Two Weeks’ Time: essential worker part two

Today’s essential worker works in administration at a storied LA based hospital recently acquired by a medical group and experiencing the strain of transition.  Their back ground is as a charge nurse in the ER till their back gave out lifting a dead guy out of a two-door car a few years ago.    I first met him up in the mountains above Big Bear a few years back when he showed me how to cook bacon in the oven.  We bonded over our affinity for logistics.

I asked him to walk me back to the day it all began for him and didn’t say another word for about an hour:

“Where to start is sort of an enigma of itself…”

“I decided to lower my life stress level and get off Twitter with all the political, you know…  and that was also when we were getting reports of how virulent this was and how quick it was spreading.  Now, I don’t know a lot about geography, so we were wondering how they are sealing borders and I realized there were positive reports in different countries, something is being passed around – and my awareness started to grow – everyone’s communally engaging in discussions on a group chat I am a part of with fellow clinicians, we start hearing about a couple cases, issues of screening and how they are evolving, now we get cases in California, my fellow employees start paying attention, there are hints, rumors, things like a possible Korean Airlines stewardess, things not too far away from us, indication that this is close, closer than we think…

“I start paying attention to the day-to-day, elderly, the data, it’s a severe flu they say- so I’m like okay, this is still manageable, and as the days go by– normally, I’d be on Twitter all the time; I would be following all kinds of data and —  but, I’m trying to keep my stress low – directed to keep it low, because I get migraines,  sometimes four to five days a week, on top of that, I got sick with a regular flu – I’ve been fighting this flu for two months, always have this cough, so, at this point my stress level is starting to build, ’cause I start thinking about how this is going to impact us at our hospital, and in our city, and it was when that nursing home in Washington has the large outbreak in just a couple days–  I can’t remember the exact number – there’s a lock-down and a cluster and only in a couple days and I’m like… that’s not normal  —

“Now, this could be a personal bias and I’m not versed on influenza data regionally – but influenza data – that is based off one patient, not a cluster, then California gets it, and then the state gets involved, directing people and doing basic governance, and it wasn’t till about two weeks ago when Gavin Newson puts non-essential businesses on close down and I was– back when I was deep in Twitter – constantly feeding information, data, from sources I was following – and I’m not following anymore, ’cause I’m trying to cut Trump out of my psyche, ’cause it’s like a parasite in my brain– and, of course, there’s no overall response from the federal government – and as of… the week before last – when Stay At Home was issued- we start building our own directives at work… two weeks ago.”

Two weeks ago.  Time takes on a whole new measure in war.

“We were just talking about what our directives are when patients arrive and at the nursing level, they’re starting to anticipate problems – and we are already starting to get reports that people are starting to take masks home, gloves home from work–

“I used to be at the bed side– so, you assume the worst – if someone comes in with a fever and is coughing, you don your PPE ’cause you don’t know – until proven otherwise – but still you protect yourself.”

“I come in and… why are people stealing things?  You shouldn’t be stealing boxes on boxes of masks and boxes and boxes of gloves… Administration gets involved and says, ‘please, don’t.’  It creates an uneasiness and anxiety… translating  hospital-wide now.  I mean, reports that physicians, not x-ray techs or cleaning people or… physicians are breaking into surgical suites to steal supplies to protect themselves: N95 masks-”

“I don’t know the quantities, but at this point, our directives are to screen for patients who might trickle in… are: fever, shortness of breath, coughs, and travel to and from China.

“Obviously, we don’t really worry about that, because during Ebola, for example, there were two or three, so there shouldn’t be a … but there is…”

“That’s a typical thing with outbreaks to screen for travel – but as we were shifting our directives when we see how this thing travels – the travel screening is still in place.  But in my head the travel thing is already a non-starter, as someone who has an education in the medical field – I don’t have the data, but once you have people getting infected in our county – it’s now a communal thing, automatically, but we keep hearing screening still involves travel and I’m like, ‘this is dumb, counter-intuitive to proper screening…” Multiple cases in Orange county, San Diego, San Francisco… and I’m talking to my own team– can we drop the travel as a screening tool?  Even though it was a directive – Doctors think it’s ridiculous and they are kind of ignoring it, too… we get the worry that it won’t be a trickle, but an influx, we will see cases, it will happen… maybe not one or two, but who knows how many…”

In two weeks. 

“Today, we are not thinking how many are we going to get, but, how much space are we going to have for regular patients – in two weeks’ time – that’s exceptionally intense to have all of that feeling, that pressure in two week’s time.  The stress I have been feeling and trying to manage…

“I have family members in the medical field, my own daughter and partner to care about… Ten days ago, I sent them to my folks house in Moreno Valley – ’cause we had our first case.  That patient was within my census– I was talking to nurses who were working with that patient, so… I have to take some caution, so I’m texting them,  ‘you should go now… should we wait for you…?’  I’m like,  ‘no.’

