Bianca Dintino, 26, is a nurse in a Tufts Medical Center coronavirus intensive care unit. This is her account of her shift on May 18, as told to Globe reporter Naomi Martin.
Many of us healthcare workers avoid the news. We get enough coronavirus at work.
But today, as the governor announced his plan to reopen the economy in phases, we greeted the current situation with exhaustion and wariness: Could this spell trouble? We’ve just seen our number of COVID patients fall. Now that people are going to be leaving home, the virus will have more chances to spread.
I’m nervous about our reopening, though. I’m worried we’ll see a spike in infections after we’ve re-filled the hospital with non-COVID patients, and we won’t have enough ICU beds or hospital beds. So many of our COVID patients have stayed really sick for weeks.
So far, we’ve done a good job not allowing the health care system to become overwhelmed. But if people try to go back to normal now, we could become inundated. That terrifies me and my colleagues.
Caring for these patients has become less hectic. Most have been with us for weeks, hooked up to ventilators and in medically induced comas. We’ve gotten used to putting on and removing the personal protective equipment, or PPE. The incoming flood of patients has slowed somewhat.
But the experience is getting more emotionally draining as it drags on. The COVID patients are so much more severe than our typical ICU patients. We’re working hard to keep them stable, but they wax and wane so quickly. It’s a roller coaster. They can be doing fine your whole shift, but then right before you head home, the smallest thing will happen, and it’s a disaster.
Maybe they suddenly spike a fever of 105 degrees. Or their heart starts beating crazy fast. Or their blood pressure plummets. Or their blood sugar is strangely high.
Usually, we know why these swings are happening and how best to treat them. Sometimes with COVID patients, though, our normal methods don’t work.
It’s frustrating that we don’t yet know exactly how to treat this disease. We’re doing everything we can, but because the virus is so new, doctors all over the world are figuring it out at the same time.
We’ve seen quite a few patients pass away. There were some on my unit in recent weeks. It’s always sad when that happens, but it’s even more heart-wrenching now because the patients’ families can’t say goodbye in person.
But we also have had moments of brightness. Recently, one of our former patients, a man in his 50s, sent us an update. He had been so sick early on with COVID, on a ventilator, on the brink. We really didn’t think he would make it.
He ended up surviving and was transferred to a rehab facility. In a photo he sent us, he smiled from a wheelchair, which he will likely just need temporarily, until he can regain strength to walk again.
It felt great to see — like we did some good.
He looked like a completely different person. After this experience, maybe, many of us will be.
Inside the coronavirus fight at three Boston-area hospitals
Overrun ICUs, patients on the brink, impossible decisions. Inside the region’s hospitals, health care workers are besieged. Every shift can be more overwhelming than the last as they struggle to care for a tidal wave of patients. And it keeps getting worse. The Globe has enlisted three such medical workers to tell their stories in their own words. Throughout the coming days, you’ll meet a top emergency room doctor at Massachusetts General Hospital, a young critical care nurse at Tufts Medical Center, and a respiratory therapist at Newton-Wellesley Hospital. All have opened up to Globe reporters about their patients and their experiences, offering a glimpse of their hospital units as the crisis unfolds. We’ll tell these stories in the first person, with installments coming every few days. Here are their stories.
| Wednesday, May 13, 2020 |
From the end to the dawn of life, one shift’s emotional drama
Samantha Cafaro, 29, is a respiratory therapist at Newton-Wellesley Hospital. Below, she describes what happened on a 13-hour shift that ended 8 p.m., May 13, as told to Globe reporter Brian MacQuarrie.
I was taking care of seven patients in the COVID intensive-care unit, the majority of them in medically induced comas, and started off by having to terminate life support for a patient who unfortunately hadn’t made much improvement over three weeks.
The day before, we had multiple conversations with the family, telling them we had exhausted everything we could do, and that we should talk about withdrawing support. Not everybody wants to hear that, of course, but there wasn’t much of an option. We had to talk about it. The family agreed and was able to say goodbye through Zoom.
We stayed until the last breath, standing over the bed and saying as many positive things as we could. We talked about all the patient’s favorite things — hobbies, animals, family, photos, and music. This patient had been in intensive care for so long, and it was really hard for me and the nurse and all the other health-care workers who had helped. We all shared that bond.
These patients in the ICU are putting up such a fight. They are giving it their all. We do the best we can to support them, but days like this hit everybody hard.
Then, only 20 minutes later, I got a phone call from the emergency room that a pediatric patient less than one month old was coming in. I was already emotional, and I had started to cry. But now you have to put that away.
Maybe it’s the adrenaline, but when you hear it’s a baby with respiratory distress, everything you just went through has to be pushed to the side. I suddenly had to switch my thought process to pediatric from an adult.
There were so many things I was thinking about — respiratory issues, possible cardiac issues. When I walked into the room, the baby was being transferred onto an emergency room stretcher, breathing very quickly through the belly, nostrils flaring.
We automatically begin treating this as a COVID case because we didn’t know if a family member had been sick. We wore the same protective gear, just because you don’t know until the test results come back. In this case, they were negative for the virus.
Through it all, the baby’s parents comforted each other. We asked if the baby had been around anybody who was sick, and how long this had been happening. We were told that the baby had been very healthy and had just started breathing harder over the last 24 hours. Unfortunately with children, they’re fine one minute, and the next they’re not.
Some weeks we have so much success, and then there are weeks like these.
We thought we had seen a plateau of COVID patients, no new admissions, and no one getting sicker. And then all of a sudden we see an influx of more patients. You think it’s going to be OK, and then this. You say to yourself, what just happened?
After the state opens up, it’s so unknown. I don’t think it’s impossible that it could spike again.
Thank God we all have to wear masks. That’s helping with the spread, but I am still concerned. We’re going into the summer, the weather is getting warmer, and people will want to walk their dogs and go for picnics and be with their families. More gatherings will happen, and that does concern me because people may think it’s all done.
Not everybody knows what happens inside the four walls of this hospital. The best thing we can continue to do as a community is wear masks and stay far apart because the moment we take our masks off, you just don’t know. You may be asymptomatic and then infect four or five people.
