I don’t know if I can do this again.

I’ve been an emergency department nurse in Appalachia for almost fourteen years now, and I’ve seen a lot of things. It goes hand in hand with the job.

I’ve seen blood pool on the floor during emergency C-sections; during ruptured ectopic pregnancies. I’ve treated kids with multiple gunshot wounds. Worked to save oxy overdoses of folks who were down just a little too long. I’ve had to stand in-between a domestic violence victim and her abuser who was threatening to kill all of us; had to live through multiple colleagues commit suicide rather than ask for help, because “so many other people have it worse, what right do I have to ask for help”.

Some of that is an inevitable part of living in a human society. It doesn’t excuse any of it. Doesn’t mean we should give up trying to prevent it. But we’re the emergency department- we’re always going to get the worst of the worst in any category.

So when things happen that don’t have to, that are completely unnecessary, it makes it unbearable to tolerate. It’s what drives people away from an already high-burnout, high-turnover profession in desperate need of experienced and talented providers.

Trying to wrap my head around the nomination of Robert Kennedy Jr to head the Department of Health and Human Services, I’ve really been struck again by what we went through during the COVID pandemic. How powerful and destructive weaponized disinformation proved to be. How many people it affected. That it was pushed by the same people who crooned about COVID being a hoax while they elbowed my colleagues and I out of the way to get vaccinated first.

I honestly don’t know how many people I had to watch die who didn’t have to; I lost count. My community never got as bad as places deeper in Appalachia, where morgue trucks parked outside hospitals and cardiac catheterization labs got turned into COVID ICUs. Where ICU capacities peaked at multi-hundred percentages, which is something that shouldn’t be possible or legal, but is what happens when you pretend the healthcare system hasn’t collapsed by paying a brand-new ICU nurse less than six months out of nursing school $125/hour to take care of four ICU patients on ventilators.

Even so, it was still bad. I’d have to guess I was part of the direct care team for maybe a couple dozen people who ended up dying. Too many by any definition, and almost all of them unnecessary; people who didn’t need to let things get bad enough to end up in the ER.

But they did.

The Delta COVID surge was bad for everyone, but for our hospital, it was the worst that we saw. This was August to December of 2021, when patient volume and acuity just kept getting worse, and worse, and worse. Every time you thought it couldn’t get any worse, it did. It was surreal.

There was a stretch where, for twelve weeks in a row, I worked overtime. And when I say “overtime”, I mean 60–70 hours a week- including a stretch where I worked eleven 7pm-7am shifts consecutively. Looking back on it now, I have no idea how I survived that. I really don’t. It’s all in a fog in my mind; just numb. Night after night after night of misery.

Every crisis we solved just led to another one. I’d leave work at 7:30am and come back at 6:30pm to discover some of the same patients were still in the ER, waiting- and more and more were waiting behind them. Trying to work a functional emergency department on a handful of beds because all the other ones were occupied by COVID patients waiting for an inpatient bed to open up. Doing lab work and chest x-rays in the parking lot. People were counting on us to make it work, to figure it out- because if we didn’t, nobody would.

There was one case I remember in particular. This was in late 2021, after Thanksgiving, when we hit the absolute peak of the Delta surge. Before the omicron strain became the predominant one, COVID had a pretty predictable track, whether it was the original “null” strain, Alpha, Beta, etc, etc. Delta was no different, it was just the deadliest strain by far.

It was like clockwork: days 8, 9, and 10 post infection were the “make it or break it” window. Either you made it through that, or you ended up in the ER. And if you ended up in the ER, it was because you were sick. So, you can imagine what happened when a bunch of unvaccinated folks got together for Thanksgiving. It was like watching a freight train derail, because we knew what was coming… and could do absolutely nothing to stop it.

And that’s when we had the worst day I personally ever saw during that time period, where we had to put multiple people on ventilators- intubate them with breathing tubes- on one shift. By this point of the pandemic, we had become pretty adept at stabilizing people, pulling them back from the edge and getting them well enough to go to the COVID unit.

