Thanks so much to our contributor, Dr Matt Bigwood for writing this for us. These are his musings, direct from a frontline healthcare worker on ICU. He is a ST5 in ITU and Anaesthesia.
News…something is coming?!!
I first heard about ‘the Coronavirus’, like most people, sometime in January. It was pretty low down the pecking order of news articles, but being medical, of course, I read it.
Could have been this…??
To be honest, I was initially nonchalant regarding this story. This was probably something that would not take place ‘in my back yard’. The word ‘pandemic’ was still very far from the lips of most.
I was still giddy from the news that I had passed the final FRCA exam! I was also busy finishing all my assessments and tick boxes ready for my ARCP at the start of February.
I had moved hospitals in February and in so doing, started my Higher Training. I was excited to start really learning my craft, and getting to choose which areas I wanted to concentrate on for my career and not just learning for exams. However, in February, the virus spread, having already peaked in Wuhan, then the rest of China, it arrived at more and more countries. It was increasingly becoming the top news story and the topic of conversation…”makes a change from Brexit”, we all said, but none of us were worried enough to stop joking every time we got coryzal symptoms to say “probably coronavirus… don’t worry!”.
In mid to late February the cases started to mount in Italy; that was a bit closer to home, the concern definitely increased and I mooted hundreds of thousands of deaths with some of my friends…worrying!
March 2020 – the end of normality!
Interestingly, the first facet of my life to be affected by COVID-19 was sport; I love to watch it all and the decision to cancel the Chinese Grand Prix was made on the 12th February, then the 6-nations Rugby followed from the 7th March. Premier League football from the 13th March and the cricket season never even started!!
The 11th of March was a day I will not forget! I was supposed to be on a training general surgery list…nothing strange there…but the consultant said at 8 am; “this is your list, I am going to be tied up preparing our response to the pandemic that’s about to hit us!”
This was all a reality now…there appeared to be no escaping this. From what I was reading about, hearing rumours about….to the reality I would potentially now be faced with, in vast numbers. Myself and my family could be at risk! It also happened to be the day the WHO declared this a pandemic, (even though it doesn’t declare anymore)! I wasn’t to know it at the time, but these would also be my last elective surgery list for nearly 7 weeks and I’ve actually still only done one since, to date. Luckily though for us, the whole department/hospital was being led by some amazing people and we were prepared very well indeed!
We increased our Critical Care capacity, we stocked up, we trained in all aspects COVID; what it was, how best to treat it, PPE, Intubation, Cardiac arrest, proning and more. We cancelled most, if not all elective surgery (moving some including cancer to other theatres/hospitals) to help with space and staffing.
The training! I have never witnessed anything like it…and organised at such pace! We underwent a fantastic and beautifully organised few weeks of very solid teaching/drilling and training. I was very aware that everyone, including the most senior in the hospital, were calling themselves to arms, getting ready for a fight ahead. In the sessions, everyone from theatre staff, to surgeons, to domestics, to porters were in attendance! People had really gone to extreme lengths to get this training sorted out.
Another astounding point that must be mentioned…under normal circumstances, when something needs to be done in the NHS, it is certainly not the most rapid as far as progress is concerned! COVID had arrived and was going to be a massive handful for everyone, but it brought with it emergency governmental money! Now…ultrasound machines we had all dreamed of getting and had to wait years for with bidding, were here. Walls were knocked down and areas were re-configured, in hours….not years! Governance processes and approvals were rapid…arguments regarding need disappeared and it semed COVID funding would be here to be used as we saw fit. It was certainly a huge positive in amongst all of this!
The tidal wave starts!
The next week, I started a week of nights. Everything was still relatively normal…still doing emergency operations and helping ITU when I was not. Not sure exactly when we had the first case in the hospital, but I remember seeing some query COVID patients in resus and taking down their numbers to later check on their swab results, (they were positive).
