Do YOU have any ICU experience? Deployment of staff across the NHS
Sophie Rintoul-Hoad is an ST6 Urology Trainee at St Georges Hospital; Olayinka Gbolahan is an ST4 Urology Trainee at Northwick Park Hospital – both were redeployed to work in Intensive Care in April, neither had prior critical care experience.
A patient recovers from COVID-19 and is moved from the Intensive Care Unit. Patient consent obtained, image courtesy of @fay.simone
Faced with the current COVID-19 pandemic, hospitals around the UK have needed to expand their Intensive Care Units (ICUs). The logistics and preparation have been staggering. These have included creating COVID and non-COVID clinical areas, halting theatre activity and outpatient clinics and converting areas such as day units and recovery areas into fully functioning ICUs. The huge efforts of those involved has probably not been fully acknowledged.
The anticipated surge in patients requiring Level 3 ICU care needed a corresponding increase in staff to care for them. The media reported the need for ventilators – but a ventilator is nothing without an expert to drive it. Across all departments staff volunteered, were recruited and deployed into positions of need to help the NHS.
With the reduction in all but essential surgical activity, many surgical teams and trainees were redeployed into new areas, teams and roles. This has included working in ICU, and we have moved from our relative comfort zones and our areas of chosen interest. There has been regional variability in disruption and junior doctor’s experiences; these are to be captured by the National and pan-specialty COVID-STAR survey organised by ASiT. We hope our reflections serve to share our experiences; these are by no means unique, but they have shaped our lives for the past few weeks.
‘Do you have any ICU experience?’ has been a common question over the last few weeks, and answers range from ‘none’, to ‘months spent in ICU’, to being in ‘critical care/anaesthetic training’. In fact, the specialties recruited could run a mini hospital within the ICU walls. An enthusiasm to learn and work with the expert ICU staff seems to be the only necessity, and we try our best to help in whatever way possible. The camaraderie, teamwork and leadership are inspiring. Rotas are sent out, changed, wards closed and re-opened overnight and staff just keep working.
Mary Shelley wrote that ‘Nothing is so painful to the human mind as a great and sudden change’; however, change can also be embraced. As junior doctors, we are regularly rotating round new hospitals, departments and into new specialties, though this was similar but somehow harder. Intensive Care is not an area of medicine that surgeons anticipate working in, or admittedly are likely to have a prior interest in. The working day is different, ward rounds longer and the rota is more anti-social (not that there is anything social to do). Yet we adjust, cope and we feel useful; we have purpose, routine and community.
The biggest challenge of working on ICU is the new knowledge needed to manage the patients’ altered physiology due to disease, and this was even more challenging due to the severity of COVID-19. Training was arranged almost overnight; comprehensive teaching sessions were delivered and shadowing was arranged to bring us up to speed. Ventilation settings, cardiac physiology, medications, and troubleshooting were learnt quickly. ‘Knobology’ is apparently not just a urological phenomenon, but also relates to fine-tuning the ventilator settings. Everyone was learning and sharing how best to treat COVID-19 patients, and online platforms helped various medical societies deliver educational webinars.
Established Intensive Care doctors and nurses are overwhelmingly impressive; from the constant monitoring and medical care they deliver to their support and guidance. The ICU consultants are ever present, approachable and forthcoming with explanations. Expertise is stretched beyond what seems humanly impossible. 1:1 nursing care remains, but with ICU nurses supervising multiple redeployed nurses. As newbies or ‘SURGE’ doctors we doubted our competence and ability to actually help, but their strength and diligence help us find our feet in a new world of ICU.
