A nurse’s fear: Is today the day?
A shift in the ER, under threat of potential surge
Before coronavirus made going to work feel like stepping into a war zone, emergency room nurse Christa Duran just rolled out of bed, put on her scrubs, threw her hair into a ponytail, grabbed her lunch and rushed out the door.
But these days, she has to start getting ready for her earlymorning shifts at San Francisco General Hospital the night before. She follows a carefully coordinated routine of packing, sanitizing — and preparing for the worst. With a husband and two little kids at home, the consequences of exposure to the coronavirus — even to just one tiny droplet — could be devastating.
She begins with the shoes: a pair of Birkenstocks for the car, purple sneakers to wear in the ER, flipflops for the walk from hospital to car, each in a separate, plastic bag. Lunch is pasta, string cheese and yogurt, all in disposable containers. Then comes the plastic and fabrics she hopes will protect her from the highly contagious and deadly disease — goggles,
a beanie, one used N95 mask and a regular surgical mask.
It’s the masks that worry her the most. Despite a national shortage of personal protective equipment, hospital management says there’s enough gear for frontline staff members like her. If they use it sparingly, that is.
A thought crosses her mind: But what if a surge comes?
Experts and politicians keep warning that an influx of COVID19 patients could still hit San Francisco. Since the end of March, the number of COVID19 patients cycling through the hospital has risen — but slowly, steadily and at a remarkably manageable pace. Does that mean the surge has already come and gone?
Duran and her colleagues often wonder. Or does that mean the worst is yet to come?
Duran scrolls through the news before getting into bed: More than 100 people have tested positive for COVID19 at San Francisco’s largest homeless shelter; more than 30 have tested positive at densely populated apartment buildings for lowincome residents; at least one patient at S.F. General’s psychiatric emergency room has been infected. Her stomach sinks. For weeks, she’s worried about an outbreak in the city’s vast homeless population, where any spread would be particularly hard to control.
And tonight, it seems, that has become terrifyingly true.
The following is a recounting of two of Duran’s emergency room shifts earlier this month. The Chronicle was not allowed inside the ER — because of a high influx of psychiatric patients, it was considered not safe for visitors. 5 a.m. Alarm blares Will this be the day the surge finally comes?
The nurse rolls out of bed, washes her face and puts on her scrubs. Grabs her lunch, prepacked gear, coffee and hops in the car. 6:30 a.m. Pulling up to work
Duran, who lives in the East Bay, zips over an empty Bay Bridge and pulls into the hospital’s parking garage. She feels cautiously hopeful about the day. But I can’t let my guard down.
She parks and swaps her insidethecar shoes for her purple hospital sneakers. Then puts on her protective gear — a beanie over her long brown hair and a slightly wrinkled N95 mask that she delicately holds by the edges as she stretches it behind her ears. She tops it off with a pair of clear goggles.
As the sun rises, she walks out of the parking garage and toward the only entrance open to hospital staff. She gets into the queue. A security guard asks for confirmation of her online personal screening, which she has to complete before each shift. Do you have a fever? No. Do you have a cough? No. Do you have a headache? No. The guard raises a thermometer to her forehead and takes her temperature. Normal.
She’s cleared for work and walks through the doors. 7 a.m. Morning briefing Who is who?
Duran stands in a large circle with her fellow nurses and listens to the nurse manager’s morning update. It’s almost impossible to recognize her colleagues when they’re covered in personal protective gear.
There was a time when wearing all this felt silly. How long will this be the norm?
The manager tells them there likely will be numerous patients from Psychiatric Emergency Services, which had started diverting patients through the emergency room to be tested for the virus before entering the separate facility for patients suffering a psychotic break.
But when it comes to COVID19 patients, things seem well under control. There are more than enough beds to handle the current capacity — and then some, if the surge arrives. The number of COVID19 patients at the hospital has fallen from a high of 35 and has been fluctuating between 24 and 28. Today the hospital has 25 infected patients — 12 in intensive care, 10 of them on ventilators. Those numbers are manageable. Nowhere near New York.
Then she walks through the department and is struck by the relative silence. Normally, the emergency room is absolute chaos. Before the pandemic, the ER was understaffed and overwhelmed by fallout from the city’s unrelenting homelessness crisis. So much so that nurses often had to park overflow patients on gurneys in the hallway. That was on top of other traumas — car crashes, gunshot wounds, falls and fights.
