diary of a hospital

A Head Nurse’s Burden

“I don’t want to play God.”

Friday, March 27: Providing emergent care to a patient in respiratory failure at Mount Sinai Brooklyn. Photo: Patrick Schnell, M.D.
Friday, March 27: Providing emergent care to a patient in respiratory failure at Mount Sinai Brooklyn. Photo: Patrick Schnell, M.D.
Friday, March 27: Providing emergent care to a patient in respiratory failure at Mount Sinai Brooklyn. Photo: Patrick Schnell, M.D.

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As the COVID-19 crisis continues to unfold, the staff at Mount Sinai Brooklyn is documenting its experience with regular dispatches. Our second installment is with Claudia Garcenot, the hospital’s chief nursing officer, who is seeing more and more of her nursing staff call out sick with COVID-19 each day. Amid constant staffing shortages, she’s dealing with the sickest patients she has ever seen, fielding frantic calls from family members, and making unbearable decisions about whether families will be able to visit their loved ones before they die. 

I start every day around midnight, when I make a phone call to find out what’s going on with staffing the following day. And then, of course, inevitably, around 4:30 a.m., I get phone calls as my people start to call out sick. Friday night was really bad. We had four sick calls and another five people who called to say they were COVID-positive. So that’s nine nurses I lost Friday. And they’re out for seven to 14 days. We’re a small hospital, so four nurse sick calls means that four floors out of six could potentially be very short.

For the most part, my staff tends to seem better after a week or ten days. Then, every once in a while, there’s that outlier. I have this young nurse who’s in her early 30s, who texted me about an hour ago, “I can’t breathe. I’m going to the emergency room.” It just seems like it’s different for everyone, which I think makes it so challenging. It’s the unknown that makes you so crazy.

Everybody’s getting sick — respiratory therapists, cleaning people. We have to get creative. We bring in more of the non-nursing staff. We put teams together of two to three people where there will be one nurse and a couple of other people who will work to manage the care for all of the patients. Our ratios are not where we want them. That’s not just our hospital; that’s everywhere.

Friday, March 27: An EMS worker helps bring an arriving patient into the already overcrowded ER. Photo: Patrick Schnell, M.D.
A critically ill patient is prepared for intubation in the ER. Photo: Patrick Schnell, M.D.

The patients are so sick. Oh my God. I’ve been a nurse for a really long time, and I’ve never seen so many people so sick in one space in my entire career. Now the vast majority of our patients in the hospital are COVID positive. We probably now have five COVID deaths a day or more, at least [at a hospital of 220 beds]. Everybody is so weak. Everybody has temperatures; everybody’s congested. They’re barely breathing. They’re kind of like little old crumpled-up fetal-position people. Some of them came in speaking; they’re not really speaking anymore. Just every bit of everything takes so much effort.

We see so many atypical presentations. Everybody says, Oh, you have a fever. You have a cough. You have congestion. You know, you have shortness of breath. But some people don’t have that. They’ll just have one symptom. One patient came in complaining of back pain, which he had had for a long time, so it isn’t a new back pain. And eventually they did a CAT scan and a chest X-ray and found that he had pneumonia. And that’s what prompted them to test him for COVID. But he would never have been one of the people that we would have thought. Every morning, I go through the symptoms in my mind. Do I have a sore throat? I don’t think so. Do I Have any joint pain? No, I feel okay. Do I have a temperature? I take my temperature twice a day. When do you ever take your temperature twice a day?

Medical staff intubate a patient in respiratory failure using a laryngoscope while watching a video feed of the patient’s larynx to confirm the appropriate placement of the endotracheal tube. Photo: Patrick Schnell, M.D.
Medical staff checking the patient’s lungs for proper ventilation and tube placement. Photo: Patrick Schnell, M.D.
Medical staff prepare an Ambu bag to assist with ventilating a patient with impending respiratory failure. Photo: Patrick Schnell, M.D.
Staff prepare to attach the ventilator to the newly placed endotracheal tube. Photo: Patrick Schnell, M.D.

My daughter every day says to me, “Mom, I really don’t want you to go to work. What happens if you get sick?” You know, it’s like there’s always something else tugging at your heartstrings every day.

I’m 62. I’m worried about my health because I think we all need to worry about it. But I’ve been a nurse for a really long time. I was a nurse during the AIDS epidemic. Nurses do this stuff, right? We walk into the unknown and say, Okay, we’ll just do all the things to protect ourselves and then keep going. I am thinking more about the patients, and about the other nurses, because how am I going to care for 200-plus patients if 50 percent of my nurses go out sick?