Communication is the foundation of good patient care and teamwork has needed to be adapted. PPE masks cover faces, muffles speech and conceals smiles, so instead we wear name labels and make expressive eyebrow movements. Thankfully, our skills as surgeons to communicate louder with masks on is put to good use. Relatives cannot visit so teams are set up to update them and donations of iPads enable video calls. We listen to families crying and saying their prayers and goodbyes. We witness the husband with the horror in his eyes right before he is intubated and ventilated, unsure which side of the coin his fate would take as he listens to his wife over the phone telling him to fight this; she tells him she loves him, but he is too breathless to return the words. We certify death, despite every effort and days of intensive, meticulous care. Then as if by a miracle, we see some patients slowly regain control of their breathing so that they can be weaned off their oxygen requirements and can have celebratory video-calls with their family. Relatives help us re-find our passion and learn more about our patients: telling us about their religion, jobs and sending in photos that we laminate.
The COVID-19 virus intensity is a spectrum and hospitals see the worst of it. We cry, we witness colleagues crying but we also acknowledge the good days. We cannot be overcome by fear. Support staff, including cleaners, runners, and porters inspire us with the level of conscientiousness with which they perform their tasks. We also learn from pharmacists, physiotherapists, speech and language therapists and expert tracheostomy nurses, while radiographers come daily to do portable chest X-rays. Different parts of the team all working together as one.
Worries are ever-present and anxiety comes with every breath. Many worry for their personal safety and transmission of the virus to their loved ones, despite good PPE availability (our experience has been that of good provision). Pictures and news articles of healthcare workers dying are haunting and sadly reflect a disproportionate number of those from ethnic minority backgrounds. We worry about keeping up with new guidelines and government advice, and also about our training and becoming surgically de-skilled and how we will be judged at future appraisals. We worry about other patients that have had their treatment delayed because of all-consuming COVID-19. We worry if this will ever end.
Wellbeing and resilience are mentioned frequently, but now everyone seems to mean it. Recently it has been the small things that make us feel valued; meals are organised and delivered daily and rest areas are established by airlines and charitable donations. Shared lunchtimes are a rare occurrence in a surgical day, but now in ITU eating lunch with others is a common and welcome occurrence. It is hugely appreciated and a time to talk and unofficially debrief.
The media’s reporting of COVID-19 and our language is war-like. There are lessons we can learn from the military. It is perhaps ironic that VE celebrations have coincided with COVID-19; we do not feel free at present but we want to protect the generation that fought for our tomorrow. The British ‘get on with it’ attitude and a resurgence in Vera Lynn’s ‘We’ll meet again’ can certainly inspire us. A urology consultant, previously deployed to Camp Bastion, gave us advice to enjoy and embrace this unique time, that he was proud of our efforts in battle – and that the Nation has never valued the NHS so much.
The ‘ups’ of redeployment outweigh the ‘downs’. There is something gratifying about being part of something bigger than ourselves, to have (some) skills to offer and play our small part. Change can be a good thing and new experiences are accepted as personal and professional development. Innovation and progress have never happened so quickly within the NHS. Never before has goodwill been so apparent, and we accept redeployment because it is the right thing to do. There is light at the end of the tunnel; we are hopeful that we will return to a ‘better normal’ and a stronger NHS.
 Elsland S, O’Hare R. COVID-19: Imperial researchers model likely impact of public health measures. Imperial College London, March 2020 (https://www.imperial.ac.uk/news/196234/covid-19-imperial-researchers-model-likely-impact/; accessed 26 May 2020).
 The Association of Surgeons in Training (ASiT). ASiT COVID-STAR Survey Launched! ASiT, May 2020 (https://www.asit.org/news/asit-covid-star-survey-launched/nwc11205; accessed 26 May 2020).
 M Shelley. Frankenstein, Or, The Modern Prometheus: the 1818 Text. Oxford: Oxford University Press, 1998.
 Cook T, Kursumovic E, Lennane S. Exclusive: deaths of NHS staff from covid-19 analysed. HSJ, April 2020 (https://www.hsj.co.uk/exclusive-deaths-of-nhs-staff-from-covid-19-analysed/7027471.article; accessed 26 May 2020).
 Anonymous.We launch our Wellbeing Hubs! St George’s Hospital Charity, April 2020 (https://www.stgeorgeshospitalcharity.org.uk/news/latest-news/post/370-we-launch-our-wellbeing-hubs; accessed 26 May 2020).