On March 11, 2020, on the same day that the World Health Organization declared the novel coronavirus outbreak a pandemic, Charlie, an obstetric emergency nurse, was on duty at the emergency room to prepare his side of the hospital for the inevitable surge of COVID-19 cases. Jane, a recently resigned intensive care nurse, was struggling to pack her entire life into her luggage for her supposed deployment to Europe before the nationwide lockdown. Peter, another critical care nurse already thousands of miles away in the United Kingdom, was doing simulation after simulation in the Critical Care Unit, trying to perfect procedures despite being bogged down by the weight of his personal protective equipment.
I, on the other hand, was on one of the last few planes travelling to Davao City before lockdowns were imposed across the country. I had just finished taking an English proficiency exam in Makati, the first of the many steps I’ve laid out for myself in my application to become a nurse abroad. Just a few months before, I had resigned from my office job to return to my roots and finally make use of my Nursing license.
Like my classmates in college who were in various stages of their application to go abroad, I was excited about working in another country that assured better working conditions for nurses. In 2020, after years floundering in a lousy job market, nurses were once again in demand worldwide, and my classmates and I finally have our pick of hospitals to work for. Suddenly, there were new clinical settings to see, new patients to meet, and the rest of the world to practice in if we so choose. The world was an open door.
I came home to Davao with a cold, fatigue, a low-grade fever, and a nagging feeling that I have picked up the virus in Manila. I tried to convince myself that I just had the allergies, that my apartment in Davao was gathering dust, and that was what brought up my reaction. I checked with my sister who was with me in Manila but was staying at another apartment in Davao. She said she was also experiencing the same symptoms. I convinced her to get ourselves checked, just in case we had the virus and were unwittingly spreading it around.
When we arrived at the hospital, we were immediately classified as Persons Under Investigation since we had relevant travel history and respiratory symptoms. The hospital that we initially went to didn’t have the capacity to test for the novel coronavirus, so we were transported to a public hospital for further evaluation.
There were 20 other people waiting to be evaluated when we got to another hospital’s Isolation Center for testing. Our vital signs were taken twice, and we were interviewed three times. Each interviewer repeatedly prodded us for the places we’ve visited while in Manila. It took six more hours until we were told that we didn’t need to get tested because we didn’t meet the criteria for testing. We were scared to go back home without a definitive diagnosis for what we were feeling, but we understood. Back then, when supplies were scarce and not much was still known about the virus, it was part of the protocol to only test those with significant travel abroad or those with close contact with people who have gone overseas. We were released from the Isolation Center as Persons Under Monitoring. They told us to go home, quarantine for 14 more days, and contact them if our symptoms worsened over the next two weeks.
That day was the last time I saw the world as it was in the old normal. My symptoms cleared after a week, but by then, Davao City had already imposed strict measures to keep people at home and away from the virus.
When the pandemic started in Davao, Charlie, an obstetric emergency nurse in the only public hospital in the city, spent many weeks redesigning the floor plan of the Obstetrics Ward. He and the other nurses in his team needed to separate the expectant mothers they classified as “clean” from those they suspect to be carriers of the virus.
During those early days of the pandemic, there haven’t been many patients in their area. Many pregnant mothers, even those from communities that usually availed the hospital’s services, sought to give birth in other hospitals or birthing homes just to avoid the only hospital in the city that catered to COVID-19 cases. Now, three months after the lockdown, women whose pregnancies and deliveries were at risk came in steady numbers to seek admission to Charlie’s side of the hospital again.
Charlie was often tasked to man the frontline of the Emergency Department and decide how incoming pregnant patients were supposed to be prioritized. One day, during his shift, a patient in labor came to the hospital with her sister. Upon seeing the patient, Charlie immediately knew that something wasn’t right. The patient’s breathing was too labored. Even without her contractions, the patient remained hunched over in her wheelchair, visibly gasping through her face mask. Her entire torso moved with every breath, and she was drenched in sweat.
Charlie guided the patient and her sister towards their desk to begin his assessment. He looked at the other nurse who was with him at triage to see if the other nurse also saw how much difficulty the patient had while breathing. Even with their faces covered in surgical masks and face shields, when Charlie caught the other nurse’s eye, he knew that they both shared the same suspicion about the patient’s condition.
“Are you having trouble breathing?” He asked the patient. “Is it because of the mask?”
The patient shook her head no, but she pulled down her mask in order to breathe better.
“Ma’am, please just keep your mask on,” Charlie said, taking a step back. The patient didn’t seem to hear him.
“Ma’am, put it back.” The patient wordlessly put her mask back on and continued breathing deeply and rapidly.
Charlie proceeded to take her vital signs and time her contractions. For the patient’s history, he turned to the sister for answers. “Where are you both from, ma’am?”
The sister mentioned their barangay’s name. Charlie noted mentally that their barangay has recently been declared as a hotspot for COVID-19.
“Has she been like this for long?” He asked.
