Alumni on the Frontline

I am an emergency medicine Physician Assistant in South Florida with five years of experience at Holy Cross Hospital. I have been helping out in the ICU since the pandemic ramped up in my community about a month ago. I have personally taken care of at least 100 COVID patients, ranging from asymptomatic worried-well 20-something year olds to a 91-year-old female on a ventilator. I saw the first documented COVID case in my county, as well as the very first COVID-associated death in my county. I have myself been infected. 

About three weeks ago, after working seven days in a row between ER and ICU, my girlfriend bought us some Chinese food to celebrate getting through the long stretch of shifts before my next five-day run of shifts coming up. I was running late, trying to stabilize a particularly-ill 39 year old COVID patient that had been in the ICU and on a ventilator for weeks and ECMO for over a week, so I didn’t get out on time.

Eventually, I was able to get him stable enough to feel comfortable leaving him in the capable hands of the nighttime. Excited to finally be done with a grueling week, I walked to the parking lot to find that my car was gone. I soon found out that it had been stolen out of the hospital parking lot. The anger, resentment, and general feeling of despair in that moment when all I wanted was some Chinese food is quite difficult to put into words. Two days later, I learned that my car had been stolen and was stripped for parts about an hour away from the hospital.

Angered beyond belief, I struggled to understand why someone would stoop so low to steal a car from a hospital parking lot. I had to try to keep things in perspective: I still had a job; I myself had been infected but showed very little symptoms; and most of all, I had a wonderful girlfriend who was able to get me back in to work to continue to serve my community. Not all are as fortunate.

A few days later, in what had to have been one of the most rewarding experiences I’ve had in my career thus far, I was able to witness that very same COVID patient that I was caring for the evening my car was stolen walk out of the hospital! I got the perspective I really needed when I heard him say to me “I REMEMBER YOU” as he was wheeled out, completely neurologically-intact... after being in the hospital, sedated, and critically-ill, for over a month.

THAT’S what it is all about. That’s what all the training, hard work, and sacrifice boils down to. I realized THAT is why we do what we do. Suddenly the loss of my car seemed so trivial. 

AMDG,
Brian Giddinge, MCMSc PA-C

Today would be the last day of her life. She was only in her fifties. We knew it was coming: her lungs were starting to worsen, and there was nothing more that we could offer. After spending much of the day talking with her family members, we transitioned our goals of care to focusing on her comfort, relieving suffering, and promoting her dignity. I asked her sisters, “What does she like? What kind of music does she listen to? What is important to her?” They didn’t want to risk exposing themselves by coming in to see her, so I would do my best to fill in for them. I learned that she loved hip hop, especially Pitbull, her cats, and science fiction. I quickly went into her room to turn off the Sarah McLaughlin that was playing and put on something that was more her taste.

Three times that day, I put on my PPE -- gown, gloves, mask, and goggles -- entered her room, and held up a phone to her ear so that each family member could say their goodbyes. A chaplain came and gave a blessing from outside the glass door -- it was too risky to enter the room unless absolutely necessary.It was time to remove the breathing tube. I prepared the medications that would keep her comfortable and entered her room. My phone, wrapped in a plastic bag in my pocket, played Pitbull for her. We removed the breathing tube and I sat beside her, holding her hand and stroking her forehead, just as her sister had requested. I talked to her about her cats and her family’s love for her. I told her it was ok to let go.

Another nurse came in to say goodbye. She was one of the many “helper” nurses, nurses who did not have ICU experience but worked alongside the ICU nurse to assist with care. (We ran out of ICU nurses weeks ago.) The nurse had never experienced something like this before. She looked at the patient and was quiet. “I don’t know what to say,” she told me anxiously. “You don’t need to say anything,” I told her. “Your presence is enough.”

Presence. If anything, this pandemic has reinforced the power and healing of presence.

Presence. We will all die at some point. As I sat beside my patient during her final moments, I thought of her family and the suffering they had experienced during the 12 days she was intubated. She had not discussed her end of life wishes with her loved ones. They had not discussed whether quality of life or quantity of life was important, whether she would want to be kept alive with artificial nutrition, or if she would want to be kept alive on a ventilator. It was anguishing for her family to try to guess what she would want. If you were driving in a car with someone and they started playing Sarah McLaughlin, but you preferred Pitbull, you would speak up. Why should your health care be any different? Your life, preferences, goals, and wishes should be reflected in your health care. Otherwise, we will do everything in our power to save your life. Sometimes, this will cause unnecessary suffering.

I urge you to talk with your family, friends, and loved ones about what’s important to you and fill out Advanced Directives and Health Care Proxy paperwork. These conversations can be difficult. But they provide you, and your loved ones, a sense of control and purpose in what can be a very vulnerable situation. They ensure your presence in your care, and communicate to your health care team what, and who, is important to you.

