Quantcast
Please log in or register. Registered visitors get fewer ads.
Forum index | Previous Thread | Next thread
Despatches 2: Last working day of 2020 17:02 - Jan 7 with 2559 viewsBlueBadger

(It's back! As before, all names and locations changed to protect confidentiality – please PM if you think you can recognise someone and I'll remove and/or amend)

A couple of weeks back, someone referred to the situation we're facing in hospitals as 'the eye of the storm'. Wrong.
The eye of a storm is the calm place in the centre where you watch chaos unfolding on all sides around you. In the COVID-19 pandemic the 'eye' of the storm was summer, when we could have preparing, making plans, resting staff, etc, etc before the inevitable chaos resumed. So, here we are again, at the edge of the storm.
Since the start of 2020 my boss(enthusiastically supported by a number of medical consultants and has been trying to push for funding to bring more Outreach nurses into the service with some success, it has to be said. We've been able to bolster our numbers slightly and we're now permitted two nurses on EVERY shift, as opposed to running with one nurse covering a whole hospital's worth of 'hi my patient is really sick and the junior doctor is /not answering their bleep/already seeing another sickie/clueless' calls at night.

I'm on the day shift, my companion for the day is Carolina, a Portuguese lady who's fearsome and energetic nature is only matched by her lack of stature. Its rumoured amongst the porters(a bottomless source of hospital gossip) that Carolina is the source of the Trust maxim of 'never argue with small Portuguese women.
Overnight has been Big Jim and Paulo – they've had a busy one. They're all busy ones right now.
Unusually for the present times, both are in the office when we roll in – right now, there's no escaping the wards at 0730 to prepare for handover, you're working till the clock hits 8 and then handing over. If you're lucky.

They hand over a pretty busy looking caseload of some 6 patients - this doesn't sound like a lot, but the average punter on our caseload is likely to require an hour, or more, of our time a day, plus we'll be answering bleeps being referred others as the day goes.
Handover done, we head for medical team handover – there's sometimes people around that the doctors have seen that we haven't that they'll want us to see – today however there's nothing to add, thankfully.
With that done, we work out our 'order of business'.
We decide to start with ward C-1, our longest standing 'hot' ward as we have three punters there – two individuals in their late 50's/early 60's who have high oxygen requirements and might need ITU later in the day and another, an elderly person in their 80's who also have high oxygen requirements.

Normally the older person wouldn't be on our list as they'd be at 'ceiling of care' and sadly, there would be very little we could add to their care to ensure bets possible outcomes, however this person is Portuguese with limited spoken English, has dementia, poor baseline health and their family has apparently insisted that they should be 'for everything'.
Carolina bravely volunteers to take on this individual – on assessing them, she quickly establishes that they probably don't have sufficient mental capacity to be involved in an in-depth medical conversation about their care and wonders if their family's English isn't entirely up to the job of such a discussion either – she corners the patient's consultant and they make a plan to allow a rare 'in hospital' visit for the family so they can realistic discuss treatment options and appropriate ceilings of care with Carolina translating and ensuring everyone fully understands.

Whilst Carolina is doing this, I see our other two caseloaded patients – the first is a Caribbean in their late 50's who's just stepped down from ITU – they've spent 12 days there, mostly needing CPAP via facemark and high-flow oxygen whilst also being encouraged to 'prone' as much as possible.

'Proning' is the act of lying on one's front in order to allow recruitment(expansion) of larger areas of the lungs(notably the bases) as an aid to oxygenation whilst also encouraging the draining and movement of secretions. It's particularly effective in COVID pneumonias as they tend to affect the upper and mid-zones of the lungs leaving bases relatively clear, so the patient is working with more 'good' lung and thus oxygenates better and needs less mechanical support for their respiratory function whilst treatments kick in and push the disease back.

