MEADVILLE, Pennsylvania — A crush of names clogs a computer screen in an office where sick and hurting people shuffle in one by one, bundled against the winter cold.
Nurse Aubrey Schmeider calls that office “the Tree Lodge,’’ with its big window into the emergency department waiting room. She will spend the first four hours of her 12-hour night shift here in Meadville Medical Center’s triage office, just beyond the waiting room filling with coughing people — coughing, dry, wet, productive, the just-can’t-shake-it coughing that’s saturating hospitals like this one in the Crawford County seat at the height of the 2022 cold and flu season.
“How would you rate your pain on a scale of one to 10? When was the last time you had COVID?” the 28-year-old Ms. Schmeider asks each patient, her voice practiced and caring. “Do you smoke cigarettes, drink alcohol or use any illegal drugs? Can you roll up your sleeve? Can you stand on the scale?”
On this particular night, she is back for her first day after a week’s vacation. Getting enough sleep can be an issue anytime. And so it was when she awoke unexpectedly nearly four hours early for her 7 p.m.-to-7 a.m. shift.
Sleep just “wasn’t happening,” she said. “Pre-shift anxiety — I get that.”
Nationally, the supply of nurses like Ms. Schmeider — the backbone of a rickety U.S. health care system — is under threat. After growing steadily since the 1970s, the number of nurses fell by 100,000 in 2021, according to a December study in the journal Health Affairs.
It was the biggest drop in 40 years.
All of the reasons for the decline are difficult to parcel out, but pandemic burnout was among them, according to the study.
Small wonder. It’s been a hard couple of years.
In Pennsylvania alone, at a two-year peak in April 2020, about one in five people died who were hospitalized with COVID-19, according to the Pennsylvania Health Care Cost Containment Council.
That’s nearly double the casualty rate for U.S. soldiers fighting in Vietnam.
During that month, the average number of new cases spiked to 1,673 per day in Pennsylvania while the number of people killed daily by the disease reached an average 159 — seven deaths an hour. To date, COVID-19 has killed about 49,000 Pennsylvanians.
Since the outbreak, a flurry of international studies have documented lingering anxiety, depression, insomnia and post-traumatic stress experienced by frontline health care workers caring for people with COVID-19, with the prevalence of symptoms ranging up to 57% for acute distress or post-traumatic stress disorder. Women were more affected than men, probably due to differences in coping mechanisms, the study said.
“Crises, such as the current coronavirus disease 2019 pandemic, represent a profound threat to mental health,” concluded a 2021 study of health care workers in Australia, which experienced comparatively lower rates of infection than other countries.
“The relationship between nursing and poorer mental health may be explained by the heightened risk of COVID-19 exposure from prolonged and frequent contact with patients.”
Schmeider remembers the height of the COVID-19 pandemic at Meadville Medical Center, a 178-bed hospital located in a town anchored by a private liberal arts college.
She’d work her regular schedule in triage, then volunteer for extra shifts upstairs, where she would care for people she’d met earlier as they came from outside, coughing and short of breath.
Nearly everyone else on staff was picking up extra shifts, too.
She remembers “bed-blocked” days when there was just no room for all the people with COVID-19.
Death came so quickly to so many, she said.
Funeral homes were asked to store bodies when the hospital’s two-chamber morgue filled, she said. She can’t talk about those days now, not even with her mother, also a nurse.
Many colleagues left bedside nursing — or nursing altogether.
“We were all under it. I was just exhausted,” she said. “I couldn’t sleep. I was having the ‘I need a new career’ kind of thinking.”
Out of view of the triage office, high above the emergency department’s nerve center where paramedics transmit medical reports by radio and doctors talk over tough cases in hushed voices, is the tiny statue of an angel surrounded by balls of cotton.
The intensity of those early days of COVID-19 is gone, but the emergency room is still a beacon for the sick. A rescue worker’s voice breaks the radio quiet: a crew is inbound with a 70-year-old man found at home in cardiac arrest. Paramedics managed to thread a tube into his lungs to boost his oxygen and get his heart beating again — all things favoring survival.
Still, his odds are not good. CPR is in progress, four-minute ETA to the hospital, the paramedic tells the doctor.
Back at the triage station, the office door swings open to reveal a man slouching in the waiting room hacking loudly. The sick and injured stream into the tiny office: a crying 5-year-old girl who banged her head on a bathtub, accompanied by her father, holding a Ziploc bag containing two tiny teeth; a middle-age woman with pain in an arm that had suddenly turned cold; a screaming 1-year-old girl who dropped something heavy on her toe, which her mom said then turned black before her leg broke out in a rash.
“Girlfriend, you have the coolest toe in town,” Ms. Schmeider tells the child, her screaming growing more urgent. “I know, I know. It’s OK. It’s almost done.”
Reaching over, she wraps her arms around the girl in a caress.
The sorting of injuries and people continues for hours.
A mom and three kids with flu symptoms get slotted to the department’s family room; a less seriously ill patient gets assigned to a hallway bed for now. Heart-related chest pain patients go straight to a treatment room.
Triage, which comes from a French word describing a way of assessing battlefield wounded, is a strategy used in the emergency department, Ms. Schmeider said.
