COVID-19: On the Front Lines
This article is part of an ongoing collaboration between the Colorado School of Public Health, the Denver Museum of Nature & Science, and the Institute for Science & Policy. Find all of our previous COVID-19 webinars and recaps here.
As the battle against COVID-19 unfolds each day in America’s hospitals, doctors, nurses, respiratory therapists, and other caregivers are working tirelessly to diagnose, treat, and improve patient outcomes. The Institute for Science & Policy’s Kristan Uhlenbrock chatted with Marc Moss, M.D., the Roger S. Mitchell Professor of Medicine and Head of the Division of Pulmonary Sciences and Critical Care Medicine at the University of Colorado School of Medicine and Traci L. Priebe, R.N., BSN, CCRN, a Charge Nurse in the medical ICU at the University of Colorado Hospital about their experiences so far. The conversation below has been edited and condensed.
KRISTAN UHLENBROCK: Thank you both for joining me today. Could you both just talk a little bit about what your role in the ICU is right now?
TRACI PRIEBE, R.N.: I've worked in the medical ICU at the University of Colorado Hospital for coming up on seven years now. Since COVID-19 began, I have transitioned to a newly built ICU for about two and a half months straight. My role is very similar in both places; I am a charge nurse where I oversee the unit, supervise, and mentor the bedside nurses that I work alongside with.
I do a lot of collaboration and facilitate communication. I try to support my nurses clinically from the administrative side and facilitate admissions and transfers of patients in and out of the unit.
MARC MOSS, M.D.: I'm a pulmonary critical care physician, and as an attending physician in the intensive care unit, I oversee the care of the patients. The thing I like about the intensive care unit is that it's very multidisciplinary and we work as a team. So Traci and I work together very closely. You really need a group of healthcare professionals with diverse yet complementary knowledge bases. We also have caregivers ranging from residents to medical students to fellows. So part of the job, in addition to caring for the patients, is to teach people how to become excellent healthcare professionals in the future.
KU: Could you talk a little bit about some differences in ICU operations pre-COVID compared to now?
TP: One of the biggest challenges is the lack of family presence. Most hospitals, nursing homes, and other types of medical facilities are not allowing family visitors or it's very limited. And that's very difficult. That human connection, that presence, that ability to hold someone's hand has been taken away. As we are helping care for these critically ill patients, I'm trying to have in depth conversations and now those are having to occur over an iPad or over a telephone without having that face-to-face interaction.
One of the other big changes is the personal protective equipment that we need to wear in order to enter these patients’ rooms as well as go just about anywhere in the hospital. We are wearing masks, but also complete head-to-toe suits. It takes a lot of time to take on and take off that protective equipment to make sure there are no gaps for potential exposure. In a typical medical ICU, you'd wash your hands or put on hand sanitizer and be able to go into the room. And so if there was a beep or a buzz and a patient needed something quickly, you're able address the need or the concern quickly. Now, regardless of what's going on in that room, it’s very important that we first appropriately put on the PPE. Our intuition and our experience has trained us that we want to go in right away, but for the greater good and for the protection of ourselves and our colleagues and other patients and loved ones, we have to take the time and be diligent.
MM: We're also interacting not just with patients themselves, but with a family in crisis. So the first time we meet the family is after a catastrophic event. And the first conversations are usually with family members who are distraught and worried about their loved ones. So you have to sit down and introduce yourself and have a heartfelt and emotional conversation about the patient's condition. And at some point during the conversation, you need to develop a bond with the family and they need to trust you with the care of their patient.
With COVID-19, no families are able to see the patients. So you're interacting with people virtually and you have a mask over your face, so they can't see your facial expressions. It's become more difficult in this era where your patients can't be in the same room as the family members. Technology has helped in that area.
In the past, I was never really worried about my own health when caring for patients. Now, when you go into a patient's room, you're a little concerned that you might get sick and that you might bring the virus home to your own family members. That's happened in Italy, with over 50 physicians that died of COVID infection. There are times in the intensive care unit where we've had a husband in one room on a life support system and the wife in another room. We also had two sisters that were both critically ill in the intensive care unit. And that's a horrendous experience for that family and something I've never had to experience before.
