2/I’m asked, almost daily now, how it felt to look after Adult ICU patients in full PPE when you I’ve been looking after children for the last 15-ish years. Intensive care is a funny old beast. We are accustomed to death and the possibility of death on a daily basis.
3/We look him in the eye, we play chess with him and in #pedsicu roughly 9 times out of 10 we win (based on last PICANET data here cutt.ly/0yMvV3t).
That is our comfort zone.
That is our comfort zone.
4/Every death affects us but we are good at facilitating a good death for those that we can’t save. Families around, enough analgesia/sedation to keep them pain free and comfortable, memory boxes, prayers, christenings, readings, singing, the lot.
5/A good death is important for the patient and their families but don’t underestimate how important it is for healthcare staff as well.
Overnight, poof, you’re an adult ICU staffed with healthcare providers that have been trained to work with children and not with “grown ups”.
Overnight, poof, you’re an adult ICU staffed with healthcare providers that have been trained to work with children and not with “grown ups”.
6/Many of us, including myself moved into hospital accommodation, to protect those living at home from #COVID19 should we bring the bug home inadvertently.
7/Even more of us, have had to work outside their comfort zone a lot more as working all day in PPE is sweaty, uncomfortable business. Human interaction is different. We cant read faces any more, we cant see the smiles, the winks , the frowns each other wears.
8/And it’s remarkable, in retrospect, on how much we rely on these subtleties to communicate with each other on the ICU. Non-verbal communication can signal most things, worry, elation, relief, the works. The job is much harder without it.
9/After the slow trickle of patients on the unit the tsunami hits, COVID19 admissions galore and with it the comfort of our 9/10 survival in children is gone. This is a different beast, and we are looking at 5/10 survival. On a good day.
10/With each passing day, I’m away from my family, in a room with no windows, increasingly feeling like that doctor from Glenn Colquhoun's haunting poem (you can buy his brilliant book here cutt.ly/cyMznzO)
11/TODAY I DO NOT WANT TO BE A DOCTOR
Today I do not want to be a doctor.
Nobody is getting any better.
Those who were well are sick again
and those who were sick are sicker.
The dying think they will live.
The healthy think they are dying.
Someone has taken too many pills.
Today I do not want to be a doctor.
Nobody is getting any better.
Those who were well are sick again
and those who were sick are sicker.
The dying think they will live.
The healthy think they are dying.
Someone has taken too many pills.
12/Someone has not taken enough.
A woman is losing her husband.
A husband is losing his wife.
The lame want to walk.
The blind want to drive.
The deaf are making too much noise.
The depressed are not making enough.
The asthmatics are smoking.
The alcoholics are drinking.
A woman is losing her husband.
A husband is losing his wife.
The lame want to walk.
The blind want to drive.
The deaf are making too much noise.
The depressed are not making enough.
The asthmatics are smoking.
The alcoholics are drinking.
13/The diabetics are eating chocolate.
The mad are beginning to make sense.
Everyone’s cholesterol is high.
Disease will not listen to me
Even when I shake my fist.
The mad are beginning to make sense.
Everyone’s cholesterol is high.
Disease will not listen to me
Even when I shake my fist.
14/As the deaths mount, you realize the solace of a good death cannot be taken for granted. We can “deal” with the high mortality rates, we internalize it, brush it under the carpet; use any coping strategies we’ve developed over our years of work on the #pedsicu.
15/What kept us awake at night during the pandemic was moral distress. The moral distress as if somehow we were accomplices in allowing these patients to die alone.
16/Alone, without their loved ones being able to say goodbye due to social distancing, visiting restrictions and PPE shortages for non-clinical personnel. Morphine and midazolam are poor substitutes for a human, familial touch.
17/Moral distress goes hand in hand with insomnia and almost complete lack of sleep. We’d work 14-hour shifts in a wearable sauna, go to bed and unable to sleep.
18/Instead we lay awake staring at the flickering fluorescent white lights in our hospital accommodation thinking about all those patients that didn't get to say goodbye to their wives, husbands, children, loved ones. There had to be a better way.
