The new normal: this week’s challenges on the ward

It has been more than a week since my last blog post and a lot has happened in that time. I was working a long week last week, often starting in the morning and finishing late in the evening. As a doctor, the COVID-19 pandemic has transformed our way of working in rather unexpected ways.

Our once wholly surgical ward is now two-thirds respiratory patients and one-third surgical patients. We have a respiratory team, often around five doctors, looking after the respiratory patients on the ward between 0900 and 1700 Monday-Saturday. The respiratory team has invaded one of the two doctor’s offices on the ward. There has been friendly back and forth between the two teams about each other’s speciality. It has been good sport. This team has been bolstered by no less than 12 new, fast-tracked junior doctors who were only medical students a month ago. These doctors can be identified, rather ominously, by their black scrubs. However in the past week the workload has been relatively light and as such the new doctors have been sent home. More than once I have walked in on the respiratory team doing a collective puzzle. Odd times.

The same pattern has been seen in many other wards, including those dedicated to COVID-19 patients. My usual roster of 40 or so surgical patients has been trimmed to a bare bones 12 patients. The workload has been light, which has enabled us to often finish jobs early and focus on other scholarly endeavours, such as working on our mandatory portfolios or debating over our music tastes. I have been able to come in late on occasions, missing my 0900 start on one day and instead permitted to start the day at 1300. This is a real treat because my personal life has been rather busy with a new addition to the flat. My fiancée, who was previously living in the USA, has been allowed to travel back to live with me in the UK. This has been a wonderful benefit to my life as we have been long distance for the past 16 months.

Whilst work has been relatively scarce for doctors, nurses have been as busy as ever. We have been trying to help our nursing colleagues and teamwork is a vital part to the successful running of a ward. However, I have noticed over the past few weeks that on occasions tensions have flared between doctors and nurses. When requesting something from one of my nursing colleagues, I have been told that I should do it myself because I have fewer patients now. Whilst this is true during the day shift, after 1700 on Monday-Friday or on Sunday I have an entire ward to look after with 12 surgical patients, who I routinely care for, and 24 respiratory patients who I have never met before. This presents a whole new challenge because I am often walking into unknown scenarios when seeing the respiratory patients during the out-of-hours periods. The propensity to make mistakes is higher with patients that you do not know. And with doctor cover to a minimal in the evenings, support is often limited.

In many ways I can empathise with the difficult nursing situation. Whilst the occasional sly comment directed at doctors is irksome, it is not without truth. In addition, the nurses are as busy as always and with a new and unfamiliar patient cohort. The usual surgical patient, with surgical-type problems, is gone and has largely been replaced by respiratory patients. This new group has different nursing and medical requirements; they require much more careful use of oxygen therapy and often have far more co-existing health issues. Surgical patients tend to be much fitter than the typical respiratory patients, as there is a certain level of physical capacity required to survive anaesthesia and complex surgery. Therefore surgical patients are carefully selected with those who are either too old or too unwell to survive surgery left to more conservative, non-operative management.

Nursing has therefore changed substantially on the ward. Nurses are dealing with a new and more demanding cohort of patients, with issues that the nurses have never experienced before. The number of deaths on the ward has increased substantially. Deaths had previously been extremely rare on our ward. If a surgical patient becomes severely unwell then they are rapidly transferred to our high dependancy unit. Our surgical patients tend not to have a “ward-level” ceiling of care. A ward-level ceiling of care means that if the patient becomes unwell then they are to be looked after on a standard ward, without transfer to a high dependancy unit and all the additional monitoring and interventions that they can offer. Many of our respiratory patients have some form of developed or late stage chronic respiratory issues such as chronic obstructive pulmonary disorder or lung fibrosis, with a smattering of pneumonias and asthma patients. Many of these chronically unwell patients have a ward-level ceiling of care and therefore are not being escalated to higher levels of care when they significantly deteriorate. As a result, we are now experiencing at least one death a week on the ward. This has affected some nurses as they are struggling to come to terms with the new normal.

Whilst the new normal for us doctors on the ward is less stressful than previously for the moment, we must take a moment to recognise that our nursing colleagues on the ward have new challenges.

More One Doc’s Stories:

• A series of unfortunate events: The difficult stories of three challenging and deeply unwell patients seen on one night shift
• Power of the past: how archives shape our understanding of epidemics A collaborative post on the power of captured experiences during previous pandemics, and how/why we should capture our experiences of COVID-19
• One Doc’s Acute Respiratory Distress Syndrome story: A terrifying story of a patient’s rapid decline due to acute respiratory distress syndrome
• Developing a vaccine for COVID-19: A tale of two approaches. Is global partnership the solution to the coronavirus problem? Does nationalism promote the health of an entire nation?
• Protecting healthcare workers during a pandemic: Why we need to do more to protect those at the frontlines