Desperate. Suffocating. Fruitless.
These are but some of Nathaniel Henderson’s impressions after working in the COVID-19 intensive care unit at McAllen Medical Center, where he’s experienced despair in grueling 12-hour shifts sometimes without bathroom relief or water, because there’s simply not enough of them and too many patients.
The 31-year-old registered nurse told this tale with candor this past week, painting a grim picture of a healthcare institution burdened by lacking resources, staff and space while waves of patients suffering from the coronavirus have flooded their facilities.
The Mission resident has worked at McAllen Medical’s ICU for four-and-a-half years but then was the charge nurse for the COVID-19 ICU for three months straight.
That soon became a huge responsibility, he said, especially when trying to prevent crises left and right with limited resources and limited staff.
Help for the overwhelmed hospitals across the Rio Grande Valley has started to trickle in as nurses are bussed in from across the state.
On Saturday, Starr County Memorial Hospital welcomed new temporary staff, including 15 registered nurses, six clinical nurse specialists, six respiratory technicians, and one nurse practitioner for their emergency room.
Earlier this week, nurses from across the state were also bussed into Hidalgo County to assist employees at hospitals that have already reached capacity.
The staffing resources are provided by the state through contracts with several agencies, according Dr. Elizabeth Cuevas with the Department of State Health Services.
For Henderson and the nurses from the Valley, the help couldn’t come at a more critical time considering what they’re facing each day.
“The issue is the COVID patients are a very special kind of patient. They aren’t your average … they do not have your average sickness,” Henderson said. “These are patients that deteriorate very rapidly.”
“You can’t just close the door on them and have peace of mind knowing that you took care of the patient, you left them alone,” he said. “These are patients that you’re constantly thinking, ‘Did they pull off their oxygen, did they pull off their mask? What’s going on behind the closed door that I cannot see?’”
“That’s a constant worry in your mind because sometimes the patients, they press the call light and it may be something as simple as ‘I need to use the restroom.’ But there’s other times where it’s as dire as ‘I can’t breathe.’”
Because of the dire situation hospitals are currently in, he said they have a larger patient-to-nurse ratio than what is ideal.
“So we’re pushing staff into the brink where they’re taking, I think, six patients per nurse on the tele floors and that’s kind of rough,” he said.
When going to work at the COVID unit, the first thing the nurses do is change into scrubs provided by the hospital.
“We gown up and sometimes we’ve got shoe covers and we try to get as protected as possible while we’re on the unit,” Henderson said. “Everyone has to wear a surgical mask while they’re in the hospital — staff and patients included. If the patients go out in the hallways, they’ve got to be in a surgical mask.”
When they go in, they get their patients and they try to consolidate their care as much as they can so that they limit exposure for the patients but also to limit the supplies that are necessary, which the nurse has to “doff,” or remove, whenever they leave a room.
“We’ve got limited supplies, obviously,” he said of personal protective equipment. “We’ve got such an influx of patients that it makes it difficult to just … we burn through supplies so fast so we really try to consolidate our care and limiting (it) only to when we have to go into the rooms.”
During the day shift, physicians generally do their rounds which Henderson said makes it a little more difficult for them.
“If you’re on the floor and the physician wants to round with (the patients) … basically you have to stop what you’re doing and go into every patient’s room so that the physician can see the patient,” he said.
Those rounds, he noted, are important as that’s how they make progress in the patient’s care, however the nurses have to balance multiple things like passing medications and doing their assessments.
“It’s trying to balance all of those and then of course we’ve got family members that are calling us at the same time,” he said. “Sometimes, it’s like five or six family members for just one patient and if you have six of them that are calling at the same time, it bombards us and it really overwhelms us.”
Ideally, one out of the three days the nurses are guaranteed per week would be at a COVID-19 unit, but because of staff shortages and the amount of patients they’re seeing they end up going there quite frequently — sometimes two out of their three days.
With regular telemetry COVID-19 patients, their constant worry is whether the patient is making progress or whether they’re regressing, and so they look at how dependent the person is on oxygen, how comfortable they are on their current oxygen level, and whether those levels will have to be increased or diminished.
For an ICU nurse the patient is already intubated, so at that point they’re trying to prevent them from regressing even further.
“Unfortunately, when they’re intubated and when they’re on sedation and they’re in, essentially, (acute respiratory distress syndrome), the patient is really close to not making it,” he said. “So you’re trying everything you can to bring them from that brink of death.”
That can entail proning, a practice that physicians have begun adopting and essentially means to turn patients over on their stomachs.