I will always remember my first query COVID intubation; the one we had trained and drilled for. At first, it went well, but then, unfortunately, they went into PEA. An unsuccessful resuscitation followed, which was a terrible way to start and to say we were upset, was an understatement. Even worse, they eventually turned out to be negative, but we couldn’t be too careful. Hindsight is a wonderful thing but also weighs heavy on the conscience.
Learning from mistakes as cases increased!
The second intubation came quick and was much better thankfully. The patient was safely transferred to ITU and subsequently recovered well. It was a gruelling week during which I went from a COVID novice to being happy with the procedures in place to protect us and the patients.
The case numbers grew and by the following weekend, I had intubated 2 more and was setting up a patient in the theatre ‘PODs’, as we had exceeded our ITU capacity. This was not straight forward, while every attempt had been made to get everything needed to make them ‘like ITU’, there were obviously things forgotten. Common ITU drugs not given during surgery and small pieces of paperwork (X-ray stickers, insulin charts and LocSSIPs), to name a few.
Then came logistics; who would be in there; ITU nurse, ODP, TSW, HCA, Theatre nurse, SHO or SpR or Consultant? Which beds would we fill first? Which anaesthetic machine would we use and would these be ‘fit for purpose’, for critically ill ITU patients with this disease?!? How to print blood request forms? How to access the handover? These were all issues we had to overcome…and overcome them we did. People really came into their own from all over the hospital! Teamwork had never seemed this good before…from ITU, theatres and beyond. Everyone clubbed in together; there were sometimes disagreements, but in general, everyone chipped in to make it work.
COVID was here to stay!
From the following day, the rota changed. There were to be no more normal days, with all shifts being 12.5 hours long. For me, it was ok as my commute was currently only 20 minutes, but I have no idea how some of the other trainees managed, some with 60 minute plus commutes! It is extremely tiring and what I often heard at the end of the shift were comments pertaining to the fact that “the commute is the worst, wish I could just magically be home now”. My words of support were always there to my peers, but in reality, there was nothing could do except be there for them at work.
As it turns out, the new rota didn’t push the hours over excessively. The issue was that many extra hours had become antisocial, so the weekend frequency increased and so did the number of nights. Again, I felt lucky, as most of our weekend plans were completely gone anyway…I am also lucky in the fact that I can switch from days to nights without much of an issue. I am aware others find it increasingly difficult. In honesty, for most of us, the weekdays and weekends all seemed to merge into one and their boundaries became fuzzier as all of this continued into lockdown.
An end to training as we knew it…
Annual leave was also cancelled at this time, which in most cases did not matter. We were not allowed out anyway, but still, it meant we had less rest time. Another ‘problem’, with this new normal, was the fact we were missing out on cases for the logbook. My Airway and ENT modules are looking a lot less meaty than I had hoped for back at the start.
I also had arranged an in-house, very well recommended leadership and management course. This had been understandably cancelled. So had my ATLS and GIC (pending). It had also become almost impossible to do any of the Quality Improvement Projects I had planned. Audit had ended for now and research opportunities…well, who knew? It was at this point that most national and international courses were all being pulled. So, I started to feel a little less anxious, as this was affecting EVERY man and woman in training!
A positive for my training, however, was getting involved with this website. I was asked initially to peer review and keep an eye on the COVID pages. To let the Editor know about any glitches/changes / out of date sections. I was then asked to oversee a live evidence section. From that flowed an invite to contribute to more of the research and papers section, then onto being a contributor. I have been lucky!
Of course, as well as looking at evidence/research in COVID (and beyond), it has allowed me to put my story across to you..thank you for reading it. I have also been able to get some training on research trial consenting and randomisation, which is very good knowledge to have. In amongst all of this, we have seen an exponential uptake and commencement of research trials involving COVID. Many of which have been shuttled in with quite some gusto!
ITU became my home from home!