But not that day.

I was the charge nurse that shift. In theory, the charge nurse in the ER is a sort-of conductor, doing no patient care themselves, and instead orchestrating the ebb and flow of patients and clinicians to ensure everyone gets seen, every problem gets addressed, every crisis gets answered. While there is theoretically a nursing supervisor and other hospital management available, the ER Charge Nurse is who runs the show when things go bad- particularly at night.

I was on duty during a mass casualty event that made national news and was a major point of the first Trump administration, and I can never give enough credit to the charge nurse we had on duty in the ER during it for us being able to handle the influx of patients we saw. Her authority in managing the event was unquestioned up and down the chain of command at our hospital; it was her show to run, and she ran it like a textbook scenario.

But that was a single incident with plentiful resources available to us. By this point in the pandemic, that textbook had long ago been burned to ash. Critical staffing and patient volume meant that I was on the floor doing patient care every single shift while in full COVID “battle rattle”: respirator with a surgical mask adorned atop of it, a visor with either a hood or a surgical hair net over a scrub cap, a respiratory-resistant full body gown, layered gloves, shoe covers, etc. An impressive bit of regalia, to be sure, though I never complained about wearing it. I remembered when garbage bags were considered appropriate PPE and we had to re-use single use paper masks for weeks at a time.

The unsung heroes on our worst days were our unit secretaries, who were experienced enough to simultaneously help manage patient flow, direct ambulances, answer the phone, arrange for helicopters to fly patients out, and pick up patient call bells. I simply don’t have the words to laud them to the extent they deserve. And this day was no different; it was our unit secretary who let me know about the “squad report” she’d just taken from an ambulance coming from a nearby rural county. A COVID positive patient right in the danger window, who was doing poorly at home, and whom the ambulance crew was trying to keep stable.

I had only had one room open- a room which had been vacated by another COVID patient mere minutes, if not literally seconds, earlier. But the nurse for that particular “zone” of patient rooms was busy with another COVID patient who wasn’t doing well, so I furiously cleaned the newly opened room, and hastily finished it just as the EMS crew rolled the patient through our doors.

I got the report from the medic, but it was already clear the patient was not doing well. He was doing what we call “tripoding”- leaning forward to make a triangle shape with his body and arms, attempting to open his lungs- while breathing maybe up to sixty times a minute, literally gasping for air. Breathing one time a second for more than a very short stretch without passing out is hard to do for perfectly fit and healthy people; try it for yourself and you’ll see what I mean. He had an oxygen non-rebreather mask on, with pure oxygen flowing as fast as the canister would allow it- though, looking at the patient, you’d think it wasn’t doing anything at all.

The thing that struck me the hardest, though, was how young the patient was. Now, in any non-pediatric medical setting, “young” is relative; I can tell you it’s not an uncommon occurrence to see the median age in a completely full emergency department to be as high as 80, 85 years old. So, when I say “young”, I mean an age range of “has kids too old for pre-school and too young for college”. I’d seen younger patients than this one, for sure, but the worst cases were still predominantly people in their mid-60s and older.

As we moved him from the EMS stretcher onto the ER bed, the paramedic gave me a run down on what was going on. The patient was COVID positive, having been diagnosed (as had much of his family) after Thanksgiving. He’d gone to see his primary care physician, who’d apparently refused to write him a prescription for hydroxychloroquine or ivermectin, so the patient had sourced both for himself. Unsurprisingly, they didn’t work to alleviate his symptoms, and the patient became increasingly short of breath.

The solution the patient had was to go to Lowes to buy oxygen. I don’t know if you’ve seen these personal oxygen canisters that came from “Shark Tank”; they sort-of look like Febreze, except they’re just oxygen. Pull the trigger, and “pffft!” As the medic explained it to me, the patient had gone through so many bottles they were littering the floor of his house like he was on the approach to the summit of Mount Everest; they had to wade through them in order to extricate the patient from his recliner in the living room.

