I haven’t written for over a week; I just had too many balls in the air to find the time to write. I’ve worked 91 hours in the past 7 days, excluding the work done on a study that I want to start soon on heroism and working conditions for healthcare workers (which added about 3-4 hours a day to that figure). I’m sure I’ve forgotten much of what’s happened over the last week because I’m just exhausted to the point where I haven’t been getting up early enough to run, or do any real self care anymore. It’s a good thing I have the hospitalist call room to myself; I’m pretty sure I stink. I did do one thing for myself over the last week, though; I stopped at a local shoe store (“Incredible Feets”) and bought a new pair of running shoes to replace the ones I’ve been wearing that were full of holes and falling apart. My feet hurt a lot less now that I’ve got shoes that don’t lose parts every time I take them off.

I feel like I’ve done so many invasive, painful procedures on people who were likely irretrievably ill. It’s a special kind of disempowering to be obligated to do invasive procedures to people who you know will not medically benefit from it.

Most of the time, I feel like I’m little more than a bill generator for the hospital - and a poor one at that; most ERs spend far more money than they bring in. One of the nurses on the stepdown unit called me an ‘inspiration’ to them by being an ER Nurse Practitioner with cross training to outpatient, inpatient general medicine, and critical care -- which is flattering, but I don’t know how to interpret it. It’s not the first time someone has said that to me, but I’m not sure my footsteps are necessarily a good set to follow. I’m 30, have been in healthcare for half of my life, and am burnt out enough that practice has lost most of its meaning; my path is not a sustainable one to follow, and I don’t know how to convey that to others in a useful way.

To back up a bit, I started four (4) days ago. Somehow my paperwork got lost, so I’ve only had access to medical record systems for two (2) of my four (4) days here. I was put to work in the vaccine clinic giving COVID immunizations instead of in the ICU. The vaccination clinic was actually fairly enjoyable and reasonably well organized by the small group of residents running it. This experience was not what I was originally expecting but it was decent. I probably gave fifty (50) immunizations personally and got the first dose of one myself. I had been holding out until more data on the vaccine safety was published; more is available now, and I’m confident enough in its safety now that I felt the benefits outweighed the risks for me. It will be interesting to try to get the 2nd dose, as I won’t be here in three (3) weeks.

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 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.

Jackie Christianson, MSN, FNP-C

I’ve bid my farewells to Hawaii and the family living there, and am now sitting in the Seattle airport on a layover back to New York. My vacation was supposed to last a bit longer, but it is impossible to relax, and was becoming challenging to enjoy the time off when the mainland is burning (and not just from COVID). So I cut my vacation short and will be in Brooklyn for 4 days and Long Island for 12 days on a crisis contract. My family flew with me for the first leg of the trip, but we parted ways in Seattle - they're headed home and I'm going straight out to New York. For all the bluster my daughter gave me about stealing my bed while I'm gone, she was still tearful when we split. The break itself was great though, and much needed. I ran down the mountain to the beach, jumped in the ocean, then ran back up the mountain on most days, and I learned how to surf.

This will be my last crisis contract. I'm starting a desk job shortly after I return from this trip, so it will very much be my last hoorah before mostly retiring from clinical practice to a desk job and academic work. If I'm completely honest with myself, it's a needed retirement. I was burned out from clinical work before COVID started. I have lots of knowledge that can still be put to good use, but if my patience for dealing with people was fleeting before, it is certainly gone now. I have no doubt I will have some degree of mourning for leaving clinical practice (which I already do, on a certain level), but it is a needed change. I lasted over 15 years in clinical practice and now it is time to get on to something different.

I had my roommate ship my respirator to the hotel I’ll be staying at. I have a single, manky old N95 that I’ve been recycling for several months now that I was going to retire after the flight back from Hawaii as I require lesser protection on an airplane than in a vented COVID patient’s room. Also, quite frankly, the fitted N95 masks are too precious a resource to just throw away before they’re abundantly past their usefulness period. I doubt the seal is fully effective, the staples holding the elastic are rusting, and the inside is a disgusting grey-brown color, but it’s certainly better protection than an unfitted mask would be. Normally I wouldn’t be very worried about receiving the respirator on time as the postal service is normally very reliable, but the post office slowdowns circa, the election situation has not improved yet…, and my only definite fallback is this month’s old mask. I don’t know if the hospital will have any masks to spare, much less one that fits me correctly.

It is very strange to be going back to New York and to not have any disaster contracts from Wisconsin. I have a few contacts who are on travel contracts there (and lots of colleagues who work in numerous health systems in WI), and apparently, most of the hospital systems are continuing to pretend their staff isn’t stretched beyond reasonable limits. It’s every bit the corporate irresponsibility/blaming workers for the hostile approach that I have come to expect from health conglomerates, but I’m perplexed that several NYC and Long Island hospitals are bracing for another surge and staffing up before the proverbial hits the fan this time. During this trip, I am keen to try to investigate what the structural differences are between these two NYC hospitals, which seem to be taking some kind of a proactive approach to ensuring they have the staff they need, and the hand waving everything-is-fine approach others are taking. In either event, it is very strange indeed to be contracted halfway across the country when my own state’s crisis is, by the numbers, presently worse than the one in NY.

More later - I don't even know for sure what I'll be doing in Brooklyn. They asked for someone who can do just about anything, from critical care and emergency to general medicine.

Jackie Christianson, MSN, FNP-C

We’re having a more normal number of deaths now, too. I’ve been primarily in the non-COVID ICU over the past week, though we have had a few people pending tests in our department. It’s hazardous to do it that way -- they were considered fairly low-risk, but the non-COVID ICU is located in a totally open unit normally used for post-anesthesia recovery. There are 25 beds here, about five of which are isolated together in their own room next to the OR. Those five are normally used for the critical care cases -- patients that were either going to the ICU after surgery or who were difficult to manage postoperatively. The remaining 20 beds are in an open area, separated by short curtains. The beds are perhaps 5 feet apart. When the unit is full during the surgical day, it’s usually bustling and space is a commodity. It's an infection risk, but almost anything looks good compared to the virtual guarantee of catching COVID by merely entering the hospital unprotected.

One of the patients, the one we staged the COVID circus for, might be approaching discharge. He’s almost entirely off his ventilator but is still oxygen-dependent. He has a particularly tough journey because he’s an undocumented immigrant, so he’ll have very limited to no access to the follow-up care he’s certain to need after discharge. A long-term facility won’t take him because of the payment issue, and he won’t be able to see a clinic or likely pay out-of-pocket for home oxygen tanks. He’ll be with us for a while yet, but we cannot responsibly discharge him while he’s still oxygen-dependent knowing he does not have access to life-sustaining care. The current plan is to keep him in hopes he is able to wean off the oxygen and go home with his tracheostomy. Even then, he’ll be in terrible condition, but the hospital will almost certainly discharge him once he’s not likely to die if sent home. He’s lost at least 50 pounds, including almost all of his muscle tone, and he will need to re-learn how to do everything: walk, feed himself with silverware, get dressed, brush his teeth, etc. If he’s lucky he might survive long-term -- most patients in that condition are not long for this world because they’re at such high risk for other infections.

It’s a bit bittersweet to return home. Wisconsin’s numbers have continued to climb. Predictably, two weeks after our Supreme Court struck down the shelter-at-home orders, the number of WI positive cases per day has nearly doubled. Some of the more rural counties containing tourist towns, like Walworth County (Lake Geneva relies heavily on summer tourism), have seen enormous increases in caseloads. Their case per 100,000 rate is over 360, considerably higher than the state caseload of 290 per 100,000. Only five counties are worse: Milwaukee, Brown (Green Bay), Rock (south central, bordering Illinois), Racine, and Kenosha (southeast Wisconsin near the Illinois border). Apparently, tourists from neighboring states like Illinois have been coming into Wisconsin to “escape lockdown,” which is a pretty big problem when you consider that Chicago is having a major outbreak. Walworth County only has two hospitals totaling about 80 staffed beds, 12 of which are ICU-capable. An outbreak there would be catastrophic to the community.

We had a new "success story" over the past week. A man in his early 50s who’s been in and out of our ICU was finally starting to improve. He’s been hospitalized for COVID for about two months straight. He’s been in ICU thrice throughout his hospital course; I've had him for both of his return trips. He came back to us because he had to be intubated for a third time. He went for a tracheostomy four days ago and he improved dramatically when we were able to reduce his sedation post-trach. He’s awake now, is completely cognitively intact, is off blood pressure support medications, and looks likely to make enough of a recovery to discharge to a long-term care setting. My guess is that he’ll be on a ventilator for the rest of his life, but he’ll probably live.

