By Larissa Pollica, RN
COVID-19 hit us like a tornado. The hospital system was completely overwhelmed. During this time, I witnessed an unprecedented loss of life. Now I am picking up the pieces, much like a survivor of a massive storm would, returning home to survey the damage.
I sort through the rubble. The roof of the house has been partially blown off, the wind shredding photos and memories and destroying structures, just as the COVID pneumonia did to so many people’s lungs.
I saw so many people succumb to coronavirus during the pandemic, but my last patient stays with me. The team of doctors I was working with that day was called overhead for a “medical notification.” This is when a very sick person presents to the emergency department and requires clinicians to stop what they are doing and assemble in the trauma room to assess the situation. A man in his early 60s arrived, breathing very fast and with a very low oxygen level. An x-ray revealed bilateral patchy white opacities that by now had become so familiar and dreaded. The medical team explained to the patient that his respiratory distress was severe, and that he might need a ventilator, but would wait for the blood work and try a less invasive BiPAP machine to support his breathing and hope for the best. When the bloodwork returned the doctors spoke to him as gently as one can to give the worst news possible. He was septic beyond salvaging. They told him he was not going to survive this illness, and he had a choice to be put on a ventilator now and likely never come off, or to die naturally, probably in a few hours. He was alert and conscious as he calmly took the news. He opted not to be put on the ventilator.
The doctors left the bedside and I was left there feeling paralyzed. I wanted to connect with him somehow. He was very quiet; he didn’t say anything, just breathed behind the non-rebreather face mask with increasing rapidity. He looked at me with big brown eyes. I did not know what he was thinking and wanted to ask him so many questions. Where are you from? Do you have any children or grandchildren? What makes you happy? What kind of music do you like? What are you most proud? Do you need to make any amends with anyone?
I wanted to let him know that I was there. It was just the two of us in that crowded ED. Due to hospital policy, there were no visitors. He appeared withdrawn, tranquil and accepting. I asked him if he needed anything and he said, “I want an orange soda.” We don’t have orange soda in the department or the vending machines. I dropped everything I was doing with my other patients and ran outside to the deli across the street. They were out of orange soda. Is this what his life hascome to? All the science of the modern world is at our fingertips, but I was powerless against coronavirus.
I took off down Third Avenue in a sprint. I threw off my mask and breathed in the air which was fresh in comparison to the stale virus-filled smog in the ED. I ran past discarded plastic gloves and masks on the sidewalk, over cigarette butts and mini tequila bottles, dog poop, and tiny sparkling shards of glass. People turned to stare at me: a woman in ugly red scrubs running in desperation. Surely, they thought I was being chased. And I was being chased. I was being chased by the memory of my father’s recent passing. What, I wondered, was the last thing he asked for before he slipped into pre-death unconsciousness? I couldn’t ask my mother because she soon followed him broken heartedly to meet him in eternity. Did she go running for whatever it was like I am now? Did she frantically grasp at something tangible to soothe a premature impending death?
The store down the block had orange soda and I ran back down the street. Don’t cry, don’t cry, don’t cry I panted as my pulse matched the primal drum rhythm of my footsteps. I returned with the orange soda breathlessly to his bedside. He drank small sips of the soda and said, “Mmm that’s good.” That may have been the last thing he said. I wrapped him in warm blankets. I gave him IV morphine. The beat of his heart became adagio.
I wanted to sing him a lullaby. What was his favorite? I didn’t know, and meanwhile the only melody to his ears was the incessant beeping of cardiac monitors and the refrain of other patients’ ventilators. The sounds of the sick and dying were an ensemble all around him. I wanted to stroke his head, but I was a stranger to him. I could not take the place of his mother or wife or daughter. There was nothing I could say or do, so I just gave him sips of his orange soda, a dying man’s poignant last request.
And then my shift was over and I left, defeated. This man was too young to die, alone, with only me fumbling for a way to comfort him.
I learned the next day that he died only three hours after I left. He had less than half of a day after the doctors told him to complete the stages of dying. I wonder if his life flashed before his eyes. His life was a record that should have played at 33 1/3 RPM as he lived out his life span, but now it was on fast forward 78 RPM and faster; warp speed. His life-song was cut short. He appeared to completely bypass denial, anger, bargaining, and depression and was the peaceful picture of acceptance. Facing his death completely awake, how did he have time to look back at his life and contemplate his accomplishments and regrets to come to a sense of coherence and wholeness, to overcome despair like one would in a natural death with the normal sequence of things? Did he contemplate what “would have,” “should have,” “could have” been? Did he wonder about the meaning of life, like I was now? Did he have faith in the afterlife or was it shaken and cloudy, an inevitable accident in this covid whirlwind blowing him off this plane of existence. Who will mourn him? Will his body be claimed? If he has a family can they afford to bury him or will he end up in the mass graves on Hart Island, like so many others?