“She’s been like that for a week, I think,” the sister replied.
“Why did you just bring her here now?” He said.
The patient hesitated. “We were afraid, sir.”
“Afraid of what?”
This has been the third time in a month that Charlie heard the same answer from different patients. Still, he couldn’t understand the fear. Local government guidelines had been so clear about isolating the sick and asking the government’s help if strict home isolation wasn’t possible. Why didn’t patients ask for help sooner?
Charlie called the Obstetrics Ward and confirmed there that the patient is a highly suspected COVID-19 case. Arrangements were made for the patient’s transfer, but there weren’t any orderlies available to take her to the ward. The Obstetrics Ward was located just a few buildings away from the Emergency Department. Before the pandemic, patients were just wheelchaired away from the triage to different wards in the hospital. These days, however, containment was necessary, especially with suspected cases. They needed an ambulance just to take the patient to another building.
Charlie checked again to see if an orderly was already available to take his patient to the ward, but he was told that all of them were already called off to other cases. He was worried. Without an orderly, he knew that he would have to take the patient to the ward himself. The patient cannot stay in triage any longer, or else she’ll put the other nurses and patients in the area at risk.
Charlie told his partner to prepare the patient for transport while he went to prepare himself. According to protocol, all personnel handling suspected COVID-19 cases are required to wear Level 4 personal protective equipment. In Charlie’s hospital, this meant wearing coveralls, a respirator, and two sets of gloves and boots. Donning the equipment took some time, and he needed to do it quickly.
He washed his hands and wore his gloves. As he got into his coveralls, he silently tried to convince himself that despite her high-risk residence and her presenting symptoms, the patient he’s about to share the cramped space of the ambulance with is not infected with the virus.
He hoped his partner already explained to both the patient and her companion that she needed to be isolated during her labor and delivery, so only the patient will be taken to the ward. The companion will have to wait elsewhere. This was always a difficult conversation, especially with worried watchers, and right now, worried as he was himself, Charlie was not in the mood to provide a long explanation. Talking takes so much effort when you have so many things covering your face. It also requires so much breathing. As much as he was protected by two layers of masks in his level 4 PPE, he didn’t want to risk it. He didn’t want to breathe any harder and any more than he needs to, especially around the patient.
Once dressed, Charlie approached his partner and had his PPE checked. His partner gave him a thumbs up and told him the ambulance was already waiting for them outside the Emergency Department. He took his patient’s chart, secured the patient in her wheelchair, and wheeled the patient away after she said goodbye to her sister.
At the hospital’s driveway, the ambulance driver, who was wearing the same stuffy PPE as Charlie, waved at him and opened the ambulance door. Charlie secured the chair and took the patient’s hand to assist her in standing up.
“Are you ready, ma’am?” He asked. The patient nodded.
Charlie helped her enter the ambulance and had her seated. The short effort of transferring seats was already enough to tire the patient. As Charlie sat across from her, the patient pulled down her mask again to catch her breath. Charlie told her to put her mask back on, but the patient held her hand up as if to say wait. The patient continued to gasp masklessly for air before she steadied her breathing and pulled her mask back up to her nose.
From outside the ambulance, the driver yelled through his masks to ask Charlie if they were ready to go. Charlie gave a thumbs up. The driver nodded and slammed the ambulance door shut. Charlie held his breath.
The last time I saw Charlie was in a review class for IELTS, an English proficiency test, only a month before the pandemic had taken root in the Philippines. I was seated in front of the class when I thought I heard a familiar voice reciting during our speaking drills. When I turned, I saw him and waved. He waved back. We were both disappointed to see each other.
Nurses are notorious for keeping their plans to go abroad a secret, and Charlie and I were no exception. Most of us fear that telling anyone will jinx our plans, so we often keep things to ourselves until we are already out of the country. When Charlie and I saw each other in class, we no longer needed to tell each other anything about our future plans. I immediately knew that he was going abroad, just as he knew that I was planning the same thing.
Charlie and I had been lifelong classmates, and I was surprised that that persisted even in an IELTS review class. We’ve been classmates through elementary and high school in Cotabato City, and even through college to study Nursing in Davao, a big city four hours away from home. We passed the boards at the same time and took our oath as nurses at the same time. When the time came to pick a job after college, we both opted for careers outside of the hospital too—he with a national organization for first responders, me with a research post at a local hospital.
When Charlie and I took up Nursing, the local and global demand for nurses had been on a downturn. Even during enrollment, we were discouraged from enrolling in Nursing by the very staff that processed our papers. There were already too many nurses and not enough jobs, they said. Would we like to be part of the dismal job market? Of course, we didn’t, but young as we were, we couldn’t imagine ourselves working anywhere else but the hospital. Most of us, at least for my classmates and I, wanted to be doctors. And if we couldn’t be doctors, we wanted to be the next best thing, medically speaking.
