The First Three Days as a COVID-19 Nurse

"May you live in interesting times"

                ~ Joseph Chamberlain

Quick backstory: I graduated nursing school in May of 2019. Was hired even before graduating at the hospital where I had done my clinical rotations. Took and passed my boards in June and started working as an RN that July. I was hired to the Med-Surg floor. Med-Surg being short for "Medical-Surgical"; we take care of people with stable medical conditions: usually COPD, complications from diabetes, pneumonia, dehydration and electrolyte imbalances, just to name a few. We also help alcoholics take their first tenuous steps towards sobriety (quitting drinking cold turkey can cause numerous health problems including seizures; we have a treatment pathway to help ease the transition). On the Surgical side, we care for knee, hip and shoulder surgeries/replacements as well as spinal fusions.There's also a variety of abdominal surgeries: appendectomies, removal of gall bladders, colon resections, etc.

I was eight months into my first year as an RN when the Coronavirus started affecting my region. Because the Med-Surg floor at my hospital is centrally located - the ICU, ER, OR and medical imaging suites are all on the same floor - we were selected to have half the floor cordoned off to be the COVID-19 isolation unit, staffed (at least for now) by volunteers. I was quick to raise my hand to volunteer since my family and myself are all in the low-risk demographic to experience complications from the Coronavirus. Plus I wanted the opportunity to see and experience first-hand how COVID-19 was being treated and what measures were being taken to protect healthcare workers.

Sectioning off half of a hospital ward was no easy task: the new unit must maintain negative pressure, meaning the air in the unit cannot circulate throughout the rest of the hospital, and it must be at a lower air pressure than the air outside the isolated ward. Air from the COVID-19 unit is filtered and sent directly outside. This involves a lot of fans and hoses that look like drier vents. The integrity of this isolation unit is maintained by water-proof plastic canvas airlocks held in place with industrial-strength tape. The airlock is accessed through heavy duty zippers. There are clear plastic windows so you can see in and out of the airlock. The airlock is just large enough to fit a hospital bed. I call this isolation unit "The Bubble".

With The Bubble being its own self-contained unit, the next problem was the supply logistics. Because there is an obvious need to limit what comes through the airlock, everything needed for patient care needs to be kept within The Bubble. Patient meds are stored in a large computerized locked cabinet called a Pyxis (pronounced pik-sis). Ours looks like this:

https://www.bd.com/assets//images/international/our-products/medication-supply-management/pyxis-medstation-system_2_DI_1011-0002.png

The Med-Surg unit has two of them, so one went into The Bubble and into a room that's usually used as a conference room. This conference room also became the supply room for IV bags and tubing, linens, diabetic testing supplies, a refrigerator and any other supplies/equipment needed to care for our patients. All in a room that was cozy with just eight people before; it now is tight with three or four.

Computers were also a tricky thing to figure out. At our hospital, we use COW's (Computers on Wheels) to document med distribution, patient charting, monitor test results. etc. We have a fair number of them on our floor, but how many should go in The Bubble? Then it became: where to plug them in to charge? In normal times they get plugged into an outlet in the hallway, and there's a fair amount of outlets...or so we thought. Remember all those fans we need to maintain the negative pressure? They need outlets too. As do the chargers for the walkie-talkies we use to talk to folks outside of The Bubble. As do the small handful of other electronics needed to keep things rolling on the inside. So power strips joined the party.

Keeping things clean comes next. Those COW's have a lot of surfaces. Glucometers for checking blood sugar also have to come in and out of patient rooms. They all need to be wiped down after every use. Thank heavens for disposable stethoscopes! There's one for each patient, so they don't need to be cleaned as often. Even so, one becomes pretty obsessive pretty quick about bleach wipes.

