The first thing Johnny Choi noticed when he walked into the coronavirus intensive care unit was the sea of ventilators.
The Michigan State University nursing student had just been pulled from a twice-monthly externship helping with victims of head injuries and strokes at Ascension Providence Hospital in Novi to a full-time position as a support nurse in the COVID-19 unit.
His first patient was in a bed at the end of a long hallway with all the classic symptoms of the coronavirus: shortness of breath, congestion, a fever. As Choi walked down the hall, every room he passed contained sedated patients, breathing only with help from a tube down their throat.
“I was thinking,” he said, ‘I don’t even know where to start.’”
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Choi is among millions of Michigan students whose semesters have been upended by the coronavirus pandemic, which forced the cancellation of in-person instruction at K-12 schools, colleges and universities. With the virus stretching hospital critical care staff thin, some graduating nursing and medical students have begun their career early to join the front lines of Michigan hospitals’ fight against the virus.
It was not the spring Choi envisioned. After graduating, he had planned a few months of easy living. He’d spend time with friends and family, get a job teaching tennis. Maybe take a vacation before easing into a job as a registered nurse this autumn.
Now he found himself in a room with his first patient, an elderly woman. In four years preparing to become a nurse, Choi had little experience with infectious disease. But nobody had much experience with this new disease, which had only arrived in Michigan weeks earlier.
He reminded himself to stay calm and return to the basics of what he learned in nursing school. Check the patient’s heart rate. Make sure their breathing is regular and their blood oxygen level is normal. Check their temperature.
He got through the day and spent the drive home to East Lansing thinking to himself “that was crazy.”
Soon, it would begin to feel routine.
“Long and tiresome”
Before the pandemic, Choi spent most of his time in clinical rotations at Lansing’s Sparrow Hospital and the Livingston County Health Department. Twice a month, he externed in a neuroscience ICU at Ascension, where he teamed up with a staff nurse to care for patients with traumatic head injuries, brain tumors, vehicle accidents, strokes and spinal cord malfunctions.
But with clinicals canceled and classes switched to online-only, Choi agreed to transition to full-time in the hospital’s COVID-19 unit. Many of his fellow nursing school or medical school students have also found ways to pitch in, volunteering to provide telehealth to homeless people, hosting face mask drives for area hospitals, babysitting the children of first-responders while their parents are off fighting COVID-19, or agreeing to begin their full-time jobs immediately after graduation, rather than the typical July or August start date.
Now, three days a week, Choi’s day looks like this: He leaves the house at 5:30 a.m. and drives to Novi. At 6:30, he reports to the ICU, meets the licensed nurse he’ll work with that day, and learns about the four patients they’ve been assigned. He gowns up — each nurse is assigned one plastic face shield and an N95 mask that must last them the entire day — then starts his shift at 7 a.m.
The first task is to visit each patient to see how they appear to be doing. Any trip to a contagious patient’s bedside carries a risk of infection, so nurses gather as much information as possible by peering through the hospital room window. They then craft a care plan and begin executing it. Choi checks ventilators and notifies a respiratory therapist if they need cleaning or adjusting. He monitors patients’ medications, along with their blood pressure, heart rate and kidney function.
With family members generally prevented from visiting, Choi calls to deliver updates over the phone, careful to be patient with questions and thorough with his answers. Because family members can’t see their loved one, he must be as detailed as possible when he updates them on the patients’ condition and goes over the day’s treatment plan. If a patient has taken a turn for the worse and may soon be moved to hospice care, Choi makes sure to let family members know that hospital staff will keep the patient as comfortable as possible.
“I just try to respect their time and be conscientious of their concerns and the grief they’re going through,” Choi said. “You ask them, ‘How are you doing with this? Is there anything you’d like me to do for the patient?’”
At the end of the shift, 7 p.m., Choi provides a report for the nurse on the next shift. He leaves the hospital around 7:30, arrives home at 8:30, showers, and goes straight to bed.
“The days are long and tiresome,” he said.
His four roommates, also students, have left East Lansing to wait out the pandemic in their respective hometowns. So between shifts, Choi, 22, spends his time in an empty house, leaving only to return to work or make periodic grocery runs. He is still taking classes online, writing papers, studying for finals, collaborating on group projects and applying for jobs after graduation.
Choi’s parents live near him in East Lansing, but he has chosen not to visit them while working in the COVID unit. The risk that he may unwittingly carry the virus home from work and infect them is too high. Frequent video calls help them stay connected. The isolation is hard, Choi said, but “self-quarantining is just something that’s necessary for me right now.”
Filling the void as patients pour in
A normal graduation year for new nurses goes like this: They spend the spring wrapping up classes and then take final exams. After graduation, a new wave of studying begins. Before they can practice in the United States, new nurses must pass the National Council Licensure Exam, a six-hour test to determine whether they’re ready for the field. Most students spend a month or two preparing. Often, they’ll then take some time off before starting their first job in late summer.
