By Christopher Cheney
With respiratory distress common among seriously ill coronavirus patients, respiratory therapists are at the tip of the spear on the pandemic frontline.
Respiratory therapists have been in short supply during the coronavirus disease 2019 (COVID-19) pandemic. A study published in 2015 identified the supply of ventilators and the staff to manage them as a weak point in the U.S. healthcare sector’s capability to function effectively during a public health crisis.
Julie Sullivan, who has worked as a respiratory therapist for the past 16 years, answered the call when hospitals were overrun by COVID-19 patients in New York City. She took a leave of absence from her Texas hospital and traveled to Brooklyn, New York, to work at NYU Langone Hospital during the height of New York City’s COVID-19 patient surge in the spring. She is currently working at Prince William Medical Center in Manassas, Virginia. She also is a spokesperson for the Allergy and Asthma Network.
“When I was in New York at NYU Langone in Brooklyn, all I had was ventilated patients. It was pretty much an all-COVID hospital when I was there,” Sullivan says.
During a COVID-19 patient surge, respiratory therapists are assigned to work with patients in respiratory distress, she says. “They are usually desaturating, so their oxygen level is low. You want the oxygen level for a normal, healthy person to be as close to 100% as possible. If a patient has an underlying disease such as chronic obstructive pulmonary disease or asthma, it might be OK for the oxygen level to be in the low 90s. I often get a call for a COVID-19 patient with an oxygen level in the 70s.”
There are three primary kinds of care that respiratory therapists provide to seriously ill COVID-19 patients, Sullivan says.
1. Heated high-flow nasal cannula therapy allows respiratory therapists to provide patients with 100% oxygen at a rate of at least 40 liters per minute. In contrast, a regular nasal cannula provides patients with about six liters of 100% oxygen per minute.
3. Intubation and mechanical ventilation is the last resort for respiratory therapists to oxygenate COVID-19 patients when other methods fail. “For ventilated patients, we maintain their airway, we draw arterial blood gases because that gives you a better picture of what their arterial blood gas levels are, and we try to maximize the ventilator settings to improve oxygenation. We also have done things like continuous nebulizers and vasodilators.”
At NYU Langone, ventilators were often unsuccessful in saving patients, she says. “I know of only two patients who got intubated and got off the ventilator. A lot of times, I felt that no matter what we did, nothing helped the patients. When they got so sick, even intubating them just prolonged the inevitable.”
Dealing with respiratory therapist shortages during a patient surge
Under ideal circumstances, respiratory therapists work with a handful of ventilated patients during a shift. At NYU Langone, Sullivan worked with as many as 18 ventilated patients at a time.
Pairing respiratory therapists with critical care nurses was the primary strategy to maximize the efforts of respiratory therapists at NYU Langone, she says. “We typically worked side-by-side with the nurses because we went into the patient rooms and tried to tag-team the patients together.”
The nurses performed routine tasks that the respiratory therapists would normally have done themselves, Sullivan says. “We trained the nurses to be a little more self-sufficient and not call respiratory therapists for simple tasks such as switching a nasal cannula or doing a couple of puffs with an inhaler for a COVID-19 patient with COPD. These are not critical emergent issues that could take a respiratory therapist away from the beside where we need to be. You can use nurses to do some of the basic things that busy respiratory therapists may not be able to get to.”
NYU Langone also used hygienists to clean respiratory therapy equipment because the respiratory therapists did not have the time to process equipment, she says.
Working in a ‘warzone’
At NYU Langone, the hardest part of working during the COVID-19 patient surge was the sheer volume of seriously ill patients, Sullivan says.
“We called one of the COVID-19 units the seventh circle of hell because it was not negative pressure. So, you would have two COVID-19 patients in a room, and it literally looked like a warzone. I still have flashbacks about how many sick people were in the same rooms and how overwhelming that was. I can’t tell you how many times we went into a room and a patient would be expired and still be on the ventilator with IVs going.”
Under these kinds of circumstances, medical staff need to brace for the worst, she says. “You need to know that the situation is intense and unlike anything you have ever seen before. In a typical week, you might have one or two code blues when a patient goes into cardiac arrest, and you might think that is a lot. At NYU Langone, there was a time when we counted 26 code blues in an eight-hour period. That is an insane number of codes in a short amount of time.”
To cope emotionally and physically with a COVID-19 patient surge, healthcare workers must draw on every strength in their being, Sullivan says.
“It’s will power, and you dig deep. My grandmother was an Army nurse, and my grandfather was a surgeon during World War II, and I just thought this was my chance to help out my fellow man. I committed myself to doing the best that I could do. I committed myself to working hard from the moment I walked through the hospital door to the moment when I would leave.”
Facing death on an epic scale was a daunting challenge, she says. “The most heartbreaking thing for me—and it still gets to me—was all of the people who were dying horrible deaths. And they were dying alone with strangers. There were not enough iPads to call family members. We did not have the passwords on patients’ smartphones. But we did Facetime with family members when we had time.”
For Sullivan, small acts of kindness helped her deal with the darkest times. “I would do little things to make myself feel better, like cleaning a patient’s face. If they had tears, I would wipe them off. I would sing to my patients when I went into their rooms. I hoped that it helped them—I hope that it showed that people cared about them.”
Christopher Cheney is the senior clinical care editor at HealthLeaders.