So now how to keep the nurses safe from catching this? How to keep them from spreading this virus to each other, other patients, their families, the general public? Enter PPE (Personal Protective Equipment): Gowns, gloves, goggles and masks.
Ah, masks. The polices keep changing on masks due to supply issues and that's a real sticking point. It partly comes down to the question of Droplet vs Airborne precautions. Here's a quick breakdown:

Droplet precautions: according to the CDC, they should be in place when "pathogens [are] transmitted by respiratory droplets that are generated by a patient who is coughing, sneezing, or talking". The pathogens hitch a ride on water droplets which are heavy and don't stay in the air for long. They can only travel about 3-6 feet before dropping down. This from of precaution is used for the flu typically and other catchy respiratory ailments. For these situations, a surgical mask provides perfectly acceptable coverage because water droplets are relatively big. We also wear disposable gowns just to be safe.

Airborne precautions: "pathogens transmitted by the airborne route". Okay; and that means....? This means the contagion can stay in the air for far longer because it's not hanging out on just water droplets. It can travel farther too because it's not drifting back to earth as quickly. In nursing school we learn the acronym MTV for "Measles, Tuberculosis & Vericella (chicken pox)". These are the three most common diseases that are transmitted via the airborne route. Airborne bugs need a more heavy-duty mask to be filtered out. Enter the N95 mask. These need to fit tightly to the face and we're tested annually to ensure the size we've been assigned still works for us.

So...is the Coronavirus a droplet or airborne pathogen?
According to the CDC, Coronavirus is "only" a droplet baddy so a surgical mask should be fine at stopping it. However if a patient is receiving a nebulizer treatment; or a nurse must handle intubation equipment, the virus is considered airborne and an N95 should be worn.
That being said, most hospitals are taking no chances and staff treating patients who test positive for or are suspected of having COVID-19 are instructed to wear N95 masks.

Here's the problem, because we rarely encounter airborne pathogens on a regular basis, hospitals do not have vast stocks of N95 masks. Pair that with the fact that panic-buying has depleted the supply and Coronavirus took a while to come to the US, these masks are in short supply. Surgical masks are also limited presently partly due to the aforementioned panic-buying, but also because we're just coming out of flu season; so rationing has been put in place. When and how masks are used is certainly a point of contention and guidelines and policies are changing day to day (sometimes hour to hour!).

That all being said, what does a day look like in the life of a COVID-19 nurse?
I get up at 5:30 in the morning, get myself together. Put on my regular work scrubs (just in case I'm not needed in The Bubble that day for some reason) and head out a little after 6:00. It's a 25-30 minute commute for me; very little traffic at that hour and with quarantining in place, traffic is even lighter. Lately I've been listening to Lindsey Stirling's album "Artemis" in the car because her music makes me so happy.

Once at work, I'm greeting by two people: one to take my temperature and one to ask if I have symptoms of Coronavirus and/or have been tested for it. Once through the checkpoint I head up to my floor, clock in and go to the locker room. I've really paired down what I take with me into The Bubble - just a four-color pen, a flashlight, my bandage scissors, some alcohol swabs and IV tubing caps. A small handful of individually wrapped hard candies helps keep the blood sugar up throughout the day.

As soon as I know I'm going into The Bubble, I slip into the patient room that's become the COVID nurse break-room. I leave my water bottle on the table, grab a set of hospital-provided scrubs, hop into the bathroom and change, leaving my badge with my work scrubs (one less thing to clean). The clothing I wear coming in goes into a plastic bag. I make sure my hair is pulled back tight, set my stuff off to the side, and into the airlock I go.

I don a rewashable yellow gown, a pair of gloves and a surgical mask and then step through the airlock and into The Bubble. I receive report from the nurse coming off shift, make sure I have enough N95 masks for the number of patients I have (we try to keep it to no more than three patients per nurse); and off I go! Because policies are always shifting, things are a little different from one day to the next. Maybe our aid(s) will do all the vital signs on the patients in The Bubble, sometimes we're supposed to as we're assessing. We pass meds, we get things for our patients, keep an eye on test results and imaging (X-rays, CT scans, etc). We do EKG's ourselves - something other people did before; to limit the number of people in The Bubble, we're doing more ourselves. We keep the doctors abreast to changes as things can change quickly with a patient. We're mostly Med-Surg nurses; we're used to taking care of "healthy sick" patients, so this is a little new to most of us.

