You can’t carry a thousand deaths around with you

Remember how proud we all were of healthcare workers there for a while? It was a whole thing. Clapping for them and shit. Big sappy TV ads thanking them. As we enter what may be another surge (?) I thought it might be worth checking in with one of the people who was “on the frontlines” over the past two years to remind ourselves how much it fucking sucks to die from Covid and what those workers went through trying to save us. Our man today is an ICU nurse in San Diego.

“When the whole unit was all Covid patients, we would have iPads at almost every bedside,” he said. “You would hear this chorus of families talking. It would be like: Uncle, I watched the Raiders last night. I was rooting for them for you. Or: Dad, don’t worry, your grandson is learning to ride a bike. All these little snippets. It’s like … fuck.”

We talked about the difficulty of building a wall inside so you don’t have to carry so many deaths around with you, public health policy and what the fuck Leana Wen’s deal is, whether or not having loved ones there when you are dying makes a difference, and some other stuff.

“We really do see very sick patients,” he said. “Some get better. But this just felt like every patient fucking died. I think you have to find a way to put it in a box. Put that box away. You have to check in with your people. It’s important to me that I have close friends I went through this with, but you gotta be able to function. If you let every death affect you the same way you would get burned out so, so quickly. It’s not like you don’t care. I care a lot.”

What kind of nurse are you and where do you work?

I’m a staff nurse in the surgical ICU. Our patient population is pretty broad. We take care of trauma patients, patients who need neurosurgical interventions, patients with cardiac surgery, and other critical needs.

There are two level one trauma centers about two blocks from each other in San Diego. We serve a large urban population. We get a lot of patients from the border. East of San Diego is very rural and there aren’t a lot of hospitals with the capacity or technology, so we get patients transferred from there too.

How bad did you get hit by Covid?

Our worst surge was the winter of 2021, after Christmas through February. During that surge we ran out of rooms to put patients, so we converted the whole unit to negative pressure. So your whole twelve hour shift, when every patient in the unit had Covid, you’d wear an N95 the entire time, a face shield. You’d spend twelve hours proning patients. It was fucking crazy.

Where do things stand now?

Things have calmed down now quite a bit. I remember the first time that things had calmed down after our first big surge it was kind of weird. Like eerie. I don’t think I was expecting it. You swim in the ocean right? You know how you first get into the water and it’s so cold, and you’re like, fuck. But then you start swimming and your body gets used to it. You’re in it. Then you come up for air you and realize you’re tired and cold. Once we had our first break after the big surge, that’s when it first hit me that we went through some serious shit. But when you’re in it you don’t think about it you just go in and do it.

I’m not going to let a guy from San Diego tell me about what swimming in cold water is like.

This isn’t Hawaii! Our water is cold as fuck.

Well I invite you to come to Cape Cod some time.

No you have sharks out there I don’t fuck with that.

The point is basically that you just had to keep your head down, you were so busy you didn’t even realize the severity of it all?

We doubled our total number of ICU beds with roughly the same number of staff. California is the only state with a mandated nurse to patients ratio as law. That got waved during one of our surges. If you didn’t have Covid patients you would have three really sick trauma patients. You’d just keep your head down. This is what it is.

They tried to pass a law like that in Massachusetts a couple years ago.

It was bullshit. I saw the AHA poured all this money into all these ads.

Yeah they pummeled everyone with bullshit about it.

It pisses me off. I saw some nurses from Boston on Twitter being like, well, I’m confused about this. The ratios seem like they would be a good thing… I was like how can you be so fucking stupid? We did it in California. It was enacted like twenty years ago. Schwarzenegger signed it into law. It’s insane to me that that kind of propaganda works on people. That’s depressing as fuck.

They’re doing a similar thing here now with the rideshare shit like they did out there.

Oh yeah. During surges some of our supervisors would show up and take shifts, but beyond that we were failed at every single level in terms of the hospital, county, and state government. We were failed at every level, but thank god we had eachother. We had to stick together. As an ICU nurse we take care of patients who get very, very sick. Some of that is preventable. So seeing people who have power to potentially prevent that not doing anything… Knowing they didn’t see what I saw and do what I did for months on end, it’s like, what the fuck?

Do you mean on a policy level?

Yeah, but also, even while knowing this director or that might not have power on a policy level, they still get up there every night in front of a mic on CNN and mouth off about why we shouldn’t do this restriction or that. Or write a Washington Post column talking about why this restriction isn’t a good idea. We’ve never done anything to meaningfully support working people in this country in terms of Covid. I have relatives in Ireland and they literally got paid to stay home. Nobody got any fucking support here. And now when people advocate for some very basic restrictions, like, hey, maybe we should still do masks here, you get fuckers like Leana Wen who are like that’s not a good idea. When you advocate for putting kids back in schools without doing anything to make that safe, ventilation, filters, doing things like that to protect teachers and kids, it’s just insane to me. It seems like a lot of people don’t fucking care. It should be the people in power who do care.

What is that lady’s deal?

