Inside the ICU: A Nurse’s View of Covid-19 in Los Angeles
Los Angeles has been experiencing a horrific surge of coronavirus cases: a patient is dying of Covid–19 every six minutes, on average. Crematoriums are so busy they are being excused from regional air-quality standards. I asked a friend who is an ICU nurse to sit with me for an interview.
I asked her everything: What is the ICU like—what are the working conditions, is there still a PPE or ventilator shortage? (Yes.) What do patients and families go through? I even asked her what we should know about dying—or, hopefully, not. Our conversation has been lightly edited for length and clarity.
What positions have you held since the pandemic started?
I’ve been working as a traveling ICU nurse in three different Southern California hospitals.
How were the working conditions early on? Were there personal protective equipment (PPE) shortages?
On my first assignment, PPE definitely wasn’t as abundant as it always had been in my whole 34 years of nursing history. The way it used to be is, you had an N95 mask and you wore it, did whatever you were doing in the patient’s room, and you threw it away. Whenever you went back in the patient’s room, you did the same thing again, so you’d use several masks in one shift. On the first assignment, we got some super-cheap isolation gowns, they were horrible. They were plastic – like a garbage bag, basically, just 100 percent plastic.
It was already warm [in the late spring], and you’d go in—you’re basically wearing a garbage bag, you have the N95 mask on your face and your gloves, then you have your face shield, which always would steam up because you were sweating so much from wearing the garbage bag. I would come out of the room drenched in sweat; like, my forearms were sweating. I didn’t even know that your forearms could sweat, I didn’t even know that was a thing! We only had those for a little while.
The biggest change was the N95 mask. They would give you one at the beginning of a shift. If you needed another one, you would have to go talk to the charge nurse and explain, why did you need another one? Because it was filled with sweat and disgusting!
At my next assignment, they were again concerned about the shortage of N95 masks, so they were planning on having the masks re-sterilized—cleansed using some sort of a hydrogen peroxide solution that was not proven to actually do anything. It’s not FDA-approved, the process was just granted an emergency use authorization (EUA) to try to preserve N95 masks. They had numbers written on them – we hadn’t actually started collecting them yet to turn them in for that.
I wrote to nursing administration about my concerns. In the end, we didn’t end up doing that, thankfully, because first of all, they’re already reusing the masks. Masks are supposed to be one-time use; yet we’re already wearing the mask all day – 12, 13 hours a day – in the rooms of patients we know are Covid-positive. Then they want you to throw it into some thing to be collected, take them all somewhere, gas them with some hydrogen peroxide, I guess, and then bring them back to the hospital, and then you get to use the old masks? Not your own old mask, somebody else’s random old mask!
Maybe the patient who is on isolation didn’t just have Covid, maybe they had something else, as well. You don’t know. I don’t know if this process is going to kill Covid, and I don’t know if it’s going to kill whatever else the patient was on isolation for. Who wants to wear somebody else’s old mask? That’s disgusting.
Did you feel any of the changes to standard practice made you or patients less safe?
Definitely. It definitely made me feel less safe with the mask situation. Whenever they were threatening to take the masks and give you somebody else’s old mask, I would bring my old mask home and recycle it myself. I’d rather reuse my old mask than somebody else’s. At least I know where mine’s been and how it’s been stored and what else is going on with it.
Did that become the general way of doing things?
It would depend. Towards the end of my last assignment, there was a Covid ICU and then there were two other ICUs. So they would rotate who went into the Covid ICU. You wouldn’t always be in the ICU because they didn’t want any one person to be that exposed to it if they didn’t have to be. You would do one day in the Covid ICU, the next day in a regular ICU. Sometimes whenever I was in the non-Covid ICU, I would bring one of those masks home, in case I needed one for the future – a “clean” mask.
You were still wearing the same mask all day?
Oh, yes. You always wore your mask all day, the entire day.
Even in a non-Covid ICU?
