Confidentiality disclaimer: To ensure the NMC’s guidelines on confidentiality are adhered to, no personal or identifying information will be in this blog. All names used will be pseudonyms and no place, staff or patient details will be used.
Covid 19 and BAME Inequality.
Previously I have talked about the gender inequalities that wearing scrubs has exposed within the healthcare system. This weeks post there will be a wider focus on the inequalities faced by BAME people that have been exposed by Covid.
Recently, the murder of George Floyd, a 47 year old Black man, has been brought to the attention of the public eye after footage was shared of the (now charged) police officer kneeling on George’s neck for a total of 9 minutes, whilst he begged for his life and can be heard saying “I can’t breathe”. The ex-police officer remained kneeling on George’s neck for 2 minutes and 43 seconds after George became unresponsive. This tragic event lead to the murder of the 47 year old, who’s death was an unforgivable casualty of police brutality and systematic racism.
It is undoubtably a difficult subject to address, however as a white person it is extremely important to talk about, regardless of how uncomfortable it may be. Leading voices on the matter include Alicia Garza, Patrisse Cullors and Opal Tometi who have been attributed to have founded the Black Lives Matter movement. I wish to speak from my own expertise and experiences. Therefore I wanted to make this next post about something I am very familiar with but might be useful to address – and that is (as you might have guessed) Covid 19!
This week I would like to talk about how BAME Britons have a disproportionate mortality rate from this virus (twice the risk of death according to the ONS) as it is a health inequality that must be addressed as a priority.
Whilst we are in the middle of the pandemic with a virus that has many victims (including young and usually health people) many people seem to think its unimportant to focus on specifics such as who is more affected. However, as the affects of the virus have unrolled across the UK, it has become ever more pressingly apparent that people from ethnic minority backgrounds are disproportionately dying from the Corona Virus. Out of the 200 health workers who have died in the UK from Covid 19, 60% of the people were BAME.
It has never been more important to collect, study and distribute the findings from a health crisis, who is disproportionately affected by it and what we can do to minimise this public health inequality. It is not ok to place unequal value on the lives that have been lost during this pandemic and its time we addressed it.
On the 10th May there were calls for a public enquiry into this issue, in which 70 public figures (including London Mayor Sadiq Khan) signed a letter to the Prime Minister demanding transparency into this matter. Public Inquiry’s are important for safety, education and can lay foundations for future policy makers and research. In this situation an inquiry could help employers make appropriate allocation decisions made upon risk assessments and contribute to increased staff safety for BAME people.
Despite the NHS looking into risk assessing BAME staff (4 weeks ago) an inquiry into the inequality in mortality still hasnt been done. Gal-dem.com outlines excellently why there is a need for an independent public inquiry into this.
Moving on from the public inquiry I would like to highlight other recent and relevant pieces of news that it is important not to forget.
The tragic death of Belly Mujinga a woman who lost her life 2 weeks after being spat on by a man claiming he had the Corona Virus whilst working her essential role at London Victoria station.
The tragic death of Trevor Belle a 61 year old taxi driver who died 3 weeks after being spat at by one of his passengers.
What you can do
If you live in London and want to support communities in the capital: https://www.londoncommunityresponsefund.org.uk supports Londoners affected by Covid 19 and have awarded £75k of funding to Ubele, Council of Somali Organisations, Inclusion London, Women’s Resource Centre and Consortium.
If you want to volunteer: https://www.ubele.org/contact-us
If you want to donate money to support memorial services for BAME families: https://www.gofundme.com/f/majonzi-fund-covid19-bereavement-fund
If you want to sign a petition supporting a public inquiry into the unequal BAME loss of life to Covid 19: https://you.38degrees.org.uk/petitions/bame-communities-and-the-disproportionate-incidence-of-covid-19?share=a99e5a5e-fa44-4862-911c-e85718582807
Dragging your body to a shift on less than 6 hours sleep that you really wish you didn’t have to go to? Been there. Here are the top 10 songs I would recommend listening to if you need a real moral-boosting-you-got-this feeling to tackle the next 12 hours. The songs are arranged to start with gentle motivation and slowly progress until you’ll be so pumped off adrenalin you’ll be ready to face the next Karen who tries to have a go at you. Spotify link to this playlist here:
- I Won’t Back Down – Tom Petty
- It’s My Life – Dr. Alban
- One Way or Another – Blondie
- Paper Planes – M.I.A.
