In a struggle to be happy and free

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COVID Alert

The COVID Alert app icon

Federal government’s COVID Alert app is out for iOS and Android. I knew it was coming and have been thinking about whether I’ll use it or not. On one side is the government’s insidious gathering of information about us, and on the other is keeping safe and learning when I’ve been in contact with someone who has later tested positive.

It’s strength and weakness is that it’s a contact notification application, not a contact tracing application. That is, it will let you know only if someone you have been in contact with has later tested positive for COVID‑19. It will not let you know who that person is, when you were in contact, or where the contact occurred. All it tells you is that you really should go get tested to find out of you caught it from the person with which you were in contact.

The weakness is the very limited information you’re given. The strength is that you’re not laying your soul bare to the government. They receive very little information.

The main COVID Alert app page. Good news for me! I hope it stays this way.

How it works is your phone periodically generates a random code and transmits is via Bluetooth. Any phone near yours will record any codes it detects from other phones. If you some day are tested for COVID‑19 and the result is positive, you inform the app of this unfortunate occurrence. It then transmits this, with all the codes it has recorded, to a central server. All copies of the app periodically download this information from the server and your app recognizes its own code from any downloaded and marked as having been infected, it notifies you that you’ve been in contact with someone who has tested positive. Then you need to go get tested and see if you caught it.

No GPS data is used. It’s a clever solution to finding out if anyone you’ve been with has caught it, and at the same time protecting your privacy. But of course, you have to trust the application to do only what the government says is does.

I would normally not be onboard with this application, but COVID‑19 is serious. I believe there is so much about it that we don’t yet know, it could be far worse than we currently realize. So I did download and activate it. But at the same time, the Provincial and Federal Privacy Commissioners were consulted during its creation and Federal privacy commissioner Daniel Therrien says: “Canadians can opt to use this technology knowing it includes very significant privacy protections. I will use it.”

The real tipping point to my decision to use the app is the fact that the source code is available on GitHub. If you have programming knowledge, you can download the code yourself and see what it does. I appreciate that level of transparency.

Get it from the iOS App Store or on Google Play. More information is available on the COVID Alert app page.

A strange four months

I’ve been so quiet. It’s partly because my mother has been having some health challenges lately. It’s mostly because the last four months have been just so off-the-wall. First the most serious pandemic in a century and then in the middle of that, all off the black lives matter demonstrations triggered (this time) by the police murder of George Floyd. It’s been amazing and wonderful to see the demonstrations in the US spread all around the world.

My problem is that I have so little to add to this movement beyond my absolute support. Indeed, I’ve done a lot of learning and I will continue to learn.

I can do more in regards to the pandemic. I’ve stayed home and gone out only minimally. As things have opened up I’ve got to Julie’s more but that’s pretty much about it. Restaurants opened Friday but I have no interest in going out to eat at this point. Why risk it? I’ll continue to call ahead and pick up my order, thank you! It just seems too early for things to be getting that much back to normal.

Look at the situation in the southern US. They’re well on their way to having everything open again and are getting slammed with the highest infection numbers since the pandemic started. Florida alone has 8 530 new cases today, while all of Canada claims 178 new cases. I understand wanting to get out, but if we open up too early, these months of self-quarantine will have been for nothing.

It’s not the widespread death of the 1918 influenza pandemic, but people are dying in numbers far higher than necessary through neglect or thinking they’re somehow immune, and that’s tragic.

As of today, the worldwide death toll is 504 078.

All Quiet on the Eastern Front

I saw this post on Facebook. I had to repost it. Please read it. I think you will understand.

I am a Covid ICU nurse in New York City, and yesterday, like many other days lately, I couldn’t fix my patient. Sure, that happens all the time in the ICU. It definitely wasn’t the first time. It certainly won’t be the last. What makes this patient noteworthy? A few things, actually. He was infected with Covid-19, and he will lose his battle with Covid-19. He is only 23 years old.

I was destroyed by his clinical course in a way that has only happened a few times in my nursing career. It wasn’t his presentation. I’ve seen that before. It wasn’t his complications. I’ve seen that too.

