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Nursing

A&E Covid 19 Story Week 7

Changes to the NHS

This week I have noticed firsthand some of the changes to the NHS that Covid has brought about. Firstly, for most of the week I have been working with the non covid patients who come into A&E. These are the patients who present to A&E with no Covid/respiratory symptoms or temperatures and signs of infection. These people are triaged straight to the non covid side of the department. 

These patients have been steadily increasing in number over the past few weeks. Whereas when lockdown started, perhaps due to the #stayhome (or now #stayalert) message being promoted to the public, there were very few patients coming in. However the illnesses and accidents requiring emergency care such as heart attacks, strokes and mechanical injuries are still happening. This lead to NHS England’s Medical Director making a public announcement. He encouraged people to attend the emergency department when needed.

During this period, as Covid patient attendances decrease and non covid patients increase in numbers, there is an uncertainty of how A&Es and wards across the country need to change and adapt again. This would be to ensure minimal cross contamination so inpatients aren’t put at risk of catching the Corona Virus.

To adapt to the pandemic hospitals are changing to have Covid and non covid areas. I.e. there may be a ‘Covid ITU’ where the normal Intensive Care Unit is situated and a ‘non covid ITU’ in i.e. a theatre recovery area.

Patient Flow

As the patient numbers are changing week by week it has thrown many things into question. For example, if the designated areas can now fit the size of the population they are treating. It is also a tricky problem to solve. This is because after having people with Covid in, these areas will need to be kept empty long enough to be extensively cleaned. This is so it would be safe for the non covid patients.

The intensive cleaning involves many steps. Firstly, removing and replacing the curtains. Then, wiping down all surfaces and walls with disinfectant and disposing of any items left in the room. This is usually unused ECG stickers, unopened cannula packets and untouched dressings. Additionally, if these areas were switched back too quickly to ‘clean’ spaces, it might mean there wouldn’t be enough spaces to treat the Covid patients if the prevalence of Covid hospital admissions spike again.

Accident & Emergency

Where I work in A&E, the changes to the NHS are very visible as the entire department has been rearranged. The non Covid majors patients are treated in the small cubicles that under normal circumstances are used for minor injuries. For example, used for people who need stitches, casts, and wounds dressings. These cubicles are not as big as the standard majors cubicles. These are equipped with a cardiac monitor, a trolley and a patient table.

The nurses looking after the Non Covid Majors patients have to work in a small number of cramped clinic rooms that weren’t designed for majors patients. The environment feels overcrowded and chaotic. For example, it makes simple tasks like getting a hospital bed into the room, difficult due to space. Someone may require a hospital bed in A&E due to being in a wheelchair and not being able to transfer to the height of a hospital trolley or requiring a bariatric bed as the A&E trolleys would not fit these patients.

Redeployment

Additionally, another change the NHS has had to adopt is the mass redeployment of staff. Services like childrens ED’s and speciality clinics are getting relocated. I personally know a lot of stroke and paedeatric nurses who have been told at a few days notice that they will now work at a completely different hospital. This is miles away from where they currently work. This has meant lots of staff have had to sort out temporary accomodation. Staff in management roles have had to leave half way through their current projects/workloads for inductions at totally new trusts.

Redeployment is not always as easy as it sounds. For many, it means going through the stress and hassle of learning new IT systems, acquiring new access badges and getting to know a totally new site or even job role. It means teams who know each other well being pulled apart and has left nurses unsure of what they are allowed to do in their new role specification. (The RCN has a useful advice page if you are going through redeployment here). 

Redeployment has meant the relocation of many specialist nurses and doctors. A lot of whom were about to commence/were mid way through training for a speciality role. They have been since asked to move to places such as emergency departments and ITU’s to support the staff with the projected strain on the NHS that Covid was thought to bring. A close family member of mine, who usually runs a podiatry clinic, has been supporting the district nurses. She has been taking some of their visits to change dressings and give medication. Although this has been difficult and a lot to get used to, she also reports it has been a refreshing change from the usual workload!

