Experience on the front line

 

21st January 2021

Back to basics

Yesterday I went right back to where my medical career began. I grew up in Germany, bilingual. A prerequisite to studying medicine in Germany is that applicants have to spend two months working as a healthcare assistant (HCA). Not a bad entry requirement - right from the outset it gives want-to-be doctors an idea of what it is like to work at the bottom of the healthcare hierarchy. An eye-opening and often humbling experience. I loved my time working as an HCA: I was part of a great nursing team, had my first opportunity to interact with patients, and received my first proper pay package!

In the end, I completed all my studies and training in England; however, memories of my time as an HCA in Germany remain with me to this day. When earlier this week, our Clinical Service Lead sent an email highlighting again the immense pressure our intensive care team is under, and asking for volunteers to help out on ITU, I immediately wondered whether this time help was needed on the nursing side. It was a no-brainer to offer some time. This is how I ended up on a long day on ITU yesterday, as an HCA - albeit with a few extra skills compared to when I last HCA’d many moons ago.

My first job of the shift was to attempt to fix a malfunctioning computer for our ‘pod’ - not exactly a task medical school prepares you for, but I gave it my best, and miraculously it began to work again a short while later. By the way, an ITU pod in our unit comprises:

- six patients,
- two intensive care-trained nurses, and
- as many extra pair of hands as they can get for the shift - we had a nurse deployed from immunology and me in ours yesterday.

Under kind and thankful supervision, I was given all sorts of tasks, by our pod leader and also the sister in charge of our unit: bed baths, counter-signing drugs, taking blood gases, checking two resuscitation trolleys contained the correct items and restocking anything missing, and creating three chest drain kit boxes from scratch so that equipment needed for chest drain insertion is to-hand immediately. The list goes on. Behind full PPE, the sweltering hours passed relatively quickly, accompanied by increasing dehydration and few breaks. Twelve hours are long when you are stuck in one place with relatively little autonomy and need a shower! A good reminder of how hard and diligently our nursing staff work on their shifts day in, day out.

Still, there were a couple of particular highlights on my HCA shift yesterday. Most importantly, one COVID-19 patient in my pod was well enough to be extubated. Another small moment of glory occurred when one of our patients became unstable: the ITU nurse in charge of our pod was unfamiliar with the ventilator this patient was on (in view of the huge influx of patients admitted to ITU at the moment, there are numerous different ventilators in use, each type a little different regarding settings and use). Having just familiarised myself with exactly this ventilator type whilst on my proning duty the day before, I was quickly able to help her change the settings according to what the patient needed. See one, do one, teach one - some things just don’t change.

NHSdoctor957

 

 

 

20th January 2021

Proning - Part 1

After four days as the airway person on one of the ITU proning teams in our hospital, my first impressions are:

First, proning - that is turning a patient from lying on their back to lying on their front - can have an immediately stabilising effect on an unstable patient. It is amazing how quickly the results are sometimes seen. Unfortunately, the opposite is also true: de-proning a patient - that is turning them to lie on their back again - can have a destabilising effect which can be equally immediate. Sometimes this is unavoidable: today we de-proned an unstable patient but had no choice as he had already been lying on his front for way longer than the recommended 16 hours in view of his fragile respiratory function. However, keeping him prone for longer would have risked causing serious pressure-related issues.

Secondly, proning requires a co-ordinated team effort. Our proning team consists of:
- one anaesthetist who oversees the proning process and is in charge of administrating anaesthetic drugs and making ventilator adjustments;
- five to six members of staff (usually deployed from theatres) who are in charge of turning the patient’s trunk and limbs, and;
- one maxillo-facial or ENT surgeon in charge of the airway throughout the turning process.
We currently have three daytime proning teams, and one night team. Proning uses a lot of (wo)man power in any 24-hour period.

Thirdly, proning requires execution of numerous carefully-choreographed small steps. This ensures the process is carried out safely and efficiently, often making it look straight-forward. The steps include:
- preparing the patient by stopping feeds and non-vital infusions;
- Increasing oxygenation and bolussing muscle relaxants and sedatives;
- getting sheets, pillows and padding in place to ensure patient comfort and avoid undue pressure on any one area of the patient’s body;
- running through a safety checklist a bit like in theatre;
- examining the position of feeding and breathing tubes as well as possible pressure areas;
- reviewing the cardiovascular and respiratory parameters;
- the turning manoeuvre itself;
- post-proning review of patient positioning, including lines, tubes and potential pressure areas, making adjustments where necessary;
- Post-prosing review of patient cardiovascular and respiratory parameters to ensure stability, alerting the ITU team of issues when necessary;
- running through a further safety checklist;
- documentation of the whole process.

I’ll save my other ‘first impressions’ for another day. For now, whilst, of course, I would prefer to be getting on with more ENT-related work, I am glad to be able to help with work that is necessary at present and certainly equally vital.

NHSdoctor957

 

 

 

13th January 2021

Virtual BACO 2021

Thanks to the pandemic, for many of us, study leave has been cancelled for the foreseeable future. Even time for Supporting Professional Activities (SPA) is suddenly becoming scarce - in our trust, it has temporarily been replaced with Direct Clinical Care (DCC) duties to further support COVID-19 services. So I missed the British Academic Conference in Otolaryngology (BACO) these past days. Instead, I spent time de-proning and proning patients on ITU, followed by being on-call for surgical tracheostomies.

Today I have been on home-school duties, but secretly had already ear-marked the day to start catching up on BACO. How amazing that this is possible thanks to BACO being virtual this year. My first delight was, that, compared to getting a primary school child logged on to the correct bits of remote learning for school, navigating around the Virtual BACO 2021 platform is positively easy! Maybe some schools could learn a thing or two here…? My second joy was the moment of enlightenment, discovering how pleasant household chores and Continuing Professional Development (CPD) can become when you are able to do them in parallel. Doing the washing up whilst listening to a colleague explain their findings surrounding transmastoid superior semicircular canal (SCC) occlusion for SCC dehiscence, and tidying the front room while hearing “my students” (now foundation doctors) had won a prize for their oral presentation, certainly takes the conference experience to new levels!

It goes without saying that all of us would have preferred to attend BACO in person, especially this year. Nothing can replace catching up with colleagues in person, dipping in and out of sessions, networking, discovering new equipment, or socialising with friends at a live conference. However, for a year such as this, Virtual BACO 2021 has brought manifold opportunities, much education and tremendous moments of light relief so desperately needed and hugely welcome. Moreover, the virtual conference set-up really levels the playing field for those who might otherwise have been precluded from coming due to ill health, disability, lack of finance, geographical distance or other. It will no doubt be challenging to attempt to combine these benefits of virtual meetings into live conferences in the future - but who knows what might be possible?

For now, I am looking forward to continuing my Virtual BACO 2021 catch-up. Massive congratulations and a huge thank you to the BACO team for successfully delivering such an extraordinary and excellent conference!

NHSdoctor957

 

 

 

7th January 2021 

2021 - not a dull day in sight! 

2020 ended with a bit of a bang, just not quite the one we had all hoped for, thanks to the new COVID-19 variant. On New Year’s Eve I received my first dose of the Pfizer vaccine and then swiftly joined an emergency departmental online meeting. Even most of those on leave logged in - no doubt a reflection of what is at stake and how concerned we all are in this surge of the pandemic. That meeting seems a long time ago already. More meetings have followed, and our working patterns and service provision have dramatically changed once again. I am finding these days almost reminiscent of the initial weeks of the first wave, with the big difference that we had not yet fully returned to pre-COVID-19 working patterns in between surges. On the positive side, we are more au fait with COVID-19-related issues than before. Nevertheless, the whole picture seems pretty serious at present. 

