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 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 in a PICU, I have had 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 smaller people. As a general paediatrician doing a stint in PICU, intensive care was new, but the steep learning curve after six 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 from 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.
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 the handover. It seems much more business-like – especially at the end of a night shift. There’s no messing around. Any issues? Who is stable or not? Salient points only. The paediatricians 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 patients 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 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 moved to the PICU. Many patients told me 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.
The adults with COVID-19 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 get 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?
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 our 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…