“At the time, I didn’t get to say a formal goodbye…”

“It was the right decision to do, and the right call to make, ’cause you don’t know – people can be carriers for five days, at least  and now show- at this time, and we hear reports the data is mostly, majority – mild to moderate symptoms.  Multiple countries are inundated; Italy, Iran, Spain… I lost track.   So many grossly impacted… Germany is closing its borders.   All these countries are feeling an impact, and we talk about mortality rates – we fear this… okay which rates are the true reflection of their health care system or the virus itself…

“I think ’bout how is everyone’s system going to respond to this – because it’s literally random, till we have more information.  But there must be some logic, but we don’t know yet – we don’t have the science yet, how it has been functioning.  But I don’t have the energy, the commitment to read up about it after work ’cause I need to rest in between…”

“I don’t have any faith that my daughter and myself and my wife will respond mild to moderately, so I make that call before.  Rather than…”

“I am on a chat group with other clinicians, and we commiserate, crack jokes on each other, now since this has been hitting, we communicate changes  on each other’s health systems – interpreting ongoing data from WHO, CDC and news and experiences from different hospitals and they are telling me – ’cause again, I’m not getting my news … I hear about the gentlemen at Huntington who died, almost a week ago.

“So far, the reports say he is a 34 year guy with a history of smoking and testicular cancer – no COPD, diabetes, nothing. Hashimoto’s,  or Parkinson’s light, no IV drug use, or chronic drug use… just a regular guy.”

“And we are like… why?”

“Everyone’s is dumb founded, social workers, respiratory workers, clinicians on the chat and we are all,  why…?  Why this guy? And at the same time, all the potentially misinformation,  and this hits – and we are all like, what the hell happened?”

“We hear other smaller cases, about the seventeen year old – asked the CDC to investigate this one – but now one of my social workers on Wednesday texted me he heard about a seven month old baby who had to be isolated from their parents – maybe the parents chose to be next to them – the numbers in LA start growing – and the Governor puts us on a safe home order – true lockdown – and now everyone in our group is feeling this stress.”

“One of my doctors shared with me – he’s a little quirky – he told his two kids, ‘I want you to know that if I don’t make it you are going to be okay.’  Looked them in the eye and said,  ‘I want you to know this is serious, that If I’m not here, mom will take care of you.”

“And they are between six and ten… But to have to say that…”

“And I get where he is coming from.  I know their kids are old enough to have some awareness of this – but with me,  and my daughter… I know I have asthma – I’m at supposed higher risk, but would it be better if my thirteen month old daughter who has no consciousness – would it be better or worse if they not even know what loss means is if ….

“The characteristics of dealing with the experience of that is on my mind, but at the end of the day, I’m dealing with what we can do, right now job-wise.  It is stressful to hear we are short on PPEs.  My frustration is with my administration – our own hospital does not know what our essential supply counts are – because of becoming a part of a larger group of hospitals we don’t…  we don’t know what’s our bleach stock.  We know those are low, but they won’t tell us how much, how low are our N95?  Hairnets, gowns… How low are our counts, for our bed side nurses to do their jobs safely …

He goes quiet.

“We have a… what feels like an increase of people who have come in and coded and died.  We are a hospital, people die all the time – we filter out faster now – our census has dropped from about 315 patients to 165 patients to keep it at a bare minimum, so we have room for this influx.   The amount of people are less, but (it feels like) many people are coding and going into cardiac arrest.  It is increasing and these are people who are not confirmed, but ruled out.”

I interject to ask them to clarify what ruled-out means in this case.

“A rule out says a test was done, but we don’t have the results.”

“We grade patients on symptomology, but it is alarming…”

Because the directives are changing, the symptoms are changing, broadening.

“And the… (nature) of this test – the competency, describing how confident we are that this test is positive… is sixty percent accurate.”

Sixty percent.  I ask him to help me better understand, or try to:

“…the other forty percent of the time that means a test is a true negative or a false negative.   The competence of the test itself, the sixty percent competence, means that two out of five patients will have the infection, but the test will rule negative.”

“Which is not great competence.  Usually, you want eighty percent. So we are basing a lot of our procedures on sixty percent… the growing stress, we are basing a lot of our plan for isolation and whether someone goes home, long term acute, or health units…”

On a test that is accurate sixty percent of the time.