I had not worked in a general ITU (other than the odd trip to help with an unwell patient or intubation), for over a year. It was quite a rude awakening, as these are some of the sickest patients I have ever seen. Not only do they have the obvious failing lungs, (needing the full works of lung-protective ventilation, APRV, proning and ECMO referrals), they also had multi-organ failure as a result of this initial insult. We started to notice patterns coming through, into which many patients would start to fit. It was almost like you could read a crystal ball and predict what was going to happen next, and in which order organs would fail. We also noticed, as did the rest of our ITU colleagues from all around the country, that these patients were extremely prone to coronary and major thromboembolic disruption. Many CT chests were rapidly followed by CTPa…if they weren’t in the first instance, as we all became hyper-alert to pulmonary thrombosis.
This horrendous virus was a nightmare – cerebral failure with lots of agitation, delirium and post-traumatic stress in those who would get off the unit and be de-escalated to the wards. The pressure ulceration was a nightmare, and that which we had never seen before! It was almost a fact that we were going to have to accept this as the ‘normal’. These patients couldn’t turn like we all do in our sleep. They were also going to be spending a lot of time proned, with pressure placed onto areas we were just not used to looking after. They were going to be spending literally days/weeks/months completely dependent on us…even more so than many new born infants. Our responsibilities to these vulnerable patients was unsurpassed.
Staff caring for these patients also came from many different non-ICU trained, walks of life. They also needed our support and we were more than willing to give it. Quite frankly, the nursing staff and support workers were the true heroes in all of this, spending hours at a time in PPE, just praying for the next break. At least we were not anchored to the patients like they were. I really felt for these legends in amongst this, and it gave me, and all of us for that matter, a new wave of respect for our non-medical staff!
The patients were teaching us!
CPAP – The Respiratory Support Group
We got some things wrong in the early days, but we learnt quickly. One area of complete controversy was the fact we soon developed a feeling we might be scooping and intubating many of these patients a little too early? We gave CPAP a bit of a hard time to start with, seeing patients escalating to levels of oxygen above 60%, PEEP’s of 10 and jumping in with intubation early. The fact was, we did not have any experience with the time course of this disease, nor did we have mortality figures/experience to fuel the best management strategy. The patients would soon dictate this to us.
It was emerging, certainly from Italy, that CPAP was becoming a very useful weapon in this and in many cases, was permitting avoidance of the physiological trespass of intubation. On these grounds, our Trust took the full punt and set up an extremely robust CPAP ward area system. Along with this, was formed a Respiratory Support Group (RSG), consisting of some shielding and non-shielding physicians, manning the phones 24/7. On ITU, we formed a tight link with them, liaising at least 3 times a day. They managed, along with our advice, to keep many patients away from the invasive wonders ITU can bring. We were seeing increasing mortality figures amongst intubated patients around the world and it may have been that CPAP allowed us to avoid a lot of this. Our ICNARC mortality figures were below many other centres in the UK. Was this the reason?
Initially, we had written off NIV, spreading the word that it did not work and was perhaps too risky. We would receive referrals from the CPAP wards early on, and they came in vast numbers pretty much as soon as the patients had landed from the ED. Staff manning the CPAP wards were obviously very apprehensive, as they had seen nothing like this before. Over time, we became more and more reluctant to just ‘scoop and run’ early on. This made the staff somewhat uneasy at the fact we were becoming more and more reticent to intubate immediately, as we had been doing in the very early days. They started to hear us saying, “give them more time”, or “be patient as intubation might carry a worse outcome” etc. At times, we were also looking at each other in disbelief that we were saying, “they are on 90% and 10 of PEEP, but they are very stable; let’s keep a close eye on them and hang on a little longer”.
Dry dry dry!
COVID causes severe pneumonitis right?! So the mantra would be to run the patients dry to permit removal of this unnecessary extra-vascular lung water, impeding gas exchange in an already stressed system. We were performing a lot of serial lung ultrasound examinations and drying patients out, both with renal dialysis and buckets of diuretic therapy. Yes; this seemed to help as we watched FiO2’s fall and gas exchange improve…but the evil trade-off started to rear it’s ugly head…AKI!