I’m not going to lie. I’m getting a little overwhelmed, and it’s getting a little exhausting, emotionally as well as physically. I’ve worked a lot over these last few months, and you can sustain this for only so long.
I’m excited about some time off. I’m hoping to take Memorial Day weekend and just sit by the water in my car and relax and decompress. I’ve had a stressful few weeks, and it’s been a roller coaster.
Our patients try so hard for so long, but the body can only give so much.
| Tuesday, May 7, 2020 |
A cautionary tale from the emergency department
Dr. Ali Raja, 42, is the executive vice chair at Massachusetts General Hospital’s department of emergency medicine and an associate professor at Harvard Medical School. This is his account of his shift on May 7, as told to Globe reporter Deanna Pan.
I’ve started seeing some real evidence that patients are avoiding emergency departments, despite the fact that they have emergency illnesses.
I saw two patients who had strokes, but both of them had come into the hospital after having symptoms for many days. We talked about why they hadn’t come in earlier and it was because of COVID. They said they couldn’t make appointments to see their regular doctors and they weren’t sure if they really needed to come to the emergency department with their symptoms.
Unfortunately, in both of these cases, there was nothing we could do to treat their actual strokes. All we could do was admit them to the hospital and hope that their bodies recover over time. In the best case scenario, their symptoms will go away with time and physical/occupational therapy. But in the worse case scenario, those changes to their bodies will be permanent.
We’re still seeing COVID patients, but we’re not seeing as many — and we’re definitely not seeing as many critically ill COVID patients. Our intensive care volume is down over the past week, but we still have about 80 intubated patients with COVID and another 20 or 30 intubated patients without COVID. At our peak, we had almost 200 patients intubated at Mass. General.
Now we’re planning for what happens when we reopen the state. All of us at Mass. General are pretty confident that when we reopen, we’ll see some more patients with COVID — maybe not immediately, but within a week or so — as more people get exposed. That’s not to say all of us in Massachusetts won’t be trying our best to wear masks in public or keep social distancing. But everyone will be interacting more. Masks will accidentally slip down in public. People will mindlessly touch their faces at the store.
These things will inevitably happen, and then we’ll see more patients at all of our hospitals. So we have to be ready for them and hopefully, we won’t see a huge surge like we did last time.
| Wednesday, May 4 and 5, 2020 |
Caring for the youngest coronavirus victims; a dying patient’s final moments
Bianca Dintino, 26, is a nurse in a Tufts Medical Center coronavirus intensive care unit. This is her account of her overnight shift over May 4 and 5, as told to Globe reporter Naomi Martin.
Last night I cared for a young COVID patient in the ICU, a man in his 20s who has been here for a number of weeks. He just had a tracheostomy, a small hole surgically cut in his neck to accommodate a breathing tube to his lungs.
“How’s he doing?” his family asked me. “Tell him we’re thinking of him, and we love him."
His family had created a YouTube channel for him so we could easily play their videos for him on the computer in his room. Visitors aren’t allowed in the hospital because the virus is so infectious. That’s one of the hardest parts of this for patients and their families.
Most of the COVID patients have been unconscious by the time I see them in the ICU, but I actually got to meet this patient when he was awake a month ago. He was in the ICU first on another breathing machine that allowed him to be awake. He was struggling then, breathing so fast, with many shallow sips of air.
He felt awful and didn’t want to talk much then. But he told us he was scared. When he got out of the hospital, he pledged, he would become healthier and take better care of himself.
We’re trying everything possible to keep him alive and give him that chance at recovery. The tracheostomy will allow him to hopefully wake up soon and start physical therapy so he can begin talking, eating, and walking again. His muscles are likely too weak after being sedated for so long.
The breathing tube is now connected to his ventilator, but we’re slowly lowering the ventilator’s settings so his lungs can get stronger and take over. The goal is to eventually have his lungs do the breathing, and just have the tube connected to an oxygen tank for added support.
Maybe he’ll be able to live a normal life, even if he has a breathing tube in his neck connected to an oxygen tank forever. Lots of people do. Maybe he’ll even heal so much he won’t need the oxygen anymore, and the tube could come out. The neck hole would close up quickly.
There is a chance his lungs may not be able to handle coming off the ventilator, though, in which case he may have to live in a skilled nursing facility. Worse, there’s a chance his condition could deteriorate again. He’s had a very high fever lately that’s been worrying us.
I just hope he wakes up soon and can return to his family, hear his favorite music, and live the life he wants.
| Wednesday, April 29, 2020 |
From fair to fatality, a patient’s rapid decline leaves respiratory therapist in tears
Samantha Cafaro, 29, is a respiratory therapist at Newton-Wellesley Hospital. Below, she describes what happened on her April 29 shift, as told to Globe reporter Brian MacQuarrie.
It was my fourth long day in a row, and all of my patients in the COVID-positive units were having setbacks. I was thinking, “Could this be the end for some of them?” Some had been on ventilators for such a long time.
So, we had reached that point; we contacted the family to talk about end-of-life measures. The hospital offered them a chance to come in, but because it was so sudden, it was hard for them to get there in time. Instead, the family had to say goodbye through Zoom on an iPad.
This was such a sad moment. I knew what the patient’s status had been, totally with it and telling me “I’m not ready. I have a longer life to live.” And by the end of the shift, the patient wasn’t able to communicate.
I left the room for about 20 minutes while the family said its goodbyes. Once they were done, our team opened the blinds. The sun was shining, and we turned the patient toward the window and a beautiful view of the trees.
It was time for comfort care: putting on new bedding, brushing the patient’s hair, and each taking turns holding the patient’s hand. Tears just started pouring down my face. I already was emotional because of all my other patients that day, but I felt for this particular family so much. I can’t imagine saying goodbye on a video call.
I told the patient, “It’s OK, I know it’s hard. You have a beautiful view.” Even though I knew they couldn’t hear me, I hoped somehow they could.
The shift had gone by so quickly because there had been so much going on, but I wanted to dedicate time to this patient. If that was my loved one and I couldn’t be there, I would be so upset.
