COVID-19

perpetual pandemic

Here we are again in another surge of cases of Covid-19 with the rise of the delta variant. Just as we thought we could finally relax and get out of our covid pods for in person activities, mask recommendations are returning even for vaccinated folks. At least for activities indoors where many people gather like stores, restaurants, and offices. We in the emergency room have renewed our attention to wearing proper PPE with all patient contact and stay masked when we hangout in the break room with our coworkers. There have been a smattering of new infections in our staff, though it is unclear whether or not they are vaccinated. Last week our psych emergency department had to close for quarantining due to a staff member reporting to work with a covid test pending that turned out to be positive. This caused a backup of patients needing psychiatric care, waiting in the ED for many hours putting stress on our staff due to the one to one monitoring necessary for these patients.

To give you some background, for most of the pandemic we as staff, we were required to enter the hospital through a single entrance where we had to show a completed online screening form and get our temp taken, we were then given a sticker that showed we did the screening for that shift. First they dropped the temp check and then they dropped the screening questions and now we just all walk in through the single entrance and get a new mask. We used to complain that it was ridiculous make us screen, it was annoying and time consuming, and with separate bank of covid sick time, it seemed like who would come to work sick? But this psych department case illustrates the denial that still exist among the staff. I wouldn’t be surprised to see at least the online screening requirement come back.

Now there is a mandate for all city workers to be be vaccinated once the vaccine receives its FDA approval or face disciplinary action including possible termination. For the state of California, all state employees will need to be vaccinated or face weekly testing. My first reaction to hearing this was resistance; I don’t like being told what to do; I love my autonomy. But the more I talked to people I trust, I have come around. This is not a crazy requirement for those of us in healthcare, as nurses we are required to have all our other vaccinations in order to work anyway. We can decline the flu vaccine but have to mask during flu season. This is moot since we are masked at work already. Since I come to nursing from a science and research background, I have always been curious why some nurses don’t trust science. The work that we do is based on science and research. I believe it is our responsibility to stay current on the research and educate our patients. In addition we owe our patients the safety of knowing that when they are come in seeking care because their health is suffering, they will not be exposed to infections during their interactions with the the staff taking care of them. Now that we have the vaccine, and it has been shown effective, it takes another level of risk away. Vaccines and masks will keep our patients safe when they are vulnerable. We as healthcare workers just spent a year without the vaccine, wearing full PPE, caring for patients with covid and did not get sick in large numbers. These precautions have kept us safe, and they will continue to do so. Our public health depends depends on us.

Since I work in a city that has a 84% vaccination rate and has had low case and death statistics, I think we will fare okay in the next wave. The latest data is showing that the delta variant is way more infectious, by and it is now the predominant variant in the US, we are facing a formidable fall. The current data clearly shows that if you are vaccinated you are much less likely to be seriously ill, be hospitalized or die if you are one of the rare cases of a breakthrough infection. I have to say, I am tired, we all are tired. We have been working with reduced staff, we have an increase in substance abuse, overdoses, intimate partner violence and random violence in general. The patients coming in are sicker than ever and we are back to 40 people in the waiting room and 6-8 hour wait times. Everybody is anxious, and stressed and short tempered. On top of this the usual activities that we use to relax and recoup our energy are still unavailable. One of my main escapes is international travel, which is still limited. We have all had to find other ways to cope. For me I have used sick days as mental health recovery, I have used writing as a way to process my stress, grief, and anger, I have taken advantage of the counseling for frontline workers. And while I know that getting outside for hikes or bike rides really helps me feel better, I have a really hard time getting the motivation up to do them. The most I can manage some days is to eat my meal outside in my garden. I am slowly learning to cut myself some slack and not berate myself for my failures and shortcomings but try to find a few things I have succeeded at and to be grateful for.

My recommendations going forward are to support those who are still hesitant about vaccination to get what they need to get vaccinated. That all of us should be wearing masks indoors regardless of our vaccination status. That we still need to avoid large gatherings of unmasked participants and we should listen to each other for understanding and demonstrate compassion. This pandemic has exposed our vulnerability and we have a choice to be clear headed and open hearted to wade through or shut down and shut out people that don’t agree with us. I will choose love, every time.

PS two insta accounts I just started following Epidemiologistkat and catalystforselfcare that I find uplifting and helpful.