On the ENT front, our junior colleagues did not return from redeployment at the start of January as originally promised, but remain dispersed across the hospital, serving different teams on different wards. Our middle grades continue to cover all junior duties as well as their own and are resident on call. At consultant level, the surgical tracheostomy team continues, and a parallel percutaneous tracheostomy team has been formed to further assist our ITU colleagues. Additionally, several of my consultant colleagues will be heading to ITU this week to help alleviate the strain where it is most severe. Our job coming from ENT will be to assist with airway management and stabilisation during the proning and de-proning of ventilated patients. Helpfully, ‘proning’ was documented nicely on the news last night - this will allow easier communication with non-healthcare friends who are checking in on how work is going. I had no idea it would take a team of nine to achieve these patient rotations on ITU, but it makes sense with all the tubing and paraphernalia that needs to be adjusted whist the patient is turned. A quick message from my first colleagues on ITU today highlighted there may also be other ancillary duties to assist with, not quite as related to our ENT background as airway support. This made me smile as it brought back memories of a year when I worked in intensive care many moons ago - I seem to remember hours of teamwork speckled with dry, occasionally dark, humour during coffee breaks. After all, when the going gets tough, it’s either laugh or cry. Of course, I am hoping that some of the more technical aspects I learnt on that job will come flooding back, too, so that I don’t arrive quite as ‘green’ as I currently feel. In any case I am intrigued to see what day one will hold. At this rate there is certainly no dull day in sight for 2021 yet! 

NHSdoctor957

 

 

 

20th November 2020 

Mass redeployment  

This second surge of the pandemic seems to be continuing in full force. Towards the end of last week, we saw mass redeployment of the most junior tier of all surgical teams in our hospital. Now, instead of being based within a surgical team, surgical foundation and core training doctors are based on a ward, where they each cover a set number of patients for 12 hours at a time. The change was pretty sudden, which left our junior colleagues with little time to get their heads around things. It is hard to imagine what being redeployed at such short notice feels like unless it has happened to you. The whole process denudes individuals of any sense of influence, let alone control, over their short-term future at work. Although we have a very committed and willing team of juniors, this sort of thing does not exactly boost morale. 

Of course, mass redeployment of a whole rung of a team has an immediate knock-on effect on the rest of the team. In ENT, our middle grades now have to cover all the daytime activities normally taken care of by the juniors. Consequently, middle grades have also gone back to a 12-hour resident on-call pattern. At consultant level, we already had a robust first and second on-call rota, with a dedicated tracheostomy team in place. Now, the second on-call consultant will relinquish their daytime elective work to provide hands-on support to the duty team of the day.  What allows us to thrive in the workplace is a concept worth reflecting on from time to time. People cleverer than I am have worked out that thriving at work involves an intricate interplay between vitality and learning: 

“People who are thriving experience growth and momentum marked by both a sense of feeling energized and alive (vitality) and a sense that they are continually improving and getting better at what they do (learning)” [1].  

How we support colleagues to thrive at work during a pandemic that demands high degrees of commitment and flexibility remains an ongoing challenge, but one most certainly worth pursuit. 
 
Reference  
1. Porath C, Spreitzer, G, Gibson C, Garnett F. Thriving at work: toward its measurement, construct validation, and theoretical refinement. J Organ Behav 2012;33(2):250-75.

NHSdoctor957

 

 

 

6th November 2020

Déjà vu

The second lockdown started in England yesterday, and so I am back to tell more of the tale. It all feels a bit déjà vu… but not quite.

Hospital admission and death rates related to COVID-19 continue to be reported daily. They have been rising steadily over the past weeks, but this time I have not jotted them down on our home calendar - it’s just too depressing. Compared to March, numbers are moderated by averages calculated over the past week, as well as the number of patients having tested COVID-19-positive within the last 28 days. Additionally, the daily rate of people with a new, positive test is reported - in the absence of whole population-testing, it remains questionable how useful this number really is. Calculations of infection rates per 100,000 of the population are also made, but again, in the absence of whole population-testing, the figures are not true representations of what is really going on. At present, Merthyr Tydfil and Oldham top the UK charts with, apparently, 741 and 738 cases per 100,000 people, respectively.

It seems a long time ago, that shortages of loo-roll, flour or eggs, let alone personal protective equipment (PPE) or ventilators, were of concern. Hospital beds seem creatable as if by magic, judging by the Nightingale hospitals that sprung up so amazingly during the first pandemic surge. Now, it seems, the most precious resource to our country may be its NHS staff: nurses, physiotherapists, speech and language therapists, managers, secretaries, cleaners, audiologists, receptionists, research scientists, car park attendants and doctors, to name but a few. None of us are immune to catching COVID-19, needing to stay at home because a child needs to self-isolate and be home-schooled, or to becoming ill in other ways. Of particular concern is the resource which senior staff across all healthcare professions represent; their expertise, often gained from many years of training and work, is not easily or quickly replaceable. Consultant anaesthetists may be the most scarce and valuable staff commodity of all at present. As ITUs fill and overflow with COVID-19 patients requiring ventilation around the country, more consultant anaesthetists will be drawn to the ITU front line. Consequently, less will be available for routine surgery. Operating will suffer - first elective surgery will be postponed, then semi-urgent work will be delayed and, lastly, cancer work will be impacted. This chain reaction is already underway in many hospitals. Déjà vu? Sadly, yes.

Cancelling surgery, even when it is non-urgent elective work, is distressing for patients and surgeons alike. Patients want their much-needed treatment, and surgeons want to provide it. Unfortunately, medical consultants, whatever their specialty, are a commodity that is not easily (re)produceable. Even the brightest cannot be fast-tracked quickly through 10 or more years of general and specialist training. During a global pandemic, the consultant commodity is also one not easily bought in or traded. If this second lock-down spares our anaesthetic colleagues, then, in my opinion, it will have achieved at least one good thing. Time will tell.

NHSdoctor957

 

 

 

19th August 2020

Holidays and thank you notes

There has been a lull in my postings in the last few weeks. Apologies to those who may have awaited a new instalment from the front line. As it is, countrywide, the front line is desperately trying to get back to ‘normal working’ - whatever that may look like, and, of course, with new measures in place to keep everyone safe.

My communication hiatus stems from a mix of needing to use up accumulated annual leave, being in the midst of a job application process, and the front line being dominated by logistical challenges that may not make for quite as exciting reading as at the start of lock down.

Having to use up accumulated leave has been an interesting problem to have. Following the cancellation of all annual and study leave, as well as bank holidays at the beginning of lock down, a veritable ‘spare leave mountain’ must have arisen. To shrink this down rapidly, and with least financial impact, once leave taking was reinstated and strongly encouraged sometime in May, those coming to the end of their contracts or due to rotate in August were informed their spare leave would go to waste if not taken when it had been possible. No doubt, many trainees might have preferred to have spare leave days paid out rather than miss newly instated, scarce training opportunities. Also, inspiration for planning holidays was not exactly easy to come by what with ongoing travel and social distancing restrictions in place. However, this pandemic is dictating (some of) the rules, and flexibility continues to be a key requirement of medics.

I ended up with rather a nice chunk of time off, which came in handy as I also fell into the group of doctors coming to the end of their contracts in August. Many jobs that had been or were about to be advertised in the early months of this year, never got very far into the process due to the pandemic making an appearance. Several friends at similar stages to me around the country have needed to be extremely patient in waiting for possible job opportunities - and continue to do so. This is an aspect of the pandemic that may seem rather paradoxical, what with greater waiting lists than ever, and not enough people to do the work. The flip side, of course, is the scarcity of resources, be it operating spaces, finance and so on. In times like these, I recognise I have been fortunate that the job I had hoped for came about, and grateful that I have been appointed to it. However, let’s not underestimate the amount of additional strain such uncertainty places on the workforce our country so hugely relies on, and currently desperately needs.

In light of everything, it was an unprecedented surprise, when the postman delivered a thank you card from the NHS yesterday! While some cynics might have complaints about mass mailings like this, I think it is a small gesture that may just go a long way. I, for one, was grateful for the little note. It seems a positive place in time to pause this blog as we wait to see how the pandemic continues to unfold. If the front line becomes in any way exciting again, I’ll be sure to be back to tell the tale. For now, I will enjoy a little more time off…

NHSdoctor957

 

 

17th July 2020

10 things I will miss from lockdown

Lockdown has been tricky for many people. As we gradually emerge from it, a wave of relief, albeit mixed with trepidation, is sweeping across the country. Some of us are fearful as to what the next few months might hold. Many of us just want to get on with life as fully as we can, despite imposed restrictions. Most of us will hold views as to what might have been done better or differently during this pandemic.

