Into the COVID-19 Fray: An Interview with an ER Nurse

Ebola test laboratory in Liberia, Image courtesy of UNMEER

This interview was recorded on the 03/20/2020 weekend.

JAV: How was your shift today?

NURSE: It almost felt more normal than I expected it to, I guess. There’s this combination of…and I feel bad saying this…ignorance, panic, and self-entitlement that we’re seeing that’s really difficult to deal with. But then, at the same time, we’re kind of used to dealing with this already. I think some of the staff, even among medical people, you’re getting some of that panic where people want all the [personal protective] gear even if they don’t need it to be in that room, or they’re a little hyper-paranoid. And there’s actually a lot of people calling in sick because they just don’t want to be around it. It’s a little crazy. We’re all at home being very careful about social distancing. Everybody is staying home and being very careful about not bringing germs home and all that and then at work all of us are super close together as if it was just any other day. It’s kind of weird.

JAV: How long have you worked as an ER nurse?

NURSE: I’ve worked down in the ER for nine years. I had previously worked in other units.

JAV: How do you think you ended up becoming an ER nurse?

NURSE: (laughs) Almost by accident! When I was a new grad I worked in medical oncology. I wanted to go back to school but the only position that allowed me the flexibility was a float nurse. Back then, I always said, I don’t want to work in the ER. It’s too chaotic. It seems crazy. I like things organized. I like to have my day and plan it but I had a friend at the hospital who kept telling me, come down and work with us…and I just had no interest. That seems like a mess.

(JAV laughs.)

NURSE: So when I was a float nurse they cross-trained me to be in the ER and I kept getting cancelled a lot. I wasn’t making enough to go to school and pay our bills so the only place where I could pick up hours was the ER, and they needed people. As soon as I got down there it was just this like…oh, I’m using my brain again. I didn’t realize how it had become so routine to hand out the same medications, do the same routines, and you never knew what was coming through the door. You could either see a sprained ankle, a baby with a fever, or a full-blown heart attack and have to do CPR on someone. You just had to be ready for anything. And it’s kind of exciting, kind of crazy. Kind of fun…and you work with people who are sharp, and smart, and ready. It was a whole different ballgame. It’s kind of like an adrenaline rush, and I got hooked right away.

After getting cross-trained I think I worked two shifts back upstairs, but I never left [the ER]. I never went back upstairs. I was like, oh, I just can’t do this again.

(JAV laughs.)

NURSE: This is where I belong, and…yeah. I can’t imagine working anywhere else in the hospital now. [pause] I don’t know if it’s what I’ll do forever, but it definitely always has an excitement factor to it…of the unknown. I always describe it as, there’s a fire, and there are people who run from it and then there’s the people who run straight in. ER is the people who run straight in. We see fires and we’re like, cool, let’s jump.

(JAV laughs again.)

JAV: So there’s definitely a difference between an ER nurse and an ICU nurse and a family nurse practitioner, right?

NURSE: Yeah. We’re the cowboy.

(Laughter)

NURSE: That’s how they always put it.

But there’s something fun to be able to take a wild situation and calm the chaos and you…put it in order almost. For me, that’s what I like about it. You get this…train wreck of a situation and you fix it, and then you hand it off to someone else to do the micromanaging of the small things…and that’s ICU’s job. We’re like, hey, we put this thing back together and they’re like, oh god, you handed me a mess in duct tape but then we’re like, hey! It’s still alive, though!

(Laughter)

NURSE: We saved him for you, here ya go. ICU’s like, you made a disaster. ICU’s very organized…and calculating, and precise, and detail-oriented. We’re like, just wrap it up. Just patch it up and move it along. Next!

(JAV laughs.)

NURSE: There’s tons of memes about the differences between ICU nurses and ER nurses and it’s funny because it’s pretty true. We’re wired differently.

JAV: Today I read that there are 75 COVID-positive cases in Alameda County. That was something that was actually comforting for me because I’ve been checking every couple of days the CDC website and also the Alameda County [Public Health Department] website to see how many cases we have here.