We started to run patient’s neutral now. We had been removing litres of fluid via our dialysis machines, particularly in those who had gone on to develop renal failure (very common). From saying, “take off 150ml/h”, we were instructing neutral balances be maintained…and even giving small fluid challenges!!!
We didn’t fully appreciate the thromboembolic risk at first. Colleagues from around the country were reporting filters clotting off after only hours, incidences of PE/DVT being off the scale and escalating doses of anticoagulation being normal. Many were on 2/3 dose or full-dose anticoagulation, as well as full systemic anticoagulation when on the filters.
Then came the banter about different phenotypes of respiratory failure…the ‘L’ and the ‘H’. Essentially, what this meant was that some patients initially did not respond to vast amounts of PEEP or proning…all they needed was a good low tidal volume, high FiO2 strategy to get them started. Whereas another type had stiffer, more difficult to ventilate lungs. These patients didn’t do well without PEEP and proning. We soon got an idea as to who was who, but it was all rather an experimental game where we allowed the patients’ responses to dictate their type. WHether you believe this or not is up to you, but it certainly seemed to have some merit to it.
As I have been studying, perusing and appraising the latest research and evidence in all of this, it is clear that the number of publications is exponentially increasing as the days go by. You read one paper on a topic to do with COVID and after a day or so, another contradicts the first!
It does seem that everyone wants to and can get published within this unknown COVID world! Peer review processes have been catalysed as journals release information far more rapidly and with less stringency than normal, in order to get vital information out to the masses. It’s almost like a race to see who can get there first!
Fatigue sets in!
About 3-weeks into this (which coincided with our initial peak of roughly 14 intubated COVID patients), I found myself fatiguing. It was the toughest shift for me, mentally, since experiencing my first death as a young innocent F1 in 2012.
Since this experience as a FY1, I have got much more used to death, not blasé by any means, but it is a natural progression and a large part of maturing as a clinician. Deaths affect us more or less depending on patient factors, personal factors and the biggest one, how much we have dealt with them and their families. Where there is experience and empathy with death, more emotion naturally follows. These feelings are something we have all had to ‘wall-off’, many times, in order to cope with the acute situations we face.
However, during this pandemic, the patients that have needed intubation have been (on the whole), fully conscious and lucid up until induction. Most patients I intubate for ITU are unconscious or semi-conscious before induction. Probably the biggest issue we were facing was the fact that these patients were often so alone! Their loved ones were not allowed in to be at their side during this extremely scary period, due to complete visiting restriction. Their vulnerability was that of a level we had never seen.
There was one particular incident that will never leave me. One of the patients I had intubated early on, very sadly died. All I could think of was the fact that I was the last person they had seen/spoken to. I hoped I had made them (at least in that moment), feel safe, even if the end result was not a victory. What made it all worse was the fact that at first, they did not want to be intubated. They had had a bad family experience on ITU, but after discussion with myself and their family, we had changed their mind. Maybe they were right…it’s hindsight again rearing its ugly head. I will always remember them.
Another thing that was entirely new, was the fact that we were having to counsel relatives regarding their sick loved ones over the phone. Face-to-face consults became impossible due to visiting restrictions. We were utilising facetime / Whatsapp and any other forms of communication we could to try to let loved ones get closer. It was absolutely horrendous having to let relatives know their loved one was going to die without being able to judge human body language nor offer a calming hand to hold.
How can I not mention this! I’m glad to say it has not really been a big worry for me, but I know that it most definitely has been for some. Pressure ulceration, staff collapsing with the heat, feelings of claustrophobia etc. You knew fine well who had just finished a shift, as they looked like they had had a ventouse stuck to their face for hours! The FFP3 masks had always been around, but were used few and far between prior to all of this! When we had to use them before, the sooner you could get them off, the better and to be honest, much of the time we avoided using them wherever and whenever we could. Now, they had become part of us, like a watch on your wrist (out of the hospital – obviously!)