Presence. Health care workers have seen an overwhelming show of support, through gift cards, generous food donations, and nightly applause. These acts are heartwarming, especially after difficult days. We are all struggling to find new ways to be present with one another and show our love and appreciation. While we appreciate these kind acts, we need your presence in other ways, as well. We need you to call upon your local, state, and federal leaders for change. We need more PPE. Fortunately, we have not had to ration ventilators for our patients. But we are rationing PPE every single day, placing our lives at risk to save yours. We are re-using and re-sterilizing N95 masks that are intended for single use only. We do not know the long-term ramifications of this, or even if the masks are still effective at protecting us from the virus.

We also need to examine the flaws within our health care system and society that the virus is highlighting.The poor and marginalized are at a heightened risk for contracting and spreading the virus. Our lives and our future are tied to how well our government cares for the poor and the sick. What are we, as men and women for others, doing to help lift them out of those circumstances? What are we doing to advocate for policy change? We all have a voice. Now is the time to use it.

A month or so ago, I was caring for a patient in his 30’s who had spent three weeks on the ventilator. The ventilator was removed the day before, but he had not regained his voice yet. He wrote me notes to communicate: What is coronavirus? Is there a cure? I want orange juice. Today is the Cambodian New Year. My heart broke as I shook my head, no, there was no cure. But you are one of the lucky ones. You survived. He thumbed through photos on his phone, showing me photos of his two little girls, all dressed up for the New Year celebrations.

Later that day, he got my attention and motioned like he was shooting a basketball. “You want to shoot hoops?” I asked, surprised. I am always amazed what patients ask for after being critically ill. We are so caught up in saving their life that we forget how much joy there is in daily activities. We sat him up, crumpled up paper towels, and held up a trash barrel for him to shoot into. On his fourth shot, he sank one. A few nurses had gathered around his bed, cheering for him. When the paper towel toppled into the trash barrel, we threw up our arms and cheered for him. We had silently been cheering him on for the past three weeks, administering medications, turning his comatose body, and bathing him. What an incredible way to start his New Year, I thought to myself.

In Massachusetts, we have been quarantined for over 50 days. Some days are lonely, and many of them are difficult. But I always think back to this moment, and the joy that this simple activity brought. COVID-19 constantly reminds me to be present in my daily life, whether I am shooting hoops, sitting with a dying patient, or noticing the Spring blossoms outside my window.

Ad Majorem Dei Gloriam
Ashley Giddinge ‘10
MSN, RN, CCRN

It’s been strange and difficult times at my job as we are dealing with the surge in New York City but thankfully things are turning a corner as hospitalizations are decreasing and it’s great to see patients that are here are starting to get better. My job has mainly been helping out as a PA in the pop-up/surge ICUs that have been created throughout the hospital to handle the huge influx of patients. I usually work in the cardiac surgery ICU and during the pandemic we have converted most of our operating rooms into ICUs so our group has been helping out in those areas.

Cheverus was a huge part of making me who I am today. Without the teachers, friends, faith, and education provided by Cheverus, I would never have gone to Saint Anselm College and received a BSN. I feel like most people roll their eyes when they think of high school, but not me. I reflect often on how I am a person for others, especially at a time like this. I am a labor and delivery nurse, certified in Inpatient Obstetrics. A lot of the time, I hear “you must rock babies all the time, I bet your job is so fun.” My job is fun; but it is also scary, serious, and constantly evolving. I don’t rock babies all day -- I support mothers trying to make it through their labor, I am a shoulder to cry on when they lose their baby, I am one of many running down the hallway to open the operating room for a stat c-section. During the COVID19 pandemic, our unit has stepped up in so many ways. From becoming experts on using PAPRs for patients with COVID19, to having an entire unit transformed into negative pressure rooms, I am blown away to be part of such an amazing team. My work family at MMC is a lot like the family I had at Cheverus. I believe it is because of my Cheverus education that I was able to find a team like the one I have on labor and delivery. I am and always will be a person for others.

Ad Majorem Dei Gloriam
Paige M. McGowan, Class of 2010

I have completed my first week working in a long term care facility at the Bedford VA.  I am the primary medical person for two floors, a geriatric psych, and dementia floors. Every day that we get to work we are screened, have our temperature taken.

Week 1:

Day 1: Arrived on Tuesday, we were the second group of nurses, a PA, and NP from Maine. Much of the day was doing covid education and getting our computer codes. We were addressed by the nurse executive.  While she was talking to us she became teary eyed when talking about how the virus has affected the Bedford VA.  There have been many staff who tested positive for covid and there were several staff who were presumed covid positive that were still working on some of the floors because they were asymptomatic.  The Nurse Executive asked us all in her welcoming remarks," I hope you all will consider staying for an additional deployment period of 2 weeks.

Day 2 -- I was driving into work that day (after getting my cup of Starbucks) and thought.... today's mantra is going to be.... " Make me an instrument of your Peace".  

The day was absolutely overwhelming.  Most of my thoughts that night were about Mr H.  I am the only medical person covering the two floors.  I did mention to supervisors both at Togus, and in Bedford, when we got there, that my most recent practice was as a psychiatric nurse practitioner.  But the need for a medical person was pretty high so I was assigned to be the primary medical person on 62 A and B.  The Bedford people have been so supportive and they have assigned the director of education, Dr M,  to us for the next week to be there to help us maneuver the different elements of the facility, and for me, helping to transition back to being a primary /medical practitioner.

