Nursing

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.

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

Rage Writing

Rage Writing with Seema Yasmin
— Read on seemareza.com/rage-writing-with-seema-yasmin/

There are people who will tell you that
you must care for the drunk driver who
was unaware that her decision ended the life of the mom whose
teenage son’s world is about to change when he
wakes up from the sedative given to fix his fractured wrist

he must heal his heart and body without her
the mom who would fill the ziploc with ice and carefully wrap it in a kitchen towel
who would wipe his tears and wrap her arms around his big man body as he cries
in the one bed in the flat they share with his school papers strewn on the floor

There are people who will tell you that
you must forgive
forgive those who slash open your heart with the betrayal
of the only promise that really mattered
they tell you forgiveness is for you not the one
who undermined your reason for living

I want to be hated by those people who want to silence the rage
that falls from my pen
the depth of anger that erupts through my scalp
at the man who harmed the child we promised to protect
that man who walked through his life with
an earnest face and a vile secret 

there are people who will tell you that
that life with three squares and no freedom is enough
enough to atone
is there atonement for the hate?

Thank you Seema Reza  for your work with us on Community Building Art Works. and to Seema Yasmin for the special online writing workshop 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

8C5A46F3-6BCF-48FF-B36B-442889D45F36.jpeg

 

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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Overwhelm

I love the adrenaline rush of working in the emergency room at a level 1 trauma center. I walk through the doors at the beginning of my night shift and enter another world, a world where keen observation precise and clear communication and  quick decisions can save someone’s life. The majority of people leave the ER alive and feeling better, some require follow up, long recoveries and rehab.  Some leave with their lives drastically altered forever.  Some though, never make it. It is part of the reality of where we work.  We witness much tragedy and violence, as well as love, appreciation and healing.  We are with people in some of their most vulnerable moments of their lives. Of course it takes a toll on us, we walk the line between opening our hearts enough to have compassion and keeping emotions in check enough to do our work and keep showing up.  We keep each other motivated, have each other’s backs, share humor, and stories of our lives and families outside of work, cheer each other on and commiserate and vent our frustrations and even share a few tears. We see so much, our hearts break, we breath deeply, maybe cry a little in the med room, and then go see our next patient.  When I walk out the doors in the morning, exhausted, calling “sleep well” and “see you tonight”, I leave that world behind and come home to regular life.  I may share a story or two with my family, but I have learned that most people don’t really want to hear details of how we had to go on lock down again after a gunshot wound was dropped at the door, or how I had to delicately determine if the woman asking me to find her husband, is the wife of the unidentified dead stabbing victim in room 6, or how my patient who had just been beaten and sexually assaulted was being harshly questioned by the police  because she allegedly hit her assailant with a bat. These stories stay inside the ED.  Before the pandemic,  the news didn’t usually cover what we do everyday.  We have been short staffed my entire career, and short of the resources we need to take care of the patients.  We are inundated with patients who are aggressive and violent, have drug addiction and mental health problems, are homeless  and without a way to stay clean and fed let alone take care of their chronic health conditions.   It is the balance of normal life outside the hospital that keeps us going and gives us the resilience to keep doing our work.

This pandemic however has been extremely challenging, in that there is no break when we go home.  The news is full of images of nurses and doctors taking care of Covid19  patients, talk about masks and ventilator shortages, counting of cases and deaths in China, Italy, Seattle, New York.  People are anxious, and concerned for their own health as well as their loved ones.  Social media is teeming with good information, bad information, advice, and some humor. There is no getting away from it. The first several weeks I found myself reading everything, and digging into the research as it was coming out, trying to understand for myself and my practice  and to be able to answer questions for my friends and family.  I quickly became buried in data, and the opinions of all the journalists and public figures.  The anxiety level at work is up as well, our preshift huddles are longer due to the daily changes in protocols as we prepare for the surge of Covid19 positive patients, and the shortages of PPE and equipment. Right now we have enough PPE, we get one mask and gown per shift, it is not ideal; they are supposed to be disposable every time you go in and out of a room. But we have them and we are protected for now. There is a sense of foreboding as we watch the number of cases and deaths go up around the country and wonder how long before our hospital is overwhelmed.  One of my coworkers described it as being in a building with an active shooter, you know they are out there with a loaded gun, you know they are coming through the building room by room and you are just waiting for the S#*$ to hit the fan.  It is going to happen, many more people are going to get sick, they are going to come to the hospital, when will it start?  will we be ready?  Right now it is eerily quiet.  Our regular patients are scared to come in, there are fewer car accidents, bar fights and drunken falls with the stay at home order.  The patients that do come in are real emergencies, today we put 5 patients on ventilators, and our ICU is full.

