How COVID is Changing My World as an ICU Nurse Practitioner

This is my story, our story. I share it not for recognition, or gratitude, or pity. I share it so you understand what it is to work in a community hospital, three blocks from my home, during this pandemic. So that the social distancing and the home isolation are worth it for you. So the empty shelves at the grocery store and the mask you have to wear are a little less bothersome. So my children missing major milestones in their adolescence is worth it. So that the days upon days of fighting a virus we don't yet know or understand are worth it. So that we remember, when we start to find our new normal.

Nurses and front line healthcare providers (nurse technicians, phlebotomists, providers, radiology technologists and so many more) have long faced violence from patients and their families as one of our biggest threats. This isn't just violence from patients intending to do harm, but those who are confused or have neurologic impairments such as dementia and do not understand the implications of their actions. This epidemic (a strange word to use now to describe something that isn't infectious) has gained more recognition, advocacy, and even legislation over the past several years. The American Association of Critical Care Nurses issued a statement on workplace violence in 2019.

Six months ago, if you asked any Nurse the biggest risk they face at work, a vast majority would have answered workplace violence. These incidents are far more frequent than the lay public would likely imagine (OSHA reported that from 2002-2013 incidents of serious violence were four times more likely to occur in a healthcare setting than in private industry).  Suddenly, we have been catapulted into the front lines of an entirely different threat. "Front line" infers a battlefield, and for Nurses and other healthcare providers and hospital workers, this is truly the closest thing to battle those of us who haven't served in the military will ever know. I say that with all due respect to those serving, knowing the threats they face on deployment every day. This is the first time each and every one of us goes to work every single day worrying about the threat we face.

"Will this be the day I get sick?" "Which of my co-workers is most at risk of getting sick?"

"Do I need to worry about this sore throat or am I just run down?"

Sitting at dinner the other night, I told my children that the way their world feels right now is much like we felt in the days after 9/11. My daughter is a senior in high school whose important milestones have been put on pause for this pandemic. I told her this is the part where we wonder what changes to our daily lives will be indelible, and what will "go back to normal".

There are things I hope do become ingrained in our healthcare culture. Our colleagues have become our "battle buddies", as we invest in keeping each other and ourselves safe and healthy like never before. Staff from other areas of the hospital have folded into our ranks, sharing their skills and strengths to make our team even stronger. The relentless teamwork, and the moments of pause that we have taken together, to laugh or cry or just debrief, are things I hope we never lose. The community support...the meals, the headbands with buttons to hold our masks, the care packages, the people who have recovered from covid and are donating plasma ("liquid gold"). My friend Jim Mazzara, #rovingDCpiper, playing bagpipes around the area to lift spirits, and serenading a new mother and her infant with "Happy Birthday" as they left our hospital. Each gesture has been appreciated in ways you cannot imagine. We thank you. We appreciate you.

There are also things that have changed which make our jobs infinitely harder, mentally, physically and psychosocially. We are professionals grounded in evidence. "Evidence Based Practice" has become our mantra. When a patient suffers a heart attack or heart failure, I always tell them "cardiologists love research, and we have a recipe for everything. I may not know the exact specifics yet, but I know the ingredients we need to help you get better and stay out of the hospital." It is said that it takes as many as 17 years for research to be fully translated into practice. Suddenly our practice is changing daily. There is little evidence and we make the best decisions we can, with the available information, guided by experts in infectious disease and critical care. We are fortunate in Maryland to have the benefit of lessons learned from colleagues in New York, New Jersey, Italy, China, and so many other places. We had time to prepare, to empower ourselves with knowledge of their successes and lessons learned. We have had to constantly pivot, then educate providers and front line staff on changes in personal protective equipment, patient management, rules, regulations, you name it. That is just the logistics and protocols, then you get to the human part of what we do....

For decades, it was thought that families should not be present in the Intensive Care Unit (ICU) during invasive procedures or cardiac arrest. Researchers slowly chipped away at this misconception, showing that family members have a better understanding of what happened to their loved one when they can be present at the foot of the bed, or outside the room, with a member of hte team explaining what is happening. They see that everything was done for their loved one, they have a better grasp on the reality of the situation than they would sitting in a cold and unfriendly hospital waiting area. We worked to change culture, to convince colleagues that family presence did not increase liability, that we could still talk through our plan of care and discuss treatment options and advanced life support protocols in front of family members. Family presence is an area in which our small community hospital has long excelled.