By the time classes started, our freshmen batch of Nursing undergrads only made up three classes when there used to be twenty. After our first year, those three classes were whittled down to just one. We made up for the lack in numbers with a dedication to the course. Our class was smart and inquisitive and well-rounded. Our eagerness to learn about how diseases worked and how specific treatments managed medical conditions bordered on obsessive. We enjoyed learning about the science of Nursing as much as we enjoyed its softer skills, like talking to patients and carrying out nursing procedures. When we took the boards, we had a 100% passing rate and two topnotchers. We were good at what we did. But even then, even with the stellar grades and heavy extra-curricular involvements, the job market waiting for us when we graduated had not been good to us.
Job opportunities in the country were scarce. And with so many unemployed nurses trying to compete for jobs, hospitals, both private and public, had the choice to scrimp on salaries and offers for tenured positions. The requirements just to be employed were steep, and the pay was and is offensively low. Some applicants were required to pay for the training they should have freely received as new hires, if they were lucky enough to be chosen for hiring. Some nurses aren’t even hired as actual employees, but just as volunteers. As volunteers, they are only paid with meals during their shifts. If they were lucky enough to be actually employed, they only received somewhere between PHP4,000 to PHP12,000 a month, a gross undercompensation, considering that nurses work more than 8 hours a day.
It wasn’t that we weren’t prepared for what we had faced after graduating. Our teachers in Nursing school were never remiss in telling us that our situation wasn’t forever, that many nurses abroad will soon retire, and soon too, we will have our turn. As we took our oath as new nurses, the Board of Nursing representatives leading the occasion were also quick to remind us that we were “the best for the Filipinos and the choice of the world,” and it was only a matter of time before we had our choice of hospitals to work for again.
They were right, of course, but Charlie and I didn’t see that yet. Back then, what we saw was how we needed to justify what our parents spent for sending us to a good and expensive college. We needed to build our own lives in a city too far away from home. We cannot afford to take volunteer nursing positions in hospitals, which were all that were available to us back then. We needed to earn a living, not a mere volunteer allowance.
And that was what we did for the next couple of years while most of our peers worked for monthly stipends or simple meal allocations for their 12 hours a day service. It was easy to say that we made the right choice when we had steady paychecks.
But soon enough, dissatisfaction with our jobs and ourselves started to set in. There was always a nagging insecurity hanging over our heads, telling us that we didn’t actually know much about what we did, and that we will never be as good as we can be for the positions that we held because we knew that we were wired and trained for something else. And we were missing that training. We missed the hospital and the patients, the hard science behind diseases, our cure in conversation.
Charlie realized early that he needed to go back to his roots no matter the cost, but I took my time. He first became a medical emergency responder before applying for a post at the hospital where he is working now, while I spent three more years cowering behind a desk. I was so afraid of leaving stable office work for the uncertainty of possible unemployment that it took me a long time before I made up my mind about going back to the hospital. When I quit my job, I had to ensure that I have my affairs in order to secure a better future for myself as a healthcare professional. This meant immediately taking the IELTS and other certifying exams that will prove my competence to practice Nursing in a foreign country before actually looking for a Nursing post in the city.
Taking the IELTS or any other similar English proficiency test is considered the first step in any application to work abroad as a nurse. For many nurses in the Philippines, the English proficiency test presents the largest hurdle one has to overcome before going abroad. Anxious to prove they’ve been educated in English for all of their academic life, most nurses expect to fail their first exam. With fees amounting from PHP10,000 to PHP25,000, it’s not exactly a cheap exam to fail.
When Charlie and I met again for the first time in years in that IELTS review class, we were both set to take the English proficiency test on different days in March. I was the only one who was able to take the exam.
It is obvious to say that plans were derailed in 2020. Every life was put in limbo during the lockdown, but more so for nurses in the Philippines who have already paid their dues in the country and were looking forward to their employment abroad.
On April 2, 2020, two weeks after lockdowns were imposed, the Philippine Overseas Employment Administration, under orders from the country’s Inter-Agency Task Force on Emerging Infectious Diseases, imposed a travel ban on all Filipino healthcare workers unfortunate enough to still be in the country. To no one’s surprise, after years of denying nurses just compensation and job security, the country was now facing a shortage of healthcare workers in the midst of a global pandemic. It didn’t help either that applications of nurses for work in the United States and the United Kingdom were being fast-tracked to meet those country’s demands for more healthcare professionals.
Citing the need to prioritize human resource allocation in the Philippine healthcare system over the healthcare professional’s “right to travel,” the government has indefinitely suspended international deployments to prevent Filipino nurses from securing employment in another country. Filipino nurses were urged to take the travel ban as an opportunity to “exercise their patriotism,” an appeal that didn’t sit well with nurses who have already done their service for a country that did not appreciate them. There were calls for immediate hiring of nurses in COVID-19 referral facilities, but they either paid too little compared to the risks nurses undertake, or offered no job security since their contracts were only good for three months.
