By Nina Shapiro
The Seattle Times
WWR Article Summary (tl;dr) As Nina Shapiro reports, “with health care workers now bracing for a possible second wave, the stress is undeniable.”
SEATTLE
It takes Tricia Jenkins a couple of hours in the mornings to psych herself up for work as an emergency room nurse at Swedish Cherry Hill in Seattle. She makes a series of phone calls for pep talks, to other nurses, to her mom, to her best friend.
“And then I go to work and step through the doors and shake off all that anxiety,” said the 41-year-old Jenkins.
Or she tries to.
“It’s hot and it’s scary and you feel like you’re alone in there,” she said, describing time spent in closed-door rooms within the ER’s “hot zone” for diagnosed or suspected novel coronavirus patients.
To limit exposure, only one nurse goes into a room, loading up on everything that might be needed because coming out is an elaborate production involving taking off personal protective equipment layer by layer to avoid contaminating the rest of the ER. Gloves, gown, face shield, a second pair of gloves, surgical mask, the N95 mask that lies beneath that. At every step, hand sanitizer is applied or hands are washed.
“Am I really going to be able to sustain this?” asked Jenkins, who sometimes cries on the drive home. She likens the trauma to PTSD. At the same time, she can’t imagine walking away.
It’s been just over two months since Washington’s health care providers began taking care of COVID-19 patients. Those on the front line, from a Wenatchee nurse whose future in the U.S. is uncertain despite her work here, to a Mandarin-speaking Kirkland doctor who reached out to colleagues in China to learn from their experiences, to a Seattle respiratory therapist who speaks of her “passion for being here” despite a predawn hour’s commute from Puyallup, have faced the unknown and survived a peak that in this state was not as overwhelming as feared.
But coronavirus patients continue to come, with roughly 400 in hospitals statewide last week. Trying to keep them alive, yet in many cases watching them die, has brought what EvergreenHealth Medical Center’s Dr. Audrey Young calls a “huge mix of emotions.”
Some, energized, feel this is why they went into medicine, Young said.
Colleagues have bonded together as never before, even internationally, as with the case of Dr. Lucy Doyle, the Mandarin speaker, also of EvergreenHealth.
There is some level of comfort, or at least familiarity, with medicine’s new normal.
Yet, with health care workers now bracing for a possible second wave, the stress is undeniable.
“Everybody knows about our emergency room physician who became extremely ill and thankfully is now home,” Young said referring to Dr. Ryan Padgett, who contracted COVID-19 and spent more than two weeks on a ventilator.
“All of that left an indelible mark on our identity, this sense, this very, very real sense that our work could affect our health drastically,” Young said.
Doctor one day, patient the next. Padgett’s near-death made the coronavirus phenomenon real. “This could be me,” she said staff at the Kirkland hospital realized. As of May 8, EvergreenHealth, the first in the country to face the crisis, had 69 coronavirus cases among its employees.
The state is not reporting figures for health care workers who have tested positive because it does not have complete data, a spokesperson for the Joint Information Center said.
But data from Washington’s four hardest-hit counties, King, Snohomish, Pierce and Yakima, reveals at least 1,626 coronavirus cases and five deaths among health care staffers of all sorts, including pharmacy, maintenance and (except for Snohomish’s numbers) long-term care facility workers.
In King County alone, 891 health care staffers have tested positive, as of May 4, representing 13.4% of all cases in the county. And that’s likely an undercount because it isn’t possible in every case to determine where someone works. Public Health – Seattle & King County spokeswoman Kate Cole also noted it’s not always known whether someone contracted the virus on the job.
Pierce County’s 290 cases among health care workers, as of May 7, amounted to 18% of its total, according to health department spokeswoman Edie Jeffers.
Heightening fears among workers, especially initially, was the prospect of running out of protective equipment like N95 masks, and hospitals’ changing policies as to their use. Providers say supplies seem to be holding steady for now. Still, Jenkins, scared to throw all her used masks away, keeps a basket of them in her garage.
The virus has intruded in other ways into the lives of providers, from making them reluctant to cuddle their children, for fear of infecting them, to causing them to physically separate from their families.
