In the Room with COVID-19: Hawaiʻi Nurses Talk About Patient Care in a Pandemic

Photo: Courtesy of The Queen’s Medical Center

The first thing Sarah Williams does when she wakes up each morning is pray. The Queen’s Medical Center nurse manager prays her team has a good day. She prays the patients stay safe. She gets ready for work, grabs a cup of coffee, and arrives at the hospital by 7 a.m.

At the beginning of August, the sixth floor of the Pauahi wing, where Williams, as a nurse manager, oversees a team of 63 nurses and 14 nurse aides, was a heart failure unit. In three weeks, the cardiac patients were relocated and the 30-bed ward, with its telemetry and acute care resources, was transitioned to treat the growing number of people showing up at the emergency room with COVID-19.

The Pauahi wing, called P6, is one of six COVID wards at Queen’s, the state’s largest hospital and only Level 1 trauma center. Manning these wards is a corps of devoted nurses who provide critical care and serve as the vital link between the sick and their families. This month, the teams were bolstered by two dozen out-of-state nurses brought in to assist with the recent surge in patients. Still, Williams describes the energy in the COVID wards as “calm and calculated,” a contrast to the chaotic hospital scenes from northern Italy and New York City in the spring.

“It’s a different kind of busy,” Williams says, explaining how the workflow has been restructured to consolidate patient care and minimize exposure. She’s proud of how quickly her team adapted to new protocols: how to properly don and doff personal protective equipment, how to administer COVID medications and what to do if a patient suddenly takes a turn for the worse. “To go from straight cardiac to straight COVID—that transition could have been a lot harder if the team wasn’t so dynamic.”

SEE ALSO: What It’s Like Being a Hawai‘i Nurse During a Pandemic

Nurse manager Sarah Williams.

Williams’ crew of nurses is fairly young—many have babies at home, and some live with parents and grandparents. “One of their biggest fears is, ‘I don’t want to catch COVID and I sure don’t want to bring it home to someone I love,’” Williams says. “It’s scary, because we don’t know a whole lot about the disease. I’ve been through H1N1, H1N5 and Ebola, and this is different in terms of knowing what to expect and how to manage it. Even I went through the emotions, like, ‘Why? Why us?’”

To manage the risk, processes are being slowed down and streamlined. “Before, if patients put on their call light, we ran right in. With COVID, it takes us 10 minutes to put on our PPE before we can go in,” Williams explains. Simple solutions like installing mirrors to help check PPE and limiting meal tray deliveries to specific times help ease concerns.

While other hospital admissions typically take 45 minutes, it takes two hours to admit a COVID patient. Nurses teach them how to use the video monitoring system and explain that instead of making frequent rounds, they will concentrate all their tasks—taking vitals, assessing needs, administering meds—into a single visit every four hours.

Christiane Nicolas and her team. Photo: Courtesy of Queen’s Medical Center

Since staff can no longer congregate in the lounge or share meals, it’s also harder to decompress together. “There’s a lot now that is not our norm, but we find a way during our huddles to support each other,” says Christiane Nicolas, a permanent charge nurse in the COVID ward on the seventh floor of the ʻEwa wing. “We laugh a little. We cry together.” A therapist is assigned to each ward for nurses to talk with, and Nicolas especially appreciates the regular wellness checks by physicians, her nurse manager and upper-level administrators. “They come in and ask, ‘How are you guys holding up? Anything we can do?’ They help us to do our job.”

The Patients’ Plight

When a COVID patient checks in, they keep only their essentials including dentures, eyeglasses and phone chargers. They’re taken from the ER to confined wards through special routes limited to COVID patients. Family members are not permitted, nor can they drop off clothes, belongings or outside food. The rooms are bare; nurses can’t even bring in stethoscopes or name badges. From the get-go, patients are alone.

Because they are so weak and their respiratory status is so tenuous, COVID patients require close monitoring. Just traveling from the bed to the bathroom can push them over the edge. “You could be speaking with them while they’re having lunch, and you’re in the room doing your assessment, and in a couple minutes, they can just say, ‘I can’t breathe,’ and their numbers start dropping,” says Nicolas, who has worked at Queen’s for 29 years.

COVID patients also need greater emotional attention. Since loved ones can’t visit, nurses become their surrogate families. But even those interactions are limited.

