A Shift In A Southern California Emergency Department During COVID

I show up for the morning "hot zone" shift and check in with the lead nurse in the ED.

Of 60 potential clinical spaces (accounting for every gurney, chair, and our fast track area), 29 are occupied by boarders - patients admitted to the hospital who remain in the ED either because there are insufficient beds upstairs in the hospital wards.  More commonly, there are insufficient staff to care for admitted patients despite an ample supply of beds.

The reality of keeping boarders in the ED is challenging. A crowded ED leads to increased ambulance diversion hours - instead of being taken to your local hospital, you bypass it for a less busy one. To keep staff "in ratio" upstairs ( 1 nurse to 4 patients), staff are allowed to go out of ratio in the ED. Local representatives have railed against the practice, and out-of-the-box academic thinkers have demonstrated that a full capacity protocol placing admitted patients in nontraditional areas on the wards is both safer for patients and more acceptable to them than one might imagine.

Since the pandemic began, emergency departments have instituted designated evaluation areas for patients suspected of COVID, attempting to separate them from everyone else. Of the 29 boarders we have this morning, more than 20 are COVID patients. One is on a ventilator. Holding them in the ED means two of our five clinical spaces are now completely out of commission, inaccessible to the crowd in the waiting room.

Me, attempting deadpan humor: So I'll be seeing COVID patients during our post-Thanksgiving surge, only there are no remaining spaces to see them in?

Salty Lead Nurse I adore: Yes, cupcake.

Me: On it.

I enter the hot zone to find a beat up crew of dedicated if bedraggled nurses finishing their shift before the day team takes sign out. One was an internist in the Philippines in a former life. One is building a real estate empire, doing every property renovation himself while raising a family (did I mention he has a working spouse?). One stunned me with the voice of an angel at an out of hospital social event a few years back. One, a muscular twenty-something with boy band good looks, just returned after recovering from COVID.

They are incredibly talented, have other options, and seem to be evaluating the life choices that led them to work last night's crappy shift. I make it a point to thank them before they leave.

I head to the waiting room, where a 60-ish lady in a wheelchair with an oxygen level of 68% is working to breathe. While sick, she's not at immediate risk of respiratory arrest, so I find a sympathetic tech to place her on a portable oxygen tank and we keep the door open to the COVID waiting room so I can see her from my work station. As she begins to breathe more comfortably, my sphincter tone decreases ever so slightly. It will be an hour before we'll find a room for her, and then she'll to be placed on the last high flow oxygen system in the ED, but we will spare her from requiring a ventilator.

I work my way through the other patients in the smallish waiting room -  by application of Solomonic wisdom, it has been divided in half to keep COVID and non-COVID patients separate. When I've finished seeing those folks, I exit to a converted outdoor patio area with heat lamps with an odd array of individual chairs spaced six feet apart, a sunny space that looks like a strip mall Cheesecake Factory gone terribly awry.

Among those I diagnose with COVID:

• A 39 week pregnant essential worker, well enough to go home.
• One of the physician colleagues I work closely with, well enough to go home. Despite the fact that she expected it, she still looks horrified at the prospect of what she might have brought home to her family.
• Countless frail elderly, all sick enough to require admission.
• Two adult siblings who'd been to a family reunion the prior week, only to find out an aunt in attendance had been diagnosed with COVID yesterday. Both go home.
• A charming person who seems genuinely surprised that first class travel out of state on a regular basis has resulted in his infection, well enough to go home.
• A woman who lost her husband to COVID only a couple of days ago, well enough to go home but not yet in that 7-10 day window after symptom onset where oxygen levels are known to drop precipitously. She will remain on my conscience until I call her back a few days later and get her son on the phone, only to hear that he has dropped her off back at our ED within the past hour after the pulse oximeter I encouraged her to purchase demonstrated the precipitous drop I'd worried about. She is stable on oxygen and has not yet required a ventilator.

Between each patient I methodically gown and glove (my double masks never come off), donning and doffing my PPE and wiping down my stethoscope, pen and face shield. I can't skimp on any steps, and have to deliberately slow myself down to ensure my technique is meticulous. Seeing a full waiting room of patients with this necessary delay feels like running in slow-motion, but I am thankful we at least have an adequate supply of gear. Many colleagues at other institutions are not so lucky.

When I get home, I'll read the latest email update from our bioethics committee, discussing how we are preparing to go into crisis mode if ICU bed demand outstrips supply. All models forecast that this will be a likely scenario in the coming weeks as we enter a post-Christmas and New Year's surge.

It's one day at a time for now...

If anyone reading this happens to be a Netflix show runner who thinks the salty lead nurse and I have a lovable, George Burns-Gracie Allen type chemistry that might be worthy of a sitcom, please contact me - at this moment she and I are both particularly open to career changes.