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Stepping Up During the Pandemic Response

By: Daniel Cook

Published: 5/15/2020

There's been no shortage of help from ORs in the care of COVID-19 patients.

Working in the ICU comes as a culture shock to surgical professionals who have grown accustomed to the immediate gratification of caring for patients where successful outcomes are the norm. "I was cleaning the bed of someone who had died, getting ready for the next patient and another chance," says Joana Borgonos, RN, pausing before finishing her thought. "That was a tough day."

It was the toughest of many tough days the operating room nurse at New York Presbyterian Morgan Stanley Children's Hospital in Manhattan has endured since trading in her scrubs for an isolation gown to help care for COVID-19 patients during this unprecedented worldwide pandemic. She helps administer medications, place feeding tubes and reposition patients, tasks she hasn't performed since nursing school. "It's sad to see patients who are very sick, but I'm glad to help," she says.

Ms. Borgonos is not used to working 12-hour shifts, which have been physically and mentally demanding. It's nearly impossible to stay hydrated or grab a quick bite to eat during the five hours between breaks when she's layered in a gown, N95 mask and full face shield. She never has two days off in a row. She works night shifts after day shifts. When she finally climbs into bed, rest is fitful. "It's hard for me to sleep," she says. "I wake up often knowing I have to be back at work in a few hours to do it all over again, to try to make it through the day without crying."

Ms. Borgonos has undergone two open heart surgeries to correct congenital abnormalities, the most recent two years ago. "My friends and family pleaded with me to take a leave of absence so I'm not exposed to the coronavirus, but I can't help myself," she says.

Her experience is unique, but not unusual. When the coronavirus shut down ORs across the country, thousands of surgical professionals rushed to the frontlines of the nationwide response to the outbreak. They volunteered to work at COVID-19 testing stations, teamed up with critical care nurses in hospital ICUs and pitched in wherever and whenever they were needed.

Their reasons for doing are based on the esoteric concept of a career calling seemingly predetermined by inherent compassion, virtue and guts. The straight shooters of the OR have a simpler view of what drives them to help heal a nation.

"My colleagues and patients need me," says Ms. Borgonos.

"Getting out would have been easy. Staying and doing as much as I can to help is the right thing to do."

Surgical nurse Megan Siddel, RN, ADN, could have stayed at home in Savannah, Ga., but knew she had to get to New York City and requested a travel assignment to NYU Langone Hospital-Brooklyn.

"It's a heartache," says Ms. Siddel, describing the visceral pull she felt to help. "It's impossible to sit back and watch people suffer when you have the skills to help make things better."

"It's impossible to sit back and watch people suffer when you have the skills to help make things better."
— Megan Siddel, RN, ADN

COVID-19 causes the lower lobes of the lungs to fill with mucus, preventing them from filling with oxygen, says Ms. Siddel. "It's a thick, tenacious mucus that can't be removed by suction," she says. "You're working to keep patients oxygenated and maintain functional heart rates and blood pressures throughout the shift."

Once patients are put on a ventilator, it's difficult to get them off. "The volume of death is indescribable," says Ms. Siddel.

She's been cheered by first responders when she's arrived for work and applauded by appreciative community members during the city's nightly salute to healthcare workers.

"This is the hardest and most rewarding thing I've ever done," says Ms. Siddel.

Out of their element

TEAM PLAYERS Andrea Marquis Farrar, CRNA (left), and Andrea Dyer, MSN, RN, were part of the COVID-19 response at Central Maine Medical Center.

New York-Presbyterian Columbia in Manhattan sits in a hot zone of the coronavirus outbreak. Margaret Cory, BSN, RN, CNOR, a nurse who usually works in the hospital's pediatric operating rooms, arrives each morning with a new assignment. "Every member of our perioperative team has been redeployed to care for coronavirus patients," she says.

"We've essentially converted the entire hospital into an ICU."

Each of the hospital's ORs are filled with four critically ill patients. Each patient is ventilated. They have fluctuating vital signs and blood glucose levels, and regularly experience heart arrhythmias. The instability of the patients is nerve-wracking for nurses who are used to caring for patients in a controlled environment with predictive outcomes. "We're checking and rechecking physicians' orders that are based on patients' constantly changing conditions," says Ms. Cory. "It's a lot to keep up with."

ICU nurses, who are typically responsible for one patient at a time, are forced to balance the care of three COVID-19 patients. Ms. Cory teams up with an ICU nurse to lessen the burden. "I have a responsibility as a nurse to do whatever I can do to help," says Ms. Cory. "I wouldn't be able to live with myself if I stayed home. The ICU nurses it's just so much work for them. It boosts their morale when we tell them, 'I'm here with you. I'm here to help.'"