Prior to Covid there were no "visiting hours"; families (biological and chosen) were allowed in our ICU and nursing units 24/7 as long as there was no impediment to patient care. Family members were encouraged to participate on daily rounds in the ICU, and if they missed the rounds at 9:30am they were repeated by our Nurse Practitioners and Physician Assistants at 9:30pm and they could participate then. Now each family must be updated by phone, and despite requests for one spokesperson, multiple understandably concerned family members call the unit inquiring about their loved one each day. These calls and video chats are their only point of contact, unless their family member is able to talk by phone. We ask family members to email photos so we can make posters for each patient, to provide them something familiar as they awake delirious from the haze of sedation and mechanical ventilation.

Covid has put us in a place where there is no physical family presence. We are the hand-holders, the cheerleaders, the person standing at the bedside shedding a tear as a patient dies. The ones giving thumbs up EVERY SINGLE TIME we walk by the room of a patient who is awake and improving. We have always been those people, but we didn't replace a patient's family. We supported them at the bedside and when they were not present we provided whatever the patients needed. Now there is no one else. It is only us, the healthcare providers, who can hold hands, soothe our patients, give them dignity and respect, bear witness at the end of their lives. And WE MUST bear witness. It is unspoken that no patient should die alone. We hold their hands, we tell them how much they are loved by their family, and that their family will get through this difficult time, we pause to recognize the person that existed before COVID, before the tubes and lines, before we became their extended family. Then we call their family again, and let them know that they weren't alone, that we were there, that (if they were religious) we prayed with them, or sang to them, or played soothing music. That someone who cared was there at the end, to bear witness.

After hearing a Public Health Service officer speak about a mural used to memorialize Ebola patients in Liberia (those who survived and those who perished), I shared the idea with our staff. Chaya, a friend and Nurse Practitioner Colleague, went to work with her art supplies and created a foundation. Our staff then began to contribute, remembering each patient we have fought to save, regardless of outcome. The painting has gained more flowers and stars since these photos, a remembrance and a moment to pause as they are painted.

Whatever your job, imagine cutting holes in a trash bag and putting it on yourself like a poncho (or like a wrestler trying to drop weight). Then put a tight-fitting mask on your face, a plastic eye shield, and gloves and go about your day. It is hot. It is sweaty. You start to discover pressure points on the bridge of your nose. You are often in a room with a "scrubber" that is used to filter the air (imagine the loudest industrial fan you can, then imagine louder). To communicate with people outside your patient's room you write notes on a whiteboard "Need a gown." "Need a new Levophed drip" "Need a boost", then knock on the glass door to get the attention of someone outside the room. Change in and out of this outfit without touching your face, approximately every 30 minutes. While in this garb, put your cell phone or tablet in a ziploc bag, and attempt to face time with someone while standing right next to that industrial fan.

We have been told this is a marathon, not a sprint. I ran one marathon. In 2008. It was 26.2 miles. I beat Oprah, which was my one goal. A marathon is 26.2 miles. It is finite. Even at mile 25, when you have hit the wall and think you can't go on, you KNOW you only have 1.2 miles to go. This is an endurance race in which the finish line keeps moving. It is not finite. When you hit the wall, you have to have your moment (and I have definitely had them- tears, frustration, fatigue, sorrow, illness), and then you have to lean in and get back to it. Sometimes it takes a kick in the pants, or a boost from a colleague or loved one. Whatever the motivation, you get back to it. For your patients, for their loved ones, for your colleagues. Because it is your calling. Because if you were sitting at home you would want to be there, helping. Because you are a helper. Even when it is hard. Even when it is risky. Even when there is no finish line in sight.

When the curve flattens and things "go back to normal", we will still have COVID patients who are days and weeks from leaving the hospital. We will still be fighting this battle as things start to reopen. The outside world will move back toward normal but ours will still be filled with COVID. The patients who are still healing, and then the worry of resurgence. But it will also be filled with so much more- with the relationships we have forged, fighting this battle together, with the people who have supported us, with the reminder that we are called to this work, with our pride in being healthcare providers and hospital workers, with the memories of patients we have gotten through moments we thought they wouldn't survive who are now home with their families. As we whisked a terrified patient from a medical floor to the ICU with his oxygen level plummeting, my colleague Rachel, a Physician Assistant, provided him an explanation of what would happen next, and words of reassurance that have since been repeated countless times.

"This virus is strong, but so are we."