Fail, fail, fail, fail, succeed

Precarious – Notes From an ER Nurse in a Pandemic

It wasn’t like we didn’t know the virus was coming, it’s just that nobody seemed to have prepared for it. The problem was that since no one in charge had ever lived through a pandemic, we had no frame of reference for what was about to hit us. At least that was my perspective, and I had been a nurse there for ten years. I had seen a lot of shit. See, my ER was relatively small and serviced a Manhattan neighborhood of poor immigrants. It was one of several emergency departments scattered throughout the city, all attached to the same sprawling hospital, which had its pluses and minuses. It was a plus in the sense that we were part of a large corporate organization with vast cash reserves. It was a minus in that our particular ER had started small, but over the years, the needs of the community we served had far outstripped our ability to service it. We just weren’t big enough – not enough space, not enough equipment, and not enough staff. And this was before the virus hit.

I remember the first time I realized things weren’t going according to plan, or rather, I realized there was no plan when I triaged a specific patient. When you have enough experience, you can triage someone with a pretty high degree of accuracy in less than five minutes. That means, in theory, you could potentially go through over 100 patients in a 12 and a half-hour shift. Even before the pandemic, there were times I approached that. But at the very beginning of this particular day, I was backed up and just going as fast as I could, trying not to miss anything important. The ambulances were coming relentlessly – but this in itself wasn’t anything unusual.

We knew that there had been a few positive cases in Manhattan at that point – probably less than ten reported. As I would soon learn, there was a problem with tracking the virus’s spread – that is, no one was tracking it at all. But I digress – this particular patient had come by ambulance complaining of chest pain, stating that his pacemaker had gone off several times in the last few days. Why hadn’t he come in earlier, you might ask? Well, you’re asking that because you, my friend, have never worked in an ER. People do all kinds of crazy shit that there’s no logical answer for.

This particular EMS crew knew what they were doing – they had a three-lead ECG that clearly showed intermittent runs of v-tach. If you’re a triage nurse, this is about as straightforward as it gets – unstable cardiac patient, level 2. Goes right in a precious cardiac monitor bed, the ones you save for when someone actually needs it. If you’ve ever been in an ER with a kidney stone or some other painful ailment and wondered why you were in a hallway stretcher instead of one of those beds with a monitor and a curtain – this is why. The triage and charge nurse is saving those beds for unstable patients who might die. You’re going to survive.

Now, here’s another thing about being an ER nurse or doc you need to know – we see so many patients on any given day, it becomes highly unlikely we will ever remember anyone in particular unless there’s something unusual about them. This, in fact, is how you learn – the “unusual” ones will teach you what to look out for in the future.

So this particular cardiac patient would have forever been lost in my memory except for one thing. When I came in to work the next day, the same doc was working, and she approached me and said, “You remember that v-tach patient you triaged yesterday?” I said yes, only because his symptoms were so obvious – he had been an easy one. “Well,” she said, “We admitted him, and he tested positive for COVID.” That stopped me in my tracks – my mind started racing. “What?” I said, like a simpleton who couldn’t quite wrap their head around a statement.

Even now, I’m not sure I was wearing a mask. I’m pretty sure the EMS medics weren’t, and if I did have one on, it was one of those flimsy surgical masks that don’t do much of anything. Well, let’s back up a second – here’s the deal. Surgical masks, the kind you see people wearing in Japan and occasionally in a hospital, are used to prevent the wearer from infecting other people around them. They don’t do much to protect the person wearing them. Maybe something, but not much. It’s just not what they were designed for.

For me, this was the moment when everything changed. As far as day-to-day operations in the hospital were concerned, everything still appeared to be normal. But that was when I realized it was here, and people could have it with no apparent symptoms – even to themselves.

I immediately went to my locker, where I had an N95 respirator I saved from my yearly fit-test and put it on. No one was wearing them yet.

High on the list of national fuckups concerning COVID-19 in the United States is this – we essentially didn’t test anyone. What do I mean by that? Just this: in NYC, no one was tested unless they were admitted to the hospital. That included the docs and nurses who were working in the middle of this shitstorm. If you got sick, you were told to stay home and return to work after 72 hours with no temperature, and only come to the hospital if you were having difficulty breathing. We wouldn’t learn until much later that if infected, your oxygen levels could become dangerously low without the usual symptoms, i.e., labored breathing and severe shortness of breath. For some reason, as yet unknown, the virus didn’t work that way. Regardless, somehow, people outside NYC had access to limited testing. I’m still not sure how that was possible since I was working at the largest hospital in the city, and it appeared we barely had the capability to test admitted patients.

