HEALTH
Despatches from the ICU
Dr Catherine Motherway, Consultant
Intensivist at Limerick University Hospital
Edel Nolan, ICU Nurse and Acting Clinical
Facilitator, St Vincents University Hospital
Every day in the ICU is very different. Some
says are quiet, some days are busy, some days
are hell, you know how it goes.
When I work in the ICU, I see patients and
decide whether or not they need ICU care.
If they do, they will come into the ICU and
receive whatever treatments or therapies are
required. I work with the multidisciplinary team:
nurses, physiotherapists, speech therapists,
pharmacists, microbiologists and radiologists.
Initially, with Covid, there was a huge anxiety
that we would face scenes like our colleagues in
Italy faced but it didnt get that bad, thankfully.
Talking to families and relatives is a big part
of the job. Being the relative of someone in the
ICU is very difficult: your life is suspended. You
have rollercoaster days when things are going
very badly or very well. There is significant
morbidity and mortality associated with the
ICU; we lose a significant number of patients.
We have to be upfront and honest with patients
relatives and with patients if they are able to
speak with us. The therapies are hard and the
recovery is often hard.
When you practise medicine, you have days
when you have good results and days when
you have bad results, days when it works out
and days when it doesnt. So long as youve
done your best by the patient thats all you
can do. But there will be patients that you
remember forever. You have to build some form
of resilience, you have to have professional
distance but occasionally you have to cry. I cry
about a patient once every two years. You must
continue to have empathy.
When youre in ICU, you are one of the sickest
patients in Ireland. All of our patients are critically
unwell so if anything goes wrong, it can go
catastrophically wrong.
By 7.30am, we know which patient we have
been allocated. Our eyes and ears are with that
patient for twelve and a half hours of the day.
We are looking at their vital signs constantly and
were titrating the medication as were looking
at the monitors. Its a lot of responsibility its a
very different type of nursing than on the ward.
But its not just the science and its not just the
machines we really care for our patients. We
clean their eyes, we brush their teeth, we make
sure their arms are in a comfortable position. We
know them from head to toe, inside out. Were
the eyes and ears for their family, especially now
when they cant visit.
Last winter was very tough because we were
so overwhelmed: the 16 beds in ICU were full and
the extra beds were open. This was before Covid
hit. We went from that busyness, when everyone
was so drained, into the pandemic. And we are
still in it. We have almost felt worse this time,
with the second wave, because last time we were
running on adrenaline.
We need more ICU nurses: we have had a
shortage of critical care nurses for many years
and that has been shouted from the rooftops. We
are opening two more beds in the ICU here but
they are just a bed if we dont have a qualified
ICU nurse standing there, monitoring and caring
for the patient.
The nursing profession is just hoping that
the public stays behind us, like they have been
throughout the pandemic, to help us protect our
health service. By following restrictions, they
help us give the best care we can to our patients.
Maria Baily-Scanlan, Clinical Specialist
Physiotherapist at Tallaght University Hospital
That first day with the first Covid patient, I was
a little apprehensive. Part of my job is to help
people cough, which is obviously high-risk. But
I trusted that the PPE would work.
With Covid patients, there are two main things
that a physiotherapist can do: one, we help their
lung function; and two, we start the process
of rehabilitation that will continue when they
leave the ICU. Patients in the ICU are often
on ventilators and using assisted breathing
machines, while sedated, so we work with them
to try and improve how their lungs are working.
Normally people can cough during the day, but
these patients cant do that.
As patients start to wake up, we want them
to start moving. Thats our main role, really. So
the first thing we do is check what strength
they have. The Covid patients have often been
on medication that has kept them paralysed
so theyll be very weak. We need three or four
people, care assistants and nursing staff, to
help them sit. Thats a big turning point, when a
patient can sit at the edge of the bed.
Each day, we are aiming for them to sit with
less support. Once they can sit, we progress to
standing, then maybe a step to their chair. From
then on, we are working on strength, progressing
to walking. Some of the Covid patients were
rehabilitated quicker than expected because
they were younger than the patients we usually
treat that was so rewarding, seeing them
regain their strength.
