Breaths, deaths, and missed breaks: How counting defined my days as a pandemic nurse

I woke myself up the other morning counting out loud. Twenty-seven. Twenty-eight. Twenty-nine. Thirty. Rhythmic, staccato counting, the familiar cycle of CPR.

Even though I was home in my own bed, it didn’t stop me from worrying about the patient I’d abandoned in my dream.

I make my living as a travel nurse. Though my home is in Montana, I spent most of the pandemic working on Covid-19 units in Arizona, including the winter and spring of 2021 when the state’s surge was overwhelming its health care system.

That’s where I developed the habit of counting: The hamster wheel in my head spun with the number of a patient’s breaths in one minute, the number of heartbeats in the next. Numbers to measure blood pressure and blood gases, along with numbers for ventilator settings, heart monitors, and intravenous pumps.

They were joined by the numbers I dialed to speak with patients’ loved ones to make bedside decisions about treatment — and sometimes about life and death.

There were other numbers I was preoccupied with, like the number of days I’d have to use my limp N-95 mask before I’d be allowed a new one, the number of overtime hours I worked each week, the number of times I didn’t get a lunch break. I held my breath and counted the minutes I’d have to wait to use the bathroom while helping a patient do the same. I also counted the number of days left in my latest 13-week contract.

I often counted the number of patients on my floor and divided it by the number of assigned nursing staff. Sometimes the ratio got as high as six patients to one nurse, though the standard for a progressive care unit like the one I worked on is normally four patients per nurse. Two extra patients might not seem like a lot, but needing to repeatedly don and doff PPE, having just one nurse’s aide for 30 patients, and tending to all of the extra Covid-related work made the increase feel exponential.

The official daily staff-to-patient ratio was calculated in some quiet office in the hospital, a galaxy away from the noise, the smells, and the overflowing bins of discarded PPE. The number was defensible by a mathematical formula designed to protect the hospital’s bottom line, with assurances that the ratio was safe and reasonable for patients and staff.

But when I did the math, the ratio guaranteed 12 hours of panicked chaos, with call lights blazing above every patient’s door and a cacophony of alarms punctuated by cries for help.

If the number of patients on a unit dropped below a preset level at any point during the day, the hospital’s calculation required a certain number of nurses and nurse’s aides to be sent home to protect the profit margin. It wasn’t unusual for these workers, sometimes referred to as bodies, to be sent home three-quarters of the way through a shift and not paid for the lost time. The responsibility for their patients was absorbed by the remaining bodies, even though they were already drowning in end-of-shift tasks.

Every nurse on the floor was required to carry hospital-provided cellphones so we could be readily reached by doctors, pharmacists, case managers, the lab, the emergency department, the imaging department, physical therapy, the kitchen, and patients’ family members, to name a few. My work phone averaged nearly 40 incoming calls during a 12-hour shift. It rang while I calculated IV drips, drew blood for lab work, suctioned tracheostomies, and slid bedpans under patients. It rang while I held patients’ hands for comfort and while I held iPads for family Zoom calls. It rang as my patients died, and while I zipped up body bags.

I tried to count the number of times I swore that this year would be my last year of nursing, but lost track. The work is hard, but harder yet is turning a blind eye to the growing spiderweb of cracks in the system. Days become crippling when you plug along in silent complicity — your professional ethics threatened, your core values compromised, your spirit crushed. This dismay is not new for nurses; the pandemic has just shone light into dark corners, exposing what was already there.

As the number of Covid-19 patients began declining, nurses like me, who had signed on to work at a guaranteed weekly rate that included crisis pay, received an email that began with something like, “Dear Healthcare Hero,” and ended with news of a 15% pay cut. That didn’t mean our workload had decreased by 15%, because it hadn’t, but as the letter reminded us, we were making “more than industry standard.”

An internet search showed me that the CEO of the Arizona hospital system I was working in had received a total compensation of $10,323,628 for fiscal year 2018, the most recent year with available data. A 15% cut of his pay, which feels to me like “more than industry standard,” represents more money than I will retire with.

Nurses form the foundation of the health care pyramid, and our backs are breaking from the weight on top.

Nearly two months have passed since my contract ended with the hospital that cut my pay. Fifty-six days is enough of a break that I don’t hear IV pumps, ringing phones, and telemetry alarms in my sleep anymore. But that’s not to say everything’s normal.

I startle easily. I wake up in the night to check if my husband is breathing. I have pain in my jaw from clenching my teeth while I sleep. When I’m driving, every time a car honks I think it is alerting me of an accident I am about to cause. Raised voices raise my blood pressure, and the beeping of delivery trucks backing up make me jump.

I count the blank squares on the calendar until my next therapy appointment, and further on to the date when I’ll need to go back to work. I count the number of emails I receive from travel nurse agencies boasting “High paying opportunities!” and “Crisis Rates Still in Effect!” I used to be lured by the exorbitant pay. Now I know that it costs me too much to make that kind of money.

I am in the business of caring for people. My bottom line is bearing witness to critical moments of a human life that aren’t fodder for Facebook or Instagram. My business transactions transcend the almighty dollar, and the profits are shared. That has to count for something.

Karla Theilen is a registered nurse based in Montana.