Teamwork

The feeling of teamwork and the liberation of being able to ‘pull out all the stops’ to support frontline services has been quite incredible to behold. It has been very useful to have extra staff around to help out when needed and I have felt very supported by this.

Sadly though, the cost of this short term relief has been great. Elective theatre lists have been placed on hold which has left patients with cancer waiting for their operations. It has meant, patients with osteoarthritis that stop them walking have been in debilitating pain. These are just two examples of the people that will have their lives affected by the changes to the NHS and the measures necessary to ensure the NHS would be able to cope with the Corona Virus. Post Covid there will need to be changes brought about to control the after affects of this pandemic, such as an increase in theatre capacity to clear the now massive backlog of theatre waiting lists.

Concluding

This post was not intended to be overly negative and cynical, only realistic and reflective. Whilst this has been a time of great tragedy and suffering, which we must not forget, there are also many things to be thankful for this week. For example, passing the peak of the Corona Virus and the relieving of some lockdown measures. I am extremely proud of my colleagues, friends and family members who have all acted and continue to act so bravely. I know my parents, like many around the world, have been so worried about me, themselves and the people they love of course, and they continue acting bravely. 

There have been large amounts of support available at work. A wellness centre to came to visit with socially distanced activities such as yoga and group support sessions. I have also had a therapist visit the department and taken part in a mindfulness session. Myself and other staff found it to be very stress relieving. 

Its easy to feel overwhelmed at the prospect of facing more long term social distancing, increasingly difficult working conditions. Especially as more changes happen to the NHS and there is a rapid crumbling of summer plans. However the mantra of taking it ‘one day at a time’ helps me here! I hope it helps others too. 

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Nursing

Covid 19 FAQs: A&E Covid 19 Story Week 6

Week 6: Covid 19 FAQs and Myth-busting

Due to the amount of questions people ask me on a day to day basis, I have put together some Covid-19 FAQs.

Do you get a lot of people in the Emergency Department with Coronavirus?

This is classic question for Covid 19 FAQs. Yes. A large number of people who come into the emergency department right now may/have the Corona Virus. Everyone who presents with respiratory symptoms i.e. shortness of breath/cough/low oxygen saturations or fever are triaged as “suspected Covid”. These people are moved to isolation in separate cubicles in the ‘Covid’ side of ED.

What happens when an ambulance calls through a priority call for a covid patient

The Resus lead selects a ‘Covid Resus’ cubicl for the patient to go into. The ambulance crew communicate the CAD sign over the phone so the ambulance can be seen as a priority at the ambulance bay. This is incase there is a queue (of other ambulances). At least one doctor and one nurse prepare in ‘full’ PPE. This includes: Gloves, a long sleeved surgical/fluid resistant blue gown, (plus a normal plastic apron if the gown is not fluid resistant) a surgical cap, a FPP3 mask, a visor and then another pair of gloves where the opening of the gloves are taped down to the gown. 

What is PPE?

Personal Protective Equipment. PPE embodies masks, gloves, aprons, visors, and long sleeved gowns to protect staff members from contracting dangerous pathogens and virus’ such as the ones responsible for Covid 19, Hepatitis, HIV or TB. PPE also protects staff from harmful or offensive substances i.e. vomit, urine and blood. 

When do you use PPE?

Where I work mask’s are worn at all times when in the department. Gloves, apron and protective eye gear such as goggles/visor are used when interacting/caring for a patient (this could include recording observations or giving medication, taking bloods etc). When engaging in an aerosol generating procedure (AGP) such as swabbing a patient or ventilation we have to wear full PPE which consists of a long sleeved fluid resistant surgical gown, a surgical cap (which is basically a hairnet), two pairs of gloves, a visor and an FPP3 mask.

What is an AGP?

