Breaking Out a guest post by Helen Miller, RN
It was the night after Christmas, a few years back, when I went back to work after a day off. I’d worked the night of Christmas Eve, and had Christmas night off. (This is important.) At that time, I worked as an RN in a long-term care facility connected to a hospital. This arrangement used to be common in small and medium-town hospitals. The facility and the hospital shared a kitchen, and the facility naturally used the hospitals’ labs and radiation equipment. The facility had two wings, and shared a connected dining room/activity room. I was the night nurse for one wing that night, and had one certified nursing assistant to help me with all resident cares that night.
When I took report, I was told that one resident, with early dementia, had tried to feed another resident, with late-stage Parkinson’s. The result was emesis in the dining room. Another resident had come back from a dinner out with family. Multiple residents had had family members in either for Christmas Day or the day after. One resident had had a fall in an urgent rush to get to the bathroom, but had only a couple of minor bruises – no broken bones or head injuries.
Part of being a night nurse means working with the CNA to do rounds – checking on residents, toileting residents, turning residents at risk for pressure ulcers, taking care of incontinent residents, talking to residents who are awake, preventing falls, and making sure residents stay clean, dry, and safe In addition, there are nursing tasks of assessing residents’ skin, changing dressings, auditing charts, doing tube feedings, giving medications, checking on ostomies, checking settings for oxygen concentrators, making sure that tracheal openings are cared for, etc. And all of this needs to be charted. Rounds take place every couple of hours.
On our first round, the resident who had Parkinson’s had loose stools – not uncommon, as people with late stage Parkinson’s frequently get medications to counter the natural constipation of late-stage Parkinson’s. His roommate also had loose stools, but had been been eating chocolates. We followed standard precautions, cleaned our patients, made the beds with fresh linens, washed with soap and water, and moved on.
(Standard precautions mean that you glove up before giving care. You always dispose of linens either by bringing the dirty linen cart directly to the door or by taking a closed plastic bag of dirty linens to the linen cart. You dispose of trash by taking a closed plastic bag to the trash cart. You dispose of the gloves. You then clean hands either with hand sanitizer or soap and water before you leave the room. Soap and water is mandatory after any bowel movement. You don’t take dirty anything from one room to another.)
A few rooms later, we came to a room where the occupants sat at separate tables in the dining room, both close to the table where our Parkinson’s patient sat. When we went to turn one patient, she bolted upright, and projectile vomited. (Yes, we have black humor. The Exorcist was mentioned.) Suddenly, things looked worse. We were meticulous in cleaning up the resident, changing her linens, and in washing after. We then went to her roommate. She had projectile diarrhea as we turned her. “Well, shit. This is contagious, and it’s just a matter of time for us. We need to start more precautions.”
Contact plus precautions are used to keep from carrying contagious matter on your skin or clothes, and also are meant to help the caregiver not catch whatever the resident has. So I went to the other wing, got the isolation cart, grabbed a box each of gowns and procedure masks, and we continued on rounds, donning and doffing gowns and masks for each resident.
Over the course of the exhausting night, four more residents began to show symptoms. The other wing got a case, and used the other isolation cart, so chairs were put outside each room with gowns and gloves. We hauled around gowns and gloves. I called our nurse manager. Hospital infection control was notified. The county health department was notified. The state health department was notified. We continued rounds. I continued duties. There were no breaks for either of us between charting and rounding.
In the morning, my relief came. She had worked Christmas day, but not the day after. I started to give her report when she excused herself to the staff bathroom. I heard the unmistakable sounds of vomiting, and sent my relief home. This was the last shift she had been scheduled to work before leaving on a family trip to Jamaica two days later. (This is important.) Now I was working a sixteen hour shift. My nurse manager came in, and confirmed my orders – all residents to stay in their rooms, all meals on trays with disposable plates and flatware and cups, no communal meals, everyone to change gowns and gloves between each resident and to wash with soap and water between each resident. In between passing morning meds and helping to feed residents who needed feeding, I called an order for more gowns, masks, face shields, and still more gowns. I also doubled our order for trash bags and linen bags. I let the house supervisor (charge nurse for the entire hospital) know that we would probably need a lot more staff, as I expected my relief would not be the last to get the whatever it was. Soon one of the day CNAs ran for the staff bathroom, and left in tears – she couldn’t afford the time off, and we couldn’t afford to keep her on shift, even though we needed the hands.
We were authorized to collect samples of fresh stool and fresh emesis, and get them to the lab. It was a couple hours before I came on duty the next night that our fears were confirmed – Norovirus.
I was not the first staff member to note either loose stools or vomit, but I was the nurse who called it an outbreak, implemented precautions, and got the ball rolling. It had been too late from that moment in the dining room when one resident vomited in the dining room. Norovirus has an incubation period from eight hours to seventy-two hours (on average), a duration of one to three days, (on average), and a period of virus shedding after the patient has no more symptoms. That virus shedding can last up to three days. Norovirus can persist on objects for up to ten days, and it only takes five or so Norovirus particles to infect someone. Norovirus kills about 200,000 people a year around the world, most of them very young, very old, or with pre-existing conditions. Long-term care facilities are full of the very old and of people with pre-existing conditions.
The outbreak was exhausting. Nobody worked the entire outbreak. My usual night CNA was sick halfway through the second night. We paid bonuses to hospital nurses and techs who came over to work. I worked three nights in a row of either twelve or sixteen hour shifts, and then succumbed. (While I was giving report, I said, “Excuse me,” and went off and puked. I bleach wiped the staff bathroom, put on a fresh mask and gown, and finished report standing five feet from my colleague.)
