Covid 19 has undoubtedly left its mark on everyone, and leaves each person with new and different perspectives and memories that they will now forever carry with them.
There’s no stand out moments when I think of the last year, it began so quickly and lasted so long, so relentlessly – that all im left with is snapshots of some of the most difficult shifts and days of my life.
There was a look we gave each other in those moments, through not only windows of bays, but through masks and plastic visors. It was fleeting and it was never spoken. But I know now – that look was fear.
I write this because we have, quite rightly, heard the patients stories from those lucky and fortunate to have come out the other side. My heart, and I know those of my colleagues needs to hear these stories and we’ve often cried joyful tears seeing photos of those we looked after now in the homes we had pictures of put up all around them. To see them petting the dogs we all loved asking about.
We all watched daily updates on the news, myself included, with constant numbers and statistics, and heard updates with new restrictions on all of our lives, and sadly, all been prey to those on social media who, with no experience or concept of the devastating effect of Covid, chose to proclaim it was a hoax, that it wasn’t deadly – “just the flu” and “only affects those with pre-existing medical conditions” as if writing off anyone with any kind of medical illness prior to this is acceptable behaviour.
But this is a nurse’s perspective – to try and explain what these days were like for critical care nurses trying to care for so many of the sickest patients with not enough space, not enough staff and the fear it wasn’t going to end.
A critical care nurse will typically, before Covid, give one to one care to those requiring organ support. This is because a critically ill patient needs constant supervision – checking the ventilator settings and that the patient is synching with it; checking the sedation that allows them to tolerate the tube in their throat; checking the tubes are still in the right place and aren’t leaking; monitoring unstable blood pressures and weaning or adding in inotropes accordingly; taking and checking blood gases to check oxygenation levels, along with the pH of theirblood, whether they need potassium and many other variables; checking on central lines and vas-caths which we need to give a great number of drugs throughout the day; checking pupils to see if they are equal and reacting; performing suction to check on secretions and send samples if necessary; checking on ng tubes to ensure they are receiving and absorbing the right level of nutrition; repositioning to prevent pressure damage; performing mouth care and eye care regularly; talking to them and reassuring them that they are safe, telling them their family love them and that we are doing everything we can.
This is just a whistle stop tour of some of our main jobs, its certainly not an exhaustive list but I want to try and explain that critical care isn’t staffed in the same way a ward is for the safety of the patients (Lee, A. et al., 2017) And that the training in itself to work here is quite rightly intensive.
But during Covid this 1:1 ratio simply couldn’t happen, the sheer number of those sick enough to require intensive care was too overwhelmingly high. And so, on a typical day we would be looking after an unprecedented number of ventilated patients, many of these requiring mutli organ support, sometimes a mix of ventilated patients and those requiring high levels of oxygen and pressure via CPAP.
This was further amplified by nursing through level 2PPE. We were taught to use this correctly by one of our own consultants and supported each other in staying safe.
All the tasks we knew needed doing regularly were now multiplied. ABG’s needed sampling, recording and interpreting; NG’s needed aspirating, risk assessing and flushing; critical medications needed administering both peripherally and centrally; suction and mouthcare needing doing regularly; ventilator observations along with patient observations needed recording at least hourly and settings adjusted accordingly; haemofiltration machines for kidney support needed setting up, calculations made based on fluid balances and calcium ratios; bloods needed requesting and sampling and results recorded and reported on and add to this that deteriorating patients needed our attention. Fast. And make no mistake there is nothing “just” about Covid, it is not “just” the flu, it does not “just” target the elderly or frail and they are not stable patients.
Help can be called of course, but keep in your mind that said help needs to don and assess the situation, and said help was also being stretched to deal with a daily growing number of other unstable patients. Any acute deterioration in any one or more of these patients often times means making the choice to turn your back on other ventilated patients – which, as ITU nurses is classed as a never event (Elliot, M. &Coventry, A. 2012)
I would like to take you through a day like this, to give you some idea of the lived experience of myself and all my work colleagues throughout the past year and maybe give some insight to the likely tsunami of PTSD and exhaustion which is likely to follow from, may I add, some of the bravest, most experienced and professional practitioners I have experienced (Walton, M., Murray, E. & Christian, M. 2020).
Instances described in this blog are based on real events that occurred during 2020-2021 but are not a description of the specific care of any specific patient in order to maintain confidentiality.
It is worth noting here that we were sent the help of theatre staff and redeployed ward staff when we were continually escalated – without whom we would have certainly crumbled. Their dedication and willingness went far beyond any call of duty and, in a time where we felt alone, isolated and fearful - they bought us the glimmer of hope one feels when dawn breaks after the longest of nightmares, and thank you will never be enough.