- Galvanize – The Chemical Brothers
- Savage – Megan Thee Stallion
- Survivor – Destiny’s Child
- 212 Azealia Banks ft Lazy Jay
9. Pump It – Black Eyed Peas
10. POWER – Kanye West
Hope you enjoy the song selections and feel like you can face whatever work throws at you after listening to this power playlist!
Week 9: Post Covid Complications & an Innovative NHS
This week I had the first patient with post viral delirium due to Covid. It was a rather scary experience as the patient, who of course will remain anonymous, was usually a healthy, non elderly person. For those who have never seen delirium, it is a term that refers to a dangerous condition in which a persons mental state is altered, meaning they can be confused, disorientated, aggressive, restless, incoherent and/or unengaged and can be due to infection, sepsis, pain or other reasons like hypoxia, extubation etc etc, despite the cause, it is most likely always a sign someone is unwell.
In this particular situation, the patient was experiencing delirium as a viral complication due to a previous infection of the Corona Virus. Delirium is very serious and it can lead to an increase in the chance of mortality. It can also mean patients hurt themselves and do not tolerate treatment interventions they desperately need, such as cannulas, IV fluids, IV antibiotics and oxygen that they may need to reverse the delirium! My patient was being violent, throwing things around the room, trying to turn on the defibrillator in the room and spitting at staff. They needed to be sedated in best interest i.e. for cooperation in care so they were not a danger to themselves and would tolerate the treatment.
Another post viral complication I have noticed is many patients attending the emergency department with chest pain. When this happens, the appropriate investigations are done to diagnose and treat the patient such as blood tests, ECGs and chest Xrays. If diagnostic test results show the persons life isn’t in danger from things like an MI (heart attack) or a PE (blood clot in the lungs) or severe sepsis/pneumonia/covid etc affecting the body, and the persons observations are stable i.e. oxygen saturation levels adequate without supplementary oxygen, then the person will be discharged. The doctors inform these people, who suffered from Covid a few weeks or even months ago that they are experiencing pain from the effects Covid has had on their lungs and it could take weeks to months to resolve.
I have also encountered many patients who are experiencing Covid 19 symptoms saying ‘do you get many people with Covid in this hospital?’ and being worried about catching it in hospital when it is most likely they already have it. Many patients are also wearing gloves, touching their phone, using public transport and touching their face with the same gloves. Thus causing much cross contamination. The importance of following guidelines such as washing hands regularly and avoiding the spread of misinformation is important to note here for infection prevention and control.
Covid has necessitated a lot of innovation within the NHS. Rapid Covid test swabs are one of the newest pieces of innovation I was excited to see rolled out. A limited number of these are now available in some A&Es for testing for patients who fit a tight criteria. For example, for patients who are at risk of becoming particularly unwell from the Corona Virus and need to be ‘shielded’ from Covid in hospital. This includes people who are immunocompromised, have diabetes or may be on chemotherapy so it would be unsafe for these patients to be exposed to Covid unnecessarily if they didn’t already have it. Ideally, these patients need to be in a ‘non covid area’. The difficulty lies when these people need to be admitted to wards and have presented with symptoms in which Covid cannot be ruled out as the cause of their illness. Therefore these people cannot go to wards in which there would be the possibility they could pass Covid 19 onto other people. There is also a limited number of side rooms available in the hospitals as most of them are already filled with similar patients. The Rapid Covid swab machine technology helps here as, resulting in 1 hour, it can dictate if these patients are suitable to go to a covid or a non covid area and it would save breaches in A&E. (Find out what a breach is here)
There has also been the opportunity to have asymptomatic testing for all patient facing staff in the trust. This allows data to be collected on Covid 19 prevalence among healthcare staff without symptoms and can prevent staff working with high risk patients such as on chemotherapy and cancer wards unknowingly spreading Corona Virus to vulnerable patients. If any of the asymptomatic staff test positive for Covid they are to follow self isolation protocols as usual. There is also the opportunity for me to take part in a vaccine trial if I wanted to! I am not going to take part in this trial however I am excited to hear more about it, especially as it is beginning to look more and more like social distancing will need to continue until a vaccine is found. So I am very much hoping there will be scientific advancements regarding vaccines quickly!
Antibody tests are another thing I am eager to try. I had Covid symptoms in early February, however this was before it was prevalent in the UK and I really want to know if I have had the Corona Virus or not as knowing this would make me feel less worried about catching Covid at work.
In conclusion, as we approach the 10th weekly #ClapforCarers this Thursday I think it is important to reflect on what the NHS has achieved during these times, I have seen an incredible amount of innovation and change in the past few months and I am incredibly in awe of everyone who made it happen and adapted to it so well.