The reason this was such a huge fuckup was simple: you can’t track a disease without reliable statistics showing where it is and how many people had it. So, of course, that means that everything you heard in the media was almost meaningless. Statistics were being published as if the disease was being tracked – but it wasn’t. For those of us working in the city ERs, this soon became obvious.

As I write this, we are now a month into this thing, and testing still isn’t routine. But it doesn’t matter at this point, because that ship has sailed. It took three weeks from the first reported cases in the city to completely break the entire healthcare system. By two weeks in, over 90% of all patients presenting to the ER had it. By three weeks, 100%. How would I know this? Because, if you’re working the frontlines at ground zero, you quickly learn the signs. It’s not complicated. Hypoxia, cough, sore throat, loss of smell and taste, fever, and shortness of breath. But not SOB like you might see with the flu. No, I’m talking about people walking around with O2 sats in the 70s, and they had no lung disease. People who were normally healthy, or at least free from disease.


Goddamnit, I thought – I haven’t been on the unit for five minutes, and this fucking N95 and goggles already feel like they’re breaking down the skin on my nose. My nasal passages are completely clamped shut, so I’m gasping for air through my mouth, a state I’ll have to endure for another twelve hours before I can take this shit off, go out the ambulance bay, and finally gulp in clean, fresh air.

Status epilepticus,” the nurse says as she gives me a report measured in words, not sentences. I love ER nurses – no bullshit, just whatever is known and relevant, which usually isn’t much. “We gave seven of versed – five IM, and another two through the twenty gauge I put in his right hand. Homeless, found unconscious and seizing on the street. He had an empty bottle of Keppra in his pocket; we don’t know anything else about him.”

She rushes off to another patient, and I look at him – dirty, clothes partially cut off, respirations about forty with retractions, on a non-rebreather, O2 sat around 75. He’s still got tremors – I realize we’ve got to intubate now, so I run out to have the unit clerk page respiratory and find out who his doc is. Normally, intubating patients like this is standard procedure; we do it all the time. Except now, there’s a fucking pandemic, and everything that used to be ordinary is now borderline impossible. I say borderline because ER docs and nurses are resourceful. I grab a gram of Keppra and push it.

In minutes the doc is there, someone I know but not well. He’s good. I ask him what meds he wants to intubate, and he hesitates. We usually give etomidate and succ (pronounced “sucks,” short for succinylcholine), but we don’t know if there’s a head injury and succ isn’t good for that. “Etomidate and roc (rocuronium)?” I ask, not wanting to wait until he crashes before I get everything together. The doc nods, but before I run to Omnicell to get the meds, I realize he’s going to need another line, and he doesn’t look like an easy stick. I’ve got no time to dick around, so I make a mental note to grab the IO kit with the meds. When I get back to the trauma room, the doc is getting what he needs out of the airway box – but the guy’s sat keeps dropping. “Any nasal trumpets?” he casually asks. I look at the guy and say, “I’m calling this a 7.5, want me to put it in?” Doc nods yes, so I grab one out of the airway box, squeeze some lube on it, and slide it down his right nares.

By now, respiratory is there bagging him, and his sat starts to come up a little, but not enough. Crashing fast. There’s now a couple of residents there, but I can tell they’re first year. I look at the doc and say “IO to the humeral head?” and he nods yes. I grab the gun, prime the line, and the residents are all perky, one of them says “I’ve always put them in the tibia.” I look at them and say “watch me and I’ll show you how to do it in the humerus.” They’re all excited and paying close attention as I drill the 15 gauge into his left humeral head.

Now I’ve got the sedative and the paralytic drawn up in hand-labeled syringes that I put in my pocket. I’ve learned the hard way that anything you set down in a code has a way of disappearing just when you need it. Within minutes, we’ve all gowned up and he’s got a 7.5 ETT, 23 at the lip, hooked up to the vent. Respiratory leaves, as well as the doc, and I realize I’ve got to start a propofol drip for when the etomidate wears off. I run back out to find the doc, he agrees, and I look at him and say, ”Start at 10?” He nods, so I run to Omnicell and override the med. When I get back to the trauma room, I look around and realize there’s no pump.