But because of the urgent need for additional front-line workers to battle COVID-19, Michigan Gov. Gretchen Whitmer issued an executive order that temporarily waives licensing requirements for new graduates and retirees. They can now get a temporary license without taking the exam, enabling them to join the front lines as soon as possible.
“Please sign up now,” Whitmer urged upon signing the March 29 order. (Once the public health emergency ends, they’ll need to take the exam and obtain a permanent license to work.)
The extraordinary measures speak to the dire staffing shortages faced by hospitals treating Michigan’s COVID-19 patients.
As of Sunday, the virus had sickened at least 31,424 Michiganders, with a death toll of nearly 2,400. The vast majority of cases so far have appeared in metro Detroit. Though the spread of COVID-19 seems to be slowing in Southeast Michigan, it is picking up speed outside the metro area. State health care experts expect frontline workers to be in high demand for some time.
Hospitals have absorbed the crush of new patients by converting surgery wings into COVID-19 units, rationing supplies such as masks, gowns and disinfecting wipes, reassigning desk workers to the front lines, hiring temp workers and recruiting retirees and students into the workforce.
Annmarie Fraser, 64, a Beaumont Royal Oak nurse who retired 15 months ago, is now back to work answering calls to the hospital system’s hotline for people who believe they may have COVID-19.
Elizabeth Luea, 22, one of Choi’s classmates in the MSU nursing program, will obtain a temporary license and start a job at Lansing’s Sparrow Hospital May 12. Luea won’t be in a COVID-19 unit (she has asthma, which makes her susceptible to dire complications if she contracts the virus), but she chose to start early so she can chip in on other needed tasks, such as processing new patients.
“This whole situation really brings to light the real purpose of why we're going into this profession in the first place,” Luea said. “It’s really not for ourselves, it’s for other people.”
There are many more like Choi, said Andrea Amalfitano, dean of the MSU College of Osteopathic Medicine. The college is graduating 213 new physicians this year, many of whom will start their residencies early. The need for new professionals could become particularly acute if doctors and nurses continue to get sick with COVID-19, taking them out of the workforce just as they’re needed most.
“As the frontline workforce gets sidelined, that’s where our graduates from medical schools and nursing schools can come in and fill those voids just in time,” Amalfitano said.
But pressing students into the field early may not be ideal for every hospital, Amalfitano said. Each hospital system will have to weigh the value of additional staff capacity against the logistics of taking on a first-year resident or nurse who may require on-the-job mentorship.
Chaos and risk in the ICU
Choi is not sure whether he’ll apply for the expedited license, which would enable him to administer medications instead of relying upon a staff nurse to fulfill that duty. He wants to watch how the pandemic develops before he makes a decision.
The MSU College of Nursing, he said, has “prepared us well” to step up to the challenge by offering lessons not just on nursing, but also on leadership. Choi also benefited from his externship at Ascension, where he learned to care for direly ill patients.
Before the pandemic hit, he already knew how to monitor patients’ medicines, create care plans and provide reports for the respiratory therapists, speech pathologists and other medical professionals overseeing the patients’ recovery.
Still, no amount of clinical work alongside seasoned professionals compares to a shift in a COVID unit.
“There’s increased patient loads, there’s staff shortages, there’s not enough ICU beds,” Choi said. “It’s chaotic.”
A lot of us are realizing that even though this isn't how we exactly envisioned our graduation flow to look, we have a unique knowledge and skill set that is needed right now. It's our duty to step up.
Choi and his colleagues have learned to “cluster” their care, he said, limiting contact with contagious patients by going into their room only a few times a day to carry out a laundry list of tasks all at once. Under different circumstances, they would visit a patient 20 or more times a day. But with COVID patients, every trip to the bedside requires a laborious process to “gown up” with masks and other protective equipment to protect them from infection.
Because supplies are thin, Choi and his partner leave a gown in each patient’s room, reusing it each time they enter. They keep their mask on all day to protect them from any virus that may be lingering in the air in hallways and common areas.
Still, Choi said, “it’s never 100 percent.”
“The more times you’re in there and exposed to the virus, the more opportunity it has to affect you.”
At 22, with an athlete’s physical fitness level and no known health issues, Choi has little risk of developing serious complications from COVID-19 if he catches it. Many of his colleagues are older. Some have underlying health complications that could cause dire complications if they get the virus. So Choi sees his work on the front lines as a service not only to his patients, but to his colleagues.
If his presence in the ICU can allow higher-risk colleagues to spend slightly less time exposed to the virus, “I think it’s my duty as someone younger to be able to step in.”
“A lot of us are realizing that even though this isn’t how we exactly envisioned our graduation flow to look, we have a unique knowledge and skill set that is needed right now,” Choi said. “It's our duty to step up.”