That’s one of the things we’re struggling with now as health-care workers. You walk down the hallways of the hospital, and there are no family members. It’s just so different.
I’ve been learning through this that I’m not always as strong as I think I am. At the start of my career I took every single death, every single patient, to heart. But I was able to get some guidance that you want to get close, but not so close that you get too emotionally attached. If you do, you’ll bring it home.
Before the virus, I had no problems going in to work because you wouldn’t have as many critical patients every day, so many patients on ventilators for this long. Now, you still think you’re so strong, and each day you go in and hope this will be a great day.
You start off with that, but at the end of some days you’re crying and emotional. This patient had gone from talking with me and being completely lucid to someone who was not able to speak and just exhausted.
When I got into my car after work, the emotion hit me again. And after I had left, sometime during the night, the patient passed away.
| Tuesday, April 28, 2020 |
‘This is still far from over.’ Dr. Ali Raja on the slowing numbers of coronavirus cases
Dr. Ali Raja, 42, is the executive vice chair at Massachusetts General Hospital’s department of emergency medicine and an associate professor at Harvard Medical School. This is his account of his shift on April 28, as told to Globe reporter Deanna Pan.
The number of patients with COVID-19 being admitted to MGH has gone down — not a lot, but it’s definitely downtrending.
I’m really glad that we’re able to do more testing around the city and state. Because of that, patients who find that they have COVID are able to isolate themselves to prevent others from getting sick and, if they do start to feel more severe symptoms, come in to the hospital earlier. Now we’re picking them up earlier in the course of their disease, so we’re able to get these patients on oxygen and watch them more closely, hopefully keeping them from getting sick enough to be intubated and put on a ventilator. During my morning shift on Tuesday, we didn’t intubate anybody.
And that’s the biggest bright spot I’ve seen. Being put on a ventilator is not an easy process for anyone. Even young and healthy patients can have complications. There can be additional lung infections (we focus a lot on preventing ventilator-associated pneumonia, but it is a well-known problem), damage to the lungs themselves, and even damage to the vocal cords. Now this doesn’t mean ventilators are bad things. If you’re that ill and can’t breathe, there’s no way around it — you need to be put on a ventilator. But when patients know they’re COVID-positive, they’re more willing to come to the hospital as soon as they start to feel worse.
This is still far from over, obviously, although we are discharging COVID patients every day. We’ve reached a plateau in terms of new cases and hospitalizations. Fortunately, by flattening the curve, we didn’t see a huge spike of patients that would’ve overwhelmed us. But now we’re in a situation where we’re going to keep seeing patients who have this disease for quite some time. It’s not a matter of weeks. It’s probably going to be at least two or three more months where we’ll still have a lot of patients in the hospital. Remember, many patients with COVID are intubated for just a week or two, but some have been on ventilators for almost a month.
This is going to change the way we practice a lot of medicine. We’re going to have to keep screening patients for infectious diseases whenever they come in for clinic appointments and routine surgeries, and they’re going to be wearing masks in the hospital for a long time. Our waiting rooms are going to have to change, since we’re no longer going to be able to keep our patients close together. More and more patients are going to be seeing us through telemedicine instead of in-person. These are changes that are going to last for many, many months, and, if this virus does become cyclical, many, many years.
However, I really do feel that — whenever we open up — as a population, we’re going to be much smarter about protecting ourselves from infectious diseases. There’s going to be more social-distancing and hand-washing. A lot of people are going to keep wearing masks. We’re definitely going to see more spread of COVID-19 whenever we start interacting with each other again, but I don’t think we’re going to see nearly as much as we did the first time, since we’re a lot better prepared and willing to do the things that will help decrease the spread of the disease.
| Tuesday, April 21, 2020 |
He’s no longer infected, but far from recovered
Bianca Dintino, 26, is a nurse in a Tufts Medical Center coronavirus intensive care unit. This is her account of her overnight shift ending 7 a.m. on April 21.
His eyes could open any moment. We’ve lowered his sedatives to a tiny trickle. Now it’s a waiting game. After three weeks of being in a medically induced coma and on a ventilator, will he wake up?
Like most of the other 15 patients in my ICU, my patient tonight — a man in his 40s — has been here for weeks. For most, the ventilators have kept them alive, giving their lungs time to heal from the virus’ damage. But the treatment can also cause its own complications.
Part of my patient’s tongue has turned black and gone necrotic, meaning the tissue has died. That can happen with the kind of positioning we must do with the most critical COVID patients. They lie face-down for 16 hours each day to best allow their lungs to receive the ventilator’s oxygen. But that position can put pressure on the face. The tube or teeth can sometimes cut off circulation to the tongue.
We try to shift the patients’ positions often, at least every two hours, propping them up with pillows and moving them from leaning toward their left side or their right while on their stomachs.
The virus is gone, but he’s still far from recovered.
We’ve reduced the ventilator settings over time to wean him off of it. Now his lungs are taking over from the ventilator, doing most of the work of breathing and diffusing oxygen into his bloodstream.
The pneumonia caused by the virus seems to have cleared. But his latest chest X-ray showed more fluid and inflammation than three days ago, suggesting he now has ventilator-associated pneumonia, which is fairly common with this situation. It can also arise from the patient lying unconscious and not moving, which can cause the lungs to develop fluid and collapse a bit, making them weaker.
To treat it, we give him antibiotics, monitor the fluid for bacteria, and try to loosen the liquid through percussions, or slight thumping, on his back and suctioning it out.
This patient has also been battling an extremely high fever of around 103 degrees for weeks. Most of the COVID patients have had high fevers, but we can usually get them down by covering them with ice or giving them Tylenol. But for this patient, nothing’s working.
Despite all those issues, we’re hoping he wakes up soon. He’s receiving a small fraction of the sedatives he used to get, just to ease the pain. It can take awhile for the previous doses to wear off though, as they hang around in the body.
I’m noticing little signs — hopeful signs — that his consciousness is returning.
When we turn him from his stomach to his back, his eyes twitch like he’s trying to open them. When we’re cleaning out his mouth, sometimes he reacts with a grimace.