But these days, as San Francisco shelters in place and many of the homeless without COVID19 symptoms are diverted to the hospital’s urgent care unit, the ER waiting room has an eerie silence to it. Like a calm before a storm. 7:30 a.m. Getting to it
Duran is assigned two patients who need to go into the PES unit, but first must get tested for COVID19. The psychiatric patients are among the most vulnerable and difficult to care for, as they are often in the midst of a psychotic break induced by mental illness, drug use or both. Nothing I haven’t dealt with before.
Her two patients are agitated, and keep wandering out of their rooms, ripping the masks off their faces and yelling obscenities. PES patients need extra compassion, care and
attention — but how can I do that while maintaining a safe distance?
So she stands at the door of one room and asks, calmly and gently: “Please stay in the room. Please keep your mask on. I want to help you, but I can’t come in unless I feel safe.”
There are thousands of people in San Francisco suffering from the perilous trifecta of homelessness, mental illness and and drug addiction.
And if they get sick, where do they go?
Here. 9 a.m. Time for a quick break
After a few hours of a steady flow of people with respiratory issues and patients from PES, Duran sneaks up to the terrace for a short break outside. She takes her mask off and relishes the fresh air against her face.
She breathes in.
Downstairs could be so much worse.
But there’s an outbreak at a homeless shelter, not enough hotel rooms for the homeless. Why isn’t the city moving faster?
At least people are staying home.
If we don’t do this right the first time around, we’re going to get stuck doing this all over again.
She lets out a long breath, and heads back downstairs. Noon. A rush begins
A small rush of patients with respiratory issues flows through the ER.
Most are directed to the COVID19 area, where they’re given a mask and a private room. Outside the room, nurses tape up a “RESPIRATORY ISOLATION” sign and a sheet that staff members must sign if they enter the room. It’s the way the hospital keeps track of who has come into contact with a COVID19 patient.
So far, 12 of her colleagues at S.F. General have tested positive for COVID19.
Those numbers are probably much lower than the real ones. How many just haven’t been tested yet?
This is why we need more information.
This is why we need more protective gear.
This is why it’s dangerous for us to reuse N95 masks.
This is why frontline workers should have been tested earlier and more frequently.
The thoughts infuriate her but follow her around every day. 1 p.m. Rotations
Duran has three patients from PES who are waiting for their COVID19 results.
As she waits for the results, which take an hour or two, her PES patients grow even more agitated and unrestrained. She does what she can — calming them with a gentle tone, giving them the medication they need to calm down, ensuring they stay in their rooms so they don’t risk infecting anyone else.
This is hard enough — how would we deal with a surge on top of this?
Then she gets a patient who came to the ER for an issue unrelated to COVID19. The patient is otherwise healthy and doesn’t have any of the common COVID19 symptoms, like a cough or trouble breathing.
But she assesses the patient — and something in the results suggests she should test the patient for the virus. Still, Duran isn’t too worried. It wouldn’t make much sense if this patient was infected. 3:30 p.m. Results
Duran’s three PES patients are negative. The young, healthy one is positive. Where is the logic to this virus? 4 p.m. Urgent Care closes
Urgent Care closes around 4 p.m. on weekends, so the ER can no longer divert patients with lessserious issues. Now they are taking up beds in the ER, along with several PES patients waiting for results.
As she walks around and checks on her patients through the unit, Duran tries to recount every interaction she had with her young patient who tested positive.
Was I careful enough around them? Was my mask on properly? Did I get too close?
It’s time to start preparing for the end of her shift. She starts by wiping down everything at her station, from the computer monitor to the pens. In her mind she plays her day in reverse, imagining what it would have been like with a surge layered on top.
How would I have had the time to calm down the PES patients if I had to care for an intubated patient at the same time?
How many more patients would I encounter who don’t look like they’re positive for the virus, but are?
Would we have enough masks, gloves and gowns to interact with more COVID19 patients during a surge? 7 p.m. Handoff
Duran’s night replacement comes in and she briefs her on the day.
It was manageable — well, relatively speaking. Not nearly as bad as it could be.
Nowhere near New York.
After the handoff, Duran goes to the bathroom to unravel from her shift: She removes her shoes and places them in a plastic bag. Scrubs go into a pillowcase that she twists shut. Her N95 mask — that she’ll probably have to use again —is delicately placed into a paper bag. She vigorously scrubs her hands, arms and face before putting on clean clothes, shoes and another mask.
She gets into her car, takes off her mask, and wipes down her keys and phone. She rubs her hands with sanitizer, then heads back toward the East Bay. As she drives over the desolate Bay Bridge, her tired mind wanders toward the comfort of home, where dinner, her husband and children wait for her to walk through the door.
Then, her mind snaps back to work.
How long will the calm remain?