nurse

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.

D7476E09-8791-436B-A3C8-82059D7A0630

 

Advertisement

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