Fr John Kelly, Director of Pastoral Care
at Tallaght University Hospital
For families and patients, the ICU is particularly
stressful. It raises a lot of questions for a patient,
questions that people wouldnt normally ask.
And while medical and nursing staff are very
comfortable with medical interventions, they can
be less comfortable with the big, eschatological
questions: Am I dying? or Will I get out of here?
I am there to listen to the patient, to help with
spiritual and emotional health.
One of the patients who had Covid in the
spring came to see me recently, months later.
He just wanted to talk about the experience. He
had spent three weeks in the ICU and he wanted
to talk about what he had been through. He
wanted to ask me about the names and voices
he had heard while he was sedated.
During the Covid pandemic, we must be
very focused. We limit our visits to the ICU to
specific interventions. We do what we can in
as short a time frame as possible. Some people
want a blessing or prayer; some people want a
discussion; some people want us to talk to their
family on their behalf. FaceTime has been helpful
but nothing can match the physical presence
of a loved one or family member. Patients miss
having that closeness. Thats the one thing that
I feel has changed dramatically patients can
feel isolated and alone. Thats why we must
offer reassurance more than ever before.
Furthermore, each nurse, doctor, physiotherapist
or other medical professional working in the ICU will
have had specialist training. To become an Intensive
Care Unit nurse requires many months of training
and a postgraduate diploma and even then youre
working alongside a senior nurse who is supervising
you, he points out.
Last spring, when the crisis was at its peak and the
health system was on the verge of being overwhelmed,
medics from other departments stepped up to support
their colleagues in the ICU. There was fantastic
teamwork and collegiality across the board, says
Professor Curley, praising people who didnt have to
do it they didnt have to take on the responsibility
of a very different job with higher stakes. However,
he says, with staff who are well-meaning but are
not experienced in the ongoing care of critically ill
patients, patients suffer.
So, when we hear that there are 30 Covid patients in
ICUs around Ireland, it might not sound like the entire
system is close to being overwhelmed. Thirty might
even sound like a small number. But heres an even
smaller number: six. Thats the number of ICU beds
per 100,000 inhabitants in Ireland, which compares
unfavourably to the European average of 11.5.
In Ireland, we have a fairly low ratio of ICU beds
per 100,000 of the population, says Professor Curley
plainly. And for a long time, it has been noted by the
ICU community that this is inadequate to provide
critical care.
That low number means that, even before the
pandemic, ICUs in Ireland were operating at 90
per cent capacity. A system that acts at 90 per cent
capacity doesnt allow for an extra thing, Professor
Curley says. People think its OK if youre not at
100 per cent. No, its not; your occupancy should be
at 75 per cent. That allows you to admit that head
injury or the patient with meningitis or sepsis or
respiratory failure.
We must begin to understand that if the ICU is
at risk of being overwhelmed, we are all at risk.
The entire ecosystem of the health system is
undermined and unsteadied when ICU capacity
reaches 100 per cent. As Professor Curley says: The
figures might look small but when there isnt much
leeway, it really counts.
Its worth remembering that last spring, ICU
capacity was freed up by cancelling scheduled
operations for non-Covid patients who would have
required intensive care after surgery. However, this
winter, during the second wave, most hospitals have
tried to avoid postponing surgeries where possible.
ICUs are also braced for the winter f lu season and
the related inf lux of patients needing critical care.
The pressure on the system is considerable and
will only increase as the winter goes on, says
Professor Curley. Our ICUs are very busy. He warns
against complacency.
In the spring, Irelands hospitals narrowly avoided
being overwhelmed as the result of an early, strict
lockdown. This winter, the fate of the health system
and its staff and patients is in our hands again. There
is hope on the horizon; the news about the vaccines is
promising. We can all look forward to a brighter 2021
but we are not quite there yet. The countrys ICUs rely
on us just as we have always relied on them.
THE GLOSS MAGAZINE December 2020 41
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