*As always, all locations and names are changed*
Alternative title: '4 episodes in, and he's already doing a clip show'.
Feeling a bit of a fraud at the moment. Apart from ITU, the workload of TWTD District General is best described as 'steady'. Whilst my own personal caseloads are roughly the same size, the bulk of the work is, unsurprisingly dominated by Covid-19 one way or another. If anything though, my caseloads are easier on the actual work front as Covid-19 management is, at ward level certainly, reasonably straightforward - (see part three for more in detail on this) with my typical pattern in reviewing the 'confirmed' being a 'remote' review of observations, bloods, medical team plans and a discussion with the patient's named nurse at the start of the shift, followed by an 'in person' if they're still of concern at around 6(morning or night) in order to be able to give accurate handover of care to my colleagues.
ITU are definitely having the hardest time of it - at time of writing we have patients in two units and staffing of the full-time ITU team is stretched to the limit with the regular ITU staff being bolstered by bank staff and redeployed theatre staff. What's happening is the redeployed staff are doing a lot of immediate care with the ITU guys 'troubleshooting' between 2 or 3 patients each. They ALL look exhausted but are somehow maintaining their spirits. My friends and former colleagues have always impressed me but at the moment they are inspiring awe.
It's not just the 'barn door' crowd that have the shadow of Covid 19 looming over them and ultimately affecting management. Any vague symptom, regardless of admitting diagnosis will now earn you a swab and a transfer to one of the 'villages of the damned'(as one of my more cynical ED colleagues is now referring to our 'hot' wards). Case in point:Friday night saw me being tipped off about an individual in their 70's who'd been admitted to one of the 'cold' wards with an AKI which can only be described as 'stonking'.
A stage 3 AKI(the most severe degree of AKI) with a urea of 61(2.5-7.1 is considered normal, for reference, I get excited when it hits mid-20's, renal physicians when it goes over 30) and a creatinine of over 400(normal levels are about 45-100) and a clear documentation of 'AKI stage 3, likely secondary to dehydration exacerbated by diuretics' this person had neither a urinary catheter in place(knowing how much urine someone is passing is a TINY bit helpful in renal medicine) nor adequate fluids with 500mls given over the preceding 12 hours and a painfully slow(and, as it turned out, attached to the patient but not actually running) further litre prescribed.
On top of this, the patient blood pressure was sitting at a rather sporting 78/42. A further 500mls of stat fluid from me and blood pressure was looking better, the attached fluids were started and sped up and I toddled off to seek some advice from Rhea the medical registrar, a cardiologist from Greece by trade.
A tighter trawl of the bloods revealed a low lymphocyte count, a classical sign of viral infection. So, off the patient(who was otherwise asymptomatic) went to C-2(one of the designated 'hots wards).
I'm pleased to report that come Monday the person in question now has considerably better blood results a urinary catheter and, if they didn't have Covid before, they probably do now.
So, how did Covid colour this person's management? Quite simply, covid pneumonia carries a high probability of ARDS(Acute Respiratory Distress Syndrome) which causes inflammation of the lungs, this inflammation then often leads to the lungs becoming very 'wet' and making it increasingly difficult to oxygenate. Excess fluid administered intravenously can exacerbate this further. It's equally understandable and frustrating that this happens, but it's nice to get a bit of variety at the moment.
National figures and interesting demographics are starting to emerge. A bulletin I saw on Friday night confirmed something I thought was purely anecdotal experience my local level appears to be happening nationally - the mortality rate for covid-afflicted ITU patients is currently running to roughly 50% and those being admitted to ITU are overwhelmingly men, aged mid-forties to mid-60's of larger builds - there's not many in [redacted] ITU that are under under 85KG at the moment. Not necessarily fat lads, but BIG lads. So, if any of you lot on here needed reminders, this demographic is pretty much the whole of the TWTD readership. It's also why when big Jim on my team went off sick with symptoms two weeks ago he was VERY firmly told to stay away for the full two weeks to ensure a good recovery. Jim is a good lad with excellent clinical skills, a wide range of experience and a heart of gold who we badly miss, but we'd rather just miss him for a fortnight, if you catch my drift.
