Between the lines #5

Much like many of the projects I started in 2020 and what is perhaps a damning indictment of my pandemic experience; blog number 5 is a year out of date. What was meant to be a piece extolling the importance of clinical education and teamwork during a crisis, has now turned into a reflection on a tumultuous year for all of us. Indulge me while I tell you story…

It’s March 2020 and having completed an eerily quiet walk into work I enter the almost empty hospital, make my way down to the surgical floor, get changed with the tired night shift staff setting off for home and enter the small education office which I share with our band 7 and 3 other nurse educators. Today, all of us are on shift, an unusual but ultimately pleasant theme of the next 2 months.

Barely having time to brew and pour the morning coffee we are ushered by our manager into the seminar room and asked to sit down. Here it is, the thing that we have been talking about and planning for, the pandemic has arrived in our trauma centre. The insidious trickle of patients will soon become a tsunami and like our Italian colleagues, we too will be facing the relentless evil of COVID-19.

Standing in front of us with a list of names in hand our leader announces that the department needs to make 150 critical care beds out of our current 28….*silence*….Our teams’ job is to train all the staff on this list (cue cartoon style unrolling of a ridiculously long list of paper) to become critical care nurses who can man these extra beds. We don’t know how long we have before the wave hits, but it’s time to pull on our wetsuits, snorkels and dive in. The list will be split into manageable cohorts of staff and we will have 1 day to teach that group how to function as a safe critical care practitioner; we will deliver this training every day until we, 

a. get to the end of the list or,

b. become overwhelmed with COVID and step back into our clinical shoes or,

c. get sick ourselves and isolate as a team.

If I asked you to boil your specialities nursing skills and experience down to their most basic parts, what parts would you think are vital for people to know and demonstrate? 

For as long as I can remember there has been a running joke between critical care and ED nurses. In order to be a good critical care nurse you just need a strong index finger on your dominant hand for alarm silence buttons and propofol boluses. You can be considered an expert practitioner if you can use your thumb and little finger to adjust the rates of analgesia and inotropes simultaneously, if only the job was that simple. 

Over the weeks and months of training the education team came up with our own simplified tropes for critical care nursing. Classics such as;

ETT in mouth good, on floor, bad.”

Wiggly lines on ventilators good, flat or no lines, bad.”

Noradrenaline pump infusing good, alarming at you, bad.”

Chest goes up and down, blood goes round and round.” Etc.

I could go on, but I won’t. The joke wore thin after a few days when it dawned on us that the critical care nurses would be supervising up to 6 other staff taking care of level 3 patients with experience ranging from ODP, HCA, scrub nurse and nurse preceptee. The wide eyed terrified look that the nurse from the eye clinic gave me while I demonstrated ETT suction on the dummy had me questioning what we were trying to achieve here. She was scared, I was scared, our clinical director and matron was scared, the scent of fear and worry was all pervasive on the surgical floor.

The training day consisted of an A-E assessment with a focus on what was safe. We didn’t need our bedside buddies (as that is what they became affectionately termed) to interpret ventilator settings and observations but I did need them to locate the 100% FiO2 button and understand that if the EtCO2 trace disappeared this could indicate a dislodged ETT and an airway emergency.

Our buddies moved from classroom to classroom learning tracheostomy care and emergencies, arterial and central venous lines safety, using the syringe drivers, proning and positioning patients and red zone PPE. For many this was a revision of skills; the team and I had been overwhelmed with the number of ex critical care nurses who opted to return to help in a crisis. Staff who we had not seen for many years returned all bright eyed and eager to help and offer their, sometimes, extensive experience. For anyone who has spent time in the military and served overseas; this returning group of nurses felt like a relief in place or RIP. That moment when you see friendly and refreshed faces arriving to take up their posts is one that is not to be forgotten and I will be forever grateful for those nurses who sat through my patronising teaching sessions. As a manager of mine once said; those guys will have forgotten more than you have ever learnt.

At the end of the study day, a first tranche of staff was identified to return for clinical shifts. We had been preparing our buddies to hit the ground running but with the slow burn of COVID in our region, we had time to deploy them onto the unit to be mentored in practice. As a team we got the band 6 and band 7 nurses together and talked to them about how they would manage a shift manned with inexperienced staff. A more task orientated way of working may be called for with a focus on safety and vital care elements being timetabled rather than the holistic approach that we are all accustomed to. Our dedicated rehab sister was beside herself with the realisation that early mobilisation, weaning and niceties like hair washing would have to be forgone in favour of safety. What is the point in all of this if we save their lives but don’t get them walking out of here with their dignity intact? She was right but it’s just 1 of the moral dilemmas that we faced while staring into the potential black hole coming our way. Just because we could look after 150 level 3 patients, doesn’t mean that we should.

What has COVID-19 taught me and the team I work with? Practice education has never been more important than in a time of crisis. Out of the hundreds of staff who attended our training sessions in those 2 months, only a couple cried (only joking), most were focussed and resolved to maintain patient safety and care in an alien environment. Everyone brought a skill to the department and made us all richer for it. The ODPs supported us when we had to implement anaesthetic machine training, the HCAs came up with ways to monitor PPE compliance and timetabled our shifts, our colleagues from recovery were unfazed by troublesome patients waking from sedation and you should see the amazing eye care provided to the vulnerable by those eye clinic nurses!

The successes of my departments approach to COVID-19 have been testament to the teamwork of all involved. Imagine what we could achieve as a team in the face of future adversities?

Holly x

Reading this a year later I am overwhelmed by what a year my team has had. I am also cognisant that it isnt over yet. Our second and third wave ended up being worse than our first and the training burden for escalation staff didnt stop.

The whole hospital approach to the pandemic in the first wave was inspiring and is probably how we should approach patient care in general. Why is it that we all train in our specialty silos, never to meet until the interface of patient handover? A future where the whole hospital works together to achieve ED waiting times, gold standard inpatient care, effective discharges into a functioning social care and everything in between….now that is a healthcare facility I want to work in.


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