Teamwork is essential in the OR, a factor Ms. Cory believes prepared her for new role as nurse assistant. She received very little training in critical care nursing, but pitches in by emptying Foley catheters, retrieving medications, measuring blood sugar levels, administering insulin, repositioning patients, performing basic mouth care and assessing patients for pressure injuries.

"We have to do what's needed to make these patients better," says Ms. Cory matter-of-factly. "The number of patients we're caring for is unbelievable. It's difficult for us all — doctors, nurses. Everyone is worn out. It's not easy, but we're getting by."

The 12-hour shifts she endures are grueling. The constant fear of contracting COVID-19 is draining. "I think about it every day," says Ms. Cory. "It's on everyone's mind. No one wants to get sick. No one wants to bring it home."

HELP WANTED Margaret Cory, BSN, RN, CNOR, cares for patients at New York-Presbyterian Columbia in ORs that have been turned into makeshift intensive care rooms.

Andrea Dyer, MSN, RN, is a traveling nurse who was working at Central Maine Medical Center in Lewiston when the outbreak hit. She volunteered to work in the hospital's ER and swab patients in the COVID-19 testing tent. "It was the right thing to do, and I had some floor experience, so I thought I was the right person for the job," says Ms. Dyer. "Turns out I was very underprepared for working in the ER."

After a 20-minute tutorial, she found herself triaging patients and deciding who should be sent to the testing tent. "It was a lot of pressure, and the tent was very intimidating," says Ms. Dyer. "You watch videos about what it will be like, but that doesn't fully prepare you for the reality of the situation."

In the tent, Ms. Dyer was forced to wear the same N95 for three weeks because the hospital didn't stock her size. She was hyperaware of what she touched and how she could best protect patients. For the first time in her career, she didn't change her PPE between patient interactions. She'd don new gloves, but wore the same face shield, mask and bright yellow gown. It was an unsettling feeling. "As an operating room nurse, it was made we sick to my stomach," says Ms. Dyer. "We're consistent with sterile technique and proper use of PPE. I had to change my mindset."

The layers of protective equipment created an emotional separation between Ms. Dyer and her patients. "I'm trained to touch patients to ease their anxieties," she explains. "Not being able to do that was awful. As a nurse, it was embarrassing."

Ms. Dyer says working in unfamiliar patient care areas has taken a toll on her mental health. "I'm usually such a stable, happy person, but I looked forward to when my travel assignment would end," she says. "I had never thought that way before."

As the de facto gatekeeper to the ER, Ms. Dyer had to inform patients and their family members of the hospital's strict no-visitor policy. The task was uncomfortable, but doable until she had to separate a Vietnam vet from his wife. Ms. Dyer's voice cracked at the memory. "Sorry, I'm not usually an emotional person," she says. "It was awful. She was desperate to be with him, and I was ripping them apart."

The workplace anxiety caused her to stop sleeping soundly, and her hair began to fall out. Ms. Dyer's extended family, fearful of being exposed to the virus, began to isolate from her. "I completely understand why they did it, but it was when I needed them the most," she says. "I was trying to put on a brave face to be the best nurse I could be, but it's been one of the most stressful times of my life."

PPE PRODUCTION

Teaming Up to Solve a Shortage

MASK CRUSADERS Kristen Dirksen, RN, AND (left), and Brady Heuer, BSN, RN, CNOR, designed a homemade mask and managed teams who produced 20,655 of them. | Anna Stonehouse Pictures

The news was grim. Staff at Valley View Hospital in Glenwood Springs, Colo., were being updated about concerns administration had about the impact the coronavirus outbreak would have on their ability to stock adequate levels of PPE, particularly N95 masks that offer the highest level of protection against COVID-19.

Brady Heuer, BSN, RN, CNOR, and Kristen Dirksen, RN, AND, immediately began to brainstorm ways they could help offset the PPE shortage. That evening, the surgical nurses used tape and pins to create the prototype of a homemade mask. The next morning, Ms. Heuer presented the design at gathering of hospital leaders, who gave her a standing ovation and put their full support behind mass-producing the mask. By noon, Ms. Heuer was at the local Walmart with her surgical director and materials manager to buy the supplies needed to produce the masks. The bought six sewing machines, scissors, measuring boards, thread, pins, rulers and cleared the shelves of 6,000 pipe cleaners, which are smartly used to create the mask's nose support.