Now may be as good a time as any to reflect on some positives we experienced during lockdown. Here are my top 10:

1. A slower pace to life (away from work).
2. Solidarity - at work and in our community.
3. Simplicity - less choice made some decisions easier.
4. Appreciation of key workers across the board - how often are we thankful for sewerage workers, delivery drivers and factory packers (to name but a few)?
5. Longer shifts at work resulting in more time off in between.
6. Being in a ‘firm structure’ on the emergency rota - working with the same colleagues for several days in a row allowed good collaboration and welcome camaraderie at a time when we were not seeing people socially.
7. Opportunities to try new methods of working with less red tape.
8. The Wellbeing Suite for medical staff providing rest and refreshment facilities (staffed by friendly, volunteering airline staff).
9. Discounts in our hospital ‘corner shop’ (enabling top-up of home essentials at the end of a long shift).
10. No car parking fees for hospital staff.

Which of these benefits we will be able to maintain only time will tell. I am intrigued to see what the future holds.

NHSdoctor957

 

 

13th July 2020

A new normal

Last week was my first week back on my pre-CV19 timetable at work. Despite some advantages of the longer working days our emergency rota had encompassed, over a prolonged period of time, 12.5 hour shifts do begin to become tiring, and I was missing ordinary clinics and operating. It has been a relief to return to a level of normal activities, albeit in their new, pandemic-related format.

For our department, clinics and theatres are now spread over several hospitals, including use of private facilities to provide NHS services. I had my first experience of the latter last week: I was pleasantly surprised with the almost cottage hospital-feel of the private facilities. Parking was easy and free, and it was almost impossible to get lost inside the small hospital (most hospitals I have worked in feel like a big maze for at least the first week). The Clinical Services Lead seemed incredibly on top of what was going on where and was readily available to answer questions. During the pleasantly speedy induction process, we were informed that surgeons have to undergo CV19 antigen testing within four days of operating, and that tests have to be repeated every 10 days. This is to ensure the site remains CV19-negative, namely ‘cold’. Dutifully, we went to get swabbed.

In turn, patients undergoing surgery have to self-isolate for 14 days prior to surgery, and get tested twice. Interestingly, their whole household has to self-isolate for the fortnight before their operation. This had not been possible for one of the patients on our list last week: his caring family members had gone out to collect medicines and groceries, and inadvertently breached the policy for this ‘cold’ hospital. Unfortunately, this meant his operation needed to be cancelled - a huge disappointment to all involved.

In this era of CV19-related measures, operating slots are precious and infrequent. Only high-priority patients are given surgery dates, and when these are missed it is unclear how soon a replacement date can be found. The policies may not always be uniform, but by definition have to be pretty rigid, precluding any ‘exceptions’. When, previously, a cancelled operation on the day of surgery might have felt unfortunate, inconvenient or sometimes even like a ‘breather’ in a busy schedule, it now has much bigger implications for both the surgical team and, most importantly, the patient. This is just one of the ongoing challenges CV19 poses - no doubt there will be more, and we will need to remain creative and adaptable in finding good solutions for our patients.

NHSdoctor957

 

 

 

3 July 2020

Mini interview with Miss Hannah Lancer

What was your NHS role prior to the CV19 pandemic?

ENT Specialist Registrar (ST5) in the West Midlands.

How has your NHS role changed since the CV19 pandemic?

When the pandemic really took force in the UK and lockdown was enforced, I was on maternity leave. So, we were very much in our little bubble at home, socially distancing and only going to public places when absolutely necessary.

When I returned to work at the beginning of May after nine months off and my son started nursery, it was slightly strange to begin with. Suddenly, I was seeing nursery staff and children, and work colleagues daily, but this situation quickly became the new normal, albeit with masks and social distancing thrown into the mix.

As registrars at the Queen Elizabeth Hospital, a four days on/four days off model was instituted, which involved rotating around being on-call 8am-8pm, covering emergency clinic with the SHOs, being ‘back-up’ in case of sickness, and night shifts. Due to the high number of tracheostomies performed in the hospital, we as ENT specialists were required to be resident for these night shifts in case of any airway emergency - prior to this it has been about four years since I had stayed in hospital accommodation!

Slowly but surely though, things are starting to normalise: elective theatres have restarted, we have reverted back to our old rota pre-COVID19 involving an on-call ‘hot week’, face-to-face emergency clinics are becoming more frequent, and the emergency department is a lot busier.

Please describe a snapshot of a typical shift you might be on this week.

As the Anterior Skull Base registrar, I tend to operate once a week at the local private hospital. The rest of the week will involve the skull base MDT, covering emergency clinics and on-calls out of hours, as well as time for CPD and admin. Currently, elective clinics are being run by the consultants and fellows, and are mainly telephone-led.

How has the pandemic impacted your work-life balance, for better or worse?

Coming back from maternity leave, I was a little apprehensive about resuming work, but returning to a rota involving four days on/four days off, and with little emergency work at the time, meant that it was actually a nice reintroduction to clinical life. Although I was eager after time off to get back to both elective and emergency work, especially operating of course, this rota meant that I actually got to spend time in the week with my son.

What are your top three concerns looking ahead at the next two months?

1. Patients waiting for their elective procedures and also their routine outpatient appointments: the backlog will be monumental.
2. Training progression: will we, as trainees, have enough evidence/operating to progress to the next stage in our training?
3. We are already starting to see local lockdowns put into place, will this mean another spike in COVID-19 cases?

Please describe your ‘best lesson learnt’ during this pandemic.

It has been great to see how healthcare professionals have worked together so well across different specialties and supported each other through this challenging time. It also makes you think about how paramount your own health and that of your family is.

Please list the top three things you miss at work from the pre-pandemic era.

1. Not seeing the whole ENT team as frequently: whilst on the four days on/four days off, we would only see limited team members, which made things feel a little disjointed.
2. Elective operating - most of the cases being performed are (quite rightly) of an urgent nature.
3. Being able to go for a coffee and all sit around the same table. Now, due to social distancing, it seems like we have to shout across a few tables just to communicate!

NHSdoctor957

 

 

 

30th June 2020

Mini interview with Mr Amit Parmar

What was your NHS role prior to the CV19 pandemic?

I work as a Consultant Paediatric ENT Surgeon at Birmingham Children’s Hospital.

How has your NHS role changed since the CV19 pandemic?

Initially a lot of time and thought was spent thinking about how we could reduce our risk of COVID whilst still maintaining some kind of service. The national guidelines published by ENT UK and BAPO have significantly helped with this.

Currently, we have been playing a stronger role with the emergency side of our service. The reasons for this have been due to us being a paediatric only hospital. We have agreed to accept additional work from local district general hospitals, to free up their resources to treat adult COVID patients.

We have drastically reduced face-to-face consultations, and elective operating has stopped for obvious reasons. This has resulted in us trying to find new ways of working whilst still maintaining a standard of care for our patients – this has been the greatest change and challenge.

Thankfully, paediatric hospitals have not felt the brunt of COVID in the same way adult hospitals have. Nonetheless our anaesthetic trainees have been redeployed to adult hospitals.

Please describe a snapshot of a typical shift you might be on this week.

We are trying to get back to a level of normality. However, no doctor works in isolation and as a result, our service is governed to some extent by other departments such as radiology, audiology and theatres (anaesthetics, etc). We have been doing lots of telephone clinics! There are no regular theatre lists, however, every week ENT get a couple of lists to share between the consultants for our urgent patients. This seems to work well for now. Clearly emergency work continues with the usual COVID PPE cover.
A lot of time is spent phoning patients that are on waiting lists, making sure that they are not becoming urgent. Additionally, we are spending more time on Zoom meetings than ever before!

How has the pandemic impacted your work-life balance, for better or worse?

On paper, we should have more time to spend at home with our families. However, the reality has been different. This new way of working has resulted in a change in the predictable routine of pre-COVID. The ever-changing rules and goal posts make for a more stressful life, despite the actual amount of clinical activity decreasing.

What are your top three concerns looking ahead at the next two months?

1. The difficulty in restarting a service - we have learnt that it has been more difficult to restart a service than to shut it!! We are so reliant on our audiologists, anaesthetists and theatre staff, and all these departments have had their own challenges with COVID. We have learnt that we cannot get back to normal until other departments do.
2. Waiting times - made worse by the fact that when we restart work it will be at a slower rate.
3. Second wave - at the time of writing this, there were news reports of there being mini-breakouts in Beijing and Germany. Whilst not quite a second wave, it does demonstrate that we are not quite over COVID yet.