I learned this weekend that one of my colleagues is a fellow acrobat (and a considerably more skilled one than I am, at that). He’s more of a partner acrobat, which I’ve not done much of (as my own solo skills are pretty sketchy), but we decided to try a simple, short trick. He had my shoulders on his feet and I basically did a headstand with my shoulders balanced on his feet. We were going to try to convert that pose into a handstand, but the ceilings were barely high enough for the headstand version, so we couldn't. The nurses allowed us to open the tent flap of the patient described above and do a brief performance for him. Then we did an encore round for the only other patient who was awake on the unit -- a nice old man with Down syndrome who had also recently been extubated. (He was awake and seemed to enjoy it.)

Thus, the COVID Circus was born. We were able to practice but didn’t have a chance to perform for any patients the following night (they blessedly slept through most of the night), so we made a pact to do a new trick every shift we work together and hopefully do a brief show for the awake patients nightly. It’s totally frivolous and silly, but these people have been through hell and it takes perhaps 15 minutes to brighten their day. The nurses love it, too, and to be fair they’ve likewise been through hell. We even got a couple of the other PAs to try it. One was brave enough to try the partner headstand with spotters. A couple of other PAs who have never tried a handstand gave it a try with spotting and instruction, too. The videos of our stunts have spread around the hospital. Nurses on other units have been asking to see more tricks or other videos from my circus escapades prior to COVID. It’s nice to have a little joy on shift for a change of pace.

An idea that keeps me sane, in the wake of knowing many of my surviving patients will have comparably low qualities of life after COVID, is the concept of the hedonic treadmill. The broad idea is that life events may change one’s happiness short-term, but most individuals adapt to new situations and return fairly quickly to their previous baseline level of happiness. One of the more famous studies on this was one in the 1970s that followed about 60 people. One-third of them were new lottery winners, another third were people who had not experienced a major life event (a control group), and one-third were new spinal cord injury victims. In short, the study found that the lottery winners were happier and the spinal cord victims were much less happy in the short term, but the change in both groups was temporary despite the permanency of their respective life-altering events. There’s been subsequent research with similar findings, and there’s more nuance to the concept of the hedonic treadmill thanks to subsequent research today, but I’d like to think that research is relevant to the quality of life questions I have for some of these patients with new chronic illness. It’s objectively awful to spend the rest of your life on a ventilator, but perhaps they will adjust and still have fulfilling lives, much like the new paraplegics adapted.

I’m pretty disappointed that a few of the patients from last week died. I had been particularly hopeful that one, the Muslim man in his 40s, still had a chance. I was expecting the rest of the patients in the department to die, and I suppose I expected him to as well, but I was hopeful nonetheless. I had extubated him and he did okay off the ventilator for about two days until he had to be reintubated. He was even responsive and able to communicate with us. I was hesitantly optimistic he would pull through. The current batch of patients aren’t much better off than those from last week. Our death rate has decreased a bit; half of the ICU is currently non-COVID patients. Some of them are non-COVID surgical cases that just need a day or two of ICU care due to the complexity of the surgery itself. Their prognosis is significantly better than most of the non-surgical cases. We’re only averaging one or two deaths per day now, as opposed to two to three when all 14 beds were COVID patients.

I always used to get a little adrenaline rush when a patient tried to die during my shift. My training was really centered around life-sustaining medical management, as that’s what emergency services is really there for, and it used to be exciting when I actually got to use that training. It was a useful rush, one that I had learned over time to focus toward what needed to be done but one that for the uninitiated can be panic-inducing or impair judgment. I’ve lost that rush entirely, and the prospect of a patient trying to die has become no more adrenaline-inducing than writing a medical record note. Every night we’ve had at least one or two patients try to die (and a couple who succeeded). Their heart rates or oxygen levels dropped, or they deteriorated in some other way, and the stress that comes with that situation is just not there anymore. It’s more like “Oh, they’re trying to die again. I guess I have to fix that.” The lack of adrenaline hasn’t impacted my ability to do what needs to be done, but it struck me as odd to feel the same way about dragging someone back from the pearly gates as I do updating the sign-out report we give to the next shift.

Some of the nurses have mentioned how exhausted they are. They’re all seasoned ICU nurses, but even they’re not used to this much death. The burnout is really showing, and at a certain point no amount of expressed support, 7pm public ovations, free meal deliveries, or hazard pay makes up for the stress of extremely sick patients and risk of disease exposure to themselves. I still can’t help but feel sorry for their situation. It’s hard to be told you’re a superhero when the reality is we’re just not saving many people here.

The juxtaposition between the reality of our situation and the public’s insistence that we’re heroes is just staggering to try to contend with. I found a scholarly article on Superman comics during the Vietnam war (which, funnily enough, cites one of my undergraduate professors, Dr. Chris York, who did a similar dissertation on Batman comics and popular culture). During Vietnam, the Superman comics went through an arc in which Superman had part of his power siphoned away by a villain and had to contend with having lesser powers than his previous normal. Part of the story is Superman learning to contend with his own perceived insufficiency. He goes briefly mad and harms a few innocents in his attempt to compensate for his shortcomings. Superman does ultimately defeat the villain who took his power and has the opportunity to have it restored. He declines restoration, declaring he has seen the consequences of excessive power and opted to stay in his weaker state. Right now, I feel like I’m in the insufficiency stage of a similar process, and I’m not sure there is a way to progress out of that stage other than coming to terms with my limitations. It’s hard not to go mad when my deficits stare me in the face with every patient deterioration death, even though mine are the same as everyone else’s. Maybe I am luckier than I realized not to feel anything about it all.

On a personal level, I am overwhelmed - physically, emotionally, mentally, spiritually.

It has been 49 days since the governor of Washington declared our stay-at-home order and 49 days since I’ve left the house for anything other than work, groceries, and random runs for takeout when we couldn’t bring ourselves to cook. 49 days since my work and life got turned upside down.

On a professional level, I am fatigued but determined – fighting for patients and access to treatment.

In a single day my job in clinical research was burst open at the seams. I went from coordinating a handful of Phase II and III trials for HIV and seizure medications just in Spokane to helping coordinate a series of inpatient Phase II and III trials for COVID-19 treatment across the state. I threw myself into the trials, frantically and tirelessly working with our incredible staff to get our remdesivir, convalescent plasma, and IL-6 modulator trials off the ground in a quarter of the time we usually take to do it. I went from working during the week to clocking in 7 days a week, poring over charts, screening patients, reaching out to families, and conducting a massive data collection for the studies. Even though I haven’t set foot in the room of a COVID-19 positive patient (we do consents over the phone, and the medications are added to the MAR and part of the floor staff workflow), I feel for them and their families. We have lost patients during our trials, and even though I may not have done more than have a 20-minute phone conversation with them or their families, those losses cut deep.

I am wounded – by the words of others.

I’ve never had to defend what I do for work until now. I have worked in clinical research for several years, coordinating Phase II-IV pharmaceutical research trials. I have spent countless hours working with HIV, Parkinson’s, Alzheimer’s, and epilepsy patients, trialing medication and treatment options to see if we can provide relief and management of their symptoms and disease process. I have worked alongside doctors, nurse practitioners, and pharmaceutical companies all set out to do right by their patients. Yes, Big Pharma can be a pain in the ass and they’ve done some genuinely suspect and shitty things in the past. We can’t paint them all with the same brush. We have a one pill once a day treatment option for HIV for the first time since the 1980s, and this one won’t trash your liver, kidneys, or bones. We’re revolutionizing the way we provide carbidopa-levodopa to Parkinson’s patients, finding ways to provide longer-term symptom management with lower doses. I’ve never had to defend the work I do until now, with mistrust and anger coming at the research world from left and right every single day. I’m not in this to help pharmaceutical companies make money. I do this day in and day out because my HIV patients need me, my Parkinson’s patients need me, my epileptic patients need me.

I am disappointed – in our country.