The thing is that — and I know everybody would say this about their field — nurses are different. The doctor comes in for 20 minutes, maybe 30 minutes, spends that time with your patient and leaves. But the nurses are there for 11.5 hours every day with that patient, with that family — they know their fears, they know the intimate details of their health, their personal lives. You’re taking people back and forth to the bathroom. You’re doing a million things that makes you so intimately involved with patients. And then we turn around three weeks ago, and we say, “Guess what, folks? No visitors.” [Starts to cry.] I found that to be such an overwhelming comment to have to make to the patients. I don’t know how the patients are doing it. I don’t know how the families are doing it. You know, my husband died three years ago. He was really sick. Every time Dennis went into the hospital, I went with him and I stayed with him and I never left.  And I say to my kids all the time, “Imagine if this was now and daddy was sick now.” Knowing that he just had a few weeks left or whatever, I would be that crazy person trying to sneak in the hospital all the time. I know I would.

Dr. Peter Shearer consulting with staff in the early morning. Photo: Patrick Schnell, M.D.
Lockers of ER staff. Photo: Patrick Schnell, M.D.

I’m trying my best to support the families. So, in the morning, we have a group of nurses who come in. They get a report on every patient on the floor and then they call the families to say, “Mom did okay last night. We medicated her for pain. She’s comfortable. She’s gonna get out of bed today.” Whatever we can give them so that they feel a little bit connected. Before we started doing that, we were getting like 10 calls a day from every single family member of every patient. If someone is actively dying, then we call the families, and we do allow them to come in. But imagine: You know that that’s the call, right? I’m calling you and I’m saying, Hurry up. Get here. Because this is it. This is the last time you’re going to see your mom or your dad or your whomever.

When a doctor calls a family and says, “There’s nothing else I can do. I’ve done everything I can for your mom,” then the children call me, or they call the nurse managers on the floor hysterical, saying, “Please, please, please let me come in and see my mom before she dies.” And every day we have to make that decision. I don’t want to play God. We’re at the point where the person has to be really actively dying for their families to come in. But then you worry that if they don’t get there in time, you didn’t do it early enough. So there’s so much weight on the nursing staff. The other day, we had these two daughters who were so hysterical. I didn’t really know that the mom’s death was imminent, but I spoke to the nurse manager on the floor and I said, “Let’s bring them in. Give them five minutes.” I think if, God forbid, something happened to this woman, they will not be able to get by for the rest of their lives if we don’t do this for them. So you have to meet them in the lobby. You have to get them all gowned up. Everything takes an hour now. And my nurse managers are just an emotional wreck.

Patients line up on stretchers on both sides of ER corridors awaiting medical care and disposition. Photo: Patrick Schnell, M.D.
A refrigerated truck is parked outside to accommodate the deceased. Photo: Patrick Schnell, M.D.

Nurses are generally a very warm group, and now you can’t even give somebody a hug if they’re afraid. You’ve got to keep six feet. And you’ve got so many other things to do. We’re losing the human side because we’re trying to save the life. The worst part is that you know that this person that you’ve been taking care of for four or five days is probably not going to make it. And we don’t usually know that about our patients. You know that about some. But, for the most part, you think you’re going to send the vast majority home. Now the pendulum is swung the other way. We’re probably not going to send the vast majority home.

The last I heard, we had 30 vents in use — 220 beds, 30 vents. That’s an unbelievable percent of ventilators for a small hospital. It doesn’t seem very likely that most of them will come off it. I read on Facebook the other day that some 95-year-old lady went home. I hope that’s really true. I haven’t seen a lot of 94-year-old people go home from us.

EMS wheel a new patient into the already hectic ER. Photo: Patrick Schnell, M.D.
Medical staff care for an elderly patient in one of the ER corridors. Photo: Patrick Schnell, M.D.

Dr. Shearer [Peter Shearer, the hospital’s chief medical officer] tells me that they’re claiming the peak could arrive in two weeks. I can only hope that’s true. I can probably keep my head above water for the next two weeks and get ready for whatever’s next. And in that time, my expectation is that I’ll have a number of nurses who have been out sick because of COVID come back and then my workforce will be replenished. We need to maintain the status quo. We need to keep cleaning our hallways, we need to keep taking care of our patients, and cross our fingers and hope that it really does peak in two weeks.

I’d like if you could highlight the hero work of the nurses. I am so proud and overwhelmed and in awe of the nurses. I’m just so honored to be leading them. Because these are the people that every day come in, no matter what’s going on at home, no matter what they’re worried about, and they spend 11.5 hours taking care of somebody else. I’m just in awe of them. I really am. Every day, I look at them and I think to myself, I don’t know if I could do that. If it was 20 years ago for me, could I do what they’re doing? I don’t know.

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Diary of a Hospital: A Head Nurse’s Burden