Despatches From The Front Line part Two: A shift in depth. by
BlueBadger 1 Apr 2020 15:04*Disclaimer: names and locations are altered to protect confidentiality*
I'd recommend taking a quick glance at the list of abbreviations and terms before reading this as I won't be taking time out to explain terms here. The link for that post is at the bottom of this post.
A longer entry than I intended but there's a lot of 'scene-setting' as well as some in-depth stuff t give you a flavour of some of the stuff I do.
I'll try to bash out more of a 'weekend summary' a bit later today.
'F*ck me, you look like a 15 year old lesbian' is the greeting I receive as I walk into the office at 6 on Friday evening.
I have shaved off the straggly collection of hairs hanging round my chin that I humorously refer to as a 'beard'. I've done this partly in solidarity with my two day colleagues, Jim, a gentle giant of 6 foot plus and over 20 stone and Paulo a affable Portuguese lad who has recently joined the team from one of the acute surgical wards. Both guys were, up until last week owners of the sort of magnificent foliage that sparrows might nest in but are now clean-shaven. The other reason I've done it is the same reason that Jim and Paulo have done, which is to ensure better, closer FFP mask fitting.
Friday I am working the 'twilight' shift from 1800 to 0200, it's a nice shift. As 'second person on' you generally don't have the irritation of holding the bleep but you do get to do all the jobs that the bleep-holder can't get to. These are usually the more time-consuming jobs of various kinds so that the bleep holder can get on.
The lads have had a busy day but it is now starting to settle down a bit. Jim is just off to see a patient on our caseload, whilst Paulo is writing up another one. As it's 2 hours until the official night person comes in, I pick up a few odd jobs and bits of 'housekeeping'.
One of these jobs is a 'follow up' visit to a patent who has been recently discharge from ITU. It turns out that the patient is one which I transferred into ITU just under a fortnight ago in severe respiratory distress. It turns out that the patient in question has swabbed 'positive' for COVID-19 and ultimately spent 7 days intubated and ventilated.
On visiting their side room, I'm pleased to see that whilst looking tired and weak, they are considerably better than when I last saw them and will, with a week or two's worth of rehab work from the physiotherapists and occupational therapists be able to go home.
Whilst visiting this patient the ward nurses ask to speak to me about another patient in their care who's NEWS score is high and has been for a number of hours now. A quick flick through the notes shows a plan from the consultant of 'consider palliation if continuing to deteriorate'.
Further perusal of observations and blood tests through the past 48 hours or so shows a consistent pattern of deterioration so I suggest that they contact the medical register on call for the ward with a view to deciding on changing the focus of treatment.
I return to the office around 1930 and Jenny, who is on the night shift is here.
Jenny is in her early 60's but with the energy of a woman half her age and a wealth of experience to draw on. Jenny is semi-retired and normally works only one shift a week but has offered to do more whilst we live in Interesting Times.
Jim and Paulo hand over and Jenny and myself make a plan for the night up to 2. One of the patients on the caseload is 'A', an individual of 80 with a suspected COVID-19. They were swabbed 2 days ago but results will not be back for at least another 24 hours. They have been seen by ITU and due to their exceptional fitness for their age(they still drive, work a few hours a week and walk a mile a day with their dog) the ITU consultant offered them an intensive care bed which the patient has refused as they do not fancy a prolonged period of intubation and ventilation.
I don't blame them, as most COVID patients appear to be needing 7-10 days of ventilation at bare minimum, enough to significantly weaken people half their age. A period of intubation that long could see them permanently debilitated(at best)and they really don't fancy that at all.
It has therefore been decided that this patient's 'ceiling of care' will be ward-based with an option for CPAP to support respiratory function if it continues to deteriorate and the patient is able to tolerate it.
The plan is for an ABG at 2100 and then review. I decide that I'll go to that to keep Jenny, as bleep holder, free to take referrals as the process of assement and set-up is likely to be a lengthy one.
We then go from our team handover to medical handover. In the daytime this is quite a formal affair, but it's much more relaxed at night with fewer people around - the outgoing day medics plus the night time, who are comprised of the medical register and two FY2's. A consultant is also on-call but they are usually at home and only called in extreme circumstances.
Tonight(and the next two night's) team are Chris a lanky but highly approachable and pleasant medical registrar who is specialised in rheumatology, Emma, a rather nervy but willing-to-learn and hardworking medical FY2 and Sam, a dryly humorous bloke who has offered to be 'dirty' FY2 covering the 'covid wards' tonight(and, as it turns out, all weekend). 'Site' and the night bed manager are also there but are quickly called away to address a staffing issue on one of the wards.