I am tired of the news, the internet, the conspiracy theories, the false narratives, the lies, the inability of people to take responsibility for their actions and choices. I don’t understand how our administration can stand at their podium every day and say they are doing a good job, but also withhold supplies from the federal stockpile and say that New York should have prepared better. I don’t understand how the idea that this is being perpetrated by individuals and countries in order to ruin other people is running amok and gaining steam. I don’t understand how people can think that because the hospital near them isn’t overwhelmed it means that no hospitals are overwhelmed and we’re blowing this out of proportion. I don’t understand how we can ignore everything we’ve ever learned about public health and management of a crisis and try to muscle our way through this. It breaks my heart that this pandemic has revealed the inherent and boundless selfishness of human nature and the impact that is having.

I am lonely - though not all the time.

In a single day I came face to face with all of the things I wouldn’t get to do this spring. My husband and I wouldn’t get to travel for spring break or our 5-year wedding anniversary, wouldn’t get to travel across the state for family birthdays, see my parents for their 43^rd wedding anniversary, celebrate my sister-in-law’s wedding. We haven’t seen my family in person since the beginning of February, and for a massive homebody like me, that has been the hardest part of this stay-at-home order. Our community of people is spread around the world right now, and for my extroverted husband and my selectively extroverted self, quarantine has been brutal and gut-wrenching.

I am heartbroken - for my students and fellow faculty.

In a single day I stopped teaching my clinical rotations and I haven’t seen any of my students since then. Our stay-at-home order was quickly followed by all clinical rotations being cancelled, all classes switched from on-campus to Zoom, and a barrage of text messages and emails from students panicking about what they were going to do. My normal routine for wrapping up a clinical rotation was to go back over everything we’d learned, cover their senior internship, and help prepare them for graduation and taking the NCLEX. Overnight I turned into a counselor, helping calm fears about life, jobs, internships, and graduation. Thankfully, the program I teach in front loads their clinical hours, so our graduating seniors could miss their senior internship and still be able to graduate and take the NCLEX. But that hasn’t stopped them from worrying about what was going to happen to them and what they were going to have to miss out on due to the pandemic. We didn’t get to do a pinning ceremony, and I didn’t get to cry my way through their names being read and then take a huge sobbing group photo before they wander off into their next adventure in the great unknown that is life. For the first time, I didn’t get to see my students graduate, and it took 49 days for that to sink in.

And yet, somehow, I am hopeful.

For all the sleepless nights, heated conversations and arguments, hours spent with worried students and patients, there have been sweet moments of joy and relief. I finally had time to take up running again. I found an incredible local yoga studio offering classes over Zoom that lets me practice in my living room while fending off my overly enthusiastic pup. I’ve gotten to work from home part of each week, giving me more time with my husband. I suckered my family into semi-regular Zoom dates, though corralling 12 wayward people is often a challenge. My husband I started weekly physically distant dinner dates with our best friends, finding community even in this time of isolation. And like most of the country, I’ve gotten to indulge and do all of the baking I talk about doing during the semester and never quite get around to (I’m one more shot away from perfecting overnight cinnamon rolls!).

But more than that I’ve seen the ways that people have stepped up for each other. My students are having Zoom dates to study for the NCLEX and helping each other prepare for job interviews and writing cover letters. The ICU doctor I worked for spent his Easter Sunday shrouded in CAPR gear sitting in a room with a pair of COVID-19 positive patients, talking through the disease and easing their fears. When I called them last week to see how they were doing, the patient and her husband spent the call in tears, overwhelmed by the thoughtfulness of the doctor and the peace he brought them that day. I have seen hospital and clinic staff come together to troubleshoot seeing patients, easing fears, and providing relief and comfort. I have seen our community step up at the drop of a hat to support local small businesses who didn’t think they would survive being closed. Companies are diverting time and funds to making masks and ventilators, offering support where they can to hospitals in need. Our Spokane community has come together to honor every single essential worker, healthcare or otherwise, adapting business plans for physical spacing and safety with empathy and intentionality.

While I am saddened by so much that is happening in our country and world right now, I am also hopeful. In this darkness that seems to go on and on, we are seeing areas of light and grace. We are seeing both the best and worst of ourselves, and I hope the best wins out.

I am weary, but I am still hopeful.

Aurora’s birthday was on Monday. I didn’t get back in time to celebrate her birthday on the proper day, but we had fun baking and decorating a cake on Tuesday. I bought her a handheld video game console as a big present for her birthday, in part because I have a degree of guilt over being gone so much over the past few months. I know I’ll be gone for most of May and June as well, as I’m already scheduled through the end of May and am pending a June schedule. The facility is asking for July dates, too, which I’ll probably end up giving them if I’m able. A friend of mine said her dad, who traveled extensively for work and was often gone for a few weeks at a time, always brought home presents for her from his travels, too. I wonder if he also felt some guilt for being away. As much as I think buying things is a poor substitute, I'm not sure what else I can really do from a distance.

People keep acting shocked that I’m going back for a second, third, fourth, and possibly a fifth contract if July pans out. I guess I understand why, but I’m able to do the work and it doesn’t seem to be bothering me too much, so it seems practical for me to keep going. The numbness I’m experiencing certainly seems abnormal at face value, but there’s a certain benefit to not feeling psychiatrically scarred by events that are quite traumatic for others. My understanding is they want to use my June and July contracts to give some of the hospital’s regular staff some well-deserved paid time off. That certainly seems like a worthy goal; none of them signed up for this, but I did.

I had to take a leave from my teaching job for the summer; while my clinical courses are taking place online again, this time the university needs me to be available during a set shift on the same day/time every week, which I can’t do consistently while I’m out on COVID assignments. I opted to keep my PhD coursework through the summer, though, which will be a pain while I’m working in NYC, as the night shift is 7pm-8am and class time is a once-weekly 10am-12:30pm meeting (plus associated coursework). It’s the perfect timing to make me very sleep-deprived.

It’s Mother’s Day today, my last day off, so Aurora and I decided to make a strawberry cake. I had to take a short trip to the grocery store to get the missing ingredients. The grocery store (a fairly nice establishment called Metcalfe’s), like most stores around right now, had signs up everywhere notifying patrons they would be required to wear a mask inside and had signs directing traffic down newly one-way store aisles. I watched the management stop someone who had snuck in without a mask on. She proceeded to get into a shouting match with the store management, who told her she needed to either put on a mask or leave. She claimed she had no way of knowing, and how dare they prevent her from completing her grocery trip.

I’ve seen plenty of similar videos and claims of similar behavior made online, but it continues to blow me away how utterly unreasonable people can be over something as inconsequential as wearing a mask. How are there so many people who are so narcissistic that they react to someone correcting their mistake by shouting them down? I can’t even wrap my brain around why it’s such a huge deal to have to wear a mask. Covering your face for 15 whole minutes is of so little consequence it’s laughable, and most stores are now selling masks if you do forget it. It’s like the people who got angry when Washington state added a mandatory surcharge of $0.05 per bag for people who didn’t bring their own grocery bags and needed the store to supply them. The stakes are so low and the effort to fight such a minor change is so great; it just doesn’t make any sense.

Aurora gave me a fairly special Mother's Day gift. She has a particular stuffed dog, Violet, she loves and has to sleep with every night. She has three, to be exact, because we always build redundancies into the system. She gifted me one of them, the one we call Pox Violet (because Aurora drew spots all over it with a marker), and told me it was to have something to sleep with while I was away. So now Violet is coming on my adventure, and I have a good excuse to bike around some of the Manhattan sights. I'll take Pox Violet with me and snap some pictures at some of the usual tourist places.

Jackie shares in her latest blog posts some difficult feelings. This is the Nurses International Community response:

Jackie, I’ve thought of you each day while you’ve been working in NYC. Your honesty, smarts, and willingness inspire and challenge me. Thank you for letting us be your community of love and care when things are difficult. We love you! - Miriam

Jackie, what you've been able to do, on both micro and macro scales in the last month, is a model of what health providers do at our very best. Proud, inspired, and delighted to be associated with you. - Erica

Jackie, I’m not a medical provider but my wife’s a PA and my brother’s an MD. They’ve both experienced that numbness you wrote about in your lung transplant post. When they go through that experience I admire them all the more; they’re making a deep sacrifice in service to their patients. Thanks for your sacrifice, which is making a difference even as you learn a new role. So many people couldn’t, or wouldn’t, do what you’re doing. May you find peace today. - Pete

Dear Jackie, warm greetings from Nepal! I want you to know that we are grateful and inspired by the sacrifices you are making to save lives during this hard time. I hope you will be able to stay strong and find peace! - Bimala

Jackie, Your posts resonate so deeply with me. As a MICU nurse practitioner now dealing with COVID in SE Wisconsin, I want to stand in solidarity with you, knowing all too well that feeling of numbness and staring down what appears to be at times insurmountable. May you have peace this day. Your labors are not in vain. You are not alone. Much love to you! - Adrienne

Hi Jackie. You have earned your compassion fatigue. I experienced this while working on an Indian Reservation. Death and despair were overwhelming. I think we develop a protective shell for our survival. Each crack in the shell will be painful, but it also allows light in. Take time to recover. If you must work, consider a new area for at least a while. Recover, rejuvenate, rejoice. Judy in Arizona.