The government also failed to consider—or has deliberately ignored—the great personal expense nurses have already spent to process their applications to work abroad. Aside from English proficiency tests, nurses are also required to take other exams to prove and certify their competence to practice internationally. None of these tests were cheap. All of them came with a two-year validity. There were also numerous other documents needed for visa issuance, such as health assessments and overseas employment certificates, that had much shorter validity.
The most affected by the travel ban were those who were only waiting for their plane tickets for deployment and those already nearing their certification’s expiration dates. With the travel ban holding them up in the country, nurses with expiring requirements were forced to shell out more money and retake tests and assessments.
Because of numerous petitions to lift the deployment ban of healthcare workers, the government decided to allow the temporary deployment of nurses with perfected contracts dated on or before March 8, 2020. With the temporary lifting of the ban for a select few, a number of nurses should have been able to leave as early as June. However, due to delays in the issuances of overseas employment certificates, the formal deployment of nurses has been further delayed to August. By then, several nurses have already been severely affected by the delays in deployment.
This was the case for Jane, another former classmate from Nursing school. Jane was one of the few lucky ones in our batch who was able to secure employment as a volunteer nurse in a public hospital right after the Nursing boards. She began working as an auxiliary nurse in various areas of the hospital and was only paid PHP4,000 a month for her services. It took three years before she secured tenure as Nurse I, and even then, she had to talk to friends in higher places just to get her name on the top of the list for regularization. As a regular employee, Jane was permanently posted at the hospital’s ICU complex, where she developed her expertise in intensive care for three more years.
Jane started to pursue her application to work in the United Kingdom after two years of experience in the ICU. She had to take the Occupational English Test twice and go on numerous trips to Manila and Cebu for interviews and requirements before scoring a contract with a hospital in Central London on February 2020. Jane immediately resigned from work after that because she wanted to give herself a month of rest before processing her papers for deployment. Her rest was interrupted by news of a worsening public health crisis in Manila due to COVID-19. Jane hoped to catch various immigration offices to process her visa requirements before stricter measures were put in place. She immediately packed her bags for deployment and went to Manila. She got to Manila just in time to see everything close down for the community quarantine.
I met Jane right after taking the test of competence for nursing work in the United Kingdom in September 2020. By then, she had already been stranded in Manila for seven months. I sent her a message right after my exam to ask if she was still in the country. A month before my test, she told me that since her perfected contract and other requirements were already prepared, she was only waiting for her plane ticket to London. I was surprised when she replied that she was still in Taguig. I asked her if she wanted to go out for lunch, and she immediately agreed.
Back in Nursing school, I was often paired with Jane to perform clinical procedures or to write case studies. She was one of the best in class. She was well-versed in a variety of conditions and was always cool under pressure. It made perfect sense that she ended up working in the ICU. When I met Jane, she was skinnier than I remember. I asked her if the community quarantine had treated her well, she said that it didn’t, but she managed.
“What are you still doing here?” I asked her after some small talk. “I thought you would be in London by now.”
“Ha!” she laughed. “I don’t know about my deployment anymore!”
It turns out that coming to Manila right as offices started to close down for the lockdown was the least of Jane’s problems. Getting stranded in Manila meant she needed to find a place to stay aside from the pricey AirBnB she booked for herself seven months prior. She initially asked a few relatives in Manila if she could stay with them. Driven by the initial panic around people who flew in from different places, her relatives declined to accommodate her during the quarantine. Thankfully, Jane befriended another nurse from her agency that allowed her to stay at a shared apartment.
“Everything in Manila is so difficult,” she said. “And expensive, too! I’ve already burned through my savings during the lockdown.”
“How do you get by now?” I asked her, knowing that processing requirements for deployment didn’t come cheap.
“My parents,” she laughed. “I hadn’t asked them for a dime when I was employed, but now I have no choice. Kapalan na lang ang mukha.”
I asked if she got any updates from her agency about her deployment. She told me that she was supposed to be deployed in early September. However, since her certificate of sponsorship already expired while waiting for the travel ban to be formally lifted, she wasn’t able to file for her visa in time for deployment. Nurses hoping to migrate and work in the United Kingdom are required to present a sponsorship certificate that proves their employer’s intent to hire them. Without a sponsorship certificate, a nurse cannot be issued a working visa.
Jane shared that her supposed cohort of nurses from the Philippines has already left for London in August. She and the nurse that she was living with had to remain in the country to renew their sponsorship certificates and secure their visas. Her certificate has since then been filed, and her visa has long been processed. The only thing she was still waiting for now was her plane ticket for London, but even with only that missing, she still ran into some problems.
“My employer told me that their next deployment will probably be in November. Probably!” she exclaimed incredulously. “I cannot wait any longer for ‘probably.’ My OET and visa will already expire by October!”
“What’s an OET?” I asked.
“It’s a new English proficiency test from Australia,” she explained. “It’s a lot easier than the IELTS because you just use the usual hospital language, but it’s a lot more expensive.”
