| Despatches From The Front Line part Two: A shift in depth. 15:04 - Apr 1 with 3149 views | BlueBadger |
*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-abbrevia
Part one here:
https://wwww.twtd.co.uk/forum/478292/despatches-from-the-front-line-part-one/#0
[Post edited 31 May 2020 2:29]
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| Despatches From The Front Line part Two: A shift in depth. on 15:12 - Apr 1 with 3037 views | BlueBadger |
Part One here:
Despatches From The Front Line part One: by BlueBadger 26 Mar 2020 10:20So, first day back at work yesterday following the escalations of the past 10 days or so.
Very much a 'calm before the storm' atmosphere at [redacted] hospital.
We now have TWO Critical Care Units - Main ITU is now the 'hot' ITU - anyone with actual Covid-19 or strongly suspected will be in here and 'cold'(a former outpatient area close by) is for anything non-Covid-y. At Present.
There's two 'cohort' wards up and running for the unwell-but-non-critical crowd and final preparations for fitting out a third being completed as well as the 8-bedded 'Isolation' ward that we already have.
A&E and the Assesment Unit are eerily slow - with the pubs shut and 'soft lockdown' in place our two main sources of timewasters, sorry 'inappropriate attenders', - drunks and the Worried Well are nowhere to be seen at present.
Anyone who can be decanted out home(or elsehwhere) has been.
Other patients needing ongoing inpatient care are dispersed elsewhere - rather concerningly, a number of very sick, long-time liver patients are currently residing on our 'winter escalation' ward, which is a cobbled-together team of various nursing staff from all corners of the building plus some really rather (I'm going to be generous here) poorly supported junior doctors and a nice-but-not-very-dynamic locum consultant - I was called there three times yesterday with a very unwell individual with some very complicated issues. thankfully, this individual has now been transferred to a more appropriate environment on one of our 'cold' general medical wards.
All elective surgery is effectively cancelled and a lot of 'specialist' nursing services are releasing staff in order to redeploy elsewhere - the main beneficiary of this has been the Critical Care Unit - several staff have left there in recent times to take up these roles and now being recalled to the mothership(and are generally happy to do so, it should be adde), in addition to this, a number of former staff who've moved out of the trust to do things in the private sector are returning to the fold on short-term contracts.
The PDN's(Professional Development Nurses) on ITU have a particularly challenging job ahead of them over the next week or two, training up theatre staff to become 'conscripted' Critical Care nurses. They will definitely be glad when the 'phone war' is over.
Very few, if any, retirees have returned - in the words of one of the wisest consultants I know 'we're seeing the return of those who went 'sideways' with their careers but not those those who retired 'broken".
From a personal point of view, it was a very odd day - finding out the the last patient that I personally admitted into Critical Care turns out to be Covid-19 positive - which means I've definitely had one confirmed exposure and throws my 'head cold' of 7 days ago into a whole new light - I'm still not convinced I've had it as my own symptoms weren't wholly 'textbook'(given that we don't really have much a Covid textbook yet), but it adds another little voice to the back of the mind.
My own team of Critical Care Outreach nurses(we act as 'eyes and ears' for Critical Care, providing support with the sickest on the wards, in a nutshell) are currently 'doubled up' on all shifts for the foreseeable future - which is quite nice as it's usually a pretty lonely job working solo, particularly at night and, as with 'proper' ITU some of our former team members are returning to the fold temporarily. How long the 'doubling up' will last is anyone's guess - I personally suspect that myself and a few other colleagues will be redeployed to Critical Care at some point.
PPE remains something of a bone of contention, with guidelines changing on a seemingly daily basis, but a consensus is developing on a few things, such as PPE during cardiac arrest and for the confirmed cases and those required procedures which are likely to 'aerosol'.
Visiting hours are hit hard - no visiting at all to critical care and extremely restricted elsewhere.
A few reminders however, that life goes on - I spend a very nice half hour yesterday helping a post C-Section lady(and new baby) to her waiting partner's car, several wards are still holding Easter raffles and one of our most treasured volunteers(a young lad with a learning disability) is still offering smiles and compliments(but has stopped offering fist bumps) on the quality of one's hairstyling to all who pass him.
Oh, and the WRVS sweetshop-in-the-broom-cupboard is still open, albeit on reduced hours as all the over-60 volunteers are very sensibly staying away.
Back in again for a few hours over Friday evening to make up some lost hours from a cancelled study day then it's a full weekend on nights Saturday and Sunday.
Stay safe out there, stay home.