Hi Jackie. Thank you for sharing such raw emotion and experience with feeling numb. I believe that the numbness that follows tragedy is a time of introspection and healing. Having worked in the operating room on patients who were really at the brink of death, it was so gut wrenching when the patient you worked on for hours passes away. You no sooner wrapped up the case and cleared the OR suite, before administration was scheduling another case. The only way to persist was to allow some bit of numbness to set in. That said, numbness turns to other emotions such as sadness, anger, confusion, and calm. Allow yourself to feel and to heal. I am inspired by your heart and your devotion. - Nancy in South Carolina.

Thank you, Jackie, for sharing your story. The contributions that you have made to the fight against COVID-19 in the field and in educating other healthcare workers are immeasurable and far-reaching. After everything that you have experienced you are allowed to feel or not feel any emotion that pops up along your journey to healing. I’m praying for a peace that surpasses understanding to surround you. We are here for you. -Madison

Dear Jackie, I am praying for your strength during these unprecedented times. The work you are doing to help others is remarkable. Please know you have fellow colleagues praying for you. You are not alone. Here’s one of my favorite verses I would like to share with you: “Trust in the Lord with all your heart; do not depend on your own understanding. Seek his will in all you do, and he will show you which path to take.” It looks like he is doing that so continue to lean on him. -Stephanie in Virginia

I did my internship in a very busy tertiary referral center and struggled a lot with the fact that many patients had already had all treatments and we seemed to have little impact on preventing their deaths. I often felt hopeless and depressed wondering what good it was to be in medicine if it didn’t make any difference. The long hours and frequent overnight call added to it as I became more and more fatigued. So I can identify with what you are feeling. It’s hard to get perspective on what is generally happening in the world when we find ourselves in such dire situations in a limited space not experienced by others. Praying for rest which can help a lot and for God’s comfort and peace. Thanks for all you are doing! I’ve felt bad that I’m no longer in practice and couldn’t find a way to help. - Shari in New York

Hello Jackie. I read your blog about just feeling numb when your patient died. Obviously, that’s not something I can relate to. But I did ask my husband, an ex Army Ranger, Viet Nam vet, retired firefighter. He said “I was there and that’s where you should be. If you can’t be numb right now, then you will not survive. The ones who took their own life (soldiers or otherwise), couldn’t go numb. You are where you are supposed to be. He further told me that you save who you can and pray for the rest. Hold onto your victories, no matter how few. You have to hold on to those victories” So, that is what my husband said. I hope that helps somewhat. Do you know that I applied for every Covid-19 NP position that I could find? I even applied for strike teams to serve at nursing homes in Maryland. I was rejected by them all. Lol. The strike teams in Maryland are volunteers. I was rejected by a volunteer project. Just saying that you were chosen. Not everyone was chosen. But you were, and you are making more of a difference than you will ever realize. Remember, the enemy has no recourse against the blood of Christ. You have taken up your cross and are serving the Lord in a way that most of us cannot imagine. I plead the precious blood of Jesus over you. You are going to be Ok. Love in Christ, Bonnie Velez

Jackie, you are seen, you are loved, and you are prayed for. I can’t even fathom the things you are seeing and experiencing, but know that you are being lifted up in prayer: for peace, for sleep and rest, and for times of quiet and stillness. --Lindsay in Norway

Jackie, I am so impressed by the expanse of your skills and knowledge that are evident through your stories. From overseeing/directing/educating nurses, technical intubation and IV skills, and your compassion in advocating for and communicating with patients and families, you seem to embody all aspects of the huge role that is nursing. I am in awe of your resilience in continuing to serve in COVID hot spots. Thank you for all that you do. -Sara

Jackie thank you so much for sharing your story with us.I pray that the Lord will be with you, give you strength, restore your spirits and guard you while you are working and traveling. You are a blessing to those in your care, even if you don’t think or feel that you are. May God give you peace, and know that you are never alone the Lord is walking with you and we are keeping you in our prayers. Lillian

Jackie, thank you for sharing your experiences. Your stories give focus for prayer and remind all of the reality of suffering that is occuring. I will add you to the local prayer chains with emphasis on strength and a refreshed spirit - and peace of heart for all those you care for. God walks with you as you touch each life.

We spend most of the night shift making sure tasks get done and putting out fires. We’ve gotten a few transfer patients who needed blood transfusions or to be intubated on very short notice, but all in all night shift is a lot calmer than days. I’m an absolute fish out of water in this department. While I do know how to do most of the things here, I am only accomplishing perhaps ¼ or ⅓ of what one of their regular providers would. The charting system is one I’ve never used before and it’s taken me several days to really get used to it. Critical care medicine is not the same in an ICU as it is in an ED, though there are enough similarities that I can squeak by. I have a lot less autonomy here than I do in the ED, where I was basically running my own show. I'm frankly a lot more comfortable with less autonomy in this setting; I can manage emergencies well, but long-term planning is just not my wheelhouse and it's going to take some time before I adjust to the thought process.

During day shift rounds, I’m expected to understand and be able to verbalize the entirety of the plan of care to date; the rationale behind that plan of care; all of the labs, previous medications, and other interventions; and then help synthesize plan changes. We don’t do a formal set of rounds on nights or make major changes to the plan, thankfully, but I still need to know those things to make good decisions when someone needs an abrupt change of plans (usually due to deterioration). Often those good decisions are absolutely contrasted with the previous plan of care, and that’s okay on a short-term basis. Many patients are being tapered off their paralytics on the day shift, for example, and are put right back on them on nights to keep the patients from straining their systems and wasting their bodies’ resources by fighting against and choking on the ventilator, particularly at night. It’s uncoordinated and ugly, but we’re getting things done anyway. Part of the disconnect is just the day/night perspective change. We endeavor to maintain a normal sleep/wake cycle, so during night shift, we try to keep the patients asleep as much as possible. Due to constant interruptions in the ICU and the fact that many patients spend their daylight hours weaning off sedatives, we often have to change previous care orders to promote nocturnal sleep. Additionally, many people sleep in the prone position (on their stomach), which they often can't do without at least a low dose of a paralyzing medication.

Much of the actual work I’ve been doing has been procedural or directly overseeing the nurses. I’ve been taking out expired vascular access lines, starting new IVs (this is the singular thing that I’m still the best in the department at), helping with intubations and extubations, and making sure tasks get done in a timely manner. I’ve been doing family conferences with families of patients I may or may not actually have any hand in the care of. In many cases, the patient is deteriorating and unlikely to live, and I get to explain that in understandable terms to family members of a patient who I’ve only seen through a plexiglass window in a construction tarp and done a brief chart review on. Some of the families are able to do video conferences with patients via an iPad on wheels, so I’ve been setting up and coordinating some of those visits.

I’ve pushed paperwork, getting consent forms and power of attorney forms signed. It’s all work that needs to be done and I'm certainly not above doing it, but I feel like a student again because my proficiency in doing everything is just not there. I still require a lot of direction to make sure everything is getting done correctly. I’ve been so used to being completely on top of what I’m doing that it’s actually very jarring to be a novice again. I feel like people are being patronizing when they say that I’m being helpful because my actual accomplishments in a 12-hour shift are less than half of what they’re able to do. I know nobody actually means it that way or thinks that, but I’m definitely projecting that less-than-useful feeling, as I’m far from competent or proficient in this setting.