NURSE: Yeah, we look at it every day. Oh, today we only went up by ten, and are we flattening the curve?, which is what we’re all curious about. But, of course, there’s going to be a bit of a delay to see the results. We’re still testing a lot. It’s going to take a while because people are still popping up from the beginning when we first started doing this. It’s crazy…the progression this has taken for us. It’s gone from, okay, there’s this virus, and we’ve always had screening tools because there’s always been something every couple of years. It’s Ebola, or the other SARS, or MERS, or this, or that. And we’ve always asked patients: have you traveled recently? Have you been exposed to anyone that you know of that’s had measles, mumps, influenza, MERS, SARS, Ebola? There’s just always the laundry list of…things. And so initially we asked, have you been to China within the last 20 days? Then it turned into anybody that’s been to China, or anyone that has been around anybody that has recently traveled outside the United States. Now it’s to the point that we’re asking if anybody has respiratory symptoms and/or chest pain. Unless your complaint is that you have a stubbed toe or an ankle injury we’re almost ruling in everybody. Everybody. It’s crazy. Everybody is a possible [COVID-19-positive] person.

And we’re taking this approach because our doctors’ group works with other hospitals. Our doctors don’t just work at our hospital. One of the doctors that works at our facility was recently with a patient that came in presenting a heart attack. A forty-year old, presenting a heart attack.

JAV: Wow.

NURSE: They treated him for a heart attack, and they did all the interventions for that, and they admitted the patient. In a couple of days, the patient started to show respiratory symptoms and it turned out he was COVID positive.

JAV: Oh, shit.

NURSE: Exactly! So everybody that had any contact with that patient from the get-go has now been exposed and now has to be taken off of work for fourteen days.

JAV: Oh, fuck.

NURSE: And, so all those nurses, every single lab person, every physician, respiratory therapist. Anybody in the cath lab. Any room that patient shared with—everybody. Everybody…the entire trail. That wipes all of that out. One patient…for fourteen days.

JAV: Oh, man.

NURSE: Yeah… So we’ve had a screener for a good long while now. The screener is a nurse’s assistant. The criteria has widened and now basically it’s, do you have anything that is bothering you from the waist up?—be it chest pain, respiratory symptoms, fever, sore throat, tiredness. It’s almost anything…automatically, boom, you need to [wear your] mask at the very beginning. Our best bet is to start out treating everybody as if they might have it because if you wear the proper protection and start out that way…you can’t be too careful. What’s best to protect yourself is to wear all your gear and to isolate it at the highest level because you can always downgrade. But if you go the other way, and you wear less to start with then now you’ve already potentially been infected because you weren’t at the higher level. It’s easier to downgrade than to upgrade.

JAV: And that minimizes the amount of surprises, which is the biggest thing you don’t want to have.

NURSE: It does, but then you’re looking at resources. That means if we treat every single patient as if they are possible that means every person that patient comes into contact with needs a mask…a droplet mask, which is a plastic mask. Our gear has changed every time I’ve come to work—what we use, what we have. Initially we had these fancy…they’re called CAPRs [CAPR®]. It’s like a helmet you wear that has a plastic screen and it creates its own little negative air zone. It has a battery pack you wear on your belt loop and then these disposable plastic screens that you add to the mask. The helmets are interchangeable but you have your own plastic screen and you would use it and then throw it away. We ran out of those plastic screens…so fast.

JAV: Ugggh, right.

NURSE: Then it was N95 masks. Even the simple masks, early on, for weeks now we’ve had to put them behind the nurse’s desk because people were stealing them. We’re having a huge problem with people stealing entire canisters of wipes that we use to wipe down beds and equipment with. We’ll put people in rooms and we’ve had to completely eliminate visitors because people are stealing the gloves—small, medium, and large—that we have in the rooms. People are wiping out those boxes of gloves and we’ve caught people shoving all the gloves in one bag before they leave.

JAV: Oh my god…

NURSE: Even staff were caught stealing masks. They were stealing them by the box. We have had to hide them behind the nurse’s station and people now have to ask individually for each mask.