I don’t know and it makes me insane. Her and Emily Oster. Wen, I don’t know if she’s gunning for an administration job or what. I’m an ICU nurse, not a public health nurse, that’s different training. Her training was in the ED I think in Baltimore. In the ED you see the failures of a lack of a social safety net. We live in a country that doesn’t care about people. I think that’s what bothers me. You saw some shit that should’ve changed you. If you were one of us at one point, why are you not advocating for us or fighting for us?

Then there’s the dude David Leonhardt from the New York Times.

That fucker. It throws me how much space is given to people in the media to espouse these views. Wen will be like, well, I’m advocating for what is practical. That’s not your fucking job. Your job is to advocate for what’s right. Public health isn’t about individuals, it's about a greater thing.

I’m sure you’ve worked with both good and bad doctors in your career. I just had my annual physical the other day. I called a while ago and they said, ok, you can see the doctor in like five months. I said, uh, anything sooner? And they said I could see the nurse practitioner in like three weeks. I said yeah I’ll do that. I like it better to be honest. Whenever I see the nurse practitioner they seem like they give more of a shit than the doctor.

Oh yeah that’s like a whole other road we could go down. Studies show that nurse practitioners are able to provide safe and effective care to patients in a primary care setting. That’s established. But then you see these doctors who get all up in arms about it. Well, nurse practitioners are more likely to practice in low income settings, in rural and urban areas and shit. They increase access to care, which is what we need, especially in primary care. Then you see some random doctor who’s like the professor emeritus of some super specialized area who is up in arms about it. Nobody gives a fuck. We’re out here trying to help people.

I assume you saw a lot of death and suffering throughout Covid. I feel like people are pretty much convinced it’s over now. I thought it might be worth reminding ourselves how terrible it is to die from this.

I vividly remember the patients on high flow oxygen. A normal person’s oxygen saturation is 95-100. Theirs would be 70-80. They couldn’t talk. They couldn’t eat or drink without it dropping. I remember doctors were very resistant at this point to intubating them. They were like, well, when we intubate them they don’t go anywhere. They don’t improve. They just die. But these patients were just miserable. I vividly remember a patient saying tell me how to breathe. What do I need to be doing? I said there’s no special technique. You’re not doing anything wrong. I’m sorry but I need you to stop talking because your oxygen level is dropping.

I’ve taken care of a lot of diseases, but with Covid I know the playbook. I know how the story ends. So that patient ended up getting intubated, and we ended up proning him, turning him on his belly to try to improve his oxygen. He went into multi-organ failure, and was on a continuous form of dialysis. He ended up dying.

It was almost harder taking care of patients before they got intubated. Before that they would be talking to you and it would suck. It was harder to put up a wall that you need to take care of them.

In order to do your job you sort of have to think of them less as a person?

Of course we fucking care, but you can’t carry and take every death with you. I don’t know how many patients I’ve seen die. It’s a lot. After a certain number… Especially when you know where it’s going. We got a big surge this past August. One night I was taking care of this early forties man. He was intubated. We stopped proning him because it wasn’t making a difference. He was on a very high ventilator setting for oxygen. I knew this guy was going to die. I could tell where this was going. I was taking a fifteen minute break, and a co-worker was watching him. I came back, and she was sitting at his bedside, and she had this look on her face like surprise. I said what’s wrong, and she goes this is really sad. It took me a minute and I was like, oh. Oh yeah. Not that I don’t care but you have to protect yourself.

That same patient, earlier in the night, his son called on a Zoom. Zoom calls are another thing that sticks with me. His son was like dad you gotta fight. Crying. I thought it’s not a fucking fight. It’s not a war. Your dad has a horrible disease. It destroyed his lungs. It’s not a fucking fight. Let’s maybe stop torturing this man’s body.

That’s how people talk about cancer and stuff too.

It’s always bothered me. You don’t lose.

Obviously people who are grieving aren’t thinking logically.

Right of course. I didn’t go over and say dude shut the fuck up.

But it implies, well, what about when someone dies? Did they not fight hard enough?

Exactly.

The Zoom calls added a whole other miserable layer to all of this right?

Yeah. When the whole unit was all Covid patients, we would have iPads at almost every bedside. You would hear this chorus of families talking. It would be like: Uncle, I watched the Raiders last night. I was rooting for them for you. Or: Dad, don’t worry, your grandson is learning to ride a bike. All these little snippets. It’s like … fuck.

The Zoom calls were rough. As an ICU nurse, again, I accept that patients die. I know sometimes I can only make small changes in the night. If I have a patient on multiple medications to keep their blood pressure up because they're in shock, I think, ok, maybe something I can do is to get them off one of them. Improve things a little. But there were some nights with Covid patients you couldn’t make any improvement. They would be so sick you couldn’t even turn them side to side. We turn patients every two hours to prevent bedsores. There were some nights we literally just held up iPads while patients were dying and you couldn’t even make small incremental progress.

What do you attribute things being a little better now to? Vaccines of course, but have you all learned treatments that are more effective?