Because our hallway garb is considered "clean" we can go right into a patient room if we have a mask for that room. Once we're done, we stop at the doorway, take off our gown and gloves. The N95 goes into a brown paper bag clipped to the doorframe. We wipe off our goggles, wash our hands and put on a new gown and set of gloves and our hall mask. We're now considered "clean" and can wander around freely until we go into another room. 

What does COVID-19 look like? Well, as of this writing I've only cared for one confirmed case. That person had a low-grade fever (100°) that didn't come down with Tylenol, they had chills and needed supplemental oxygen via a nasal cannula. They remained alert throughout all this, but felt weak. Though their pulse oximetry reading looked fine, their ABG (Arterial Blood Gas) report wasn't so great and their chest x-ray showed a deterioration in condition. For these reasons that person was transferred to the ICU (which has also become a negative pressure Bubble).
But we have discharged COVID-19-positive people who were perfectly stable, with the instructions to self-quarantine.

The vast majority of patients inside The Bubble have tested negative; but that can cause a false sense of security. To get a positive test, one has to have enough of the virus within their body for the test to detect the viral RNA. Easy-peasy. But if there isn't enough virus within your system, it may come back negative even if you actually have it, so we're telling everyone we discharge from the COVID-19 unit to self-quarantine for two weeks even if their test comes back negative. [source]

We're encouraged to leave The Bubble periodically for food, water and rest. We're usually pretty good about lunch and dinner, but we rarely remember to take breaks. When you leave the Bubble, you go into the airlock, take off the gown, and gloves. Your goggles and mask go into another brown paper bag. Squirt some sanitizer onto your hands and you're good to leave the airlock for fresh air and food. (We have a staff bathroom within The Bubble, so we don't need to leave for that). We have been instructed to take our temperature at least two times per shift.

At the end of the shift, after leaving the airlock, I grab my bag of clothes and another bag with shower flip-flops and a hair brush that always stays at work. I hop into the bathroom and shower real quick - someone has lovingly provided shampoo, conditioner and body wash for communal use. After which I put on the scrubs I came to work in, toss the hospital-provided scrubs and my towels and washcloth in a linen bin and chill for a little bit before heading home.

I'm the one getting groceries for the family, so if we need something, I stop at the store on my way home; careful to maintain an appropriate amount of social distancing, but also being as friendly as possible because people are nervous right now and a smile here and there never hurt anybody! I get to chill at home for about an hour and a half before getting ready for bed so I can do it again the next day.

I've had two glorious days off since those first three days in The Bubble and tomorrow I go back for another two days. Likely things will be a little different tomorrow; and things will continue to change and evolve as the presence of the virus changes and evolves in our area.

While things are going on inside The Bubble, the rest of the Med-Surg floor is waiting and holding its collective breath. Patients that usually go to our floor are being sent to the other Medical floor in our hospital. All elective surgeries have been cancelled; so there's very few patients outside The Bubble on our floor at the moment. There's been talk off turning the whole Med-Surg floor into a negative pressure COVID-19 ward. If that happens, we'll go from 10 rooms and 14 beds to 20 rooms and 30 beds.

Who knows where this will take us. In a year one might reread this and think, "Oh, my sweet summer child. You knew nothing." or they may go, "Welp, that was overkill." Right now though, we just don't know where things are headed. Current quarantine measures may successfully flatten the curve and we'll all come out of this just fine; or things can go to hell in a hand basket very quickly and hospitals will become overwhelmed in a matter of days. We're doing the best we can with the information and supplies available to us. Our goal is to keep people safe and healthy.

I absolutely love the outpouring of public support and the desire multiple people have had to make rewashable fabric masks for healthcare workers. Unfortunately, according to this study, fabric masks are not terribly effective and most certainly won't replace those N95's, but I very much appreciate people's desire to help where they can. Right now you can help best by staying home as much as possible and washing your hands. Buy only what you need; but by all means buy a little ahead so you don't need to go out as frequently. Eat well. Love your neighbor and stay safe!