Week 8: Scrubs and the Inequality Beneath
Today I am going to address something that has come to light due to Covid 19.
If you ask people who work in healthcare if they enjoy wearing scrubs, the majority of nurses (myself included) would say they prefer scrubs to the usual uniform as they are far comfier. Historically scrubs were adopted as people began to realise the importance of a clean surgical environment. Since then, in England it is my understanding that most nurses wear a uniform (with the exception of surgical/recovery nurses and nurses in some emergency departments). However, due to the Covid 19 pandemic most staff members who work in hospitals are now wearing scrubs. This is for infection prevention and control reasons i.e. to prevent staff members bringing the harmful virus particles home and on public transport on their clothes.
In a time before Covid, nurses, physios, health care assistants, domestics and porters wore a uniform whilst doctors seemed to be the exception to this rule. It seems doctors had the choice between wearing their own (smart) clothes or scrubs. This meant they could wear suits/dresses or ‘professional’ clothes whilst working on a ward, despite being involved in direct contact with bodily fluids. Whilst there is the argument there to say that doctors are involved in less direct patient contact than the nurses; it does not explain why it is suitable for a doctor to do a rectal exam in a suit with a thin plastic apron on whilst the nurses who hold clinics or research studies are still required to wear a uniform. There is Department of Health published guidelines known as the ‘bare below the elbow’ guidance. It also outlines the three objectives when it comes to what health care professionals should wear which, in a nutshell are Patient safety (ie infection prevention and control), Public confidence (clean and professional workwear) and Staff comfort (I.e., cultural practises). Reviewing this guidance, as long as everybody follows the rules it lays out, I cannot see any possible reasons in there being differences between what doctors and nurses should wear whilst at work.
Now I may be mistaken here, but I believe the contradictions present in these rules date back to a time, pre Florence Nightingale, when doctors were the Professional staff members who held a degree and nursing was an uneducated profession. Hippocrates who is widely regarded as the father of western medicine, claimed doctors should be “clean in person [and] well dressed”.
I believe that due to nursing being a ‘pink collar’ job i.e. a profession held mostly by females (89% in the UK) there has been a long withstanding lack of respect and recognition for the level of education and professionalism required nowadays in the nursing profession.
Sadly, there is a very intense hierarchy present in healthcare. Anyone who doesn’t work in healthcare probably couldn’t grasp just how tangible that hierarchy feels sometimes. I have seen some people take absolutely no notice of people in job positions such as health care assistants, domestics and student nurses. I myself remember being so scared of doctors when I was a student nurse which I now realise was ridiculous. Obviously most organised workforces involve a hierarchical structure, however it can also lead to people being made to feel that they are less important than others. I find uniforms to be an important reflection of hierarchy.
Nowadays, to be an RN (registered nurse) a Bachelors degree in Nursing is required, along with registration to a professional body, the NMC. The discipline of nursing also encompasses many advanced roles such as ANP’s (advanced nurse practitioner) and specialities i.e. heart failure nurse. Many of these professionals take on active roles in the Medical team as they can prescribe, advise and consult- skills which are historically attributed solely to doctors. Many nurses also take on a senior roles in the hospital and community settings as matrons, managers and coordinators etc. So, yes it did raise a bone of contention when I saw an advanced nurse practitioner wearing a uniform whilst the doctor holding the same clinic in the room next door did not.
Going back to the present day, everyone, despite their role is wearing scrubs. Whilst this is more confusing and this practice will not last, I think a lesson we can learn from this is that nurses and doctors deserve equality in their uniform or non uniform policies.
Week 7: Changes to the NHS
This week I have been working mainly 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 in which 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 to ensure minimal cross contamination so inpatients aren’t put at risk of catching the Corona Virus. To adapt to the pandemic hospitals have changed 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. As the patient numbers are changing week by week it has thrown into question if the designated areas can now fit the size of the population they are treating. It is also a tricky problem to solve, as after having people with Covid in, these areas will need to be kept empty long enough to be extensively cleaned to be safe for the non covid patients. This intensive cleaning involves removing and replacing the curtains, wiping down all surfaces and walls with disinfectant and disposing of any items left in the room such as 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.
Where I work in A&E, the non covid majors patients are treated in the small cubicles that under normal circumstances are used for minors patients- aka people who need stitches, casts, and wounds dressings. These cubicles are not as big as the standard majors cubicles, which 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 and 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.