When I met him, we were trying to get him on the lung transplant list. Most COVID patients aren't transplant candidates for a variety of reasons. Many are too sick; patients who are on the ventilator aren't candidates until they're stabilized off the vent. Patients with co-existing problems plus COVID are generally also not eligible. Older patients aren't eligible. Patients who still show signs of the inflammatory condition thought to cause most of the long term lung damage aren't eligible. Lungs are in short supply, both because there are fewer donors currently and because demand is so high despite there being a very high bar for eligibility. The bar patients have to jump is so high because they want the people who do receive new lungs to have the highest possible chance of a good outcome, so the organs that are available are used for what is hopefully a long and fairly healthy life after transplant.

He met those requirements: he was in bad shape and not expected to improve significantly, but not in such bad shape that he was unable to breathe, was otherwise heathy and fairly young. He was cognitively intact, so much that he was very aware of what was happening. He was accepted as a transplant candidate.

He stayed at our facility for a few days waiting for a bed at the transplant facility to open. He had a few close calls on my shifts. One time he dared to sit up, from a 45 degree angle resting in the bed to a 90 degree angle for about 60 second so he could use the urinal. He never took the BiPAP off. The result was about an hour of struggling to breathe, oxygen levels in the 60s (normal is 94-100, usual range we intubate someone is the 75-80 range with oxygen support or a device like BiPAP). Every time we looked in on him while he was struggling and we were trying to prevent him from being intubated he will give us a thumbs up. He knew the consequence of going back on the ventilator; he'd lose his only chance at survival. Whenever we looked in at him and he was awake, regardless of if he was actually okay, he would give us the thumbs up. Everything is fine, because things could be so much less fine.

He was transported to the other hospital to wait for a transplant to become available, so that he would be able to get the lungs immediately if they found a match. Something went wrong during transport. It's unclear exactly what happened, but some piece of breathing equipment failed. The transport time between our facility and the transplant facility is about 15 minutes, less than 10 miles in distance. In that 15 minute transport, he deteriorated so much that his oxygen level dropped precipitously, he was working hard to breathe, and his mental status had started to deteriorate. He was emergently intubated and placed on a ventilator as soon as he got into the receiving facility. In the span of 15 minutes he lost his transplant eligibility, and over about 12 hours continued to deteriorate. He was placed on medication drips to keep his blood pressure from dropping below the threshold at which his organs would continue to function. His family was allowed to come see him, which is only allowed when someone is dying during COVID. He died shortly after.

His death isn't anyone's fault. The paramedics caring for him couldn't have known their equipment would malfunction, especially since they had likely used the same machine for the patients they had transported during the rest of their day. The incoming facility did what they had to do to preserve his life when he arrived. It was the worst outcome possible for his circumstances. He was never guaranteed a transplant, nor was getting a new lung or set of lungs a guaranteed success for him, but at least he had a chance at the transplant facility.

His story is tragic, as are a lot of the stories of the other people here in the ICU. On a personal level, I think one of the hardest parts about being surrounded by these awful stories is that I don't feel anything at all. I understand, superficially, why they're heartbreaking, but I just feel numb to everything on anything but the most emotionally shallow, cognitive level. I'm told it's normal to be this way, but how can that be true? - Jackie

The situation at the hospital is evolving but fundamentally boils down to the following: The hospital had been trying to gradually cease operations in anticipation of a move to a new hospital building. Their previous capacity was about 850 beds but was down to about 200-250 staffed beds prior to COVID-19. COVID surge happened three weeks ago, and the hospital had to abruptly reopen those 600 beds. They had successfully opened three new ICUs for unstable patients on ventilators. They are now in the process of opening up a few long-term ventilator units. The long-term ventilator units are for patients who are alive and at least somewhat functioning, neurologically speaking -- they are stable enough to be taken out of ICU, but can’t get off the ventilator. Those patients need a place to go so they’re not unnecessarily taking up ICU rooms and blocking out patients who need the treatments that can only be done in an ICU.

The long-term ventilator units are supposed to be operational in the middle of next week, pending some additional staff onboarding. My understanding is the long-term ventilator unit will be working toward managing and rehabilitating patients who are vent-dependent for more than two to three weeks. The damage to the lungs of most of our COVID patients is extensive, far beyond what a normal respiratory failure causes, so many are having difficulty going off the vent. Some of those long-term ventilator patients will end up on a ventilator for the rest of their life due to the damage to their respiratory system, and some may consequently never return to their homes. Some may be able to return home, perhaps vent-dependent only at night, but will need rehabilitation to relearn how to brush their teeth, walk, or perhaps even care for their own tracheostomies and ventilators. Others will have to undergo further surgeries to repair the tracheostomy and restore their previous airways.

These people have nowhere to go without a long-term vent unit, and they’ll likely be in the hospital for months. The hospital I’m at is expecting to keep these patients at least through June, possibly into July and later. I imagine other hospital systems are contending with the same issue -- what do you do when COVID surge is over, you’ve got thousands of people who are alert and cognitively intact, and you can’t take them off the ventilator? What happens if your ICUs and vent units are full and a second surge happens because the state has released shelter-at-home restrictions? I wonder what the death toll will be like during the second surge, when we've absolutely exhausted ICU resources.

The COVID ICUs are a world unto themselves. The staff safety is significantly better in the ICUs; COVID patients are recommended to be in negative-pressure rooms (rooms in which the air pressure is less than the rest of the building, to prevent the infected air from seeping into the rest of the building and infecting others). The ED can’t even come close to accommodating this necessity, but ICU has managed to. All of the rooms have been haphazardly converted into negative-pressure rooms, some using plastic-zippered construction tarps and fans. All of the ICU patients are undergoing experimental treatments. Some of the treatments are being studied and trialed, but none of them are proven or even established to be effective. The risk of possible death isn’t so high when the alternative is almost certain death, so they’re receiving those unstudied treatments despite the risk. Nothing is by the books because there isn’t a book on this, and the treatments recommended by the books we had before make the disease complications so much worse. It’s truly cowboy medicine.

I’ve been doing some things for myself while home, most of which are probably unhealthy. I spent the first three days at home in my pajamas living on cake and Easter candy. I usually bring my five-year-old daughter a small present of some kind when I travel for extended periods of time, so this time I brought a strawberry shortcake from a local bakery in NYC for her, but I ended up eating most of it myself. I got home in time for Easter, one of my daughter’s favorite holidays, so we had fun with egg hunts. I’ve had the urge to go out running a few times, but it’s been too cold here, so I’ve done very little exercise other than some light stretching and some very short bike rides.

During the reprieve, I got an email from the university I teach at part-time. They were seeking medical staff to volunteer to staff the tent hospital that’s being set up in anticipation of a surge in Milwaukee. Funnily enough, the tent will be open almost exactly two weeks after the spring election happened. Our state governor tried to cancel in-person voting in favor of vastly expanding absentee voting, but the state supreme court forced the election to be held anyway. The election took place and, I extrapolate based on the tent hospital opening two weeks later, they are expecting a major increase in cases due to the breach in social distancing by voters. I contacted the group that is setting the facility up and had a conference call with them about my experiences running the tent hospital in NYC, which hopefully gave them useful information. I also offered to give them access to a free, open-access COVID-19 education module I’ve been helping develop to prepare nurses and paramedics for dealing with COVID-19 patients, which they were happy to accept. The course should be out in several days; the portion I wrote is going through an expedited peer review before it’s published.

I’m not personally interested in volunteering in the tent. I certainly have no intention of working without fair compensation in an area that would put myself and my family at risk for contracting the disease, even if our actual risks for complications are very low. A huge segment of the nursing profession as a whole has this bizarre martyrdom complex, treating their professional work strictly as a duty regardless of personal risk or visible neglect by their employers to mitigate that risk. I would like to postulate that this is a faulty (if noble-appearing) viewpoint that places ourselves and our patients at risk with no benefit except to healthcare administrators. I’ve seen that postulation start to play out, particularly in facilities locally that refuse to provide adequate protective equipment for their nurses working with known COVID patients, despite having the equipment available. Some facilities are even disciplining their staff for using the correct protection based on evidence, and I hear some nurses buying into and voicing the rhetoric that it's their "duty" or "what they signed up for" to take unnecessary risks.