As mentioned above, an AGP is an ‘Aerosol Generating Procedure’. It is an activity that generates droplet particles that could transmit Covid such as CPAP or swabbing a patient with covid, the Resuscitation Council UK have stated they are as yet unsure if CPR is a AGP. The poster I have attached is useful for healthcare professionals who are unsure about resus scenarios regarding covid.

Why do people wear different types of PPE?

People employed in different professions and trusts have different PPE policies that seem to have been developed due to supply and what the professional may come across in their role. For example, many paramedics wear hazmat suits due to the potential exposure to a variety of things during a call. A nurse working in a place like intensive care where AGP’s are happening constantly may have different PPE practises than someone working in a care home. It would be reasonable to expect less AGPs to happen in a care home. Some wards made preparations for the Covid outbreak and could ensure their staff had fitted reusable FPP3 masks.

A Reusable FPP3 Respirator Mask

Do you always have access to it?

Where I work I luckily have access to the correct PPE at all times, however I understand this is not the situation many nurses are in. 

How long does it take to put on and take off?

It can all be put on in the space of a few minutes if you are in practice in doing it and if it is readily available to put on in an emergency. Taking it off involves tearing off the apron from the front by pulling it forcefully, putting in the bin, washing hands, wiping down the reusable visor, stepping out of the room and then changing your mask and rewashing/sanitising hands. 

Do you use fresh PPE for each patient?

Yes, apart from masks which we change regularly throughout the day but not between each and every patient. 

What happens in Intensive care?

In intensive care many patients with Covid are require invasive ventilation. This means they might be producing aerosols that can transmit the virus into the air in the form of droplets. In these areas the patients with Covid are in a cohort and the people working in those areas will have to wear the full PPE for long stretches of time.

What happens in these areas when nurses need breaks?

As wearing the full PPE is heavy, uncomfortable and hot it is important the professionals working in these areas have regular breaks as they are unable to have a drink or go to the toilet whilst wearing this PPE. This is where wards and Intensive Care Units are struggling with having enough staff to cover each others breaks. Every shift, 1 or 2 A&E nurses work on intensive care for the day to support the staff there. Additionally, the trust set up more intensive care units to cope with the increasing demand for ventilators/intensive care beds. These were in places like theatre recovery whilst there was temporary cancellations of elective theatre lists. 

Do you get breaks?

Yes. Where I work, staff nurses get 2 thirty minute breaks each day. We also get additional tea or coffee break in the morning. In A&E we cover each other’s break and if something comes up for one of your patients during your break (e.g., someone needs pain relief) someone is there to help.

I previously worked on an acute medical unit. If something needed doing during my break it was rare anyone would be able to step in to assist. Some of the time the nurse in charge/another nurse or support worker may have been able to help. However most of the times the other nurses were too busy with their own workload. This meant the task would be waiting for when you returned. This definitely wasn’t anyone’s fault. On the ward the ratio of nurses to patients was 1:8 whereas in A&E majors the ratio is 1:4. However in A&E there are different pressures, such as a quick patient turnover more critically unwell patients in need of stabilising. This means it would be difficult to keep track of what was happening to more than 4 patients. 

Social Distancing at work?

It is incredibly hard to maintain social distancing at work. Up until a week ago I could still be in a squeeze in a lift when 6 other people decide they would rather get in, than wait for the next one. There are now lift rules – which means there is a long queue in the morning for people needing to use it. Happily, A&E is on the ground floor. In the staff room at break times people don’t have space to suitably socially distance.

Further FAQs?

Thank you to the people who submitted Covid 19 FAQs to assist me in writing this post. If anyone would like to know anything further I would love to help answer your questions. Feel free to comment anymore Covid 19 FAQs. Thanks for reading.

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Nursing

Clap for Heroes: A&E Covid 19 Story Week 5

Week 5: #ClapforHeroes

This week a 99 year old man walked around his garden 100 times and raised £23m for ‘NHS Charities together’. People were participating in clap for heroes on Thursday at 8pm and Westminster Bridge was (ironically) filled with supporters who were turning a blind eye to social distancing rules.