“I’m a people person. I love to sit in my patient’s room, hold their hands, just talk about life and get to know them,” Nicolas says. “The hard part now is we’re covered up. We have the mask, the goggles, the shield, the bonnet and the gown on. They can’t see our reassuring smiles. I’m hoping they can see the concern and caring I have for them in my eyes, since they can’t see it on my face.”

SEE ALSO: COVID-19 Hits Home: Three Oʻahu People Who Contracted COVID-19 Talk About Their Illness and Long Recovery

To combat the isolation, nurses provide some meaningful TLC. They make birthday cards and treat patients to ice cream and cupcakes. One nurse aide sings while she bathes her patients. Nicolas distributes art supplies.

The most effective remedy for loneliness, though, is seeing familiar faces. The hospital uses multiple video chat platforms—Zoom, WebEx, FaceTime, and even a translation device called a MARTTI (My Accessible Real-Time Trusted Interpreter) for patients with language barriers or hearing deficits. Williams says these communication tools help quell anxiety among both patients and families. “You can actually lay eyes on your loved one and think, ‘OK, you do look all right. You look like you’re sick, but not what my imagination is telling me.’”

Nicolas sits with older patients who can’t hold the phone or iPad. Family members have asked her to hold a patient’s hand. They have pleaded, “Can you please tell him I love him?”

“The families say prayers, they sing songs, they reassure the patients that they’re there and supporting them, and that they’ll come home soon,” Nicolas says. “It’s worked wonders.”

One of Nicolas’ patients was a gregarious elderly man who loved to talk story with the nurses. “Every day, a couple times a day, he would yell out for his girlfriend, just yell out her name randomly. She would call once a day, and when she spoke with him, his face would light up. She was his world.”

The girlfriend didn’t have Zoom, so Nicolas and her staff would hold the telephone to his ear. “He would say, ‘I miss you, baby. I miss you, baby. I’m coming home.’ And every day, that conversation would settle him,” Nicolas says. “As days went by, he got weaker. He wasn’t able to yell out her name anymore. When we would go in to do our care, we would tell him how much she wanted to talk to him. She would call and we would hold the phone. We could hear her say how much she missed him, but he wasn’t responding back.

“A couple of days later, a nurse was in the room when he passed. She had called out to us, asking us to notify the physician. All of us who were working went to his room, and we formed a half-circle outside. We all said a prayer to him and his family. And we just cried,” she continues, her voice cracking. “We sat in silence for a couple minutes. It was … It was really sad his family wasn’t there. All these days he was calling out for his girlfriend—and every phone call, ‘I miss you, baby. I miss you, baby.’ It was so beautiful.”

Nurse Janice Nakatani-Cuyno doffing personal protective equipment.

Says Williams: “When a patient does pass, we don’t want them passing alone. So, when that time is imminent, a lot of my nurses have taken steps to be the one that holds their hand when they transition.” It’s agonizing, she says, to tell families they must say goodbye through a screen rather than in person, a dignity that COVID has taken away. “They say when you’re passing, your hearing is the last sense to go. We hope and pray they hear that their loved ones are there.”

For Nicolas, watching patients decline so quickly is difficult—and different from what she’s used to. “Coming from a surgical unit, we’re used to taking care of patients after surgery and they get better and go home,” she says. But that’s not “the nature of this beast.”

Thankfully there are also happy endings: When patients are discharged, Nicolas and her team line the hallway and cheer them on. “We’ve had patients who cried and grabbed our hands and said, ‘Thank you so much. I lived. Thank you.’”

SEE ALSO: A COVID-19 Timeline: How Honolulu Got To This Point

The Human Touch

“Nursing is not a job that a robot could take care of,” says P6’s Williams, who points out how nurses can often detect slight changes—differences in a patient’s speech or a delay in responsiveness, for example—before they’re reflected on a monitor. “It does require a human touch.”

For COVID patients, a nurse’s compassion is gold. “One patient just needed me to hold his hand. Just to be connected with a human was a relief—even though the human looks like an alien or an astronaut,” says Janice Nakatani-Cuyno, who works on the seventh floor of the Diamond Head wing, a trauma unit that was converted to a COVID ward. “I try and bus’ pidgin, like, ‘Eh, where you work? How much kids you have?’ Since we’re both emotionally loaded, the small talk normalizes things.” The conversations also help alleviate fear, because many patients are already scared they will die. She says that, fortunately, she has been seeing more COVID recoveries recently.