Additionally, another change the NHS has had to adopt is the mass redeployment of staff with services like childrens ED’s and speciality clinics 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, 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 to face 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 many specialist nurses and doctors who were just about to commence/were mid way through training for a speciality role have been 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 by 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!
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 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.
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, such as 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 including a wellness centre 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 which myself and other staff found to be very stress relieving.
Its easy to feel overwhelmed at the prospect of facing more, long term social distancing, increasingly difficult working conditions and a rapid crumbling of summer plans, however the mantra of taking it ‘one day at a time’ helps me here and I hope it helps others too.
Week 6: Myth-busting
Do you get a lot of people in the Emergency Department with Coronavirus?
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” and are isolated in separate cubicles in the ‘Covid’ side of ED.
What happens when an ambulance calls through a priority call for a covid patient
A ‘Covid Resus’ cubicle is selected for the patient to go into. The ambulance CAD number is communicated over the phone so the ambulance can be prioritised at the ambulance bay if there is a queue (of other ambulances). At least one doctor and one nurse get prepped in ‘full’ PPE: 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?
PPE stands for Personal Protective Equipment and 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 are largely developed due to supply and what the professional may come across in their role. For example, many paramedics wear hazmat suits due to the variety of things they could be exposed to when attending to 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 where less AGPs are expected. Some wards that were more prepared for the Covid outbreak ordered their staff fitted reusable FPP3 masks.
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 practised in doing it and if it is readily available to put on in an emergency (such is the case where I work). 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 there are areas in which there are lots of patients with Covid who are invasively ventilated (aka producing aerosols that may transmit the virus to others). In these areas the patients with Covid are cohorted 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 are moved to intensive care for the day to support the staff there. Additionally, there are now new intensive care units set up to cope with the increasing demand for ventilators/intensive care beds. These have been set up in places like theatre recovery whilst elective surgical lists have been temporarily cancelled.
Do you get breaks?
Yes. Where I work, staff nurses get 2 thirty minute breaks each day (plus an 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 that cannot wait (e.g., someone needs pain relief) then if someone has time they will usually help/do it for you. I have worked on an acute medical unit previously and if something (that was not an emergency) 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 own workload and the task would be waiting for when you returned. This definitely wasn’t anyone in particulars fault as on the ward the ratio of nurses to patients was 1:8 whereas in A&E majors it is expected to be 1:4. However in A&E there are different pressures such as patient turnover is a lot faster and they can be more critically unwell/in need of stabilising, so it would be difficult to keep track of what was happening to more than 4 patients.
How do you maintain social distancing at work?
It is incredibly hard to maintain social distancing at work, up until a week ago I could still be squeezed into a lift when 6 other people decide they would rather get in, than wait for the next one. There are now rules about the lifts 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.
Thank you to the people who submitted FAQs to assist me in writing this post, if anyone would like to know anything further I would love to help answer your questions so feel free to comment any q’s. Thanks for reading.
Week 5: #ClapforHeroes
This week a 99 year old man walked around his garden 100 times and raised £23m for ‘NHS Charities together’. People clapped 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.
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 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 as many, 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. Before lockdown, my friend told me her dad was visiting pret to grab an NHS free drink and was approached by a stranger, only to be heralded for being a ‘hero’ and thanked profusely. This made for a rather awkward and borderline uncomfortable exchange as he thanked her whilst also trying to explain that he ran a clinic and was just doing his job.
In my opinion branding NHS workers as #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 on the front line, 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!
Week 4: The Logistical Issues of Discharging Patients with Covid
This week marks the start of finishing my supernumerary time. I start the shift in majors where I get a steady flow of patients, it’s a fairly quiet day in ED. One of the first tasks I’m given is working out how to discharge a homeless patient who is suspected to have Covid. I initially thought ‘oh thats easy i’ll just follow the usual guidelines on discharging homeless people’ and then realised, as the patient had Covid, I actually had quite a complex logistical problem to deal with. The worst part being as this is such a novel issue facing the health service, not many people knew what to do either!
The hospitals are understandably doing everything they can to avoid unnecessary admissions so I didn’t have the option of admitting the patient overnight until social services could support them in finding somewhere to go. The homeless team weren’t working as it was a bank holiday and the patient didn’t have anywhere safe to go to self isolate for 7 days. The patient had been in the emergency department for a few hours already and the managers didn’t want them to ‘breach’. A breach is when a patient stays in A&E longer than the government target of 4 hours and the numbers count towards the performance of the trust. Hospital trusts face fines if they have long or a large number of breaches and they must always give a reason for a breach. This could be ‘waiting for a ward bed’ or a ‘clinical breach’ if the patients current condition was not stable enough for them to be safely transferred. A breach could be caused by waiting for ambulance transport to pick them up or awaiting a specialist team to review them (ie surgical, Medical, gynea etc) to accept them under their care or discharge them.