I love the well wishes and support. Seeing tube stations lit up with ‘Thank you NHS’ after work does makes me smile and feels directly like a ‘thank you’ for the shift I just worked. Food is delivered to A&E every day, often we get deliveries twice/three times a day! The NHS is inundated with people and businesses showing their gratitude and for that I am very thankful, it is much appreciated.

I was very happy when I was given 4 easter eggs this easter from work. Thats more easter eggs than I’ve had in the entirety of my adult life. Just yesterday a charity donated a bag of groceries individually packed for everyone in A&E (and I imagine other departments). Inside was a baguette, a packet of pasta, a banana, a protein bar and a carton of 6 eggs. Meanwhile, my friends and family members have been messaging to check in and all have been very kind. I would very much like to say thank you to everyone for the support.

I do not for a second wish to seem ungrateful for the nationwide effort to support the NHS but I do have some doubts about wether thinking of the NHS as a charity is a harmful stereotype to purport. The NHS is a public service that is funded by taxes, the fact that it has been left in a position where people feel the need to donate their hard earned, already taxed earnings does raise some questions.

What will the money be spent on?

It is also unknown what the money will yet be spent on. A guardian report suggests established NHS charities such as Guys and St Thomas’s can apply for grants. This would be to fund wellbeing projects, refreshments and relocation funds for the staff. Apparently the money cannot be spent on core necessities such as paying wages etc. This makes me wonder if the money could even be used to procure/manufacture PPE. Meanwhile, many news articles now suggest hospitals, hospices and care homes are struggling to supply staff with a safe amount.

This raises a topic I wanted to address this week which is the insistence on branding health-care staff as heroes. This is especially apparent in the clap for heroes practice. Before lockdown, my friend told me her dad was visiting pret to grab an NHS free drink. During this, he was approached by a stranger, only to be heralded for being a ‘hero’ and thanked profusely. This made for a rather awkward/borderline uncomfortable exchange as he thanked her whilst also trying to explain that he ran a clinic and was just doing his job.

#Heroes

In my opinion branding NHS workers as #Heroes during clap for heroes, makes the tragic loss of life almost explainable, rather than the atrocity of what it is. If NHS workers are making a ‘heroic sacrifice to save lives’ by turning up to work, it brands us as martyrs, rather than what we are. People. Every nurse, doctor and healthcare worker is a normal person. Yes brave, yes hardworking and yes rather selfless but still just a normal person, who does not want to die. I work as a nurse, I frequently treat covid patients, I still go into work everyday. It doesn’t make me ‘fearless’, because I’m not, I’m still fucking terrified.

Here are some of my favourite tweets from the week which express my point in tweet format.

Next post I will set up an FAQ’s page so feel free to comment any questions you have for me to answer!

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Nursing

A&E Covid 19 Story Week 3: Covid 19 Emotional Strain

Week 3: Covid 19 Emotional Strain and Covid Resuscitation

Week 3 in A&E addresses Covid 19 Emotional Strain. My third week in the Emergency Department started off with the tragic news. This was of two nurses losing their life to Covid 19. Reading this along with all of the heartfelt online tributes really shook me. It took a few hours of relaxing, including talking to my housemates and having a nice walk around in the sun to start to feel better

News

However, the next day I woke up to the news that another nurse had lost their life. This time a 23 year old. This was the news that affected me the most. 23 is my age. I think that I had rationalised the other deaths by characteristically distancing myself from them. This was in order to try to convince myself that I am not in any danger. This was what showed me there was absolutely nothing stopping the next nurse to die being myself. This terrified me. I ended up in tears on the phone to my parents twice in the same day, telling them I wanted to quit my job . 