After handover, Jenny and I go our separate ways. As I arrive on the ward the outgoing FY1 there has just taken A's ABG, so I run the sample for him and it shows a significant drop in A's oxygenation. A quick call to Chris to confirm plan of treatment and then I go into A's room to start CPAP therapy.
I explain the process nd rationale for treatment to A and they consent to treatment.
Normally when starting any kind of non-invasive ventilation the standard practice is to start up the CPAP machine, place the mask on the patient's face and then adjust the mask to fit. Due to the risk of 'aerosolling' germs everywhere from the tubing of the mask it is Trust policy that we apply mask, then start the ventilator. This makes it a bit more dangerous than usual, so I attach some saturation monitoring to 'A' and 'pre-oxygenation' by turning up the oxygen he's currently on as high as it will go. When I'm happy I quickly apply the mask, fire up the machine and step back to monitor proceedings.
Thankfully, I have worked quick enough that A's sats haven't dropped too dramatically - 95% to 90% isn't bad at all, considering how compromised the respiratory function is. I make some quality-of-life checks with A - how does the mask feel, is it too tight, is there any air leaking out from underneath the mask?
A reports feeling very comfortable and, over the net 20 minutes as I fine-tune and ramp up the settings on the ventilator to where I think we'll get a decent balance between comfort and effective therapy, actually falls asleep.
After I've established the setting for the machine, I then wait an hour closely monitoring vitals all the time. When the hour is up I repeat an ABG - A is surprisingly tricky to get a sample from but I persist and get a sample. One of the ward nurses very kindly runs the sample for me and it shows a decent level of improvement in oxygenation.
At this point I message 'site' requesting that a member of staff from the respiratory ward come relieve me. Presently on A's ward there are no staff trained to run NIV safely so the agreement overnight has been for the nurses on the respiratory ward to take over A and a nurse from A's ward will go to the respiratory ward for the rest of the night.
'Site' messages back to tell me that she's presently, and I quote, 'busy at the moment coaxing a patient off the roof'. Evidently the current lockdown isn't deterring the psychiatric patients from ED then.
Half an hour later she messages me back to tell me that relief is on the way and sure enough, my relief appears. Whilst she does the changeover I take another set of obs on A, update my paperwork and message Jenny to let her know I'm free.
I get back to the office around 1230 and do a 'cuppa and catch up' with Jenny, who's had a busy night. Most of her night so far has been with a patient in ED who's drank a litre of vodka to themselves and then fallen down the stairs. They are unhurt but has been intermittently 'kicking off' as well as having a rather varied consciousness level and needing som input from both our team and the ITU team. Eventually they wake up enough to be viewed as 'safe for the wards' and are despatched to the assessment unit.
My final call of the night is to 'B', another suspected Covid who is intermittently desaturating. On turning up to the ward it emerges that the patient has been not particularly co-operative with keeping an oxygen mask on and has been removing it to walk to the toilet, take drinks to other patients in their bay and to eat and drink themselves. This results in a rather inconsistent oxygen delivery. Jenny decides to 'kit up' and see this patient in person. Through the door in the bay, whilst she is reviewing him I can hear Jenny issuing what can only be described as ' a bit of a boll0cking' to the patient, telling them in no uncertain terms not to remove their oxygen. When they protest that they can't drink due to the mask, I pass in a fistful of drinking straws.
With this final action of the night, I ask Jenny if there's anything needing doing, she says 'no' so I leave to drive home. On my way home I decide to get fuel from the all-night unmanned petrol station at a nearby-ish supermarket. Town at 2AM on a Friday night is usually busy with people falling out of pubs and clubs, taxis and post-pub fast-fooding.
None of that is going and it's very, very eerie indeed. My chosen soundtrack of 'Folksange' by Myrkur adds to the vibes.
The only person I see on my drive home is a sole delivery driver dropping of at the supermarket. He gives me what can only be described as 'a Look'.
Interesting times indeed.
Useful terms and abbreviations here:
https://wwww.twtd.co.uk/forum/478292/4576782/common-terms-practices-and-abbreviation-by-bluebadger#4576782
Part one here:
https://wwww.twtd.co.uk/forum/478292/despatches-from-the-front-line-part-one/#0
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