By Robert Irving Miller, R.N., M.S., J.D., May 19, 2020
People who have never worked in an ICU have no idea how difficult it can be to keep a critically ill patient alive. Survival is not always possible. Illness, suffering and death are not abstractions to nurses. Nurses know all too well the high cost and ravaging effects of pulmonary infections and systemic sepsis. People who refuse to wear masks in public places, who deny the existence of a life-threatening virus, or don’t comply with social distancing recommendations most likely have no idea how much harm they are possibly causing, until they or someone they love becomes ill with the COVID-19 virus. They are literally putting their own and others’ lives at risk. They are also putting our economy at risk because infecting others will prolong the pandemic. Apparently, it is at least as easy to catch COVID-19 as it is to catch a head cold.
In a very ill person, coronavirus pneumonia interferes quite badly with the respiratory gas exchange between the lungs and the blood vessels. Not enough oxygen can get into the body, which is needed for the function of all the important organs, including the brain, kidneys and heart. The waste products of cellular metabolism need to leave the body or they accumulate in the blood as acids. Usually some acids leave the blood in the lungs, become carbon dioxide and are exhaled. But if a person cannot exhale efficiently, the acids accumulate and cause harm throughout the body. Acidosis can lead to death, just as can lack of oxygen. To facilitate breathing and the blood/lung gas exchange, the patient will often be put on a ventilator, a machine which mechanically moves breathable air into and out of the lungs.
A patient on a ventilator with COVID-19 pneumonia needs a plastic tube positioned from outside their mouth into their trachea, with a cuff around the outside of the tube that is inflated to prevent air and oxygen from the ventilator from escaping up and around the outside of the tube. It is called an endotracheal tube, which is connected to the ventilator by other tubing. The tube is pretty much intolerable to a conscious person, so the patient is sedated. The ventilator moves oxygenated air into the lungs and facilitates exhalation of carbon dioxide, if the patient’s lungs will permit that. Because the patient is unable to cough in the normal way while on the ventilator, and needs to have secretions removed from the lungs, a nurse or respiratory therapist will periodically disconnect the ventilator, put the ventilator alarm ‘on pause’ and introduce a suction catheter through the endotracheal tube and into the patient’s lungs. The procedure of having secretions sucked out of the body and into a plastic canister is extremely uncomfortable if the patient is conscious and causes coughing or choking reactions on the part of the patient.
The nurse talks to the patient a lot, even if it is not clear that the patient can hear. The nurse is always explaining to the patient what is about to be done to them, and why it is being done. The nurse tries to reassure and distract the patient, since the reality of being very ill with a fever, on a ventilator, in an ICU, and surrounded by people wearing hazmat outfits can be terrifying and depressing.
Of course, the nurse has reason for apprehension as well, given the risk of contracting the patient’s life-threatening infection. Health care providers have disproportionately become infected and many have died because of COVID-19.
This process of suctioning an intubated patient with COVID-19 poses a grave threat to the nurse and respiratory therapist. Suctioning may release the potentially lethal virus into the air. The nurse, therapists and others caring for the patient will wear a face mask or two, a fluid impermeable gown if one is available, gloves and a face shield. Nurses spend a lot of time at the bedside of a ventilated patient managing intravenous fluids, administering mediations, listening to the patient’s lungs, checking their heart rhythm on the cardiac monitor, and checking blood pressure, temperature and blood oxygen saturation levels. They reposition the patient regularly and may percuss the chest periodically with cupped, gloved hands to break up congestion in the lungs. They also make sure that the patient is getting nutrition through one tube or another, and attend to the patient’s hygiene, among many other things. Drawing blood from the patient, checking fingerstick blood sugars, communicating findings to the physicians and implementing orders are among the many activities of an ICU nurse.
If the patient is very fortunate, he or she will recover lung function and be weaned off the ventilator. Repositioning heavyset patients in a way that takes abdominal pressure off the chest has sometimes been found to be helpful, even to the point of eliminating the need for mechanical ventilation. Patients have reportedly required a week or more of mechanical ventilation before beginning to recover, all the while receiving attentive and continuous care around the clock from highly skilled and educated nurses.
The nurses, along with social workers and others, are also usually the COVID-19 patient’s only link to their family. Hospital staff members try to find opportunities for patients to see loved ones via video using phones or tablets. Sadly, those are often the last communications between the patient and their family.
Despite all these efforts, most patients placed on a ventilator do not recover. They die. Reports indicate that 80% of patients who required mechanical ventilation for COVID-19 died during a period of several weeks. COVID-19 patients reportedly are at risk of developing blood clotting complications in organs including the lungs, kidneys and brain. Some COVID-19 patients have had strokes.
Inside those uniforms: the gown; the mask; the gloves and the face shield; it is hot and uncomfortable. Nurses used to be able to wear separate masks for separate patients and had access to several masks each day. Now they often have to put their only mask in a paper bag at the end of the shift and use the same mask the next day – and the day after that, while standing next to, turning, washing, suctioning, medicating and consoling their COVID-19 infected patients. Changing out of their gown and other protective equipment, even for a restroom visit, is complicated and risky.
If a store won’t let you in without a face mask, they are trying to protect their customers and workers from an infection that may land them in an ICU, may put them through hell, and may ultimately kill them. You have no good reason whatsoever to refuse wearing a face covering in public. You have no legitimate reason to ignore social distancing recommendations.
As mentioned, nurses are well acquainted with suffering and death. Do your best to make sure that it is not your suffering and death they have to deal with next.