“We can’t do that without guidance from department of public health…  and if about a quarter of our census (which means hospital population) are ‘rule outs’ or ‘positive,’ that means we can’t do CT Scans.  Without a pure negative test – we can’t put them in an MRI.  Without a negative test- we can’t do the things…”

I put it together in my mind.  And that slows the discharge down.  And keeps beds occupied in a holding pattern where staff burns resources, I was starting to get it.

“To clean that MRI machine every singular time in between, I mean…  Regulations say with bleach, let it sit for five minutes.  Then after (letting it sit) you continuously wipe it for another three to five minutes… every time.”

“We can’t do that, unless we can ‘rule out’ – but how can we rule out if our directives keep…”

Again, a little silence. 

“If they come in for… altered state of consciousness, you know, have a fever and general malaise, but we can’t do that MRI till we get a test result; and that may be a false positive… They sit, for four to five days, and the whole time are transmissible.  Everyone has to gown up.  It consumes supplies.”

“With all the growing patients we have… I mean,  till we get a negative test… The confidence of which  is not great so… we could still be… you know?”

“But we are just going to go on.”

“A compounding issue for our hospital, as you start to see the exponential usage of supplies, is delay.  And because of these delays…”

He goes quiet again. 

“There are about 26,000 hospital beds in the entire county of Los Angeles, and that’s for ten million people.  Ten million people.  And 26,000 beds.  That’s crazy.  The available beds we have, according to what the Mayor said, the ones we have left are 1500.  Today.  1500 beds.  For all the other stuff.  Anything that can come in.”

“And now our cases have grown.  To several thousand, and the ongoing “Safer at Home” order is there…

He laughs.

“But as far as I have seen…  There are still plenty of people on the road.  Plenty of people going shopping.   Doing their exercises to distract themselves, stay normal, feel human…”

“We have our first confirmed homeless patient that is positive, which is a whole new bit of chaos. There is not enough reduction of movement to flatten the curve as it has been broadcasted.  Not enough.  Not to where we can’t anticipate a moderate spread of this disease pattern, and we are still going to be impacted.”

“I don’t know if opening up that USS Mercy – don’t even know what it is going to be used for – don’t know exactly what the plan is – that will be developed over the next week – we are shifting our own room assignments.  Designated units for isolation at first are now…

“We have entire floors.  The fourth floor is an isolation ward.  I mean, every day this week I have gotten different instructions on how to discharge patients – new directives, new information, from our new ownership, updates multiple times a day, trying to keep up with information.  Home isolation guidelines. How to interview people, how they can isolate – – there’s one guy who is not at all susceptible – he’s got some severe unrelated issues, but his wife has been exposed.”

“How do we get him home and discharged, if his wife has been infected and no one’s taking anyone?”

“That will compound when this wave actually hits.   In getting patients out.  I had a grueling discharge – trying to get family members calm  for an hour as I’m also divulging my own personal information, saying that,  ‘listen  the hospital is going to be an inferno of infection at any moment.’ That they need to have them home now…”

“Trying to keep my head on, my stress low, so I don’t get migraines – not to think about my own family and my own exposure, and all the bed side nurses are asking me questions- and my own administration  restricting information so not to create a panic and let everyone remain professional… as we all move through this, this, this in a rapidly changing fashion… and not trying to lose my job cause I’m fortunate to have it, is a….”

“This type of thing was theoretical.  But never realized.  And I still have to show up and be diligent for these patients.  And part of it is frustrating on the human level.  It is easy to see people, you know?? At Target.  The parking full, or as full as before this broke out… and people on the trails… It’s hard.  When you know what you know and hope and scream at everybody, ‘I don’t want to take care of your ass when you come into my hospital, but I will!”

“Metaphorically, you want to slap them in the face and wake them up.  They are upset that they’re displaced cause they can’t go to a watering hole, go to a movie.  It’s frustrating to see this and know what  I know.”

“All the financial fall out, economic activity, shifting resources for a while, people are going to default, lose homes, businesses.  We will shift our framework to online services  – we may become less personable, because we are going to be afraid.  This is going to shape our society for a while.”

“But at the same time, I have to focus on the now, and the now means you need to stay at home unless you are really sick.  At some point, we are going to hit a peak here.  I don’t even know yet. We haven’t even hit a moderate level  at my hospital.  But we are not prepared.  The C.O.O. is trying to buy hospital supplies at a premium rate,  so they have something.  But they’re buying for the whole system,  all the hospitals, and we are not sure if it is coming to us.  That is info I need to know.  So we can know our limitations and stretch them out further.  We have to be part of the conversation, ’cause it’s our lives at risk.”