JAV: Jesus fucking Christ.

NURSE: The masks thing started weeks ago. Now we’re to the point that today we rounded up all the wipes in the rooms. We’ve collected them and put them at the nurse’s station so that people can’t get them. We’re not allowing people to come in with bags. No visitors with the patients because people are stealing things. The level of panic is…unreal.

I was recently in charge. What we’re doing now in our storeroom is packing one paper bag with your supplies for the next twelve hours. Like, here’s the number of allotted N95 masks, and here’s your number of plastic masks. This is what you get for the next twelve hours. We hold them behind the nurse’s station and people have to come up to the charge nurse and ask, can I have a mask? And they’re like, did you get one already today? Initially it was, these things [masks] are disposable. Then it turned into, oh, save your CAPR® masks, but clean it. We started that a little too late. We had already thrown most of them away, and then we had none. Then it turned into these plastic blue shields that have these foam headbands, and you can wear those. Then it was, okay, you can keep using those but you have to wipe them down and they’re good for 72 hours. So they would send us a stack of paper bags, wipe your masks down, put it in the paper bag, and keep it for 72 hours. Now it’s, if you have one of those, use it indefinitely until they are broken.

JAV: Wow. So the messaging is just changing every single shift?

NURSE: Yeah, every day. Now we’re down to, use what you can. Now they’re starting to tell people, if you have your own bandanna, or your own fabric mask you can use those because they don’t even have simple masks. It’s chaotic.

Today we had these really flimsy…you know like those cheap water bottles? The one’s with that thin flexible plastic you push just a little bit and they bend.

JAV: Uh huh. Yeah.

NURSE: We’re wearing these new masks that have a rubber band on the back, and they’re thinner than that. They’re even telling us, those are technically disposable! But if you want to start conserving them, wipe them down. We have a wire rack shelf in a room where we’re putting them in paper bags and reusing them because we’re eventually going to run out of all of that too.

JAV: Wow…

NURSE: Because like I said, every single patient who comes through those doors, everyone who comes in contact with them needs gowns, simple masks. We’re using expired N95 masks from the manufacturers. They quality tested it supposedly, but they’re expired because we ran out a long time ago of the other ones, and that’s only supposed to be used for aerosolized procedures. Even though they technically still say this disease is an airborne disease the CDC won’t come out and say that because they don’t have enough information. It’s a fairly new virus. We haven’t done enough testing. So they can’t officially come out and say it’s only droplets—influenza is something we consider droplet only. Someone comes in with influenza we can wear a simple mask. But this they’re still saying it’s potentially possibly airborne in some cases and so we should only be wearing N95 masks with particulate masks but they’re saying, well, use the best of what you’ve got. If all you’ve are simple masks and droplet masks…use that. But yet, it’s not because it’s what stops it. It doesn’t really protect us, and it puts us at risk big time…but that’s just where we’re at.

Today—and this is every day—we had a 19-year-old person come in and say, well I’ve had a cough for a couple of days. I started to worry, and I just want to be tested. Even that person, even if they look perfectly well and haven’t had a fever we have to completely use the gear…every single person who comes into contact with that patient, from the person who does their triage, to the registration clerk, to the doctor, to the lab person, to the person who comes to do the swab [test] and so it’s just resources that we’re just hemorrhaging. And then, that room has to be what we call “terminally cleaned,” which means completely wiped down, inside out with a curtain change, and then we have to keep that room empty for an hour after they leave so that the particulates in the air can settle and it can be wiped down. At any given time, on my last shift we had eight rooms shut down at the time…out of thirty, forty rooms. On a Monday, usually every room is packed with a two-hour wait in the waiting room, so eight rooms being closed means eight heart attacks could be sitting in the waiting room…and they just have to wait.

JAV: Ugggh…wow.  

NURSE: Because a 19-year-old who got worried came. [long pause] It’s a scary misuse of resources. If a tuberculosis patient came, and needed airborne precaution, and we don’t have the proper gear, we could all get tuberculosis. And we don’t only have those patients. You take care of the tuberculosis patient. You gear up, you walk out, then you walk right into a cancer patient’s room.