It was the grief. It was his parents. The grief I witnessed yesterday, was grief that I haven’t allowed myself to recognize since this runaway train got rolling here in early March. I could sense it. It was lingering in the periphery of my mind, but yesterday something in me gave way, and that grief rushed in.

I think I was struck by a lot of emotions and realities yesterday. Emotions that have been brewing for weeks, and realities that I have been stifling because I had to in order to do my job effectively. My therapist tells me weekly via facetime that it’s impossible to process trauma when the trauma is still occurring. It just keeps building.

I get home from work, take my trusty companion Apollo immediately out to pee, he’s been home for 14 hours at a time. I have to keep my dog walker safe. No one can come into my apartment.

I’ve already been very sick from my work exposure, and I’m heavily exposed every day that I work since I returned after being 72 hours afebrile, the new standard for healthcare workers. That was after a week of running a fever of 104ºF even with Tylenol around the clock, but thankfully without respiratory symptoms. I was lucky.

Like every other healthcare worker on the planet right now, I strip inside the door, throw all the scrubs in the wash, bleach wipe all of my every day carry supplies, shoes and work bag stay at the bottom of the stairs.

You see, there’s a descending level of Covid contamination as you ascend the stairs just inside my apartment door. Work bag and shoes stay at the bottom. Dog walking shoes next step up, then dog leash, then running shoes.

I dodge my excited and doofy German shepherd, who is bringing me every toy he has to play with, and I go and scald myself for 20 minutes in a hot shower. Washing off the germs, metaphorically washing off the weight of the day.

We play fetch after the shower. Once he’s tired, I lay on the floor with him, holding him tight, until I’m ready to get up and eat, but sometimes I just go straight to bed.

Quite honestly, I’m so tired of the death. With three days off from what has been two months of literal hell on earth as a Covid ICU nurse in NYC, I’m having an evening glass of wine, and munching on the twizzlers my dear aunt sent me from Upstate NY, while my dog is bouncing off the walls because I still don’t have the energy to run every day with him.

Is it the residual effects of the virus? Is it just general exhaustion from working three days in a row? Regardless, the thoughts are finally bleeding out of my mind and into a medium that I’m not sure could possibly convey the reality of this experience.

There’s been a significant change in how we approach the critically ill covid-infected patients on a number of different levels over the last two months. We’re learning about the virus. We’re following trends and patterns. We are researching as we are treating.

The reality is, the people who get sick later in this pandemic will have a better chance for survival. Yet, every day working feels like Groundhog Day. All of the patients have developed the same issues. This 23-year-old kid walked around for a week silently hypoxic and silently dying. By the time he got to us, it was already far too late.

First pneumonia, then Acute Respiratory Distress Syndrome (ARDS), essentially lung failure. Then kidney failure from global hypoxia and the medications we were giving in the beginning, desperately trying to find something that works. Then learning that it doesn’t work, it’s doing more harm than good in the critical care Covid population.

Dialysis for the kidneys. They are so sick that your normal three-times weekly dialysis schedule is too harsh on their body. They’re too unstable. So, we, the ICU nurses, run the dialysis slowly and continuously.

They are all obstructing their bowels from the ever-changing array of medications, as we ran out of some medications completely during our surge. We had to substitute alternatives, narcotics, sedatives, and paralytics, medications we’re heavily sedating and treating their pain with, in an effort to help them tolerate barbaric ventilator settings.

Barbaric ventilator settings while lying them on their bellies because their lungs are so damaged that we have to flip them onto their bellies in an effort to perfuse the functioning lung tissue and ventilate the damaged lung tissue.

Lungs that are perfused with blood that doesn’t even have adequate oxygen carrying capacity because of how this virus attacks.

Blood that clots. And bleeds. And clots. And bleeds. Everything in their bodies is deranged. Treat the clots with continuous anticoagulation. Stop the anticoagulation when they bleed.

GI bleeds, brain bleeds, pulmonary emboli, strokes. The brain bleeds will likely die. The GI bleeds get blood transfusions and interventions.

Restart the anticoagulation when they clot their continuous or intermittent dialysis filters, rendering them unusable, because we’re trying not to let them die slowly from renal failure. We are constantly making impossible treatment decisions in the critical care pandemic population.