In the non-Covid ICU, I did. We all had to wear a mask, of course, and face shields in the patient’s room, regardless of what kind of patient it is. I would wear an N95 mask because I don’t know who does and who doesn’t have Covid. Just like you don’t know when you go out in the street on sight who has it and who doesn’t. Maybe it’s an asymptomatic patient who has Covid, I don’t know. As it turned out, there was a Covid outbreak amongst the staff at the last hospital I was at. So it’s a good thing I did have my N95 mask on at the nurse’s station, since the nurses there had Covid.
At all three hospitals, each of them had the same practice of giving you a single mask per day?
Yes, one mask per shift.
Have you had Covid?
No, I have not.
How often are you tested?
I had myself tested, because I wanted to visit my parents in October. I took time off work so that I was isolated before I went there, and then shortly before I left, I got a Covid test. That was on my own. They don’t test nurses routinely for Covid. They were supposed to begin, I thought, in December. But that hasn’t been implemented yet, as far as I know. I did see that the CDC is recommending now that even if nurses have Covid, if you’re not symptomatic and you’re working with Covid patients, you can still go to work.
Do you take any preventive steps? What are you doing to keep yourself safe and how worried are you about getting Covid–19 or transmitting it to others in your household?
I’m definitely as safe as I can be, in the patient’s room. You always go in with all your PPE on and your N95 mask. There’s never been an instance when I wouldn’t do that. I take vitamins. I take melatonin, zinc, Vitamin D, Vitamin C. They’re giving a lot of the patients at the hospital supplements, too. Not the melatonin, really, I don’t know why. But they’ve been giving zinc, Vitamin D, Vitamin C routinely to the patients at the hospital I noticed, on my first assignment, which is a big departure from back when I used to do ICU nursing, years ago.
How sick are your patients? By the time they are an ICU patient, versus being at home or in a non-ICU room, how sick are they? What defines that they need to be in an ICU?
If they’re on a ventilator, obviously they’re going to be in an ICU. If their oxygen saturation is so low that they’re either on a ventilator or in imminent danger of being put on a ventilator, then they’re generally in the ICU. We have patients on high-flow oxygen and sometimes high-flow oxygen and a non-rebreather mask, both at the same time. A non-rebreather mask is an oxygen mask with an oxygen reservoir, so they get 100 percent oxygen. Then they also get the high-flow oxygen. They’ve been trying not to intubate patients more so than in the beginning.
I have the impression people still think it’s only seniors and/or people with preexisting conditions who are getting seriously ill. Has that been your experience?
Absolutely not. I’d say back in March or so, probably yes. We saw a lot of nursing home patients. More recently, the patients have been getting younger and younger and with no known co-morbidities. The last few patients I’ve taken care of were in their 40s and 50s with no known co-morbidities, people who are not obese, people who are not having any other issues. They’re fit, relatively young people. A lot of men in their 50s. It seems like there are a lot of people who are laborers, like construction workers, people who are in good physical condition are getting Covid. We’re getting a lot of younger patients, too, now, in their 30s.
Did the level of care, type of treatment or quality of care vary from one hospital to the next and if so, how?
The level of care I think was pretty much the same. The quality of care, I think was good at each facility I went to. Maybe the things that changed were maybe just the things that evolved as doctors got more used to treating patients with Covid.
Like trying not to intubate them?
Yes. I think at first we were intubating people a lot. More recently we’re trying to avoid intubating people, if we can help it, and also using less pressure support, which I think causes a lot of complications. We found out early on, putting patients on too much pressure support sometimes causes complications and they end up with chest tubes and other problems from our treatment.
What is pressure support?
It’s a ventilator setting, just giving more end-expiratory pressure to keep the alveoli open.
If they’re trying to intubate less, what are they doing more, is that where proning comes in?
As much as we can before patients get intubated, if we can, we help them self-prone. A lot of times, patients are like, “I don’t like sleeping on my stomach, it’s not comfortable.” It’s like, “Look over at the bed next to you. Do you want to be that person? Sleep on your stomach.” It helps.
Proning means sleeping on your stomach?
Proning means putting them on their stomach, which is very difficult to do with intubated patients. They’ve got the breathing tube down their throat, they’ve got multiple IVs – because if you’re going to be ventilated in that way, you’re trying to rest the lungs. So they’re on a lot of ventilator support, we have them on a lot of sedatives, and sometimes we have them paralyzed, also. They have multiple IVs, they have catheters for their feces, catheters for their urine, catheters for their everything. It’s not easy to prone these patients. It takes at least five or six staff members.
