By G Gonzi, R Gwyn, K Rooney, M Horner, K Roy, J Boktor, A Kumar and H Pullen
Royal Gwent Hospital, Newport
Corresponding author e-mail: [email protected]
Published 14 May 2020
As a group of orthopaedic registrars in Wales, we are proud and privileged to have joined our intensive care (ITU) colleagues in the fight against coronavirus (COVID-19) over the past four weeks. At the Royal Gwent Hospital in Newport, the worst hit hospital in Wales, we were recruited onto the ITU emergency rota. Throughout this experience we have become more resilient, gained clinical and procedural skills but also non-operative skills that will enhance our abilities as surgeons and improve our patient care. We feel it is important to record our role as orthopaedic registrars in this historic pandemic and share our learning experiences.
Pre-deployment feelings, concerns and expectations
In preparation for the COVID-19 outbreak great efforts were made to increase ITU capacity in our health board. Extensive reorganisation and redeployment of staff and resources took place with all elective theatre activity cancelled. We were all aware of the serious pressures on ITU and how it was operating far beyond its normal capacity.
Following speculation and rumours we received confirmation of our redeployment to the ITU by our clinical director on the 8th April 2020. A well-structured formal induction describing ITU layout, team structure, safe donning/doffing areas and logistical issues on the 10th April prepared us for our first ITU shift. Team morale was high as we were all keen to join our colleagues in ITU in treating the sickest COVID-19 patients.
There were obviously significant anxieties amongst us; catching COVID-19, bringing it back to our families and whether we would be of any help in Intensive care setting? We were also concerned about our own orthopaedic training and risk of skill loss. Our surgical training was effectively on complete standby, compounded by the fact that most of us are yet to reach our operative numbers and workplace-based assessments for the year. More importantly few of us had prior critical care experience and were apprehensive on how we may apply our orthopaedic skill-set to this new scenario. Luckily, we had frequent communication with our training programme director who understood the current situation and provided support and guidance. As a group, we saw this opportunity as a unique learning experience, a chance to challenge ‘orthopaedic stereotypes’ and we encouraged each other to enjoy our redeployment.
In preparation for the role, we familiarised ourselves with important guidelines provided to us by the ITU department such as up-to-date trust personal protective equipment (PPE) protocols, daily COVID-19 checklists and re-familiarised ourselves with the current CCRISP (care for the critically ill surgical patient) provided by the Royal College of Surgeons.
ITU emergency ROTA
Our group of seven training registrars (ST3 to ST6) joined the ITU emergency rota full time having been released from orthopaedic commitments. This rota was divided into five teams each containing eight doctors: (team Draig, team Melyn, team Gwyrdd, team Glas, team Porffor); each led by a senior ITU/anaesthetics trainee with overall care supervised by an Intensive Care consultant on a day to day basis. Each team included a balance of airway trained personnel and non-airway trained doctors, from accident and emergency trainees, to foundation doctors, dermatology trainees and general surgeons. A rolling rota was designed with six days on, progressing from two early shifts (08:00-17:00), two late shifts (16:00-01:00) and two night shifts (00:00-09:00) followed by three days’ rest. Each team was divided into smaller sub-teams in charge of manning Main ITU, converted theatre recovery ITU, and upgraded HDU/CCU ITU.
Our roles as orthopaedic surgeons in ITU
The first day on the units was an overwhelming one, we found ourselves faced with large numbers of staff and patients, it wasn't possible to truly appreciate the enormity and severity of the situation until we got there. We quickly found that we each occupied wide, versatile roles in ITU adapting our skills to make ourselves as useful as possible. In some cases, our orthopaedic skills and knowledge were beneficial. In one patient our diagnostic skills expedited the discovery of the source of sepsis of a critically unwell patient admitted with suspected COVID-19 complicated by multi-organ failure, and a prior history of back pain. On reviewing the abdominal CT scan, we identified changes consistent with infective discitis that had been previously reported as ‘no bony abnormalities’ and highlighted this to the ITU team. A lumbar puncture performed drained frank pus and the diagnosis of a spinal epidural abscess was suggested, confirmed on a subsequent MRI. This was then treated operatively by our spinal surgical team.
We were valuable members in ‘proning’ and ‘supinating’ teams bringing our skills learnt from theatre positioning to the unit. Particular attention should be paid on relieving pressure points and preventing future injuries from our experience.
Many theatre nurses and operating department practitioners (ODPs) have also been redeployed to ITU. We found that the presence of a friendly, familiar face and the acknowledgement that we were all out of our comfort zone but learning and pulling together in a time of crisis was a boost to morale and camaraderie.
Our main role was in the assistance of the day to day running of the unit which involved administrative, procedural and communicative roles. We were part of the twice daily ITU ward rounds and were involved in executing generated jobs. They ranged from inserting peripheral venous lines, catheters, nasogastric tubes and arterial lines following training. Further tasks include communication with other specialties (radiology and microbiology commonly) and assisting in transferring patients to the radiology department for imaging studies. Our involvement in these tasks, albeit simple at times, proved to be great help to our ITU colleagues who could focus their energy on tending to unwell patients on the unit such as resolving airways or troubleshooting ventilator issues. We were thus important ‘retractors’ that allowed for the provision of high quality, safe in and out-hours critical care for COVID-19 and non-COVID-19 patients at a time of unprecedented demand.
The first point we wish to mention is the respect we have gained for our anaesthetic/ITU colleagues, ITU nurses and theatre nurses/ODP’s. Looking after ITU patients wearing full PPE is both physically and emotionally exhausting. The deaths are harrowing and discharges such joy. The way they have all admirably stepped up to the task of reworking their intensive care units, looking after multiple, incredibly sick patients in such a demanding environment, with limitations to their normal resources, has been a privilege to witness and play a small part in. As previously mentioned, we had limited prior experience of ITU, our colleagues have been welcoming and supportive mentors. They have each taken time, and effort to teach us. No question was too simple, silly or irrelevant. All previous pre-conceived specialty stereotypes were discarded, we were all one team in treating this disease.
This experience has been a hugely positive one. We have gained skills that will improve us as orthopaedic surgeons. First-hand ITU experience has given us confidence in managing critically ill patients with acute breathing and circulation disorders and has enhanced our interdisciplinary discussion. We envisage that this will be useful when managing complex polytrauma patients along with our medically complex neck of femur fracture patients. We have gained new procedural skills including inserting resuscitative lines, arterial lines and central lines.
At the time of writing this article, we are awaiting the relaxation of lockdown measures along with reintroduction of some elective surgical services wherein we will shortly be recalled back to our home specialty. We will take the lessons with us and they will allow us to become better orthopaedic surgeons. We will not forget the patience, or the kindness, dedication, and sheer hard work of the intensive care team. We stand ready to help our ITU colleagues again at short notice should we encounter a second peak in the months to come. We hope that need never arises.