HOW ICU CAPACITY WORKS
JESUS CHRIST IT IS NOT THAT HARD TO UNDERSTAND aka THE ICU IS YOUR LAST STOP BETWEEN HEAVEN AND HELL
Hey there, ICU RN Cassie here. Let’s break down how ICU capacity works and what effects it, m’kay?
BECAUSE I AM SEEING THINGS ON TWITTER THAT MAKE ME WANT TO STRANGLE PEOPLE.
(I’m usually brusque with idiots, but this is a very special late night ‘I’ve worked two very long 12s and have another long-ass 12 to look forward to tomorrow’ so there’s going to be extra curse with curse-sauce.
So people keep saying ‘Oh look, the numbers are fluctuating’ or ‘Can’t we bring in a Navy med boat?’ or ‘Why aren’t they building tents’?
Here’s the FIRST THING TO UNDERSTAND:
Hotels have beds!
Beds are not the problem here!
The problem is STAFFING THE BEDS.
When you talk about ICU capacity what you’re really talking about is STAFF.
Someone (who meant well) was asking me on twitter today why we can’t just press gang people into helping with covid patients, ala women going into factory work during WWII while the menfolk were off at the front.
But that’s a really shitty analogy, when it comes to ICU capacity.
I’m not in isolation gear for 12 hrs a day pounding rivets into steel, man.
I’m saving fucking lives (well. Trying to.)
So a more apt comparison is ICU RNs to the fighter pilots. I’ve got roughly the same education as one (at least 7 years to become an RN, and that’s without a bachelors) and I have to know JUST AS MUCH SHIT and arguably what I do is just as expensive because what’s more precious than a human life? (And y’all know how much they charge for things at the hospital, heh. But really. Yes. A day in the ICU — a casual day, is like, what, ten or fifteen k? Anything bad happens to you it goes up exponentially. But medical costs can be another essay later.)
You cannot just shake a tree and knock more ICU RNs out of it. Nor respiratory therapists! Or doctors! Or nurse practitioners!
I hope by now people aren’t buying the whole ‘but it’s just a flu season!’ canard that Tucker Carlson would have you believe, ‘cause it ain’t. Yes, though, in a typical flu season, we can get up to 100% full (and hey, you know, off season, someone hits a bus full of nuns or whatever, shit happens.)
The problem currently is though that:
A) EVERYWHERE IS FULL.
There’s no one we can call for reinforcements! We can’t send extra patients to southern California, nor can they send their extra patients up to us.
THERE IS NO ROOM AT THE INN.
B) Usually, we use traveler RNs as stopgaps in these situations.
But right now — THE ENTIRE NATION NEEDS TRAVELER NURSES.
I’m hearing stories of travelers getting $8000/week pay! That’s utterly unheard of in normal times! (Not that they don’t deserve it though, they’re working their asses off! Much love to my traveler RNs, get that money honey.)
C) Normal staff nurses are quitting jobs they currently have to cash the fuck out.
Can you blame them?
We fucking watched maskless fools parade about in our faces for the past goddamned nine months.
If I worked in a place where I’m going to get intentionally coughed on or assaulted in the grocery store for wearing scrubs, you’d best believe I’m going to get PAID THE FUCK OUT FOR IT. What loyalty would I have to a city that allowed parades of maskless people out and about? (What’s that Huntington Beach? Am I looking at you? WHY YES I AM you fucking armpit full of yahoos.)
D) Nurses are getting sick or having relatives of theirs get sick that require care and they themselves need to be out.
I’ve got a new nurse who we’ve been training to be an ICU nurse — two of her relatives have covid right now. (One coded yesterday!!!!) She didn’t have to quarantine because she didn’t live with them, but it’s happening to tons of nurses everywhere. (And as long as we’re still forced to participate in a non-lockdown, masks-optional society because of capitalism and poor governmental planning it will continue….)
E) Covid patients stay hospitalized (in those precious beds) longer.
A typical ICU stay is 5-7 days. Fourteen days on the ouuuutttsidddeee.
You wanna know why?
Because that’s about how long you can have a breathing tube in normally before you start to risk mouth-throat erosion. (Yes, we’ve all seen people be vented for up to three weeks, other HCW don’t you dare get pedantic right now with me.)
