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The 30-bed Medical Intensive Care Unit (MICU) at UNC Medical Center currently houses three-quarters of COVID-related patients. As patients are hospitalized across the U.S., nurse manager Loc Culp explains what life is like inside her unit as her staff adapts to this new way of critical care.

Pure silence is what Loc Culp values these days. She doesn’t get much of it.

“The 10 minutes in the morning, driving to work, and the 10 minutes leaving for the day are the only times I have to myself, when I’m awake,” said nurse manager Loc Culp, BSN, RN, CCRN, MICU, leader of a 110-member team at UNC Hospitals Medical Intensive Care Unit (MICU).

Every day at 6:45 in the morning, you can find Culp arriving at UNC Hospitals to start her rounds in the MICU halls. First, she visits the night charge nurse for an update on the latest information surrounding the events from overnight. Then, she checks on dozens of nurses finishing their 12-hour night shift. At 7 a.m., nurses who have already clocked in for their dayshift begin their morning briefing, which lasts several minutes before the group disperses into a flurry of activity to start the cycle of providing care for COVID-positive patients.

“We house all the critically-ill COVID patients,” said Culp. “In this unit, we see the patients in the worst condition. We have people on ventilators, vasopressors, paralytics and sedations.”

Over the past six months, her MICU team has learned how to best care for patients, putting them first during a trying time for all of us.

Staff at the MICU, before the pandemic at UNC Hospitals

The Beginning Stages

Before the crippling disease called COVID-19, caused by the SARS-CoV-2 virus, made its way to U.S. soil, the MICU patient census was high. Twenty-nine patients were typically on the unit daily, and highly trained doctors, nurses, and other healthcare professionals saw a wide range of severely ill patients.

“I’ve been working in the MICU for the past 19 years,” said Culp, who was born in Vietnam, raised in Louisiana and now resides in Chapel Hill. “I became interim nurse manager in November of 2019. I got hired as nurse manager in January of 2020.” Two months later, the MICU saw its first COVID-19 patient.

As the pandemic raged on, clinical changes evolved rapidly at the MICU. Currently, three-quarters of the 30-bed unit houses COVID-related patients, and the number of patients being admitted or discharged fluctuates daily.

“We had to come up with a plan on how to staff the unit properly and safely. We have our high-risk areas and low-risk areas,” said Culp.

“In the high-risk area, nurses don gowns, gloves, N-95 masks, and face shields or CAPRs (Controlled Air Purifying Respirators). For the next three hours, those nurses are hands-on with their patients. Each nurse is assigned 1 to 2 patients.”

After hours of continuous care while standing on their feet, it’s time for a PPE break, which is only a couple minutes. The high-risk nurses switch roles with low-risk nurses. The break consists of grabbing a snack, getting a drink of water, and using the restroom. Or just a few moments of rest. Then, while in the low risk area, it’s back to gathering supplies and medications for the high-risk nurses.

“I’ve had nurses come out of the high-risk zone with their scrubs soaking wet from sweating,” said Culp. “What they do is laborious. They’re going from one room to another to help patients, check on coworkers, making sure everyone is safe, trying to make sure their gear is on correctly, and so on. It’s more than just taking care of patients; it’s about looking out for one another. On average, the nurses spend about 9.5 to 11 hours in PPE during their 12-hour shifts.”

An Interdisciplinary Approach

Culp spends her days supervising daily operations to achieve best-practice and organizational objectives. Her job is filled with human resource components, and, in recent months, protocols pertaining to the coronavirus. The criteria that lands a COVID-19 patient in the MICU involve continuous BiPAP (Bilevel Positive Airway Pressure), a ventilator, or if they are on a high-flow nasal cannula. For those suffering from constant respiratory distress, “proning” has become an important part of patient care.

“For a patient having high oxygen demands, they are often proned or flipped over onto their abdomen to help improve their oxygenation,” said Culp.

It takes about four to five people to prone a patient, including a nursing assistant, a respiratory therapist, and two nurses. And a patient may have to stay on their abdomen for a few hours to two days in the hope that oxygen levels improve.

“For the most part, a lot of patients begin to improve their oxygenation while they are proned.” said Culp. “Some patients do better than others. But, some are so unstable, just moving them could cause their blood pressure to decrease or the heart rate could elevate.”

When hospitalizations increased during the spring and summer, nurses have had to step into the role of being with a patient during their final moments.

“Some of our patients have died alone,” Culp said as her voice quivers. “Due to visitor restrictions, family members were unable to visit their loved ones in the hospital. So, whether it’s just being in the room, or holding a patient’s hand, our nurses are sometimes the last person to be with the patients.” Culp sniffs and wipes her tears. “We don’t want our patients to die alone.”

UNC Medical Center and other hospitals across the state have loosened visitor restrictions, and hospital personnel began thinking creatively to overcome visitation barriers due to the pandemic.

“We use iPads for communication,” Culp said. “Sometimes we’ll have those propped up so the families can talk to a patient if they so choose.”

Life outside of work

At 5 o’clock, Culp walks to her car to head home. As she gets in, she welcomes the silence once again.

“Driving home is my time to decompress. I try not to use my phone to talk to anybody. I need the silence because when I come home, my job goes from nurse manager to being a mother,” she said with a soft smile.

Culp’s husband is a University of North Carolina employee, but he has been working from home for months. During the day, he works while looking after their three children.

“School’s been out. My daycare is closed. When I get home I pretty much take over so he can finish his work. So, I take on the responsibility as caregiver when I get home. It’s just been non-stop since March,” she said, exhaling.

Living to fight another day

The fluidity of the situation is constant, but the MICU team remains steadfast. However, with the learning of new protocols and adapting to changes, extreme fatigue and potential burn out are very real challenges for healthcare providers.

“I’ve got some staff who work three days a week, but on their days off it’s taking them longer to recover and recharge before coming back to work. Often times they leave here very physically and emotionally tired,” said Culp. It’s been tough because I have to stay positive for the staff. I love my team and I just want to support them in every way I can.”

To help support the mental health of healthcare workers, a new Heroes Health App was launched by UNC School of Medicine and UNC Health. The tool is available with links to immediate mental health support and resources. During times like these, Culp believes that through collegiality and selfless teamwork, her staff will continue to be one great team.

“I’m just amazed at how our nurses have taken on these complex patients,” said Culp. “We’re in unprecedented territory; we’ve never been through something like this. I want my team to be proud of the work they’ve done and see how much of a difference they have made for our community and for the people of this state.”

Written by Brittany Phillips, UNC Health Communications Specialist.