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The Eye is pretty scathing, even for the Eye, this fortnight
at 09:36 5 Apr 2020
Despatches From The Front Line part Two: A shift in depth.
at 15:04 1 Apr 2020

*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' young generally don't have the irritation of holding the bleep but you do get to do all the jobs that the bleep-holder can' 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 suspect 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, enough to significantly weaken people half their age. A period of intubation that long could see them permanently debilitated 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 'thorough b0ll0cking'' 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 ASDA. 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 at a supermarket.

Interesting times indeed.
Useful terms and abbreviations here:

Part one here:

[Post edited 3 Apr 15:23]
Toby Young is a vile piece of sh*t part 78789526762816845185
at 13:34 1 Apr 2020

I haven't forgotten my front-line updates, Mrs Badger is finding me jobs.
at 10:56 1 Apr 2020

To be getting on with, here's a list of common terms that I'm likely to be using:

Common terms, practices and abbreviation by BlueBadger 1 Apr 10:49
A few helpful terms and abbreviations for you here. I'll probably add to these as time goes on.

ABG - Arterial Blood Gas - common blood test used to measure exchange of oxygen and carbon dioxide within the body. Generally obtained by sampling direct from an artery in the wrist. Generally more uncomfortable than a standard blood test.
Values of interest are roughly: Blood pH 7.35-7.45
pO2(oxygen) 10-13
pCO2(carbon dioxide) 4-6
HCO3(sodium bicarbonati) 22-26
Tests generally take about 60 seconds to run and the machines can also test for things like blood glucose, haemoglobin and some electrolytes, although these results aren't as accurate as a full lab test.
If you're interested in how to fully read one, I recommend this:

AF - Atrial Fibrillation. Irregular heart beat. Can be chronic or acute, 'fast' or 'slow'. Treated in a variety of ways

AKI - Acute Kidney Injury(sometimes called acute renal failure). Sudden(as in 'occurs within the past 7 days') loss of kidney function due to damage to the kidneys. Most commonly caused by dehydration, but can happen in response to drugs or illness. Has three 'stages' of severity with 3 being the worst

ANP - Advanced Nurse Practitioner. Have a variety of roles around the place. Are usually able to prescribe as well.

Asytole - one of the rhythms of cardiac arrest. The 'flatline' beloved of films and TV. Contrary to media myth, you don't shock this one(shocks need some kind of electrical activity to work. There is effectively none in asystole). Treated with chest compressions, adrenaline and hope.

Bi Level Postive Airway Pressure - a form of non-invasive ventilation, administered by tight-fitting face mask. Often used on those who are unsuited to mechanical ventilation but used on those that are in an attempt to avoid having to intubate and ventilate. Used to manage a number of respiratory issues but I mostly use it for treating type 2 respiratory failure(discussed down the page).

Cardiac arrest - total loss of cardiac output. Doesn't neccessarily mean your heart has 'stopped'. There may be a rhythm that means the organs cannot perfuse or function, instead of the complete 'stop' of aystole.

Cannula - any tube that can be inserted into the body. For the purposes of this thing, when I say 'cannula' I'm referring to IV cannulas used for administering drugs.

CO2 - Carbon dioxide

Consultant - the most senior doctor or surgeon in a team. Will be an expert practitioner in their specialist field. Hold ultimate responsibility for patients and teaching of junior staff.

CPAP - Continuous Positive Airway Pressurea mode of Non-Invasive Ventilation(NIV) used to treat type 1 Respiratory Failure(discussed down the page). Administered via a tight fitting face mask. Also commonly used treat obstructive sleep apnea. Works by applying constant air pressure to hold open airways and, at higher pressures re-inflate bases of lungs which may have become 'sticky' due to infection or the presence of fluid. Often used on those who are unsuited to mechanical ventilation but used on those that are in an attempt to avoid having to intubate and ventilate.

CRP - C-reactive protein. blood test. An 'inflammatory marker' indicating the presence(or lack of) infection. Rises in the event of infection.

CPR - Cardiopulmonary Resuscitation. Emergency procedure for the event of cardiac arrest.

Critical Care - For the purposes of this thing, Intensive Care. Involves a higher level of monitoring and nurse-to-patient ration than ward-level care. Ward level care patients are generally about 1 nurse to 7 patients, Critical care is 1 nurse to 1 or 2 patients. If someone is sick enough, it's not unknown to go 2 nurses to one patient. Also known as CCS(Critical Care Services), ITU(Intensive Therapy Unit) or ICU(Intensive Care Unit). I generally favour 'ITU'.

ED - Emergency department. A&E. Place for drunks and hypochondriacs to have a day trip out to.

ETT - Endotracheal Tube. Tube passed into the airway to allow mechanical ventilation.

FBC - Full Blood Count - blood test looking at types and numbers of cells in the blood - most common cells and values we're interested in are red blood cells, white blood cells and platelets. The other biggie here is haemoglobin(the main protein resposible for the trasportation of oxygen within the body.

FY1/FY2 - Foundation Year 1/Foundation Year 2. The most common species of junior doctor. They are generally 1-2 years out of medical school and in 'basic training'. Used to be known as 'junior' and 'senior' House Officers(JHO/SHO).

Hb - Haemoglobin - main protein used for the transport of oxygen in the blood. Low levels are usually a sign that you don't have enough blood in you.