On arrival at the bedside, they're sat up in a chair, talking ninety-to-the-dozen on their phone in patois to a family member and have just polished off a large breakfast and what looks like a gallon of coffee. They graciously put down the phone and offer effusive greetings, smiles and thanks for their care so far. A quick 'once over' shows that they need minimal amounts of oxygen to maintain saturation levels and are only feeling breathless if they're on their feet for a substantial amount of time. Great news – I happily inform them that they're doing brilliantly, double check with their nurse that there's no concerns that I might have missed(there aren't) and triumphantly remove them from the caseload. I'm doubly happy because I had a hugely frustrating day trying to get them into ITU 14 days ago no avail – the next shift finally achieved that, so it's good to see them on the other side.
Next patient is a different job altogether.

They are in their early 60's with no significant previous medical history other than high blood pressure(if you look hard enough, everyone has an 'underlying condition') came in 24 hours ago and oxygen requirement has gone from 24%(a shade over room air) to 40% overnight and was put on the caseload by Paulo because 'I didn't like the look of them'.
'I didn't like the look of them' is perfectly valid caseload criteria, by the way. There's studies out there suggesting that nurses' instincts are often a better indication of trouble brewing than 'early warning' tools.
Arrival at the bedside worries me somewhat. Firstly they're lying flat on their back – if proning is the best for oxygenation then lying supine is absolutely the WORST thing you can be doing.
Checking oxygen saturations I get a result of 84% - anything over 92% is considered the value to aim for in those with COVID without pre-existing respiratory conditions, so 84% is a bit of a concern.
As is typical with COVID patients, they're also 'happy hypoxic' – fully able to talk in long sentences without getting out of breath – a feature which appears to be pretty unique to COVID – it;s not uncommon to see life-threateningly low levels of oxygen saturations whilst the patient experiences little to no symptoms of respiratory distress that you'd expect to see in other chest complaints.
I make them sit up and turn up the oxygen to 60% and take a listen to the chest whilst I'm waiting for the oxygen increase to kick in. A listen to the chest yields bilateral(both sides) crackles to the upper and mid-zones of the chest – a textbook feature of COVID(assuming it's made it into textbooks yet), but that's not really what's bothering me. Oxygenation is painfully slow to recover – in the time I've been listening to chest(and doing some other bit of poking and prodding) saturations have only risen to 86%. I increase the oxygen to a non-rebreathe mask – these are the oxygen masks with the reservoir bags on the bottom of them that you've probably seen used on 'Casualty'. They deliver around 85% O2 and are the most O2 you can deliver in a ward based setting. They're generally only ever used as an emergency measure to get you out of a hole.
I watch the saturations slowly creep up to 92% and hover there without getting much beyond it.
The words 'Guess I'll be calling ITU then' crawl across my mind with weary resignation – the unit is packed and short-staffed. It'll need to be a good 'sell' to get this one in.

And then I hear a raucous laugh from across the bay followed by and explosion of rapid-fire patois and a flash of inspiration hits - the punter across the way, the one I've just seen, avoided needing intubation because they was able to lay prone for the thick end of a fortnight.

I flatten the bed, get the patient to lie prone. Within 30 seconds, saturations at at 98% so I wean the O2 back down to 60%. The patient sees my demeanour change and asks 'it's working then?'

Not half.

I have a quick chat with them about why it's worked and advise that they prone for as much of the day as they can stand – happily they normally sleep on their front and have a good good to read so they think they can manage.
I decide to nip off to write up some notes on both patients and decide to come back when I'm done to see if I can get the oxygen down further. Ten minutes later, I return and we're well able to get the oxygen back down to 40%. I'm tempted to drop it further but decide not to chance my arm too far and have a look again later.

A few other odd jobs get done and then it's a quick cuppa and catch-up with Carolina – her patient's family are coming in soon and she's braced for a difficult and long conversation – I tell her to take herself off 'on call' on our bleep system so that all calls are funnelled to me so she's not interrupted and we split off again.

