Dec 21, 2020
Canadian nurses run the COVID-19 ‘marathon’ in Los Angeles
Liz Balian can’t forget a patient she comforted during the elderly woman’s last hours.
The long-term care resident arrived in respiratory distress at Valley Presbyterian Hospital in Los Angeles, where Balian, a Canadian, is an emergency department (ED) nurse. The COVID-19 pandemic was spreading rapidly.
The woman did not want to be resuscitated. When the nurses and doctor told her she was dying, she understood, but couldn’t speak.
So Balian stayed beside her, administering medication to make her comfortable. Through layers of protective equipment, the 36-year-old nurse from Toronto held the woman’s hand.
And she talked.
“I just told her — ‘I’m here with you. I’m going to make it as pain-free as possible. Close your eyes. You won’t be alone. You can go now,’” Balian remembers.
Like most hospitals, Valley Presbyterian was prohibiting visitors from visiting COVID-19 patients unless they were minors or at the end of their lives. Even then, only one family member was allowed, if they got there in time — which this woman’s daughter could not.
For Balian and other nurses, that lack of family and friends at patients’ bedsides has been among the hardest aspects of their pandemic work.
Many patients Balian’s hospital serves are older, and English isn’t their first language. Before COVID-19, family members interpreted and provided crucial histories.
These patients’ isolation has prompted Balian and her ED colleagues to refocus on the human aspects of patient care.
“Before, you didn’t even think twice about a protocol, a routine,” Balian says. “We’re really — ‘Treat ’em and street ’em.’ Now … it calls for a nurse to just be a human. To sit down, hang on to a hand, and take that extra moment to Facetime a family member or let a patient call their family.”
“I’ve seen a shift in a lot of my co-workers and myself, and it’s a good thing.”
Although differences between the Canadian and U.S. health-care systems are stark, especially during the pandemic, individual experiences at the bedside are remarkably similar. Nurses simply do their best during an unprecedented situation.
Balian moved to Los Angeles after she married her husband, Shant Balkian, a Hollywood set dresser. Their shared heritage drew them together at an Armenian cultural event in Toronto. Since Shant didn’t want to leave California, Balian moved there.
Because she’d graduated from Toronto’s George Brown College as a registered practical nurse, Balian realized she’d have better opportunities if she upgraded her education. The RPN designation is not recognized in the United States.
Wearing the protective equipment is “physically exhausting, and we’re already exhausted. It can feel very daunting, but you can always push through it.”
She graduated from West Coast University with a bachelor of science degree in nursing in 2014. Because she had already received her green card, Valley Presbyterian hired her almost immediately.
During the pandemic, Balian has been balancing her roles as nurse and mother by working four shifts a week in the ED while her husband cares for their young daughter and son.
Although the intense stress Balian felt at the start of the pandemic about potentially contracting COVID-19 has eased, she continues to be vigilant about her personal protective equipment (PPE). She changes, showers, and washes her hands before coming home.
When the epidemic is over, she won’t miss the protective equipment.
“To wear all those things is so heavy — it’s physically exhausting, and we’re already exhausted. It can feel very daunting, but you can always push through it.”
Just 20 kilometres south of Valley Presbyterian at Ronald Reagan UCLA Medical Center in Los Angeles, fellow Canadian Natalie Wray mentors and manages 125 nurses as an assistant nurse manager, along with the unit director and another assistant nurse manager, at a 24-bed intensive care unit.
Wray, 39, began working in the United States in 2007 through a short-term contract in Tucson, Arizona. She was seeking opportunities to travel and learn how nursing differed south of the border.
When she had the opportunity to train as an intensive care nurse at Santa Barbara Cottage Hospital, she took it. Her Canadian training served her well, she says, and when she met her husband she moved to Los Angeles.
Wray currently spends 70 per cent of her time on administrative tasks, such as payroll and shift scheduling. Otherwise she’s on the unit, relieving other nurses, answering patient care questions and teaching nurses, respiratory therapists, and other staff to doff and don protective equipment.
Although Wray enjoys training, it has been challenging to help colleagues and staff adjust to the changes COVID demands.
Relaying fluctuating information about COVID-19, managing the fear and the emotional intensity on the unit, and reconfiguring protocols to reduce risk of infection have been taxing.
“One week as a leader you’d say one thing because we were working with the information we had, and the next week you’d be saying something different,” she explains. “Just acknowledging that was important.”
When Wray surveys the ICU, she sees the innovation the pandemic has sparked. Only one patient occupies each room on the ICU. A cart containing protective equipment — masks, gloves, gowns, and face shields — sits outside each room’s glass doors, which are closed. Intravenous pumps are also outside the room, not inside. Bedside tablets enable patients to hold virtual chats with family and friends.
Wray and other nurses no longer move continuously through rooms. Instead, one nurse now tends each patient inside a room, for hours at a time.
Outside the room, other nurses are resources, communicating via phone with the bedside nurse, and becoming runners to bring any required equipment. The changes reduce the amount of time the nurses don and doff protective equipment, as well as the chance of infection.
“I try to find those moments during the day when I can pause and focus on what’s in front of me.”
Even if a patient needs intubating or a code blue is called to resuscitate someone, only three to four nurses and other professionals enter the room, rather than eight to ten.
These innovations were the brainchild of her nurses, Wray says proudly.
But it’s hard on those nurses, given the hot, tight masks and shields they wear for hours at a time inside patients’ rooms.
Even harder is the moral distress Wray feels when, like Balian, she is at the bedside of a dying patient with no family present, or she is absorbing her nurses’ emotional reactions to those events.
To cope with the stress, Wray practises mindfulness. She carries essential oils to use between meetings. She concentrates on breathing, or on water flowing over her hands as she washes them.
“I try to find those moments during the day when I can pause and focus on what’s in front of me,” she says.
The pandemic provided an unexpected opportunity for Wray to learn that she thrives during a crisis, she says.
“I found the changes and the chaos almost exciting,” she confesses. “I didn’t find myself stressed or fearful. I trust our institution — I trusted our PPE process.”
What has been difficult is not being able to return to Vancouver, where she grew up, to visit her parents and sister, as she did every other month pre-COVID.
Still, Wray is confident that she and her husband Christopher, an anesthesiologist at the same hospital, will make it through the pandemic by continuing their routine of running, walking their dog, and cooking together.
“In the beginning it felt like a sprint — now it’s more of a marathon,” she says.
Eventually, she and her team began to normalize processing the speed and volume of new virus information. “We were expecting change and new information,” Wray says.
The hospital’s command centre and dedicated COVID website, which kept staff updated on how many patients have COVID, how many have been discharged, how many staff have been tested, and how many are positive, has helped Wray maintain her trust in her hospital as her main information source.
Like Balian, she minimizes her exposure to the news. Unlike Balian, she is tested for COVID-19 twice a week, as part of a health-care workers’ study.
“That provides us with a little reassurance … a lot of staff want to be part of it,” Wray says.