Imagine you have two or three critically ill patients, and they all need to be proned, and none of the places I went to really had any ancillary staff. There’s no nursing assistants, there’s no LVNs, there’s no secretaries, even. It’s just the nurses there. So you’re all overwhelmed with taking care of your patients, and then everybody has to take time out to help turn all the patients. A couple of days of that in a row, it’s really pretty backbreaking work to flip these patients onto their stomachs for a number of hours a day.
So why do it?
Because it really helps with the gas exchange. A lot of times once you prone them, a lot of times their saturations will initially drop, but then they end up going up higher than they were whenever they were on their back. So they get a better gas exchange whenever they’re proned.
Their lungs are working better?
What should family members know about what’s going on in the hospital when they can’t be there? In terms of what nurses need from them or how they can help?
Most families are very patient and I think they can maybe imagine how busy we are taking care of their loved one. But then you get the occasional family member who’s calling constantly. It’s hard for us, too. They’re like, “How are they doing?” You’re like, “The same.” I always feel like I’m just saying, they’re the same. There’s nothing – nothing is going on here. They’re on maximum ventilator support. They’re on maximum blood pressure support. We’re doing everything we can do right now for them. We can do no more. Then they call and ask you, “How are they?” You’re like, well, they’re gravely ill. But you don’t want to say that on the phone. You just say, “Oh, they’re the same. Their vitals are stable.”
So I don’t always know if they really appreciate whenever you’re saying, “Their vitals are stable, there’s no changes,” are they still understanding the part that, they are gravely ill? That’s why they’re here, that’s why we’re doing all these things for them. If we were to turn off their blood pressure medicine, they would expire immediately. You don’t want to say that to people, it’s awful. And it’s awful they can’t be there. So we try to set up Skype calls. You’re so busy, and they say, “We have a Skype call set up for 3 o’clock. This is our Skype call now.” You’re like, “Well, I’m sorry. We’re intubating the patient next door.” What do you want me to do? That’s not a high priority, but I feel for these families, how awful it must be.
I usually just let them Skype for as long as they want to. You wheel the Skype thing in there and you get the patient in the middle of the screen so when the family calls in, you can see them on the big screen and you can see what they can see, which is the patient in the bed, and the patient is just laying there with all these tubes in and can’t respond to them at all. The family is there having this one-way conversation with this person in the bed and it’s awful. It’s a terrible thing, it’s really bad.
If a loved one is in the ICU at what point should families be thinking about things like DNR?
If it doesn’t seem like they’re going to have much quality of life, should a patient have a DNR, Do Not Resuscitate? That’s a minimum thing [families] should consider. If their heart stops, the treatment is potentially very traumatic. We’ve had quite a few patients who have been [in the ICU] for a month or more and we’ve had them on 100 percent support for so long. We have them on four different things for their blood pressure, on maximum ventilator support, 100 percent oxygen all this time. At one point their bodies can’t take it anymore—their blood pressure still plummets despite all the medications, and their hearts stop or they go into arrhythmia or something. We’re pounding on their chest and shocking them. The likelihood of anything good coming from that at that point is probably little to none. Why put them through that?
Families need to be realistic. If your loved one is in a nursing home and they were bed-bound or have to get dialysis and have little quality of life before getting Covid, why are you going to pull out all the stops just to get them back to that point? I wouldn’t want to live like that, I can tell you that right now. I wouldn’t want that for any of my loved ones.
I think people have strange ideas about things. Like, people die. Everybody dies. Not intervening isn’t killing somebody, it’s letting nature take its course sometimes. A lot of patients need to take it upon themselves, before they get to that point, to have a durable power of attorney for healthcare. They should have their wishes known; I can’t imagine anyone wanting to exist like that.
The patients who are not going to make it, what are the signs? Are they stable and then suddenly go downhill?