I asked if she would take the OET again. She said she didn’t want to anymore, but she would have to. She might still find a loophole or an alternative for the English proficiency test, but she lamented that she could not find a loophole for an expired visa. Visas for the United Kingdom are only good for 90 days. With her visa issued in August, it was also set to expire by October. She would have to file for a re-issuance when her agency and her employer finally decide to deploy her. When that was, she still wasn’t sure yet.
I told her the waiting time for her deployment was getting ridiculous. “Maybe it’s time to look for another employer?”
“I already signed my contract,” she said. “If I go against it, I’ll be penalized with the cost of the sponsorship.”
I asked her how much the penalty will be, and she told me it was more than a quarter of a million pesos. “I wouldn’t pay that much, even if I had the money,” she said. “I can’t even work part-time because of the contract. You know it’s my first time to have a seven-month gap in my resume? I worked immediately after college just to not have that gap, but now here I am.”
“Well, don’t you want to wait it out at home?” I asked. “At least the wait won’t be that bad if you’re spending it with family.”
“I can’t go home,” she said. “My lola is living with us at our house. I can’t risk getting her sick.”
“Maybe you have other relatives that could take you in?”
“They can’t. They’re all so old,” she said. “Sayang nga, I would have wanted to spend my birthday at home, but I don’t think I can.” When we met for lunch, Jane’s birthday was only a month away, and she had to spend it at an apartment full of strangers who have now become her friends.
“I don’t know what to do anymore,” she said. “I’m already so depressed, so I try not to think about it. Right now, I just try to accept whatever happens.”
I smiled at her. I didn’t know Jane as one to wallow in her own misery. “Well, think about it this way,” I told her. “Maybe you lucked out that you missed the first wave of cases that hit London.”
“Maybe,” she gruntled. “I still wish the travel ban didn’t delay me as much as it did.”
“Maybe it was saving you for an easier job,” I said.
“I doubt it,” she shrugged. “Anyway, how about you? Have you checked your test results yet? They usually have it posted already by this time,” she said.
I told her I was nervous to check my rating because I wasn’t confident with some of my answers. Five years of working outside the hospital have weakened my instinct in answering clinical questions. She assured me that she was confident I had passed, even without the relevant clinical practice.
With her encouragement, I opened my account with the test provider and looked for my result. Right next to my name, in bold, capital letters, was the word “passed.” The ticking clock on my test’s validity officially began.
The Philippines is the only country that expects and encourages its nurses to leave. Both public and private hospitals in the Philippines operate under the assumption that its nurses will soon leave their company and the country, and they use that assumption to keep their nurses—world-class nurses, by any standard—overworked and underpaid. Everyone accepts the dismal working conditions that nurses experience in the country as the dues they have to pay for a better life overseas, as if being forced by economic conditions to move away from friends and family is what constitutes a better life.
In the Philippines, nurses aren’t valued for the service they provide to the sick or the immense support they give to the nation’s imperfect healthcare system. We are valued only as exports, and as such, our welfare as healthcare workers is decidedly the concern of another country and certainly not that of our own.
The Filipino nurse is the choice of the world, but our own country refuses to choose us, to address our pleas for better wages, to meet our need for job security, to give us the respect and dignity that our profession rightly deserves. This country chooses to send us away, forces our hand to brave new and strange lands just to be able to provide a better living for ourselves and for our families. And that is what we have been conditioned to do—to leave, to spend thousands of our hard-earned money to process applications to go abroad, even when we do not know what is waiting for us in another country.
The coronavirus first reached London on the first week of March. Peter, a critical care nurse stationed in a city north of the British capital, was immediately prompted by his supervisors that they only had two weeks before COVID-19 patients also began knocking at their door. Peter was another classmate from Nursing school. He was, and still is, one half of the power couple of our class in college. He arrived in Britain in 2016 with his then-girlfriend and now-fiancé, Sarah. Before the pandemic, both Peter and Sarah’s applications to migrate to the United Kingdom only took six months from start to finish.
When the pandemic finally hit the United Kingdom, Peter was already inundated with information regarding the novel coronavirus and the procedures he needed to perform in order to prevent its transmission. Their hospital unit has disseminated internal guidelines and conducted hospital-wide training ever since they learned about the unexpected rise of coronavirus cases in Italy in February.
Still, however, the panic was setting in among his teammates at the Critical Care Unit. Most of them didn’t feel safe, even with numerous supplies of personal protective equipment. Peter told me that it was one of the good things about the culture in British hospitals. Nurses were always free to speak their minds and not just do as they’re told. As a result, the hospital presented them with more drills to simulate various COVID-19 cases that they may encounter in the days to come. Peter and his teammates prepared the Critical Care Unit as best as they could. Patients who were well enough to be discharged from intensive care were sent to other wards. Trays of life-saving supplies were prepared and stocked in each room. Donning and doffing of PPEs were studied and practiced to the point of mastery.
