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When good nursing care is not possible during a pandemic, what happens to patient outcomes? Makenzie tells her tales as an ICU nurse in NY as we explore the role nursing care plays in saving and restoring lives.

Episode Transcription

Kali Dayton 0:28
Makenzie, thank you so much for being with us on the show. Tell us a little bit about your experience or your early nursing career before going to New York.

Makenzie 0:38
Okay, so I started as a nurse on a step down and ICU stepped on floor, which was great experience. And then my first experience as an ICU nurse before I went to New York was in an ICU where patients are awake, and they walk and work with physical therapy on the ventilators. So that was that’s kind of my background before going to New York.

Kali Dayton 1:01
So then after that experience, what was it like to be thrown into the one of the worst COVID-19 hotspots in the world?

Makenzie 1:09
It was insanity, just completely different than everything I knew. It almost feels like it kind of goes against everything I was taught to do as a nurse, and what I felt like I should be doing for my patients as a nurse, so it was really hard. It was a hard adjustment to to go there. Definitely. But yeah, it was just people describe it on social media as like a war zone or the group of people I was there with called it cowboy medicine. It actually fits like that’s really what it felt like.

Kali Dayton 1:48
Yeah, last episode, Dr. Harris talked about the difficulties and staffing ratios and the hospital she was at nursing care was for patients on ventilators, sometimes CRT machines on top of that to one nurse, what was the what were the staffing ratios like for you? And what point did you come in to that hospital.

Makenzie 2:09
So when we got there, to the hospital, we were at the administrators were saying that we were kind of at the tail end of it that things were starting to slow down, which almost seemed comical, just with the like, level of patients that they still had in how things were functioning, I was lucky enough to be in a hospital where the icy ratios were still two to one ish. I know there were other people that I went out there with that were at different hospital systems and their ratios were higher like five to one on the ICU. But where I was, we were two to one. And if we had a third patient, they would give you an extra nurse like a step down nurse to help you. But they were still inappropriate loads, you would have multiple patients on CRT, which back where I work is a one to one load or ECMO patients in two to one loads. So which seems really, really unsafe. So there were still things like that that made the ratios harder. And yeah.

Kali Dayton 3:12
And what did you see? Were the impacts to patient care, because of those loads, or just because of the crazy acuity of the patients and the crazy situation. And it was what kind of impact did that have to patient care.

Makenzie 3:29
Patient care suffered severely due to the situation there. I’ve never seen….I’ve never seen patients being cared for that way. I’m lucky to work where I do and have all the resources here that I do. But that was probably one of the most shocking things was just the state that these patients were in. And I don’t think that it was malicious or anything like that. I think those nurses in New York are amazing, and they’re doing the best they can. But those patients suffered. All my patients had bed sores. All of their mouths were like bleeding or pissy just due to lack of oral care. They weren’t getting turned or a position. They weren’t moving at all. Yeah, I’ve just I’ve never seen anything like it. It’s really an awful thing to say. But most of my patients, I felt like I was just taking care of corpses or like zombies. That’s what they felt like.

Kali Dayton 4:29
And I’ve heard nurses say that. That must be so traumatizing for everyone. And so I’m just I’m in awe of these amazing providers that have stuck it out there that have been there for seven plus weeks or however long, hardly any days off and doing that day in and day out. And so none of this is against any nurses and if anything, it’s just an awe of those that have stuck with it for so long because it’s been hard to keep staff healthy or able to endure all that kind of hardship.

But it is important to recognize what happens to patient care and patient outcomes. You know, you came into a situation where especially in New York when things hit… the talk in the ICU community was to intubate after six liters nasal cannula, which automatically meant, because of our sedation cultures, and the desperation of the situation there, that these patients after six liters, were being deeply sedated and immobilized. Right after needing six liters nasal can’t nasal cannula. So you came in, however long after to see the effects of that kind of practice in the care. And what did you see as for patient outcomes?

Makenzie 5:53
They were corps when I was in New York. They had been dealing with this for six weeks. That was kind of the timeframe. And most, no, actually all of the patients I took care of had been intubated for at least three weeks. So I didn’t have any new patients. They’d all been there. They were established in the ICU, I guess, they were well known.

But yeah, so they’d been there for three weeks still on sedation still on. Versed and precedex. Lots of versed drips, actually. Yeah, so they were still sedated after three weeks and not moving. The most I had a patient move was just the right hands, they could lift their hands. And that was it. No one was really restrained, because they just couldn’t move. They weren’t going to go for there tube, because they were so deconditioned and delirious. None of them could interact with me. I had one patient that would open his eyes when I talked to him. So that was really hard. But yeah, that was the most interaction I had with a patient the whole time I was out there.

Kali Dayton 7:02
So at that point, after three weeks, their lungs are getting better, most of them, right?

Makenzie 7:07
Yeah, I mean, everyone was really on minimal when settings they were on 40%. And like five or 10, five of peep. And that’s their minimum, like they don’t go lower than 40. But no one was getting extubated. Just because they were so weak that they wouldn’t be able to protect their airway. They can’t even lift their head. So they weren’t getting extubated. They weren’t weaning ventilators. Patients were, you know, hyper oxygenated at this point.

Kali Dayton 7:39
And yeah, you mentioned a blood gas.