While the process of refusing healthcare workers the necessary equipment to do their jobs safely and effectively is guileful under normal circumstances (and does happen during regular business; ask any healthcare worker about available overtime), it’s outright unconscionable during a pandemic. I’ll use protective equipment as the example; hospital systems are reducing costs and use of their existing stockpiles of protective equipment by refusing to let their staff wear the correct protective equipment. I personally know many healthcare workers, including at some facilities I usually work at, who get only a single surgical mask per week to be worn solely in the room of confirmed positive tests, not in suspected or unconfirmed patients (tests are taking up to a week days to come back, certainly leading to further exposure of staff). A surgical mask does not provide adequate protection for staff under OSHA guidelines for this pandemic or follow evidence-based practice for this disease, but hospitals are disciplining and even terminating staff who use the correct protective equipment because it’s “against policy.” Moreover, I’ve had discussions with real, practicing nurses who believe that it’s “part of the job” to be exposed to disease unnecessarily. Some of my coworkers will likely get sick as a result. While the correct protective equipment is not 100% effective, it reduces risk significantly compared to a surgical mask. The more coworkers I have that get sick from this disease, strictly statistically speaking, the more I will know who die, sometimes unnecessarily. We need to be angry about this, but much of what I see is simple complacency.“It’s what you signed up for” and “be grateful you have a job at all” is exactly what the hospital administration refusing to protect us would want us to think, and we’re cowing each other into saying it by maintaining the delusion that it's our ethical obligation to work under whatever conditions we're given.

Tonight is my final night, and I feel like we’re finally getting a little reprieve. Don’t misunderstand -- it’s still chaos here, but the chaos is far more controlled. The USS Comfort, the naval ship that has been in port and ready for patients since Monday, finally started taking COVID patients on Wednesday. They were refusing COVID patients at first but started taking them willingly when they realized most of the “negative” patients weren’t as negative as they had hoped (and a few crew members also tested positive, apparently). I’m glad they started taking the COVID patients -- I don’t know what the point of having the ship was, if not to help with the overflow of COVID patients. It’s not as if we have an abundance of patients who are disease-free, especially when most people spend hours or days in the ED hallways. The USS Comfort is primarily taking patients who are ventilator-dependent, so it’s essentially a floating ICU. Most of our patients who have been on ventilators for more than about eight hours have been moved either to the USS Comfort or to the Javits Center, a convention hall-turned-ICU also staffed by the military.

I had assumed the trucks behind the hospital were food trucks for patient meals or something hospital supply-related. I learned today they’re outfitted with coolers for all the dead bodies. There are so many dead that the funeral homes are full and the city morgue is over capacity. They must have filled the first trailer, because the second one showed up over a week ago. NYC had over 700 confirmed dead from COVID on April 8th alone, and I guess they’ve got to go somewhere.

We’re commonly seeing patients with COVID who have blood clots in various places (mostly lungs and brains). Apparently a huge number of patients have had blood clots in the lungs found on autopsy. We’ve seen more than a few patients with a (normally) extremely rare condition called DIC. DIC is usually a post-traumatic or post-surgical blood condition. It starts as an uncontrolled cascade of blood clots form throughout the body, which cause their own life-threatening problems that can obstruct circulation to the lungs. Eventually, if the blood clots themselves don’t kill the patient, the body runs out of material to make blood clots with and starts to hemorrhage because it can’t heal micro-tears in the vessels like it normally can. I’ve only seen DIC two times in my career other than my time treating COVID patients. One was one of the worst cases -- medically, emotionally, and ethically -- I have ever had to wrestle with. She ultimately died after dragging along in multi-organ failure, eventually developing serious infections leading to such profound abdominal swelling that they had to open her abdomen surgically and leave it open for six weeks. The other case was a younger woman who developed it after an injury and ultimately survived, but she lost all four of her limbs due to complete loss of blood flow to the extremities. That’s the horror level DIC is operating on.

Tonight we ran out of endotracheal tubes. We have put so many people on ventilators that we only have small and XL size intubation tubes. If your airway is the size of a bratwurst, you’re in good shape, but for anyone who’s even close to average, we just don’t have the right size. They’ve been using the too-big and too-small tubes anyway because it’s better than nothing, but I never even considered the possibility of running out of those tubes because they’re so damn common. The OR, on a normal day, probably uses 50-100 of them. Why the hell are we running out of such a commonly used supply? We’ve run out of BiPAP machines, too, so that tool is no longer an option to keep people off the vent. The endotracheal tube issue will likely be fixed during the day shift, but there isn’t a good BiPAP alternative. We have a jury-rigged CPAP machine made from a CPAP mask, a certain type of manual bag ventilator with a special valve, and two high-flow oxygen connections. It’s a good temporary solution, but it’s only a matter of time until we run out of those supplies, too. I wonder if running out of oxygen supplies in the hospital is possible?

Things seem to be better (in the sense that it’s better to be hit by a bus than a train), but the lack of resources is still pronounced. The department is now staffed by about 30% regular ED staff and 70% contractors like me, but most people are still getting a feel for the department, and many of the agency nurses here don’t have ED experience. Medical and surgical wards are completely different from ICU and ED settings. You can’t even attempt to plan your day when you work in an ED, but the contractors seem to be holding up despite the comparative chaos. Most are happy to learn, and now that things have calmed down a bit more, I’m happy to teach what I know. A number of contractors have stayed only for a few hours or days and left because the stress is so high. I don’t blame them; there’s almost nothing that can prepare you for a situation like this.

I ended my last shift in this stretch of 11 shifts in a row with a wake-up resuscitation one hour before the end of shift. I mentioned to a couple of friends (and in a previous journal article) that obtaining vascular access by drilling a hole and placing a tube in someone’s bone marrow (in lieu of an IV) was the only trick up my sleeve I hadn’t had to use yet. I should have kept that thought to myself because that “wish” got granted tonight -- we had two patients with CPR in progress and difficult vascular access, so I got the drill out twice tonight. It’s been at least five years since the last time I’ve had to use that skill, but I’ve still got it, apparently.

Once I got back to my hotel room, I had to hustle to bag up my contaminated scrubs and white coat (the coat is so gross I’m not even sure it’s garbage-worthy), shower, and gather my belongings to hop on my first flight home. I got off shift at 7:30am and my flight left at 9:30am. Under normal circumstances that would be a near-impossible itinerary, but luckily for me, there’s a pandemic going on and the airport is basically empty. I made it to the airport by about 8:45, was through LaGuardia security in <15 minutes, and made my flight without a problem. This time, I don’t have a functional private jet. There are about 12 people on the flight in total, though I may get the Detroit to Madison airplane to myself.

I don’t have a definitive contract to fly back out yet, but I expect to go back on April 16th and spend another two weeks on the Eastern front. I’m excited to see my family but a little apprehensive. I don’t want to be a Typhoid Mary to them, but we talked about the return plans before I went out. Everyone in my household is low-risk; I live with three men (one husband and two long-time roommates) who are between 30 and 35 years old and my five-year-old daughter. I looked into the illness odds before I flew out and learned that we adults each have a 0.3% chance of hospitalization and a 0.1% chance of critical illness if we catch it, and the odds are even lower for my daughter. About 85% of people who end up on ventilators die, so my back-of-the-napkin math says the adults individually have a 0.085% chance of death from catching it. Despite knowing the odds are markedly in our favor if I do infect the house, a 0.3% chance of hospitalization and <0.1% chance of death is still not 0%.

When I return to the hospital -- if I return to the same hospital -- they’re offering everyone the COVID antibody test. I’ll definitely get it done the day I return; if I have antibodies, that means I can start the clock and 14 days post-test, I shouldn’t be contagious and have a degree of immunity, which will make me feel much safer about returning home. The hospital is asking for volunteers for people with high antibody counts to donate plasma for an experimental COVID-19 treatment: plasma transfusion from a person with antibodies to a person who is infected and critically ill. It’s almost a form of immunization, and I’ll definitely donate if my blood antibody count is high enough.

I haven’t yet decided if I’ll write in the journal while I’m on shore leave. Some of the facilities I normally work in have been asking for our protocols at the hospital in NYC, so I’ll write some of the things I’ve learned down and forward the protocols under development to those people. I’ll be working on a side project I’ve been doing in my spare time (haha) in NYC: assisting development of an online clinical alternative program for a rather large group of emergency medicine resident doctors. Much like my own nursing students, they’ve been kicked out of their clinical experiences to preserve masks and gowns, so they need activities to continue their learning. I’m hoping to include a Dungeons & Dragons-style role playing activity; I’ll call it Medicine & Madness, and I’m hoping to give them some of the difficult cases I’ve had in real life.

