COVID-19: the frontline view from ITUJun 22, 2020
Health Bar Special
Welcome back to the Health Bar. Normally what I would do is take you on a journey through an illness or a disease and talk about the cool history, the nuts and bolts of how it works and all the ways we treat the issues. Not today though. Today we will talk about dealing with Covid whilst on the frontline.
You may have noticed that I haven’t put out much in the way of content or articles on Coaching for Geeks and I am sorry for that but the reason is actually the basis of what I will be talking to you about. My own first hand experiences from the frontline.
There are tons of articles, press releases, medical experts advise, etc, out there for you to read up on regarding what Covid-19 is and how to protect yourself, which is why I am doing it this way, giving you a brief insight to what we do and why.
In my hospital, I normally work in surgery (ENT and paediatrics) but when Covid-19 started to become an issue in the UK around March time I put myself forward to join the intensive care team. What follows are some of the trials we faced, the often difficult decisions we had to make, the treatments we used and everything in between. Strap in.
PPE – Personal Protective Equipment
Ah safety kit, the bane of my skin for the last few months. Early on the PPE we had was good, the team and I certainly felt protected going onto the department that had become completely Covid-19 positive (over 30 ITU bays full). That physical feeling of being protected was good, right up until around the 2nd hour in full kit, knowing you’re on a 14-hour shift with skin that’s already going red and the start of a headache you didn’t realise would be your companion for the next few months.
We changed PPE roughly every 2 hours as per manufacturer instructions, or if we were headed into a bay to do something for the patient, but it was tough. The ward was very hot from lots of equipment, no open windows, and people with fevers radiating heat. Mix that with layers and masks and you won’t be surprised to hear a few of my colleagues passed out. It was unpleasant. The news, and the government, constantly updated us with positive PPE news, which was always met with laughter in the staff room – we never actually saw this oft-promised PPE after our initial supplies depleted.
Then it got worse. The good stuff had run out and the mediocre kit was just about hanging in there. Along with management changing the guidelines seemingly hourly, government lies and despite the trusts best efforts, very few people felt well-informed on what was right or wrong. Most of the time we just tried to employ common sense and do what we could for our patients and our own safety. At times it seemed like the blind leading the blind whilst gambling with staff and patient safety.
PPE still hasn’t improved, sadly, but I don’t want to spend too much time on it. Though if anyone can recommend a good moisturiser for broken, dry, skin my face and hands will thank you.
Monitoring the situation
We watched patients 24/7. This was split between 14 hour day teams, and 12 hour night teams (with overlaps for handover). Each patient was cared for one on one and had a whole host of kit to support them. “What kit?” I hear you ask, well fellow geek, I will tell you.
The basic monitor gives us stuff like:
- A second-by-second blood pressure which we got via something called an arterial line. Think of a needle that goes into the artery in your wrist and picks up the pressure against it. Measuring blood pressure by the second helps us respond far more effectively than doing a cuff reading, even as often as every 5 minutes. It also gives us the luxury of taking blood samples from it without having to stab a person again and again.
- Heart rate and pulse are recorded here via electrocardiogram (ECG) dots and a finger probe called a Sats monitor/pulse oximeter. These numbers are often the same, and in the general public are interchangeable terms, but medically your heart rate measures the electrical component of your heart beating and the pulse shows the mechanical component of your heart beating. This is really useful in identifying some types of cardiac arrest like a PEA (pulseless electrical activity).
- Cardiac trace from the ECG, so we can get a better view of the heart and whatever rhythm it’s in.
- An end-tidal carbon dioxide detector is plumbed into the tube and measures the amount of CO2 that comes out per breath. We love this because it confirms the tube is in the right place, and that the body is still using oxygen and producing carbon dioxide.
- Oxygen sats via the sats probe. This is the saturation of peripheral oxygenation. Simply put, this tells us how much oxygen is in the body at the peripheries, because if it’s good at the fingertips, we are confident it’s good in the tissues of the organs
- Respiratory rate. Via the ECG, and gives us an indication of that person’s work of breathing. Too fast can mean they are in pain or that CO2 needs to be blown off, too slow can mean respiratory failure.
These help us out a lot with what we need to know, but it isn’t the whole picture. For that we need to measure and record a few more things like:
- Urine output
- Fecal output
- Capillary refill time (squeeze the end of your finger for 5 seconds, release and it should be back to normal within 2 to 3 seconds)
- Skin tone/colour
- Nasogastric feed
- Pressure areas
- Pupil reaction
- Chest sounds
- Tube pressure
- Plus a few more that would be patient specific but there is a big one left to talk about. Bloods.
Bloods are taken regularly and dictate a lot. Bloods will tell us things like the levels of potassium, calcium, lactate, glucose; it tells us the oxygen and carbon dioxide fractions; if they are respiratory or metabolic acidotic/alkalotic at the time, if we need to change the rate of heparin etc. Bloods, to me, are the best indicators of how someone is really doing.
As you can tell we keep an eye on a whole host of things, and it’s also why ITU nurses are incredible. But it doesn’t stop there, as we monitor, we treat. So what sort of treatments have we been doing?