19/So we reached out to @twitter (one of the platforms better uses is that it links up healthcare professionals to create a common pool of knowledge) .
@Twitter 20/The idea was to start compassion ward rounds on the ICU where a doctor and a family liaison nurse videoconference a family member at a specific time during the day so they can see and speak to the patient.
@Twitter 21/During the end of life families would get the chance to say goodbye remotely. The initial plea for help is here cutt.ly/CyMxmxY . @Twitter didn't disappoint.
@Twitter 22/With inspiration from @freermary and her compassion revolution , @mrastvad as well as @natsfordocs that had already designed the following questionnaire we had our battle plan. A battle plan against #COVID19 related moral distress and patients dying alone.
@Twitter @FreerMary @NatsforDocs 23/We discussed it first with our ethics committee and legal team after I made some changes. The general consensus was that there were some subtle cultural nuances that had to be taken into consideration to make a questionnaire more British so we had to tweak it slightly.
@Twitter @FreerMary @NatsforDocs 24/Special thanks to my very close friend and medical ethics Prof @beckiblb that put up with my constant emailing /phoning on the matter for her expert guidance.
@Twitter @FreerMary @NatsforDocs @Beckiblb 25/A big challenge we had was consent (especially if the patient was already intubated on ICU) and online security with the various video conferencing platforms.
@Twitter @FreerMary @NatsforDocs @Beckiblb 26/The questionnaire went some (but not all) the way to addressing those issues and more work needs to be done to make it better.
@Twitter @FreerMary @NatsforDocs @Beckiblb 27/Given the timeframe, gravity of the situation and people dying alone the legal department and ethics committee ratified this questionnaire within a week. A pretty speedy turnaround.
@Twitter @FreerMary @NatsforDocs @Beckiblb 30/It was used across the hospital for adults with #COVID19 symptoms and allowed us to use their phones or ward based tablets to call their loved ones.
@Twitter @FreerMary @NatsforDocs @Beckiblb 31/It also allowed us to tailor their end of life care, if it came to that based on their belief system, religion, musical/literary preferences and so on. It wasn't perfect but it was the better than dying alone. We made them available in a number of different languages.
@Twitter @FreerMary @NatsforDocs @Beckiblb 32/Within a week, word spread across the region and various charities donated 250 tablets to the hospital for this purpose alone. To be used to help patients communicate with their families.
@Twitter @FreerMary @NatsforDocs @Beckiblb 33/About a week later Mrs X came to our #pedsicu , she had already been in the hospital for a week and gradually deteriorated enough to be admitted to ICU. She had bleak chances of survival was the consensus.
@Twitter @FreerMary @NatsforDocs @Beckiblb 34/ She had very limited use of English and had not spoken to her family in more than 10 days as her phone had died.
@Twitter @FreerMary @NatsforDocs @Beckiblb 35/Now imagine the fear these patients go through when they’re fighting for their lives, on a ventilator, with multiple drugs to support the heart and not having the ability to understand the spoken language or to communicate with us. Terrifying.
@Twitter @FreerMary @NatsforDocs @Beckiblb 35/She was one of the first patients to pilot the compassion ward round.
The first time she heard her daughters voice over a video call, in her own dialect, there were tears of joy. Not just from Mrs X but everyone else on the unit. From that point on Mrs X was galvanized.
The first time she heard her daughters voice over a video call, in her own dialect, there were tears of joy. Not just from Mrs X but everyone else on the unit. From that point on Mrs X was galvanized.
@Twitter @FreerMary @NatsforDocs @Beckiblb 36/We thought she wouldn’t make it but on hearing her family speak to her made her go from strength to strength. A week or so on she was wheeled out the unit to a general ward.
@Twitter @FreerMary @NatsforDocs @Beckiblb 37/She summoned the strength to whisper something to me in her own language with tears in her eyes on the way out. I can never be sure of what she said but I suspect it was an expression of gratitude.
@Twitter @FreerMary @NatsforDocs @Beckiblb 38/You cannot deny the impact that compassion has on our moral distress; nor can you deny the impact that it had in giving this patient her fight to survive back. The compassion rounds had done their job. That night I had no trouble sleeping.