Everyone keeps sending me messages and affirmations and telling me I’m a hero for coming here, but I feel more like I’m prolonging the inevitable for most of the people I see. I’ve used almost every skill out here that I’ve ever learned in my entire career, but I very much doubt I’m saving anyone. It’s a bleak, nihilistic place to work, very much like the ICU was. Doubly so, perhaps, because the rest of the city is so empty. I biked through Manhattan before my shift tonight. Times Square, other than a couple of fellow gawkers, was completely empty. Park Avenue, empty. The Queensboro bridge had almost no traffic.

I’ve gotten numerous questions about personal protective equipment, so here’s a long and short of what I’m doing to protect myself. When I get up in the morning, I go about my usual business and when I am ready to go to work, the last thing I do is put my scrubs on before I leave the hotel room. I bike to work in my scrubs and put on my N95 and face shield from the previous day before I enter the hospital. I do sometimes replace it with a fresh N95, depending on the state of the one brought, and I wear a surgical mask over the N95 to reduce the likelihood of soiling it. When I go into patient rooms, I wear gloves and a gown, though I sometimes skip that step when seeing hallway patients in a non-contained area to preserve our supplies. At the end of my shift, I remove the face shield and N95. I bike back to the hotel without a mask, then as soon as I am in the door of my hotel room, the scrubs come off and are left next to the door, to reduce contamination of my hotel room. I usually shower after this as well, but if I’m too exhausted, I just wash my hands, arms, face, neck, and chest before proceeding to bed.

There's absolutely no way I'm not infected, despite having mostly adequate equipment. I don't have any symptoms, other than a sore throat from dehydration on shift. I'm 29 and healthy, so I'm highly unlikely to become seriously ill and, based on the statistics published by countries like South Korea that can be bothered to test extensively, I'm extremely likely to be an asymptomatic carrier. Many nurses and doctors I know from back in the Midwest have told me they're only getting a surgical mask for confirmed cases, or nothing for patients who haven't had a confirmed positive test. We're lucky here; our test only takes 12-24 hours to result because my hospital runs them in batches twice a day. It's still taking 4-7 days minimum for results for ICU patients back in Wisconsin. I wonder how many nurses will die a preventable death from COVID. Numerous coworkers here, where protection is required for every patient regardless of test status, have tested positive. A few are on ventilators or in intensive care as I write this.

I’ve had numerous patients die under my care now. Yesterday, I admitted an elderly man who seemed to be doing fairly well on an oxygen mask. He deteriorated rapidly. In a span of about 30 minutes, he went from alert to confused and agitated to cardiac arrest. I felt sorry for doing chest compressions on him, even for the short 15 minutes we did CPR, but his next of kin wanted “everything done” to keep him alive. Hopefully he was too far gone to feel the pain of all his broken ribs as we compressed his chest. The resuscitations we're attempting on the elderly are almost certainly a futile effort. Even in the unlikely event they do survive COVID, they're even less likely to live for a meaningful length of time or with any quality of life with the injuries inflicted from resuscitation.

I started yesterday’s shift in the same way I ended Saturday’s: by assisting resuscitation efforts on a patient. We have so many patients who become pulseless that they’ve stopped calling for the resuscitation team overhead every time. The process has changed from a specific resuscitation team of three people who respond to all cardiac arrests to a free-for-all in which whoever’s available hops in. There are just too many cardiac arrests and intubations happening to rely on the availability of a designated team, and we don’t have the staff to have a team set aside to respond solely to resuscitation. I ran my first resuscitation independently yesterday. Under normal circumstances, the MD usually medically manages them, but the one covering was just exhausted. He poked his head in when he heard we were starting CPR on yet another person, looked at me, and asked if I was good to medically manage it. I said yes, and he left to go do something else. We worked harder on that one than we had on others. He was young, in his 40s, and had a breathing tube placed and was on a ventilator that we didn't know was faulty. We realized it quickly, only about five minutes after the ventilator malfunctioned, but not quickly enough to reverse course. We couldn’t save him. It was especially hard because one of his roommates, a dialysis patient in his 40s with every comorbidity under the sun, had regained a pulse twice from CPR in the span of about two hours. The deceased probably even watched us get the other guy’s pulse back the first time; there's no privacy whatsoever in these rooms.

Tonight they reopened the tent hospital, so I was solo in the plague tent throughout the night. Somebody must have complained about the lack of security, because there was a security guard sitting near the tent for most of the night. The tent was full all night with eight patients, several of whom rotated in and out throughout the night. One guy got confused -- I was uncertain whether from hypoxia or dementia -- and started wandering around the tent adjusting everyone else's oxygen settings. Another patient's oxygen abruptly dropped, and they had to be sent in for BiPAP. At one point, all four of my oxygen tanks ran out at the same time. I couldn't get any help for most of the night --the department was too busy managing back-to-back resuscitations and intubations -- so I had to leave my patients alone in the tent numerous times to get supplies or deal with problems. I ran all night long.

On a more positive note, I learned today that at 7:00 every evening, the community around this hospital gives everyone working for the hospital a standing ovation. People driving by turned up their music, people yelled out their apartment windows, and passersby joined in. I hadn’t noticed the signs around the block or heard it previously, but another staff member told me it’s been going on daily for at least a few days.

For more listen to Jackie's radio interview below:

The last two days have been brutal. The tents closed. Some of the other city hospitals started accepting patient transfers several days ago, so we’ve been transferring some people elsewhere and haven’t had to overflow the oxygen-only patients to the tents. Unfortunately, we can only transfer the patients who are stable enough to be moved, so offloading some of our patients to other hospitals is only so helpful. The raw number of patients in the department has improved a bit, but the sickest patients are still in our department and we’ve had many deteriorate over the past few days. I’ve lost track of the number of patients we’ve placed on ventilators, and many who have been on ventilators for a few days are deteriorating and dying despite escalating support. Yesterday we had 1,000 total COVID-confirmed deaths in the United States. We don’t test people post-mortem unless they have an autopsy, so I’m sure those numbers under-represent the total deaths by a significant margin. We’ve had at least three patients tonight arrive via EMS and simply be declared dead on arrival; they weren’t tested and likely won’t count toward the official COVID-19 count, even though odds were good they had it.

I’ve had to both order and place restraints on many patients because some are becoming confused and agitated. Sustained low oxygen levels, even when they aren’t low enough to be deadly, have a negative effect on brain function. I suspect many are also becoming combative due to a phenomenon called “ICU delirium.” Patients are in a chaotic, noisy, brightly lit, constantly stimulating environment for days on end, with no clear indicator of day or night, how much time has gone by since the last event that happened, and no rest period. I remember seeing similar problems when I worked in the ICU years ago, and the chaos here is on another level compared to the semi-predictable, rhythmic noise of that ICU.

I feel like I’m in a haze in this environment, too. I’ve done so many things that under any other circumstances would be very remarkable and memorable, but the intensity in this area is so high and things are happening so quickly that all of the crises start to blend together. I barely remember doing anything last night, and I've had to reread my own journals to recall what happened just a few days ago. I'm duller when I wake up, too. Normal tasks that I remember spontaneously are being forgotten, and I have to stop and think about what I'm doing multiple times when I'm responding to an email. I normally never proofread my emails or even these journals, but I've had to lately because I'm just not cognitively functioning at 100%.

While I did a lot of IV starts and restarts (delirious people like to rip theirs out), I practiced more medicine in the past couple of days than in the tent hospital. The department is at the point where I, the person who’s been here for all of four days, am medically managing critically ill patients who are unstable or newly intubated. I haven’t yet done an intubation myself, but I may need to as our load of critically ill patients continues to increase. I’ve done almost every other skill I’m qualified to do in the critical care setting, from jugular IVs (in the neck) to ordering continuous infusions of blood pressure support and sedative medications. I guess I haven’t drilled into a bone for IV access yet, but that also strikes me as a likely possibility in the coming week. I’ve been extremely grateful I’ve maintained these skills over the years and that my medical practice is fluent enough that the stress-haze I'm in isn't impairing the care I can provide.

In emergency medicine, a not-insignificant portion of our patients do not have a likely medical emergency. While most have the good sense to stay away from the hospital during a contagious disease outbreak, the things people come in for never cease to astound me. While we have definitely seen a decrease in those non-emergent “emergency” patients, it amazes me that anyone would risk exposure to a possibly deadly and highly contagious disease to have their foot fungus examined in an emergency department. Moreover, many of these non-emergent patients ask why they have to wear a mask in the emergency department and act bewildered when I tell them there are many confirmed and suspected COVID patients in the department. The lack of introspection is truly mind-boggling.