“We all know our lives are being risked, we knew that when we signed up, but we need to know what we have in order to…”

“Other systems are more inclusive, and I get it, HEPA laws are what they are, but we need to know infection rates, real infection rates…”

I never thought about patient privacy rights would factor into the new normal.

“It’s just stressful to think about what is coming … we have a wave that is just hitting us now… this two trillion dollar package seems semi bogus, until we feel it on the local level. Thank you for publicizing it.  It is good PR for you.  Now I can see my 401 k is being devalued a little less then it was, great, thank you, but that doesn’t mean anything to me now cause I’m not retired tomorrow, I’m retiring in thirty years.  I want to live to see that retirement.”

“So how about you fork over some money… to get masks over… gowns over; and get them over to major cities.  Cause it is in all fifty states.  Every one of our United States of America.  Every state is feeling some type of pinch right now.  Every continent is feeling it.  India.   South Korea is top of the food chain in terms of how they are demonstrating  we should be treating  citizens.  Fifteen thousand people a day.  Granted, they are not the U.S.,  but we had these numbers months ago and nobody acted on them .. no shift in production, directives, from public health, C.D.C.”

“Just insider trading.”

“It’s really disheartening. There could have been action taken way before it hit our shores.”

“The hospital is going to become one big isolation (unit) once this… … And compound that with dwindling PPE supplies… I mean, we are just a walking-stationary-high-risk-for-transmission-locale.”

“That’s being dramatic, but where are they going to come from…? (Resources) A hundred thousand masks?  It is drop in the bucket of what is needed in California.  A hospital can go through seven hundred a day.  Just our hospital.  One of my colleagues said she had  to wear the same mask for a week.  The same one.  It’s hard to get one in general. We sequestered masks in each unit, with the department supervising nurses in charge, and you have to have a need to get a mask…”

“We had a patient in an acute rehab unit.  We discharge to another unit, six days later he is positive.  After his initial admission– no signs of anything,  and then six days later…”

“All the people he has been around during his admission, nobody knew.  Just hand washing, you know basic bed-side… He was working with dieticians, physical therapy, attending physicians, x-rays, CT scans…how many different areas of the hospital he was going into, none of us knowing he was positive… so, it created a mini-panic cause word travels fast.”

“Right now, we got a directive, if you have symptoms, you have to self-isolate; no mention of being tested – whether the test is necessary or even competent…”

There’s that word again.

“I’ve had two colleagues in my chat group who are positive.  Now they can’t come to work; that’s two less people who can come to work and help others, now we are facing a human resource shortage.   We don’t have people to treat the people, so if we don’t have people to treat the people, we can’t take the people…”

In the silence, my mind fills in the blanks.  I resist the urge to time travel and listen.

“We have to stick to ratios, nurse to patient ratios.  Now, we’ve done away with some restrictions; you used to have to use one mask-per one room-per one patient– Now… you can keep that mask, as long as it is not compromised or soiled, and continue to wear it.  People are wearing them for hours, I mean…”

“When we start losing health care providers, x-ray, ultra sound, when do we crack that bedrock of that ratio…? Because community demands are compromised… and I don’t know, it’s all theoretical.  Are we dispensing with that?  (He speaks of the golden ratio of nurse-to-patient standards).  If all the patients are mild to moderate, and they don’t need a vent, or to be intubated, what we call telemetry monitoring… well, you could theoretically have one nurse… one nurse could moderate ten patients.   If we are stretched so thin because a lot of our clinicians are self-quarantining… it could… we don’t know.”

“Our capacity is  220 beds.  Do we get agency nurses and pay through the nose – with the premiums, and our capacity is compromised beyond- do we flex this ratio – one to seven, one to eight – no one knows.”

No one knows.  I think that’s the big take-away from my conversation.  What is going on now from someone who is there to witness it.  As it evolves.  No one knows.  My own doctor said the same thing when I went in for my yearly physical.  No one knows.

“Will it be seasonal, or…a really long year.?”

“Will it crash in the water, or when the curve flattens, and people go out and we hit another wave… and it’s another spike and flux again – no one knows.”

“This is all so random and out of control, we don’t know. ”

“We haven’t hit any staffing crisis yet, but we are in the first wave – New York is being hit super hard, symptomology is changing, and… how do we screen if symptoms change…

“Like my directive does not involve abdominal pain and diarrhea – nowhere does it say abdominal pain and diarrhea – but those are the new … so many inconsistencies and changes all the time I don’t know how we can keep up.  Every day is just a day.  I get home, clean my belt, glasses, shoes, phone… dump everything into a separate container,  jump in the shower and hope I didn’t expose myself.  That I did well enough.”

 

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