Treating the unknown
Covid-19 doesn’t yet have a cure, nor a vaccine. It is a foe we have had to fight with one hand behind our backs and no game plan. Different trusts spoke at length with one another on things that seem to help and what didn’t. Anecdotal evidence was all we had. Let’s cover what we did do
- Tubing. Every single COVID-19 patient in my trust who was ITU worthy was intubated and ventilated. This gives us the best control and gives the patient the best chance. The lungs are shot so we take over and the ventilator allows us to control the whole process of breathing. The tube goes beyond the point of the vocal cords but above the carina and is sealed in place with an inflatable anchor. The downside to this is pressure sores. They can be horrific, even with every attempt to negate them. Though, if the choice was a crappy lip scar or death, I’m taking the scar.
- Proning. Every few hours we put people onto their fronts. Again pressure areas are a concern but this helped really open up the base of the lungs. A good percentage of people responded well to this and were turned often for days/weeks until they improved or no longer responded positively to it. The ones that did respond we found their oxygen requirements were far reduced whilst on their fronts.
- Dialysis. As the lungs start to fail other organs can follow suit giving you multiple organ failure. The kidneys are hit hard and they suffer a lot in this scenario so we try to help by cleaning the blood outside the body and popping it back in again. This will ease the workload the kidneys have to deal with.
- Infusions. Each person will have had a cocktail of meds going in constantly via pumps at varying rates for varying reasons. The main offenders are propofol to keep them asleep, morphine for pain, metaraminol for blood pressure, and noradrenaline also for blood pressure. These primarily were attached to a central line in the neck.
- Tracheostomy. Finally something in my ENT wheelhouse. A big thing to do and a decision to give someone a trachy is never a light one but patients responded well to having the procedure done. We found it reduced the work of breathing which helped people recover. The recovery after is long as you need to work the central nerve again as you quickly forget how to swallow. Lots of time with the incredible speech and language specialists follow.
Those are the main treatments we tried, for better or worse, in my trust and thankfully they seemed to help in a lot of cases. Sadly not all though.
The fan (that the shit is hitting)
People died. Lots of people died because of COVID-19 and it’s likely lots more still will. I am going to tell you about one such situation that happened at the end of April.
I was 9 hours in on a day shift and my patient was responding well to treatment so I was feeling pretty good. Relatively. I was in the PPE that we wore in the middle zone as I didn’t need to get fully suited and booted for around half an hour to do meds. I was typing up notes when I heard those horrible words
I NEED HELP
2 bays down from me a colleague pulls the alarm and we spring into action. Normally we dive in, do a quick assessment, confirm an arrest and I get on the chest and start CRP. But. This is Covid. I’m not, like a few others who are free, in the full PPE. I am only the standard mask, gloves and apron. We can’t jump in. Every bone in my body pulls towards getting in that bay and doing everything we can to save this poor person’s life, but I can’t. I have to think of my safety, other people’s safety too. We have to get into full kit before we can go in.
I am getting kitted up as quickly and as safely as humanly possible, all whilst I can see my colleague doing everything in her power to keep this person alive. I’m putting on gloves whilst someone’s relative is losing the battle with Covid-19 and it’s horrible. It only takes a minute but it feels like an age.
We make it in and take over. It’s grueling, hot, stressful work.
47 minutes later, we stop.
There was nothing more we could do. We then have to go back to what we were doing, putting on our best impression of someone who hasn’t just done that, who hasn’t just failed.
It’s tough. I hadn’t seen my kids in 2 months because of Covid and needing to protect them, I had worked a horrific number of 12+ hour shifts around the clock, insomnia was kicking my ass. My body, mind and emotions were shot and I’d seen more people die in that time than I care to recall, despite everyone’s best efforts. These are all people with families who sent letters, pictures and wishes. People who didn’t deserve this fate. I got into the shower at work a few hours later, sat on the floor and cried. I felt beaten. Weak. Useless. Alone. Tired.
The light at the end
Mercifully, not all the stories end that way. Plenty of my patients, after weeks on ITU, went home. It was one of my greatest joys as a healthcare professional to chat with them, hear about their lives, meet (via the internet) their wives, husbands, kids, etc and to tell them all their loved one was doing ok. The belief that all our hard work and sacrifice had worked, paid off, was phenomenal.
To hand over, for the last time, to the rehab ward and wish them all the best followed by a handshake (gloved, obviously) and a thank you, warmed my soul. No, their journey isn’t over, but the light at the end of the tunnel was that much clearer and brighter.
The whole process was exhausting. The cognitive load needed to look after Covid patients is immense. You would get in, hoping that Mr X or Miss Y were still there and you would buckle down. Aware you were not likely to get a decent break, you were going to hurt, but it was ok because they were ok. They needed you in their most vulnerable moment so you did everything you could despite the cost. Just so they get to have another birthday or see their child get married in the future. It made it worth it.
A few months have now passed since the start of the pandemic and for everyone on the front line it has been a painful battle. Full of lows, frustrations, anger and pain. The work has been something that will live long in the memory and continues that way. Covid is a killer. It kills in a horrible way, but we will fight on.
A second wave is likely, so I hope you all stay safe, think and plan with the best scientific advice in mind, oh and wash your damn hands.
I hope this insight has helped you appreciate all that’s going on a little more and you can even say you have learnt a little something.
As always geeks, stay safe and healthy
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