Please describe your ‘best lesson learnt’ during this pandemic.

As ENT surgeons, we can be quite relaxed about infection control. This episode has shown the importance of infection control.

Please list the top three things you miss at work from the pre-pandemic era?

1. Routine - monotony has its benefits.
2. Having the flexibility to increase my workload easily to accommodate our waiting list demands.
3. Planning – the ability to plan our lives! Even now, several months into the pandemic, you really cannot plan more than one-to-two weeks at a time - in all aspects of our lives.

NHSdoctor957

 

 

26th June 2020

Mini interview with Mr Miran Pankhania

What was your NHS role prior to the CV19 pandemic?

Anterior Skull Base & Rhinology Fellow at University Hospitals Birmingham.

How has your NHS role changed since the CV19 pandemic?

Prior to the pandemic, I was in the enviable position of doing an average of six theatre sessions a week under the auspices of Shahz Ahmed, pushing the boundaries of endoscopic surgery. I covered research clinics as well as conventional skull base and rhinology clinics. In mid-March, virtually all research and elective clinical activity was stopped overnight. The quarterly regional rhinology meeting, BACO, ERS, and BRS were all cancelled one by one. Clinics turned to telephone consultations. Our last elective operating list was a joint ophthalmology and ENT list, and the fellowship ground to an unceremonious halt - a complete anti-climax given the visions a month earlier of a leaving party, as I left my fellowship early to start as a Consultant Rhinologist in Rotherham and Doncaster.

Birmingham was hit early, so going back to Yorkshire infected with COVID, where there were still plenty of intensive care beds, felt reassuring in view of my ethnic minority (and associated risk factors). I self-isolated but knowing the wave would soon hit the north meant we were able to use the data and experience from Birmingham to create guidance for local practice. A combination of PPE, social distancing, and adapting to changes in practice was shored up by the robust leadership and guidance from ENT UK. Clinics are now a hybrid of telephone triage and follow-up, with screened patients coming for face-to-face appointments when necessary. It has taken just under two months since starting formally in post to do an elective case, and we are regularly undertaking planning meetings via MS Teams, when I am sure most of us would rather arrange our lives over a pint given the weather.

Please describe a snapshot of a typical shift you might be on this week.

A typical day for me now might involve a morning theatre list with an urgent diagnostic case, or an emergency airway if I'm really unlucky. We are pooling efforts to get urgent patient cases done on fewer lists than we might previously have had. Lunch is punctuated by clinical admin and chasing results, now that only urgent scans are being performed, before hitting the afternoon clinic, which has a combination of telephone and face-to-face patients on it. This is a fantastic way of honing your clinical acumen, but is increasingly stressful, now that referrals are coming in thick and fast again.

How has the pandemic impacted your work-life balance, for better or worse?

Having the ability to use a remote desktop or VPN is a game changer, particularly when dealing with admin or telephone clinics, but I am still going stir-crazy from not operating. The improvement in work-life balance is not to be sniffed at though. Sourdough is rife in our household now.

What are your top three concerns looking ahead at the next two months?

In no particular order...

1. Training the registrars.
2. Getting through the backlog of elective patients.
3. Cancer follow-ups.

Please describe your ‘best lesson learnt’ during this pandemic.

You will be doing the job for a long time, so choose colleagues who will have your back and with whom you can have a socially distanced beverage.

Please list the top three things you miss at work from the pre-pandemic era?

1. Doing lists of five-to-six tonsils in quick succession whilst training core trainees.
2. Accessing bits of the skull base through the nose, tag-teaming with Shahz and Paresh, our MTI trainee.
3. Having money in my wallet to spend at M&S instead of on moisturising face cream, and Pirinase and Nasogel for my occupational rhinitis from perpetual FFP3 wearing. (Other nasal sprays are available).

NHSdoctor957

 

 

22nd June 2020

Not exactly what we set out to do…

It has been fascinating to read my colleagues stories from around the country, and to hear how the pandemic has impacted their working lives. I hope to bring you more interviews in the coming weeks. For now, I am struck by one overriding theme: working life for most of us in ENT and audiology just does not resemble what it used to be, even with the reintroduction of elective activity.

By now, most of us have got accustomed to regular donning of FFP3 masks and related kit, despite ongoing controversies over what should and should not count as an aerosol-generating procedure (AGP). We wear masks around the hospital all day now, without blinking. We conduct meetings online, and clinics remotely - many prefer this. In my trust, the ENT middle grades have been amongst the longest to remain on an emergency pattern rota in view of the large number of post-ITU tracheostomy patients present on CV19-wards in May. Happily, this is about to change. In parallel our trainees are getting some opportunities for training in and out of theatre again, albeit in a much-reduced volume compared to before. How we ensure quality compensates for the lack in quantity of learning opportunities looks to be a challenge for the foreseeable future. It may well end up significantly increasing surgeons’ time in training.

In the meantime, the ongoing challenge in ENT and audiology remains how we conduct face-to-face appointments. Back in April, we introduced procedure rooms in our department in which AGPs can be performed safely. This led to a multicycle, iterative change in practice process, as well as formation of a Working Group. Turns out, working out how many AGPs can be done in one day is quite complex, when needing to take into account the room ‘rest period’ required prior to an ‘amber’ room clean, following each AGP. An ‘amber’ room clean in our trust involves disinfecting all surfaces with a chlorine-based disinfectant, followed by a second wipe-down of all surfaces with a specific disinfectant wipe, before mopping of the floor can take place. The whole cleaning process takes approximately 20 minutes, even with as much superfluous kit removed from the procedure rooms as possible. I did it once, just because I wanted to perform an AGP after most of the nursing staff had left. It was pretty tiring behind the full level three kit! The calculated number of AGPs that can be performed in one day has to additionally be balanced with the reduced number of ENT waiting room seats now available to us due to social distancing measures.

We thought we had worked out a good, new clinic-booking template with which secretaries could book in patients requiring a face-to-face appointment or an AGP. Then, yesterday, it transpired that the cleaning routines in clinic are so demanding, they are resulting in physical symptoms for some staff and low morale for most. It looks like our optimised clinic booking template will have to be severely reduced until such a time when more staff are made available. Ideally, this should include cleaners, but they seem in short supply at present.

So, while I sometimes consider my current work life really not to look like what it used to be, or what I perhaps set out to do in life, I really I cannot complain: I am operating again, I don’t mind telephone clinics and I see patients face-to-face when required. I even bump into ENT peers on some days. However, my heart absolutely goes out to my healthcare assistant colleagues in clinic, who really did not set out to be full-time cleaners in life, but now suddenly and involuntarily find themselves in exactly such a role just because they work in a clinic which needs to continue delivering AGPs during a respiratory pandemic. How we mitigate this, is yet another challenge for the coming months - one we absolutely should take seriously.

NHSdoctor957

 

16th June 2020 

Mini interview with Mr Ian Street 

What was your NHS role prior to the CV19 pandemic? 

I worked as a Consultant Paediatric ENT Surgeon at a dedicated paediatric hospital and continue in this role. I am also the Clinical Director for ENT and Audiology. 

How has your NHS role changed since the CV19 pandemic? 

The job has changed radically, particularly because our throughput of patients has decreased drastically. There was a significant period of time when only urgent cases were being performed, which was limited mostly to children with airway disease and the odd oncological case. As a paediatric hospital, we were also preparing for the potential for airway intervention in the small number of adult patients sent to the ITU in Alder Hey! 

Administratively, whilst the ENT and audiology departments have really pulled out all the stops to work well with the current system, there has necessarily had to be some juggling of the departmental workforces to ensure some of our more vulnerable members are adequately protected from infection. 

Please describe a snapshot of a typical shift you might be on this week. 

Now that the workload is slowly increasing, my work pattern is approaching its pre-COVID appearance qualitatively. Quantitatively, I am managing a markedly reduced number of patients. For example, I have a day-case list tomorrow and, whilst I had space to do eight to 10 cases over the day in the past, I am now restricted to five cases. There are significant concerns about the availability of PPE, but the hospital has been very proactive in finding alternatives, such as Powered Air Purifying Respirator hoods. 

How has the pandemic impacted your work-life balance, for better or worse? 

Working from home has become more normal, doubtlessly. The time at home is certainly preferable to being at the workplace, so life is arguably better, but this is tempered by the worries of infection and the difficulty of childcare for families such as mine, where both parents are NHS workers. 