Their first COVID-19 patient came to the hospital on March 17, 2020, just as predicted. It was a Polish patient who recently arrived from London and was suffering from difficulty of breathing. Within 24 hours after the first patient’s arrival, half of Peter’s 25-bed Critical Care Unit had already been filled with other COVID-19 patients. Peter barely remembered the first few days of their city’s first surge of cases. The influx of patients had been a blur. He only remembered feeling that there were already too many cases all at once.
At the start of COVID-19’s first wave, people who came to the hospital usually had it worse than healthcare professionals wanted them to be. It is understandable because at the onset of any infectious outbreak, people often do not yet know what to look out for. This was especially the case for COVID-19 because its initial symptoms looked too much like those of the flu. As a result, COVID-19 patients only come to the hospital when they are already in a dire situation and would need critical care to address their worsening state.
Peter could no longer recognize the Critical Care Unit two weeks after they admitted their first COVID-19 patient. Every day, when he came to the hospital, he was greeted with chaos. “Para kang nakatira sa ibang bahay,” he said, describing how he felt every time he started his shift. He knew he was still in the same environment, but everything also felt so different. Every patient he handled were intubated and on dialysis. The bed capacity in the CCU increased from 25 to 40. The number of patients Peter had to take care of and oversee also rose from 1 to 5. There were new nurses on the CCU floor, too. Experienced nurses from other wards and retired intensive care nurses had to be called in just to meet the CCU’sneed for more nurses.
Even with three years of experience in critical care, Peter felt that he was at a loss for what to do. He wasn’t sure that the procedures he was doing to patients were helping them in any way, but he knew he had to push through. “I don’t think I was ever prepared to handle this pandemic,” he told me. “But I had to step up.”
During those days at the height of the first wave, Peter felt like he always on his own. Every other critical nurse who used to assist him with procedures were all suddenly so busy with their own patients. He had non-ICU-trained nurses to assist him, but he also still had to oversee them and their work. With so many patients in the unit, Peter was under a lot of pressure to work fast to make sure all patients under his care got their needs met. They had to be fed and changed and medicated, their blood transfusions and dialysis closely monitored, their intubations assessed, their life support equipment properly attached. There was always so much to do and not enough time to do them in.
One night, Peter was assigned to work a long shift in the CCU. Halfway through his shift, he noticed that his charge nurse hadn’t taken his mandatory 30-minute break yet. He told the charge nurse to take the break before the doctors finished their handover because the charge nurse will be a lot busier once the handover was done. The charge nurse expressed hesitation over taking the break, because he was worried about the patients on his side of the unit. Peter assured him that he and his partner, Anna, another Filipino nurse, will be on top of things. The charge nurse agreed to take the break and left Peter and Anna to look over the patients.
Not even five minutes after Peter and Anna were left alone that Anna called Peter to ask him to take a look at her patient on the other side of the unit. Peter immediately went to the patient’s room, and found a man in his 50s hooked to a mechanical ventilator through an endotracheal tube.
“What happened?” Peter asked.
“I think his tube is dislodged,” Anna told Peter, looking nervously at the patient.
“What do you mean, ‘the tube’s dislodged’?”
“I think the tube is dislodged.”
“How do you know?”
Anna didn’t have time to answer because the patient suddenly gasped for air, which immediately confirmed to both Peter and Anna that the mechanical ventilator was no longer helping the patient breathe. The patient continued to struggle with his breathing, his restlessness indicating that not enough air was flowing into his lungs.
“What did you do?” Peter asked, immediately taking out his stethoscope. He tried to auscultate the patient’s chest for breath sounds, but he could barely hear any.
“Nothing,” Anna replied, moving closer towards the patient to recheck for chest movement. “I think he just moved, and that dislodged the tube.”
Peter rushed to press the emergency buzzer near the patient’s bed to alert nearby doctors that the patient was in an emergency. He also sent a message to the charge nurse to tell him that the patient’s endotracheal tube was dislodged. He was worried. With the handover still going on, he wasn’t sure if any doctor will reach them in time. He pressed the emergency buzzer a second time.
“What do we do?” Peter asked Anna, their eyes both glued to the patient’s monitor as his oxygen saturation level plummeted from 90 to 80 to 70. His blood pressure was also falling. The patient was heading for respiratory arrest in front of their very eyes.
“I don’t know.”
Peter knew that to save the patient’s life, they would have to immediately disconnect the patient’s tube from his mechanical ventilator and provide the patient with supplemental oxygen through manual ventilation. Years of training have also taught both of them that chest compressions will also have to be done continuously to prevent arrest. However, both nurses knew that they were not allowed to do those procedures on COVID-19 patients.
Cardiopulmonary resuscitation, disconnecting the endotracheal tube from the mechanical ventilator, and manual ventilation were all aerosol-generating procedures. Performing them would generate a high concentration of infectious respiratory aerosols into the air, putting them at a greater risk of exposure and infection.