At home, we had advance warning. I had called my husband, so we had bleach wipes, pads, garbage bags, Sprite, soda crackers, gelatin cups, Nuun tablets, and other sick kit supplies laid in. My husband had gone to the local pharmacy and bought a big box of nitrile gloves, and another of masks. He had pulled out the couch in the family room. Our master bedroom had an ensuite bathroom. When I got home, I stepped on the waiting towel, stripped as soon as I got in the door, and put my uniform and the towel in a garbage bag. My coat went in a separate garbage bag. My nursing bag went in a third garbage bag. My masked-and-gloved husband carried the garbage bags to the laundry room in the basement. I “skated” on bleach wipes to the slippers and bathrobe left out for me.
I went to the master bedroom, all stocked with supplies, put my phone to charge, and fell asleep. I was sick from both ends multiple times, and bleach wiped everything. I didn’t allow any of our family into the bedroom for 48 hours except my husband, who came masked and gloved into the bedroom while I was in the bathroom to take out garbage bags of garbage and dirty laundry, and plop a pile of clean sheets on the bed. I made the bed. I communicated with my family in the same house via phone. During the time I was in self-imposed quarantine, my mother had a stroke. I could only encourage her to go the hospital from a distance, as I couldn’t add virus exposure to a very vulnerable person. Nobody in our house got sick. Once I was symptom free, I maintained quarantine, but padded down and did bleach-heavy laundry. From the time I went home until I was eligible to go back to work was around five days.
Meanwhile, back at work, it was Norovirus. Everything was bleach wiped or steri-wiped. Anything that could be UV sterilized was UV sterilized. Fluids were encouraged. Linens were changed. Bottoms were cleansed. Gowns and masks and gloves were donned and doffed and disposed of. We didn’t lose a single resident out of a very vulnerable population. Of 53 residents, a total of 18 got sick, most in the first two days. Of 40 staff, a total of 20 got sick, most in the first two days. We used extra staff from the hospital. In the hospital proper, three patients got sick, and four staff. Everybody who could work did work twelve to sixteen hour shifts for the ten days of the outbreak. And then worked some more after the outbreak. Everyone was exhausted.
- Any outbreak will probably hit caregivers hardest, because they will have already been exposed by the time they realize that this is something unusual.
- We were lucky – we were associated with a sister facility that could share staff with us if we offered bonuses. In a large outbreak, this isn’t possible.
- Norovirus sucks. It can be shed before a patient has any symptoms. Even after staff no longer had symptoms, they had to wait 72 to report to duty, because of how long virus could be shed. It hasn’t been clarified how long novel corona virus will be shed before or after symptoms.
- Norovirus sucks. Although the most common method of contamination is fecal (touching something contaminated and then touching the mouth, or eating something contaminated), aerosolized emesis (vomit) can cause Norovirus to act like an airborne or droplet contagion. From infection patterns on the Diamond Princess, it appears that the novel corona virus can cause airborne contamination. This is bad. Please don’t run and buy all the N95 respirators and filters – leave some for health care.
- Having supplies in advance (and a bedroom with an ensuite bathroom) allowed me to do in-home quarantine. This isn’t possible in a large outbreak, because the supplies are needed by the medical facilities.
- Taking care of an outbreak uses So. Many. Supplies. Disposable gowns. Disposable masks. Disposable face shields. Disposable gloves. Bleach wipes. Steri-wipes for equipment that cannot be bleached. Disposable plates and flatware. Disposable bottles and cups. Gelatin cups not needing refrigeration. Sleeves of soda crackers. Juice cups. Applesauce cups. Trash bags, laundry bags, so much extra linen, hot water, and laundry soap. More bleach.
- The holiday brought food, guests, and outings. All potential sources of contamination. The ultimate primary source of contamination was never truly pinpointed. It was narrowed down to three possibilities—one of them was the hospital kitchen, but norovirus was not found on any surface there.
- The staff member who went home sick first? Went to Jamaica on the planned vacation, because she was symptom free by then. Had a family member get sick on the plane. Had four extended family members sick at the all-inclusive resort. Mentioned that “they must have had it there, too, ‘cause lots of people were sick there.” Oy, vey. Really. I don’t care what your plans were. Don’t share the horrible stuff.
- Over the next six months, we had multiple staff resignations. Exhausted staff still work, but may be lost to caregiving professions entirely after they have time to take stock. The night CNA I was with now works in a factory.
- Long-term care centers, dormitories, casinos, and cruise ships are frequently the centers of outbreaks, because people have communal dining areas, and share hallways, and may share bathing spaces.
Some of this is applicable to the current outbreak—symptom-free does not mean that somebody will stop shedding virus. However many supplies you think are enough, double them. Then double them again. When I see the photos of staff in Wuhan going from room to room, I can only think that cross-contamination is occurring, and that they must be so very short on supplies.
Most of all, I know that terrible moment when you look at another staff member over a sick patient and realize, “This is contagious, this is awful, and we have been exposed. It’s only a matter of time for us.” And then you keep working until you can’t, because you are needed more than ever.
Do me a favor? Please cover your cough, and wash your hands. It’s still flu season.
Helen Miller, RN works as a staff nurse in a hospital, and has worked in long-term and skilled care nursing.