My ITU experience

This letter was received in January 2021 from a clinical radiologist who wanted to share their experience of volunteering in intensive care during the COVID-19 pandemic.

Dear RCR Fellows,

In response to a trust-wide request for medical and nursing staff from other specialties to help out, on 23 January 2021 I took the opportunity to volunteer for a 12-hour shift in the expanded intensive critical care unit (ICCU) of the Royal Wolverhampton Hospitals NHS Trust. The Royal Wolverhampton Hospital is a medium-sized district general hospital (DGH) with tertiary facilities including a cardiothoracic centre. The shift started at 07:30 with a disciplined handover in a small conference room where some surgeons, nurses from various wards, ophthalmologists, ear, nose and throat surgeons and registrars from various specialties were also present.

I was  nervous when I started my shift but very quickly got sucked into looking after patients on my side of the ICCU ward. I was initially assigned to one patient alongside a brilliant critical care nurse called Grace but I was helping out the nurses in the neighbouring beds as the day went by. There was no dearth of personal protective equipment (PPE).

Most patients in the ICCU were on assisted ventilation of some kind. My patient started deteriorating even as I walked in and very soon his blood pressure (BP) and cardiac output deteriorated severely. He was able to maintain an oxygen a saturation of only 70–80% despite being on 100% oxygen. ICCU consultants (along with two clinical fellows) promptly responded to our call for help, reviewed the situation, increased his vasopressors and optimised the ventilator parameters. Despite this, the gentleman continued to deteriorate until 14:00 when a young ITU consultant discovered on a chest ultrasound that there was a suspicion of a pneumothorax. This was confirmed on a bed-side X-ray which took an hour to materialise as the radiographer was very busy with other patients on the ICCU. I was delighted to help identify the small apical pneumothorax. The small conclave of ITU consultants and fellows (all the while pretending they would have missed the pneumothorax were it not for a radiologist!) decided to drain the pneumothorax to improve the oxygen saturation much to my apprehension. Despite my help in positioning the patient, the ITU consultant couldn't get the drain in to the pneumothorax satisfactorily, partly due to the large body habitus (physique) of the patient. A  thoracic surgeon was requisitioned urgently  and sprinted over promptly to give us  a lesson on how to insert bed-side chest drains in ICCU singlehandedly, with his customary flair and meticulous approach. I was pleasantly surprised when he knew me by my first name despite my badge being well hidden under PPE – he seemed generally delighted to see me (although I could only remember the various computed tomography [CT] requests of his that I had rejected during my vetting sessions!). Following the intervention, the patient's oxygen saturation improved dramatically although there were other hair-rising ups and downs throughout the rest of the day.

I was constantly occupied making up infusions, signing drug charts, noting down observations, doing arterial blood gas (ABG) measurements and checking lab results, not just for my allocated patient but also the neighbouring beds when the nurses went on their breaks.  Proning was a revelation; a team exercise as daunting as it was interesting. Do you know that there is a World Health Organization (WHO) checklist for this too! I do not remember the nurse or myself sitting down even once during the first five hours. Soon I was allowed a generous break but cut it short so I could learn more. The critical care nurses were extremely kind and willing to show me how everything was done, from doing an ABG on complicated looking arterial lines, filling in the charts, explaining ventilator settings, measuring urine output, calculating fluid balance, to eye and mouth care and taking temperature recordings. Soon I became a pro at these things.

The ITU consultants, registrars and fellows were complete strangers to me but totally amazing – competent, kind and constantly available to provide guidance and initiate any change of management for the patients. One never felt unsupported. I was given impromptu bed-side lessons in respiratory pathophysiology and use of ventilators and was treated with respect (my knowledge deficit was perhaps too obvious). Initially I was rather suspicious that the ICCU clinical team seemed to take some pleasure out of loudly hailing my presence by my surname whenever they passed by and ‘just dropping in'  to check on me. I got used to the infamy pretty quickly however and, I guess, I will have to think twice as hard from now on now before I reject an ICCU request because of ‘inadequate clinical information’ having experienced the frenetic ITU activity first hand.

One saw a unique aspect of patient care, at times fraught, but almost always practised in a good humoured and disciplined manner. I learnt a lot very quickly and it was nice to occasionally help out with my specialty expertise by giving opinions on X-rays, ultrasounds and positioning and repositioning nasogastric (NG) tubes. I came across a kindly cardiologist looking after another sick patient, but wheeling an ultrasound machine around in his 'spare time' to get some echo done on some stubborn patients whose BP was down in their boots. I received a few free ten-minute tuitions on four and five chamber views with the doctor loudly muttering about how bad the portable ultrasound machine was compared to the Lamborghini in the cardiac wards. His meticulous approach and perseverance in obtaining the desired echo findings in trying circumstances was impressive. Very soon, I was part of the larger team and was extended every courtesy and kindness that one could possibly wish for. It was a great opportunity indeed to refresh one’s clinical acumen, pharmaceutical armamentarium and knowledge of acute medicine.

I felt privileged to help the ICCU nurses who otherwise would have felt isolated, helpless and alone in their struggle to nurse these very sick patients. The very fact that doctors completely out of their comfort zones – seniors in specialties they knew little about – were standing by their side helping in the tedious but important jobs that kept up the hopes of loved ones as far away as London and Leicester, seemed to bring a large dose of optimism into the hectic atmosphere of the ICCU energising their efforts to fight this terrible illness. Their focus and passion for their work and their incredible kindness is a life force that will almost certainly help humanity to beat this terrible disease. I remember Nurse Grace simultaneously gathering the drip sets, changing the infusions in the syringe drivers, keeping an eye on the monitors, cradling the phone in the crook of her neck and, without a hint of exasperation, talking to and answering the probing questions of an anxious wife. When the patient's BP nose dived yet again she had to suddenly but gently put and end to the call and   hustle to increase the noradrenaline dose and call for the ITU doctor. I vividly remember the immense delight mixed with astonishment on Grace's face when I assured her that I could load up the Roc (500 mg Rocuronium coming as 50 mg in a glass ampoules in 40 mls of normal saline) or the Propafol (a new one required every two hours) into the pump drivers. She simply couldn't believe that I was offering to do a simple job freeing her up to go and do some eye care or gather some syringes for the next lot of infusions. The guilt attached to  not volunteering to help much earlier during this awful third peak will stay with me for a long time.

There is no doubt that our skills as doctors and radiologists will be put to good use to not only improve patient outcomes but also to support our clinical and nursing colleagues emotionally and psychologically in these very difficult times in the ICCU and other wards.

I would heartily recommend volunteering in the ITU. There is no need to feel anxious or the least bit nervous. You will be among some of the kindest healthcare colleagues to walk the earth. The experience has greatly reinvigorated my enthusiasm for medicine and radiology and kindled my faith in humanity.

Kind regards,
Sanjay