What are your top three concerns looking ahead at the next two months? 

1. I am confident that we have been proactive about dealing with urgent cases but inevitably there will be a backlog of less urgent cases who are genuinely suffering. The difficulty will be dealing with them in a systematic manner. 

2. I would have concerns about protective equipment for staff as well, although so far, good planning seems to have mitigated this. 

3. My greatest concern by far is that the NHS will just return to its previous, unsustainable ways of working, with insufficient physical capacity for the work required of it, lurching from ‘winter crisis’ to ‘black alert’. I really would like for this pause to have meant something; where we could wisely and sensibly use remote working to make more rational use of the physical infrastructure that we have. 


Please describe your ‘best lesson learnt’ during this pandemic. 

The best lesson is that the old chestnut that is, communication is one of the keys to an effective NHS. The slow and deliberate speech when wearing PPE is an illustration of this and highlights how much unnecessary and distracting noise and conversation used to happen, particularly in theatres.  

The higher echelons of management locally have been quite particular about making sure news and directives are communicated back and forth from the clinical staff to the management, which has made coping with this unusual situation significantly easier. 

Please list the top three things you miss at work from the pre-pandemic era. 

1. Seeing many of my colleagues at work together, and the resulting sociability. 

2. Being able to move around the hospital without donning and doffing PPE. 

3. Having plenty of secure spaces to lock my bicycle up at – loads of people seem to have discovered the joys of the bicycle commute. 

NHSdoctor957

 

 

12th June 2020

Mini interview with Ms Hannah Snowdon

What was your NHS role prior to the CV19 pandemic?

I was working as an Audiologist for North Tees and Hartlepool NHS Trust.

How has your NHS role changed since the CV19 pandemic?

At the beginning of the pandemic I was redeployed as an Oxygen Runner. Due to the increased levels of patients requiring oxygen therapy, it was vital to monitor the oxygen levels in the hospital 24/7. The role involved contacting all wards in the hospital every four hours, reducing to every two hours when nearing 80% oxygen capacity, for an update on how many litres per minute of oxygen each patient was using. This was then entered onto a database for the operational managers to analyse and determine if further action was required. We were often required to perform difficult calculations to convert the readings into litres per minute, and had to become experts in a completely new field overnight. As monitoring was needed 24/7 it did mean shift work was required. Working 12-hour nightshifts for the first time was definitely a struggle! It was lovely to work with different staff from a range of backgrounds such as speech therapy, podiatry and radiography (to name a few) and interesting to get an insight into how other specialties work.

Please describe a snapshot of a typical shift you might be on this week.

This is my first week back working in my audiology department, and we are gradually opening the department for limited appointments. This week has mainly been spent calling patients and triaging them, to determine which patients need to be seen as a priority and which patients would be happy to attend clinic. To start with, we have prioritised our paediatric hearing aid caseload, who had appointments cancelled at the beginning of the pandemic, which we have booked in at the end of the week. Our appointment times have been extended, and gaps have been created between these for extensive cleaning and donning and doffing PPE.

We will be working to a fixed timetable which has been created so all appointments are staggered to ensure there are a limited number of patients in the waiting area and in the department. One new way of working is that instead of moving around sites, as we usually do, we now have ‘bubbles’ of staff at each different site. This has been introduced to prevent a complete shutdown of the department if a member of staff did test positive or begin to show symptoms.

How has the pandemic impacted your work-life balance, for better or worse?

Better in some ways, as working shifts meant I have only been working three days rather than my usual four – this meant more time off to spend with my partner, which we would not have ordinarily had. The downside was the stress of working in a pandemic alongside changing job roles, and the shift pattern was quite difficult to adapt to.

What are your top three concerns looking ahead at the next two months?

1. Working our way through the backlog of patients. We have always been proud of our short waiting times, and it will be hard work getting through the cancelled patients and the patients still waiting to be seen, as our referral rate has not slowed down during the pandemic.
2. How our service will cope with the changes and our new way of working.
3. How long it will be until I can see my family again and regain some kind of normality.

Please describe your ‘best lesson learnt’ during this pandemic.

To appreciate the little things more. During the pandemic, it has not been the big things that I have missed – it’s more not being able to pop round to see my family for 10 minutes or not being able to give them a hug, just to name a few. It has put into perspective what is important and what isn’t.

Please list the top three things you miss at work from the pre-pandemic era.

1. Not needing to wear PPE to see patients - this is especially difficult when working with children, who can often be wary of uniform to start with.
2. Being able to work at different clinical sites, with different members of staff.
3. Having a varied timetable. Previously, each week would be different, so I might have done a mixed session of adult and paediatric appointments, changed location during the day etc. The pandemic now means we have a fixed timetable of appointment types that cannot be deviated from.

NHSdoctor957

 

 

9th June 2020

Mini interview with Mr Navdeep Upile

What was your NHS role prior to the CV19 pandemic?

I am a Consultant Head and Neck Surgeon working at Queen Victoria Hospital, East Grinstead, and Medway Maritime Hospital.

How has your NHS role changed since the CV19 pandemic?

I am very privileged to be working at Queen Victoria Hospital, the first centre in the south east of England to be confirmed a designated cancer centre during the CV19 crisis. This has allowed me to continue providing a surgical oncological option to patients within the region, and thankfully for me, I have avoided being redeployed.

Please describe a snapshot of a typical shift you might be on this week.

The ‘shifts’ are really unchanged in structure. Ward rounds, clinics and theatre are all still undertaken, but there have been many adjustments to reduce potential transmission of the virus.

For example, normally most patients are reviewed by the on-call surgical team, the operating team, and several different allied health professionals during the course of a day, all on a variety of ward rounds. This number of reviewing teams increases the risk to the patient. We have, therefore, adapted this by instituting virtual ward rounds, where a core number of individuals physically review the patients, whilst it is simultaneously ‘livecast’ to other consultants, trainees, and associated healthcare professionals via a weblink. This has taken some getting used to but has provided more pros than cons; it is just one example of how CV19 may have provided some silver linings to our future working patterns!

How has the pandemic impacted your work-life balance, for better or worse?

It certainly has impacted on the work-life balance, with more time being spent at work. However, my wife (who is also a medic) and I remember we are very lucky to be able to continue with our jobs. Our children, probably a testament to our bad parenting, love to go to school as ‘the key worker kids’.

What are your top three concerns looking ahead at the next two months?

1. I fear more cancer patients will present later and with more advanced disease.
2. We may go back into lockdown and the negative impact on the economy will ultimately have a greater negative impact on the NHS.
3. Childcare over the summer holidays is going to be precarious. We, like many, rely on grandparents, which isn’t an option…

Please describe your ‘best lesson learnt’ during this pandemic.

Don’t panic… not only a quote/mantra from a fabulous science fiction classic but a real-life lesson. At the beginning of this pandemic, I had this fear of undertaking a large resection and putting a patient through a long hospital stay, only for them to catch CV19. This fear nearly paralysed me. Whilst we aren’t through this yet, I’m glad to say so far, the measures we have undertaken as a unit have meant we’ve been lucky with no CV19-related morbidity.

Please list the top three things you miss at work from the pre-pandemic era.

1. Communicating with my patients as a human. Telephone consulting or being behind a facemask doesn’t cut it when delivering the life-altering diagnosis of cancer to a patient. Not being able to show my empathy through non-verbal communication has made one of the hardest parts of my job harder.
2. Benign cases! At the moment everything is urgent cancer work.
3. Good coffee! Our nice onsite coffee shop closed down during the crisis. Having done a fellowship in Australia, I’ve become a coffee snob and I can’t bring myself to drink instant coffee.

NHSdoctor957

 

 

4th June 2020

Mini interview with Ms Rosalyn Parker

What was your NHS role prior to the CV19 pandemic?

Research Audiologist at the Queen Elizabeth Hospital, Birmingham.

How has your NHS role changed since the CV19 pandemic?

Due to the incredible ‘call to arms’, many of the audiology team have been working long day and night shifts assisting in ITU, working in bed spaces for COVID patients or in donning and doffing roles.