Next punter is the one that Big Jim was most worried about overnight – they're in their late forties, have two negative covid swabs under their belt(so at least there's not THAT to worry about) have a history of recent travel to Africa as part of their work for a petrochemical firm and were showing low blood pressure, poor urine output, jaundice, spiking temperature and, most worryingly, confusion(always a guarantor of Something Very Nasty) in younger patients particularly.

On the ward, the patient's consultant is already there. Dr Atif, an affable medical consultant in his early 60's has pre-empted my thoughts and called the ITU team to come and review. However, they're busy intubating someone so they'll be a while and could I take a look? Of course.

When I get into the side room, the patient is obviously unwell, blood pressure if 93/40 – not catastrophic but could be much better, temperature 37.8, heart rate 111 and they haven't passed urine since midnight(it's around midday at this point). They are jaundiced, shivery and a bit 'vague' in conversation – not actively confused but very easily distracted. Word has just come through that they've been confirmed as having malaria.
There's some IV fluid running but they look VERY dry – they've been sweating buckets and also have diarrhoea. I speed up the fluids to 'wallop them through' as fast a possible(think about it, if you feel dry you neck your drink, you don't sip it over an hour)and insert a urinary catheter. The resultant urine I get draining into the catheter looks like cold black coffee. The technical term here is 'crispy'(as in 'dry as a crisp').

I emerge from the side room to see the ITU team in attendance, they go see the patient and ask for more fluid to be given quickly – they would take the patient if need be, but they'd like to see if they respond to 'aggressive basic' management first, they make some recommendations and depart.

One of these recommendations is to repeat some bloods following some more fluid, which I do a few hours later – all the numbers are worse. Bloods are now showing an incipient AKI as well as an increasing lactate. Lactate is a by product of the body working hard, be it to fight disease or a result of strenuous exercise. The higher it goes, the more concerning it is. Starting value this morning with 3.0. After fluids and further treatment it's now 5.3. Anything above 2.0 is generally considered worrying.

I ping a message to James, who's ITU registrar for the day with the results. His reply is near instant – 'I'm organising a 'cold' ITU bed they'll call you when they're ready'.

Result. I convey the news to Dr Atif and the ward team and busy myself with two referrals from anxious ward nurses on newly created 'hot' wards whilst I await the bed – one needs a visit to the ward, the other a simple phone call.

It's not even halfway through the day yet.

Further reading/viewing:

Intuition vs early warning tools: https://www.florence-health.com/latest-news/registered-nurse/nurses-intuition-se

Lactate: https://www.nursingcenter.com/ncblog/march-2017/elevated-lactate-–-not-just-a-

Lung sounds:



Previously:
(links to all previous entries) - https://wwww.twtd.co.uk/forum/481875/dispatches-from-the-front-line-part-9-suns-

Abbreviations and explanations : https://wwww.twtd.co.uk/forum/478292/4576782/common-
[Post edited 7 Jan 20:30]

Ham>Lam
Poll: Which Lambert is the worst one
Blog: From Despair to Where?

40

Despatches 2: Last working day of 2020 on 17:20 - Jan 7 with 2454 viewsfactual_blue

Yeah, but the corridors are empty.










Ta neige, Acadie, fait des larmes au soleil
Poll: What's the best name for this scandal?
Blog: [Blog] The Shape We're In

3
Despatches 2: Last working day of 2020 on 18:12 - Jan 7 with 2409 viewsPendejo

Despatches 2: Last working day of 2020 on 17:20 - Jan 7 by factual_blue

Yeah, but the corridors are empty.











My wife's community have been sharing the Gloucester Hospital footage, having been to Lewisham Hospital a number of times since March (supporting elderly uncle and father) it'd be easy to say covid doesn't exist because I haven't seen "it" .

Lewisham, however, far busier than Gloucester.