USUALLY though, we know whether or not you’re gonna die well before that — but if you’re still on ventilator at 10-12 days and we can’t get you off for non-covid reasons, we’re going to need your family to shit or get off the pot: we’re involving palliative care because chances are we’re going to compassionately let you go or we’re going to trach and PEG you (give you a tracheostomy to breathe through and a tube into your stomach for feeds) and downgrade you to another floor or send you to a skilled nursing facility for rehab.
But covid’s a little different because it can rollercoaster you.
I took care of a guy two weeks ago who had been in our hospital since October, and in the ICU for half of that.
He got better, went to the floor, got worse, got reintubated and ICU. Got better, went to the floor, got worse, got reintubated and ICU. Got better — you get the picture, right? He was hospitalized (when I had him) for over 45 days and at least half of those were in the ICU.
He wound up getting better! And leaving! (Miraculously enough.) But he ate up an ICU bed for 25 (at least?) days!
And again — he survived! So it was all worth doing!
I’m not saying that’s normal, but when your grandma comes in and has a stroke we’re not pussyfooting about her chances of living past day 10 all that often, my friend.
Whereas with covid, sometimes…yeah.
F) Complexity of care
So this goes back to the fighter pilot vs riveters, riveting things — right now in California we have ICU staffing ratios of max 1 RN to 2 patients.
These are going to go out the window any minute now, alas (although I understand why, see above) but that’s optimal conditions. Why? Because it’s safer and produces better patient outcomes (markedly. You can look up the literature on your own.)
What gets you your own nurse? Depending on the facility?
ALL THE THINGS THAT HAPPEN WHEN YOU HAVE COVID, FREQUENTLY.
Are your lungs shot by covid? Do you need to be turned on your stomach to maintain lung function? Do you need to be medically/chemically paralyzed to keep you on your stomach for your lung function? You might be a 1:1!
Do you require multiple pressors (blood pressure medications that can require frequent titrations) to keep your blood perfusing to your organs so they keep working? You might be a 1:1!
Did covid fuck over your kidneys? Do you require continual renal dialysis? (Not the kind your elderly relative gets MWF — we’re talking livetime 24/7 right at the bedside plugged in and don’t stop washing your blood dialysis.) You might be a 1:1!
Are you getting ECMO? (This is the heart-lung machine you hear people talk about on TV — where all of your blood is being siphoned into an external device which both pumps and oxygenates it for you so that your heart and lungs can recoup.) You might be a 1:1!
Did covid give you clotting issues that gave you stroke-like symptoms that require frequent neuro checks so we know that you’re not getting worse and/or requiring surgical intervention? Or are you experiencing numbness and tingling in your legs from showering clots due to covid? You probably aren’t a 1:1, but you maybe should be!
ARE ANY OF TWO OF THE ABOVE THINGS HAPPENING TO YOU?
Three?!?!
YOU SHOULD DEFINITELY HAVE YOUR OWN NURSE SO YOU DON’T DIE OF COVID.
(Also? If any of the above things sound scary/interesting, as they should, please google them and you’ll see why not just anyone can magically pop up to my floor and function.)
G) Other reasons we can’t take people off the streets to be ICU nurses
We have access to a lot, and I MEAN A LOT of narcotics, heh.
We’re also in isolation gear all the time with covid.
Getting into isolation gear mode — it’s a state of mind, and a nursely way of being.
You remember that completely embarrassing video of FL Gov DeSantis wearing his mask wrong?
How about being in a room where if you did that, you might die?
Or those gross super spreader shots of, who was it, Bill Barr? Sneezing, wiping his nose, and shaking hands with people at that confirmation party in DC?
Like — I don’t want to work with people who that shit hasn’t clicked for (which, if you look at how many people are still fighting masks IS A LOT OF PEOPLE) and honestly, it’s not ethical to, either.
I don’t want to take some newbie and have them get covid because they’re not as hyperaware as I and my fellow nurses are, for them to take home.
Some people aren’t born paranoid.
Those people shouldn’t become ICU RNs, lol.