I’m not sure aerosol vs droplet spread was taught or explained very well and that did not help the anxiety. I’m also aware that as an anaesthetist, I had 24/7 access to an FFP3 and it was reusable. I could wear the respirator with filters in any situation I felt warranted. It was clear that not everyone had that luxury. Yes, they were very uncomfortable for hours on end, unforgiving to the bridge of the nose and like a vice on your head after hours. But, these special forces regalia soon became my ally!
We did have one issue a month or so in; we were running low of fluid-resistant gowns, we never ran out, but it was close. As a trust, we had washable gowns, (the same used for scrubbing in theatre). I always used to hate them (could never find the armholes), but they soon became my best friend, as arguably, along with the FFP3 masks we hated, they were saving us!
I did find it an interesting distinction though, that our forearms needed a waterproof covering but our neck/hair/cheeks did not. Although granted, our arms were more likely to touch something infected, it just meant we would have to wash our arms more!
We had no problems accessing PPE, but wearing it brought up some issues. Firstly my beard (if you could call it that). I had not been cleanly shaven for 8 years, it was grown to make me look older so everyone would believe I actually was a doctor and not a med student, but it ‘crossed the seal’ so it was no good.
At first, I shaved it in so it would all fit inside the mask, but I quickly realised that would be too much effort to keep up so clean-shaven it had to be. Lots of trendy beards have been lost during the cause…I think it will take a long time until they return. Secondly our faces; I think at first we were all putting the masks on too tight, it was leaving our faces red and sore. We learnt, in time, to only have them tight enough to make a seal and to use barrier tapes with a multitude of moisturisers. My face is still in one piece, but many others bare the wounds of the battle against this virus and may do so for quite some time to come.
It also made communication much more difficult, especially from inside rooms, which was an issue we had to overcome. It became necessary, quite early on, to wear ‘full PPE’ for all anaesthetic cases due to the aerosolising risk. Added to this, we were facing the mist of not knowing the infection status of emergency patients coming in as ‘non-COVID’ cases. Even simple cases were now much more complex and any long cases now required much more frequent (and longer) relief to allow PPE free time.
My personal life
On a personal level at home, we decided to stay inside even before the government put us into lockdown. We already home-schooled our 4-year-old, so when the schools closed, it was not as big an issue for us as it was for some.
I have been very careful to scrupulously clean my things at work before I leave and wash/sanitise my hands several times. I also shower the second I walk through the door, but over and above that, I have tried to reduce contact with my family a little bit (it’s pretty much impossible with an 18-month-old), to reduce their risk.
Families of all key workers should not be forgotten during and after this! They share a lot of the risk and have to deal with us when we get home after our shift, in various states of exhaustion.
I have not (as far as I am aware) had COVID. Close colleagues have, some with very few symptoms, some fairly florid! I know of circumstances throughout the UK where healthcare workers have been admitted to their own hospitals as a result of their roles (most probably). Some sadly have succumbed to COVID and passed away. The scary thing about all of this, and I have learned this through experience, is that no one can predict nor blueprint who will react to COVID badly, if at all. There is no clear time course/pattern to it either. Some get it, are completely asymptomatic; some are knocked for six; some sadly die. It’s all the same insult. From this angle, I do feel scared as I or my family could react badly, but it’s not something you can dwell on too much because it would paralyse and prevent us from doing our job; the key is to just follow policy to stay as safe as possible.
Appreciation …perhaps beyond what was due???
That brings me quite well to the Thursday Clap for Carers. When it was first done; it was really nice, and I honestly felt very emotional hearing and seeing it. However, over time, I feel it has lost it’s meaning somewhat. There seemed to be a growing clap ‘one-upmanship’ going on, with people almost being looked down upon for not clapping. In my opinion, it may have seen its best and should be officially ended somehow, though I am not sure how.
