During Nurses Week, our Chief of Staff gives a glimpse of nursing in the Critical Care Unit.
For the past year, as a hospital, we have been ruled by Covid-19. This has stretched us in previously unheard-of ways. The last line of defense for a sick Covid patient is the Critical Care Unit. Staffed 24 hours a day, 7 days a week, every day of the year, it is the make-or-break area where people are either healed of the disease or die. Much has been made of the front-line workers during the global pandemic, and rightfully so. I was wondering to myself whether most people were really aware of what caring for a CCU-level Covid patient entails. In a very small and abbreviated way, I would like to attempt to describe what Covid care is like for CCU nurses.
The day begins with “Report” or the “shift change.” The outgoing nurse tells the incoming nurse everything known about the patient in terms of condition, trends, critical events, medications, and expectations for the coming shift. Always thoughtful and comprehensive, the report provides seamless care for the patient, much like passing a baton at full speed in a relay race. What follows is the most structured portion of the day.
After Report, the nurse checks the orders and labs, reports critical values to the doctor, does his or her own head-to-toe examination of the patient, gives the morning medications, does rounds with physicians, Pharmacy, and Case Management. In the Critical Care Unit, a head-to-toe survey is done every four hours, and a pain assessment, I.V. checks, and repositioning of the patient’s body are completed every two hours.
This is a very busy day with CCU patients, but when a Covid infection is added to the patient’s problems, the nurses’ job becomes much more difficult. It starts with the transfer of a Covid patient from the Medical-Surgical floor to the CCU. This is a very complex process that is extremely complex and needs to be done as quickly as possible.
The first step is admission into the CCU. The patient typically arrives from the Medical-Surgical unit when all attempts at conservative methods of maintaining an adequate oxygen saturation have failed. The patient is exhausted from the effort and is usually in need of urgent endotracheal intubation. The nurse attends the patient from the first moment and then for the next two to three hours, nonstop.
Preparations are made to sedate and chemically paralyze the patient for intubation and placement of the intravenous and arterial lines and feeding tube. This involves setting up a multi-channel IV pump to handle up to 5 or 6 medications simultaneously, helping the Respiratory Therapy team, if needed, to set up the ventilator, all while also monitoring the patient and administering whatever medications the patient may urgently need.
This would be taxing enough, but during Covid, it all has to be done in full N95 protective gear. Every time the nurse enters a room, they must don the mask, hair covering, gown, face shield, and gloves. It is really like suiting up for a football game, except that it is done 10-12 times per shift.
The nurse gives the medications to enable the doctor or Certified Registered Nurse Anesthetist (CRNA) to intubate the patient with everyone assembled. These medications often cause the blood pressure to drop, requiring an immediate response. The placement of the central venous access is next, followed by placement of the arterial line, which monitors blood pressure. Both are sterile procedures requiring the nurse and doctor working closely. Lastly, the nurse places the feeding tube. He or she then assists the Radiology Tech with placement and removal of the x-ray plate behind the patient to verify correct placement of the lines and tubes. These x-rays are typically shot through the glass door from outside the room, with the nurse moving into the bathroom to avoid x-ray exposure.
Once a nurse is in N95 gear, it is prohibitively difficult to leave the room for medications or supplies. So, when a nurse is not actually in the room, he or she is just outside acting as an extension of the nurse in the room. The EKG tech/unit clerk often serves in this capacity as well.
Then there is the issue of “proning” the patient to help better ventilate other areas of the lung. This is an “All Hands on Deck” event and must be done quickly and correctly as the patient can decompensate rapidly. In this process, a team of medical professionals quickly moves a patient from the position of being on their back to being on the bed face-down. Typically, this is done once per day. The set-up for proning is elaborate and time-consuming, but the execution takes just seconds.
There are other elements of caring for Covid patients that are unique, but the difference is not limited to the time in the hospital. Routines vary, but many frontline Covid care providers have their home lives disrupted as well. This may take the form of taking clothes off in the garage, showering at work or as soon as they get home before seeing the family, or even living apart from their loved ones in a hotel or RV or another part of their own house. Voluntarily, these workers were especially isolated so as to minimize the threat of infecting others.
This short account does not do any real justice to the CCU nurses' effort to care for critically ill Covid patients. We have endured multiple major waves of Covid at LVMC, and the contributions of the nursing staff cannot be overstated. Everyone here has put in a herculean effort to see us through our corner of the pandemic but, in my opinion, none more so than the nurses in the CCU, and of course, the nurses on Med-Surg.