I try to calm him when he coughs, as I can imagine that must be scary. When people have a breathing tube, it can feel suffocating, like they’re breathing through a straw. All the COVID patients have extremely hard coughs, which I imagine makes it even worse.
When he coughs, I increase his ventilator oxygen and lightly rub his arm, saying “It’s OK, just calm down, you’re OK, you’re safe, you’re in the hospital."
He seems to relax. His coughing eases a little.
We’re not positive he will wake up, but it seems like he will. It could be tomorrow. Or next week. I just hope it happens.
| Wednesday, April 29, 2020 |
Stress and a respite for respiratory therapist
Samantha Cafaro, 29, is a respiratory therapist at Newton-Wellesley Hospital. Below, she describes to Globe reporter Brian MacQuarrie an overnight shift that ended April 21 and the two days off that followed.
This was a 16-hour shift, and it was wearing on me by the end. I had six patients in the ICU, all of them critically ill. I felt that every time I went into a different room, someone was having a setback, whether it was blood pressure, or renal failure, or something else. In my mind, I was asking, why aren’t they getting better?
The activity is constant. From one room to the other, you’re constantly taking off all your protective gear, you’re washing your hands, and you’re putting on a new gown and new goggles for the next patient.
There was a physical therapist there, an occupational therapist, a nurse, myself, and a doctor. We all discussed before we started the process what we were looking for, what we wanted to achieve, and how we wanted to position the patient.
We had to make sure that the blood pressure remained stable, as well as the oxygen saturation levels. And that we had good positioning, and that the hips were aligned and supported, as well as the chest.
The room was so quiet, all you could hear were people breathing. There I was, at the head of the bed, looking at everybody and thinking, I want this patient to return home.
Overall that shift, I spent 12 hours in the ICU and then four in the emergency room, where it was the same thing. It was a floor of patients all having the same problems, low oxygen levels and breathing difficulties.
A nurse asked me how I was dealing with everything, and I said that after this is over, I think it’ll sink in, mentally and physically. You want to help every single patient, to send them back home, but you know that sometimes you can’t.
We’re all looking for that light at the end of the tunnel, but I can tell you we’re all starting to feel it emotionally. But when you come in and out of the hospital, there are posters, uplifting quotes, and other things that are helping us. People understand what we’re going through. Even though this has been a very challenging and emotional time, I am lucky enough that I work with some amazing therapists who have really stepped up and helped with this process.
After the shift, it was time to take care of me.
As usual, I call my fiance as soon as I get in the car for my ride home to East Providence. I’m really exhausted, and I just want to take a shower and relax. Once I pull up, I leave my shoes outside. The scrub tops and the pants, like always, go into the basement to be washed.
I’m not really concerned about catching the virus myself. But I am concerned about giving it to someone else, like a loved one. My fiance lives with me, and it’s extremely tough. We’ll stay 6 feet apart, but we still want to have dinner together and have a semblance of a life even though we’re not able to go out anymore. Even if it’s watching a movie from opposite ends of the couch, that’s OK.
Outside the hospital, you don’t really have much to help you decompress. All you have is your family, but I won’t even talk with them on my first day off. I don’t want to talk with anybody. Maybe it’s because I talk about this so much when I’m at work.
I try to do as little as possible, but I’ll cook dinner at home. I enjoy that. My favorite recipe? Shrimp Mozambique, which has a buttery, garlicy sauce, and shrimp and onions. It’s pretty good.
This is the first time I’ve taken two days off in a row since the first week of all this, and I feel rejuvenated. I was able to get a full night’s rest last night, and I’ve been able to clean my whole house, and also wash all the door handles.
It feels so good, just to go outside and walk the dogs.
| Wednesday, April 29, 2020 |
‘Our doors are open’: Dr. Ali Raja on the worrisome dearth of non-coronavirus patients
Dr. Ali Raja, 42, is the executive vice chair at Massachusetts General Hospital’s department of emergency medicine and an associate professor at Harvard Medical School. This is his account of his shift on April 23, as told to Globe reporter Deanna Pan.
We’ve hit our plateau. We’re still seeing a lot of COVID patients — and it’s too early to say whether or not we’ve got this under control — but we’re not seeing the steady rise of COVID cases that we were seeing before.
Now we're wondering what's happened to all of the patients we normally see? The heart attack and stroke patients, or the patients with diabetes and asthma, or those with substance use disorder and psychiatric disease? These are all illnesses that patients might be trying to deal with at home, but that’s very hard to do. We want to get those patients back to the emergency department.
There are some emergency department visits that are preventable, like bar brawl injuries and drunk driving accidents, and I’m glad those aren’t coming in as we all physically distance ourselves. But we know patients, for example, are still having heart attacks. It’s not as though high cholesterol, high blood pressure, and smoking have gone away. We need to see those patients and we need to see them quickly. Once you have a heart attack, there’s nothing you can really do outside of the first few hours.
We had a couple of patients today with acute psychiatric disease who were just out-of-control anxious, more anxious than they would have been if they’d come to the emergency department earlier. They were anxious about the general state of everything, but what made them most anxious was the fact that their care had been discontinued. Normally in the emergency department, we see patients when they are suicidal or, even worse, when they are homicidal. Typically, many patients with psychiatric disease are able to see their therapists or psychiatrists to get some care, and then, when things get worse, they come to see us. Now we’re seeing patients because they haven’t been able to connect with their clinicians and their care has been cut off. Even worse, the medications they rely on have been made unavailable to them. For patients who are paranoid and anxious, they’re just not leaving their homes, they’re slowly decompensating, and they’re not willing to come to the emergency department until their symptoms have gotten so bad that they don’t have any other choice.
I’m also really worried about our substance use patients. A lot of methadone clinics have changed their policies because of COVID, and it’s even more difficult to get into an inpatient detox program. And undoubtedly, because they’re stuck at home, some of these patients are falling back into old habits. I know, in my heart of hearts, the problem has actually gotten worse during all of this. But we’re not seeing those patients with substance use disorder in the emergency department, and I’m afraid that they’re still using and, sadly, in many cases overdosing. Some of those obituaries in the Globe are probably for patients who have fallen through the cracks, who we haven’t been able to treat in the emergency department because they didn’t come in when they could have.