During the busiest time of the pandemic we could not manage to take care of the massive numbers of patients and also talk to their families, so they were referred to a family support center hotline. A team looked at their charts and spoke by phone to their families. This was the only viable solution, given that the doctors and nurses were overburdened with bedside care. How distant, how unnatural, and inhumane it felt.
All the days swirl together as St. Barnabas was pummeled with more than one thousand cases of COVID-19. The morgue overflowed early on. A big refrigerated tractor trailer truck pulled up to the morgue and became an extension of it, filling up quickly with dead bodies. Soon, there was a second tractor trailer truck. Inside, people were wrapped in white body bags, looking like butterfly cocoons. When I walked down the ambulance bay driveway and passed the trucks I wished for then all to grow figurative beautiful orange and yellow monarch butterfly wings to fly to their next destination, to wherever their faith leads them.
A Bad Morning
One morning, at 9am, I counted 17 ventilated patients in the emergency department. This is an extreme number given that on even a busy day we might have three or four critical vented patients, ready for transfer to the ICU. But, there was nowhere for these patients to go. The ICU was full, virtually all with covid patients. One of our patients began declining and became pulseless, and the doctors and nurses ran over to attempt resuscitation. We were all crowding around the bed with no curtain, while the other patients watched the horror of a futile attempt to bring life back into a shell of a body. The chest compressions were cracking ribs, and covid was misting into the air while the patient was ventilated with a bag-valve-mask. A few minutes later, there was a second code and we ran to the other side of the department. Then another, and yet another. By noon that day, there were four dead.
Later that week new EMS guidelines emerged. The whole network in New York was so overloaded that we had to create new standards of practice that were unthinkable before the coronavirus crisis. The Regional Emergency Medical Services Council of New York City (REMSCO), a state-designated coordinating authority for the region, declared that if someone is in cardiac arrest in the field and cannot be revived, they are not to be brought to a hospital emergency department for continued resuscitation efforts. In accordance with REMSCO and working within disaster protocol, St. Barnabas followed suit. If a patient were on a ventilator with known or suspected covid, we were to confirm bilateral air entry and not do CPR, and
Our ordinary practice is to attempt resuscitation until the very bitter end. It goes against our very nature as emergency nurses and doctors to not give a valiant effort because one never knows a patient’s fighting spirit. I have seen many miracles in my career. Now, the very clock that makes us tick had changed to a different time zone. There was no choice in the matter because the influx of coronavirus patients had vanquished our resources to the degree that we had to focus on patients we knew had a chance at survival.
Many staff were out sick, and the relief of agency nurses from around the country had not arrived yet, but the relentless virus did not care. One morning I took report for 13 patients, seven of whom were on ventilators, each with several IV drips. I felt panic rise in my throat. I am only one nurse, how could I take care of all of these patients? They were all packed together, stretcher after stretcher, all lined up, bodies with endless tubes and IV lines and Foley catheters that all needed tending to. We only had three Bair hugger warming blankets to keep body temperatures compatible with life. The rest of the patients were getting colder as the only thing that kept hearts beating was the IV medications. The ventilators pushed air methodically and rhythmically, oxygenating tissue, prolonging inevitable demise. The ER became some sort of a bizarre hospice. There were no families to gather and comfort the passing. I never could have anticipated being in this type of situation in my lifetime. I cared for them one at a time, to the best of my ability, thinking of the nurses who had come before me. My mother, my paternal aunts, and nurses I never knew but had read about during times of crisis, war, or plague were my inspiration.
No IV Pumps
One morning I came in for my shift and there were no IV pumps. I walked through to assess my patients. I had five ventilated patients and not one IV pump. On the snippets of news I saw here and there – given that I was working every day during this stretch at the end of day had no emotional energy to watch the news – I heard everyone talking about ventilators. How many ventilators does New York City have? How many ICU beds can we make out of other units? How many ICU beds can we fit in the convention center? Ventilators were the hot topic. But that is not realistic when examining the whole picture. For each ventilator you also need a respiratory therapist to monitor it and a critical care nurse to titrate it the necessary intravenous medications. You could have 100 ventilators, but if you lack experienced nurses to care for patients the ventilator becomes irrelevant. The same goes for IV pumps. If you don’t have IV pumps to carefully and precisely deliver exact amounts of crucial medications, the ventilators become a moot point.
