For young nurse, caring for sickest coronavirus patients has 'scary' moments

WILTON — At 22 and with less than a year on the job, Kim Ugarte never expected to be one of the nurses with the most experience to take on the sickest patients in the medical intensive care unit at Yale New Haven Hospital.

“In a pre-coronavirus world, I never would have gotten them,” Ugarte said in an interview with Hearst Connecticut Media. “A month ago, I didn’t know how to paralyze a person.”

A member of the class of 2015 at Wilton High School, Ugarte graduated nursing school at Catholic University last year. She was inspired, she said, by the kindness of nurses who cared for her through numerous high school sports injuries.

An internship in the emergency department at Yale during the summer before her senior year pointed her in the direction she wanted to take.

“I loved the critical care aspect, the speed, it’s so in-depth, that’s what I loved about ICU,” she said.

Working at the MICU at Yale New Haven was her “No. 1 job” she applied for and she began last July.

“Coming out of nursing school, you know how to take a test and you have clinical skills. Being new in the MICU is terrifying. You don’t know how to work with people on ventilators.”

Orientation takes four and a-half months, she said, and she was paired with a nurse who had more than 30 years of experience.

“I call her my work mom,” she said. “We would get the most critical patients because they wanted to expose us to more.”

Most of those patients had pulmonary issues such as pneumonia, heart failure, liver failure or kidney failure, often in combination with other factors like hypertension, high cholesterol or diabetes.

On the MICU, nurses are assigned to one patient or two for their 12-hour shifts. Coming off orientation, new nurses like Ugarte, who works 7 a.m. to 7 p.m., was mostly assigned two patients who were not among the sickest.

“They would try to give us the more stable patients,” she said, “but you never know what’s coming in the doors.”

In mid-March, that was COVID-19.

“We had two positive patients and it was a shock,” she said. “Which nurse is going to get that patient?”

At that time, Ugarte said, “we were still getting used to the idea of wearing all the equipment and having a negative-pressure room.”

They did not have much time because within two weeks two floors were filled with coronavirus patients. About a month later, two cancer floors were converted to MICU floors.

As the pandemic progressed, Ugarte was given one-on-one assignments. She spends her entire 12-hour shift, fully suited in protective gear — filtering mask, goggles, face shield, gloves and gown — alone with her patient in a room with negative air pressure to prevent airborne germs from escaping and infecting others.

When Ugarte enters a patient’s room, the first thing she does is check the monitors and set the parameters for heart rate and blood pressure. She checks the ventilator. Are the breaths big enough or synchronized?

“Then I look at the patient. It’s different than other patients because you can’t fully assess them,” she said.

Some patients on ventilators must be sedated and paralyzed.

“What we are finding is that a large amount of COVID-19 patients are needing to be heavily sedated and paralyzed in order to be synchronous with the ventilator; a lot of times that is the only way we can better ventilate/oxygenate the patient,” she said.

“The only way to see how adequately paralyzed they are is a nerve stimulation test,” she said, which she does by attaching two monitor leads to their wrist or eyebrow and setting it for a twitch.

“That’s become the norm for me,” she said. “It’s crazy to be a new grad in the MICU in a pandemic.”

When the attending doctor comes by outside the room, they discuss the plan for the day.

“The plan is when are we going to flip them,” she said, explaining ventilated patients tend to do better on their stomachs. “We have a ‘prone team,’” she said, consisting of nurses and a respiratory therapist, to manage the ventilator tubes, with a doctor in charge.

“It’s a dangerous procedure but it helps them significantly,” she said. Generally, a patient will spend 16 hours on their stomach, with their head moved every two to four hours, and eight hours on their back.

Because Ugarte gets the sickest patients, she only has them for a day or two. Once they are doing better, she is reassigned. But in one case, she cared for a woman over the course of three days. She was improving and the doctor was reducing her sedation, but as they did so, she became agitated and confused, something Ugarte said is typical.

On the third day, Ugarte suggested a different type of sedation, which they tried, and by the end of her shift the woman had improved.

“She was looking at me and noticed I was there. I was asking questions and she was nodding her head. It was first time I saw her lucid and I saw tears from her eyes,” Ugarte recalled. “That was an extremely happy moment for me.”

Two days later, Ugarte returned to work to find the woman had been extubated and sent to a floor.

Not all stories have happy endings, of course.

“Some days are really worse than others,” she said. “If, unfortunately, you lose a patient and you’ve tried everything, that’s hard to deal with. It’s never easy to come home after you’ve lost a patient.

“The daily struggles of going in and being alone in the room and gowning up, doing all this stuff to keep patients alive, it’s hard. We don’t allow any visitors unless a patient is so close to death, then we allow two visitors to come in when they are nearing the end of life.

Ugarte finds comfort in the fact she has been living in Guilford with another nurse, her best friend from nursing school. But that situation will change soon as she returns to her home in Wilton to live with her parents, Cathy and Gonzalo Ugarte, and her younger brother Kevin, a finance major at Catholic University.

“I try to think on the bright side, patient situations like [the woman] make me truly happy to be a nurse. What’s helped is the love from community and the families.

“When I speak with families on the phone, they are appreciative,” she said. “I put myself in their shoes, I’d be a crazy family member, I’m sure. It’s for their safety, when every single patient is coronavirus you can’t risk exposure.

“I think this is a big growing step for me as a nurse and after we come out of this, I’ll be a better nurse than before,” she said.

Lonely work

In a pre-corona world, the MICU was much more open. The nurses did not wear gowns and there were few ventilators. “We kept the doors wide open and we could call for help,” Ugarte said.

Now, “the main person in the room all day constantly is the nurse and it can be scary. Sometimes something happens you don’t expect and you have to call the charge nurse.”

If she went into the room and forgot something, she’d have to bang on the window to get someone’s attention or call on her cell phone. Now, the hospital has been getting Alexa devices so the nurses don’t have to touch their phones.

“It’s extremely lonely,” Ugarte said. “I have the TV on for the patient and myself, it’s so quiet in those rooms and if you see the monitors going off, it can be a little frazzling. It is lonely a lot of the time. With them opening four floors, you don’t see the nurses you’d normally see.”

But they are seeing more unfamiliar nurses — nurses from post-anesthesia care or endoscopy — who don’t have the training to work in an MICU. So now Ugarte is helping to train them. Former MICU nurses have also come back to help.

As of last week, Ugarte said the hospital had more than 100 coronavirus patients with 60 on full life support.

When asked what she would say to the public on the cusp of the state reopening, Ugarte said, “I totally understand things need to reopen, but people really, really need to take precautions. Every day I go into work I have fear for myself, my patients, my family.

“There are some not taking precautions and unfortunately those are the ones we see in our ICU. It’s hard hearing this patient was out and about and not wearing a mask. This is real and it is still going on. We’re on a plateau but we’re still definitely getting patients. It’s happening and it’s real.”