Intubation - name of the procedure of inserting an ETT - HAS to be performed by someone 'airway trained', usually an anaesthetist.

Medic Bleep - a phone app used at [redacted] hospital in place of bleepers. It's basically WhatsApp for medical professionals. It has its advantages and disadvantages.

Med Reg - Medical Registar. Bar maybe the porters the hardest-working people in the hospital. Specialists in their own right they are the next generation of consultants and shoulder a lot of the day-to-day decision-making and planning of care. 'Night Med Reg' is usually responsible for every medical patient in the hospital, will see unwell patients that the more junior doctors can't manage, usually 'lead' at cardiac arrests and have a 'clerking' responsibility(that they will usually share with an FY2) for any medical patient admitted to hospital.

NEWS/CREWS score - National Early Warning Score/Chronic Respiratory Early Warning Score. Tool used to help ward staff identify patients at risk of deterioration. Anything more than about 5 is a concern.
For more info, see here:

NIV - Non-Invasive Ventilation. Form of ventilation administered by means of a tight fitting face mask rather than the insertion of an ETT. Comes in two forms - BiPAP and CPAP

O2 - Oxygen

Obs - observations, vital signs.

Outreach Nurse - Me. A senior nurse with a background in acute, emergency or intensive care medicine who works 'on call' to support wards and departments in various ways.
At [redacted] hospital our job is three-fold - 1. Early identification and management of the deteriorating patient 2. Support of the post-ITU patient 3. Other Things. Can be anything from taking bloods, placement of various invasive devices, attending cardiac arrest or giving directions around the building to lost pensioners.

PEA - Pulseless Electrical Activity. Another of the main cardiac arrest 'arrhythmias'. Presents as a normal ECG on a monitor but the activity of the heart, whist organised, is too feeble to actually move any blood. Hence the term. Another rhythm that is called 'non-shockable' because the activity is organised and won't benefit from being 'reset' by a shock. It's treated with adrenaline and chest compressions.

Respiratory Failure - Condition in which you either have not enough O2 or too much CO2 or sometimes both at the same time. Both will kill you, but Type 1(insufficient O2) will kill you a LOT faster than Type 2(excessive CO2). Treated in a variety of ways from simple oxygen therapy to NIV to mechanical ventilation.

Saturations - 'sats' - Oxygen saturation. Quick and simple method of measure oxygen levels in the blood. Done by infrared and measure in percentages. Normal adult reading is 94-98%.

'Site' - At [redacted] hospital, the name for the site co-ordinator. Fancy term for 'night sister'. The senior nurse with ultimate responsibility for patient flow and safety. Probably the busiest person in the hospital at night after the porters and the med reg.

Ventilation - for the purposes of this thing, mechanical ventilation. sometimes abbreviated in notes to 'IPPV'(Invasive Positive Pressure Ventilation). Requires the patient to be intubated and sedated in order to be able to tolerate the ETT.

U&E - Urea and Electrolytes. Blood test measuring kidney function and body chemistry. Typical values we're interested in are Urea and Creatinine(measures of kidney function), potassium and sodium.

VT/VF - Ventricular Tachycardia/Ventricular Fibrillation - the two 'shockable' rhythms in cardiac arrest. Characterised by rapid activity of the heart which may be regular(VT) or irregular(VF)
Both can be reverted into normal rhythms by shocking during CPR

Cardiac arrest rhythms:

Normal values -

Pulse - 60-80 beats/minute
Blood pressure - around 120/80 mm of mercury
Oxygen saturation - 94-98%
Temperature 36.5-37.5C
Respiratory rate - 12-20 breaths/minute
Urine output - 0.5ml/kg of body weight per hour.

Quick question for you lot re: my 'whats going on at the sharp end' posts
at 14:48 30 Mar 2020

Would some kind of post with an explanation of common terms/practices be useful for you lot?
Hoping to do next update tomorrow once 'night brain syndrome' clears.
[Post edited 30 Mar 15:09]
Utter, utter incompetence.
at 23:22 26 Mar 2020

Blue passports over your lives people.
Despatches From The Front Line part One:
at 10:20 26 Mar 2020

So, 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.

[Post edited 26 Mar 13:57]
Just been cleared by occupational health to go back to work tomorrow.
at 14:39 24 Mar 2020

Wish me luck kids....

Where does Mr Tickle's Covid-19 exclusion space start?
at 12:02 24 Mar 2020

Where does Mr Tickle's Covid-19 exclusion space start?

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Just hearing news that in an effort to keep spirits up...
at 10:38 24 Mar 2020

...Paul Lambert will be organising a massive house party...
In all of this, there's one cataclysmic thing we've all missed.
at 23:33 23 Mar 2020

The DFS sale has FINALLY been brought to an end.
So, I watched Mick's Message To The Nation...
at 21:58 23 Mar 2020

...and my eye was drawn to this...

So basically, because some people couldn't behave..
at 21:44 23 Mar 2020

..we've ALL got detention.
Derby being given tons of money and failing to get promoted?
at 15:45 22 Mar 2020

Seems far fetched nowadays that doesn't it?
[Post edited 22 Mar 15:46]
State of the pitch there.
at 15:30 22 Mar 2020

Clegg out.
We've all been there.
at 19:03 19 Mar 2020
If you're currently out of work and want to help out the front line...
at 15:12 19 Mar 2020

....we can find something for you to do.
Finally, some good news in all this.
at 13:52 18 Mar 2020
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