To them, and to everyone else in Boston who might be afraid of coming to the hospital because of COVID, I just want to say: Our doors are open. We’re ready — and we can safely take care of you.
| Tuesday, April 21, 2020 |
After two weeks in a coma, a coronavirus patient awakens in recovery
Samantha Cafaro, 29, is a respiratory therapist at Newton-Wellesley Hospital. Below, she describes what happened on a 13-hour overnight shift that ended 8:30 a.m., April 16, as told to Globe reporter Brian MacQuarrie.
These are the moments that give you hope. This was the shift when a patient who is near and dear to my heart, someone whom I had cared for since the person was admitted to the ICU on April 1, was finally brought back from a medically induced coma after 15 days of being on a mechanical respirator.
You remember what the patient looked like when first coming into the hospital -- pale, a lot of sweat pouring down, working hard to breathe -- and then you develop a connection over the days that follow, even though they’re unconscious.
But before we did that, the patient made a phone call to family members, telling them in a very emotional conversation what was about to happen. The patient was very sick at this time, very weak and tired, and very worried. It was gut-wrenching to hear.
On Day 10 of being in the ICU, the patient developed a pneumothorax, a condition in which air collected under the skin around the neck and chest, and also escaped into the space between the chest walls and the lungs. Fortunately, the patient had a mild case, and it was able to be resolved on its own.
Using the ventilator for 15 days was a longer process than I had ever experienced with any other patient. Here it was, Day 10, and I wanted the patient to come off the ventilator. But I wanted it to be for the right reasons.
When I went into the patient’s room that day, I noticed a beautiful poem that had been written by a relative. A nurse was at the bedside reading it to the patient, even though the person was not awake. It was just so uplifting, and emotional, and it reminded us how we really wanted this patient to be reunited with them.
We both teared up.
By Day 12, the patient was being weaned from the ventilator, which means we took away a bit of the mechanical support so the patient could begin breathing without it. By Day 15, on Wednesday, the patient was doing very well and could be taken off the ventilator, and we could stop the medications that had been used to induce the coma.
When they first come off, they’re a little groggy, and it takes them a few hours to regain full consciousness. But once that happened, once the patient’s eyes were open again, there were the photos of the family near the bed. And there was this beautiful poem, which the patient, with tears trickling down, was finally able to read.
The nurse and I cleaned the patient’s face and wet their lips with a sponge. The patient was still groggy, and we let the medication wear off slowly. Four or five hours later, the nurse and I gathered again at the bedside, telling the patient about this emotional journey that had taken 15 long days.
Then, the patient read the poem again, so grateful, thanking us constantly for all the care and support. Emotional moments like this are when you really appreciate what you do.
| Tuesday, April 21, 2020 |
Why I cried after my shift today
Bianca Dintino, 26, is a nurse in Tufts Medical Center’s coronavirus intensive care unit. This is her account of her April 14 shift, as told to Globe reporter Naomi Martin.
My overnight shift went well, but as I left to go home in the morning, the gravity of this pandemic struck me unexpectedly.
As I walked down a hallway, two nurses wheeled a bed past. In it, a man lay curled up. He looked to be around 50 years old. He wore a mask and looked really sick. He may have been on his way to the ICU.
His eyes met mine. His pupils screamed: I’m terrified.
Tears welled in my eyes. I kept walking, crying quietly. When I got into my car, I sat there for a few minutes, head bowed, and sobbed.
Their faces often look peaceful and serene. Closed eyes. No emotions.
But that fear in the passing man’s eyes reminded me of my own patients, and how scared they must have been before they were sedated, and how awful this experience must be for them. I can’t even imagine what it’s like. They can’t see their family and they’re stuck with all these strangers.
This man could have been on his way to be sedated for weeks, like my patients.
COVID patients require more sedation, and for longer, than others. If they’re not sedated enough, they often try to breathe on their own, instead of letting the ventilator breathe for them, which can cause problems. Patients also need to be unconscious to lie in a face-down prone position for 16 hours, allowing their lungs to most effectively fill with oxygen. And they need to be on the ventilator longer to give their lungs time to heal from the virus’ damage.
Our 15-bed ICU is now full. Other ICUs in the hospital are filling up as well. It’s crazy because at least half of our patients are getting “proned” onto their stomachs. Before the coronavirus, we rarely had any who needed that. Maybe one every couple of months, if that.
The critical patients who recover enough to wake up have a surreal scene to take in. Nurses and doctors in alien-looking hoods and protective gear.
I often wonder what those patients are thinking. They’re likely already disoriented from what we call ICU delirium, where they don’t know where they are or why they’re here.
Those ones, at least, are fortunate. They made it that far.
| Tuesday, April 21, 2020 |
‘We are not at the apex yet, but we are in the upswing’: Dr. Ali Raja on translating life and death decisions into dozens of languages
Dr. Ali Raja
Dr. Ali Raja, 42, is the executive vice chair at Massachusetts General Hospital’s department of emergency medicine and an associate professor at Harvard Medical School. This is his account of his shifts on April 13 and 14, as told to Globe reporter Deanna Pan.
We are definitely in the surge.
We are not at the apex yet, but we’re seeing more patients than we did last week, and we are seeing more patients today than we did even a few days ago. We expect to see even greater volume over the next week to 10 days. It’s really hard to say exactly when the peak is going to be, but we are in the upswing now.
I’ve noticed that a lot of the patients we’re seeing with COVID don’t speak English. While there are dozens of languages spoken by our patients in the emergency department, lately it’s predominantly Spanish and some Haitian Creole. This disease seems to be disproportionately affecting patients in parts of the city that aren’t English-speaking or of lower socioeconomic status. Normally, with non-English speaking patients, we can get a Spanish interpreter, for example, who will arrive in 10 minutes or so, or we can use a phone-interpretation service in a matter of seconds. In these COVID cases though, that’s pretty tough because we sometimes don’t have 10 minutes to spare; some of these patients are really, really sick. And using a phone interpreter is very difficult. When I’m wearing a mask and the patient is wearing a mask, the interpreter on the phone often can’t understand what either of us are saying.