I have been fortunate to work alongside the brilliant staff at the Queen Elizabeth Hospital ITU, assisting with patient care and monitoring. This has resulted in rapidly acquiring new skills, including critical care patient observations, understanding ventilator settings, suctioning airways, taking blood gases and samples, aspirates and general patient care. This has very much been a huge shift from life as an audiologist. Nevertheless, when you consider audiologists routinely support a patient’s wellbeing and assess their health, through equipment or test results, the role actually draws some interesting parallels.

Please describe a snapshot of a typical shift you might be on this week.

My shift pattern has changed from 8-5 Monday-Friday to three condensed 12.5-hour shifts covering days, nights and weekends. These will typically start with allocation to an ITU ward and bed space to assist the nursing staff. Handover from the previous shift would take place, followed by safety checks in the bed space. Duties would include routine patient observations, maintaining feed and fluids, assessment, assisting in drug rounds and infusions, as well as general patient care including hygiene and repositioning needs.

How has the pandemic impacted your work-life balance, for better or worse?

I started my current NHS research role in September last year. I live away from my family home in Newcastle upon Tyne during the working week, so my work-life balance had already seen quite an adjustment. Whilst the new role has been incredibly demanding, both physically and emotionally, the longer shifts have allowed me to return home for longer periods between duties. Fortunately, my husband is working from home and has approved my returning home between shifts! The roads have been considerably quieter allowing for an easier commute, and the staying at home guidance has meant that I have a new appreciation of the simple things of home and togetherness with family. The support that my friends and family have shown has helped me prepare and cope with the stark realities of the effects of the pandemic that I’ve encountered. I have also been able to access my usual work remotely from home, which has kept a sense of familiarity and inclusion with my colleagues during my redeployment.

What are your top three concerns looking ahead at the next two months?

1. The impact that the pause to audiology services will have on those living with hearing loss, tinnitus and balance conditions.
2. The impact that the audiology and healthcare services of the future may have on patients with hearing loss, for example the effects of PPE or alternative methods to face-to-face consultations have on effective communication.
3. The general unknowns! How and when we can get the paused research running again, and how we will adapt to any changes required to continue with research safely.

Please describe your ‘best lesson learnt’ during this pandemic.

The importance of working together and being supportive as a team to adapt to the changing demands and guidance. It has also reinforced the appreciation of your health and those you have around you.

Please list the top three things you miss at work from the pre-pandemic era.

1. The lack of social distancing! Being able to walk past or sit with colleagues without having to ensure a strict 2m distance. It is often quite an alien concept for audiologists to have to use telephone or considerable distances when communicating with others. Even being able to have a face-to-face meeting with colleagues is something that I am missing.
2. Audiology research! Advancing the way for hearing and balance care of the future and making a contribution to people’s hearing health.
3. Working with our Patient and Public Involvement group and having engaged discussions with people regarding audiology and ENT research.

NHSdoctor957

 

 

1st June 2020 

Mini interview with Mr Bernhard Attlmayr 

What was your NHS role prior to the CV19 pandemic? 

ENT Consultant at Leighton Hospital, Crewe. 

How has your NHS role changed since the CV19 pandemic? 

My role has not really changed. For a period of three weeks we were placed on the ITU rota for a few shifts, as well as covering the ENT on-call. Some of my colleagues did act as ITU SHO for a few shifts but, by the time it would have been my turn, we were stepped down.   

However, the way we are providing the service has changed significantly: virtual clinics for follow up patients, postponing of routine new patients, postponing of any elective surgery and more frequent ENT on-calls, as we uncoupled from our joint on-call rota with a neighboring hospital (change from a 1:14 to a 1:5). 

Please describe a snapshot of a typical shift you might be on this week. 

Sitting in the outpatient department in front of the computer doing telephone consultations, and maybe seeing one or two patients in full PPE that need seeing on an urgent basis.  

How has the pandemic impacted your work-life balance, for better or worse? 

Childcare has become more of an issue and adds extra stress. The school my daughter attends has reduced the childcare hours now twice since the start of the pandemic. From June they will only operate between 8:30 and 16:00, which will be difficult on days when I work from 8:00 to 17:30. Overall, I spend more time in hospital, but work less during that time, as work has become less efficient. The main impact on my work-life balance is that I cannot freely move within the UK or Europe. 

What are your top three concerns looking ahead at the next two months? 

1. Closed European boarders. 

   
2. Theatre waiting lists. 

   
3. The outpatient backlog. 


Please describe your ‘best lesson learnt’ during this pandemic. 

Even though it feels uncomfortable, it is possible to manage quite a number of patients remotely without them attending. I was very skeptical about virtual clinics and I do hope there won’t be another negative lesson to be learnt after the pandemic. 

Please list the top three things you miss at work from the pre-pandemic era. 

1. Not having to use full PPE for routine procedures such as flexible nasoendoscopy.  

   
2. More efficient theatre use (there is now significant downtime between cases). 

   
3. Personal patient contact rather than via the telephone. 


NHSdoctor957

 

 

25th May 2020

Mini interview with Mr Anand Kasbekar

What was your NHS role prior to the CV19 pandemic?

ENT and Neurotology Consultant at Nottingham University Hospitals NHS Trust, Training Programme Director for ENT Surgery, Health Education East Midlands, Honorary Assistant Professor, University of Nottingham. So, a few different hats to juggle.

How has your NHS role changed since the CV19 pandemic?

My role has significantly changed. On the NHS side, routine operating has stopped and therefore that time is being redeployed to other activities. For me personally it has been developing new ways of working in otology when we get back to routine work (which is around the corner at the time of this interview).

Much of my time has gone into dealing with training-related matters, as one might imagine. With the annual trainee appraisals in June, there are many concerns about competencies not being met. Continuing medical education and training (non-operative) has taken a leap forward. In my region, we are offering online training days to replace the face to face ones, and along with my training director colleagues around the country, national teaching webinars have now been developed, which have been a huge success. Thank you to Mr Samit Ghosh in Manchester for driving this forward.

I am also lucky enough to work with the NIHR Nottingham Biomedical Research Centre and I have had more flexibility to work on COVID-19-related topics, including the potential ototoxicity caused by anti-malaria medications used to treat COVID-19 in many parts of the world. I have also had more time to devote to my PhD student, which is always good!

Please describe a snapshot of a typical shift you might be on this week.

We now do virtual/telephone clinics and that often takes longer than seeing patients! The on-call frequency has doubled as some colleagues are self-shielding. In addition, we have devised a back-up on-call consultant rota. Operating days have been turned into management days, and we are working on improving pathways, teaching nurses to upskill, etc. Everyone in the department is working on innovative new models of working, including developing and testing appropriate PPE to start routine activity. Every day there are Zoom/Microsoft Teams meetings, and it can fill your day pretty quickly! Instead of separate days of the week being devoted to research, training and clinical work, as my work is now more fluid, I have flexibility in how I plan my week, which is a bonus. Reducing travelling time helps enormously as we realise we can work remotely.

Initially we had a daily Microsoft Teams meeting at 5pm, with everyone in the department attending, including SHOs, registrars, nurses, speech & language therapists and consultants. This helped significantly in making sure we all knew what was going on from the ground upwards and could instigate changes very quickly. This has now changed to a weekly meeting, and we will keep it that way as the benefits are enormous.

How has the pandemic impacted your work-life balance, for better or worse?

For me personally, it has improved. I have more flexibility, so I can work at various times of the day or night and spend more time with the family when needed. This includes picking my child up from nursery when previously I couldn’t. I know that for colleagues working where COVID-19 has hit hard, it has been more difficult with redeployment to ICU.

What are your top three concerns looking ahead at the next two months?

1. Routine/semi-urgent patients will be waiting for an extended time to be treated, and their disease might have worsened, leading to potentially poorer outcomes.
2. Not having adequate protection or evidence-based protocols when operating or seeing patients. We don’t know enough about COVID-19 to be able to say with any certainty how ‘risky’ various procedures are, and how best to keep safe while ensuring we don’t run out of resources and PPE.
3. My trainees will suffer with their progression through training, and it is taking its toll on them mentally. There is help being provided by the relevant bodies to address this.

Please describe your ‘best lesson learnt’ during this pandemic.

Communication is key. Working together and supporting each other is vital as these are stressful times for all.

Please list the top three things you miss at work from the pre-pandemic era.

1. Operating regularly.
2. Seeing patients face to face so that you have a high likelihood of treating them appropriately. Currently with virtual consults there is a higher element of managing risk as the patient cannot be examined.
3. Being able to take trainees through procedures and see them gain proficiency with each attempt.