The thing that got me is the person who takes / narrated the video gets very snotty when challenged on not wearing a mask. They also think ambulance crew aren't working because they are organising the back of the ambulance rather than flying around all blues and twos. Wonder what she'd think if she needed them and they weren't properly stocked?

uberima fides
Poll: Who will Charlie Austin play for next season?

0

Despatches 2: Last working day of 2020 on 18:20 - Jan 7 with 2397 viewsSteve_M

Thanks again BB for keeping us informed and for the work you do.

I didn't really get why this provided you with inspiration though:

"And then I hear a raucous laugh from across the bay followed by and explosion of rapid-fire patois and I gain some inspiration.2

Poll: When are the squad numbers out?
Blog: Cycle of Hurt

2
Despatches 2: Last working day of 2020 on 18:21 - Jan 7 with 2398 viewsBlueBadger

Despatches 2: Last working day of 2020 on 18:20 - Jan 7 by Steve_M

Thanks again BB for keeping us informed and for the work you do.

I didn't really get why this provided you with inspiration though:

"And then I hear a raucous laugh from across the bay followed by and explosion of rapid-fire patois and I gain some inspiration.2


The first patient had been proned in ITU - might have to clarify that bit up a bit!
[Post edited 7 Jan 18:31]

Ham>Lam
Poll: Which Lambert is the worst one
Blog: From Despair to Where?

3

Despatches 2: Last working day of 2020 on 22:27 - Jan 7 with 2151 viewsNthsuffolkblue

Thanks again for all you do, Badger. I could never do your job. I am truly grateful for you and your colleagues. These insights, though never easy reading, are excellent.

As for that text book, it is already written in the minds of you and your colleagues. There is nothing like first hand experience and you are all, unfortunately, getting plenty of that.

Keep safe as far as you can.

Poll: Who should leave the club?
Blog: [Blog] Ghostbusters

4

Despatches 2: Last working day of 2020 on 09:57 - Jan 8 with 1968 viewsHARRY10

thanks for what you are doing, and for putting up a very worthy read

the Thursday dose of the clap (now reinstated) should be replaced by folk taking time to read your posts
3
Despatches 2: Last working day of 2020 on 12:39 - Jan 8 with 1889 viewsBlueBadger

Despatches 2: Last working day of 2020 on 09:57 - Jan 8 by HARRY10

thanks for what you are doing, and for putting up a very worthy read

the Thursday dose of the clap (now reinstated) should be replaced by folk taking time to read your posts


Steady on, they're just a bit misguided and think they're helping, they don't deserve this!

Ham>Lam
Poll: Which Lambert is the worst one
Blog: From Despair to Where?

0

Despatches 2: Last working day of 2020 on 08:49 - Jan 12 with 906 viewsStokieBlue

Thanks for the latest post Badger.

Have you been seeing a change in the demographic of people being admitted with C19? I just read that 25% of the hospitalisations are now below 55 which seems to be quite a shift.

SB

“You may not feel outstandingly robust, but if you are an average-sized adult you will contain within your modest frame no less than 7 X 10^18 joules of potential energy—enough to explode with the force of thirty very large hydrogen bombs, assuming you knew how to liberate it and really wished to make a point."

0
Login to get fewer ads

Despatches 2: Last working day of 2020 on 20:45 - Jan 12 with 782 viewsNthsuffolkblue

Despatches 2: Last working day of 2020 on 08:49 - Jan 12 by StokieBlue

Thanks for the latest post Badger.

Have you been seeing a change in the demographic of people being admitted with C19? I just read that 25% of the hospitalisations are now below 55 which seems to be quite a shift.

SB


Would that fit with a reduction in care home infections and an increase in infections from schools and a more lax lockdown leading to the infection spread moving more towards a younger demographic? As the effect of vaccination begins to be seen that change should continue shouldn't it?

Poll: Who should leave the club?
Blog: [Blog] Ghostbusters

0

Please log in or register. Registered visitors get fewer ads.
About Us Contact Us Terms & Conditions Privacy Cookies Advertising
© TWTD 1995-2021