May 7, 2020–my first COVID patient. May 7, 2021, one year on the front lines.
This diary was compiled from my personal journals but I have tried to integrate into events happening outside of own nursing bubble. Hopefully, the numbers and dates don’t make it tedious reading.
The first COVID case appeared in the US on Jan 21st and in Oregon on Feb. 28th. By March 31st, Italy was in crisis. Sometime in mid-March the powers that be decided we needed a COVID CCU. It was a logical decision—we have a core of highly trained and experienced ICU/CCU nurses, a well established ECMO unit, AIIRs, familiarity with PAPR use, and clinical experience in treating infectious airborne diseases. It wasn’t a big leap—the physical facilities were already there, we brought in more ventilators (and parts), checked our PAPRs, and tried to stockpile PPE supplies.
By May patients were coming in regularly, not in great numbers but very sick. About 90% of our patients were transfers from other hospitals arriving already in ARDS with high fevers. They came directly to our unit by-passing the ED. We intubated and vented, administered heavy sedation including paralytics, put them in AIIRs, hung IV antibiotics, fever reducers and fluids. It’s all we had—there no COVID specific drugs available yet. We used the same treatment protocols we used for virulent pneumonia—it was not particularly effective . The patient’s lungs filled with fluid which we had to suction constantly to keep them from drowning. We used cooling blankets to help reduce fevers, blood gas draws to check lung function, we proned our patients —we monitored and we waited. Our ward was locked and a guard placed outside. You had to be authorized to enter, couldn’t just use your badge. Absolutely no visitors. Some weeks 50% of our patients died—their passing marked by a solitary nurse in attendance. Except for our unit, the hospital was quickly becoming a ghost town. Patients cancelled scheduled procedures, ignored medical issues, just stayed away. Our unit was losing nurses, in the first 5 weeks we lost 10% of our unit’s RNs. Nurses I had worked with for years left—transferred to other units or quit. New York City had so many COVID dead, they were storing them in refrigerated trailers. On May 11th, 80,000 deaths in the US, 130 in Oregon.
On June 21st, dexamethasone became the standard of treatment for ventilated COVID patients. It was readily available and we began administering it immediately. Remdesivir was approved under a EUA on May 1st—limited supplies of remdesivir began trickling in late June. We triaged, rationed, and begged for more remdesivir. The drugs helped, our patients were surviving longer and in greater numbers—our mortality rate dropped to about 35%. We had patients that were no longer infectious but still critically ill with no place to put them. We had the beds but not the staff. We put out the hospital wide plea for any RN experienced in treating ventilated patients with the assurance that they would not be treating any infectious patients. We had a few volunteers and were able to cobble together a second CCU for the no longer infectious, we transferred some of the no longer infectious to other hospitals. In mid-June our hospital went on lockdown, there were widespread staff furloughs, the remaining staff had their hours reduced. Except COVID CCU, we’re had now lost about 15% of our staff and were routinely working 50 hour weeks. Our unit always ran lean but we were down to the bone—or so we thought, currently have lost 25% of our staff. This was our first surge with about 400 new cases per day and 10 deaths per day in Oregon. As of June 30th , there were 126,140 total deaths, 2.59 million confirmed cases in the US; 207 deaths, 8,656 cases in Oregon.
By July the surge had ended but troubling symptoms were appearing in our our patients. For reasons beyond my knowledge of immunology, COVID can set off a out of control immune response which can attack pretty much any internal organ. This immune response can also include an inflammatory response which can also be life threatening.
About 30% of COVID patients develop VTE (Venous Thromboembolism). Blood clots in ventilated or bed ridden patients is a well known phenomenon but not at this level. Blood clots can cause a MI, PE, DVT or CVA—any one of these can kill the patient. Researchers believe these clots are caused by an autoimmune antibody triggered by COVID. We use blood tests as a one of the tools to diagnose clots—Fragment D-dimer, can help rule out blood clots and TEG, thromboelastography, measures how long it takes whole blood to clot. Treatment includes pressure stockings, leg elevation, and blood thinners. Treatment with blood thinners must be closely monitored—too little, the clots remain or too much, the patient hemorrhages.
We began seeing precipitous blood pressure drops in hypertensive patients. Particularly in those being treated with ACE inhibitors and ARBs. This condition can cause AKI (acute kidney injury) which necessitates the need for dialysis. We can’t use traditional dialysis so we use CRRT (Continuous Renal Replacement Therapy). Rather that do a complete blood exchange in a matter of hours, CRRT runs 24 a day hours as long as required —it’s less traumatic for our critical patients. We also use a class of drugs called Pressors (Vasopressors)—they contract the blood vessels which increases blood pressure. It increases the blood flow in the body’s core which helps reduce damage to internal organs. Unfortunately it reduces the flow of blood to the extremities which can cause our patients to lose fingers and toes (particularly in diabetic patients).
I may continue this diary at a later date. Writing it has been taxing, a struggle—remembering events that I would prefer not to, researching dates to integrate them into events in my unit. This last year has required levels of personal strength that I didn’t realize I possessed. As an RN, as a human, I learned lessons that I will carry with me the rest of my career, probably the rest of my life. This knowledge came at a high cost—physically, mentally, and spiritually. Would I do it again?—yes, I would.