It has also, in some ways, changed the nature of their jobs.
One of the things Jenkins said she liked best about nursing was the human connection. She would walk into a room with a smile and words of encouragement.
“I try to talk to people as I normally would,” she said. But coronavirus patients are often so sick they can’t respond. In any case, it’s hard to hear her through her protective equipment.
“And no one can see our faces,” Jenkins said. “It’s got to be scary. You can see my eyes and that’s it.”
It works the other way around, too. COVID-19 patients are often put in a prone position, on their stomachs, which helps them breathe better.
With their faces down, Jessica Esparza, an ICU nurse at Confluence Health’s Central Washington campus in Wenatchee, said she can’t see them. Sometimes, weeks will go by.
“It’s just heartbreaking for me to not see their face, to know the person behind all the tubes and lines and devices,” said the 26-year-old, an enrollee in the Deferred Action for Childhood Arrivals program who came to the U.S. from Mexico with her mom when she was 11.
And yet she knows, that with family barred from visiting due to risk of infection, she has the most intimate connection with a patient.
When she gives patients bed baths, she strokes their heads. She talks to them, even if they’re on a ventilator, because it’s said patients can still hear.
“Your daughter called to say she loves you,” Esparza will say. Or “you got this.”
With so many people dying from the virus, it hits Esparza with painful force, “Here I am, the last person this patient will hear.”
And the last thing a patient says may be to a nurse, said Kayla Durler, who works in the Harborview ICU.
The nurse recalled one patient who died recently. “Such a sweet man,” she said. Durler got to know him a little, as she tries to with all her patients.
“You’re in the room for hours,” she said. By the time COVID-19 patients get to ICU, they need a lot of care, and because nurses can’t easily go in and out, they simply stay there.
This patient could chat a little, until suddenly he needed a ventilator and was sedated, a tube stuck down his throat.
“To see them decline, it’s hard,” Durler said. “You hope they will make it home. Or at least come off the ventilator to talk to their families again. And some of them don’t.”
“It gets pretty mentally heavy.”
“I wish I had a magic bullet,” said Dr. Mark Wurfel, a Harborview physician who in addition to attending in the ICU conducts research into factors leading to organ failure and death in critical illnesses. “It is very scary to watch some of these people decompensate and feel like you don’t really have anything to offer.”
“You just feel helpless.”
Researchers in Seattle and around the world have launched a flurry of studies into potential therapies, including hydroxychloroquine, praised as a “game changer” by President Donald Trump, and remdesivir, predicted to be the “standard of care” by National Institute of Allergy and Infectious Diseases Director Dr. Anthony Fauci.
Cause for skepticism has arisen just as quickly, noted Wurfel, pointing to some early data about the drugs showing limited or no benefit, or even, with hydroxcholoroquine, an increased mortality rate.
“We as critical care physicians have started to get fairly nihilistic and are falling back to what we know, using the basics of trying to avoid harm,” Wurfel said.
So doctors are giving patients on ventilators the lowest possible size of breath to minimize damage to the lungs. They are taking care not to overload patients with fluid, or write prescriptions for unneeded antibiotics. These tools of the trade are geared, he said, “toward letting patients get through on their own.”
Those on ventilators have about a 50% chance, Wurfel said he is finding, though estimates around the country differ.
Dr. Nick Mark, a critical-care physician who works at various Swedish campuses, says he tries to focus on the people he saves. “It’s gratifying to see people close to death walk out of the hospital,” he said.
He feels he can help even those who don’t survive by trying to make them more comfortable.
But breaking news, over the phone, to a family member that their loved one is dying, that’s been tough, he said. “There’s so much more you can convey sitting in a room with someone face to face.”
Mark, 35, was about to become a stay-at-home dad for a couple months when Washington got its first coronavirus cases. He and wife Dr. Sarah Buckley, the medical director of a bio-pharmaceutical company, had just had a baby and they also have a 3-year-old.
Instead of ramping down, Mark ramped up, with all the risks that entails. As part of his ICU work, he inserts breathing tubes into COVID-19 patients, with maximum potential exposure to infectious droplets.