It’s hard because we have a lot of patients paralyzed/sedated; it’s hard to tell what their neurological status is. You need to wean them off those medications and see if they’re waking up and responding. But then the problem becomes, they wake up and their saturations drop because they’re fighting the ventilator. Okay, so neurologically they’re there when you take the sedation off, but they can’t sustain life without it at that point, because they’re working against the ventilator and things—that’s keeping their oxygen saturation up. We give it time, try it again. If at first you don’t succeed, try again later, maybe they have less inflammation and maybe they’re doing better, maybe the antibiotics they’re on are clearing up whatever pneumonia they also have.
Once patients start having cardiac arrest, a lot of times we can get them back, but in some cases they’re going to do it again and again—until they succeed, basically. These aren’t normal things to happen to people. If you’re going into cardiac arrest because your potassium, your electrolytes are out of whack, that’s something you can fix and then you’re great. But this isn’t that. This is, they’re having multi-system organ failure. Their bodies are shutting down.
What is it like for you when you hear people saying they don’t think Covid–19 is real?
I want to scream at them! It’s very unbelievable to me that somebody can be that willfully ignorant or just believe in conspiracy theories. I’m watching these people die in front of me. It’s awful to hear people say that. Like, you have no idea what you’re talking about, no idea. Then you see people at these superspreader things. What is wrong with you? You know what? Don’t come to my ER and tell me you can’t breathe, I don’t want to hear it, really. That’s just awful.
You’re going to be so irresponsible and not care about yourself or anybody else, and then our systems are overwhelmed? You go home and give it to your poor grandmother? We’ve had a lot of husbands and wives, both of them in the ER. They got it from their kids or their grandkids. We had a guy and his mother both in the ICU at the same time. It’s awful. She died. He ended up dying, too. He was in the ICU but not on a ventilator, he was conscious and with it for a while. Nobody told him when his mom died.
We didn’t want to tell him that. I’m probably glad we didn’t, because he ended up dying anyway. He didn’t need to find that out before he died, because I’m sure that’s where she got it from. He wasn’t being careless, he was just somebody who was working in a service job and was around the public a lot.
Are hospitals adding ICU beds and taking away other beds and is this going to negatively impact someone who, say, is in a car accident?
It’s going to negatively impact anybody who needs to be in the hospital and in the ICU, especially. Nurses are spread so thin that there’s no way that an ICU nurse can give the same quality of care to three patients as she can two. It’s just physically impossible. It’s too much work.
You told me you’d pass the emergency room on the way to your car and see that it’s swamped?
Yes. It’s just full of people. I know there are no beds for these people. I know that they’ll probably send some home, but the sickest of them are going to be in the ER until we get an ICU bed, and I don’t know when that’s going to be, probably when somebody else dies.
Have your working conditions changed in the current surge LA is experiencing?
The more recent problem is the hospital association giving the hospitals waivers to allow ICU nurses to have three patients instead of two, and then for the other floors to have patients above and beyond what they’re supposed to be legally mandated to have. I know it’s eating at a lot of the ICU nurses and I’m sure the nurses on the floor. It’s already hard to take care of all the patients we’re taking care of. Then just to add more patients on top of that is sort of like, “Here, have this, too.”
You’ve already been struggling for all these months now, and then you’re going to throw that out? It’s adding insult to injury. Like, “Here, now you’re going to have to take this many patients, just deal with it.” Really? A lot of nurses I knew at the last ICU quit to go to different hospitals, maybe ones that aren’t doing that. They take travel positions instead. If they’re going to be doing all this backbreaking hard work, they want to get paid better for it.
Were the hospitals where you were working asking you to give up days off, work extra hours?
I am getting paid for 12 hours but I’m at the hospital for 13 hours, with 30 minutes for lunch and two 15-minute breaks that are unpaid time. But in the pandemic I never have time for breaks and it’s rare to take more than a few minutes for lunch, so that’s all time that is not paid at all. And yes, they’d always ask us to come in extra, beyond whatever we were contracted for.
Is there a staffing shortage?
Having two patients versus having three patients sounds like 50 percent more work. Does it pay 50 percent more?
No, it doesn’t pay anything more [LAUGHING].
What can go wrong with that additional workload?