Over the past few days, we’ve actually started placing Spanish-speaking doctors in the emergency department during our busiest times, so that we have the ability to speak with these patients about life and death decisions in their native language as soon as they arrive. These doctors aren’t always emergency physicians; they’re surgeons and allergists and other specialists, and their role is to have those really hard conversations, like, “We need to put you on a ventilator. Let me explain what that is.”
This week, we got completely full on the acute side of our emergency department; there were days when all of the beds were occupied. We were saved — and continue to be saved — by the fact that our ICUs still have bed availability. We’ve continued to build and staff more ICUs every few days. That’s the main reason why we haven’t found ourselves in the same situation as some of New York’s emergency departments, where they have had to hold dozens of patients waiting for beds in the ICU. Instead we’re able to get our patients upstairs and into the ICU, opening up emergency department beds for more new patients, which is the only reason we’ve been able to stay above water. Otherwise, we’d definitely be drowning.
What I’m worried about now are things outside of our control. For example, when other hospitals around the city and the state run out of beds, they often send their patients to us. Our plans take into account the number of patients we expect given our usual volumes. What we can’t take into account is what happens if another big hospital in town just gets too full and needs to send us their patients. Or if another nursing home or two has an outbreak, and we get dozens more elderly patients with COVID at once. How do we account for and model that? It’s those unpredictable factors that keep me up at night worrying if we’ll run into a situation too big for even MGH to handle.
| Tuesday, April 14, 2020 |
For a respiratory therapist, a 70-hour work week and glimmers of optimism
Samantha Cafaro, 29, is a registered respiratory therapist at Newton-Wellesley Hospital. This is her account of her overnight shift on April 11, as told to Globe reporter Brian MacQuarrie.
I began my shift in the intensive-care unit and heard all the familiar sounds — the monitors, the alarms — as soon as I walked onto the floor. It’s been a long week. As the department head, I chose to log more than 70 hours, but I feel that we’re seeing a plateau with the amount of patients we have. Our admissions to critical care are now about equal to discharges.
It’s giving us a little more hope. But then again, you think you have plateaued and I could go to work tomorrow and we could get another influx of patients. You get excited, and you feel there is so much success happening, but in that same breath there are some setbacks. It could change in an instant. Still, I can’t tell you how encouraging the number of COVID discharges has been. Right now, we’re up to 62.
Through all the work, though, you try to imagine what the families of our patients are going through. Their loved ones are in the ICU, and they can’t visit them. So, we are surrounding them with photos — photos of their families, photos of people they’re in a relationship with, photos of their dogs. When they open their eyes, this is what they see.
The first patient I see is someone who has been near and dear to me, from admission to the hospital until now. I look around the room, and I see photos of all the patient’s family members and pets hanging on the walls in an otherwise bleak-looking room. The patient is unconscious, but I’m hoping that the outcome will be great, and that the patient will make a turnaround and recover.
From there, I walk into another room where a patient is conscious, but where we’re delivering oxygen at a high rate and they have to be monitored. There will be photos here, too, some dropped off at the front desk, others mailed to the ICU.
The patients will describe for us what’s happening in the photos. You know they want to get back to their loved ones, and the fact that they can’t have them here is very hard. Before all this, I would just walk into a room, and the family would be at the bedside, and they would communicate with me about the patient.
Now, without them, you try to become a huge advocate for the patient, almost a surrogate family member. I haven’t been able to hear some of them talk yet, which is so different from the relationship you would have developed with many patients before this disease. I want them to come back healthy, come back from this exhausting illness, and then we can talk about everything.
For the ones who are able to communicate, we talk about how they’re doing, how long they’ve been married, how long they’ve been in a relationship. I talk to them as if they were one of my family. Some of the patients haven’t seen their family in days, and some even longer than that.
You really have to have compassion for this job, and it has to be natural. You also need the ability to adapt very quickly to what’s going on. When you walk into those rooms, they don’t want to see you unable to deal with them emotionally. These can be difficult conversations. The ones that are more severe, you don’t know how long that severity is going to last.
And then, you also have to think about protecting yourself, too. You have to get as close to the patients as physically necessary, of course, and you always want to form a relationship with them. But you can’t get too close. If we did, we wouldn’t be able to protect ourselves emotionally.
I just got home, and I’m exhausted. I can’t wait for a full night’s rest.
| Monday, April 13, 2020 |
‘He could soon go into cardiac arrest and die’
Bianca Dintino, 26, is a nurse in Tufts Medical Center’s coronavirus intensive care unit. This is her account of her April 6 shift, as told to Globe reporter Naomi Martin.
We knew it was likely to happen, but that didn’t make it any less stressful.
The patient — a man in his 70s who had been in an induced coma and on a ventilator for about a week — had suffered a serious drop in blood pressure a day earlier when the nurses turned him from his belly to his back. The man had prior heart problems before contracting COVID-19, so he was especially vulnerable.
Today, we turned him over again. Again, his blood pressure fell and his blood-oxygen levels plummeted. We needed to get them back up immediately. He could soon go into cardiac arrest and die. Another COVID patient in our ICU passed a few days ago after a cardiac arrest.
We wondered if we needed another drug that wasn’t in the room. This would normally be anxiety-inducing enough, but the coronavirus’ contagiousness adds layers of complexity on top. We can’t just run out of the room to grab other medications now.
It takes six minutes, fastest, to leave the room because you first have to remove and clean your protective gear — your hood, gown, gloves, and face shield. That’s time that a patient who’s barely clinging to life doesn’t have.
So we’ve set up baby monitors inside and outside the rooms to be used as walkie-talkies. We ask a nurse or clinical care technician to wait outside and listen to see if we need anything while treating each patient.
After 10 minutes, the patient’s blood pressure finally stabilized. Next, we needed to get his oxygen levels back up. Because of the way the virus had attacked, his lungs were struggling to diffuse the oxygen from the ventilator into his bloodstream.
