World’s Smallest Nurse
Thursday 30th April 2020
COVID Figures for 29th April
UK Deaths 795 / Total 26,097
James Cook Hospital – Total deaths – 180
James Cook Critical Care COVID cases – 12 / 8 ventilated
James Cook Critical Care non-COVID cases – 33 / 13 ventilated
NB. UK Death figure from Public Health England now includes COVID deaths outside hospital.
A more enjoyable day at work today. I am looking after one of the COVID Intensive Care Units. You will see from the figures above that the number of COVID Critical Care cases in our unit remains low whilst the number of non-COVID cases continues to rise.
I am greeted by Janet, aka Sister Pugh, who used to be one of our ICU sisters. She has a Batman bandana for me that her friends Bernie, Kath and Ann have made. Some of the nurses are wearing these to keep the PPE facemasks off their sore ears. We have also been given 3D printed headbands for the same purpose (a big thank you to Nathan).
Sister Pugh isn’t really Sister Pugh anymore. After many years she decided to become an Advanced Critical Care Practitioner (ACCP). ACCPs come from a nursing, physiotherapy, paramedic or similar background. They are trained in the care of critically ill patients and can diagnose, investigate, treat, prescribe and perform invasive procedures. They are extremely useful people to have around on the ICU.
Me and Sister Pugh – winner of the World’s Smallest Nurse Competition 1998
I am relieved to find that all but one of my ICU patients are better than I was expecting to find them. One patient, a gentleman in his early 60’s is ready to step down to the Surgical Assessment Unit (SAU). This is what we have wisely decided to call the previously named Day Unit Recovery or ‘DUR Unit’.
Another patient who has come to us from a nearby hospital due to a lack of ICU beds, is also looking good. He has a tracheostomy and has been slowly weaning from the ventilator. Today he has improved to the point where we can deflate the balloon cuff on his tracheostomy. This may sound like a minor achievement but the implications are huge. Any breathing tube, be it in your mouth (an oral endotracheal tube) or through your neck (a tracheostomy) has a balloon ‘cuff’ on the end of it. When inflated, this seals off the trachea and allows the ventilator to inflate the lungs without a leak. Only when the patient has made enough progress can we think about deflating this cuff. The loss of pressure that results means the patient has to be capable of compensating by performing more work of breathing themselves so it’s only an option once patients are close to coming off the ventilator.
However, by far and away, the most important effect of this is that the patient can now talk! Your voice depends on you moving air across your larynx, or your vocal cords. An endotracheal tube or tracheostomy stops this. When the balloon cuff is deflated, some air is free to pass through the vocal cords again and often the patient can talk. Having that first conversation with a patient is always a pleasure, even if they swear at you. I’m pleased to report that this particular patient was far too polite for that.
Another lady in her 50’s has been extremely unwell over the past three days. She has required to be repeatedly ventilated in the prone positon. Today things seem a little better and this improvement, albeit small, is very welcome under the circumstances.
My final patient has only been ventilated for a couple of days but he too has been very unwell. Unfortunately he is no better today. He is also being ventilated on his front (prone ventilation) but his oxygen requirement has remained surprisingly high. The appearances on his chest X-ray do not completely explain this and so we decide to take him for a chest CT to look for pulmonary emboli (blood clots). First he has to be flipped over onto his back.
In this matter, we are ably assisted by our Anaesthetic Consultant colleagues. They have formed a prone ventilation team which, twice a day, will attend the ICU and conduct the surprisingly difficult task of turning a patient over. The difficulty comes from the fact that the patient is attached to a ventilator, several infusion pumps and is festooned with lines, catheters, drains and drips. Today it is Izzy who is in charge and it is a pleasure to watch such a slick operation.
I have joked before about calling the Emergency Anaesthetic Team the Thunderbirds due to their ability to turn up when there is trouble and save the day. Izzy is a very calm, level-headed consultant colleague who also works as one of the resident doctors on the Great North Air Ambulance so it seems strangely apt. However it’s perhaps not the best analogy as the only female Thunderbird I know is Lady Penelope, unless you count that strangely dysmorphic and terminally irritating mermaid in Stingray.
Izzy and the team transfer my patient to CT scan and I tag along to pretend I’m helping. Sure enough, the CT confirms numerous pulmonary emboli and we start treatment with a blood-thinning agent called heparin in order to prevent any new blood clots forming or the existing ones getting bigger. The body’s own clotting system will begin to dissolve the clots over time.
We are seeing lots of pulmonary emboli in ventilated COVID patients. We should probably be looking harder for them. The problem is that the only way of diagnosing them is a CT scan and moving our very sick patients to CT can be fraught with danger. However, the danger of not diagnosing these is such that we should be taking the risk.
Just before I leave for the night I decide to pay a visit to the High Dependency Unit. This is now a non-COVID unit and some of the patients there are recovering from their COVID pneumonitis. One such patient is a young gentleman in his 30’s who we have been looking after for many weeks now. He has been horribly ill and despite his young years we were very concerned that he may not pull through. I last saw him five days ago when he was just starting to make consistent progress towards recovery. I am delighted to find him looking a lot better than I expected; he is sitting up in bed and able to say hello and fist-bump me. The change over the past few days is remarkable.
It’s important to focus on the good outcomes when you can, especially at the moment.