KU: What are some of those other ways that you are trying to humanize yourself and make that connection to patients which is often so vital?
TP: I try to make sure I introduce myself every single time, let them know who I am, ask where they are at, make sure they feel safe and know that I have been watching over them. Over several days or weeks, I just try to bring that familiarity to them. A lot of critically ill patients are sedated in order to help alleviate pain and anxiety. But, you know, we have a deep belief that they can hear us. The hope is that they recognize my voice and that they can hear and feel my genuine compassion.
I'm also trying to communicate with my eyes because facial expressions are hard to convey under masks. It’s a bigger emphasis on holding someone's hand, stroking their hair, or really any type of communication that I can use outside from smiling.
MM: You can't ever treat someone with too much respect. And one way to be respectful, as Traci said, is just to explain everything that you're doing to the patient, even if they're in a drug-induced coma. I really do believe they know that you're there and can hear you.
The other thing is that I’m actually spending more time in patients’ rooms than I was in the past, because there's no one else and you realize that you're going to be one of the few people that they interact with during that day. They don't have their family members in the room to hold their hand. I really make sure that I communicate and answer all questions of the family members even more because the family members are under even more stress because they can't even be there. You're both standing in for those families as well as trying to do your job as a medical provider, so I think everyone is very appreciative of that.
KU: What are some of the stories you have about the impact that this is having on families?
MM: I have a few examples. The first patient was someone who, unfortunately, passed away. And it's very difficult in that situation when someone from the family wants to come in and be with the patient, but doesn’t want to get infected. We arranged for the patient’s sister to come in and set up an iPad so other family members could say goodbye. They were very appreciative of the care in light of the risks and acknowledged that in what was a very, very difficult time for them.
There was also a young man who was 37 years old who came in very sick. We worked very hard to try to get him better, but over the course of five hours, he just got sicker and eventually passed away. He had two young children who couldn't come be with him and his wife had to deal with all this alone without any support from her family. The tragedy and the grief that you could tell she was going through was just really, really, really sad. It was as if she was physically wounded. We can try to help with that. But that’s what's been the hardest for me: seeing people dealing with these tragic situations and having to go through it alone.
TP: Beyond just physically caring for them, we are there to care for them psychologically, spiritually, and emotionally. We are doing everything we can to support them and to make sure that they don't feel alone.
MM: I think it’s also important to remember that, in general, the majority of the patients in the intensive care unit are going to do well. The majority of the patients that are on life support systems are going to go home and live. And that's the rewarding side of working in an intensive care unit; you can work very hard with the patient, communicate with the family, and the majority of the patients are going to get better. So talking about the tragedy side of it is important, but I think I just want to make sure everyone understands that we do take excellent care of people, as do all the hospitals in the Front Range.
KU: Could you talk a little bit about how the pandemic is impacting you personally?
TP: I am extremely grateful for the job that I have and grateful for the opportunity to be able to impact and improve lives and support people through the worst times of their lives. I know that there are a lot of people who are facing obstacles that I'm not. One of the big things for me is that my father was diagnosed with terminal cancer last fall. He is back home in Iowa, where I'm from, and prior to this epidemic, I was flying home every two or three weeks to spend time with him and to go to his palliative chemo appointments and to support my mom. I am no longer able to do that because I'm working in a high risk environment and he is extremely immune-compromised.
So in order to protect my dad, I can't see him. And that has impacted me in ways that I can't even express. His wish was to spend time with his wife and his kids and his grandkids and all of that has just been completely taken away. That has been a big sacrifice.
MM: I try to look for silver linings whenever I can, and one of them is that a crisis can either tear us apart or pull us together. And within the hospital, this has really pulled people together. A lot of the walls and barriers that existed before have been broken down. Everyone sees a common vision and mission and goal of why we do what we do. I have seen a lot more camaraderie, collegiality, and collaboration. Not that it was a problem in the past, but people have really risen to the occasion. If you ask them to do something and the answer is: absolutely. If we need someone to do an extra overnight shift, we hear: absolutely. We need someone to do an extra week caring for patients; several people let me know they’d help. So, I think sometimes in crisis, you see the good in people.