Along with this sentiment, we were seeing box after box of goodies, takeaway after takeaway being delivered to the unit and a multitude of freebies being thrown at us from well-wishers amongst the general public. Cards, rainbows and drawings from children all over the county were sent to us. Captain Tom raised millions…the world had been turned on its head and the NHS was being appreciated, really for what we had always been doing…perhaps finally. But, at the end of the day; heroes…maybe to some, but to us, we were just doing what we had trained to do for years, and ultimately, what we loved doing…looking after the sickest patients.
This all highlighted how the public felt about us in all of this. It was extremely humbling to receive and to witness. Our NHS had become the pinnacle of everyone’s lives, Nye Bevan would have been proud! It occupied every discussion as far as your ears would hear. It also received the most government funding we have ever seen…and rapidly. It was as if they finally got it’s importance once again! The inertia on this has worn down now, but I hope the sentiment towards the NHS and it’s value does not diminish.
We are nearly 10 weeks into this now. I did not have to intubate as many patients as I thought I would, because our consultant anaesthetic colleagues stepped up to do most of them. We must hand our hats to them, as they have been true front line soldiers in all of this, appearing on the wards and sweeping in to deal with the worst situations on our behalf. Like the special forces!
This has allowed us to get stuck in with the patients in critical care areas. We now have many fewer patients than at our peak (well COVID at least), though we are seeing increasing numbers of sick non-COVID patients. POD’s have cleared for now. To be honest, we are glad of this, as we soon discovered that the anaesthetic machine ventilators were full of gremlins and are not really suitable for the advanced ventilation some of these patients would require. Having windows again out of theatres was also pleasant. The one thing that stood out about the theatre pods was that they were certainly cooler and a less stuffy environment to work in.
The numbers on the rota have reduced (some due to sickness) and we have been allowed some annual leave, which means we don’t have to work quite as much. As a result of this, however, the days we do work can sometimes be harder.
What does the future hold?!
The future; it’s very uncertain with so many questions still unanswered. Does having COVID render one immune; and if so, for how long? How effective are the experimental vaccines and will we ever see them? When will we be confident to de-escalate and will that be in vane as we see further surges? How long will we have to wear PPE for…could this be our future everywhere in the hospital to varying degrees? Will the virus mutate and how many times? Will test/isolate/trace be enough? Will it become endemic, not just pandemic? We are currently on the down-slope of deaths, but when lockdown is released, what then?!
The answers to these questions will hopefully become apparent sooner rather than later, but I can’t see things being anywhere near normal for me until next year at the earliest.
I am due to move to another hospital in August, onto the obstetric rota and one thing that COVID-19 cannot stop is the need for obstetric services! Will we be needed more or less I wonder…? More worrying perhaps for me is my training. I will not have done all of the required modules I hoped to get signed off. What will that mean? An increase in training time? Hopefully not! The cases and assessments can be done in time, but it all depends on how quickly we can get back to some sort of normality.
The race for a COVID vaccine should be the priority now…rather than a race to get published on which random drug will ‘cure’ COVID or lessen its damage to patients. This may, unfortunately, be evolution in action….whereby more and more resistant bacteria and more virulent viruses will eventually get us all!
Are we heroes in all of this…no! We are just doing what we love to do and that’s help the sickest people. The sentiments towards the NHS after all of this will hopefully be left intact, if not uplifted? One thing is for certain, I think COVID is here to stay, we have started the battle…can we win the war though?
Again, we must offer a massive thanks to the other people involved in fighting this fight with us. The true heroes are all of the other staff in the hospital, without them, we would all be burning out….you know who you are!
This article was written by Dr Matt Bigwood – ST5 in Anaesthesia and ITU
Edited by Dr Jonny Wilkinson – Consultant intensivist (CCN Founder)