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this week

this week I
had a mammogram
which is always painful 
and degrading and cold
something suspicious sent
me back for a repeat
more compression and waiting
possible biopsy
turned out to be a cyst
I drank a mimosa and ate avocado toast in the sunshine

this week I 
worked at the triage desk
and received patient after patient
with small and dire emergencies

this week I 
saved the life of a young man
with a GSW to the chest
pouring unit after unit of blood into his body
while the trauma surgeon opened his chest
and shocked his heart and
gave him intracardiac epi

this week I 
lost the life of someone's 
mother and grandmother
all the efforts to repair her head wound
keep her heart beating 
and warm her body enough to support her blood pressure
failed to save her
she had told her family 
she wanted to die and jumped
down a ravine into the cold creek

this week I called my brother 
in the hospital with sepsis from a
necrotic wound from his wheelchair
he sounded discouraged 
to not be able to tend to his patients
the children of migrant workers
instead he is the patient
going to the OR and ordered 
to not work for 6 weeks

this week my phone died
disconnecting me from everything
I learned how dependent I am on the 
small block of glass and metal
that is also a powerful computer
as well as a lifeline
I didn't know I was missing calls
and texts, the silence was 
unnervingly blissful

this week I 
had an out of body experience
my hands and feet carried out
their usual activities but
my mind could not connect to the present moment
was I dreaming
did that happen
did I have that conversation
the words went through my ears 
but never reached my heart

this week I 
had an argument with my love
hearing  his voice raised in frustration
my heart slamming against my cold sternum
shocked muddled confused
what just happened
why are you yelling
I am not like you
yet I apologize
but don't know what for

this week I 
held the phone for my patient
to speak to his family 
in breathless one word phrases
just before he was intubated 
the virus claimed another set of lungs
and I pushed his bed to the ICU

this week 
I launched a new nurse into practice
after weeks of training her
to think critically under pressure
advocate for her patients 
recognize subtle but dangerous trends 
in her patients conditions
speak up in a noisy trauma room 
because she noticed  the problem
she is ready to be independent

this week I 
laughed and joked with my nurse colleagues
inappropriate and crude
to let off pressure after a grueling shift
the young man whose heart stopped twice
after we shocked him back to life
will probably not recover
and we will never know the truth
about what happened to him
I think of his mother getting the call 
and my laughter turns to tears

this week I 
slept for days
exhaustion never leaving my body
or my soul
no matter how long I slept
my eyes burning from the light
my legs so over tired they feel like cedar logs
my breath slowing
as dreamlessness takes over
then bring coffee




life suspended

I look at the body I was given

lying there on the alley pavement

unmoving and cold

paramedics surrounding me

pushing hard on my chest

but I don’t feel the gravel bite into my back

they shove what looks like an inflatable plastic shovel

in my throat and scoop me up

am I dead?

should I go with my body to the hospital?

for a moment my heart flutters and I feel

a rush of pain in my head

my chest burning

and my feet feel so cold, can’t I have a blanket?

next thing ten faces are

shouting things at me prying open my eyes

and I hear “pupils six and fixed”

someone is pushing air into my lungs with a large purple balloon

and I realize I am seeing my body again from the outside

shredded cloths all around me and my body exposed

it looks like me but it doesn’t feel like me at all

in fact I don’t feel any pain

that must mean I’m dead then I feel the jolt of

electricity sear through me and my heart jumps to life.

the thing is…

the thing is….

we couldn’t predict what it would feel like
to be inside all the time
not touching except with our eyes
inside homes
inside heads
isolated in our individual lives
zoom connection that felt like the stuff of the new millennium
is how how we desperately connect
our world is funneled through a
thirteen inch Brady bunch screen
masks cover our expressions in real life
the world outside spells danger
in viruses, violence and ubiquitous smoke
when will it lift you ask?
the thing is…
…it won’t

Thank you Seema Reza for your work with us on Community Building Art Works. The writing group for healthcare workers has been so nurturing and inspiring, giving me hope through these dark days

pandemic continues

And though we know that the pandemic cannot last forever
the end is beyond my sight
around the corner or just ahead
or beyond th e horizon where the moon rises
swollen and blurred behind the fog

and though we know there will be an end
the self proclaimed experts do not know what that will look like
the day we can leave our cocoons
with our faces turned up to the sun and breath in the unencumbered breeze

the day we forget what it felt like to hesitate before a hug
not because we fear intrusion

it has been a while since I first learned to recognize my coworkers
by their eyes behind goggles and shields
or the way they move their bodies
or the sound of their muffled lipless speech

it has been a while since the waiting room teemed with bodies jostling for the chair near the outlet
knowing they would wait hours for help with what they cannot tend to on their own
on the days when the radio rings with yet another unresponsive likely overdose
so many that we have run out of curiosity
so many that the act of giving breaths and placing tubes and giving narcan
no longer leads to surprise or annoyance that the supply drawer is never stocked
and the floor is a field of wrappers and blood and vomit
on these days we just look at each other in understanding and sadness
there are no words

