Nursing in the Covid19 Pandemic: Notes by a trauma nurse at a London Level 1 Trauma Centre (blog first published on 17 March 2020)
Matt Hancock, the health secretary, recently called on industry to begin manufacturing ventilators in anticipation that there will be huge demand for them over the coming months.
The government are right, we don’t have enough ventilators for the number of patients who will need them to stay alive, but there’s a problem with this; a ventilator isn’t an autonomous machine.
Ventilators require highly trained staff to use them. The average doctor or nurse isn’t able to care for a ventilated person safely.
Patients requiring mechanical ventilation are kept in intensive care units (ICU/ITU), where doctors remain close by – doctors who have had years of post-medical school training and are highly competent in managing a patient’s airway. No airway. No patient.
Once a patient is ventilated in an ICU, they receive 1:1 nursing. That means that patient always has a nurse at the bedside, a nurse with specialist training that understands what the ventilator is doing, and after completing advanced courses can alter the settings on the ventilator according to what is required. There are a few reasons a ventilated patient needs a 1:1 nurse.
“The average doctor or nurse isn’t able to care for a ventilated person safely”
One reason is if someone is under-sedated they can self-extubate and stop themselves breathing. It wouldn’t be safe to expect ICU nurses to care for multiple patients on ventilators (realistically this may be where we’re headed).
We don’t have the staff in the NHS to man these machines. This isn’t something you can teach someone in a day. Manufacturing more ventilators wont be of any use if they can’t be used safely.
At the hospital the concerns of most of the staff that I speak to have nothing to do with the number of ventilators we have. We don’t have adequate Personal Protective Equipment (PPE) and are almost certainly contributing to the spread of this virus around the hospital and outside of it.
This is a new virus and we are still figuring it out, but we’re pretty sure that like other respiratory pathogens it is spread primarily through fomites and respiratory droplets.
Anyone coming into contact with a patient in respiratory isolation has to wear gloves, an apron (so that the virus doesn’t stick to our uniforms), and a respiratory mask because we get into close contact with patients when assessing them and giving personal care.
“Staff were nursing confirmed Covid19 patients with only basic surgical masks”
Without a mask we are at risk of infection through respiratory droplets. A month ago, the hospital began trying to mass test staff to see if the FFP3 masks fitted (most of us during our lunch breaks or our days off because the hospital was busy enough before this crisis).
I failed my test quite quickly as did 60% of the staff in the testing room. I was told in no uncertain terms not to nurse patients with coronavirus. Prior to this pandemic we would normally wear FFP3 masks to nurse patients with confirmed Rhinovirus (a cause of the common cold).
Last week there were no fit tested staff on shift and one of us had to go to a ward to nurse patients infected with Covid-19.
I failed my fit test and my colleague hadn’t had a test at all so on the balance of probabilities we agreed she should go because at least she had a chance. These are the hard choices we were making last week, and its only getting worse.
Yesterday staff were nursing confirmed Covid-19 patients with only basic surgical masks (an even less effective mask than an ill fitting FFP3), and that had been directed by Infection Control.
I’d had a conversation with a consultant prior to this who told me we should probably be using FFP3 for suspected cases and certainly for confirmed patients.
It turns out that Public Health England had changed the recommendations that morning, so the hospital was following the governments recommendations. FFP3 masks were now only required to nurse ventilated patients with the virus.
“We are told if we show symptoms to stay home and yet, this virus is so new”
There have been no new studies into the virus in the last two days. Bedside nurses are being exposed in high numbers to the virus, as are any doctors who that nurse calls to assess them.
Moreover, at least in my hospital there hasn’t yet been a policy of ‘clean’ or ‘dirty’ nurses, i.e. only nursing one cohort of patients.
Nurses at my hospital are nursing patients with the virus without decent PPE and then on their next shift going to another speciality and nursing non-infected patients.
None of us have been tested for the virus. We are told if we show symptoms to stay home and yet, this virus is so new we aren’t completely sure whether you can be contagious whilst asymptomatic.
My hospital hasn’t stopped visitors even to infected wards. It’s still very easy for the virus to come in from the outside.
Regardless, if we continue to nurse patients without the correct PPE it won’t matter because the staff will facilitate the spread of infection and some NHS staff may even die.
Yes, we need more ventilators but how can we be talking about that when we are nursing without the most basic protective equipment? If we had the right PPE, we might not need as many ventilators.
Nursing Times is publishing blogs written by Covid19 Nursing, a trauma nurse at a London Level 1 Trauma Centre. Find out more at their blog site and follow them on Twitter @Covid19Nursing