We’ve seen this with many COVID-19 patients — the virus causes secretions of fluid in the lungs that are super thick, far thicker than what we see with typical pneumonia or chronic obstructive pulmonary disease. That thickness makes the fluid harder to remove.
We put saline down his throat tubes to loosen the secretions and then suction them out so he could breathe better. That sort of worked. We also tried “chest therapy,” which involves either clinicians or the bed itself thumping “percussions” across the patient’s back to try to move the liquid so it can be coughed out.
Eventually, he was stabilized. It’s too early to say whether he’ll survive, and if so, what his life will be like.
Fatalities are part of our job, but they’re still devastating.
So when a hospital leader came by and told us that we’d discharged a couple of COVID patients from the hospital that day, it was a relief.
It felt good, like we’re doing a good job, helping people recover. That’s all we all want to do. Sadly it’s not always in our control.
| Monday, April 13, 2020 |
‘None of us signed up for this’: Dr. Ali Raja prepares for tough decisions ahead of the surge.
Dr. Ali Raja
Dr. Ali Raja, 42, is the executive vice chair at Massachusetts General Hospital’s department of emergency medicine and an associate professor at Harvard Medical School. This is his account of the week of April 5-10, as told to Globe reporter Deanna Pan.
I just had a cough.
It started early Tuesday morning and kept me up all night. Normally, that means I would just go to work a little tired; I’ve never missed a shift because of a minor cough. But we have this really strict policy at work now: If you have any symptoms — a cough, a runny nose, a sore throat, muscle aches, shortness of breath, loss of smell — you have to stay home until 24 hours after your symptoms have cleared.
I got tested at Newton-Wellesley Hospital and got my results back on the same day. Negative! My symptoms finally resolved yesterday, so today I was cleared to go back to work. It’s been tough, being away from the hospital over the past few days. It’s been really tough. With something like this, you actually feel a lot better when you’re at work because then you’re part of the solution, as opposed to sitting at home, knowing you can’t be there for your team.
This week, we had a big group-wide call with all of our faculty about what we’re going to do when — not if, but when — we run out of ventilators. We need to have a plan for who gets them and who doesn’t, and we don’t want to wait until we’re completely out of ventilators or close to it. If we end up using a ventilator on a 90-year-old person with a lot of medical issues and then later, a 45 year old comes in who really needs it, we’re going to really regret not having one available for someone who has a higher chance of survival.
I think everybody on that call was uncomfortable with that discussion, but we all understood why we had to have it. That doesn’t mean we have to like it. None of us signed up for this. As physicians and nurses, we never went into this career thinking, “Oh, somebody really wants us to resuscitate them, but we’re not going to let them have a ventilator.” That’s completely foreign to us, and yet those are the decisions we’re talking about making now.
We have about 120 patients at MGH on ventilators. Before COVID, we usually had 40 or 50 patients on ventilators in a single day. We have enough ventilators for our patients, but what we don’t know is what’s going to happen around the city and the state. The fact is, other hospitals are running out of ventilators and ICU space. Earlier this week, Boston Medical Center had to send some of their patients to our ICU. If we get a lot of patients from other hospitals, we might not be OK.
My next shift is in a couple of days. I know it sounds horrible, but I’m both excited and scared for next week. It’s like being in the blocks at the start of a race and just waiting and waiting and waiting to run. I really hope that we don’t see a surge and that all the physical distancing we’ve all been doing works. However, if we do see a surge of sick patients, we’ll be ready for them.
| Friday, April 10, 2020 |
COVID-19 ICU nurse Bianca Dintino on what it means to have a day off
| Friday, April 10, 2020 |
At Newton-Wellesley Hospital, respiratory therapist Samantha Cafaro on the decision to induce a coma
Samantha Cafaro, 29, is a registered respiratory therapist at Newton-Wellesley Hospital. This is her account of her overnight shift on April 8, as told to Globe reporter Brian MacQuarrie.
I immediately go up to my patients and tell them who I am. Even if a patient is in a medically induced coma and can’t see me, I still communicate with them. I treat them as though they’re awake, because you would want to know who was at your bedside. I want them to know I am listening to them.
In normal times, there are so many things that respiratory therapists do, but the bottom line in this job is that we help patients maintain their breathing and airway. We can start off with a resuscitation, or we can be going down to pediatrics for respiratory distress. My work can take me all over the hospital.
Now, COVID has changed the balance of cases we see. On this shift, I had about 14 patients, the majority of them COVID patients and most of them critically ill, needing many more resources.
A few hours into the shift, I get a call that a patient has just arrived in respiratory distress and is in the emergency room, not far away from where I am. The patient has an oxygen saturation percentage in the low 70s -- that’s the level of oxygen in the blood -- and that’s a critical number. It should be 95 and higher.
“I’ve been sick 10 days with a fever and a cough,” the patient says. For privacy reasons, I won’t reveal the gender or any other personal detail.
There’s a doctor and a nurse with me at the bedside, and we decide on the best course of action. In this case, it’s a non-rebreather mask, which provides a high flow of oxygen. Now, the patient is starting to perk up, and feel a little bit better. The oxygen levels go up to 94 percent, and I think that maybe this one will be OK. But a few hours later, the patient declines pretty quickly.
They call me to the bedside again. The doctor has already had a private conversation with the patient, and we discuss whether the patient wants further treatment, which will mean a medically induced coma and a mechanical ventilator. The patient does.
The induced coma helps reduce the amount of oxygen the body uses, which means there is more oxygen available for the lungs to heal and to protect other organs.
There’s a doctor, myself, a nurse, and a patient-care assistant. Everybody’s extremely calm, but it’s one of the scariest points in a patient’s life. We describe the procedure, telling the patient they’ll feel so much better when they wake up. Our tone is very important through all this, and we’re calm, reassuring.
The emotions I’m feeling don’t come out at this time. My main focus is making sure that my patient is stable, that they’re comfortable. You wait to reflect on what’s happening afterward.
