Winter is over? Time for a new challenge in ED

Think back to the start of March 2020… Team ED was still dealing with what seemed like the longest winter in the history of the world, Twitter was a-buzz with stories of how “crowding kills”. Corridor care was still a national problem, Staff were tired, and it didn’t look like we were getting any let up. The UK was leaving Europe, Harry and Meghan were leaving the royal family…

…and a virus over in mainland Europe was causing some serious problems.

We’d already been asking people at triage “have you travelled to the Wuhan area of China recently”, just like we did similarly when Ebola happened, and SARS, and it was another virus that we thought we’d be prepared for if and when it happened…

…Until it happened, and we found actually maybe we weren’t prepared after all.

Now I should clarify here… We were prepared in that we had plans for respiratory illness, we had major incident training, I still had my trusty respirator mask that I’d carried round four different hospitals since bird flu was a thing. But I don’t think we were prepared for the thought that it would actually happen, I certainly wasn’t. Suddenly the news was filled with hospitals in Italy being completely overwhelmed, their doctors and Nurses were dying, and we were going to be next.

That’s how it felt anyway. I like to think I’m pretty good at poker face, but between close colleagues was happy to admit that I was worried, and I wasn’t alone.

So what do you do to overcome that fear? Well in our case… we sim!

I’m very lucky to work with some excellent simulationists across ED and anaesthetics, and it became our personal mission as a team to ensure our departments were as prepared at we could possibly be.

It turns out there was a lot of things needed thinking about. Where were we going to put the COVID patients? How were we going to get them from ED to ITU without contaminating the whole hospital? Who’s idea was it to put curtains on all these cubicles instead of doors!?!

And if that wasn’t enough, the list of what did and did not constitute an aerosol generating procedure was changing on what felt like an hourly basis. Suddenly the first thing to do in a cardiac arrest wasn’t to start compressions, but to ensure you had the right PPE on. Nursing patients in corridors wasn’t going to be an option any more. So we started making some plans.

We held our first joint simulation between ED, anaesthetics and ITU on 18th March 2020. It was clear afterwards that we had a lot to think about (what’s in the mist that comes out of a nebuliser!?!?!?). If I’m being perfectly honest I went home that night and cried down the phone to Poppa Mids rather dramatically. But it gave us a starting point on what we needed to do. We wrote protocols. And flowcharts. And protocols about how to follow the flow charts. Then we ran the sim again. And when we picked up a new problem we made a new flowchart and started again. And once we were happy with it, we laminated the flowchart. Where previously guidance had taken forever to get through meetings and boards and panels, a JFDI attitude was adopted.

The next thing to tackle was estates. It may not come as a shock but our department, like every other I’ve ever been in, isn’t designed for a respiratory pandemic (did I mention the curtains?!?!).

Luckily for us our footprint means that the day case theatre complex sits directly behind ED, complete with four operating theatres, a recovery room, brew facilities and an adjoining ward. Thanks to great cooperation from our theatre staff we had them moved out and us moving in by the end of the week. But again, there was lots to think about. Where were people going to ‘don’ and ‘doff’ PPE? How would the ambulance crews ‘don’ and ‘doff’? When did ‘don and doff’ become some of my most used vocabulary?

The beauty of using operating theatres as resus rooms means that there’s a nice clean area at one side where the anaesthetics live, and another room at the other side with a massive sink in, so all that needed to be done was to make my body weight in laminated signs and “ta-daaah” you’ve got a one way system with donning and doffing areas.

On 23rd March 2020 the UK went into its first lockdown. On this day we held our first full team simulations in our new resus rooms. Still, we had some issues to overcome. Communication through a respirator is, to put it mildly, a bit of a nightmare. So we put our best Blue Peter skills to use and made white boards so we could flash messages to each other through the doors (all hail Kirsten’s never ending supply of magic whiteboard sheets). And our trusty laminator stepped up again to make quick reference lists for the most commonly used drugs and requests (my favourite being “can I have a break now please?”). Being inside the resus room, and therefore contaminated, meant that you couldn’t go in and out to get things from the storage area, and so the term ‘dirty nurse’ forever took on a new meaning. This now meant that you needed twice as many staff for each patient as you needed a team inside the room and a team outside the room. We also needed a lot of equipment setting up. Our Anaesthetists and ODP’s played an absolute blinder setting up all the anaesthetic rooms with plan A, B and C trays so things could be grabbed quickly in an emergency. The ITU staff helped plan how we were going to transfer patients down to the basement. Our porters demonstrated why they are, in fact, the absolute heroes we always knew they were by helping with arranging the kit and planning and helping teach their colleagues so that transfer could be as smooth as possible. Same goes for the radiology teams who helped set up plans to get people to and from scan and X-ray. Everyone pulled together to ensure we could work smoothly and keep each other safe.

More and more simulations were run and over the next few weeks we had trained hundreds of staff, and everyone felt more confident and prepared to deal with what was coming our way.

Outside of resus we had further planning to do. To try and reduce contamination we trained all our junior doctors to do some tasks previously done by the nurses like administering some of the drugs and treatments, and they stepped up to the plate amazingly. Our educators were getting everyone through fit testing and donning and doffing training. A new pod was positioned at the front of the dept to ensure screening could be done prior to entering the dept.

What was previously our medical escalation ward became our new COVID amber ward, and furniture needed to be moved and rearranged for this to happen. Yet more laminated signs, lots of hazard tape and massive vats of alcohol gel later and it was all starting to come together, and hopefully our efforts helped the staff feel prepared.

So here we are in April 2021. We’re just heading out of lockdown and nothing has gone back to ‘normal’, and perhaps it never will. It seems weird seeing people’s naked maskless faces in pictures, I’m still rubbish at baking and killed a few sourdough starters and there wasn’t an ED Christmas party for people to make a muppet of themselves at, which is unheard of.

But vaccines are happening and whilst life has changed for a lot of us, and being stuck at home has been tough, it’s also made me realise I have a lot to be thankful for. A year down the line I continue to be proud of how we as a team pulled together in the face of the pandemic. My take home message is that you can get through anything with an incredible team, a laminator and large amounts of cake.


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