After my flatmates comforted me (both of whom have been very supportive in the past few weeks) I messaged colleagues from my previous job to find out if they were going through Covid 19 emotional strain. As I have recently started in A&E I didn’t feel there was anyone I knew well enough yet to talk to about this. Reactions were mixed. Everyone who I contacted said they could relate in some way to the emotional strain. My friend, who works in A&E elsewhere said she, finds the increased amount of patients dying in A&E upsetting.

Additionally, another friend told me she didn’t want to be a nurse anymore. My friends working on wards have told me they have trouble sleeping. A colleague who I spoke to at work told me she misses her family. This is because she is currently living in hospital accommodation (which lacks any cooking facilities/fridge) as she has elderly parents who she wouldn’t want to risk exposing to the virus. 

In A&E

Despite a shaky start to the week, the rest of the shifts went well. I commenced treating a Covid patient on CPAP (Continuous Positive Airway Pressure) and attended to 3 blue light calls. A ‘priority call’ or ‘blue light call’ is an expression in the nursing/medical profession. It is used to describe an ambulance ringing the A&E red phone (usually located in Resus) en route to the hospital with a patient who is particularly unstable/needs prioritising and urgent medical/nursing attention upon arrival. In the A&E that I work in, these patients are now directed into Covid Resus. This is a Majors cubicles with doors, entirely stocked as a Resus bay) or Non Covid/ ‘Clean’ Resus. Previously, all ambulance priority calls would go straight to Resus.

Covid 19 Emergencies

Covid blue light calls now require all attending staff to dress in level 3 PPE. This is a full length waterproof or surgical gown, a surgical cap, FPP3 mask, 2 pairs of gloves and a visor. They require at least one but preferably more ‘Runners’. The runners are dedicated people (in step-down PPE) who are situated outside of the cubicle and are on hand to assist the staff who are inside the cubicle. 

The runners can take, fetch and process anything the people inside the cubicle need them to. This could range from getting the patient something to drink, bringing in specialist machines such as an ultrasound machine for particularly difficult to place cannulas or a bladder scanner to gauge wether the patients bladder is retaining urine, to complex and vital ventilation machines.

Running

Being a runner often involves being handed blood samples and covid testing swabs from inside the room, in a sealed and wiped plastic bag, to then be placed in another plastic bag to send to the lab. The people inside and outside the cubicles ideally communicate through a walkie talkie, however as people are speaking in noisy environments and are wearing masks, it often means the walkie talkies are useless, meaning shouting and over the top hand gestures are commonplace. 

Another important job for the runners is to liaise with people such as specialist doctors i.e. ITU or medical teams, on the outside and communicate and document this to minimise the amount the cubicle door is open, to minimise the spread of harmful Covid-19 droplets.

Resuscitation

Speaking of Resuscitation, I wanted to cover the changes to CPR/Resuscitation guidelines brought in due to recent events. The CPR guidelines may differ depending on independent trusts but Resuscitation Council (UK) guidelines state that it is unknown if CPR is an Aerosol Generating Procedure (AGP) but expert opinions have suggested it may be, and in the interest of protecting health care workers and medical staff it is advisable to treat chest compressions as if they are an AGP and wear appropriate PPE.

2222

In my induction week I am informed of cardiac arrest procedures. Normally a resuscitation/emergency 2222 call to the cardiac arrest/ crash team includes “(adult/Paediatric) cardiac arrest”. However now it is mandatory to state “COVID” amongst this information. This is so the responders can arrive in the correct PPE. I recieve an email later in the week stating level 3 PPE is the minimum requirements for all arrests. Another difference to note in my trust Resucitation guidance (name held) is that ward staff are not to use a bag-valve mask. Additionally, there is to be no use of stethoscopes in arrest situations. These changes, whilst necessary, poses questions about what to do for an ‘Out of Hospital Cardiac Arrest’. This will inevitably delay life saving CPR. I believe this will undoubtably have impacts across the entirety of health care for considerable time.