I go to the charge nurse, and it’s chaos – we’re at triple capacity with ambulance’s lined up out the door and short-staffed because nurses are out sick with the virus. “I need a pump,” I say, and she calmly looks back at me and replies, “We don’t have any.” I look at her again, dumbfounded. She’s a great nurse, so I repeat, “We just intubated my trauma room patient, and I’ve got to start a propofol drip, I need a pump.” She gazes at me, eyes wide, but somehow, amid this clusterfuck, without any excitement, she replies, “We don’t have any left in the hospital.” See, this is what happens in a pandemic – you start running out of shit you never dreamed you’d run out of. Now I’m starting to get that sickening feeling in my stomach – it’s the beginning of my shift, and everything’s already breaking down. I glance around, and it looks like the end of the world. There are so many sick patients you literally can’t walk down the hallway. Dead bodies on stretchers in hallways not even covered with sheets, people slumped over in chairs, delirious patients screaming and tearing off their facemasks, coughing into the open, so many untriaged EMS patients on stretchers they’re backed up out the door.

I glance in the trauma room at my patient, and he’s starting to move; at the same time, alarms start going off on the vent. I see his blood pressure is now 250/120, and I realize I’ve got to give the propofol now. I run back out and tell the doc, “There are no pumps, so I’m going to have to titrate it on my own.” He looks at me with a blank face and nods. So that’s what I do – I figure I’ll stay with him in the trauma room and watch his BP and movements. If his pressure goes too high, I’ll increase the drip; if it goes too low, I’ll decrease or stop it. It’s either that or let him die.

At this point, I have no idea what’s even wrong with him besides uncontrolled seizures. I look at the EMR to check my orders, and there is a shit-ton of them. Labs, meds, x-rays, CTs, ECGs, viral testing for COVID. He’s hyperglycemic, so it looks like he’s in DKA on top of everything else. There’s an insulin drip ordered. Now I’m starting to feel seriously overwhelmed, and I’m by myself. The ER is in full meltdown mode, something I’ve never seen in ten years as an ER nurse. The disease is fucking everywhere.

But now I realize I’m fucked, propofol I can maybe titrate manually, but even that could be lethal. An insulin drip HAS to be given on a pump because you’ll definitely kill someone without it. I call the supervisor and tell her, and she tells me she’s working on it. I pull the labs off the 20 gauge and send them off, swab his nares for the virus – but I realize that has to be walked down and hand-delivered to the lab. So that’s what I do. His pressure is OK.

When I get back, pharmacy has tubed me the insulin drip. I walk into the trauma room and his pressure has now dropped. 80/40. I look a the propofol bottle, and it’s empty. My heart sinks as I grab another bag of NS and start it wide open, running out to grab the doc. He looks at the patient, his pressure, the empty propofol bottle, and calmly says, “He got too much – that’s a potentially lethal dose.” My heart feels like it stops – I can’t let this guy die because I didn’t have a goddamn pump and overdosed him with propofol. I look at the doc and say, “Phenyl stick?” He nods yes, so I run back to Omnicell – BUT THERE ARE NO GODDAMN PHENYL STICKS. We’ve fucking run out. No phenylephrine drip either – that’s gone too. My mind is racing – what pressor can I override? I grab a bag of Levophed out of desperation.

I get back to the trauma room and tell the doc there’s no phenylephrine. “How about a dirty epi drip?” I ask, trying to think of anything to get this guys pressure up. “No,” he calmly says. I show him the Levophed and say, “What rate would you want to give this if I had a pump?” Now, Levophed is only supposed to be given through a central line, on a pump, because it’s a very dangerous drug. But this guy is dying. He tells me the dose, and somehow I find a drip rate conversion chart on my iPhone. I know I can use the IO as a temporary central line, so I spike the bag and hang it. Fifteen drops a minute. The doc is standing there watching the drip chamber, and I say, “I’m calling that fifteen drops a minute,” and hit the BP button on the monitor. First reading – no change. I wait two minutes and hit it again—slight change. The third time it starts to come up. I silently rejoice for a second – it’s working! I stop the drip and tell the charge nurse again what’s happening. Somehow my boss shows up, and she sees I’m clearly shaken – not my usual state of affairs. I grab her hand, look her in the eye, and try and tell her what I’m doing. I’m in an impossible situation, but I’m also in the middle of a goddamn pandemic, and I’m just trying to keep this fucking guy alive.

Within minutes, a pump shows up, along with some ICU residents to put in a central line. I page respiratory again because the vent alarms keep going off, and when they show up, it turns out the motherfucking vent is malfunctioning. Meanwhile, it looks like he’s starting to seize again. So I get two of Ativan. I can’t tell if he’s bucking the faulty vent or seizing. It’s a shitshow. I spend the next two hours waiting for the medics to show up and transfer him to the neuro ICU downtown, while I’m constantly juggling meds and trying to fill orders to keep him stable. I still don’t really know what’s wrong with him; I’m just putting out fires.