JAV: Oh, god.

NURSE: If we don’t have these resources there’s nothing to protect people from one to the next…and that’s what people don’t understand. By those people showing up, and wasting those resources, they’re taking that away from everybody else. They’re taking that away from us!

JAV: Yeah.

NURSE: Then we have to come home, to our elderly parents, and to our kids…and it’s so scary. That’s what people don’t understand. [imitating a patient:] Well this isn’t going to make a difference if I just stay home. IT DOES. Staying home to manage this as if it was a flu instead of demanding testing means that’s one less person who comes to the hospital means we don’t have to risk five masks on. A test swab. A room…all of that. That whole bundle. We can save that for someone who is super sick. It’s just about making it manageable and I think that’s the hard part for people to understand.

JAV: Yeah.

NURSE: I was fielding calls, all of Monday. [imitating a back-and-forth call with a patient:] Well, I want to come get tested. And I would have to repeat the CDC recommendations of staying home and trying to manage this like a cold or a flu. But I want to know if I have it. I understand that, but if you’re able to manage this at home you should unless your symptoms are unmanageable at home. What does that mean? If you can’t breathe, if this feels like more than just a flu. People are acting like they’ve never had the flu, or been sick at home before. Well I have a doctor that is Chinese and he has Chinese patients. I need to get tested. Somebody straight up told me that.

(JAV laughs.)

NURSE: You get to a point where you’re like, I don’t even know what to tell you.

[about the masks, about COVID-19:] I don’t think this is necessarily our institution…in general, I don’t know. My partner and I, who is also a health worker, we go back and forth asking, did we get blindsided? Could we have…? But hindsight is always 20/20, right? Today I was talking to my director and I said, man, looking back, doesn’t it just hurt to think of all the CAPR® masks we threw away? And now looking back, why didn’t we start conserving then when we were throwing them away? Why didn’t we start conserving harder so much sooner because all of a sudden we came to a screeching halt of, whoa, we have nothing. But we didn’t know it was just going to drop off like this.

When Ebola happened we were so ready. We did all these instruction classes, and they had us practice how to remove all the gear. We had a [protective] door. We had a temporary shower set up. We had all these protocols in place and we never saw a single Ebola case.

JAV: Hmmm, yeah.

NURSE: And then SARS came and we didn’t see a whole lot of that either. MERS happened…didn’t really hit us. And I think there was almost this sense of, oh this is another one of these…you know, foreign diseases. We might in the United States see a couple, and it will blow over. I think there was this sense of, oh, yeah, it’s just the newest one. I don’t think a lot of people thought it was going to turn into this pandemic.

JAV: Oh, wow.

NURSE: Different hospitals have done different things. Different counties have done different things. There were things in place for them to request extra supplies through the county and some hospitals applied. And each hospital has different populations they serve. My partner works at a different hospital. They don’t have the same issue we have with people showing up [to get tested]. They’re a more affluent, educated population so people there may not be as panicky and showing up. They may be a little more up to date [on the virus and guidelines] but they also handled things differently as a county. They applied for more PPE…personal protective equipment, and they have a surplus of stuff we ran out of a long time ago. And they don’t actually need it as much as we do. They’re more protected. And other hospitals are doing different things, like drive-thru testing.

And then there’s the other side of the coin where a lot of people are looking at this, like epidemiologists, and they’re saying, well eventually there’s going to be what we call “crowd immunity,” just like with other viruses. And, eventually, it will trickle out into the community and we’ll build immunity and…yes, we’ll see susceptible populations, but this will just exist, like the flu. And we’ll build immunity to it. But we don’t know enough about it. And then some people are, no, it’s not the flu. It’s thirty times more deadly. Look at the death rate. There’s so much back and forth debate…can we compare it to the flu? Is this that much more deadly than the flu? There’s so much we don’t know and we’re trying to learn it all as we’re in the thick of it, you know.

JAV: How do your shifts work? Does everyone work twelve-hour shifts? Do you all have huddles where you get to talk about what’s happening?