Still, I’m doing my best to be as positive as I can. I live in East Providence, R.I., and I use the whole ride home to decompress and reflect on the shift. I think to myself, ‘I can’t believe I’m working through a pandemic.’
I also think about the patients I’ve just seen, and that they’re unable to be with their families. I put myself in their position -- 'I’m doing this alone. I’m alone, and I’m helpless.’
| Wednesday, April 8, 2020 |
‘I immediately said yes’: Bianca Dintino, the ICU nurse who volunteered to treat coronavirus patients
Bianca Dintino, 26, is a nurse in Tufts Medical Center’s coronavirus intensive care unit. Below, she describes what happened on her April 1 shift, as told to Globe reporter Naomi Martin.
The patient is unconscious — has been for two weeks — but I always talk to him when I’m in his room. Who knows, maybe he can hear me.
“Hi, I’m Bianca, I’m going to be your nurse today,” I say through my airtight plastic face shield, in a strangely loud voice. We have to yell slightly when we’re in our protective gear. Motors on our backs blow cold filtered air by our ears, making it safe for us to breathe — but difficult to hear.
I try to tell him something nice from his family every day. Before the coronavirus struck, back when families would sit nearby and talk to their loved ones who were unconscious in the ICU, we would sometimes see a calming effect — maybe the patient’s heart rate would fall. This patient doesn’t react in any way that I can see, but I still hold out hope he hears.
“I just talked to your wife on the phone, and she says she loves you and stay strong,” I say.
I never got to meet him before he was sedated. It’s sad knowing that there’s a family out there who loves this man and can’t be here. The hospital, like many others, has had to largely bar visitors to keep people safe. We barely have enough protective equipment for ourselves — we would burn through it real fast if visitors needed it, too. But it’s awful watching people die alone. Some nurses sit with their patients during their final hours. One of my colleagues rubbed her patient’s head for five hours the other day as he passed.
Treating COVID patients is unlike anything I’ve ever done.
Early on, before the outbreak exploded in Boston, my boss asked if I’d be willing to work in a COVID ICU. I immediately said yes. I’m 26 and healthy. I’d rather me go than someone else, someone who has kids, or medical issues, or who’s older and more at risk of deadly complications. Later, the hospital assigned my entire former unit to the COVID ICU because we were experienced dealing with pulmonary disease.
I figure I’ll probably get sick, but I’m trying my best not to. I’m terrified. I see every day what this disease can do to the lungs.
The patients started really coming in around March 26. They say the surge is still a few weeks away. Now, we have 40 or so patients in the hospital with the virus, but we are prepared for nearly all 400 beds to be filled by COVID patients in the next few weeks. We have cleared other ICUs — pediatric, cardiac, and surgical — to make space for more critical COVID patients.
The COVID patients are sedated for the most part to keep them comfortable. Some of them, we have to paralyze with medication to flip them onto their belly to help them breathe better because it helps open up their lungs. They have to stay that way for 16 hours, then they’re on their back for eight hours.
That’s the scariest part of my job — when we have to flip the patients over. So many things could go wrong. We have to make sure the IV lines giving them medication don’t get tangled or ripped out. If the breathing tube from the ventilator falls from their throat, they could die. It takes a few of us to roll them over. We yell to each other about the plan first, and then keeping yelling to each other throughout the process.
Many of our patients could go either way — survive or die. They get sick very fast. And then they take a very long time to fight the virus.
So far, we haven’t seen any of our COVID patients recover. Some have died. Nearly all the deceased had underlying medical conditions.
My patient is becoming more stable than last week, but he’s still riding a very fine line.
We check every day for signs of progress. We do a chest X-ray to see whether the level of inflammation and fluid in his lungs has improved. We lower the ventilator settings to see if his lungs can take over the extra breathing work. We test how well his lungs diffuse oxygen by taking a blood sample and running it through an analysis machine.
Today was a good day. My team that does rounds together — an attending physician, some residents, me, and a respiratory therapist — compared the patient’s latest X-ray with one from six days ago. It was phenomenally better. The lungs looked clearer, less filled with liquid, damage, or inflammation.
We smiled. We clapped.
“Good job everyone,” the attending doctor told us. “You’re doing a really great job.”
This was our first case of actually seeing things get better.
Those X-rays gave me hope, knowing that some good has already happened. I just hope that progress continues.
| Wednesday, April 8, 2020 |
‘We’re waiting for the other shoe to drop’: Dr. Ali Raja, emergency medicine physician at Mass. General, braces for surge
Dr. Ali Raja
Dr. Ali Raja, 42, is the executive vice chair at Massachusetts General Hospital’s department of emergency medicine and an associate professor at Harvard Medical School. This is his account of his April 2 shift in the emergency department, as told to Globe reporter Deanna Pan.
The very first patient I saw had an oxygen saturation level of 60 percent, which is exceptionally low. Normal oxygen saturation is 95 percent or above. Anything in the 80 percent range is concerning. Sixty percent means you’re about to die.
This is the most unique situation I’ve ever experienced in medicine and unlike anything I’ll probably ever experience in my entire career. I worked the Boston Marathon bombing. I’ve treated abused children, gunshot wounds and heart attacks. But those are temporary events. I don’t take them home with me.
My family’s worried. My wife is sick. She probably has the coronavirus. She’s a nursing professor at Regis College, so the only way she could have gotten it is from me. I don’t have it; I feel fine. I probably exposed her two or three weeks ago before I did everything I do now after a shift: I throw all of my clothes in the garage washing machine. I go straight to our guest shower. I get totally clean before anyone gets near me.
I feel pretty guilty about it. She’s in bed all the day and she feels miserable. A lot of my colleagues have moved out of their homes. One of my colleagues has moved into a completely separate apartment and hasn’t seen his wife in a week. I’ve got coworkers who are uprooting their spouses and kids to their in-laws’. So this is really taking a personal toll on people. And there’s no chance for our staff to decompress. It’s going to happen again tomorrow and the next day and the next day and maybe the entire month of April. Normally after a shift as crazy as this, I would take our residents across the street to one of the bars by MGH and we would all have a beer together, but we can’t do that anymore.