When COVID-19 brought our EP clinic visits to a screeching halt in mid-March 2020, I, like many others, scrambled to find ways to stay active, less anxious, engaged, and informed. Telehealth options opened up at Duke, and our EP team’s adoption of it was seamless — many months before coronavirus became a part of the mainstream vernacular, we had already been moving toward this initiative as a way to alleviate long wait times for clinic appointments. However, so many of my device patients were comfortable with replacing their clinic visits with a remote transmission, or postponing their appointments altogether until clinics reopened, that I felt myself growing antsy almost immediately. The APPs in our group took turns staffing an EP Acute Care Clinic each day for urgent needs, and I volunteered for 2 of those days as a way to feel useful. I also read, interpreted, and signed remote monitoring transmissions 1 or 2 days per week. Still, I did not feel like I was doing enough, so when a call for volunteer onsite providers at one of our COVID-19 testing tents was placed in one of the many COVID-19 update emails that we received daily, I jumped at the opportunity. Not really knowing what was expected of the onsite provider but feeling confident that I was a good candidate based on my health alone, I threw caution to the wind and signed up for several shifts.
Armed with zero preexisting conditions, my laptop, and an abundance of pent-up energy, I showed up for my first shift at the tent on May 7th to find an impressive setup. The tent had 4 lanes and room for 2 cars per lane. Each lane was manned by personnel who checked in patients for their appointments, printed labels for the testing kits, and performed nasopharyngeal swab testing for COVID-19. Initially, we also had CMAs and RNs checking vital signs on every patient prior to their swab. A tent commander, which was typically one of 4 RNs who had been involved since March, was in charge each day, making assignments, ensuring lunches were covered, and more. My role was to be available to enter missing orders for COVID-19 tests, triage abnormal vitals (including heart rates >100 bpm, O2 saturations <95% or <90% if the patient had COPD, and temperatures >100.4 ºF), and fill in when we were short on swabbers. The abnormal vitals, specifically heart rates, kept me running from car to car, as patients routinely presented for their tests in a nervous state. My background in EP usually made that part easy to triage. However, I realized that we needed age-specific guidelines for heart rates, as I was fooled more than once by a report of a patient with a heart rate of 200 bpm, only to arrive at the car to find that the patient was a crying infant.
Abnormal vital signs did not mean that we would not test the patient, but they did help me to gauge whether further intervention was warranted. For example, I made calls to a few oncologists after finding fevers in patients undergoing chemotherapy. I also referred an asymptomatic teenager, who I suspected to have some form of SVT, to her PCP’s office for an ECG and cardiology referral after she presented with a pulse of 200 bpm that broke when I made her laugh about the “brain probe” she was about to receive from the swabber.
When our hospital started phasing in the more urgent but still elective procedures on May 18th, our tent volume exploded, and the decision was made several weeks later to do away with vital signs in order to keep up with the testing demand. We were easily seeing over 400 patients during an 8-hour shift, as negative COVID-19 tests were required for any patient undergoing a procedure requiring anesthesia. Once we stopped checking vital signs, I assumed that the need for a provider presence at the tent would diminish, but I soon found that it was still beneficial to have a provider in the tent to consult for missing orders or appointments, or for unusual or emergent situations. For example, the same week that we stopped taking vitals on each patient, we had a medical emergency with a visitor who had come by the tent to observe the process. The visitor suddenly collapsed with left-sided weakness and altered mental status, and I was there to call 911 and run through stroke protocols with the patient until EMS arrived. I was also the onsite provider at the tent the day a gas line was hit by construction on the sidewalk next to our tent, and I hurried to evacuate all staff and patients while we waited for the fire department to arrive.
And then there was Tropical Storm Isaias. The storm was forecasted to start affecting our area during the early morning hours of Tuesday, August 4th, so we thought we would outsmart the storm by moving as many of Tuesday’s patients as possible to Monday and Wednesday, and plan to close down on that Tuesday. Isaias had other ideas, though, and a very strong outer band arrived at the tent at around 11 am that Monday morning. We experienced several 15-minute periods of torrential downpours, and I had water rushing over the tops of my feet while standing inside the tent. I remember thinking how unsafe the whole situation felt, given that we have wires running everywhere to keep us powered and connected to the Internet. I posted a video on Twitter of the rain from inside the tent because it felt so surreal while it was happening. I am an outpatient EP nurse practitioner, but for a moment, I think several of us felt like we were at a field hospital. It was incredible.
The day-to-day conditions in the tent have not been unbearable, but I do have to keep a close eye on staff and have pulled several of them off the line to take breaks on days when the heat index crosses 105 ºF. I am there to pass out water and Gatorade, bring donuts, or simply provide comic relief on occasion. It is not always easy to be out there, but my time in the tent cannot even begin to compare to the sacrifices made by my colleagues who have provided direct care for inpatients admitted with COVID-19. Although I have had to deliver news to patients of all ages, even entire families, that they tested positive for COVID-19, I do not follow their clinical course once they exit the tent. I continue to average 2 days per week in the tent, and use my office days to be there. It is not unusual to find me finishing up my clinic notes or reading and interpreting remote transmissions while supervising at the tent. It has given me perspective as to how widespread the effect of COVID-19 has been on my community, my patients, and my coworkers. The tent has become my third home, with my first home being the EP clinic and my second home being my actual home. I cannot seem to stop signing up for shifts, and I am scheduled to serve as the onsite provider for 2 days per week through the end of the year. I would like to think that I am making a difference by being there, but the tent has also benefited me and helped to decrease my anxiety by providing me with a sense of purpose during this pandemic and an opportunity to burn off some nervous energy. I am working longer hours during the week and weekends, but it feels worth it to contribute in such a small way. With flu season quickly approaching and the presence of point-of-care testing machines available to run flu swabs in the tent, I have no idea what to expect in the coming months as far as patient volume. I can say, though, that I am excited to be a part of whatever is to come, tropical storms and all.
Find the author on Twitter at: @ryapejianFNP