When Schmeider was growing up in Butler, 33 miles north of Pittsburgh, playing high school volleyball and softball and thinking about a career strategy — she even considered engineering for a time — her mother said, “Why don’t you go to nursing school? At the end of two years, you could have a good job while you’re looking for something else.”
Looking for something else never happened.
Ms. Schmeider’s first job out of nursing school, which she attended on an academic scholarship, was in the intensive care unit at Allegheny General Hospital on Pittsburgh’s North Side. She loved the unit’s detailed patient care plans that required obsessive attention.
But the controlled chaos of the emergency room, the never-knowing-what’s-coming-through-the-door-next quality, appealed to another part of her.
It was a job, she said, that demanded that she be at the top of her game every moment, always pushing her limits — from listening for the underwater swoosh of fetal heartbeats, to executing the cardiac life support drill in reviving an elderly man whose heart had stopped, to simply consoling the grieving.
Ms. Schmeider left Allegheny General to become an emergency room nurse at Meadville Medical Center in 2017. In warmer weather, she bicycles to work — 10 minutes from the apartment outside town that she shares with two cats, Eddie and Little Foot.
By 11 p.m. on a recent night — four hours into her shift — only a few people remain in the waiting room as Ms. Schmeider winds up her stint in triage. She’ll soon move to overseeing the care of patients in four bays of the 18-bay treatment area down the hall.
By then, the woman with the shard of glass in her finger is leaving through the department’s double doors, her hand bandaged; resuscitation efforts had ended for the 70-year-old man brought to the hospital in cardiac arrest; the vacuum system in the department’s nerve center inhaled another plastic football-size tube with a snort, whisking off tissue samples to a hospital lab for analysis.
The emergency department grows quiet for the first time this cold winter night.
For Meadville Medical Center emergency room nurses, the punishing years of COVID-19, when the outbreak was still young, have been papered over by the newest surge in flu and respiratory illness cases. Still, the pandemic is never far from the surface.
It’s not just her, Ms. Schmeider said. None of her colleagues in this rural northwest Pennsylvania county of fruit farms and tool and die companies — the staff who powered through the worst of the pandemic — are eager to talk about the experience.
The 60-hour workweeks, the shifting treatment regimens and above all an unknown pathogen. And death after death on a scale not seen outside a battlefield in 100 years.
“It’ll probably be a while before anybody can talk about it,” she said, her eyes suddenly moist. “Probably the day will come, but not soon.”
The nurses’ searing experience caring for COVID-19 patients worries Meadville Medical Center Chief Nurse Executive Valerie B. Waid. The hospital has reached out in a number of ways to nurses to ease stress, including providing free take-home meals for their families, making hospital behavioral health services immediately available to them and opening additional beds to absorb the tide of COVID-19 patients who were waiting then for care in the emergency room.
Ms. Waid, a nurse with nearly 30 years of experience, said she has also encouraged nurses — especially those in the emergency room — to talk about any problems coping in the aftermath of the disease outbreak.
“We cannot close the doors to the ER,” she said. “They took it the worst. They got no reprieve.”
But the take-charge skills that allow ER nurses tame the most stressful days may be the very thing keeping them from asking for help.
“‘We don’t need that. We’re tougher than that,’ “ Ms. Waid said. “That’s the persona they give.”
At a recent meeting with the hospital’s ER nurses, Ms. Waid urged them, “Look, it’s OK not to be OK; it’s OK to be in a dark place.”
“I got very little follow-up from them,” she said. “We have to be ready for any crack of an opportunity to talk whenever they’re ready.”
Nurses continue to be in short supply, with a workplace survey conducted by the the Hospital and Healthsystem Association of Pennsylvania finding that vacancy rates for registered nurses rose to 27% from 21% between 2019 and 2021. And it’s just not the small institutions that are looking for help: In December, Pittsburgh hospital giant UPMC had openings for more than 3,000 nurses.
Labor shortages are pushing up hospital expenses. Employment costs at Meadville Medical Center rose 5% to $41.1 million for the three months ending Sept. 30 when compared to a year ago, helping drive an operating loss of $4 million for the period.
The losses come as emergency rooms at Meadville Medical Center and other hospitals crowd again with patients, this time suffering from flu and other respiratory viruses along with fewer cases of COVID-19.
The wee hours of the morning drift by with Ms. Schmeider changing sheets in a treatment bay, checking on patients and catching up with paperwork at a computer screen. She moves in a blur even as the pace in the department slows.
The lull lasts until 5 a.m., when five patients arrive at the emergency room nearly simultaneously: a 61-year-old man by ambulance who’s having trouble breathing; a 38-week pregnant woman with nausea and vomiting; a 56-year-old man with chest pain; a woman with leg pain lasting 16 days; someone suffering a head injury.
Ms. Schmeider is scrambling again, helping back at the triage station, restocking a treatment room to prepare for new patients, ordering chest x-rays, blood samples. The crush comes as her shift is winding down, offering the promise that morning nurses will arrive to ease the burden. She starts the handoff, briefing the early nurses about patients.
In a little while, she’ll be making the short drive home, drawing the blackout curtains at her apartment, slipping on an eye mask and trying again to find sleep. Working as the rest of the world sleeps may sound upside down, she said, but it doesn’t bother her.
“It’s a hard job, but I’m here for it,” registered nurse Aubrey Schmeider said. “I wouldn’t do anything else.”