Makenzie 7:42
Yeah. So I had a patient that I drew a blood gas on ran it, the Pa02 was 300. And I showed it to the NP there. I was like, “Hey, here’s this blood gas.” And she was like, “Amazing!” and was like showing it to people. She said, “Look how great my my girl’s gas is! Look how good it is!” And I was just like 300? Here if we have a blood gas that’s like at their like- wean.

Kali Dayton 8:06
Yeah. Let’s get ’em moving.

Makenzie 8:08
Yeah. So they weren’t waiting. The ventilators which we think was a big problem, why they couldn’t get them off. And then after three weeks of this, of being deeply sedated, being intubated, they would just be like, well, let’s treat them without even trying to get them off.

Kali Dayton 8:25
And so no physical therapy on them. No one was trying to move them. And you said that they’ve been sedated. But today she was coming off at that point?

Makenzie 8:33
Yeah. So I didn’t see a physical therapist work with any of my patients the whole two weeks I was there until the last day. So that was the only physical therapists I saw. And I was like, “Amazing! Thank you so much for trying to work with my patient!” But yeah, so that was the one time I saw physical therapist, I had a lot of patients that we had weaned off of sedation that still had just delirium that weren’t waking up, weren’t arousal. And they weren’t on sedation, at that point.

…and that can go on for a long time. And then what happens after they get trached?

They try and send them out of the hospital to like an LTACH. I think they were trying to make a floor in the hospital where they could send these patients that didn’t need ICU care anymore, like a step down that could take these stable trach patients. But yeah, they were trying to send them to LTACHs. I did have a patient they were trying to transfer that had gotten tricked, but they were just spacing like back and forth with the facilities because they didn’t want to take patients who are still testing positive for COVID, which my patient was still positive after three weeks after getting trached. So yeah, it was just kind of up in the air about where they were gonna go.

Kali Dayton 9:47
So no physical therapy coming and, you know, mobilizing patients isn’t necessarily an ICU skill set for most nurses. We, as ICU nurses generally titrate drips, turn suction, do thothe things but moving an adult newborn, a 200 pound floppy, weak, debilitated newborn is not in most nurses’ skill sets. So these patients were just waiting to move on to rehab at some point. If they woke up or qualified to go.

Makenzie 10:22
yeah, that’s, yeah, I mean, I don’t know how they would have ever gotten back to the quality of life they had before just because of how deconditioned they were. And then, with a trick, a lot of these patients that had been trach’d are still on trach vent. So they were still needing to be ventilated. And I don’t know, they would go somewhere where they would never get the rehab that they needed, because no one would be able to move them.

Kali Dayton 10:50
So what has this taught you or how has this impacted your perspective and your practice as a nurse moving forward?

Makenzie 10:59
I feel like my biggest takeaway from this is just the importance of nursing care, and mobility and our patients. In nursing school, my instructors, I remember, they would always tell me how important it was that I get my patients up and walk them. And that I turn them every two hours, so they don’t get sore, and nutrition. So they can heal.

And those are all things that we know. But in the ICU, normally those things are at the bottom of my list of things to do. Because you know, airway, breathing circulation, the important thing is to manage the drips, make sure they maintain their airway anyways, especially in a crisis situation, like it was in New York, those things literally did not matter. They were not doing any of those things. And so I’ve I’ve seen with my own eyes, what happens to patients when they aren’t receiving nursing care, and they don’t get better. No matter what the physicians are ordering. It’s, it’s… may or may not be reaching the patient because of nursing care. And that’s what’s making the biggest difference here. I’m used to my patients getting up and walking. But there I really saw the detrimental effects of, of no mobilization in the ICU.

Kali Dayton 12:25
And sometimes that’s the biggest way to learn is to see the complete opposite and to such an extreme that I hope that the rest of the country doesn’t imitate or doesn’t have to breach. Hopefully we can continue our good practices, but especially with our sedation and mobility. We’ve been so worried about this being a different virus, that a lot of our discussions have forgotten or excused the basics that we know, get people better and give them quality of life. How have you seen now that you’re back, the outcomes be different with even our COVID patients?

Makenzie 13:01
I might cry when I talked about this. We had a COVID patient that was here for a long time he was COVID Positive was intubated, as at one point sedated and paralyzed. And I took care of him before I left for New York. He was on high ventilator settings, he was sick, needed a lot of support. Anyways, after working a few shifts in New York, I really wanted to come home. And I had a day off. I remember sitting in my hotel room and I was checking my work email. And I had gotten an email from you about this COVID patient that we had all had taken care of throughout the weeks talking about how he discharged home.

And how he walked out of the hospital. I literally sat in my hotel room just crying. Because it made me so happy to know that I work in a place where we help patients get better. And I didn’t feel like I was helping patients get better in New York. I felt like I was just prolonging their sickness, like I was just trying to get them through the next 12 hours.

But here with the limited sedation and early mobility that we focus on, we really helped patients retain their quality of life. And so hearing about that, while I was gone kind of put it in perspective and helped me realize kind of what got me through my last few weeks is just thinking about that and that if I could just do one thing for my patients every day that I knew wasn’t getting done, whether it be oral care every two hours or making sure I turned them that it would be worth it because it wasn’t getting done without me. So yeah, that kind of changed my experience and it’s definitely changed my opinion on sedation in the ICU.

Kali Dayton 14:57
We need your voice You were going to do so much good for our ICU community and especially in even in our unit. Thank you so much for sharing all of this and for going into that kind of battle zone and doing your best and you should be proud of everything that you’ve done, and will yet do. Thanks so much.

Transcribed by https://otter.ai

 

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