Nurse Janice Nakatani-Cuyno

Still, the most harrowing tightrope she walks every shift is the thin, invisible line between safety and exposure. DH 7 sees some of the most acute, “pre-ICU” cases, and her days are devoted to keeping those patients alive. One of them was a gentleman who used to walk 6 miles a day. “He had so much physical reserves, but he became so debilitated as far as functioning,” she remembers. As he succumbed to COVID, Nakatani-Cuyno brought an iPad into his room to have a difficult video chat with his daughter. “I wanted her to understand where he is now, because months ago, he was probably getting around fine and going to the store. The person I was seeing was not that man. I can only imagine how his daughter felt when the physician recommended changing his care to be palliative.”

Such moments weigh heavily on nurses. With COVID, that weight is compounded by a competing survival instinct that pulls them in the other direction—the voice that reminds Nakatani-Cuyno to monitor her time of exposure even as she’s delivering painful news over the iPad. That voice of caution is even louder now that she’s had to take care of one of her own colleagues, whom she suspects contracted the illness at work.

“We were never selfish with our time as nurses,” Nakatani-Cuyno stresses, “but now it’s like somebody’s watching over me, pointing at the clock, asking, ‘Is this absolutely necessary?’ That voice never stops being like, ‘OK, how long are you going to be in this room?’”

Life After Hours

“If something sad happened during the day, it’ll be on my mind, and then I compartmentalize it,” says Nicolas. She knows what she signed up for, but it takes a toll. “I’ll cry it out in the shower and come out with a fresh mind.

“Queen Emma’s mission was to care for the sick, whomever they shall be. So whether they have a cough or they have COVID, our job is to care for them and make them feel like they’re our family.”

A resident of Hilo, Nicolas has been staying at her father’s house in Makakilo since the interisland quarantine order took effect in March. She looks forward to getting home, where she can read on her lānai next to her dog or go for long walks with her fiancé. She recently started dancing hula again, a pastime she put on pause while raising her daughter.

Nakatani-Cuyno also likes to spend time outside. She finds solace in her garden. “There’s something really therapeutic about just having some fresh air, being surrounded by trees,” she says. When the stay-at-home order closed hiking trails, she took to jogging around her block in McCully.

Having a healthy work-life balance has always helped her to be effective on the job, Nakatani-Cuyno shares, but COVID has forced some difficult trade-offs. “We all yearn for the world that was pre-COVID. I know with this shutdown people are making sacrifices, and I appreciate that,” she says. Her book club was suspended, and when she and her husband go to work, her two sons are left to navigate distance learning on their own. “I want people to know that we are making a sacrifice, too. We’re nurses, but we’re also mothers and we’re also people. I’m going to do my part, but just know it’s been a real struggle. I’m typically a very mellow, non-anxious person. This has been one of the most stressful times in my life.”

She pauses to fight back tears. “Patients are alone. Some of them are dying. Alone. I am there and it’s a privilege. It’s a privilege to be the one that gives them their last video visit. It’s a privilege to walk beside these people at the end of their lives or through their recovery.”

When Sarah Williams returns home to Kailua each night, she goes for a walk with her dogs. She meditates a lot. She limits her scrolls through social media, infuriated by posts that call COVID a hoax.

“When I get off of work, I watch people walking around and still having get-togethers, and I think, ‘Oh my gosh, we’re going to fill up with COVID,’” she says, and implores the community to mask up and socially distance with everyone outside their households. “Here, there are nine hospitals for the state and not all of them take high acuity patients. If we run out of beds at Queen’s, where are your loved ones going to go? Stroke patients aren’t stopping. Cancer patients aren’t stopping. Heart failure patients, they’re still there and they still need care. But COVID has offset the units that normally take these patients.

“People have to understand, when it hits you, it’s a whole different story,” she emphasizes. As of Sep. 17, 685 Hawai‘i residents have been hospitalized with COVID-19, and 106 have died. “To realize that you dropped off a loved one at the hospital and what you get back could potentially be just the body, that is the worst for us as nurses, because we know you saw the person walk in talking, and the next thing you know, they’re gone.”

Williams considers how working through a pandemic impacts a nurse’s career. “It’s kind of like being in a war, which we are in against this virus. This is the time for nurses to really shine, to show people what we’re made out of.

“We’re pretty tough cookies,” she says. “We do have our own human fears. We do have our own anxiety. But we’ve also got a heart that says, ‘I might put myself at risk, but I’m here to make sure we save lives.’”