Who will die today? A nurse’s typical day in the COVID-19 ICU. | Expert Opinion
I’m bombarded with sound and chaos. It’s a visual and auditory assault.
I stand in front of the ICU doors and remember what this unit was like before March 2020. It was a spacious and controlled environment. Now it’s Temple University Hospital’s COVID ICU, and the difference between then and the present never ceases to jar me, even now, 10 months into this deadly pandemic. As the doors swing open, I’m bombarded with sound and chaos. It’s a visual and auditory assault. I start my shift wondering the same thing I do every shift: Who will die today?
As nurses gather for shift change, the central monitor is beeping at our station. The patient’s oxygen saturation is dropping, and his ventilator is alarming as well. We discuss the need to prone him (position him on his stomach) after shift change.
Ventilator alarms have a distinct sound, similar to a car horn. In the COVID ICU, where COVID pneumonia requires the highest ventilator support for extended periods of time, they sound all day and all night. The respiratory therapists responsible for ventilated patients and those on high-flow oxygen are the unsung heroes of the pandemic. Several of these Temple therapists have contracted the virus due to their prolonged exposure to the aerosolized particles that carry it. They have all returned to work, dangerous though it may be. We need them.
I take report from the night-shift nurse and learn that I have three patients today. I want to complain, but I’m reminded of the nurses throughout the hospital who struggle with six-patient assignments. I think of the overworked patient-care assistants, with 20 or 30 patients. I think of all the X-ray techs, pharmacy techs, and housekeepers, who are burning out, and the lab personnel, who are exhausted. No ancillary staff has been spared the physical, mental, and emotional toll of this pandemic. I accept my assignment without comment. Only the alarms sound.
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After report, we assemble four nurses and a respiratory therapist, put on our personal protective equipment (PPE), and place the alarming patient on his belly. Lying in the prone position typically requires a 1:1 assignment — one nurse to one patient. But no patient gets 1:1 care anymore. There are simply too many very ill patients. Turning sedated adults in a hospital bed without dislodging tubes or lines is a physically demanding and tricky endeavor, but we do it every day now. His oxygen saturation rises immediately.
As I take off the PPE, an IV alarm sounds in another patient’s room. It’s not unusual for COVID patients to be receiving six to 10 infusions at a time. Pain medication, sedation, blood thinners, vasoactive drips, paralytics, and antiarrhythmics are all delivered through central IV lines. To an outsider, it looks like a tangled mess of tubing. Even for a skilled ICU nurse, it’s a complicated task to maintain each drip, titrate the medications, and ensure that none of them run out before a new bag is hung.
I glance at the patient’s nurse, who has several medications in her hand. She has it. We nod to each other because no words are necessary.
The low-pitched honk of a kidney dialysis machine sounds. Maintaining this life-support equipment requires replacing and emptying heavy bags of fluid round the clock to ensure that the circuit doesn’t clot. If that were to happen, the patient would lose considerable blood volume — yet another emergent situation. I put on my N95, face shield, gown, and gloves and change the dialysate bag because the patient’s nurse is busy at another bedside.
I still have yet to see my own patients. At this point, I’ve been on duty for an hour.
The telephone rings and rings and rings. Concerned family members call all day long for updates. They long to be with their loved ones. Unit secretaries are invaluable, but we don’t always have one. The phone also rings with admissions. The patients never stop rolling through the door.
Most of the single ICU rooms have been converted to doubles. The rooms are crammed with twice as much equipment and every electrical socket is utilized. However, only one of the two patients can be hooked up to the monitors at the nurse’s station. For a nurse to hear the portable alarm attached to the other patient through the glass, it must be on the highest audible setting. My patient’s alarm is blaring because his oxygen level is dropping while he drinks some water.
In an effort to keep this patient from being intubated, he is receiving 60 liters of oxygen at 100% (people typically receive 2 to 6 liters of oxygen at 28%) through a high-flow nasal cannula. He has been in the ICU for two weeks and witnessed many body bags being wheeled out of the unit. His roommate is sedated on the ventilator, and the alarm is making him anxious. From the hallway, I instruct him to supplement his oxygen with the non-rebreather face mask as I put on my PPE. He complies, and his oxygen level rises.
I enter the room and the loneliness and fear are palpable. As I begin my assessment — something I will repeat many times throughout the day — he recognizes my eyes, the only part of me he can see. I smile under my mask, and we hope together, silently. We hope today is the day he turns the corner. We hope this nightmare ends soon. We hope no one dies today.
The din of the ICU recedes a little bit as we hope. This moment, it’s what keeps me coming back.
But it is only a moment. The alarms break through. The telephone rings. The tasks are unending.
Mary Adamson, RN, BSN, is an ICU nurse at Temple University Hospital and the rising president of Temple University Hospital Nurses Association, which represents more than 1,400 registered nurses at Temple University Hospital. She has been a bedside nurse for 25 years.