The day we ran out of IV pumps, there was levophed, versed, nitroglycerin, heparin, fentanyl and epinephrine running on dial-a-flow meters. A diala- flow is a fairly simple and archaic device that does allow some control to the flow from the IV bag, preventing the entire bag from going in all at once, but it is anything but precise. It’s like trying to thread a sewing needle with a shoelace. I was petrified when I took responsibility for these five people; their lives were in my hands but I didn’t have the equipment to do my job. I ran up to the ICU. One of their patients had just passed a few minutes before, and I grabbed the six pumps he had been using. I was able to get the pressers for all my patients on pumps fairly rapidly, then throughout the day scavenged throughout the hospital from patients less fortunate. Later that afternoon a donation of pumps arrived from FEMA. I recognized these big giant pumps from earlier in my career. It’s like using a flip phone instead of an iPhone. You couldn’t program in the medications, but they ran at a basic rate and that was all we really needed. I left after my 12-hour shift that day with all of my patients surviving. It was a miracle really. I wonder if they were ever extubated and recovered? There were too many to follow, to keep track of, and more and more coming in the door. The hospital was full as we were running 90 ventilators in pop-up ICUs, where ordinarily the hospital would sustain approximately 15 ventilated patients.
The amount of exposure we were all getting while intubating patient after patient was disconcerting. We wore one N-95 mask all day. Are we going to survive this? I made arrangements with one of my nurse friends for what to do and who to call if I became sick and incapacitated, given that it was looming possibility. I wondered what my two daughters would think if I caught the virus and died. Would they think I was a hero or would they still be angry at me for coming to the city to offer my expertise and risk my life? I hoped that they would understand that it was my duty to all of humanity. The positive impact I could make on my microcosm of patients and colleagues and hospital and city, could expand outward like the ripples in a lake, out to the macrocosm of the entire world.
My desire to make a difference in the world and ultimately protect my children and everyone I loved overcame my fear. Several other staff members at St. Barnabas died of coronavirus-related illness, may they be remembered for their ultimate sacrifice. What kept me going was not only a sense of duty, but my fellow nurses and doctors and nursing assistants and housekeeping and security. Every morning the nurses would suit up in what protective gear we did have in the break room. My fellow nurses’ unwavering commitment was contagious, we were all in it together. Our leadership, Dr. Dan Murphy, chair of the department of emergency medicine and Dr. Jeffrey Lazar, medical director and department vice chair were on the floor with us during the most unmanageable times. They did not direct from safe administrative offices, but were taking care of patients alongside us, working full shifts. During morning huddles, they gave us information, encouragement and support. Nurse manager Danielle Lucarto also worked with us in the trenches, which gave me strength. If she could do it, I could do it. With our nursing director falling ill, Danielle, despite taking on this new role, held it together for us during the peak of the pandemic.
The Fire Department of New York came to the hospital at shift change just when we were so drained it seemed we couldn’t go on. They came in uniform with their lights and sirens to salute us. That was an honor that lifted my spirits exponentially.
The worst of the pandemic has crescendoed over New York City. The curve has flattened. I worry about a second wave when the city releases restrictions. I also wonder about our emotional well-being. We have seen intense death like veterans of war. Were we as prepared as we could have been? We made extraordinarily difficult decisions, were they the right decisions? When we allocated scant resources to those who were more likely to survive, does that wound our conscience?
We are emergency nurses, we are strong. We did not drown during the flood, and we did not sink. We swam. On an ordinary day we see horrific injuries and senseless human suffering. But the covid influx was mayhem. When I close my eyes at night the path to my dreams is lined with the faces of those we couldn’t save. Now, we are the proverbial wounded healers.
Yet, along with countless tragedies I have also witnessed some miraculous recoveries. There is something to be said about the strength of the human spirit when faced with extreme hardship and adversity, both with patients and we who care for them. This experience makes one rethink life and death. Life is precious, and can be fragile. I can’t count the number of infected, the number on ventilators (there were hundreds), the number of body bags. They are not numbers to me, like the tally you constantly hear on the news. They are human beings who were whisked away by circumstances beyond our control.
We are putting order back into our universe after the unforeseen event of the covid tempest. The storm has blown over, but the landscape has forever changed. I suspect that long after we have reconstructed a new normal, I will still honor the deceased. I’ll be counting stars.