At that point, I already knew how things were likely to go. If he had come in even a few hours (or days) earlier, could we have gotten him stabilized without having to intubate him? Who knows. There was no point in entertaining “shouldda, wouldda, couldda” at that point. Our staff was busy with similarly ill patients, including another in similarly dire straits and being prepared to be intubated. Alone, I began to get everything ready, rushing to get the supplies we’d need to put his gentleman on a ventilator.

I’d just finished placing an IV in each of the patient’s arms and was attempting to swap a functioning end-tidal carbon dioxide monitoring module into the bedside cardiac monitor, when the patient reached out and grabbed my arm. I was single-mindedly intent on the task at hand, and this startled me so abruptly that I almost literally jumped. I turned to see the patient looking me directly in the eyes… and I mean, directly in the eyes. Through my PPE, through my visor. Straight into the depths of my soul.

But all he did was continue to breathe rapidly. I stood there for a moment, confused, and was about to ask him what the deal was.

And then he asked me a question.

One single question.

“Am I going to die?”

When you’re struggling to breathe like he was, getting five words out might take ten or fifteen seconds. Recuperating from the effort required to speak at all can take several times as long. When I tell you it took everything the patient had to ask me that question, understand that I mean it took everything the patient had to utter those seven syllables.

All the while, his eyes never left mine.

Never deviated a millimeter.

Now, I’d like to think I’ve developed the ability to keep a poker face and unerringly neutral demeanor that is second to none. Not that it’s easy; far from it. I once had a doting grandfather show me pictures of his brand-new granddaughter, and had to happily make small talk with him as he told me about the trip they had planned to fly out to see her, smiling even though I knew the doctor hadn’t yet been in to tell him what I’d just read the death sentence the radiologist had written about the CT Scan he’d just had: “Pancreatic mass concerning for probable metastasis to multiple sites”.

We once had to tell a mother her fifteen-month-old had a sexually transmitted infection. She was momentarily stunned, and then seemed relieved and somewhat embarrassed, telling us she’d recently had that same infection. You see, her boyfriend had cheated on her. They’d reconciled things, but before she knew she was infected, she’d taken a bath with the baby. So, she explained very earnestly, that had to have been how her daughter got it, too. Then we had to explain that, no, that’s not how her daughter could have gotten infected. That it could only have been through direct sexual contact. And we asked her if her boyfriend had ever been alone with her daughter. Then I had to watch as the realization of what that meant dawned on her… and break her completely, as she began to break down and sob in a way I’d never heard before.

And I’ve had to take care of honest-to-God, Swastika tattooed Nazis. Who took pride in the fact they, and their buddies, had come to our community to cause trouble; to walk down the sidewalks in predominantly minority neighborhoods and threaten the people who lived there. Who felt empowered enough to hold an entire tiki torch rally, screeching “YOU WILL NOT REPLACE US.” Who attempted to sexually assault our nurses; who told me they hoped I’d have to call the police on them, because it’d let their buddies “kick the shit out of the (racial and antisemitic pejoratives) downtown”.

It’s never easy. Anyone who tells you holding your cool in those sorts of circumstances is easy is lying. But I managed to do it, each and every time.

So I’m not sure why this patient’s question made me flinch. Thinking about it now, I suppose that in all those other examples, I was able to get a “game face” on. I had time to internalize things and cope with them, ever briefly, before I had to do my job. I didn’t have any time here, and even the best of folks can be thrown off their game every once in awhile.

Because I knew what the likely answer to his question was. I knew what we’d been seeing for months with the Delta COVID strain. I knew how many people made it home after getting the point he was at, and being intubated.

I knew.

I did my level best; truly. I promised him we were going to take good care of him. That we were going to do everything we could for him. Everything we could to get him back home to his family. I know for a fact that my voice never broke or faltered from the confident tenor I’ve developed over a decade and a half in healthcare to reassure people who are terrified and want some reassurance that everything is going to be okay.