NHSdoctor957

 

 

21st May 2020 

Mini interview with Mrs Louise Craddock 

What was your NHS role prior to the CV19 pandemic? 

Clinical coordinator of the Hearing Implant Programme/Audiological Scientist. 

How has your NHS role changed since the CV19 pandemic? 

A few weeks prior to lockdown, I injured my finger and have had to wear a splint for 12 weeks. As I am unable to wash my hands properly, I was not allowed to see any patients. Therefore, I was not allowed to join other audiology colleagues in Critical Care but had to stay behind in the department. Since then we have not been open to patients, and so I have had many weeks doing a purely administrative role. 

Please describe a snapshot of a typical shift you might be on this week. 

Usually my schedule is very busy, but now it has been much more unstructured. Although I was very disappointed not to be able to perform a clinical role in Critical Care, I have actually had the time to deliver on projects that will see a radical change in how our service is delivered when it re-opens to patients. I have made the most of online resources such as attending GoTo or Zoom meetings and doing webinar training courses. 

How has the pandemic impacted your work-life balance, for better or worse? 

Greatly for the better! I am spending more time at home and enjoying time with the family. There are no evening meetings or conferences away from home. I am leaving work on time rather than staying late. On the other hand, at the beginning of lockdown my levels of anxiety were significantly higher than usual which affected my sleep – I think this has been quite common. 

What are your top three concerns looking ahead at the next two months? 

1. Cochlear implants (CIs) are regarded as a Priority 4 treatment and in surgical terms there is no medical harm to patients waiting more than three months. However, the consequences of prolonged profound deafness have not been taken into consideration. I am also concerned that a lengthy delay in resuming CI surgery will have a detrimental effect on referrals, as our usual referrers may decide to send patients to other CI centres that are able to offer surgery. 
2. There is little or no guidance as to how we will be able to run clinics effectively in the outpatient setting. 
3. I am concerned that we are pushing the growing backlog further down the road, and that it will become unmanageable. 

Please describe your ‘best lesson learnt’ during this pandemic. 

There is no need to fly to another country to participate in discussion and learning. 

Please list the top three things you miss at work from the pre-pandemic era. 

1. In direct contradiction to the last point, flying to another country and networking with colleagues from all over the world was one of the most enjoyable aspects of the job!  Although learning and discussion is possible via Zoom etc., it does not replace those informal conversations that take place over dinner where you can get so much valuable information as to working practices in another centre. 
2. I have been meticulous about social distancing, but it is not in my nature to keep two metres from others. The social interaction with colleagues and patients was one of the most rewarding aspects of my job. 
3. I have not seen any patients for 12 weeks and the clinical element of my role is the one I enjoy the most. I am looking forward to being able to resume clinical work again, and hope that the measures of infection control are not too much of a barrier. 

NHSdoctor957

 

 

18th May 2020

Mini interview with Mr Sirhan Alvi

What was your NHS role prior to the CV19 pandemic?
I was working as a post-CCT ENT facial plastic fellow at Doncaster Royal Infirmary.

How has your NHS role changed since the CV19 pandemic?
All non-urgent and non-cancer work has been cancelled. With outpatient department (OPD) clinics cancelled, clinic notes and referral letters are now reviewed remotely. Patients are either given a routine post-COVID appointment (three months), or telephone consultations are carried out to discuss results or issues. Anything deemed a two-week-wait appointment is seen with appropriate personal protective equipment (PPE) cover. 

Operatively, I was doing a lot of FESS and rhinoplasty procedures. These cases are deemed high risk and non-urgent, and have all been cancelled. The skin cancer work has continued, but only for potential SCC cases.

Please describe a snapshot of a typical shift you might be on this week.
8am: We do a ward round - only one ENT clinician wears PPE and examines all the patients. Inpatient numbers have greatly dropped off.
9am: I go through OPD clinic notes and letters, and then rearrange appointments or carry out telephone consultations.
11am: Most things are done at this point. I then see if any emergency cases are taking place in theatre, or if one of the bosses has a cancer case that I can attend in the morning or afternoon. 

How has the pandemic impacted your work-life balance, for better or worse?
Things that have changed for the better are that my travelling to work time is now greatly reduced. I have enjoyed the free or discounted meals and valued the appreciation of NHS staff from the public. There has been time to watch and learn from webinars during work hours, and more time to spend and chat to work colleagues rather than having to rush around all day.

Things that have changed for the worse are the worry that I may be getting de-skilled. Additionally, the time for my fellowship is limited, and this pandemic has, consequently, greatly eaten into my training time. Wearing PPE can be cumbersome, and the pandemic has naturally heightened personal welfare concerns at work. When things are quiet, boredom can be an issue.

What are your top three concerns looking ahead at the next two months?

1. The lack of operating time.
2. Personal and family welfare concerns.
3. The current lack of jobs being advertised, so not knowing what will happen after my fellowship. 

Please describe your ‘best lesson learnt’ during this pandemic.
I think one of the better things to have emerged from this pandemic is a recognition that healthcare workers are valuable and important members of society. I still recall the Jeremy Hunt days, when doctors were alienated by the government, and pictured as selfish money grabbers who didn't care. It is good that this picture has been rectified somewhat.

Please list the top three things you miss at work from the pre-pandemic era.

1. Operating on noses.
2. Operating on noses.
3. Operating on noses.

NHSdoctor957

 

 

 

14th May 

Antibody testing 

While COVID continues to wax and wane around the globe, most of us have reluctantly begun to accept that it is here to stay for much longer than originally thought. Today’s news that Public Health England has approved an antibody test produced by Roche is most welcome, although it is not yet clear how soon or easily it will be able to be accessed more widely.   

Antibody testing performed from approximately 14 days after infection aims to identify whether an immune response involving antibodies to the infection has been mounted. Of course no test is 100% specific and 100% sensitive, and so false negative and false positive results will occur. Even if the antibody test identifies antibodies related to previous CV19 infection, there is, of course, no guarantee that the individual is immune to re-infection. It also continues to be unclear how long the antibodies remain present, that is whether potential immunity to CV19 is transient or longer lived. 

While we all wait for antibody testing to become more readily available, members of staff working in the trust I work in have been invited to take part in a study aiming to investigate the immune response of people who have recovered from CV19 infection. Any member of staff who has had to self-isolate, due to having become symptomatic with CV19 infection or a family member having been ill with CV19, is eligible to participate in this study. The aim is to gather information from at least 1000 staff members, test them for antibodies in their blood and saliva, and then follow them up for six months to see if they become ill again. 

I enrolled in this study this morning and dutifully had several blood samples taken, before collecting my saliva into a small pot for four minutes. Spitting into a narrow tube is harder than one might think! My self-isolation for CV19 symptoms took place before our trust rolled out its antigen testing protocol, so this will be the first opportunity for me to confirm whether or not my illness was secondary to CV19 infection. The results will take at least a week - here's to them being true positives! 

NHSdoctor957

 

 

11th May

Mini interviews

Over the next weeks I will be conducting short interviews with ENT colleagues around the country.  So many changes have taken place within our specialty, let alone the NHS, since this pandemic started, and I am intrigued to learn what working in ENT during this era now looks like for my colleagues elsewhere. My friend, Hala, is kindly starting us off.

NHSdoctor957

 

Mini interview: Ms Hala Kanona, The Royal National ENT Hospital, London

What was your NHS role prior to the CV19 pandemic? 

I was working as a post-CCT SpR in an otology, implant and lateral skull base job. 
 
How has your NHS role changed since the CV19 pandemic? 
Although my job title has not changed, like many trainees, I am now part of a rolling on-call shift pattern that covers ENT at the hospital. Since many of our SHOs have been redeployed, some of my shifts are resident, which has reminded me to appreciate the hard work that the SHOs put in to keep the system running.  
 
Please describe a snapshot of a typical shift you might be on this week.
On a 12-hour resident day shift, I start the day getting handover from the night SpR and begin the ward round at 8am. I then join a 9am virtual handover meeting with the on-call consultants and two remaining on-call SpRs that cover the other hospital sites. Once this is finished, I see patients in A+E or perform ward reviews, many of which have been tracheostomy patients following the increase in tracheostomies over the recent weeks.   
 