I was called to the floor this day by one of the nurses to assess a potential positive covid patient- Mr H,  I reviewed the patient presentation with  Dr M, -- elevated temperature, SOB, delirium, and recent diarrhea. After I presented the case to Dr M, he said to me, "How are you with talking to families about end of life care, you should call the health care proxy and have that discussion.”

Day 3 -- I started the day by going to both floors to meet with the nursing staff at the change of shift. Dr M. wisely told me the first day, "The nurses are going to be your best friends." Both floors had 2 presumptive positive patients that were pending test results. Most of this day was writing orders, and I did my first transfer for one of our patients, who tested positive, to another floor within the facility..

Day 4 --  " The MOLST"-- During a team meeting the discussion was that we needed to complete end of life paperwork on 18 patients, including four from the floors that I was covering. This involves having a conversation with families about end of life decisions.   Because the day was filled with so much activity I did not start working on my four until around 5:00 yesterday. One of the doctors from another floor was kind enough to help me with this paperwork process and he left last night at the same time I did at 7:45 pm.

The one highlight of this day was going to visit Mr. H. I asked him if he remembered me and he said, "yes” (but I am not sure he did).  I asked him if he wanted anything and he said, " ice cream".  the nurse got him some, and I was able to spend time feeding him the ice cream and asking him about his life".

I believe the most important thing I learned this week is that whenever I/ we can expand our comfort areas we are always enlightened by the kindness of humanity.... example....Dr M.
 

Week 2 in Bedford:

Monday:  Mr. H passed today.  Mr H was one of the first people I examined and treated, and he was a presumed positive covid pt.  I heard the morning report and it was reported that he had not been eating much during the weekend.  I asked if we had tried to feed him ice cream, because he seemed to enjoy it the past Friday.  After report, I went in and fed him some strawberry ice cream.  Approximately an hour later I received a call from the nurse to come to the floor and when I got there two of the nurses, the nurse manager and a MA were around his bed. He had passed. The medical assistant told us that she had also fed him some ice cream and left the room, and when she came back a little while later he had passed.   One of my responsibilities as the attending on the floor is to pronounce death.  I listened to his heart, and for any sign of breath, and checked for a pulse.  I also talked with him and wished him peace and thanked him for allowing me to meet him.   And then called his health care proxy. Carol, she told me that he was very well known in the Massachusetts city where he lived and told me a little bit about his life.

I did not sleep well that night and kept thinking of what more I should have done, and did I spend enough time with him.  A few of the nurses I’ve talked with about Mr H, who have worked in hospice, tell me that this is a common reaction to the death of a patient. 

Tuesday: Am covering two floors and on one of the floors two patients tested positive for covid.  When they test positive, they are transferred to one of the 4 covid floors that have been set up with ventilators, and negative pressure rooms.  I called all the health care proxies to let them know we were testing and also called when the test results came back.

Wednesday: The anxiety is high within the facility and it seems to show in many ways.  Every day I go to hear nursing reports at 0700. After report, I went to see a veteran, and when walking by the nursing station two nurses with raised voices were arguing.  I was unsure what to do in this case so just stood there and observed , at this point it stopped and the only thing I could think to do was to tell the nurse how sorry I was about this incident. Later, I reported it to the chief of geriatric care who is also an Advanced Practice Nurse.

I also proposed that I start doing a brief meditation practice at change of shift each day and we will start this on Monday for both floors that I am covering.

Thursday:  There is a daily lync message that connects all of the doctors, clinicians, nurses, and nurse managers. This serves as a collection of new research and a way to ask questions about patient care.   We heard on this day that the FDA has approved the use of remdesivir to treat covid patients.  I also saw an article on the site that there is no definitive research that a person cannot be re-infected by the virus.

Friday: A lot of my work on the floors in addition to detecting the virus is managing complex medical cases.  This week I have worked with patients with end stage renal failure, congestive heart failure , hyperglycemia and COPD.  I am regularly monitoring vitals, ordering tests and calling families to update them and get consent for certain treatments.  At one point I asked Dr M., “Are you going to send me a bill for this residency”?  He is one of the kindest people I have ever met in the field, he replied “no, I know you’ll use this knowledge to help someone else”.  My learning curve is straight up, and I am so grateful every day that I am in this experience.

I left work last night to come home to Portland.  Before I left Bedford I attempted to go out the front door and was told by the person there that she could not allow me to go out the front door and I had to go down to the basement to exit the building.  I asked her where to go down the basement to exit and she said, ” go downstairs and take a right, go past the morgue and take a left, and the door will open to the parking lot”.  Well, I  followed( think I did) all of her directions and ended up trapped in a hallway between the morgue and an exit door that was locked.  When the door would not open, I thought to myself…no one will ever believe this…… After about 5 minutes I realized that I may have the key, which I did, and was able to go back up and after I told my story the receptionist she looked at me and said  “ok ,I will open it this time only”.

One of the thoughts I had as I went out for coffee today was: Covid is a respiratory illness that if left unabated will follow a clinical pathway to respiratory failure and death.

Please, please stay safe……