The rhythm of my days has not changed, I am not home with extra time on my hands. I am not going to lie, I am a little jealous of the people who can work from home, spending time with their families, planting gardens, reading more books, getting projects done, or even meditating more. I miss hanging out with my family. I miss coffee with my friends.  I miss going out to dinner, seeing movies, going to the theater and the opera.

I know I have been exposed to the virus, but I am more worried about bringing it home to my partner or kids, than I am about getting it myself. I have a pretty tough immune system, but my partner does not.  At this point we are not  quarantined from each other at home but it may come to that.  We all handle anxiety in different ways and I have had to learn to be more vocal about what I need to replenish during my time away from the ED.   What helps me is SLEEP!  Walks outside in the sunshine, playing my guitar and singing, watching sappy funny movies, talking on the phone with my friends and my kids. Just seeing my kids on a screen, live, in real time warms my heart and settles the protective mama bear in me.  We are lucky that we have some amazing technology to stay connected in so many ways. For this I am grateful.

Some links if you are interested:

How COVID-19 Actually Spreads (w/Dr. Gloria Hwang)

https://hbr.org/2020/03/that-discomfort-youre-feeling-is-grief

The Four Possible Timelines for Life Returning to Normal

 

stay home stay healthy

We are 10 days into our local stay home order, and a week into our statewide order.  I had to cancel my trip to the midwest to visit my mom, who is elderly and 2 years out from open heart surgery.  She lives alone with my sister nearby and is doing great by the way.  This meant I had 6 nights off before going back to my ED nursing job.  I was faced with a choice; do I pick up extra shifts because our department always operates short staffed even before the pandemic started, or do I take advantage of nights off at home, to rest up and eat well and get outside in the sunlight. I spent time reading the emails from my manager and the hospital administration, I read posts from colleagues about nurses being quarantined, I read about the PPE situation in the department and, the posts from my union rep about actions to take and I realized that this pandemic is going to be a marathon so I decided to take the time off as a gift.  I rarely stay home when I am off from work more than a few nights, we usually travel somewhere, so this time at home feels like a gift.  I have been spending the time doing spring cleaning and reorganizing the kitchen. I am working on a project clearing out 32 years of stored stuff that I have been avoiding for the last 5 years.  I have had time to snuggle on the couch in front of movies, do a little cooking and play my guitar.

I find myself reading studies about SARS trying to understand the truth about what we actually know.  Nursing is my third career and my first one was as a research microbiologist.  I know how to look at data, and read research studies, and I understand infectious diseases and how they spread.  I question every headline and statement I see in the news or on social media, how do they know that? what studies are they basing that statement on?  I follow the CDC, WHO and other data driven websites and make my own conclusions about what the data seems to be telling us.  I try not to post statements that I can’t back up with facts, and I don’t apologize for being a nerdy science type. Because of this background I am usually  calm and don’t freak out at every little thing because I can look beneath the sensationalism and find the facts.  This virus is new however, and we have little history about it’s behavior.  We can extrapolate and predict based on the behavior of similar viruses, we can model systems of transmission and study how to protect ourselves. The truth is, we are not far enough into this pandemic to have the data we need to make some of the decisions we need to make.  It is going to take time and trust in the scientific community (not the political or corporate community) to do the experiments; studying the epidemiology, developing a vaccine, and developing antivirals that can mitigate course of infection and maybe even act prophylactically.  We have not seen anything like this on a global level before.  Other novel infections have been contained in certain locales long enough to develop ways to fight them with vaccines or medication protocols. The time for containment of this virus is long past; we must self isolate, be meticulous with hand washing and take care of our immune systems.

So what is the good in this?  Many people get to spend more time with their families, focused on each other and what is important to them.  We as a community are finding ways to help each other with errands, check ins, and support.  We are all learning more about technology and how we can connect virtually.  There has been an outpouring of music on the internet from artists all over the world.  In the long run our healthcare system will have to improve, as this pandemic is exposing lots of places where we are grossly unprepared for a pandemic or other kinds of disasters.

I tend to look at the world though a healthcare and science lens, and rely on others to take care of the economy.  I don’t have talent or much interest in deeply understanding how the economy works, however, I  have been forced to learn a lot in the last five years  since becoming a single parent and putting a child through college on a single income. I am grateful that I have a good, stable job (that I happen to love) with great benefits. But not all are so lucky. Two of my 3 young adult children are without income right now. I am supporting one and the other is managing on savings and scrambling to create new income streams. It is a scary time for everyone,  and I am quite aware that my family is privileged. My kids will be ok in the long run, they are resourceful, smart and generous, and I am in a place to help them if they need it.

