COVID-19 Experiences from the Front Lines

Michael T. Vest, DO

Delaware
 
Patients with COVID-19 now are somewhat younger than patients were earlier in the pandemic. They are more likely to have been vaccinated. They are more likely to have single organ failure and longer duration of mechanical ventilation.
 
We have had families request ivermectin, high-dose famotidine, extracorporeal cytokine removal, and other nonstandard treatments. I think declining treatment is much less common than wanting nonstandard treatments. When things look grim in terms of prognosis, this is when families are most likely to want nonstandard therapies. I think the thought process is, “If my loved one is going to die with standard treatment, what do we have to lose by trying something else?” It’s often after we discussed the possibility that the patient may die that the family starts searching for “something else” to try.
 
As a group, we have declined to administer treatments that we do not think are beneficial and might be harmful. Hospital leadership has been very supportive of this. I explain the rationale for treatments we are using and potential or known harms of unproven therapies. I try to use “NURSE” statements—naming, understanding, respecting, supporting, and exploring. For example, I don’t start by saying, “Giving your loved one ivermectin for COVID-19 is a terrible idea.” Instead I say things like, “You are such a great advocate for your loved one. It’s really obvious how much you care. This patient is really lucky to have your support.” I try to give time for these types of statements to reduce some of the emotional intensity before launching into a scientific explanation of my recommendations. That said, if a patient isn’t doing well, it’s really hard for families to hear, regardless of how well you communicate. Sometimes even the best communicators end up at an impasse with families.

Maureen A. Seckel, CCNS, CCRN, CNS, MSN

Delaware

Pre- and post-vaccine surges differed in several respects.

Pre-vaccine: We were unsure how to treat, patients were dying, and we were unsure how to protect ourselves. We didn’t feel like heroes, but the public treated us like we were. Everything was moving very fast. As we gained experience, it was tragic and difficult, but it became less scary personally for the staff. And we had staff. In retrospect, it feels like we were naive about the changes to come.

Post-vaccine: There is a different feel. We know some therapies that work and how to treat hypoxemia. The staff are more secure in their personal protective equipment and feel safer providing patient care. But there are a lot of agency staff and posted positions. It is still tragic, but it has also become demoralizing, and we are all working harder with less staff.
 
Patients fall into one of several categories:

1. A small subset are vaccinated patients who are in the ICU and also have some other risk factors (e.g., immunocompromise, obesity, smoking).
2. A larger group of patients are not vaccinated for various reasons but are not hostile.
3. A smaller group of nonvaccinated patients are hostile and angry. The hostile group takes its toll on the team. Also, it is difficult for these patients to understand that the vaccine could have saved some of them and prevented these recurring surges.

Team members are coping in different ways using a variety of resources. The biggest help is that we had a strong interdisciplinary team before COVID-19 whose members are still supportive of each other, driven to provide the best care that we can, and watching out for each other. We have multiple staff on leave for various reasons and with various coping abilities. Our staff is about 25% agency, but the entire team is trying to maintain the standards of care. We have multiple care-for-caregiver support mechanisms and are starting up some new peer-led groups. Simple things like daily huddles and focusing on positives help with meaningful recognition.

What also seems to help is our focus on maintaining a high standard of care. It seems to give the team a purpose and something positive. Outside of the first surges, we have not seen an increase in healthcare-associated infections or other quality measures. We have been one-year central line bloodstream infection free and nearly three-year catheter-associated urinary tract infection free despite the highest device utilization we have ever seen.
 
This is a moment in healthcare that will always be remembered. “Where were you when COVID-19 struck?” There are positives that make me proud. I am proud of how the entire international healthcare community shared articles, blogs, education, etc., during COVID-19 and came together. I am proud that the healthcare team talks openly about how difficult this is, particularly now, but moves forward in providing evidence-based care. I am proud that my healthcare team cares about how each of the team members is doing and watches out for each other. I am proud that, despite anger and hostility from some patients and families, they are treated with dignity and compassion.

David Butler, MD

New York
 
Enlist support from colleagues. If you are an intensivist and the ICU is overflowing, delegate what you can. For example, procedures such as inserting lines and chest tubes can be performed by surgeons, routine family updates can be handled by team members who are skillful in communicating, and more stable patients with tracheostomies can be transferred to a unit with nonintensivist pulmonologists managing the ventilator. Hospital administration must be willing to divert if the ICU is saturated or patients are accumulating in the emergency department awaiting a unit bed.