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  • Writer's pictureRichard Cree

Old Dog

Updated: Apr 16, 2020

Wednesday 15th April 2020

COVID Figures for 14th April

UK Hospital Deaths 778 / Total 12,107

James Cook Hospital – Total deaths – 106

James Cook cases in Critical Care – 22 / 12 ventilated

Back again to pick up the pieces after yesterday’s disappointing day. I’m pleased to say that things are better today than I thought they’d be. The first half of the unit is full of patients who are all steadily improving. I’m struck by how many of these patients are overweight, hypertensive women in their 50’s. Only last week it was full of their male equivalents. It’s almost as if it’s now ‘Ladies Week’. One noticeable difference though, is that the women do not appear to be getting as sick as the men and relatively few of them end up ventilated.

The second half of the ward round features the sicker patients. The sickest three were the ones that I talked about yesterday. Of these three, two of them have shown a surprising degree of improvement.

However, the third patient who had taken the drug overdose has deteriorated further overnight. Despite valiant efforts, he was desperately ill by the time I saw him on the ward round and it was clear that survival was no longer possible. We decided to withdraw his treatment and change our priority to ensuring he was comfortable. He died shortly afterwards.

On a more positive note, the lady with the horribly acidic blood started to get better last night, just after I left the hospital. I steadfastly refuse to believe that these two events are connected.

Looking at things in the clear light of day, it looks as if part of the severity of her illness was due to her adrenal glands not working properly. These produce steroid ‘stress’ hormones during a severe infection. When they are not working properly, it can make a bad situation like a coronavirus infection an awful lot worse. This adrenal insufficiency could have explained her terrible blood results so we gave her intravenous replacement steroids earlier in the day. It was these steroids taking effect some hours later that led to her improvement. She remains extremely unwell but there is now hope that she could survive.

My third patient, the elderly gentleman with COVID pneumonitis was also better, now that he had been flipped over onto his back. He had not worsened overnight but I wondered if we could improve his ventilation somehow.

Now modern ICU ventilators are pretty fancy. Like any high-tech piece of electronic equipment, there are all sorts of features and modes that in reality, you never use. These are great selling points. After all, if you are going to spend £20,000-£40,000 on such a machine you want the one with the most whistles and bells and the thickest instruction manual, right?

Well, one of the ventilation modes that’s not used a great deal is called ‘Airway Pressure Release Ventilation’ or APRV. It is often used as a last ditch, rescue mode when patients cannot be ventilated adequately using more standard techniques. The concept has been around for longer than I have been working in ICU but it has become quite popular recently. In an attempt to ‘get down with the kids’ as well as improve my patients oxygenation, I start to fiddle.

It seems I have learnt nothing from the day before, when my meddling led to things getting worse. I seem to have temporarily forgotten the great advice that one of my senior colleagues passed onto me many years ago – “Don’t just do something, stand there.” I have practised his ‘less is more’ approach to ICU ever since but every once in a while I need to be reminded of this.

My attempt to use APRV does not produce results. After adjusting every conceivable variable on the ventilator I am becoming increasingly frustrated by the lack of improvement. Once things start to get worse I soon realise that ‘Airway Pressure Release Ventilation’ is an anagram of ‘bloody stupid ventilator not doing what I want and wasting everyone’s time’. Well, it is if you add a few letters and take some away…

I give up and go back to what was working before. Things get better. Lesson learnt.

Old Dog - 1 New Tricks - 0

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5 commenti

16 apr 2020

I love your blog. Thank you for sharing with us, but also (obviously) for the incredible job you do. I recently read ‘The Language of Kindness’ and there was a passage about an experienced nurse furiously slapping away the hands of a doctor who was fiddling with the ventilator dials. Another passage told of the way that experienced NHS staff have to let more junior ones learn, by calmly watching them attempt to do things and being ready to quickly intervene when things go off course. It also spoke about ‘compassion fatigue’ which is something I was reflecting upon after reading yesterday’s blog post. I’m happy to know that Three Strikes does not mean ‘you’re out.’ Lucky for us all.

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Richard Cree
Richard Cree
16 apr 2020

I do like picturing John Cleese attacking the ventilator with a birch tree - brilliant!

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15 apr 2020

I’m in awe really, that you’re able to write your blog report after what has clearly been another full on day for you. I hope it is cathartic for you to write and therefore allows you to go to sleep peacefully. Praying for you and your team at this time and the patients in you care . But most of all praying for that ventilator as I have visions of you giving it a damn good thrashing a la John Cleese! 😂 On a serious note, rest, sleep well and thank you for the amazing job you’re going .

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Richard Cree
Richard Cree
15 apr 2020

I never tire of hearing that quote. True in all branches of medicine I am sure!

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15 apr 2020

An old adage from an old surgeon said, "As a registrar, I learned how to operate. As a senior registrar I learned when to operate. As a consultant I learned when not to operate." Seems the same cold be true of using equipment?

God bless you all as you continue the age old care of the sick, under new and enormous pressures. Many of us are praying for you. It's safer than an old surgeon picking up his scales again.

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