Treating big people (adults) with COVID…

Cite this article as:
Vicki Currie. Treating big people (adults) with COVID…, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.32313

Reflections from a Paediatric Registrar

‘I won’t touch the feet- I’ll do ANYTHING else’. Avoiding adult feet was one of the reasons I chose a career in paediatrics was one of my responses when I found out that the PICU I was working in was being converted to an adult COVID ITU. I chose paediatrics as a career for so many other reasons, but this was the first thing that popped into my head. 

The world has been turned upside down by this pesky virus.If one year ago you would have told me that I would be looking after adult ITU patients with this new disease I would have refused to believe it. For so many, working lives have changed, roles have been adapted or learnt at lightning speed and working outside your ‘comfort zone’ has become part of the ‘new normal’. 

After a few weeks of looking after adult COVID ITU patients on a PICU I have had some time to reflect on how different things have been. Some things will change my practice forever, some of the big differences in ways of working between those looking after big and littler people. As a general paediatrician doing a stint on PICU, intensive care was new but the steep learning curve after 6 years of looking after ‘littler people’ was even steeper. 

After working closely with adult ITU team members for the last few weeks, we have had a chance to see how each other works. It has proven an opportunity to learn form each other. There are a lot of similarities, and a few differences. There are also some things which both sides can hopefully take forward into our future practice. 

Handover

As paediatricians we LOVE a handover- in some places I have worked it can feel like handovers take over the entire day. One of the biggest differences is the way the adult team do handover.  It seems so much more business-like – especially at the end of a nightshift. There’s no messing around. Any issues? Who is stable or not\? Salient points only. The paediatrician’s in the room added their own twists ‘Had the family been updated? What had they eaten today? What did their poo look like? And how had they slept?’

After a few weeks a happy medium had been found. There was a nice balance achieved between getting the night team off on time, and reducing information that could be found out easily on the morning round whilst including some of the more holistic aspects of care.

Communication with relatives and patients

Those who look after children are used to having to flip between conversing with patient and family. This is a great advantage. We are constantly thinking about updating relatives and keeping family informed. Using FaceTime allowed us to communicate with relatives. They could see their loved ones when they could not be with them. 

The adult team, who have had much more practice with the difficult conversations, seemed to be so slick, having the same realistic and honest conversations. It was business-like and well-rehearsed. Delivering the information succinctly meant that time could be spent talking to more families. 

Patients told me that the way medical and nursing staff spoke with them was different when they made the move to the PICU. Many patients told me that they could tell we were used to dealing with children. The way we spoke was cheery, informal, and most importantly, personal.  I wonder if this was always what they wanted though, especially when delivering difficult news. With the help of the adult ITU team, a delicate balance was maintained. 

Attachment

The adults with COVID in the ITU seem to be long- stayers.Having the same set of patients for a few weeks is great in some ways; and hard in others. Often, with PICU patients, there can be prolonged stays but one of the things the adult team found hard was the attachment they formed to their patients  from seeing them shift after shift. Couple this with the need to look after so many patients on adult ITU , whilst rotating through different pods. On PICU it was one area with the same patients.

On the plus side, you knew the patients REALLY well. You understood things in detail things, like what ventilation strategies they responded to- or didn’t. You knew what previous infections they had been treated for and you knew what families had been told. The downside: you became more attached. It was harder, emotionally, when a patient you knew deteriorated or didn’t better. I wonder if we carry more of an emotional burden in paediatrics because of this. Any doctor will get emotionally attached to certain patients. But are we more likely to do so by seeing fewer patients but more often than our adult counterparts? 

Teamwork

Without question, the amazing paediatric ITU nurses stepped up to the challenge of looking after grown-ups. The incredible camaraderie, between nursing staff, paediatric doctors and the adult ITU team, proning the most unwell patient at 2 in the morning is something which should be bottled up and stored for reuse when this is all done. Truly working together to pull, not only the patients but also each other through the difficult shifts. 

The adult ITU team helped whenever they were needed. They supported us and also credited us paediatricians on many occasions for out strict attention to detail – with anything from charting blood results to charting fluid balances. 

This has been an eye-opening experience. It has been challenging, terrifying, devastating at times. It has also provided opportunities to work with amazing colleagues and witness teamwork between medical and nursing staff like never before. It has been a unique opportunity for adult and paediatric teams to work side by side and siphon bits of each other’s practices. 

As for the feet- it wasn’t as bad as I expected- but I drew the line at a request for a foot massage!

An excellent resource for those working on the front line who are struggling or just looking for that little bit of extra support…

https://www.rcpch.ac.uk/key-topics/your-wellbeing-during-covid-19-pandemic

Making sense of death in paediatrics

Cite this article as:
Annabel Smith. Making sense of death in paediatrics, Don't Forget the Bubbles, 2016. Available at:
https://doi.org/10.31440/DFTB.8834

Per unitatem vis – ‘Through unity, strength”…

A patient died in our unit last week. A child. His parents were two of the loveliest, bravest souls I’ve ever encountered. I looked after him on a series of night shifts. He deteriorated, slowly but surely, over those nights.

I found it hard to look after him. When he became agitated, he’d settle if his hair was stroked. His parents did it if they were around, but on nights they took the opportunity to sleep, and so the task fell to us, his doctors and nurses. As I stood there by his bed, stroking his hair, I couldn’t help but think about how hard this was for me. Then I’d admonish myself, thinking how much worse it was for his family, let alone for the little boy himself.

He died during the day, so when I came on again for my last night, he was gone. The staff were shaken. The handover process was subdued, and prolonged by some much needed general chatting and debriefing. We hugged, and we talked about all the patients we’d lost this term (intensive care has an unfortunately high rate of loss compared with my previous general paediatric jobs). We tried then to remind ourselves of the successes, and talked about patients who made us smile, and patients who’d made it through against the odds.

It’s often like this with difficult events. The juniors rally around each other as best we can, and sometimes there’s a debriefing session with seniors – not always though, which is sad. It’s a vulnerable time for all of us, particularly as doctors in training. I myself tend to feel overwhelmed with a sense of inadequacy for the job. Will I ever be smart enough? Skilled enough? Strong enough? For an occupation in which these are the stakes? I inevitably contemplate alternative careers at this point, for on the alter of my own self-judgement, I always come up wanting.

No wonder doctors quit, burn out, became depressed, even suicide. Every day in medicine we walk a tightrope, holding aloft the heavy burden of our patients’ needs, praying at every moment that we don’t all come crashing down together. If we make it to the other side, to the end of the day or the end of the shift, and all is still intact, we’re grateful, but we rarely acknowledge the strength it took to make that journey.

Doctors – medicine is brutal. It’s also wonderful, mysterious, joyful, and an absolute privilege to practise. A success can bring us to dizzying heights of elation, but every failure rocks us to our core. At times we’ll all feel like frauds, like failures, and like a change of career. The important thing is that it’s normal to feel that way. I believe many of the doctors who take their own life have an extremely misinformed concept that they are the only ones who feel lost.

When we lie to each other and say all is well all the time, this myth holds. There is great power instead in being honest with one another. In admitting that we don’t have it all together, and reaching out for help and support when times are tough. We must focus on a change in the medical culture in which no doctor is ever left to feel alone in their pain. If we don’t, we stand to lose much more than pride.