I stood there with him for a minute, as he recuperated from the exertion it took to ask me that question. A look came over his face. As I sit here, I cannot for the life of me describe it, even though I can see him- clear as day- in my head now. “Resigned” isn’t the right word, nor is “melancholic”. Depressed? Fatalistic? All of the above? It was coupled with him gasping for air, which didn’t help anything.

And as he looked me in the eyes, I saw he knew the real answer to his question.

As a cold slug of despair formed in the pit of my stomach, I patted the patient reassuringly on his shoulder, and got back to work getting things ready. I was so buried in attempting to busy myself with thinking about anything but what had just happened that I almost missed what he wheezed out next; I had to pause and wonder if I’d actually heard what I thought I’d heard.”

“My kids,” he said aloud- to me, to himself, maybe to nobody in particular. I’ll never know for sure. “My wife.”

“Sir. It’s okay. We’re going to get you better and get you back home to them,” I said, desperately praying I wasn’t a liar, “you just work on breathing! That’s your only job right now, okay? All you have to do is breathe. We’ll take care of all the rest.”

He nodded, and after a minute I’d gotten everything as ready as I could until our doctor and respiratory team were done with the other patient they were working with. Before I finished, I went back and again put my hand on the patient’s shoulder as reassuringly as I could. I looked him in the eyes, and told him I would be right back, that the doctor and respiratory team would be in immediately, and reiterated we would take good care of him. And, as I do before I depart from any patients’ room, as I’ve done tens of thousands of times during the course of my career, I asked him “Is there anything else I can get for you?”

And then he said the very last thing he’d ever say. The culmination of a life of decades, of laughing and crying, of pain and joy, anguish and relief, of tugging at his mom’s skirt, of skinned knees on the playground, of goofing around in class, of ice cream on a hot summer day, of taking off and driving on a road trip to nowhere in particular, of falling in love, of a marriage and honeymoon and kids and a house and a dog, of preschool pickups, of parent-teacher conferences, of plans for retirement, of seeing kids grow and laugh and cry and love just the same.

The last thing he ever said was, “I really fucked up, didn’t I?”

When you intubate a patient, when the paralytics and sedative drugs kick in, you can watch as the lights in someone’s eyes get dimmer and dimmer, and then disappear entirely.

And I had to watch as the lights went out in his eyes for the very last time.

He stayed in our ICU for awhile. Every day I worked- every single day- I’d go check on him. I’d come in early. I’d stay late. I’d find an excuse to run down to the ICU. I’d stare through the window of his room, through the door if it happened to be open, and wish. Pray. Hope, beyond all hope, that I would come down one day to find the miraculous had happened. That he’d been off his breathing tube. That his family would all be crowded around him, jubilant. That he’d be discharged and run the gamut of a hallway full of cheering nurses and doctors, cheering and clapping like wild.

But it wasn’t to be.

I struggled with that. A lot. Because all of the people who fed him malicious misinformation weren’t going to be there for this man’s family. Elon Musk was never going to show up to high school graduation. Donald Trump isn’t going to come to the 4th of July. RFK isn’t going to dote on grandkids on his behalf.

And they won’t be there for any of the millions of Americans they’ve set themselves out to hurt. They’re the walking embodiments of the Dunning/Kruger effect, so sure that they’re God’s gift to the planet Earth that their feelings can override any facts or evidence to the contrary. They’ll be eating McDonalds and slapping a Zyn pouch in their cheek, totally unconcerned they have no desire to live by the standards they expect you to. They’ll stand by and let the country wreck itself before they’d ever admit they were wrong. That they have no idea what the hell they’re talking about.

Leadership matters. Policies grounded in science and compassion matter. Truth matters. We need leaders who prioritize public health over politics, who understand the stakes, and who are willing to fight for a stronger, healthier society.

To my fellow healthcare clinicians: speak up. Share your stories. Hold those in power accountable. Our voices are the most powerful tools for change we have- and they may be the only chance we have to save our country and our people from utter ruin.