In mid-March, the day before I flew back to New York City to return to work as a pediatric intensive care unit nurse, my brother, an emergency physician, urged me to quit.
Stay in Chicago near family, he argued, and find a job in a local hospital. That way, if I were to contract Covid-19, my brother could manage my ventilator. And if the city ran out of ventilators, he promised he would manually ventilate me. In retrospect, that’s a very loving proclamation: to personally squeeze the breath into me hour after hour. It would be a tiring, impossible task.
But in the moment his comments made me angry. I wanted him to give me calming platitudes before I flew into the epicenter of the pandemic, not fan the flames of my fear.
I was definitely anxious during my first weeks back at work in New York. The environment in the hospital was chaotic and fraught with unknowns. By April the situation had become clear. One of the worst-case scenarios had happened: Adult intensive care units were already overwhelmed and our pediatric intensive care unit (PICU) was converted into a general Covid-19 ICU to care for the overflow of patients.
Once we were in the thick of it, I no longer felt scared. The morale on the unit has never been higher and, strangely, I’ve never been so eager to go to work.
A recent study published in the Journal of the American Medical Association showed that among Covid-19 patients between the ages of 18 and 65 in New York City who were put on ventilators, 76% eventually died. In our unit, we successfully removed 18 patients with severe Covid-19 from their ventilators. And so far, not a single patient on our unit has died from the disease.
How have we achieved that kind of success? To our advantage, we get younger patients. At first, patients in their 20s were mainly admitted, but then we began caring for patients well into their 40s. Another contributor is that the patients transferred to our unit had to be stable enough to survive the transport, so we received the relatively “better” patients, those who had a shot at surviving.
That said, our patients are extremely sick. Many of them have underlying health conditions like obesity, high blood pressure, and diabetes, each of which increases the odds of dying from Covid-19. We have cared for several patients who many of us were sure would not survive — those maxed out on ventilator support, on multiple intravenous drugs to sustain their blood pressure, and on machines to do the work of their kidneys.
I can’t say for certain exactly what accounts for our success rate, but I know that our staffing ratio has made a vital difference. In our PICU, each nurse still cares for one patient, at most two. In other hospitals, the unprecedented volume of patients and shortage of staff have meant that nurses are caring for as many as four ICU patients at a time.
Being responsible for four critically ill patients is extremely difficult, a recipe for error and unavoidable neglect. And the makeshift ICUs created in operating rooms and procedural areas are largely staffed by redeployed nurses and physicians who aren’t trained in critical care. Mistakes are inevitable.
During the Covid-19 crisis, much of the national focus has been on the number of ventilators in hospitals. There’s no question that having ventilators on hand is important. But in order to work, these machines require highly trained professionals to constantly adjust their settings, respond to sometimes incessant alarms, and frequently suction secretions from patients’ airways. Without enough nurses, respiratory therapists, and doctors trained in critical care, the number of available ventilators is almost irrelevant.
In our PICU, the staff is plentiful and all are trained in critical care. There are enough of us to turn our patients to prevent bedsores, give them chest physiotherapy to loosen up secretions in their lungs, suction those secretions, and carefully monitor and adjust their medication drips.
The appropriate level of staffing also gives us the luxury of time. I was able to reassure a woman by phone that we were treating her husband as if he were one of our pediatric patients. I constantly had my eyes on him and was ready to rush into the room if he was coughing on his breathing tube or in distress. Since we care for just one or two adults at a time, we can provide all the clinical care they require and still have time to hold the phone to a patient’s ear so she can hear her husband say, “I love you.”
Because of the care we have been able to provide in the PICU, a policewoman in Washington Heights will get her husband back, a 2-year-old in the Bronx will grow up under his father’s watchful eye, and a graduate student will return home to his family in Lebanon.
It’s impossible to know what percentage of patients in New York City during the surge died from Covid-19 and what percentage died as a result of an overburdened, short-staffed health care system. But the success rate of our small PICU offers a clue.
When my dad drove me to the airport in Chicago in March, we rode in silence. I wondered if he was feeling the same way he did when he drove my brother to the airport for his tours of duty as a soldier in Iraq.
Although I’ve never been to war like my brother has, my work in the PICU offers some glimpses into what it is like, with the strong sense of camaraderie, a necessary illusion of invincibility in order to do the job, and a collective mission we are all intent on achieving. And because we have had enough soldiers and resources so far, we are doing just that.
Emily Williams is a registered nurse in the pediatric intensive care unit at NewYork-Presbyterian Morgan Stanley Children’s Hospital.
What a beautiful story! I wholeheartedly agree with Emily regarding having enough highly trained staff in critical care .
Precisely and accurately written during these unprecedented times. Having been a NICU nurse for 20 years I will tell you that ICU nurses have always had a certain camaraderie and innate ability to bond when their units are overcrowded . It’s in our DNA. You stated so well the palpable rush you feel when you do your job and do it well. As a pediatric nurse of 45 years (now in peds heme/onc) I was briefly deployed to a non-covid PACU of ventilated, trached and dialysis dependent adults. I was able to suction and give chest physiotherapy and turn and tube feed. Make no mistake however, I was not qualified to tweak the drip rates and add or take away multiple IV medications to keep those patients hemodynamically stable. Like you our staffing was excellent. I did the other jobs and let the nurses qualified in those areas do their job. I hope I made it a little easier for them. I can only hope that people will behave appropriately with distancing and masking so that the numbers never get to this level of acuity again. In that way the proper professionals can do their jobs appropriately well. Thank you for bringing attention to this most crucial of all matters. Consistent evidenced based care appropriately administered. Proud to be your colleague and the mother of one of your close colleagues.
Even in “normal times” studies have shown that adequate nurse staffing results in lower mortality rate.
Your eloquent description of high quality care reveals the truth of technology- qualified professionals are essential to care. The knowledge and compassion humans put into care are essential to good outcomes, not the machines alone. I fear the staff in NY, unable to respond to overwhelming needs, will be damaged by moral injury and not return. At the beginning of the pandemic in the U.S., I was bemused to hear of wealthy people purchasing ventilators and even inquiring about ECMO machines as covid spread. The gear without the staff is useless.
Emily, what a personal as well as professional take on the rigors as well as pitfalls of caring for Covid-19 patients! Your hometown neighbors and friends salute you!
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