A lot of people have asked me what it’s like here. I truly don’t have adequate descriptors in my vocabulary, try as I might, so I’ll defer to the metaphor of fire.

We are attempting to put out one fire, while three more are cropping up. Then we find out a week or two later that we unknowingly threw gasoline on one fire, because there’s still so much we don’t know about this virus.

Then suddenly there’s no water to fight the fire with. We’re running around holding ice cubes in an effort to put out an inferno. Oh yeah, and the entire time you’ve been in this burning building, you barely have what you need to protect yourself.

The protection you’re using, the guidelines governing that protection, evolved with the surge. One-time use N95? That’s the prior standard, and after what we’ve been through, that’s honestly hysterical. As we were surging here, the CDC revised their guidelines, because the PPE shortage was so critical.

Use anything, they said. Use whatever you have for as long as you can, and improvise what you don’t have.

As we’re discussing medication and viral research, starting clinical trials, talking treatment options in morning rounds for your patient with the team of doctors and clinical pharmacists, suddenly, surprise! Your patient developed a mucous plug in his breathing tube.

Yes, that vital, precious tube that’s connected to the ventilator that’s breathing for them. It’s completely plugged. Blocked. No oxygen or carbon dioxide in or out. It’s a critical emergency.

Even with nebulizer treatments, once we finally had the closed-delivery systems we needed to administer these medications and keep ourselves safe, they’re still plugging. We cannot even routinely suction unless we absolutely have to because suctioning steals all of the positive pressure that’s keeping them alive from the ventilator circuit. One routine suction pass down the breathing tube could kill someone, or leave their body and vital organs hypoxic for hours after.

Well, now they’re plugged. We are then faced with a choice. Both choices place the respiratory therapists, nurses, and doctors at extremely high risk for aerosolized exposure.

We could exchange the breathing tube, but that could take too long, the patient may die in the 2 – 3 minutes we need to assemble the supplies and manpower needed, and it’s one of the highest-risk procedures for our providers that we could possibly carry out.

Or we could use the clamps that have been the best addition to my every day carry nursing arsenal. You yell for help, you’re alone in the room. Your friends and coworkers, respiratory therapists, doctors, are all rushing to get their PPE on and get into the room to help.

You move around the room cluttered with machines and life sustaining therapies to set up what you need to stave off death. You move deliberately, and you move fast. The patient is decompensating in the now-familiar and coordinated effort to intervene.

Attach the ambu bag to wall oxygen. Turn it all the way up. Where’s the PEEP valve? God, someone go grab me the PEEP valve off the ambu bag in room 11 next door. We ran out of those a month ago, too. It’s all covid anyway, all of it is covid. Risk cross-contamination or risk imminent death for your patient, risk extreme viral load exposure for you and your coworkers, and most certain death for your patient if you intervene without a PEEP valve.

You clamp the breathing tube, tight. The respiratory therapist shuts off the ventilator, because that side of the circuit can aerosolize and spray virus too if you leave it blasting air after you disconnect. Open the circuit. Respiratory therapy attaches the ambu bag. You unclamp. Bag, bag, bag. Clear the plug. The patient’s oxygen saturation is 23% with a perfect waveform. Their heart rate is slowing. Their blood pressure is tanking. Max all your drips, then watch and wait while this patient takes 3 hours to recover to a measly oxygen saturation of 82%, the best you’ll get from them all shift. These patients have no pulmonary reserve.

All of our choices to intervene in this situation risk our own health and safety. In the beginning we were more cautious with ourselves. We don’t want to get sick. We don’t want to be a patient in our own ICU. We’ve cared for our own staff in our ICUs. We don’t want to die. Now? I’ve already been sick. I am so, so tired of the constant death that is the ICU, that personally, I will do anything as long as I have my weeks old N95 and face shield on, just to keep someone alive.

I’ve realized that for many of these patients in the ICU, it won’t matter what I do. It won’t matter how hard I work, though I’ll still work like a crazy person all day, aggressively advocate for my patients in the same way.