With critical care what we do is provide life supportive measures. With Covid when you progress to respiratory distress syndrome, there’s really only so much we can do. I don’t think we can take credit. It’s nothing we have done. That’s why it comes back to public health. It’s not because of failures on our part, it’s because it’s a really, really horrible disease. The therapies we provide are supportive, not curative. That’s why it’s frustrating to me when I see people who supposedly have public health expertise or power in those areas speaking out against things that could prevent more of this. I can take care of a Covid patient excellently because I’ve done it so many times, but that doesn't mean they’re going to do better unfortunately. I can dot my i’s and cross my t’s, but once they get really sick there’s only so much we can do.

Is that hardening yourself against death just something medical professionals have to do? Was it hard to do at first?

We lost a lot of nurses in the past couple years. They went to work as travelling nurses to make a lot more money, or they just said I’m fucking done with the ICU. One thing that shocked me was that I had nurses that trained me, who had been doing it for ten or fifteen years, saying I’ve had enough. The sheer volume of it. We really do see very sick patients. Some get better. But this just felt like every patient fucking died. I think you have to find a way to put it in a box. Put that box away. You have to check in with your people. It’s important to me that I have close friends I went through this with, but you gotta be able to function. If you let every death affect you the same way you would get burned out so, so quickly. It’s not like you don’t care. I care a lot.

You can’t carry a thousand deaths around with you.

No you can’t. We had a trauma patient in our unit. He passed. I was texting with a good friend who had also taken care of him. We said we have to know we did everything we could. His family was at the bedside luckily, and it seemed like he was obviously loved. But we can’t carry that with us. But then that night I barely slept. It surprised me. This shit is heavy. We admit that to ourselves and to each other. You don’t want to not see your patients as human, but there’s a very fine line. You have to step back and realize what’s not yours to carry. Did we provide the care we could? Did the patient get everything they should? Were their loved ones around them? You can’t let it eat at you or it will destroy you.

How much does it matter for people to have loved ones with them when they’re dying?

I think it absolutely matters. Sometimes that’s harder for us as healthcare providers to witness, because then we have to see how sad and upset they are, and make room for these family members howling in pain and shit. But it’s worse to me when we find a homeless person and we can’t find a family member. It’s like, fuck, is there nobody who cared about this person? I think it does matter.

I said there were some nights we couldn’t make incremental progress on Covid patients, but I vividly remember one that I knew was going to pass that night or very soon. One lady, in her forties, she was so sick, we couldn’t turn her, her blood pressure was very low, her oxygen was low. She had a fresh trach. I was telling the resident she wasn’t improving. They wanted to prone her. I said I’m not against that, but if we do there’s a very strong likelihood she could code and die. So what you need to do is call the husband, because he lives an hour or two away. You need to call him and say your wife might die. It’s 3 in the morning. You need to call him now and tell him what’s going to happen. I think that’s one of the most important things that we can do. I think it’s important both for the patient and the family members.

I think it’s uncomfortable for us, speaking largely, because Americans aren’t comfortable with death. But I think it’s important. And much, much better than the alternative.

I’ve been pretty preoccupied with mortality lately. Maybe because I’m getting old. My thinking is, well, of course I’d rather have my wife there and my loved ones when I’m dying some day. But then I’m like, eh, in five minutes what is that going to do for me? I’m just going to be gone so who cares?

Dude it’s also not just about you.

Wait, you're telling me I’m not the protagonist of reality?

You’re not the main character of the universe.

Shit.

You’re Irish Catholic right? I am too. We want to do it quietly. Not bother other people. You’re fucking Irish Catholic. But, no, it’s about the other people. I think it’s hugely important to have loved ones there.

Fine you convinced me.

Again, I think Americans as a whole are very uncomfortable with death. I almost wonder if that’s been part of our response to this pandemic, especially now. Early on we did nothing, because America doesn’t want to show that we invest in or care about poor people. Now it seems so much more of what we’re doing is trying to push shit under the rug. If we admitted now how this all went it would bring the magnitude of how many people died more into focus. I don’t think Americans are comfortable with that.

That’s part of the big push for “back to normal.”

Right. We don’t want to think about the staggering magnitude of how many people died. We had nights when people would die and we didn’t have room in the morgue. We’d have to wait for outside coroners to come pick them up.

Ok one more question for the road. How painful is it to die from lung cancer?

Do you still smoke? Are you asking if you can get away with smoking for another forty years?

How about one or two?

Quitting now as opposed to two years from now can have a big difference. Research shows that your lungs can be fairly healthy, say, if you stopped today, ten years from now. But wait, do you smoke normal cigarettes or do you vape?

Normal.

At least that’s better. I think it’s horrible and hilarious that people have taken up vaping later in life. You never had a nicotine addiction and you started sucking off a USB drive? What the fuck?

Vaping is worse?

Public health was very successful with smoking cessation for young people for years but vaping has almost closed that gap.

I think dying from lung cancer would be very painful. I think you would feel a lot of air hunger. You’d feel like you can’t breathe.

Ok thank you for the reminder. Air hunger. I hate the sound of that term. It’s kind of grimly poetic, sure, but I don’t like it.

I don’t know if there’s a comfortable way to die, but I don’t think that would be a good one. If you’re trying to pick one I think you could do better.