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The War in Scrubs

How nurses are leading the fight against COVID-19

Before Amy leaves her downtown apartment for a shift at the hospital, she puts on a pair of scrubs and her stethoscope. When she arrives at the hospital, she changes into a new pair of scrubs and stocks her pockets with pens, scissors, highlighters, tape, and alcohol swabs. She will have to change again before she leaves the hospital each evening. All of this back-and-forth is for the sake of the children, spouses, elderly parents or roommates that nurses go home to after each shift; they say it’s better to be safe than sorry.

Amy is an orthopedic nurse at a Dallas-area hospital who has been in the profession for about a year. She typically works on broken or fractured bones, elective surgeries like joint replacements, and trauma such as gunshot wounds. Since the COVID-19 pandemic brought cancellations of elective surgeries and the number of accidents has decreased significantly, the number of patients in Amy’s orthopedic unit is dwindling. As a result, she was floated to a different unit of the hospital specifically to take care of patients with the coronavirus.

“My life has changed a lot,” Amy said. “It’s kind of all hands on deck right now, no matter what your standard unit assignment is.”

The novel coronavirus and the disease it causes, COVID-19, have affected virtually everyone in the world in some form or fashion. According to the CDC, in late May, the COVID-19 death toll in the United States reached 100,000 people. Worldwide, more than 400,000 people have died as reported by Johns Hopkins University of Medicine as of June 10. The U.S. officially accounts for a quarter of all COVID-19 deaths.

Social distancing, a term many of us had never heard before March 2020, has become a new way of life for millions across the county, but those working for businesses deemed as “essential” by the government are still venturing out of their homes and into many disease-infested areas daily—and healthcare professionals are on the front lines.

For the first time in quite a while, healthcare professionals are all facing one common, fierce enemy. COVID-19 does not discriminate; early reports that the disease wasn’t a threat to children turned out to be completely false. In fact, late March saw the death of a six-week-old infant from Connecticut who died from complications of the coronavirus. It was also said that young adults who caught the virus would likely be able to recover at home, yet two Dallas-area hospital patients in their 30s were unable to breathe on their own. Individuals may be infected with the coronavirus but remain asymptomatic, going about their daily lives without a clue that they are contributing to the wildfire spread of the virus. Others are on ventilators, alone in hospital rooms, fighting for their lives. Perhaps the most unnerving part of this whole ordeal is that you don't know which you will be. 

People who contract the virus and are deemed as high risk need to be hospitalized. Patients are considered high risk if they have underlying health issues like lung disease, asthma, heart disease, autoimmune diseases or diabetes. Most people are admitted to the hospital because they are having respiratory issues. Many contract pneumonia or other life-threatening illnesses caused by the coronavirus. 

The many layers and obstacles associated with COVID-19, and the unknown component of the virus, has complicated the jobs of healthcare workers worldwide. Many doctors are working seven days a week. Most nurses normally work three 12-hour shifts per week, but many have started to pick up extra shifts due to the influx of patients.

The nurses see it all. They take pulses and record blood pressure, start IVs and administer medications, serve meals while listening to grim prognoses, listen to patients’ fears and hold their hands while they take their final breath. Every day, nurses make sacrifices; they don’t eat or go to the restroom. They put the patients’ needs before their own. And somehow, nurses have become even more devoted to their patients during the COVID-19 pandemic. Some are sleeping in hotels or Airbnbs to protect the families they have at home. Others have amended their wills and given their spouses their important passwords in case they contract the virus and don’t make it. 

"I just keep wondering … Did no one wash their hands before this?"

Amy, Orthopedic Nurse

Nursing can sometimes be a thankless profession, but the coronavirus has shown light onto the dedication and devotion of these caretakers all marching off to war in scrubs morning and night. They stare death straight in the face.