The other thing that's kind of been nice is that everyone needs a little external validation now and then. And when we walk through the neighborhood, there are signs in people's yards that say “we love our health care professionals” or “thank you for taking care of people.” And not just for healthcare professionals, but people working in grocery stores, etc. And it's nice to see that. So whenever I've had a particularly bad day, I take the dog for a walk and see the signs.
KU: Do you feel that you currently have enough personal protective equipment to care for your patients and yourselves?
TP: We have been very fortunate that we have the equipment we need overall. I know that our institution has worked very hard and focused very heavily on this, because they understand the importance of our safety and therefore the safety of our patients and their loved ones in the community. We've all heard the stories from New York and other places where that's not the case and I feel very fortunate that that's not something I've run into.
We want to remind people that a hospital is generally a safe place to be. With this going on, a lot of elective surgeries and other things were cancelled or delayed a little bit, but we do want to assure people that if you have a medical condition, you are safe to come in and get treated or get yourself evaluated.
MM: I think the other thing to come out of this over the last eight weeks is that people are communicating. Denver benefited from the fact that the COVID pandemic hit us a little bit later than other parts of the world and the world has gotten very small. We were calling people in Italy and in China and learning from their experience and saying, “Are you are you seeing people with a lot of blood clots, because I think we're seeing more” and they were saying “Yes, we are too” and so on. I really do think this is unprecedented in medical history that people are communicating and learning in real time. There are clearly things that we're doing slightly differently now that are leading to better outcomes. Medicine is pattern recognition and the more times you see the pattern, the better you're able to care for that patient. And now we've seen this pattern of COVID infections in the ICU and we're more comfortable and therefore can anticipate problems better.
KU: Could you talk a little bit about the use of ventilators and how that's changed and what that environment in the ICU looks like?
MM: There are different types of life support systems that patients will need in an intensive care unit. One is the mechanical ventilator, which is when a tube is put down the back of the patient's mouth into their windpipe and it's hooked up to a machine that then breathes for the patient. Another is the artificial kidney or dialysis machine. There's a catheter inserted in the patient's vein, the blood comes out and it's cleaned in this machine like what your kidneys do, and then the blood goes back in. There are also medications we can infuse to regulate blood pressure. And there’s also something called extracorporeal membrane oxygenation, or an artificial lung, because sometimes when the lungs are badly damaged, a ventilator can be dangerous. We put a catheter in, blood comes out, this machine puts oxygen into the blood, and then that blood goes back into the patient. So those are just some of the systems that we utilize for COVID patients to try to save their life.
KU: Any final thoughts on any permanent changes to our healthcare systems that might come out of this experience?
TP: One thing that I hope will carry on moving forward is the increase in interdisciplinary collaboration. Again, that wasn't necessarily an issue before, but the respect and admiration and communication between all the disciplines within hospital systems and around the city and state and country and the world will be something we can learn from.
The other thing is just overall preparedness. Learning and knowing that something like this may flare up again and making sure that we continue to be prepared for things that may very well come up in our lifetime.
MM: For me, I always knew I work with really great people and I've never been prouder of all my colleagues and the amazing hospital employees. It’s been an honor to witness their extraordinary efforts to care for the sick patients in the intensive care unit. I think in terms of how it's going to change healthcare, a lot more is going to be done virtually, especially in an outpatient setting. I think people are going to use technology to care for patients more.
I do think there's going to be a need for psychological support for a lot of the healthcare professionals who are going to be exhausted and burned out. You can kind of gear yourself up in the moment. But when it's all over, we should anticipate that and plan for that. As a society, we must make sure that we attend to the needs of all the health care professionals who are going to need to recover from this crisis. People are becoming more in tune with mental health issues and this might be a way to try to remove the stigma.
The Institute for Science & Policy is committed to publishing diverse perspectives in order to advance civil discourse and productive dialogue. Views expressed by contributors do not necessarily reflect those of the Institute, the Denver Museum of Nature & Science, or its affiliates.