Sixteen Puffs and Terbutaline: Tales from the COVID ward

She is young, overweight, and suffers from asthma.  Her O2 sat on 15L on a non-rebreather is 82% and dropping.

We can hear her wheezing from where we stand at the foot of the bed.

Were the ED not a ceaseless roar of noise, we would be able to hear her across the room.

The doc says, “Did her puffer show up yet?”

We sent a med request for an albuterol rescue inhaler down to the pharmacy more than 2 hours ago.

“No,” says her nurse.

Another nurse, sitting at the desk, finds an albuterol inhaler amidst the piles of chaos and vials and paper.  According to the dose meter on it, it has been used twice.  58 out of 60 puffs left. We have no idea who it belonged to.

She wipes it down with sani-wipes, and hands it to the doctor.  He MacGyvers a spacer from a cannibalized nebulizer.

We can’t use the nebulizers in the ED anymore.  Too much danger of aerosolizing the virus, although it seems like a pointless precaution in a unit where literally every single patient – every single one – has COVID-19.

He holds the re-purposed puffer and spacer up to her mouth.  He looks her dead in the eye, and yells through his N95.  “We’re going to do this SIXTEEN times.  And I need you to work as hard as you can, harder than you’ve ever tried before, to breathe every single one of those puffs in.  OK?”

She nods.  She is terrified.

He looks over his shoulder, towards the nurses.  “And someone get me some terbutaline!”

*

Y’all remember terbutaline?

Neither did I.

*

16 puffs of albuterol and SQ terbutaline later, she is holding stable at 90% on the NRB, although it drops if she moves or talks.  We get her onto her side, and an NP who was furloughed from her primary care practice upstate and has no ED experience stands at the patient’s bedside and whacks her on the back for twenty minutes.

Pulmonary toilet, an almost-forgotten term outside of those who love and care for patients suffering from cystic fibrosis.

We roll her down the hall from the ‘stable’ COVID room to the “unstable’ COVID room, although there is no BiPap available yet for her.  Either someone will need to get intubated off their BiPap, or someone will need to die despite their BiPap, for the machine to show up at her bedside.

~

An unstable patient arrives by ambulance and somehow ends up in our ‘stable’ room.  He is thrashing on the bed, tearing his mask off, gasping that he can’t breathe.  He suddenly coughs hard and deeply bloody sputum flies past us and lands on one of the intermittent curtains.

The curtains used to delineate the space between each patient.  Now, we fit three patients between each curtain.

We land an IV, draw his blood, tie his arms down, drop the NRB over his face, and roll him quickly to the ‘critical’ COVID room.  By the time we get there, fifty feet down the hall, he is see-saw breathing.

Less than five minutes later they push ketamine and he is intubated.  His x-ray shows massive pulmonary infiltrates and effusions.

Back in the stable room, I bleach the blood off the curtain, and five minutes later another COVID patient rolls in from triage.

~

We are now working with ratios of anywhere from 3:1 to 6:1 in the stable room, depending on the time of day.  Agency nurses are shocked by the residual, lingering chaos.

Staff nurses are relieved.

During the surge two weeks ago, the nurses, at one point, were literally taking care of anyone they could reach.  Everyone cared for everyone.  Because if you took the volume of patients sitting in the ED, and divided it by the number of nurses on shift, the staffing ratio would have been 30:1.

~

She is tiny and very old and tied to the bed with soft restraints, tight enough that she can’t pull her foley or IV out, but loose enough that she can reach the edge of her diaper and dislodge it, which she does continuously.

Her husband died in the ED from COVID a week ago, and when EMS did a welfare check yesterday they found her alone, weak, unable to stand, unable to speak intelligently, and terribly dehydrated.

We have been trying to get her admitted for seven hours.  Every single available space in the hospital has been converted to an inpatient unit, and we still don’t have enough beds.

Her mouth is caked with dry spit and debris, but we have no mouth swabs that anyone can find.  I MacGyver some out of 2×2 gauze, tape, and tongue depressors.  I clean her mouth as best I can, but when I touch her gums with the gauze, they start to bleed.

She kicks her blanket off again, and starts working at the edge of her diaper.

Two more patients have rolled in from triage.

We make a futile effort to cover her once more, walk to the picked-over Omnicell, gather IV supplies, and head to the new beds.

12 inches away from the old woman, in the next stretcher over, another woman sits up, and begins to gasp.

//