But, as each of us has skills ascertaining to different specialities and environments, some had not completed medicine competencies, had not received any training in dealing with NG’s and were unfamiliar with ventilators and recording the observations, and as our NMC Code (Nursing and Midwifery Council (NMC), 2018) tells us, we cannot expect anyone to practice outside their level of competence.
Fortunately, and again, as testament to their dedication to help us, seeing what we were facing - all were willing to learn. And so we tried to teach, again, thankful at the sight of any support. How to safely sample an ABG from an arterial line, using aseptic technique; how to aspirate an NG and then follow a risk assessment to ascertain if the patient is absorbing the feed and that the tube remains secured in the right position – what is the pH of the aspirate? Has the cm marking changed? Is the patient in the correct position? Have they experienced any coughing fits? Are they showing any signs of respiratory distress? (Curtis, K. 2013).
Check on chest drains; perform mouth care; check IV sites; check pressure areas (if the patient is stable enough to roll) - allowing us to respond to alarms and emergency situations – of which there were many, daily – and help calm distressed patients.
So this is your day, every day, for a year. Teaching, checking. Repeat. Feeling overwhelmed and isolated.
Bed one needs unproning after 16 hours on their front to aid ventilation and bed 2 is showing signs of deterioration and needs proning, Each time this requires at least 5 people. Cue our wonderful physio colleagues who, again, we could not have coped without and who went above and beyond every day. Checking critical medications and there is enough leeway in the lines to tolerate being slid across, turned on their side and then turned onto their stomach without any kinks or occlusions; that pressure areas are protected and then monitoring to check for any respiratory or CVS instability (Tyler, S., Ahmed, S., Davidson, R. & Thompson, K. 2018).
Due to deterioration of these two patients needing our attention, you ask your non ITU colleague to record the other patients observations and aspirate the NG’s. You ask across the room how much did you aspirate? What is the pH? Whats the cm marking? Have a look in their mouth just to check its not coiled at the back. The answers you receive reassure you.
You unprone bed 1, saturations drop and the oxygen is increased while they recruit, blood pressure drops so inotropes are increased and you wait to see if they settle or need further treatment , as you check pressure areas, tubes, and reattach any disconnected lines.
The haemo filter on bed 4 alarms, the access has become too negative and needs attention to make it run again.
Again, you’re immediately back with bed 1 trying to stabilise oxygen levels and blood pressure, as your colleague performs blood gases on the other patients, adjusting IV insulin and administering any required drugs. You check your infusions – you need IV morphine, propofol, alfentanil and noradrenaline – all of which are outside and require double checking out of CD cupboard, drawing up correctly, double checking with patient details and administered via the correct route, at the correct time at the correct rate (Local Health Board, 2020).
Bed 3 is struggling on CPAP. They are on maximum support – 100% oxygen with a PEEP of 15, they are desaturating, hypertensive and tachycardic and tachypneic, not helped – understandably – by anxiety and panic attacks.
You give them any medication you can to help, you sit with them, trying to talk them down – “look at me, nice deep breaths, just focus on me – you’re ok”. Do a blood gas and see if its helped.
Now its time to prone bed 2, same process as before, relying on your colleagues to watch the other ventilated patients and a patient on maximum support on CPAP. They arrest during proning. The crash trolley and various medications needed to maintain the output that’s been restarted are passed through to you by colleagues from other bays on their break.
Later, bed 1’s oxygenation decreases, they have a chest drain in situ from a pneumothorax, they are on 100% oxygen and maximum support via the ventilator, Drs come and tirelessly attempt every possible procedure to optimise them, but saturations are now 79%. Sadly, the decision is made that after several weeks of incredibly invasive procedures, maximum support and resuscitation from 2 previous cardiac arrests – nothing else can be done and the family is called.
It goes without saying that I cannot disclose to you the exact number of hands I’ve held and heads ive stroked as patients took their final breaths. How many relatives must have had the worst imaginable news via a phonecall. How many mums, dads, daughters, sons and other loved ones said their goodbyes via facetime. But its too many. We do, and always will, carry the memory of all those who didn’t make it as well as those who did.
During our time in those bays, over 3 different wards, we did everything within our power to ensure each critically ill patient received effective, compassionate care in a safe, effective way.
Ensuring treatment and procedures were safely carried out at the correct times, with the help of our amazing non ITU colleagues, who I will forever be in awe of, when deteriorating patients needed our attention; when a patient was receiving end of life care so they were never left alone, when patients needed intubating, proning and resuscitating; doing IPad visits, or saying goodbyes.
Our priority was always our patients and I know each of us gave our absolute all whilst feeling scared, alone and isolated. And I’m in awe of every healthcare worker that was physically present through the worst of times and still gave 110%, and since this is a nurses story – to every other nurse out there – I salute you. Because no one will everunderstand just how hard its been.
REFERENCE LIST
Comments
Post a Comment