[Post edited 31 Dec 2020 10:25]

Dispatches From The Front Line Part 9: Sun's Coming Over The Hill by BlueBadger 10 Jun 2020 15:27
This will probably be the last one of these I do for a while, if at all.
Life is slowly returning to something resembling a normal, or at least a new normal.
As I noted on the TWTd forum last night, the 'hot' ITU at [redacted] was empty of anyone with Covid-19 as of 10Pm last night.
I'll be returning to my 'proper' job middle of next month.

So, where to finish? I feel that an angry letter to my MP, whilst distinctly part of My Adventures With Covid isn't the way to conclude

Last 'clinical' update I did was a bit of a heavy read, so I thought I'd finish with something nice.

A few days after the events of Part 7, I'm back again in the 'hot' after the Powers That Be recognised my rough run and pulled me from the 'hot' area into the 'cold' ITU for what they thought would be some relatively straightforward bread-and-butter ITU work.

As ever, this didn't really work out well with my two 'cold' nights shifts ending up with me either managing or assisting colleagues with two different deteriorating young and sick patients who both ended up needing emergency intubations at 6AM in the morning on two separate nights after struggling along all night with them.

So, we give up on that idea and I'm back in 'hot' a week later.
My patient for the two days I'm there is a person in their mid-40's who's spent a few weeks in various ITUs.
About 6 weeks ago, they were admitted to a Specialist Unit Down The Road for treatment for Something Rather Nasty Needing Specialist Input. Following on from the Something Specialist they had a recovery period which is best described as 'stormy' which involved a prolonged post-procedure sepsis which turned into multi-organ failure the subsequent weakening of body(sometimes referred to as 'ITU neuropathy), particularly their lungs which meant they couldn't be safely extubated and so had a tracheostomy inserted to facilitate weaning from the ventilator.

Where an ET tube is inserted orally and passed over the vocal cords to allow mechanical ventilation, a tracheostomy('trachy') is inserted into the neck either by an ENT surgeon or suitably qualified anaesthetist and is considerably more comfortable than an ET tube, meaning that a patient can be woken and become an active participant in their own rehabilitation.
More about trachies can be found at the bottom of the page.

Following trachy insertion, the patient was then transferred back to [redacted] for ongoing rehab.
They then spent a few weeks on 'cold' before developing a dry cough and reporting persistent tiredness and muscle aches, so they've been swabbed and transferred to 'hot' pending a swab result.

Thankfully someone has been sensible enough to put them in a side room so that if they do come back negative(which turns out to be the case - personally I suspect a combination of irritation to the throat from the trachy cuff and tiredness due to intense physiotherapy) then at least they've been kept away from the worst level of risk.

If level 3 end of life care is my least favourite ITU job, then rehab and weaning is probably my favourite. Unlike a lot of ITU care it is VERY nurse-led and, certainly at [redacted] ITU you're generally given a lot of license to just get on with it by the consultants.
In a way, it's quite similar to end of life care in that it's not necessarily 'hard' to do, but it IS still very easy to b*gger up if you don't go about it properly.

I like to make a project of it and set a 'this is where we're going to be' target for the weekend.
At the start of day 1, the patient is still being ventilated, albeit at minimal ventilator settings, not sleeping overly well at night and very low in mood having spent the thick end of 2 months away from family. On top of that, because the trachy is inserted above their vocal cords, they'e been unable to speak, eat or drink.

My first words to them after introducing myself is to say - 'right, by the time I go home tomorrow, you'll have that trachy out and we'll have you eating, drinking and speaking to your family on the phone. The look I get back is one of cynicism, which isn't surprising, given how slow the progress has been.

First job of the day is to make the big psychological step of 'off the ventilator'. I cannot understate the importance of this. Having gotten approval from the day's consultant and worked out a plan for the weekend, I switch off the ventilator and place a specially shaped oxygen mask(called, surprisingly enough a 'trachy mask') over the tracheostomy tube. Initially I increase the oxygen percentage that I'm delivering as we're losing a level of ventilator support. This is peace of mind for both me and patient.
After a couple of hours of them being comfortable on this I ask them 'how do you fancy a proper chat than trying to write things on a pad?'
I get a look of surprise but a nod of consent so I break out a Passy-Muir valve, generally known as a 'speaking tube'. The speaking tube allows those with trachies to be able to speak by the simple means of acting as a one-way valve - the patient breathes in through the trachy but it closes off when breathing out, allowing air over the vocals, thus permitting speech. An added bonus is that with this in place it also allows us to assess a patient's swallow, meaning that we can start them eating and drinking normally(subject to safety checks by the speech therapists).

You can never tell how well a speaking tube trial is going to go until you try. Some really struggle and never truly get on with them, some need time to adapt and the final third, like today's punter, take to them like ducks to water.