Thank you Seema Reza for your work with us on Community Building Art Works. The writing group for healthcare workers has been so nurturing and inspiring, giving me hope through these dark days

Patience

This is nurses week, the internet is swirling with recognition for nurses in the midst of two months of talking about the frontline heroes. It makes me squirm a bit. While it feels good to have a moment to recognize the work we have chosen to do, I don’t feel like a hero.  Before the pandemic put us in the limelight, we were doing the same work, just different dangers and on a different scale.  We have always paid attention to hand washing, wearing masks, isolating patients at risk for infecting others or at risk for becoming infected.  But we face more dangers than infection on a daily basis. We deal with an inordinate number of patients who have poor coping skills and treat us badly for trying to provide care to them. They verbally abuse us,  threaten us and assault us, then accuse us of not caring.  As an ER nurse, I am presented with unknowns with each patient and have to balance protecting myself with making that patient feel like a human being and not a potential threat. I am thrilled when I have a patient that appreciates my care, one who says thank you, or even just doesn’t yell at me.  I think the worst thing someone can accuse me of is not caring. I care so much that I put my health on the line to come to work every day. I care so much that I work at a public facility for lower pay because this patient population needs care.  I care so much that I strive to hear each patient and look into their eyes with reassurance.  I care so much that I risk being wrong or ridiculed when something just doesn’t seem right with that patient and I drag a doctor to the bedside.  I care so much that I want to learn everything I can about this current pandemic so I can answer their questions, so I can keep my family safe, so I can keep working and support my coworkers.  So when a patient screams at me that I just don’t care and storms out of the ER unhappy, I am brought to tears.  I realize that this is an indication of how overwhelmed we all are.  I usually have  a tougher skin at work, and I know the insults are really the patient’s lack of coping skills.  Yet this is how fragile I am.

Our hospital has not been overwhelmed by COVID-19. Nor have other hospitals in SF. The bay area has been successful in flattening the curve and keeping the death toll low.  I watch what is happening in other areas of the country in horror. I read about the experiences of the doctors and nurses in those areas and my heart breaks. I worried at the beginning of all of this what I would do if faced with having to choose which patients to tend to, knowing that others would suffer.  To be honest we were already doing this before the pandemic when our waiting room routinely had 40-50 patients waiting hours to be seen. We always seemed to find room for the ones that were truly at risk of losing life or limb, but others also with genuine complaints had to wait.  I hated telling patients that I could see they were suffering but there were no open beds and another patient  was in worse shape.  As triage nurses we know that some need immediate care and some can wait, and we are skilled in discerning the difference. However as a human being, I also know that all suffering is real suffering and everyone deserves to be heard and receive care.  The hard part was that we couldn’t provide what many of the patients needed, such as warm, dry shelter, regular nutritious food, connection with people that care about them, purpose in life, healing for their trauma that landed them in the place that they are.  In the end they all get seen and cared for if they are willing to wait, though for many a tylenol, a sandwich, a clean shirt and socks, and a bus token is all we can truly offer.  Most of these patients are not coming in right now.  They are scared, they don’t want to get sick, and if they are able to cope a little bit, they stay away.  We are definitely seeing  more suicide attempts, more intoxication with alcohol and drugs, and more peopleunable to cope with the anxiety and depression. I get that, I have resources and coping skills and I also feel it.  This week we are starting to see more accidents and fights which makes me think some people are at the end of their patience with the shelter in place order and are going out anyway.

I think we are coming to an understanding that we have to balance the risks we are willing to take.  The risk of being ill, or infecting others vs the risk of the mental health effects of sheltering and not connecting with people vs the risk of a failing global economy.  As we learn more about how this virus works it becomes clearer that we can emerge from sheltering in a controlled way.  The scientist in me understands that we won’t have herd immunity or a vaccine for quite a long time, and this virus is proving to be very infectious and quite dangerous for anyone with chronic health conditions.  By using a reliable antibody test in a widespread way we can find the people who have likely developed immunity and can safely circulate.  We know how to protect vulnerable people from infection, we have done that for patients in cancer treatment, who have HIV or other immunocompromising conditions. We should be able to shield or shelter the elderly and the ones with chronic health conditions while we slowly have others get back to more social interactions.  It will be a new normal; groups will be small, people will wear a mask, more hands will be washed and attention to cleaning commonly touched surfaces. We will continue to test both for the virus and for the presence of antibodies to understand how this virus is spreading and how we as people are responding.  We will need patience with the medical and scientific community to digest and process the garden hose flow of new data.  We will need patience with our governing leaders to help us organize how to be in society with each other.  We will need patience with each other and our various levels of acceptance and anxiety around the pandemic. And lastly we will need patience with ourselves as we adjust to a new normal and regain some balance.  Breathe, and be grateful for that breath.