Ms. Heuer and Ms. Dirksen set up shop in a hospital conference room, where they organized assembly-line crews who cut, pinned and sewed.

Satellite crews have popped up throughout the hospital and surgical nurses have been joined in the workshop by scrub techs, physical therapists and acupuncturists, and staff members from integrated therapies, in-house daycare and physical therapy. An athletic trainer from a local high school who's employed by the hospital even pitched in to help. A plastic surgeon joined in on the first day of production. She started off learning how to cut and pin blue wrap and ended the day sitting behind a sewing machine.

Ms. Heuer says the response and support they've received has been overwhelming. The nurses originally considered using cotton fabric material but wanted to make an evidence-based decision — they're nurses, after all — on what material would be most effective. They determined cotton does not filter small airborne particles, so they came up with the idea of using sterile blue wrap instead.

Staff place the mask over N95 masks to extend the life of the critical piece of PPE. "It's functional and very similar to the standard surgical masks we wear," says Ms. Dirksen. "A major blue wrap manufacturer unofficially backed the mask's bacterial infiltration efficiency and applauded our efforts."

Ms. Heuer and Ms. Dirksen have overseen the production of a staggering 20,655 masks before pausing in production to assess the burn rate. "Our efforts will have been successful if we end up with a surplus," says Ms. Heuer.

If their inspiration, initiative, and ingenuity are any indication, the project's success has never been in doubt.

— Daniel Cook

Safe surgery?

GEARED UP Staff members at New York Presbyterian Morgan Stanley Children's Hospital suit up to care for patients in the ICU unit.

Throughout the outbreak, surgical professionals have continued to perform emergent surgeries. Andrea Marquis Farrar, CRNA, says the anesthesia team at Central Maine Medical Center assumes every patient is infected with the coronavirus and intubates each one, no matter how minor the procedure, to create a sealed airway and eliminate exposure risks in the OR.

Anesthesia providers are inches away from the airway and in the direct path of virus particles that become aerosolized during intubation. During intubation, Ms. Marquis Farrar wears two sets of gloves, eye protection, a face shield, and a regular surgical mask over an N95. She also uses a video laryngoscope, which lets her stand upright while viewing the airway on a separate monitor instead of leaning inches away from the patient's mouth while inserting a standard laryngoscope. The video laryngoscope also allows for a quick first-pass intubation, which helps to avoid a patient's reflexive coughing that can spread the virus throughout the room.

Once the airway is secured, Ms. Marquis Farrar peels off the gown, gloves, face shield, and outer mask. She reapplies the layers before extubation, during which risks of coughing are increased.

Elective surgeries are beginning to ramp up at Denver (Colo.) Children's Hospital, according to Orthopedics Service Line Leader Heidi Manzanares, BSN, BS, RN. She's been forced to wait outside the OR with other members of the surgical team for 20 minutes until anesthesia providers intubate patients and secure the airway. There's been confusion among her colleagues about the effectiveness of COVID-19 testing and whether the PPE they wear during cases is enough to protect them from exposure to the virus.

The pressure political leaders are feeling to reopen state economies and hospital administrators are feeling to reopen ORs to elective procedures has trickled down to the frontlines of care. Word can come down that it's safe to proceed with elective cases, but it's the nurses, surgeons and anesthesia providers who put themselves in harm's way during this time of unprecedented uncertainty about the risk they face every time they step foot in the OR. Still, when patients need care, teams of dedicated professionals will deliver it.

"I chose to be a nurse, but I didn't choose to do it during a pandemic," says Ms. Manzanares. "I'm not going to walk away. We all want this to end, and we have to figure out how to get through it."

Better times ahead

There's hope amid reports the curve is beginning to flatten. Elective surgeries are starting up again in certain parts of the country and optimism is growing that the nation is emerging from one of its darkest periods. "Once things settle down we'll be able to reflect on the magnitude of what we did," says Ms. Marquis Farrar.

The days and nights are long for Ms. Borgonos, but she can't keep from smiling when "I Gotta Feeling" by the Black Eyed Peas plays over the hospital's overhead speakers every time a patient is removed from ventilation. It's a small gesture to mark big victories in the gradual shift back to some semblance of normalcy, when the busiest of days in the OR won't seem so bad after all.

In the meantime, talented and dedicated surgical team members will continue to help the nation recover. "This is what we were born to do," says Ms. Dyer. "We're in this together." OSM

Stepping Up During the Pandemic Response