“Studies have shown it actually decreases the mortality rate on a lot of these COVID patients,” he said.
“It may sound easy, but when a patient absolutely cannot do it by themselves and you’ve got just a couple of nurses to turn them, it really makes it hard,” Henderson said. “If you prone the patient incorrectly, or one mishap, you could end up pulling the tube out a little bit and then you’re in for it because now the patient is definitely not getting oxygen and you have to flip them back over. Try to fix the tube a bit.”
The ICU nurses also have to keep an eye on a patient’s urine output because if that begins to drop, it’s an indicator that the patient is going into renal failure.
“And if the patient goes into renal failure while they’re on your shift, you’re going to see a lot of electrolyte imbalances and the patient’s going to very quickly deteriorate,” he said. “You’re going to see blood pressures drop, you’re going to start seeing heart rates go haywire, your oxygen’s going to begin to get affected.”
“So the ICU nurse is constantly worried about every little facet of the patient’s body from the skin color, the skin tone, how warm the extremity is, if their sugars are controlled. I mean we’re trying to balance a dozen things at the same time with just one patient,” he said.
But, of course, because of the surge of hospitalizations and the shortage of nursing staff, it’s often not just one patient they’re dealing with.
“A friend of mine yesterday — and she was supposed to be the charge nurse — …ended up taking three recently intubated COVID patients,” he said. “That’s generally unacceptable for anybody, but we just did not have anywhere or anybody to give them to.”
Any COVID-19 ICU nurse knows that recently intubated COVID patients are a lot of work, he said, stressing their critical condition.
“I’m talking the patient’s on a ventilator and you so much as turn the patient to the side a little bit, their oxygen drops and you’ve literally done nothing else but turn the patient to their side. That’s it,” he said.
On top of those concerns, he said they’re running medications so fast that they’re constantly on the phone with the pharmacy, which itself can barely keep up.
“They can’t keep up because they’ve got so many medications to make for everybody,” Henderson said, adding that they have to request medication hours ahead of time in order to maybe have it by the time they run out.
With so many things to worry about, so many possible crises to field, resting is not really an option for them.
“There’ve been whole shifts where I don’t, literally, get to use the restroom at all,” Henderson said. “There’s whole shifts where I don’t even get a sip of water, the entire 12 hours that I’m there.”
He doesn’t get a chance to eat, he said, and he often ends up leaving at midnight after being awake since 5 or 6 a.m.
“I don’t think my experience is an isolated one either,” he said. “I think if you speak to anybody that’s been on the unit for any length or any duration of time, they’ll tell you pretty much the same thing — that they’re just constantly on the go.”
But in addition to the physical grind, Henderson said it also wears down their mental fortitude because walking into work, they know what it’s going to be like.
“It’s like an adrenaline rush from the moment you start,” he said. “You’re always constantly concerned that you’re maybe forgetting something or maybe there’s something you’re neglecting or perhaps there’s, maybe behind a closed door, a patient that’s unable to press a call light, maybe they’re in respiratory distress, or maybe they passed out.”
It’s that anticipation of the unknown, he said, that’s the most taxing.
”Even if it’s unknown, you also know that there’s something bad almost around the corner and you just don’t know if it’s going to be you that’s going to be the one receiving it or if it’s going to be someone else,” he said.
But the worst part of the entire experience, he said, is being witness to the slow suffering of the patients.
“You just see them slowly begin to whittle down,” Henderson said. “They’re essentially suffocating right in front of you and here you are, you’re trying desperately to intervene to just try to stem that tide knowing that every effort is pretty much fruitless.”
“If they’re already on that trajectory, headed down where they’re going to end up intubated, it’s like you’re on the Titanic and you’re trying to bail water as fast as you can but that ship is halfway under the ocean by that time,” he said. “A lot of times, you’re trying to keep them from being intubated but you know that they’re going to end up intubated and many of them, most of them, will not make it.”
That’s the pending reality that nurses know that looms around them when they enter the intensive care unit where patients infected with the novel coronavirus fight for their lives. But it’s those nurses patients rely on, when that status of their health can change in a matter of minutes.
Henderson said medicine has evolved over the last 40 to 50 years in a way that there’s many things that nurses do differently now.
“There’s a lot of independent functions that nurses can do themselves and we’re really kind of like the hands and feet of the physician,” he said. “The physician provides us an order but we carry it out.”
If there aren’t enough people to carry out orders, that really endangers those critical patients.
“When you have really critical patients and you max us out and there ain’t enough nurses, then obviously things are not going to get done and patients end up suffering as a consequence,” he said.