The patient continued to desaturate as both Peter and Anna tried to defy their own instincts. As critical care nurses, responding to impending respiratory arrest was second nature to them. They were compelled to do the life-saving procedures as they should, but they also knew that doing so will put them at unnecessary risk. Help was coming soon, they knew. But they also knew that help couldn’t come fast enough.
The patient was already limp and unconscious. His oxygen saturation level has dropped to 30. The machines hooked to him can no longer read his blood pressure. The patient’s monitor was a flurry of noise and flashing signals to warn both nurses of the patient’s worsening condition as he desaturated even further. 20, 10, and all of a sudden, flatline.
The high-pitched monotonous alert of the flatline seemed to move both Peter and Anna into action. “Bahala na!” Anna exclaimed, and she and Peter immediately got to work. Anna put down the bed rails, laid the patient flat, and began doing the chest compressions.
Peter rushed to disconnect the ventilator from the patient’s tube and immediately hooked the tube to a bag valve mask. Once he had the mask in place, Peter pressed the bag and checked for a chest rise to ensure he was ventilating properly. Once he saw the patient’s chest rise, Peter turned his head to one side to avoid close and direct contact with the patient’s face. Anna, still doing the compressions, did the same thing.
The team responding to Peter and Anna’s emergency buzzer came a few minutes after they started resuscitation. They told the responding doctor that the patient’s tube was dislodged, and that the patient already went into respiratory arrest. The doctor told Peter to stop the manual ventilation as he went towards the patient’s head to assess the intubation. Peter immediately prepared the materials needed for reintubation, while Anna continuously performed chest compressions. The doctor began to reinsert the patient’s endotracheal tube, a process that took the doctor two attempts to finally perfect. He secured the tube and ordered to recheck its placement through a chest x-ray.
Peter was worried they would both be reprimanded for initiating the resuscitation, but to his surprise, after reintubating the patient, the doctor talked to both of them to tell them that they did not need to worry about breaking protocol. “At the end of the day,” he told told them, “You still saved a life,” he told them.
Peter was relieved, but his relief was short-lived. Wins in the Critical Care Unit during the pandemic were rare and few in between. The revived patient’s lucky outcome was also not an often-repeated success.
In the days that followed, Peter was plagued with patient death after patient death. He remembers spending an hour trying and failing to resuscitate a 29-year-old patient during one shift, so he went ahead and performed post-mortem care on the patient. In the United Kingdom, this meant cleaning the patient, removing all their intubations and insertions, cleaning up their bedside, and finally wrapping them intricately in a white shroud. Just as Peter finished taking care of a dead body, the patient on the next bed also coded.
“I have just finished doing the post-mortem, and the next thing I know, I was already on the next bed, trying to revive another patient,” he shared. “And that patient also died.”
He told me how the coronavirus was almost an amazing pathogen in its unpredictability in wreaking havoc in the body. They couldn’t predict the patients’ conditions. He has seen first hand how quickly it kills patients, even those who are seemingly well. “You see them well and alive before you take your day off, but when you return two days later, they’re already dead.”
I asked him how he dealt with his dying patients, knowing that they’re dying away from their loved ones. “It must be hard,” I told him. “to be an entire family’s stand-in.”
He said that it was. Every time a patient nears expiration, Peter tries to be there for them to hold their hand as they pass away. “It’s cruel for the British to leave a person to die alone,” he explained. “So, we try to be there for them. There are times when families ask to see their sick loved ones over FaceTime, so we’re there for them too, to hold up the gadgets so the patients can hear them.”
Peter shared that he was also the one to call families when their loved ones have already died. The doctors usually call the family first to tell them about the patient’s condition and how there was no longer any way that the patient will survive the disease. When the patient finally dies, Peter is the one who gives a family the bad news. “I try to break it to them gently, but it’s hard in English. Their language isn’t as emotional as ours. It’s hard to soften the blow in a different language.”
“How do you deal with this?” I asked him. “It all seems so heavy.”
“It’s exhausting!” he exasperated. He admitted that he was usually burned out after only two weeks at a full-packed CCU. “It’s difficult because you’re also just stuck at home after your shift. There’s no escape. You just go home to rest, and then you come back to face it all again. It’s the same thing every day.”
Peter used to travel with his fiancé to different countries every few months to escape their hectic lives in the hospital. But now, with lockdowns in place, there was nowhere to go except to work. His only means of truly escaping the pressure of being a critical care nurse was also taken from him by the pandemic.
Nurses aren’t usually taught about how to survive a pandemic. Pandemics are so self-contained in the pages of medical history, its end through vaccinations so definite, that even when we were studying previous infectious diseases, we were only taught about their signs and symptoms, their diagnostic procedures, their course of treatment, their prognosis, their prevention, and the many different ways that we could help save a patient’s life.
But we were not taught about the toll pandemics take on the healthcare professional. We were not told about the relentlessness of their loss. We were not informed about the hands we had to hold just so patients will not be alone during their last moments, not told about the number of bodies we had to clean and zip up in white shrouds or black bags. We were not taught that we would be putting the lives of even the ones we loved on the line.