To safely discharge this patient and to avoid a breach, I managed to liaise with a temporary service which had been set up to provide accommodation for homeless people who need to self isolate.
Another issue that has been increasingly difficult to manage due to Covid is organising transportation home for patients who get discharged. Many patients who initially present with Covid symptoms, are clinically stable and therefore have no requirements to be in hospital must be discharged, to ensure there are free hospital beds for those who need them.
Patients often take public transport or perhaps call an ambulance to come into hospital. Medical and nursing staff are then faced with the logistical issue of getting these people home. If we suspect the patients may have covid it would be socially irresponsible to let them travel home on public transport and risk transmission to the other people who are using it. Many people in London rely on public transport and may not drive/know someone who owns a car. It then means nurses are involved in a lot of phone calls and time consuming administration involving calling up patients family members and asking if they can collect their relative. Quite often people are very reluctant to do so (all patients are given a mask when entering the department to minimise this risk).
If patients do not have anyone to pick them up the only option left is ambulance transport to be booked for them, however this isn’t ideal as ambulance services are seeing an increase in calls and are having to factor in diverts. Diverts are put in place when an emergency department has an unmanageable amount of patients and is completely at full capacity, so ambulances divert all patients to a different hospital, I believe it is initially on for an hour but is reviewed hourly with the view of stopping it as soon as able. Diverts can lead to paramedics driving longer distances with patients and I imagine can subsequently cause delays in care and longer waits for ambulances/a backlog of patients. With this in mind calling ambulance transport to take someone, who would usually be able to take public transport home, is awkward and difficult. It also means that since the transportation of stable patients is not a priority, there can be long waits to get them home.
Week 3: Emotional Strain and Covid Resuscitation
My third week in the Emergency Department started off with the tragic news that two nurses had lost their life to Covid. 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
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, 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 and it terrified me. I ended up in tears on the phone to my parents twice in one day and telling them I wanted to quit my job.
After my flatmates comforted me (both of whom have been so amazing and supportive in the past few weeks) I messaged some colleagues from my previous job to find out if they were going through anything similar. 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 an A&E in the North said she, understandably, finds the increased amount of patients dying in the emergency department upsetting and 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 as 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.
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 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 (aka 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 blue light calls now require all attending staff to dress in level 3 PPE (a full length waterproof or surgical gown, a surgical cap, FPP3 mask, 2 pairs of gloves and a visor) and 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.
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.
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.
In my induction week I was informed that in pre covid times a resuscitation/emergency 2222 call to the cardiac arrest/ crash team would have included “(adult/Paediatric) cardiac arrest”, however now it is mandatory to state “COVID” amongst this information so that the responders can arrive in the correct PPE. I am sent an email later in the week stating level 3 PPE is the minimum requirements for all arrests. Another difference to note in my trust guidance (trust name held for confidentiality) for Resuscitation is that ward staff are not to use a bag valve mask and 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’ and will inevitably delay life saving CPR and will undoubtably have impacts across the entirety of health care for considerable time.
As always, follow the NHS advice on where to find urgent support if you are experiencing a mental health crisis.
If you work for the NHS and are currently, understandably experiencing more stress, struggling and feel like you need support, here is a list of resources I have compiled in an easy-to-access format. This list is by no means exhaustive and can be used by anyone. As health care workers, it is really important to look after yourself first in these challenging times, as I’m sure we’ve all heard the phrase: ‘you won’t be able to look after others if you don’t look after yourself first’. I hope this list helps.
If you prefer to call
0300 131 7000 is a confidential staff support line offered by Samaritans for NHS staff. (Open between 07:00-23:00 everyday).
If you prefer to text
Text FRONTLINE to 85258 for 24/7 text support
If you prefer to read a guidebook
There are a selection of good NHS guides to be found here covering useful topics such as an ABC guide to Resilience, Personal Resilience and creating a ten minute pause space (a place to reset and recharge).
Able Futures is a useful signposting website if you feel anxiety relating to work or think your work is being affected. It offers free support to people who are employed (in Great Britain) on behalf of the department for work and pensions.
Their free number to call is 0800 321 3137.