When I finally give report to the ICU nurse, she’s nice, but I feel like an idiot. I can’t tell her what I’ve been going through because it’s not pertinent to her job. So I give the best report I can, and she seems satisfied. By the time EMS gets there, I’ve got three other sick patients I haven’t even seen yet, and I feel both dehydrated and like my bladder’s going to burst. For the first time in four hours, I go to the bathroom and very carefully take off my PPE. I pee what feels like a liter, drink about a liter of water, and very carefully put my PPE back on. I’m hungry, but there’ll be no lunch break because there’s no one to relieve me. I feel like I’ve been beaten with a stick.

Eight hours to go.

By the middle of April, the military had set up a temporary field hospital next to my ER with a capacity for over 200 COVID patients. Travel nurses showed up around the same time. We were all grateful, but it was too late. My ER went from a month of Armageddon with a severe shortage of nurses, to a low daily census with too many nurses overnight. At the height of the pandemic, my medical director, a strong, brilliant, and dignified woman, committed suicide. I had worked with her for ten years – she was my boss, mentor, and friend. She had contracted the virus and came back to work at a point where our ER was functioning like a poorly equipped MASH unit in a third-world country. I can’t imagine how she felt.

It turned out New York City was the perfect storm – a city of 8 million people packed into a small geographical area was the very definition of a “large gathering of people.” The virus burned through the population, particularly the poor neighborhoods and the elderly, like a raging wildfire. Emergency medical responders, ERs, and ICUs, broke under the crushing pressure of the sick and dying. But it was the emergency departments that bore the brunt of the load. Our doors are always open, and under federal EMTALA laws (which I believe in and strongly support), we can turn no one away. Every other part of the hospital can “fill up,” meaning they can no longer take any more patients because their beds are full, but this is where the ER differentiates itself as an entirely different animal. No matter how many sick people show up, we must somehow treat them. If the ICU is full, then we will take care of their patients until a bed shows up or the patient dies. ICUs have a 2:1 nurse to patient ratio. There is no limit on how many patients an ER nurse can take – as many until the nurse falls over, I guess. For several weeks in our ER, we did our best to treat the deluge of those sick with COVID while functioning as an ad hoc ICU with a rapidly diminishing nursing staff – because, one by one, they were getting sick. With no organized preparation or early response from anyone, all frontline workers (including medics, nurses, and docs) had to scramble for PPE, leaving them unprotected against the virus. The result was a dwindling of staff sick with the disease while the number of ill continued to rise. It was as if the whole thing was a complete surprise to all leadership – even though China, Korea, and Italy had already experienced devastating outbreaks.

Most people in a first world country will only see a dead body when there is an open casket at a funeral. The responders in my ER, already acclimated to death on a daily basis, will somehow have to cope with the moral injury of feeling helpless in a mass casualty event. For roughly a month, from mid-March to mid-April, death was everywhere. We had nowhere to put the bodies because the morgue was full. In our small ER, someone was dying all the time. Over and over and over. Because the virus was new, there was no treatment except oxygen. Eventual cause of death: Hypoxia and organ failure.

On top of the existential crisis placed on frontline workers, there was the constant threat of becoming infected yourself. Or of infecting a loved one. Death and fear, always there in your mind. Adding to the disconnect is the realization that nowhere else in the country experienced anything remotely like this. In NYC over a thousand people were dying a day.

If you lived through this experience as a frontline healthcare worker, you’re left with quite a few uneasy observations. The first is that no one will ever understand what you went through. You realize this must be how veterans felt when they come back from the war. You’ve got all this trauma festering inside you, with no one to share it with—a perfect recipe for PTSD.

You also quickly begin to see how your mind will try to “erase” the memories to protect you. This, of course, is a dysfunctional response that will lead to later complications in life. Talking about it can help, but see observation number one.

Then you realize the virus is still out there, and you have no protection against it except for your PPE and isolation. And of course, we all know how good isolation is for your mind.

Finally, you’re left with the grim realization that life is a brutal and short affair, and there is no one there to protect you, except yourself. You just witnessed an example of ineptitude on a grand scale, and now you know there’s no one helming the ship. In the absence of leadership, it’s just one giant shitshow.

Before the virus, we had the hubris to think we had some control over our lives, but that was just an illusion. As an ER nurse, you know that until there is a reliable vaccine, it’s not going to stop. It can take its time and do whatever it wants – we’re helpless as a newborn. I wish I didn’t know what I’m talking about here but trust me – you don’t ever want to see what I’ve seen and make the decisions I’ve had to make.

Maybe the biggest takeaway is this: In the grand scheme of things, we mean less than nothing.

Try to find the silver lining in that.