G) Some last thoughts
So, Cassie, you ask, if you can’t take people off the streets and turn them into ICU RNs, who can you cannibalize from the rest of the hospital?
Whelp, part of the problem right now is that covid’s all over the hospital. They’re using ICU capacity as the official metric because we see the sickest of the sick — there’s no place to go from us but home, heaven, or hell — but honestly, looking at the board, all floors of the hospital are getting evenly hit. So it doesn’t do us any good to snag a med-surg nurse or a stepdown nurse (the next level down from ICU) internally, when those floors are hurting just as bad as we are.
I know Newsom wants to crash course ICU RNs. I haven’t heard any more from that since Stanford said, eff you, but….
Have you ever started a new job and wondered where the fuck the copier was? And then once you found it, why the fuck it required a keyed in password or a badge, because, like, what, they can’t afford copy paper or some shit and want to make sure you’re not making posters for your lost cat?
Hospitals also have work flow.
I’m not saying they’re impossibly complex. But I am saying that it’s one thing when you can’t find the secretary to tell you how to use the copier, and IT IS AN ENTIRELY DIFFERENT FUCKING THING IF YOU DON’T KNOW HOW TO FIND THE CRASH CART.
Like, all hospitals have the same shit inside them. But they’re not built the same, organized the same, stocked the same, etc, past all the science-shit.
Nurses with experience who come to the ICU get 6 months of ICU specific training.
Traveler nurses with ICU background still get a few days orientation.
And what they both get, in Normal Times, perhaps most importantly, is plenty of staff around them that they can ask for help.
If your staff is new, or less experienced, or trapped inside an isolation room doing continual dialysis/ECMO by their lonesome — there’s just a brain drain. Sometimes the covid wing looks like a ghost town, because we’re all working very, very hard, in our own rooms.
But usually? We ask each other for help/opinions/ideas ALL THE TIME. That’s one of the most awesome thing about being a nurse, is working with amazingly intelligent women and being all, “Yo, I need back-up,” and everyone figuring out what to do together. Someone will have seen something like what’s happening to your patient now, only ten years ago, and remember exactly how to fix them. Some other coworker will remember that you have to hit that piece of equipment with four lbs of pressure on the upper right hand corner to make it behave. Some other other coworker will remember the oddly elaborate process that it takes to get sterile processing to send you a Dingle Hopper, which is, of course, the only component of the thing that you need to do immediately that you do not presently have.
(Please don’t give me guff about non-optimal workflow if, again, you have ever had to badge into a copier in your place of business. Thank you.)
We’re going into a dire time here, my friends.
I’ll take those warm bodies that do that ICU crash course, no problem. I’m not going to turn my nose up at people who know where shit is and have hustle.
But surely you can see, after I have wasted a PRECIOUS HOUR OF MY SLEEPING TIME TYPING ALL THIS that between now and Jan 31st is going to be A BAD TIME TO BE HOSPITALIZED FOR ANYTHING.
NOT JUST COVID.
Because we’re going to be short-staffed, we’re going to be exhausted, we’re going to be emotionally traumatized from being the LAST PEOPLE WHO WITNESS all the deaths that should’ve NEVER OCCURRED in the first place HAD OUR GOVERMENT ACTED LIKE A GOVERNMENT AND GIVEN A SHIT (and I haven’t even touched on all the mental issues that come along with being expected to work under these sorts of conditions — later essays! I need sleep!), we might have friends/relatives/coworkers out with covid — or lost people, personally! — we’re going to be sweating our asses off in n95 masks and plastic gowns, dehydrated and cranky, utterly unpretty and entirely irreplaceable.
H) So, in closing….
We’re gonna try and keep you alive, okay?
But like, please, meet us half-the-fuck-way?
Wear masks and don’t go out if you absolutely don’t have to. Don’t troll Target for funsies. Don’t go see your Grandma at Christmastime, I don’t care how emotionally manipulative she is.
PLEASE FOR THE LOVE OF GOD AND SOME NURSE NAMED CASSIE — stay home.
I’m sure you’re awesome and all, but I don’t want to meet you in person.
And you sure as shit don’t want to meet me.
— Cassie
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