NURSE: We have mostly twelve-hour shifts. They overlap by almost four hours. People basically come in every four hours except 3 a.m. there’s not really a bunch of people who come in at 3 a.m. Lately, since this [pandemic] happened, and because it’s changing day by day, hour by hour, our huddles have become very important. Now it’s, hey, this is what we’re doing. This is where the sidelines are today. This is what gear we have available today. This is what’s changed. This is what’s new in the testing, or this is how many nurses we have out on exposure leave today. It’s basically an update of where we stand today. I worked on Monday…and Monday and today are completely different…what we’re doing, what we’re dealing with. You would think two months passed.

So we do have huddles, every four hours. This morning it was, okay, mask anybody with respiratory symptoms. By eleven o’clock it was, mask everybody with respiratory symptoms or chest pains because of that heart attack patient that had been admitted.

What made today less horrible than what we anticipated is that our volume has significantly decreased. We’re seeing a lot less patients than we normally would. So, it makes it a little more manageable.

JAV: And that’s because people are afraid of coming to the hospital?

NURSE: I think so, yeah. I think a lot of people are taking the shelter in place very seriously. And I do think the majority of people understand how important it is. They’re seeing Italy and know that they wish they would have taken it seriously much sooner. Because of the lower volume, we do get to chit chat a little more about what happened on previous shifts. We have a TV in the break room where the news is constantly running because we all want to know what’s going on just as much. We’re all keeping up with the news. We’re always sharing, oh, did you hear this? I heard that. This happened there. We’re constantly living it and in the grind of it as the general public is too. It’s just we’re looking at it how it affects us.

JAV: Oh, well of course.

NURSE: I had this funny sense this morning when I was driving to work of feeling…not quite like you’ve been deployed, but, we’re serving. When you sign up for the military you know that at any point you could go to war. When you sign up to be a nurse you know that at any time there can be a natural disaster, or a pandemic. It’s not something that happens as often as war, but this is kind of what we’re called to do.

JAV: Yeah.

NURSE: And it’s kind of a strange feeling because, well, this is kind of bigger than—like yes we signed up for this. No one signed up to not be protected but we did sign up to take care of the sick, whether it be the flu, or the coronavirus, or a simple cold or ankle sprain. This is what we do. There’s this camaraderie of, okay guys, let’s do it. And a person here will be taken off for exposure but those of us still left standing are, let’s do it. It almost feels like those military movies where they’re onboard and they’re all joking. It’s kind of like that. And very dark humor…it’s how we get through it. Us medical people have a really dark sense of humor because you can’t cry about it the whole time.

JAV: Of course.

NURSE: It’s a difficult thing to be around sickness and death and illness all the time…and there’s nothing else to do but just kind of joke and laugh even after the scary situation of the lack of gear and all of that.

JAV: You mentioned earlier that some people are calling in sick at the hospital. Have people been quitting?

NURSE: I don’t know if anyone at our hospital has but I know it’s happening at other ERs. I heard of a nurse who has a family and resigned because this is too much. She was afraid of exposing herself and putting her family at risk. I heard of another nurse who was due to return from maternity leave and she was like, I’m hearing about a lack of protective equipment. I’m hearing about shortages in staffing. I have a new baby and need to be able to pump for my baby and will not return if I can’t pump for my baby. She inquired about working in any other department because she didn’t want to be exposed to this virus and bring it home to her newborn. There are definitely people who are like, no, I cannot do this…and I totally understand.

JAV: I know that you had mentioned earlier that you worked on Monday, and then worked today, and Monday feels like it could have been months ago. I’m wondering if you and your colleagues have seen any difference in the public this week in comparison to last week. Have you seen any shifts in terms of how they’re reacting to the pandemic?

NURSE: Yeah, definitely. I think this…this panic has brought out the worse. I think the good we’re not seeing as much because as an ER we tend to see people at their worse.

JAV: Yeah.

