next four hours.
Twenty minutes before the end of my shift last night, I sat with the attending physician and the parents in a quiet and deserted family waiting room outside the unit. I told his mother that no matter what I do. I cannot fix this. I have maximized everything I have, every tool and medicine at my disposal to save her son. I can’t save her son.
The doctor explained that no matter what we do, his body is failing him. No matter what we do, her son will die. They realized that no matter how hard they pray, no matter how much they want to tear down walls, no matter how many times his mother begs and pleads, “take me instead, I would rather die myself than lose my son”, we cannot save him.
We stayed while she screamed. We stayed until she finally let go of her vice grip on my hands, her body trembling uncontrollably, as she dissolved into her grief, in the arms of her husband.
This is ONE patient. One patient in one ICU, in one hospital, in one city, in one country, on a planet being ravaged by a virus.
This is the tiniest, devastating snapshot of one patient and one family and their unimaginable grief. Yet, the weight is enormous.
The world should feel that weight too. Because this grief, this heartbreak is everywhere in many forms. Every person on this planet is grieving the loss of something.
Whether that’s freedom or autonomy sacrificed for the greater good. Whether that’s a paycheck or a business, or their livelihood, or maybe they’re grieving the loss of a loved one while still fighting to earn a paycheck, or waiting for government financial relief that they don’t know for certain will come. Maybe, they’re a high school senior who will never get to have the graduation they dreamed of. Maybe they’re a college senior, who won’t get to have their senior game they so looked forward to. Maybe they’re afraid that the government is encroaching on their constitutional rights. Maybe it’s their first pregnancy, and it’s nothing like they imagined because of the terrifying world surrounding them.
Or maybe they lost a loved one, maybe someone they love is sick, and they can’t go see them, because there are no visitors allowed and they’re an essential worker. Maybe all they can see of someone they love is a random Facetime call in the middle of the day from an area code and a number they don’t know.
Everyone is grieving. We’ve heard plenty of the public’s grief.
I don’t blame anyone for how they’re coping with that grief, even if it frustrates the ever-living hell out of me as I drown in death every day at work. It’s all valid. Everyone’s grief is different, but it doesn’t change the discomfort, the despair on various levels. We are at the bottom of Maslow’s hierarchy of needs. Basic survival, physiological and safety needs. I’ve been here before. I know this feeling. How we survive is how we survive.
Now that I’ve had the time to reflect and write, now that I’ve let the walls down in my mind to let the grief flood in, now that I’ve seen this grief for what feels like the thousandth time since the first week of March as a nurse in a Covid-19 ICU in New York City, it’s time you heard our side. This is devastating. This is our reality. This is our grief.