Five days down, six to go until I return home for several days. I haven’t gotten confirmation yet, but it seems likely they’ll welcome me back with open arms after my break.

The situation is still severe, despite having only about 70-100 patients in the department over the past two days. You can still barely navigate the ED hallways for all the patients in beds or chairs occupying the hallway. Workups (all diagnostic and treatment procedures) that normally take 2-3 hours in totality are taking 8+ hours due to the delay in order completion, so in truth I've been more useful completing orders and rounding on patients than I’ve been at ordering workups. Yesterday, I did vital signs and rounded on about half of the department at least once. I caught a few patients with oxygen tanks that had run out or who were showing signs of deterioration and needed their oxygen turned up or blood pressure management. Hopefully that work helped a few people stay off the ventilators. I haven’t experienced enough yet to know firsthand, but the internal medicine and other ED providers have told me that most people who deteriorate to the point where they need a ventilator usually die. I believe them based on what I have seen in the past three days.

I arrived a little early to my shift, just as they were starting CPR on a patient. Most codes take immense resources on the best of days, and there are usually five or six team members participating when CPR is in progress, but the patient who went into cardiac arrest was a COVID patient, so they limited the team to three (an RN, an MD, and a respiratory therapist). Resuscitation efforts are light under current circumstances -- perhaps 15-20 minutes instead of the 45-60 minute average. We can’t reasonably justify taking away that many resources from so many other ill patients to run a code, especially since only about 15% of people who have CPR done get a pulse back and maintain it for 24 hours. The hospitalist told me around 4am that they had attempted resuscitation on seven patients since night shift started. They’ve reached the point where they’re so busy trying to resuscitate people that they’re almost at a standstill with their living patients. One wonders how much longer it will be until all our COVID-19 patients have blanket do-not-resuscitate orders to conserve resources needed for people more likely to live.

Tonight I’m out in the tent ED, which is a surprisingly nice environment. The tent is heated and relatively sealed from the outside. It’s much quieter here, so patients can sleep a little. My patients have to meet certain criteria to be able to come out here: they must have a positive COVID-19 test, require respiratory support up to a non-rebreather mask (no ventilators or CPAP/BiPAP), must be semi-ambulatory, and must be able to verbalize their needs. I’ve had 4-6 patients throughout the night, which is a very manageable number. I had a nurse out here for the first half of my shift and was on my own for the second half. There’s no security out here and no lock on the tent door. Throughout the night, there have been about 15 people waiting outside the emergency department to be seen. I’m genuinely surprised none tried to come in here, especially since it's not labeled as a plague tent.

I only had one patient in the tent deteriorate tonight, and I feel like we caught his decline in a timely manner. I have so few patients compared to everyone else that I've been able to round on everyone at least every two hours. The closer monitoring made a huge difference; I had been trending his decline and made the decision to send him back inside for CPAP before he deteriorated so much that it was no longer an option. Monitoring is so sporadic inside that he may have ended up seriously deteriorating before it was recognized, and CPAP might not have been an option if he got bad enough. Hopefully, the early intervention will keep him off the ventilator.

They’re going to try to open a second tent in the next day or two, though it’s unclear what the staffing situation will be like for the second tent. It's difficult to predict what the next day will bring.

I walked to work this morning and was pleasantly surprised at some of the gardens kept despite the small yard space. There were numerous trees in bloom, including a couple of magnificent magnolias, and several small gardens with daffodils and hydrangeas. Several of the yards had enormous climbing rose bushes, though they weren't in bloom; it reminded me of some of the "bad parts of town" in Milwaukee with yards full of roses.

I arrived at the hospital and reported to the emergency department. I learned that I'll be the first nurse practitioner ever to work in the department, and that I will be in the current busiest hospital in the city. Presently they are at “surge capacity,” which means it's all but standing room only. The normal capacity of the department is 60-70 beds, and there are currently about twice as many patients as beds, despite efforts to discharge and divert patients. Most of the patients are seated in a chair or, if they're unlucky enough to need one, a cot in the hallway. The rooms are reserved for the least fortunate people: patients who need respiratory support, heart monitors, or invasive procedures. Patients are all assumed to be COVID-19 positive. If they didn't come to the ED with it, chances are good they'll leave with it.

My goal today was to get the lay of the land. I'm a traveler and am used to adapting to new facilities, but there's always a learning curve, no matter how many places you've worked at previously. I only saw a few patients today but got to struggle through figuring out the hospital admission process, figuring out who to ask to get testing done (and where to get the equipment to do it myself), and working through the discharge process. "Admission" is a very loose term when you don't have any hospital beds to admit someone to. The medicine is significantly different now, too. What would have been the "million dollar workup" requiring many resources is now a simple workup if the patient can reasonably self-manage at home. Tonight's night shift had truly horrific nurse-to-patient ratios, with fewer than 12 nurses for the entire emergency department, so odds are good I’ll be fulfilling plenty of my own orders. (Normally, an ED nurse takes 3 to5 patients at one time, depending on how much each one needs.)

Tomorrow I flip to night shift and head to the tent ED, the hospital's temporary solution to admit and treat even more patients.

I'm currently a nurse practitioner and normally work in an emergency department or urgent care setting. I work as a contractor, so I go from facility to facility and am used to a somewhat unstable work environment, as I don't really have a "home base.". I've been a contractor for about three years. Prior to becoming a mercenary nurse practitioner, I was a registered nurse working primarily in emergency department settings.Before that, I was a patient care technician in the hospital, mostly in the ICU and ER settings. I've also worked in the pre-hospital setting as an EMT-B at various points during my career.

The COVID-19 (coronavirus or novel coronavirus, colloquially) pandemic has been apparent and "real" to the general public here in the US for several weeks. I live in Madison, Wisconsin ; I am writing this journal on March 26th, 2020, as a point of reference for the following timeline. Our state governor declared a state of emergency on March 12th. The next day (March 13th, a Friday), he declared schools statewide would close the following Wednesday, which was later revised to immediate closure. About 10 days following school closure, on March 25th, a shelter-in-place order went into effect, along with closure of all non-essential businesses. Today, March 26th, Wisconsin has 707 confirmed cases and eight deaths. For comparison, New York City currently has over 21,000 confirmed cases and 281 deaths.

That comparison of the major coastal cities like NYC to Wisconsin is the primary reason I decided to seek out a disaster relief contract in a hard-hit area. The facilities I work at in Wisconsin are currently experiencing very low volumes, as most people (wisely) don't want to be in our waiting rooms during a pandemic. It's clear to me that Wisconsin is not where my skills are presently needed, andI want to go to a place where my skills are useful. I'm also a healthy person under 45 years old; if I do contract the virus, I'm statistically very unlikely to become seriously ill, so it’s better someone like me get sick than someone in a higher-risk group.

I find most of my contracts through an agency. I contacted my usual agent, who knows me well and found me a contract in NYC fairly quickly. I got the impression that the hospital requesting contractors was rubber-stamping anyone with emergency medicine experience, as they waived my state license requirement (which they have the leeway to do during a declared state of emergency), let me dictate my hours and dates I was willing to go out, and did not even have time to contact me directly for a brief phone interview. They emailed me before confirming my contract to make absolutely sure I understood what I was getting into. In that message, they made it clear they wanted me in the emergency department, not the triage tents set up outside, to help manage an overwhelmingly large number of critically ill patients.

I fly out in three days and will be there for a 10-day block of 12-hour shifts. I’ll return home to Wisconsin for a week, then I’ll fly back out for another 12 days. My primary preparation is securing a food source; grocery stores are open, but the news suggests lines to get in are hours long. I purchased four boxes of protein bars and will bring a large bag of trail mix with me. I'm also planning on packing a bottle of vitamins (which I find unlikely to provide me much protection but won't hurt anything) and a modest supply of acetaminophen (paracetamol) in case I do contract the virus. I obtained a few waterproof suits (expired from one facility I work at that was giving them away) that I will bring out in case the hospital runs out. Finally, I made three cloth masks with pockets inside that I'll put an air filter in for use if the hospital runs out of masks.

We'll see what I'm actually getting into in short order. More when I arrive.