Treating big people (adults) with COVID…

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. It 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. 

This pesky virus has turned the world upside down. If you had told me one year ago 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-19 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 working methods 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 that both sides can hopefully take forward in our future practice. 

Handover

As paediatricians, we LOVE a handover. In some places where I have worked, it can feel like handovers take over the entire day. One of the biggest differences is how the adult team does 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 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. A nice balance was achieved between getting the night team off on time and reducing information that could be easily found out on the morning round while including some of the more holistic aspects of care.

Communication with relatives and patients

Those caring for children are used to switching between conversing with patients and family. This is a great advantage. We are constantly thinking about updating relatives and keeping them 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 had much more practice with the difficult conversations, seemed to be so slick. They had 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 medical and nursing staff spoke with them differently when they moved to the PICU. Many patients told me they could tell we were used to dealing with children. We spoke cheery, informal, and, most importantly, personal.  I wonder if they always wanted this, especially when delivering difficult news. With the help of the adult ITU team, a delicate balance was maintained. 

Attachment

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 in 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, like what ventilation strategies they responded to or didn’t. You knew what previous infections they had been treated for and 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? 

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, should be bottled up and stored for reuse when this is all done. We truly work together to pull not only the patients but also each other through difficult shifts. 

The adult ITU team helped whenever they were needed. They supported us and credited us, paediatricians, on many occasions for our strict attention to detail – 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 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!

This is 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