Peter told me about his experiences as a critical care nurse during a call over Facebook Messenger. At the time, he was on the last few days of his home quarantine and already bored out of his mind. He had to take a leave of absence from work when one of his housemates caught COVID-19. Sarah, his fiancé, was not spared by the disease.
I kept asking Peter if it was alright that I called him, because I told him I didn’t want to disturb their rest. He assured me it was alright. He didn’t have any major symptoms, so he wasn’t sure that he even caught the virus in the first place. Sarah, on the other hand, was still on the mend. A few days ago, she was suffering from severe coughing and colds. She also lost her sense of taste, a problem that has persisted for weeks, even when her respiratory symptoms have finally cleared.
I asked Peter how many days off they had left before they had to get back to the hospital. While he was off, his other teammates shared to him that they already saw an increase in new cases, their first warning of the upcoming swell of the second wave.
“In two days,” he said.
“Already?” I asked, surprised that he had to go back to work immediately after fighting COVID-19, even at home. “That’s too soon.”
“Yep,” he agreed. “All too soon.”
Seven months after the pandemic began in the country, I found myself following a crowd of passengers from Manila inside the Davao International Airport, on our way to get tested for the coronavirus. After passing the test of competency in Makati, I went back home to Davao and prepared myself for the swab test and my upcoming two-week home quarantine.
I had only been in Manila for less than three days, and I had only seen one person while I was there. Despite my precautions, I was still worried that I had inadvertently inhaled the virus while I was out on the streets or inside the airplane.
Davao’s local government unit provided free swab testing for all air passengers arriving at the airport, so I took it as an opportunity to finally get tested and finally feel what it was like to get a nasal swab. For the record, it was not nearly as uncomfortable as it looked. In fact, it felt mildly satisfying. I was surprised to learn, however, that a throat swab was also done for RT-PCR testing. That one was worse than the nasal swab.
After the swab testing, we were ferried by a contracted jeepney to the Tent City just outside of the airport. We were given food before we registered our names at the Nurses’ Station manning the quarantine facility. Afterwards, we were showed our assigned tents where we would stay until our swab test results were released.
The Tent City was made up of sixteen or so big tents, and inside each big tent were ten cubicles that could accommodate two passengers. Each cubicle was only separated by a thick plastic that served as the accommodation’s sole partition. I wasn’t able to see the person on the other side of the partition, but we shared a small toilet behind our cubicle. Every other cubicle was also provided with their own toilet.
The accommodations in the Tent City weren’t that bad. A small cot is provided for you, along with a blanket, a sheet, and a pillow. Meals were also given three times a day. The entire tent was also airconditioned, and several exhaust fans were installed around the tent to make sure that air was circulating freely.
I expected to wait for my swab test results for only 12 hours because that was the experience of other passengers on previous flights. I ended up waiting for more than 24 hours. To say that I had a restless night at the Tent City was an understatement. I was anxious about the person I was sharing the cubicle with, because I didn’t know where she was from. I was also anxious about the other people with me in the tent, because it was so easy to imagine their exhaled pathogens moving around the tent and finding their way to me. I slept with an N95 mask on. My face was creased and bruised by the time I took it off in the morning.
Finishing my last exams for my application to be a nurse abroad also brought with it some anxiety. With them done, I no longer had any other excuse to put off the next step of my plan of coming back to Nursing. That next step was to finally look for a job as a nurse at a local hospital, something that I have not done since I graduated from college.
I began thinking of my time in the Tent City and told myself I couldn’t possibly last 13 more days in the facility, which was a must for nurses who were exposed to COVID-19 patients. I already knew quarantine was part of the nurse’s new normal, but being in a quarantine facility myself made the experience all the more real.
Twenty-five hours after my flight landed in Davao City, the doors of my quarantine tent finally opened, and a nurse with loudspeakers called for us to get ready for discharge. I was ecstatic. I immediately packed my bags and went outside my cubicle. A line has already formed towards the tent doors.
We were marshalled towards the Nurses’ Station assigned for patient discharge. Our names were called one by one, and we were given certificates that proved we tested negative for the coronavirus. I was happy to learn that my paranoia about inhaling the virus on the plane, even through my N95 mask, was unfounded.
They gave us instructions about how to conduct the home quarantine and told us to give our Barangay Health Workers a copy of our negative swab test results and our contact numbers for easy monitoring. They also gave us a symptom monitoring sheet that the barangay will certify by the end of our home quarantine.
After the instructions, we were free to go. I grabbed my bags and waited for a ride. While waiting for a taxi, I looked at the nurses manning the isolation facility. I observed them moving in their stuffy Level 4 PPE and saw them performing their duties behind a clear pane of glass. I began to doubt.
Gracielle Deanne Tubera is a nurse and a writer from Davao City.
This essay first appeared in Agwat-Hilom, an anthology of pandemic-related works published by the National Committee on Literary Arts (NCLA).