For years, he said, it’s been his custom before inserting a breathing tube to “take like 10, 15 seconds and just sort of relax a little bit, calm myself down so I’m as levelheaded as I can be … And one of the first times I was intubating these patients, I did that. And I got the thought in my head, wow, if my PPE fails … I really could die.”
It’s gotten easier. Mark’s confidence in his protective equipment, including a contraption called a PAPR that sends purified air into a hood, has grown.
Still, Buckley, especially before hospitals implemented universal masking, worried her husband might contract the virus from colleagues, bunched up together in hallways without the gear they wear into patient rooms. With a newborn, in what she called her “most protective head space,” she broached the notion of Mark going elsewhere if he developed symptoms.
It got complicated. “Does that mean the second he has a scratchy throat he needs to find a hotel room somewhere? … And for how long?”
If he stayed, and passed on the virus at home, who would look after their kids, far too young to fend for themselves? The thought was absolutely terrifying, Buckley said.
They finally agreed to call Mark’s brother in New York to ask if he would be willing to fly to Seattle if needed, knowing he’d be exposing himself.
Buckley was nervous about the big ask, but her brother-in-law said yes. “That’s huge,” she said.
Jenkins and her husband, a garbage collector who is also an essential worker, decided to send their 10- and 5-year-old children away because of the risk of infecting them. They are staying with Jenkins’ mom, who lives close to them in Burien.
“Sometimes I visit them through the fence at her home,” Jenkins said. “Most of the time, because it’s very disruptive …” She broke off. “It’s very emotional. I miss them.”
Jenkins’ daughter, the 5-year-old, doesn’t really understand why she can’t hug her mom. The nurse’s son conveys his feelings by not looking at his mom.
Recently, Jenkins starting taking the kids back for a few days at a time between clusters of shifts. She makes sure she’s symptom-free for two days before picking them up. Why two days, when the incubation period is thought to be up to 14?
A co-worker developed symptoms a couple days after her last shift. “It’s just a guess, just a shot in the dark,” Jenkins said.
She had been separated from her kids for weeks, with no end to the pandemic in sight. Her mom was feeling the strain, too.
“I don’t know that I’m qualified to be a full-time parent forever,” said Karen Jenkins, 63, noting her stamina is not what it once was.
Amrit Singh, a 25-year-old Harborview nurse, got physically close to her mom one Tuesday in April. She had taken a coronavirus test because of a sore throat and the results had come back negative.
“I can actually feel my mom’s arm for a second,” Singh remembered thinking. They stood side by side in the kitchen of her parents’ Kent home, where Singh has been living. She drank tea on the patio and watched her mom garden. They ate lunch together.
It was a huge relaxation of Singh’s normal routine: calling her parents from the garage after a shift to tell them she was coming into the house and to get into a faraway corner; running upstairs to shower; calling her mom from her room afterward to say she was ready for dinner; eating the meal left outside her door; keeping to her room even during off days.
Just one day after Singh dropped her guard, she heard from the hospital that a patient she had cared for the Sunday before tested positive.
It was on the neuroscience floor, not a COVID-19 unit. That’s the thing about working amid the pandemic: You don’t know if patients have the disease or not.
“I was spiraling,” Singh said. She kept thinking about how close she came to her mom, and how her parents might die as a result. The test Singh had taken was too soon after exposure to be reliable.
“I need to leave,” she resolved, feeling even more sure of her decision when she learned she had been exposed to a second patient that same Sunday who later tested positive.
Singh moved into the Executive Hotel Pacific in downtown Seattle, one of two in the area with free rooms set aside by officials for front-line workers wanting to protect their families.
Singh says she has a nice room overlooking the downtown library, one of her favorite buildings. The staff, who interact only by phone, have been very friendly. They deliver three meals a day to her room.
“It’s probably been a silver lining in a weird way,” Singh said, a week into her stay. Free from worrying about infecting her parents, she realized how on edge she had been.
“I was not living,” she said.
Finally, she felt able to work without fearing the consequences, and when her shift ended, she could relax.
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