Name and Trust withheld to protect patient identity
Correspondence to: [email protected]
Published 08 April 2020
The pleasant memories of my short FY1 ITU placement receded as the anaesthetist greeted us with ‘I’ve been given the impossible task of condensing 2 weeks of ITU courses into a 1 hour session’. We were 50 nervous doctors spaced 2 meters apart in a sports hall starting our critical COVID-19 care retraining. After a short session on donning and doffing PPE we learnt how to prone (think front crawl). The session finished with a 45min session by a senior nurse waxing lyrical about a ventilator found in a decommissioned ITU store cupboard. I knew from the opening ‘I haven’t used one of these for 10 years, it’s an old American machine… and like all things American, it's really complicated’ that I need not take notes. After studying around 15 different documents (varying from 2 to 90 pages long) I was officially ready for redeployment. There was just enough time to call HR to inform them I’ve been re-deployed. They ask if I was still employed by the trust as I’m not on the payroll despite working here for 6 months.
I arrive on my first day, change into scrubs and head for the 8am redeployed Fellows handover. I notice no one wears a mask in general areas, let alone practises social distancing and all handovers are still face-to-face. My Singaporean and Korean medical colleagues were shocked by the lack of general PPE and distancing rules. We are the highest risk people in the hospital, yet we are all tightly knitted in one big group. There’s no handover lead amongst our FY2, CT and ST group as the consultants and anaesthetic teams are handing over elsewhere. But no one cares about seniority and we soon establish that our unit is understaffed due to sickness and pull a junior doctor from one of the other areas.
I take the bay with 6 patients, which is a mix of really sick and those expected to be stood down from the unit. But first there is no PPE and we have to wait for the kit to arrive before I finally enter the bay. There are two extra patients in the small bay built for four patients and everything is compact. The night staff are still handing over at 9:30am and they look exhausted. I survey my patients – 3 tubed, 2 CPAP and a patient with a nasal canula who I need to step down. He is whisked off to the ward before I complete the discharge summary. After 4 years in theatres, I never knew porters could move so quickly. The empty bed is almost immediately filled by a patient who was intubated on arrival at A&E. He was found unresponsive by the paramedics whilst self-isolating and is clearly very sick. He’s quickly assessed by the ITU consultant and we make rapid plans to stabilise him by cycling through various ventilator modes and inotropic drugs.
As I turn to survey my bay’s other occupants I’m told “Doctor, his heart rate is suddenly 140/min, it was 90/min an hour ago”. I rapidly assess the large diabetic patient and his respiratory history who has been intubated for 6 days. The ECG confirms a sinus tachycardia and the parameters suggest underfilling. The consultant is now busy in another bay and I need to act quickly. A prompt fluid bolus of 250ml plasmalyte drops the rate to 120/min and allows time to pause. The consultant returns and agrees with my plan.
Only 1 of 3 computers is working inside the bay, so the various staff take turns transcribing written notes into the EPR. I can't leave the room with my handwritten notes to go to the 'clean' office outside as anything in the bay stays in the bay. I therefore wait my turn.
Suddenly it's 13:30pm and the face mask and goggles are etched into my skin and I have a bruise over my nose but what I really need is a wee. I doff, grab a coffee and go to the toilet whilst a colleague babysits my bay. I take the opportunity to call my patient families from the ‘clean’ office and update them. I’m called a ‘hero’ but I don’t feel like one and return feeling embarrassed and inadequate.
At the donning station, I’m relieved to find one last gown and quickly change whilst the nurse-in-charge tells me to stay in the COVID bay as long as I can because more PPE isn’t due until the late afternoon. Top donning tip: drink water and use the toilet before donning and apply blister protection patches to facial PPE pressure points.
As my name and role are emblazoned on the front of my gown, I feel like I’m wearing a running vest for spectators to call out encouragement and help me to finish a marathon. I felt a similar emotion last night listening to the public applause for NHS workers.
I re-enter the COVID bay and notice a haemofiltration patient is hypotensive (MAP is 60) so I slow the filter, up the noradrenaline and give a fluid bolus. The arterial line on another patient stops working and I site a new cannula whilst a nurse tries a flush. I quickly assess the remaining patients and as I changed the ventilator settings according to the latest blood gas results, I realised I’m beginning to adapt to my new role.
Our new admission is steadily deteriorating and his sats are 75% on FiO2 of 100% and I’m worried he’s slipping into multiorgan failure. His ventilator is working overdrive and he needs inotropes and vasopressors to support his failing cardiac output. His kidneys are shutting down and he’s going to need dialysis. I quickly realise I’m out of my depth and go to the ‘dirty door’ and ask the runner to call the on-call consultant ASAP. The consultant appears and adjusts the anaesthetic machine (we’re out of ITU ventilators) and agrees the plan for haemofiltration. His parameters improve as she calmly brings him back from the brink. I’m both relieved and in awe but there’s no time for reflection as I turn to survey the bay and find another intubated patient showing sats of 75. I try all the airway manoeuvres to no avail and call for a portable chest x-ray. No pneumothorax and the tube is sited correctly. I ask the proning team to flip him onto his front but he doesn’t improve. But it’s now time for handover and reluctantly I leave him in the care of the consultant.
I am the only one masked at handover, in line with today’s new hospital PPE guidelines. Not surprisingly, the others don’t believe the evidence, which reflects the confusion surrounding COVID-19 prevention and transmission but I had already concluded that that individual avoidance of infection is essential. I politely suggested we try and conduct future handovers remotely before leaving to mentally prepare for my first night shifts, which start tomorrow.
As I collapsed exhausted into bed at the end of the first day, I realised I’m gaining valuable airway and general intensive care knowledge, which will be so useful when managing polytrauma in the not too distant future. And at least, the next time my anaesthetic colleagues are taking too long, I'll be able to pop my head in and ask if they 'need a hand'.