A few of our sicker patients are now on the mend. I've had the pleasure of visiting one young(defined here as 'in their 40's) patient who's back on the ward after nearly a fortnight in ITU, all of it bar 1 day intubated and ventilated. They awoke CRAZY delirious but are now happily 'out of the fog' and doing well after a very shaky first 72 hours which saw the security team called out to physical restrain them and a nasty post-ITU hospital acquitted pneumonia(a common side effect of being ventilated, immobile and surrounded by other sick people in a warm building) and starting to engage with the physios in getting back on their feet and ultimately home.
It's interesting to see how people are adapting to our current Interesting Times. By and large the 'good' wards have doubled-down on this and are happily adopting new practices and learning new skills to be able to cope with changed circumstances - case in point - ward C2's registered nurses have all had to take a crash course in managing non-invasive ventilation for those who are unfit for ITU but may benefit from a bit of CPAP or BiPAP and have simply taken it in their stride(with support from us in the Outreach team). Conversely, during the period in which we've been training up C-2 staff, the team from the respiratory ward(currently a 'cold' ward) who's role is also to provide support(in the form of swapping staff with C-2 when needed) to the C-2 guys have been unhelpful, slow and obstructive at times. On more than one occasion I've had to ask 'site' to intervene so I can be freed up when dealing with this patient group(the policy is Outreach start and fine-tune NIV therapy, the trained ward nurses carry it one once we've established the patient on therapy).
Another place who've REALLY stepped up are ward C-5. These guys have really copped for the sh1tty end of the stick. Normally a ward for the frail elderly requiring a long stay these guys are the unsung heroes of the hospital, C-5 in normal circumstances is the sort of place you tell Trust newcomers 'this is where you'd want your nan to be looked after'. Their brief in The Event is to take in those who are expected to be 'poor doers', the very frail with the poorest prognoses of them all.
It's a touch gig and they're seeing the bulk of our deaths but they're carrying on with their jobs to the best of their abilities and the care and respect they offer is humbling.
We're all very grateful for all the cakes and nice things from well-wishers but could I add two requests?
1. Some fruit occasionally would be REALLY nice.
2. Don't just send stuff to the wards, parcel up some stuff for the 'backroom' staff like the porters, housekeepers/cleaners, kitchen staff and maintenance people.
PPE. The elephant in the room. Supplies are somewhat hit and miss and Public Health England's recommendations are probably more 'to the letter of' rather than 'the spirit of'.
For someone 'suspected' that you're not performing aerosol-generating procedures with WHO recommended PPE is 'gown, gloves, medical mask, eye protection'
This has translated to 'backless, sleeveless,plastic apron, roughly the same thickness as clingfilm(as opposed to a whole-body garment with full sleeves), gloves, paper surgical mask(these things are frankly, rubbish - flimsy and ill-fitting, they have a nasty habit of slipping off your nose at the most inconvenient moments) and eye protection(with types of kit carrying greatly from ward-to-ward from comfortable lightweight full-face visors to rather more cumbersome items donated by a local builders' merchant). Strictly speaking it's not 'wrong' but it's frankly on lip service with regarding to staff protection and we're seeing the results at the coalface - I've personally been out to half-a-dozen staff members too see with regard to a 'help with a deteriorating patient' role and know of at least a dozen more(at all levels from cleaners to consultants) who've been admitted to hospital with symptoms. My own team has seen three of us off at various times with symptoms - me, Big Jim and Ana, a small-but-fearsome former ED sister from Portugal.
Finally, thank you all for your support both in mostly staying home and being sensible, for your generosity and kind words and fr looking out for your families and neighbours.
Stay safe all.
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
Abbreviations and explanations : https://wwww.twtd.co.uk/forum/478292/4576782/common-terms-practices-and-abbrevia [Post edited 14 Apr 2020 15:23]
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