My coworkers will go without meals, even though they’re being donated and delivered by people who love and support you. Generous people are helping to keep local restaurants afloat. We can always take the meal home for dinner, or I can devour a slice of pizza as I walk out to my truck parked on the pier, a walk I look forward to every day, because it gives me about eight minutes of silence. To process. To reflect.

I’ll chug a Gatorade when I start feeling lightheaded and I’m seeing stars, immediately after I just pushed an amp of bicarb on a patient and I know I have at least five minutes of a stable blood pressure to step out of the unit, take off my mask and actually breathe.

Every dedicated staff member is working tirelessly to help. The now-closed dental clinic staff has been trained to work in the respiratory lab to run our arterial blood gases, so that the absolutely incredible respiratory therapists who we so desperately need can take care of the patients with us.

Nurses in procedural areas that were closed have been repurposed to work as runners. To run for supplies while the primary nurse is in an isolation room trying to stabilize a patient without the supplies they need, runners to run for blood transfusions.

Physical therapists, occupational therapists, speech and language pathologists being repurposed to be part of the proning teams that helps the nurses turn patients onto their backs and bellies amidst a tangled web of critical lines and tubes, where one small error could mean death for the patient, and exposure for all staff.

Anesthesiologists and residents are managing airways and lines when carrying out these massive patient position changes. Surgical residents are all over the hospital just to put in the critical invasive lines we need in all of our patients.

The travel nurses who rushed into this burning building to help us are easing a healthcare system. The first travel nurse I met came all the way from Texas. Others terminated their steady employment to enlist with a travel agency to help us. Every day there are more travelers arriving.

A nurse from LA came to me after she found out I was part of the home staff, in my home unit, where this all first started in my hospital what feels like a lifetime ago, and said, “I came here for you. For all of the nurses. Because I couldn’t imagine working the way you guys were working for how long you were working like that.” During our surge and peak in the ICU, we were 1:3 ratios with three patients who normally would be a 1:1 assignment. And they were all trying to die at the same time. We were having to choose which patients we were rushing to because we couldn’t help them all at the same time.

The overhead pages for emergencies throughout the hospital rang out and echoed endlessly. Every minute, another rapid response call. Another anesthesia page for an intubation. Another cardiopulmonary arrest. A hospital bursting at the seams with death. Refrigerated trailers being filled.

First it was our normal white body bags. Then orange disaster bags. Then blue tarp bags. We ran out of those too. Now, black bags.

The heartbreakingly unique part of this pandemic, is that these patients are so alone. We are here, but they are suffering alone, with no familiar face or voice. They are dying alone, surrounded by strangers crying into their own masks, trying not to let our precious N95 get wet, trying not to touch our faces with contaminated hands.

Their families are home, waiting for the phone call with their daily update. Some of their loved ones are also sick and quarantined at home.

Can you even imagine? Your husband or wife, mother or father. Sibling. Your child. You drop your loved one off at the emergency department entrance, and you never, ever see them alive again.

Families are home, getting phone calls every day that they’re getting worse. Or maybe they’re getting better. Unfortunately, the ICU in what has quickly become the global epicenter for this pandemic is not a happy place. We are mostly purgatory where I work, so this snapshot may be more morbid than most.

These people are saying goodbye to their loved ones, while they’re still walking and talking, and then maybe a week or two later, they’re just gone. It’s like they disappeared into thin air.

That level of grief is absolutely astounding to me, and that’s coming from a person who knows grief. I was there at the bedside, I held my young husband’s hand when I watched his heart stop beating. I was there. That grief changes you immeasurably.

But this grief? This pandemic grief? It’s inconceivable. These families will suffer horribly, every day for the rest of their lives. They might not even be able to bury their loved one. God, if they can’t afford a funeral with an economic shut-down, their loved one will be buried in a mass grave on Hart Island with thousands of others like them. What grave will they have to visit on birthdays and holidays?

Yesterday, I was preparing for a bedside endoscopy procedure to secure a catastrophic GI bleed in this 23-year-old patient.

