Today the 4West ICU at Missouri Baptist Hospital is being closed down. Hospital numbers are on the decline and our emergency service is no longer required. It is a joyful day for all of us who have worked here over the last four months. It is a beacon of hope that we as a community are on the path to returning to normal life. These are days not soon to be forgotten. Here are some of the lessons I have learned from working in the ICU:
COVID is Tough:
By now, I assume that all of you know someone who has had COVID or you may have had it yourself. Chances are, the disease may have made the individual feel real bad for a few days but that was about it. Most feel tired and worn out for a few weeks but get back to normal pretty quick. Some of you, unfortunately, know people who were hospitalized and have even succumbed to the disease. Unless you work in the hospital, it is hard to explain how bad COVID can get. With no visitors allowed family members have a hard time understanding how a love one could look and act so well just a few weeks prior and be at the brink of death a short time later. When COVID hits hard, it hits really hard. Most commonly it hits the lungs. Once its intense inflammatory reaction sets up in the lungs, it is very hard to recover. We have learned better how to care for such patients but there is only so much that can be done. When days turn into weeks, the inflammation causes scar tissue. Mechanical ventilation is now put off for as long as possible. Very few of those who are intubated survive the hospitalization.
In addition to the severe lung disease, respiratory (breathing) failure usually cascades into damage into other organ systems. Such patients are more prone to blood clots which commonly travel to the lungs (pulmonary embolism) or less frequently to the brain (strokes). The kidneys are often the first to be affected due to decreased oxygen deliver. Powerful steroids which are used to tamp down the inflammatory response commonly result in the acquisition of diabetes requiring every increasing doses of insulin to control. The heart can be strained. Arrhythmias are common (atrial fibrillation) which can then trigger heart failure and low blood pressure. Each blow contributes to overall fatigue and even outright delirium. Such patients are as complex as any we ever see in the hospital.
ICU Nurses are Tougher:
My colleagues and I have been in awe of our battle hardened ICU nurses. They have literally been in the trenches from day one. Coming into the ICU was a scary experience for us. From my first shift, I could see that these nurses had their "game face on." Their attention to detail was stellar and they were always on point. Despite their clearly superior level of experience in patient care, I never felt anything but support. They were never condescending. We quickly learned to work as a team. What I lacked in knowing the intimate details of how to care for each problem, I was able to help them in understanding the overall disease process and why such problems were occurring. When I was asked what I would miss most about working in the ICU by one of the nurses, I simply and easily replied, "working with all of you."
Power in Partners:
Though the idea of working in the ICU was a bit terrifying, we quickly learned and remembered that we know how to care for complex patients. We do it all the time in the office, they just aren't critically ill. It really was like reliving my days as a resident physician in training. I did learn that I am getting much too old to do 12 hour night shifts. Luckily, I found younger colleagues who were willing to trade those for day shifts with me. Even though we never worked side by side with each other, we worked as a team. We scoured each other's notes, gleaming as much information from the chart as we could as we quickly got up to speed when coming on service. Handing off the patients well to the one coming on for the next shift was crucial to providing excellent care. Those conversations were laced with an emotional understanding of what the next one would be dealing with. It was a comfort to never feel uneasy about the physician coming on. When we would see each other in the doctor's lounge, we now had so much more in common. We were all in this together. When we started, our physician leader texted, "We got this!" We still do.
Compassion is Key:
Every patient has a story. Every patient has a family. At the beginning of the pandemic, doctors would rely on nurses to examine the patients and use telemedicine to communicate with the patients to minimize risk. As time went on and we could see that our personal protective equipment (PPE) was truly effective, we were able to spend more time with patients. Despite the constant hum of the negative pressure fans, speaking through thick N95 masks and face shields, the patients truly appreciated a quick conversation. Families who were desperate to know details of their loved one's condition were so appreciative of each phone conversation. The nurses were excellent in giving daily updates. Part of compassion is understanding when we have done all that we can do and having the difficult conversation to provide comfort rather than prolonging the dying experience. I am passionate about allowing family to have time to say goodbye and ensuring that a patient is comfortable in their last moments. Any dignity that can be found in death is worth the stress of seeing one pass on.
Staying Strong:
Resiliency is measured one bite at a time, hour by hour and
day by day. Working in the ICU was no
vacation from our usual practice. My patients still required ongoing daily
care. Thanks to my awesome team (see
previous blog), we were able to do this together. I couldn't allow myself to look too far
ahead. It was too overwhelming. By
taking it one shift at a time, one patient at a time, I was able to keep
going. It is the same as my professional
life has ever been but on a much higher scale.
As we come out of this pandemic we all need to pay attention to
detail. It will literally happen one
mask and one vaccine at a time. It
requires persistent vigilance so that we never have to open up another
emergency ICU again. We are all in this
together. "We got this!"