Though the thought of taking care of patients with COVID-19 is still surreal, Amy wasn’t entirely surprised when her unit assignment changed. She knew it was only a matter of time; leadership at the hospital where she works has been sending multiple emails per day to their staff, announcing unit changes, new protocols or processes that are being implemented. Unlike many nurses across the country, Amy actually feels safe and well prepared. She has the supplies she needs to properly treat her patients, and the hospital is precisely following guidelines from the CDC. When she arrived at work one morning in late March, she was handed a thick packet of paper that explained her new assignment. 

Amy and the other nurses treating patients with COVID-19 are assigned just two patients; normally, each nurse has double that. The hospital’s strategy to keep nurses safe is to limit the number of patients they come in contact with. They also try to limit the amount of time spent in patient rooms to about 15 minutes and only allow nurses to take patient vitals every four hours, which is strange for Amy who is used to visiting her patients every 60 minutes. Now, she looks through the window and calls them from outside the room to see if they need anything. They talk to each other through the glass.

Amy feels the weight of the uncertainty that plagues her patients. Most nurses always try to get to know the patients they treat, but Amy has placed an even greater emphasis on the human connection part of her job now that hospitals have banned visitors. If you aren’t having a baby or taking your last breath, hospital policy leaves patients without any family or friends to support them in perhaps the most trying time of their lives. Amy recognizes that many patients are scared—sometimes the personal protective equipment (PPE) nurses wear looks like something out of a movie, and the empty, visitor-free hospital carries an eerie vibe. 

Hospitalized COVID-19 patients are kept in negative pressure rooms, which act like vacuums, pulling the air from the room inward so that it does not circulate out into the hallway of the hospital. In between the hallway and a negative pressure room is the “anteroom” where the doctors and nurses put on their PPE. Amy’s routine starts with an isolation gown, shoe booties, gloves, a hair bouffant, a second isolation gown, second pair of gloves, a facemask and a face shield. A nurse technician or patient care technician is also in the anteroom watching the nurses put on their PPE, reading off a checklist and making sure everything is on correctly. Before she leaves a patient room, she takes off her gown and gloves very carefully, rolling them inside out so that they touch her scrubs. Then, she enters the anteroom where she takes off her mask and goggles and properly disinfects them using alcohol wipes before letting them dry for three minutes.

“There are a lot of infection control guidelines we have to follow, and it takes so much time but it’s necessary to keep ourselves safe,” Amy said. “I literally could not even tell you how many times per day I wash my hands. It has to be more than 100.”

“I’ve been a nurse for eight years, and I have never experienced so many deaths of patients of mine."

Mary, Charge Nurse

Some nurses are lucky enough to wear a PAPR hood to shield themselves from the disease, but those are in short supply. Others are having to wash and re-wear face masks because there aren’t enough to go around. Nurses in New York City, the epicenter of the outbreak in the United States, are protesting in the street about the lack of PPE. Some have tearfully quit the healthcare jobs they loved in order to protect the family they go home to at night.

Dallas is preparing for the worst. Since it is a densely populated metroplex with thousands of cases of the coronavirus reported, some experts think the virus epicenter could eventually migrate down south to Texas. Amy says that right now, nurses at her hospital are not experiencing a shortage of anything, but that if the number of cases continues to increase at this rate, they will eventually run out of hospital beds and ventilators.

Amy says she feels bad coming home to her roommate after working with patients who have tested positive for COVID-19. She disinfects the door handles, light switches, and anything else she touches after a shift at work. She’s purposefully trying to limit her exposure to her loved ones as well as complete strangers; she doesn't get on the elevator at her apartment if others are on it, and though she talks to her mom on the phone every day, she hasn’t seen her family in weeks. They’re proud of her. They think she is making history. 

“My spirits are high because I love what I do, but I’m nervous,” Amy said. “My big concern is keeping patients safe. I don’t know how long this is going to last. No one does. I just keep wondering… Did no one wash their hands before this?”