Their voice is loud and clear if slightly husky. I assure the that the 'husky' is normal and bring in the unit's cordless landline phone and call their family. The next of kin answer the phone quickly, as they've no doubt been doing for the past few weeks, forever in anticipation of the worst.
I don't speak to them but instead hand the phone to the patient and allow them to deliver an update on their condition to their family personally. You don't need to be on Zoom to see the tears of relief and joy from the family.

The rest of the day sees some gentle exercise for the patient, the removal of some invasive lines that are no longer needed now that we're moving on(one of the hardest ITU skills to learn is when to stop tweaking and fiddling - if you can't monitor it as easily, you can't overthink it) as well as some careful swallow trials.
Swallow, like all functions driven by muscles tends to weaken with a prolonged ITU stay and this patient is no exception. After witnessing them coughing on water I regretfully tell them they're nil by mouth for the moment until we can get a speech therapist to assess their swallow and establish if we can feed, albeit by giving thickened fluids and liquidised or softened food.
Following a chat with the speech therapist we agree to do it the next day, so I can see if I can remove the trachy before they come and assess.
Finally, at the end of the day, I get the clearest indication yet that trachy removal is potentially a 'goer'. Barry, the consultant for the day says 'why don't we try keeping them off the vent overnight and whip that out when we hit 24 hours off the vent'.
Bingo. I gleefully relate this to the patient, handover to my night cover and head for home.

Next morning, thanks to the night nurse exercising some solid judgement and 'grouping' their interventions overnight, they're well rested and raring to go.
Barry comes round at about 11. At this point we're 26 hours off the ventilator.
'For God's sake BB, haven't you taken that bloody thing out yet' he asks me at the start of his patient review. Barry is a chap in his mid-40's from north Essex and doesn't tend to mince his words.
Knowing I've got an anaesthetist in the area I happily proceed with removing the tracheostomy and slap a dressing over the top of the stoma(hole). The patient's oxygen is switched over to a nasal delivery system and I again, offer the phone to them. Again, they call their family and the cries of joy at the latest news are clearly audible.
Days like this are great. This, in the words of a wise man, is what I go to school for.
Next visitor to the patient's room is the speech therapist - they work weekends and bank holidays at [redacted] - we want patients off artificial tube feeding and/or intravenous fluids as quickly as possible- paper food is much better for you.
Half an hour later, the patient has a fresh cup of tea, which has been thickened specially, sitting in front of them. Their first cuppa in two months.
They're too tired by all the morning's fun for lunch, but an evening meal of thickened soup, gravy-heavy roast chicken and mashed potatoes doesn't touch the sides and I can go home deeply pleased with my weekend's work.

Like my patient from a week earlier, I will never see this one again either - but this time it's because the next time I'm at work, they'll have been transferred to the ward to continue their long journey to the front door. A journey I'm proud to say that I've taken a small but significant role in.

Stay safe all.

If you've enjoyed reading these and want t say 'thank you' Can I steer you in the direction of a donation to these brilliant people:
https://www.sars999.org.uk

SARS are a team of volunteers providing critical care support and specialist skills to the East Anglian Ambulance service. A number of them are my colleagues and have been continuing with this as well as their day jobs. Help some brothers out, eh?

Further reading:

Tracheostomy insertion and care: (Possibly a one-time-only link, some technical terms)
https://www.nursingtimes.net/clinical-archive/respiratory-clinical-archive/tracheostomy-1-caring-for-patients-with-a-tracheostomy-09-05-2016/

Where I nicked the title of this piece from:
https://www.youtube.com/watch?v=V0xkz-lTLE8



Previously:

Part one: https://wwww.twtd.co.uk/forum/478292/despatches-from-the-front-line-part-one/#0

Part two : https://wwww.twtd.co.uk/forum/478646/despatches-from-the-front-line-part-two-a-s

Part three : https://wwww.twtd.co.uk/forum/478885/despatches-from-the-front-line-part-three-w

Part four: https://wwww.twtd.co.uk/forum/479197/despatches-from-the-front-line-part-four-id

Part Five: https://wwww.twtd.co.uk/forum/479404/despatches-from-the-front-line-part-five-ho

Part Six: https://wwww.twtd.co.uk/forum/480252/despatches-from-the-front-line-part-six-arr

Part Seven: https://wwww.twtd.co.uk/forum/480784/despatches-from-the-front-line-part-seven-b

Part Eight: https://wwww.twtd.co.uk/forum/481128/despatches-from-the-front-line-part-8-a-letter-to-my-mp/#0

Abbreviations and explanations : https://wwww.twtd.co.uk/forum/478292/4576782/common-