It’s been an interesting few days, that is, if ‘interesting’ is a good stand-in for disastrous. I’ve finished my 4th and final day at the hospital in New York City (NYC), and I am relieved to be done. The staff is absolutely exhausted and has likely been so for quite some time, and the facility is barely functional.
The last two (2) days, on the other hand, have been absolute hell. The issues are numerous for the staff there so much that I do not know where to really begin. One very noticeable problem: there is staff burnout and they are exhausted, to the point where it is hard for them to really function at all. The ICU I was assigned to was split into three (3) parts: an 8-bed intensive care unit, an 8-bed cardiac care unit (which is, for all intents and purposes, another normal ICU right now), and an 8 bed ICU step-down area. The hospital has a sizable residency program, so they put me and another nurse practitioner in the ICU step-down area. About 75% of our patients are COVID pneumonia patients who are unstable but not on a ventilator, the other half is composed of more routine patients who are just well enough to be extubated. The hospital serves primarily impoverished and underserved people, so the 25% who are not COVID patients are there with an illness associated with poverty.
The unit is essentially what I expected with regards to patient needs, but the organization and staff camaraderie on the unit is non-existent. Staffing is about the same as it normally is here, but the patients are far sicker than the nurses typically manage in the step-down and non-critical care areas. We often have patients whose oxygen levels or blood pressures abruptly drop. I try to respond to the crisis or help manage problems that are not typically even brought to my attention. I suspect the staff is just exhausted from the constant chaos of trying to care for the crashing patients. It’s been like this for ten (10) months without a reprieve now. Patient volumes have started to increase again, and there’s just no end in sight. It’s like running on a treadmill that you can’t control, but someone else keeps increasing the speed.
There’s immense pressure from the unit manager, as well as the house supervisors, to prematurely discharge patients from the ICU stepdown so they can treat another acutely ill, half-decompensated patient who looks like they’re ready to imminently die. We had one patient we were strong-armed into discharging prematurely yesterday, a lady in her early 30’s on Bipap with 100% oxygen who still had a respiratory rate about three (3) times the normal limit and oxygen levels well below normal. She was put off our unit for about two (2) hours before she suddenly worsened again in the medical/surgical area, an area where nurses get 5-6 or more patients each and cannot closely watch any individuals. She came back to our unit; in transit, it was discovered that her oxygen had never been plugged in. Today, she was still on our unit, but slowly getting worse. We taught her how to put herself in a prone position, laying on her stomach, but she continued to gradually get worse even with that. It seems likely she will need to be placed on a ventilator within the next 24 hours; her lungs are already horribly scarred from COVID itself, so the ventilator is a last resort. She is only 34 years old, but I’m not sure she will even live. If I were gambling, I would estimate her odds of survival are about 50/50 at this point, but even that feels generous. Despite the tremendous pressure to transfer patients to lower acuity areas of the hospital who are not ready, I’ve had several patients with genuinely safe transfer orders who have been waiting for a lower acuity bed for days. I discharged two (2) of them today, both non-COVID, but never got a bed in the less acute areas. We don’t have any beds available, but neither do any other units where we can reasonably transfer people to, so we’re stuck in this pressured limbo in which we’re being told to move people who should not be moved to make room for stable ICU patients, then to move people around again when the failed transfers have to return to us. It is a colossal waste of everyone’s time and poses far more risk to patients, both individually and in aggregate, than it provides benefits. It also exhausts our staff and makes it harder for them to care for all the other patients because they’re being overburdened with extra work in an already-untenable environment.
The nurses are exhausted to the point where I’m taking partial responsibility for their nursing care, which is nothing short of insane as I’ve never been trained in this department. There is no support from other staff, so I’ve been left to figure out what I can and leave what I cannot. ‘Urgent’ becomes a relative term when you cannot use the tools available, or when the tools you need are not locatable and nobody can help you find them. Stocking is a disaster in this unit. We continuously run out of mundane supplies like IV tubing, even though there is no particular shortage here. The stock rooms look like a bomb went off in them, and the lack of organization makes it impossible to find anything.
The problem with staff burnout wasn’t limited to nursing. Asking the hospital supply management staff to come stock our unit is an exercise in futility. Waiting for medications to arrive from the pharmacy is like waiting for Godot – today we had a patient who needed a paralytic urgently after deteriorating and needing to be placed on a ventilator. It took three (3) hours and about thirty (30) phone calls to finally get the paralytic from the pharmacy. It took over six (6) hours, from the time of intubation to transfer, to get the patient to the ICU. Labs take hours to be drawn and resulted, and abnormalities are not addressed until hours after the fact. Respiratory therapy won’t even ventilate a patient while they’re moved from one bed to the next. Everyone is in survival mode – asking anything beyond the minimum required to get through the day is a waste of time, and offering to help around the unit does not bring anyone any relief.
I feel worse for the staff, but the patients aren’t exactly getting stellar care either. One patient asked to use the bedpan, and the nurse told her to just pee in the bed because she didn’t have time to get her a pan; they would clean her up when she was done. Imagine, being an adult who is possibly dying of COVID, and one of the last memories you get before [likely] deteriorating and being placed on a ventilator is being told to pee on the bed.
I have it fairly easy, compared to most staff working in this pandemic. I’m a traveler – I bounce around and have options with regards to my work schedule and environment. I can take time off without any repercussions or bosses telling me I’m being mandated to stay (or trying to coerce me into staying) for overtime or an extra shift. My contracts are finite in these situations, and I don’t have to renew ones with terrible working conditions. I’ve exercised that option earlier during this pandemic when one of my facilities told us we could only test a fraction of the patients who needed COVID tests (which succeeded both in making the pandemic in that area significantly worse, as patients did not know if they had it or not and often opted to continue to work while ill, and in making our job utter hell by subjecting us to a lot of verbal abuse by patients seeking tests). I’m grateful I’m switching to another facility in a NYC suburb after today, and I’m only there for 12 days before I return home, but I have regrets for the staff that’s been dealing with having their livelihoods constantly sapped away with no respite periods.
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