It was a bleed that required a massive transfusion protocol where the blood bank releases coolers of uncrossmatched O negative blood in an emergency, an overhead page that, ironically, I heard as I was getting into the elevator to head to the fourth floor for my shift yesterday morning; a massive transfusion protocol that I found out I would own as a primary nurse, as I desperately squeezed liters of IV fluids into this patient until we got the cooler full of blood products, and then pumped this patient full of units of blood until we could intervene with endoscopy.

Before the procedure, I stopped everything I was doing that wasn’t life-sustaining. I stopped gathering supplies to start and assist with the procedure.

I told the doctors that I would not do a required “time-out” procedure until I got my phone out, and I facetimed this kid’s mom because I didn’t think he would survive the bedside procedure.

She cried. She wailed. She begged her son to open his eyes, to breathe. She begged me to help her. Ayudame. Ayudame. She begged me to help him. She sang to him. She told him he was strong. She told him how much she loved him. I listened to her heart breaking in real time while she talked to her son, while she saw his swollen face, her baby boy, dying before her eyes through a phone.

Later in the day, after the procedure, his mom and dad came to the hospital. He survived the securement of the bleed, but he was still getting worse no matter what we did. He’s going to die. And against policy, we fought to get them up to see their son.

We found them masks and gowns that we’re still rationing in the hospital, and we let his parents see him, hold him. We let them be with their son.

Like every other nurse would do in the ICU here, I bounced around the room, moving mom from one side of the bed to the other and back again, so I could do what I needed to do, setting up my continuous dialysis machine, with the ONE filter that supply sent up for my use to initiate dialysis therapy. This spaceship-like machine, finicky as all hell, and I had one shot to prime this machine successfully to start dialysis therapy to try to slowly correct the metabolic acidosis that was just one of the problems that was killing him as his systolic blood pressure lingered in the 70s, despite maxing all of my blood pressure mediations.

Continuous dialysis started. You press start and hold your breath. You’re not removing any fluid, just filtering the blood, but even the tiniest of fluid shifts in this patient could kill him. But you have no choice.

His vital signs started to look concerning. I could feel the dread in the pit of my stomach, this was going south very quickly. Another nurse and the patient’s father had to physically drag this mother out of the room so we could fill the room with the brains and eyes and hands that would keep this boy alive for another hour.

She wailed in the hallway. Nurses in the next unit down the hall heard her cries through two sets of closed fire doors. We worked furiously to stabilize him for the next four hours.

Twenty minutes before the end of my shift last night, I sat with the attending physician and the parents in a quiet and deserted family waiting room outside the unit. I told his mother that no matter what I do, I cannot fix this. I have maximized everything I have, every tool and medicine at my disposal to save her son. I can’t save her son.

The doctor explained that no matter what we do, his body is failing him. No matter what we do, her son will die. They realized that no matter how hard they pray, no matter how much they want to tear down walls, no matter how many times his mother begs and pleads, “take me instead, I would rather die myself than lose my son,” we cannot save him.

We stayed while she screamed. We stayed until she finally let go of her vice grip on my hands, her body trembling uncontrollably, as she dissolved into her grief, in the arms of her husband.

This is ONE patient. One patient, in one ICU, in one hospital, in one city, in one country, on a planet being ravaged by a virus.

This is the tiniest, devastating snapshot of one patient and one family and their unimaginable grief. Yet, the weight is enormous.

The world should feel that weight too. Because this grief, this heartbreak is everywhere in many forms. Every person on this planet is grieving the loss of something.

Whether that’s freedom or autonomy sacrificed for the greater good. Whether that’s a paycheck or a business, or their livelihood, or maybe they’re grieving the loss of a loved one while still fighting to earn a paycheck, or waiting for government financial relief that they don’t know for certain will come. Maybe they’re a high school senior who will never get to have the graduation they dreamed of. Maybe they’re a college senior, who won’t get to have their senior game they so looked forward to. Maybe they’re afraid that the government is encroaching on their constitutional rights. Maybe it’s their first pregnancy, and it’s nothing like they imagined because of the terrifying world surrounding them.

Or maybe they lost a loved one, maybe someone they love is sick, and they can’t go see them, because there are no visitors allowed and they’re an essential worker. Maybe all they can see of someone they love is a random facetime call in the middle of the day from an area code and a number they don’t know.