According to the CDC, the coronavirus is only airborne under certain circumstances. For example, when patients are getting a nebulizer breathing treatment, the humidification can trap the virus in the air for up to three hours. This complicates the course of treatment significantly, since one of the leading symptoms of the coronavirus is difficulty breathing. In fact, COVID-19 patients are not eligible to be on a BiPap machine, which is one of the most critical pieces of breathing equipment for patients with respiratory issues. BiPap machines also cause positive pressure ventilation, which leaves healthcare professionals highly exposed to the virus. Normally, a patient with breathing issues would first be placed on a nasal cannula, then a BiPap machine, and then a ventilator. Because COVID-19 patients are not eligible for BiPap machines, healthcare professionals are forced to go from nasal oxygen assistance straight to ventilators —contributing to the severe shortage of the life-preserving machines nationwide. 

At another hospital in Dallas, Mary is working in the noncritical COVID-19 unit, which started as a small 10-bed unit in early March and tripled in size by April 1. As a charge nurse, she is managing about 15 nurses and oversees the unit’s admissions and transfers. Mary normally works on a special team of nurses that regularly floats to different units in the hospital depending on staffing in the patient census, but she has never encountered anything like the coronavirus before.

“I’ve been a nurse for eight years, and I have never experienced so many deaths of patients of mine,” Mary said. “It is so scary. It’s a whole different perspective for every single healthcare professional.”

Mary has seen a huge increase of nurses being pulled from other units to serve on the COVID-19 unit. The initial response is major anxiety of the unknown, but by the end of the shift, some nurses actually ask to go back. They feel like they have a new purpose. They feel a calling. They want to be part of something bigger than themselves. 

Oftentimes nurses are in the room when physicians deliver the news to patients that they have tested positive for COVID-19. As expected, the patients are scared. It’s a serious diagnosis. Some get very emotional, especially those with chronic illnesses who know it will be a bumpy road to recovery—if they make it that far. When things get bad, some patients wrestle with the idea of being on a ventilator. If they’ve reached old age and have a grim prognosis, many opt for a “do not resuscitate” (DNR) status. Since visitors aren’t allowed, they face death alone. Nurses, along with a chaplain, are the ones who coach them through it. And when a patient passes away, the nurses mourn. In the span of three weeks, Mary has lost two patients of her own and five more in the unit she manages—the most she has ever lost so quickly in her entire career.

“It’s heartbreaking,” Mary said. “I have lost sleep over it. Many nurses do. We are in mourning all the time. ”

While Mary has yet to treat a patient who has recovered from the virus during their stay at the hospital, several patients have tested positive, stabilized and been sent home for a 14-day quarantine. Many of these patients are terrified and would rather stay in the hospital, but there aren’t enough beds to keep patients who don't truly need them. 

Both Amy and Mary try to limit the amount of time they are in a patient room by clustering their care, but the exposure to the virus is still there. Mary knows of several doctors and nurses who have died from complications of COVID-19. The weight of it all is a lot to bear.

Mary has two daughters at home. She takes every precaution to keep them safe, but the fact that she could bring the virus home and infect her loved ones is always in the back of her mind. She showers at the hospital after her shift is over and then showers again as soon as she gets home. She wears personal scrubs to and from the hospital but changes into a new pair for her shift. When she’s not taking care of patients, she’s attempting to homeschool her kids—a challenge that many nurses are juggling. They never get a break.

If the United States follows the path of Italy and other countries that have been plagued with the coronavirus, it seems that things will continue to get worse before they get better. As the number of sick patients increases, nurses quit their jobs due to the lack of PPE, and more healthcare professionals fall victim to the virus, the shortage of hospital nurses in this country will likely reach a level of deficiency we have never seen before. Several university nursing programs are even offering an option for nursing students in their final year to take a fast track and finish their degrees in just a few weeks so they can join the war on COVID-19. We are truly in unprecedented times. The stakes are high. Yet nurses around the world are raising their hands, offering to lead the way through the darkness. They will shepherd us through until we see light again.  

Originally published in the July/August issue of Local Profile