Facing a South Florida Surge: An APRN’s COVID-19 Experience

Hi, I'm Linda Bell. I'm a clinical practice specialist at the AACN national office. And right now, I'm with one of our colleagues experiencing the surge in Southern Florida who has agreed to spend some time with us today.

Thanks Linda. My name is Kevin Cho Tipton. I'm a critical care nurse practitioner here in South Florida. I've been practicing in nursing and medicine for about 10 years. I started as a CNA, an LPN and RN. For the last five and a half years I've been working in critical care units, mostly across South Florida. I work in ICUs at the two public hospital systems here. They happen to be the first and the third largest in the country. That's Jackson Memorial in Miami and Memorial Regional in Broward County. I'm also a captain in the Florida Army National Guard. I've been there for about 10 years. And I teach as an adjunct at the local community college.

I noticed on your Facebook posts that, almost daily, you're including the data about Southern Florida and Florida. How did you get involved in managing or looking at the data as part of your daily routine?

Well, to be perfectly honest with you, I don't have a lot to do at home these days. My family is dispersed. I don't have kids to take care of. So, it's given me time to focus on researching how to feed this disease process better and keep up-to-date on the knowledge. At that same time, I found myself getting more in-depth into the epidemiology and what was happening locally. A lot of national reporting goes on, but I wanted to drill down to what's happening in Miami and understand why it's getting so bad here right now.

I don't necessarily have an answer for why it's so bad, but I did start to find a lot of discrepancies in the data reporting from the county, from the city and from the state. And I just started looking at raw numbers and realized that a lot of nurses and doctors and healthcare professionals across the country talk about their personal experiences in the hospital, but, without the data, it's difficult sometimes to marry what's happening in the hospital with the gravity of what's happening nationwide. I wanted to impress upon people, look, these numbers represent people, but these people are also part of a greater whole that we're seeing thousands, even record numbers of people hospitalized, diagnosed. And now we're seeing increasing amounts of deaths. And I wanted to paint both a data-driven picture and the very nurse-driven, people-driven picture, and that's what was important to me.

Given what you know, what you've been through, what advice would you give to other APRNs who are either expecting a surge or in the middle of a surge? What would you like them to know?

I will say to any advanced practice person, remember that you're going to be more than just a medical leader. You're going to be a team leader. Spending the last 10 years as a reservist in the military, I've realized that ... Let me put it this way: For a nurse's aide, the circle of what we could do was very small: Take vital signs, talk to the nurse. As an LPN it got bigger, as an RNA it got bigger, but as an APRN it's even bigger. But it still includes all of those things that go down to the very, very smallest level.

I'm not saying that nurse practitioners, PAs and providers need to start getting at the bedside and doing these things, but remembering your roots; remembering that the stress and the strain on the bedside staff is incredible. And that we have the privileges as advanced practice nurses to go create an environment that is both conducive to learning because everyone's stressed and also conducive to understanding that these nurses and bedside care providers like respiratory therapists and pharmacists that are sometimes forgotten by hospital systems in recognition of what they do, are just as stressed as we are. So, taking that understanding, taking that bedside knowledge and also translating it to compassion, I think is important, not only for our patients, but for our co-workers.

Kevin, you've been an active voice in social and public healthcare issues, and you recently put out a call for the authorities in Florida to mandate mask usage. Any progress on that front?

We have not had any progress on the statewide front. I think it's probably a mistake for us not to get more involved at the state level, because there are 67 counties in Florida. Haphazardly inserting mask laws allows people to have, I think, a reasonable excuse to say, "I'm from Naples. I'm from Clara County. I'm driving over to Fort Lauderdale. I don't need to wear a mask in public." And with 20 million people here, it's very difficult to get everyone on the same page, unless you have state-mandated orders from Tallahassee. And that's what we need when we have record-breaking hospitalizations, diagnoses and now increasing guests across the state.

Elsewhere across the country, we hear stories about healthcare disparities during this pandemic. What are you seeing in your area?

Well, like New York City, we have a huge immigrant population. Let's take, for example, Miami-Dade County. More than 70% of Miami-Dade speaks a language other than English at home. In addition to that, we have a large Native population; the Seminole Indian Tribe is here. Almost all of internal South Florida, between Miami and the other coast, is a Native reservation. We are seeing huge disparities, not only among that population, but really distributed among those that are poor.