Everyone is grieving. We’ve heard plenty of the public’s grief.

I don’t blame anyone for how they’re coping with that grief, even if it frustrates the ever-living hell out of me as I drown in death every day at work. It’s all valid. Everyone’s grief is different, but it doesn’t change the discomfort, the despair on various levels. We are at the bottom of Maslow’s hierarchy of needs. Basic survival, physiological and safety needs. I’ve been here before. I know this feeling. How we survive is how we survive.

Now that I’ve had the time to reflect and write, now that I’ve let the walls down in my mind to let the grief flood in, now that I’ve seen this grief for what feels like the thousandth time since the first week of March as a nurse in a Covid ICU in New York City, it’s time you heard our side. This is devastating. This is our reality. This is our grief.


Reposted without permission (until I get it).

Prepare: COVID-19

The best tweet in a long time:

And here’s her thread, for your information.

I know we’re all tired of hearing/talking about it, but one thing I haven’t really seen going around is advice for what happens if you do get coronavirus (many of us will), only advice for how to try to avoid it. So as your friendly neighborhood RN, a wee thread:

Things you should actually buy ahead of time (Erm, not sure what the obsession with toilet paper is?): Kleenex, Acetaminophen (Tylenol) in 350 mg tablets, Ibuprofen (Advil) in 200 mg tablets, Mucinex, Robitussin or DayQuil/NyQuil, whatever your cough medicine of choice is.

If you don’t have a humidifier, that would also be a good thing to get. (You can also just turn the shower on hot and sit in the bathroom breathing in the steam). Also a good time to make a big batch of your favorite soup to freeze and have on hand.

If you have a history of asthma and you have a prescription inhaler, make sure the one you have isn’t expired and refill it/get a new one if it is.

You basically just want to prepare as though you know you’re going to get a nasty respiratory bug like bronchitis or pneumonia. You just have the foresight to know it’s coming.

For symptom management, use the meds I mentioned. For a fever over 101, alternate Tylenol and Advil so you’re taking a dose of one or the other every 3 hours. Use both cough suppressants and expectorants (most cough meds have both). Drink a ton, hydrate hydrate. Rest lots.

You should not be leaving your house except to go to the doctor, and if you do, wear a mask (regular is fine, you don’t need an N95). You do not need to go to the ER unless you are having trouble breathing or your fever is very high and unmanaged with meds.

90% of healthy adult cases thus far have been managed at home with basic rest/hydration/over-the-counter meds. We don’t want to clog the ERs unless you’re actually in distress. The hospital beds will be used for people who actively need oxygen/breathing treatments/IV fluids.

If you have a pre-existing lung condition (COPD, emphysema, lung cancer) or are on immunosuppressants, now is a great time to talk to your PCP or specialist about what they would like you to do if you get sick. They might have plans to get you admitted and bypass the ER entirely.

One major relief to you parents is that kids do very well with coronavirus — they usually bounce back in a few days, no one under 18 has died, and almost no kids have required hospitalization (unless they have a lung disease like CF). Just use pediatric dosing of the same meds.

I’m always around via DM if you have questions, and if I don’t have the answer I’ll just tell you to call your doctor. 😉 But feel free to contact me any time. 😘

So tired…

I’m in the home stretch. This week is my last week of classes for the term. When I leave Friday, I won’t be back until January 7, when I start the second term.

When I left school today, I came home, ate, and promptly slept for an hour. I wouldn’t say the day was hugely demanding, but still I slept. Yesterday I slept for two hours. The only explanation I have is that I sometimes push against going to sleep but I haven’t been entirely unreasonable about that. Reassuringly enough, some of my classmates and even a few in their second year brought up how they’re feeling the same way, entirely without prompting from me. None of us seem to have any explanation for it.

20191203-103745 iPhone8 IMG_2451.jpg: iPhone8, back camera @ 3.99mm, 1/2700, f/1.8, 25 ISO
The Willowbank upper campus was a picture-perfect winter wonderland today.

Perhaps learning and physical activity is just demanding. At least I hope that’s it because I have no other explanation!

As much as I want a shorter Christmas break, I will certainly take the time to rest and make sure I’m ready to attack the second term next month.

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