My heart aches for those without safety nets.  Without income, or most of all without people to lean on. I try to end each day with gratitude.

Pandemic

When I came back to my blog last week I had something entirely different in mind to talk about.  However in light of the global health crisis, I want to talk about THE VIRUS.  Yes SARS-CoV-2 that causes COVID-19 disease.  I work as a nurse in an emergency room at the only trauma center in a large west coast city. We are busy on any given day with traumas, strokes, heart attacks, drug overdoses, stab wounds, gunshot wounds, falls, alcohol withdrawals, psychiatric emergencies….. I could go on and on.  Since we are  the county hospital we also take in our share of homeless seeking shelter and sandwiches, patients in custody, and sexual assault cases.  This time of year we are geared up to handle people with the flu and other respiratory infections.

When I first started hearing about this novel virus, I thought, as many did that it was going to play out just like the flu, but maybe just a little worse because it is new and we don’t have a vaccine yet.  We already had a protocol for masking people with coughs and fevers, we assumed that would be enough.  Fast forward to the last couple of weeks as the data started rolling in from around the world showing that this virus is more deadly and likely more contagious than the flu. We watched as China, Italy and Seattle shared their experience and their data.  Each day I would go to work and be briefed on the current status for handling patients and testing, and what we should be doing to protect other patients in the ER and ourselves.  We rearranged triage areas, changed workflow, brushed up on higher level PPE. Every day we were told that the tests are limited, with very strict criteria for testing patients. At first the samples had to be sent to the CDC for testing, then much later we got the capability to test in our state, but still limited quantities. As I write this we are still not testing health care workers in my hospital.  As far as I am aware, though  several nurses are out on quarantine for having been exposed, some have symptoms but since tests are scarce none have been determined to be positive for Covid-19.

Earlier this week all our local counties were asked to shelter in place, and yesterday the governor initiated a statewide order. Only essential workers can go to work and only essential activities are allowed outside the home, such as grocery shopping and medical appointments.  Schools, theaters, restaurants, bars, gyms, all closed.  My days have not changed, no Netflix and chill for me, I am still going to work.  My family has been instructed to wash hands when they walk in the door, and watch for fevers or coughs.  College is online and graduation is cancelled for one of my children, two of them have little or no work. We are a multigenerational household with some concern for bringing the virus home so we are all being vigilant.

It is hard to keep up on all of the data coming out, but it has become clear that two  significant assumptions we made have to be adjusted.  First, a study came out showing the viability of the virus on surfaces and in aerosols. Now that we have more information, actual data that shows the virus behaves more like the SARS-CoV-1 (from 2002) with persistence in aerosols, this information makes me more concerned.  This requires higher level of isolation and precaution similar to that of TB.  If we get a surge of patients testing positive, we are not prepared to maintain that level of isolation on many patients.   Second, we have been thinking that this new virus does not affect young people that much, that they would only suffer mild symptoms.  Two studies have shown this not to be true one from China and one from United Kingdom, while young people (under 60) still have a significantly lower risk of death from Covid-19, many do get hospitalized and some even need intensive care.  What this says to me is that young people still must be careful and not assume they will not get sick.

Some other sobering news came out of UCSF Infectious disease meeting, more than half of the US population will likely get the virus and with a 1% fatality rate that means 1.5 million Americans may die.  We will need 1 million ventilators, we have about 160 thousand.  It is time to mobilize manufacturing in this country as we did for WWII; build ventilators, produce masks, gowns, gloves and sanitizer.  We haven’t seen the likes of this since 1918 with the Spanish flu.

This brings me to being a canary.  Those of us who work with sick patients, are 4 times more likely to get the virus, it is imperative that we have adequate protection.  Enough PPE, support of hospital leadership, cooperation of the population to do their best to shelter in place and minimize the spread of the virus.  We are crazy dedicated to our work and often put caring for our patients before our own safety. I don’t want to face the decision of do I care for my patient or not because I don’t have the necessary PPE.

Every day we learn something new, about the virus and about ourselves in a global state of crisis.  Our lives are changed, our priorities reordered and gratitude for the small things we overlooked becomes our focus.  Stay positive, stay connected (virtually) and remember all of us have an important role  in slowing and eventually halting this pandemic.  Step up and lean in with a smile, check in with people, and if someone is struggling, be present with them through the fear even though we don’t know all the answers. STAY HOME AND WASH YOUR HANDS.

Jennie

PS some links

josh lerner MD

aerosols

Atul Gwande

Larry Brilliant

SF Chronicle on nurses at SFGH

young people

maria shriver