There is, of course, a racial component to this because of the disparity between poverty within communities. Since 25% of African American and Latino families are in poverty, we are seeing increasing numbers of these people in hospitals. The problem is, at the same time, there was a supposition about the sociocultural aspects of Italy — how people kiss each other on the face to greet each other — there was some suspicion that may be why the virus is infecting more people locally in Miami, because of the heavy influence of South American and Caribbean communities.

In addition, we are seeing how poverty during shutdowns is really destroying communities that have a lot of people who are in poverty. And not only are these people more likely to live in multigenerational houses or with grandparents taking care of grandkids, but they're also the most likely to lose their job during the shutdown, and also during shutdowns in general. Also, they’re most likely to be working in areas like service industries or as barbers and at restaurants where they're going to get exposed to the virus with little to no preparation.

I think it's doubly unfair that they're being affected most by the shutdowns, because as nurses and doctors and healthcare workers, we have too much work. We are still getting paychecks, but these people that are being affected are truly the victims, both from the virus itself and from the economic effects. And today, unfortunately, about 15% of Miami is out of work. And 25% of Miami is at or below the poverty line. They're facing the combined effects of the disease, plus if they've lost their job ... 50% of Floridians get their healthcare from work. So now they're out of work, out of access to their doctors and with unemployment and Medicaid taking so long to get signed up for, they're in a unique position where they're facing a pandemic, don't have access to their medical care and they're jobless. And it's just a very cruel cycle that’s not just here in Miami but across the country, certainly in these communities of color and especially in Native communities right here in Miami.

When the first big news hit, a large percentage of people were dying. Number one, are we still seeing the same level of severity? Number two, have we learned anything that helps decrease our mortality rate at this point?

The simple answer is yes, we've learned a great deal. Initially, we were intubating everyone very early if they got to 60% FiO2; we were not giving anyone steroids. We were trying to take people off their ACE inhibitors if they were on them. However, in the last four months, we've been able to digest the evidence.

There's some supposition that remdesivir has been helping. I will say, at least anecdotally and the evidence seems to agree, that steroid therapies such as dexamethasone were studied to see if they had a benefit on mortality. And it [dexamethasone] seems to be keeping people off mechanical ventilation if it's given early enough. The same thing with remdesivir, the same thing potentially with tocilizumab and the same thing potentially with convalescent plasma.

I think what we're doing now is we are being more aggressive at the hospitalist level of care by giving these drugs, these interventions earlier, before they reach the peak of the cytokine storm with most organs failing and getting intubated. As we do this, I believe we are seeing less people end up on mechanical ventilation.

That being said, we have so many patients coming in at the same time. Visually, when I look at my census, I don't see anything different with severity. What I do see is that we're not intubating as early. So had these patients been here in April, all of the patients that are ICU would be on ventilators, but we are now putting them on other breathers plus high-flow nasal cannula at 100%, dual oxygen therapy, things that we've never done before in critical care, but we're doing it to try to keep them off the ventilator; to keep them mobilizing their own secretions; to keep them mobilizing themselves to reduce the critical care polyneuropathy; trying to reduce the amount of delirium caused by the drugs we have to give them [so they don’t] end up on ventilators for so long. I think we're also diuresing people less, or keeping them more net zero rather than net negative. And we're pushing less onto dialysis and CRRT.

I think we're doing better taking care of them. But I think it's still too early to see this new cohort of patients who are getting diagnosed, and what the hospitalization rate is going to be. Before, it was 14%. We're now at about 9%. We're not sure yet if that's because they just got diagnosed and they're not sick enough to be in the hospital yet, or if there's truly a lower hospitalization rate, which would be great news. And I think we'll see the mortality rate change as we continue to progress in this new wave here in Miami.

And by the way, to any advanced practice providers out there, use this opportunity — if you're not facing a surge now — to read up on the evidence, become an expert, because it doesn't matter if you're a physician or a nurse at the bedside or an APP, those resources, that knowledge, is going to be invaluable. And we've had contributions on every level of medicine as we take care of our patients.

Well, I want to thank you for giving us your time. Is there anything else you'd like us to know before we sign off?

I would just say that look, I think that this is going to be a marathon nationwide, and I focus so much of my attention on Miami because of the national media, so it's truly national. And so, thank you for letting me talk about what's happening here. And look, there are 200 nurses and doctors and respiratory therapists and pharmacists coming from all over the country to our public hospitals here in Miami. And for them, if anyone sees us, thank you so much for coming. We all really appreciate it.