I saw my name followed by “RN” for the first time on July 27, 2020. The next day, my instructor, or preceptor, and I were assigned to the COVID intensive care unit at our hospital in Nashville, Tenn. I read the assignment sheet with a strange knot in my chest. It wasn’t fear or dread rising into my throat but something much harder to name.
For months, as a nurse intern, I’d watched the battle-weary nurses emerge from COVID rooms, taking off their PPE like warriors stripping off armor, their faces lined from the pressure of the respirators. There was something etched in their faces I couldn’t fully understand at the time, something that ran deeper than sadness, some terrible weight that came from caring for these patients. Now it was my turn for what became a grim initiation into the world of nursing and medicine. I learned how to be a nurse behind a respirator and a yellow gown amid the constant beeping and hissing of ventilators that couldn’t support failing lungs. I learned how to be a nurse with death constantly at my heels.
Because I was so new, I had no baseline for what normal nursing looked like; I just had a vague sense that it couldn’t look like this. The unit was bleak, and everything we did felt futile, and I realized at some point I felt more like a ferryman to death than anything else. Some people lived—if they never got to the point they needed continuous BiPAP, a type of face mask that constantly pushes air into the lungs. Most didn’t live. By the time they came to us, they were too sick and were beyond the power we had to heal. They were in renal failure, respiratory failure, liver failure, cardiac failure. One organ system would fall, and it brought down the next and then the next like dominos, a horrible cascade that we could predict but not stop.
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I watched, feeling helpless, as patient after patient progressed through the stages of the disease, each requiring a higher level of oxygen support: nasal cannula to Vapotherm to BiPAP. Then, when their chests started heaving and they started sweating despite the BiPAP mask forcing the strongest possible concentration of oxygen into their lungs, I knew with heavy dread that soon they would be intubated. I remember every single time I made the call to the doctor to tell her that it was time. Then came the quiet acquiescence on the end of the line and the flurry of activity as we prepared the ventilator and the medications that would keep them comfortable after. I remember every single 2 A.M. phone call to family members so they could hear the voice of the person they loved at least one more time.
“Is she going to be okay?” they would ask. I tried not to lie, not to give false hope. I heard too many voices cracking on the other end of the line, the family beset with helplessness and with grief. “We’re going to do everything we can,” I would say.
There are places we can’t call you back from—places you go where we can’t follow. And this is one of them. The ICU felt like purgatory, like a punishment, like we were torturing these people whose bodies were wrecked beyond hope. And I couldn’t shake the feeling that we were failing them. The feeling of wrongness was so pervasive that it followed me home and would have choked me if I let it. So I didn’t let it. I got used to the death. I walled it off, pushed it down and did my job. I advocated for death with dignity, with as much kindness and comfort as we can muster, and I accepted very early on that we can't save everyone.
Every time I try to describe the COVID unit in anything more than metaphor and allusion, I falter. I can tell you that for a while, walking into work felt like Dante following Virgil past the gates and the warning inscribed there. I can talk about Charon and the river Styx and how the nurses flitted between worlds, crossing that river of death every time we entered a COVID room. What I’m saying is dramatic and probably pretentious, but language fails here. I don’t think there are words for what this is. The COVID unit is mottled limbs and scorching skin; bloody secretions and constant alarms from one patient after another going into abnormal heart rhythm;. It is the beeping of the Prismaflex delivering continuous renal replacement therapy because the circuit pulling the patient’s blood outside of their body to filter it, as the failing kidneys should do, has clotted yet again. The ventilators sound the alarm from inside the rooms for 1,000 reasons, some of them fixable, some not. Room after room of patients are on life support, silent except for the relentless chiming and beeping that remind us that they are dying, we are failing. Those alarms ring in my head when I get home, reminding me of every way I couldn’t save them. We are haunted by failures now, starting with the failures of policy that allowed human lives to be sacrificed on the altar of the economy and ending with us telling a family that we can do no more. COVID has made martyrs of us all.
This past December through February was the worst of it—until now. For months, the ICU took over part of the postanesthesia recovery unit because so many ICU beds were taken by COVID patients that there was nowhere to put the people who had heart attacks or strokes or major surgery. The unit was on diversion constantly, not accepting new patients. When we came off it for even an hour, we got slammed with six or seven admissions. Even on diversion, the patients kept flooding in—from the emergency department or the people on the medical surgical units who rapidly decompensated into respiratory failure, nurse after nurse being burdened with triple the normal patient load for a critical care unit. Normal ICU ratios of one or two patients per nurse were abandoned by necessity. Every shift, we drowned. The onslaught was brutal, relentless and unsustainable.
Spring came, and the numbers started going down. Three COVID intensive care units became two, then one, and then we had fewer than six COVID ICU patients. And for the first time since becoming a nurse, I could breathe. I started to see what it was like to be a nurse in pre-COVID times and realized how many people normally survive the ICU. The things I did mattered; my actions actually saved lives; no longer was death my constant, silent companion. The more time I spent out of the COVID unit, the more I realized exactly how bad it was; all the vents, the CRRT (blood purification), the relentless march towards death that we could hold off for a time but never stop. Walking through the much smaller COVID ICU felt like walking through a graveyard, haunted and eerie with souls who just wanted rest.
I began to think that soon, we would be free. I was wrong. Like so many others I let my guard down, cautiously stopped wearing a mask in the grocery store when it wasn’t packed, even went on vacation with my boyfriend. I started to see a future that didn’t have a dark cloud looming over the horizon, a future in which my family was safe and my patients didn’t die these slow, torturous deaths. But we all know what happened next.
It is so much worse this time. We all have so much less to give. We are still bearing the fresh and heavy grief of the past year and trying to find somewhere to put all this anger. But the patients don’t stop coming. And the anger doesn’t stop coming. Underneath that anger, I feel defeated. Nothing we do makes a difference. The world spins on, oblivious and belligerent, as we fight to save the tidal wave coming our way—with less staff, less resources and much heavier hearts. The numbers are higher now than they’ve ever been, the patients coming in younger and sicker. Death is at my shoulder again, as silent as he is relentless.
I don’t know what to say that will make people listen to us, to take the basic steps such as masks and vaccination that could be our way out of this nightmare. I wish I could snap so many people out of their selfish stupor, but I can’t, so I get to watch instead as people learn the hard way. Imagine a tube down your throat—and a “Code blue, code blue!” and the crack of a sternum from the force of the chest compressions. I make a 3 A.M. phone call to your family, my hands still trembling from the rounds of CPR, voice shaking, knowing that I am about to shatter someone’s world. In a little over a year, I have gotten very good at telling people that someone they love is about to die.
You learn the hard way, and I see it through. I carry the weight of your choices and the pain they cause.
It didn’t have to be like this. We could have changed course at any point in this horrible, sinking story; we could have made the decision to do the right thing. Pandemics cut to the heart of us because they reveal the intricate, unrelenting web of human connection that has become easier and easier to ignore. Americans have always been individualistic, sometimes to a fault, and I see this more clearly during the pandemic than ever before. We have forgotten that we are all connected, a giant golden web with threads of light among friends, parents, children, siblings. This web spans the globe and ties us to each other. The actions of a single person impact the lives of many, and the pandemic illustrates this in the most brutal way. A man with a sore throat goes into a Kroger and infects eight people, each of whom infects eight more people, then eight more. No one is an island, and all of our actions have an impact on the world and community around us. There is a truth deep at the heart of this that goes much deeper than political parties or vaccines or even science itself: there is nothing more important in this world than being good and kind to one another. There is no legacy that matters more.
This is an opinion and analysis article, and the views expressed by the author or authors are not necessarily those of Scientific American.