helpful links:

https://medium.com/the-atlantic/why-some-people-get-sicker-than-others-f64796b01486

https://medium.com/the-atlantic/the-real-reason-to-wear-a-mask-e6405abbc484

https://www.sfchronicle.com/health/article/Inside-SF-s-main-emergency-room-nurse-faces-15230001.php?fbclid=IwAR3kwSKE3hV6nt7a3CueiQPK7EvOgdE5Iy6guu1IPx8V07zhEm79eRRTSrI

https://www.sfchronicle.com/bayarea/article/Meet-the-Bay-Area-nurses-battling-the-coronavirus-15249110.php?utm_source=facebook.com&utm_medium=referral&utm_content=headlines&utm_campaign=CMS+Sharing+Tools+%28Premium%29&sid=53b750d9fdd5ac3a49000373&fbclid=IwAR1RuuSM4Mscs734Oxeoh_ChfkCJ_jCCCACJkMMKD6ogvDcZbcTXZ8D3Dec

https://www.newyorker.com/magazine/2020/05/04/a-city-nurse?utm_source=nl&utm_brand=tny&utm_mailing=TNY_Daily_043020&utm_campaign=aud-dev&utm_medium=email&bxid=5be9e7f53f92a40469fc3ae5&cndid=50793798&hasha=13a5956591fd5aa41a23502f69f091ae&hashb=f101abd5ae6ae47be38befa1cd0eb35a933b4dec&hashc=655c20833ba25cd38ec12a980262018c7ca486019456e25dee2cd915c778aaae&esrc=bounceX&utm_term=TNY_Daily

https://www.nejm.org/doi/pdf/10.1056/NEJMp2009405?articleTools=true

What We Don’t Know About the Coronavirus — The New Yorker

https://podcasts.apple.com/us/podcast/unlocking-us-with-bren%C3%A9-brown/id1494350511?i=1000470370881

erinbromage.wixsite.com/…/the-risks-know-them-avoid-them

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for the long haul

I had a  night off the other evening and I was walking in the neighborhood in SF looking for coffee, a nightshifter’s perpetual quest, when I heard the sounds of a party.  People were yelling, drums banging, and I was completely confused.  I have gotten used to the quiet in the streets, the feeling that I am alone in the world, even outside.  I wondered, who is partying? in defiance of the distancing? I felt my anger rise at the disrespect, until I started hearing people shouting THANK YOU! and my heart shifted.  I realized this is the 7pm cheer for frontline workers it was the first time I had actually heard it.  I looked up at open windows with people in them clapping and cheering.  I sat down on a nearby stoop and cried, letting the gratitude wash over me.  I have been holding it together for weeks, I heard about the 7pm cheer, but hearing it in person was so encouraging.

These weeks have been exhausting.  while the ER is not seeing as many patients as we usually do the patients we do see have been changing.  There are very few traumas, no commuting= no car accidents,  no bars open= no falls and fights, there are fewer of the traumas of violence that we usually see.  These have been replaced with more people in respiratory distress, and more psych patients.  The virus is moving through the homeless population as well.   These patients come to us when there is nowhere else to go  and they stay with us because the psych ward is full and the shelters won’t take patients until they have a negative test.  There are special accommodations  for the homeless that are positive called COVID hotels but they only take people in the daytime. So we hold psych patients and the homeless as a social service.  This greatly reduces the number of beds available for the actual emergencies.

We have actually sent ER nurses up to the ICU every few hours to help with the turning of patients. The ICU is eerie, everyone in full PPE, talking to each other over the banana phones on speaker through the door to the patient room.  We carefully follow the step by step instructions to turn the patient while minding all the IV tubing carrying life supporting drugs and nutrition, the breathing tube, the feeding tube, the urine catheter and on some patients, the continuous slow dialysis lines. The patients are almost all latino, male and in their 40’s and 50’s.

In SF the curve has been flattened, the hospital can handle the number of patients coming in because the public has followed the recommendation to stay home and distance from each other. It is working for now, slowing the rate of infection and death, and bought us some time to learn how to best treat patients, and how to best prevent the spread.  It buys time to develop a vaccine, though we need a long time for that.

We are beginning to realize that this will be our normal for the months ahead until we come up with a vaccine or a lifesaving treatment. What looked at the beginning to be similar to the flu, has turned out to be so much more infectious and so much more deadly.  What looked like a purely respiratory infection has turned out to have dangerous effects on the heart, kidneys, brain, and blood. It is not easy to predict who is most at risk, though we know the age and chronic health conditions do increase vulnerability, there are deaths among the seemingly young and healthy.  We must stay the course until we learn more.

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