Everything can go wrong. Say you’re on an ICU and you have 12 patients, usually you would have six nurses. Now we have four nurses instead of six. So if something goes wrong with one of those patients, it’s hard for the other nurses to help you, because then they’re leaving three patients, not two, to come and help you. If a patient is coding or something, you need more than one nurse to come and help you. You also need somebody to watch the other patients that you’re leaving unattended. So it’s really not leaving any margin for anything.
It ends up being more patients than that, a lot of times, because if you’re already maxed out, you have your three patients, and somebody is going to transfer out, so you get one patient out, you know you’re going to get another one in, because they’re waiting in the ER for you! You end up actually having four patients, then, that shift, don’t you? And you still have to chart on them all.
Is this all part of the job? Is this what people sign up for when they go into nursing? Is there an emotional toll?
Definitely. I think most nurses go into nursing to take care of patients, and we want to take good care of patients. It’s really demoralizing, whenever you come home, when you feel like the patient had substandard care that day, under your watch. It wasn’t because you were sitting there playing video games or something. It’s because you can’t be in three places at once. It’s hard. You try the best you can.
How do you deal with that?
I quit. [LAUGHING] I don’t know. You exercise, you drink, I don’t know.
Is there anything else on your mind?
Why is there still at this point a PPE shortage? Why don’t we have enough N95 masks for everyone to have as many as they need? It’s ridiculous at this point, with masks. I know hospitals get money from the state to help pay for more nurses and I don’t think the hospitals have always been getting as many traveling nurses as they could have or in a timely manner.
You feel like the nurses are out there to be hired, the hospitals are just not opening their wallets enough?
Yes, I think that. It feels like that.
Any final thoughts or comments in terms of what people should know?
I would just say that people need to really be more mindful and more careful right now. Why does it take until you know somebody or until it’s your family that has Covid before you understand that it’s a real thing and it’s killing people? It’s not “only as deadly as the flu,” that’s ridiculous. And it’s not only killing old people. They’re getting younger and younger. It’s sad, it’s awful.
People out there, they don’t want to die this way?
No, definitely not a way to die. If you happen to be in a car accident now or have a heart attack, then you’re not going to get the care you need because of all of the Covid patients in the ICU. We used to have, there was one Covid ICU and then there were the other ICUs. Now it’s all Covid ICU, basically. Like, that’s what there is. It’s not pretty. We’ve got to prone these patients. You’re naked in a bed on your stomach, with tubes hanging out of you everywhere. Of course we cover you up for people passing by, but it’s no joke. It’s heartbreaking. You just think, how many of these cases are avoidable?
Do you feel respected by the public for what you do? Do you feel –
Like there’s a disconnect? Definitely.
When you see someone out in the world not wearing a mask, do you get –
Yes. I’m like, don’t come to the ICU, okay? [LAUGHING] People go for walks around my neighborhood all the time. I don’t care if they have a mask on. They’re by themselves, they’re not near anybody, I don’t see a problem. It doesn’t bother me. But you see people packed into places. What are you thinking? What’s going on here? I hear parties in the neighborhood. What are you doing?
I was horrified a couple weeks ago: We literally ran out of ventilators at the hospital. We ran out of ventilators. That’s tragic. That’s unbelievable. We couldn’t even rent any from anywhere, because all the hospitals are the same. I texted some friends of mine, like, “Please be careful. We ran out of the ventilators at the hospital today.” They’re like, “Oh my god, really?” How is that so surprising? I listen to the radio, I listen to the news. I hear them saying the ICUs are overflowing, they’re full. I know that knowledge is out there, so I don’t understand: why are people so shocked about this? What do you mean, “Oh my god, really?” Yes, really!
I don’t know why people think it’s not true. It’s true. They brought in a refrigerator truck for the bodies not that long ago. Nobody told me; I happened to be in the staffing office whenever they were trying to find somebody to transport a body, and they had to explain to them where the refrigerator truck was.
They don’t park it right out front, you mean?
No. They don’t. The morgues are full, and there’s just nowhere to put people. Like I said, sometimes we get husbands and wives in the ICU at the same time. Then one of them passes away and who is there to make the funeral arrangements for them? Nobody, because they’re in a bed in the ICU. It’s terrible.
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