NURSE: We don’t see people at their best. Some people come to us, and they’re in crisis mode. They’re either in a psychological crisis, a physical crisis. Sometimes it’s just plain…fear, and we’re getting a lot of that right now. People want their fears alleviated and unfortunately this is something that we don’t have the cure for. We don’t have all the testing for. We don’t have the supplies for. And, I think, sometimes people are looking for a form of reassurance, and not having that is making them more on edge, more panicky.

Every once in a while you would see people taking a handful of gloves, or something, but this desperation…I need to come here and get something out of it, whether if it’s a test, or I come here and steal stuff. There’s this sense of panic. It starts out as a fear, and just…what we in the medical field kindly call “knowledge deficit.” It’s this way of saying, you don’t know what you’re talking about. We don’t say, “stupid.”

(JAV laughs.)

NURSE: We say, they have knowledge deficit.

(JAV laughs again.)

NURSE: Knowledge deficit related to lack of, you know, lack of information on this. It’s how we base our education plan, and care plan. It’s a kind way of saying you have an ignorance in a certain area.

So there’s this knowledge deficit plus fear and when they’re not getting what would make them feel better—be it a test, or an answer—then there’s this ugliness. There’s this entitlement. [NURSE imitates a member of the public:] Are you testing? We don’t have public testing. Well we need one. Sorry. We have limited tests, and we need to save them for the critically ill. But I need one. Then they start getting insulting. People have yelled at us. People are getting desperate and they don’t know what to do with their fear.

It’s hard not to let that panic get a hold of you, even for us, knowing what we know, because there’s still so much unknown.

JAV: Yeah…  

NURSE: We’re all human, and this fear is so real. And it becomes this…bottomless pit, that the further you get, the further down you go it just gets darker and darker and you’re like, I don’t know where the bottom is. And that’s everybody…health providers included. Like you’ve said, we’ve never had a pandemic in our lifetime. We’ve never seen this. I mean, Italy had 793 die last night.

JAV: Yeah. It’s just…brutal—

NURSE: In one day.

JAV: Yeah…

NURSE: That’s crazy. [pause] And we keep getting told we’re only a week behind where Italy is at.

JAV: Right.

NURSE: And we see that and that’s…sad. It’s like being in one of those horror movies where the water’s overtaking a city, you know. And it’s like, oh my gosh, we’re one block away. That’s us. That’s us. And there’s a real sense of that, and we’re like, what do we do? What do we do? [pause] It’s hard. My partner and I go back and forth every day. Are you scared today? Do you think we should be worried about this? Are we worried enough? Or are we worried too much? It’s hard.

JAV: What’s been the hardest thing for you to deal with?

NURSE: I think just like everybody else, it’s not having any answers. I don’t know. I think everybody needs something different to make them feel better. Some people need someone to blame. For me, the hardest thing is having some sense of purpose. If I feel like I can do something about it then I feel better, and going to work and finding out that we have no masks…I…I can’t, I can’t do anything about that. That gave me a sense of, ooh, I’m really anxious to go into work now. I think the hardest thing for me, and I think this is everybody, but germs are something you can’t see.

JAV: Yeah, right.

NURSE: There’s no, oh, see the blue things floating in the air? Just stay away from those.

JAV: Yeah.

NURSE: It’s the unknown. Every single patient I encounter, every person I talk to. I don’t know if that person will be the one that infects me. And we go back and forth about this too. There’s times when I’m thinking, man, I wish I just got it so I can get it over with and be immune and then I wouldn’t have to worry about it. But then at the same time, if I get it and I pass it on to my mom…how sick is she going to get? It’s just the unknown of it. How bad is this really because we don’t know the full story. We don’t know how this is going to roll out entirely.

JAV: Yeah, exactly.

NURSE: And just the unknown is so scary. We don’t have the answers. Is this vaccine they’re creating going to work? What are we going to do when we run out of equipment? Is this flatten the curve going to work? If it doesn’t, what does that mean for us as health care workers? If people start dropping like flies because of exposure are patient ratios going to change? Are we going to have ten patients to take care of? Is this going to be an unruly situation? The unknown of it all is daunting.