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| Despatches From The Front Line part Two: A shift in depth. on 15:23 - Apr 1 with 3018 views | urbanblue |
Respect BB ... Full of admiration for what you are doing. Then to have the energy left to write all this!
Best Wishes mate. |  | | |
| Despatches From The Front Line part Two: A shift in depth. on 15:24 - Apr 1 with 3012 views | BlueBadger |
| Despatches From The Front Line part Two: A shift in depth. on 15:23 - Apr 1 by urbanblue |
Respect BB ... Full of admiration for what you are doing. Then to have the energy left to write all this!
Best Wishes mate. |
It's only 8 hours out of 31 covered there as well! | |
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| Despatches From The Front Line part Two: A shift in depth. on 15:25 - Apr 1 with 3008 views | PJH |
| Despatches From The Front Line part Two: A shift in depth. on 15:23 - Apr 1 by urbanblue |
Respect BB ... Full of admiration for what you are doing. Then to have the energy left to write all this!
Best Wishes mate. |
I have been trying to think of what to post in relation to Badger's post, you have done it for me. |  | | |
| Phil/Gav... on 15:28 - Apr 1 with 3002 views | BlueBadger |
..is there any way to index/link these without the whole mass of text coming across each time? | |
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| Despatches From The Front Line part Two: A shift in depth. on 15:36 - Apr 1 with 2991 views | GeoffSentence |
As well as everything else, you write very well. |  |
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| Despatches From The Front Line part Two: A shift in depth. on 08:49 - Apr 3 with 2702 views | Alan_Handsome |
Hats off to you, Sir. I love the window of reality, into the fight agiainst COVID-19, that you open up. It's refreshing reading something unfiltered these days.
I don't envy you, but i do admire you.
Brilliant Stuff, keep going!!!
THANK YOU!!!! |  |
| You can't polish a turd....but you can sprinkle it with glitter! |
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| Phil/Gav... on 09:14 - Apr 3 with 2689 views | PhilTWTD |
| Phil/Gav... on 15:28 - Apr 1 by BlueBadger |
..is there any way to index/link these without the whole mass of text coming across each time? |
Sorry, only saw this late last night, spent Wednesday transcribing the Jim interview and did little else. I don't think so re the text thing. It's the way the site works, although I'll have a play to see whether something works. Thanks for the posts, think they give a great insight. Keep safe. |  | | |
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| Phil/Gav... on 09:16 - Apr 3 with 2682 views | PhilTWTD |
| Phil/Gav... on 09:14 - Apr 3 by PhilTWTD |
Sorry, only saw this late last night, spent Wednesday transcribing the Jim interview and did little else. I don't think so re the text thing. It's the way the site works, although I'll have a play to see whether something works. Thanks for the posts, think they give a great insight. Keep safe. |
I think I've done something which makes that appear as a link. | | | |
| Despatches From The Front Line part Two: A shift in depth. on 14:30 - Apr 3 with 2431 views | Nthsuffolkblue |
Gave you all your round of applause at 8.00 again last night.
Reading what you have written helps understand the reality of it better.
Thanks again and keep safe. So hope this really does change attitudes towards public service funding and the value we in general put on our public servants after. |  |
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| Despatches From The Front Line part Two: A shift in depth. on 15:07 - Apr 3 with 2406 views | BlueNomad |
BB, you are all heroes. Thank you and all your colleagues. Hopefully you will, in future, always get proper respect and support from our political "masters".
Stay safe E_B |  | | |
| Despatches From The Front Line part Two: A shift in depth. on 18:18 - Apr 3 with 2259 views | EdwardStone |
| Despatches From The Front Line part Two: A shift in depth. on 15:07 - Apr 3 by BlueNomad |
BB, you are all heroes. Thank you and all your colleagues. Hopefully you will, in future, always get proper respect and support from our political "masters".
Stay safe E_B |
Might I suggest a minor amendment to your post Mr E B
Last sentence to read ...….support from those intellectual pygmies who pose as our political "masters" |  | | |
| Despatches From The Front Line part Two: A shift in depth. on 20:08 - Apr 3 with 2213 views | Bluespeed225 |
So interesting, and a window into the frontline. I’m in an ‘essential business’ (yeast), but having a missus within the NHS this stuff is different level. Thank you for posting. |  | | |
| Despatches From The Front Line part Two: A shift in depth. on 20:00 - Apr 4 with 1858 views | syntaxerror |
When I read these, and remember the abuse certain members of the community gave you because of your job, I just hope they are reading these and thinking about what they did.
Thank you BB, thank you very much. |  | | |
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