sars

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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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