How has the pandemic impacted your work-life balance, for better or worse?
My husband works as an SpR in ITU and it is not uncommon that our shift patterns tend not to overlap. When we are together, in the context of the lockdown, there have been fewer distractions compared with normal life, which has enabled us to spend some quality time together. When alone I rather geekily spend my time finishing off projects and papers, whilst trying my best to keep abreast with all the news and publications around COVID. I also spend my newfound time painting whilst listening to classical music and smooth FM. More recently I have begun to feel saturated with the monotony of life and welcome the arrival of a newfound focus in recovering elective services.

What are your top three concerns looking ahead at the next two months? 

1. The uncertainty of how our service and specialty will transform, and how this may impact upon my future and that of my colleagues.
2. The likelihood of a second surge, and how it may stall any progress made in recovering elective services e.g. if SHOs get redeployed again and emergency cover dominates day-to-day activity.
3. How long it will take before I can see my family again.

Please describe your ‘best lesson learnt’ during this pandemic. 
How much one’s creativity is stunted when life is so busy, and how much money and waste can be accumulated in the pursuit of work and/or entertainment. 
 
Please list the top three things you miss at work from the pre-pandemic era. 

1. Operating
2. Operating
3. ….and operating!

 

 

5th May

Tracheostomies and subjunctives

I have had a somewhat surreal 24 hours filled with tracheostomy issues and the German subjunctive.

Since yesterday, I have been back on night shifts. Whilst arriving at the hospital for the start of my shift last night, I had an urgent call asking me to attend a COVID-positive patient who had recently been discharged from the intensive care unit (ICU) with a tracheostomy in situ. There was no time for the usual team handover. Instead, I started donning the PPE I carry in my bag ‘just in case’ whilst in the lift on my way up to the ward. Fortunately, the tracheostomy issue was sorted out swiftly. However, an interesting conversation ensued with the respiratory consultant in charge of the ward this patient was on. Said ward is one of our current ICU step-down wards for COVID-positive tracheostomy (trache) patients. As the ferocity of the wave of COVID-positive patients presenting to the emergency department, needing admission to hospital, and requiring ventilation on ICU eases, we are seeing an interesting tracheostomy-related secondary wave in its wake.

Original recommendations for COVID-positive patients requiring ventilation were to hold off tracheostomy insertion during the first 10-14 days of ventilation. However, these guidelines were quickly abandoned when evidence emerged that early tracheostomy insertion at around seven days might significantly improve overall patient outcome. Thus, most of the COVID-positive patients being discharged from our ICU now have tracheostomies in situ. Interestingly, these trache patients are typically much less well compared to the trache patients we would normally have received back from ICU to a ward prior to the COVID19 era. This is partly explained by early patient discharges from ICU in order to maintain intensive care capacity, and partly by the delirium which typically accompanies severe COVID19 infection. In ENT we have been anticipating this secondary wave of COVID-positive ward-based trache patients, so its arrival is no surprise. In the last seven days we have received enough trache-related urgent and emergency calls to recognise a need to step up the ENT presence in the hospital. Consequently, our ENT middle grades will now need to remain resident on call until this COVID-related trache-wave abates. Flexibility continues to be the motto.

Meanwhile, home education in the past 24 hours has seen me challenged by the German subjunctive. Having grown up in Germany and been raised bilingual, I decided to bring up my own children speaking German, too. One of my children is currently working on his German A-level; very sensible. When lockdown first began, I decided to offer to help with regard to this German A-level. Although repeated gently a few times, the offer has essentially lain fallow until yesterday. Quite unexpectedly, I was asked to help with German schoolwork, but my joy soon dissipated when I discovered I was going to have to explain the subjunctive. Anyone who has ever studied German grammar will agree that the two forms of subjunctive found in the German language are nothing less than beasts. The German subjunctive is not a grammatical tense, but a ‘mood’. One definition of its use is ‘to express unreal situations’. Flipping from the German subjunctive to tracheostomies during one 24-hour period certainly felt unreal, if not surreal, yesterday. I guess at least I am not teaching tracheostomies during home ed. Now that would be surreal.

NHSdoctor957

 

 

30th April 2020

Behind the mask

Yesterday turned out to be my busiest day yet, wearing the personal protective equipment (PPE) required to perform aerosol generating procedures (AGPs). In a COVID19-infected patient, an AGP potentially exposes anyone in close proximity to high viral loads, thus putting them at increased risk of infection. Consequently, higher-level PPE is required for AGPs compared to any procedure that is not aerosol-generating. PPE requirements for AGPs include an FFP3 mask, which offers protection against liquid and solid aerosols, and forms a snug fit against the skin of the face. Additionally, a full-length isolation gown, disposable gloves and a face shield, visor or goggles are required. Disposable head covers, such as the ones we wear whilst operating in theatre, are optional.

In ENT, even outside theatre, procedures form an integral part of our patient assessment. Almost all of these procedures are classed as AGPs. This explains the early evidence from China regarding ENT surgeons being amongst the highest at-risk group of healthcare professionals for falling ill with COVID19.

When performing AGPs, in addition to the recommended gear, I choose to wear a head band to keep straggling long hair out of my face, a disposable head cover, goggles and a face shield. Call me paranoid, but my half-German heritage and health-conscious father have rendered me thorough and careful in matters such as we currently face. Even though most of us have seen healthcare workers fully clad in PPE on TV, it is hard to imagine what the kit actually feels like, until you are wearing it whilst trying to do your normal day-to-day job.

During recent weeks, I have needed to don PPE intermittently on most of my shifts, but, fortunately, never for any great length of time. Yesterday looked somewhat different. It was a busy on-call that included a patient with a neck laceration, a case of severe epistaxis and a patient with a brewing neck abscess. Additionally, we had a run of tricky inpatients to deal with, starting with a dislodged tracheostomy tube in a delirious COVID19-positive patient, and ending with an impossibly difficult-to-place nasogastric tube in another COVID19 positive patient with pneumonia. The list kept growing as the day progressed. At some point I lost track of how many times I had donned and doffed my PPE. Whilst encased in all those layers of fabric and plastic, I felt swelteringly hot, found it hard to communicate, and had to battle against my visor or goggles fogging up. This was no easy task, as the nose part of the mask fits so tightly that it prevents me from breathing through my nose, rendering me a mouth breather. At several points I wondered if I would manage to complete whatever task I needed to perform without ripping off the PPE beforehand. I am pleased to say, I toughed it out and finished all my jobs. By the end of the shift, however, I had worn FFP3 masks for so long that the bridge of my nose had become sore, and I began to feel somewhat sorry for myself. Call me a wimp.

To say performing complex tasks whilst wearing PPE suitable for AGPs is challenging is a complete understatement. I am developing a newfound antipathy to donning AGP-level PPE. The novelty has definitely worn off. Nevertheless, I am determined to soldier on. After all, if Captain Tom can raise £30,000,000 for the NHS, I definitely do not want to be the one letting the side down. Happy birthday Captain Tom! And thanks for inspiring us all to keep going.

NHSdoctor957

 

 

27th April 2020 

Back at the ranch

Thursday nights at 8pm you will find me clapping for my home team: it is my husband and four children who are keeping the show on the road at home, while I go to work. I briefly mentioned work-life balance here last week, and feel the need to set the record straight a little. It is my family who are creatively, wonderfully and patiently adding the ‘life’ part into my work-life balance - I am enormously grateful. Here is a small snapshot of what has gone on back at the ranch in recent weeks 

During the last week of March, i.e. the first week of lockdown, we moved house. The date for completion of our house purchase had been planned a long time in advance, way before COVID19 had arrived in the UK. We had 10 friends lined up to help with the move, and had imagined an intense but fun 48 hours of work, surrounded by people we love. When move day arrived, reality looked somewhat different: ironically, the government advised against house purchases on exactly that day, and social isolation precluded us from receiving help from anyone. In a pretty heroic act, my husband, our two eldest children and a van ended up taking care of the entire move. It took several days, and we still have plenty of boxes to unpack, but we are all glad to have arrived! 

Meanwhile another absolute treat at home has been that there is always company around for anyone wanting or needing it. We have played board games, baked cakes, paddled in the paddling pool and watched silly programmes on TV. While I have been at work, my husband and eldest daughter have also developed a cooking, DIY and home schooling rota, whilst three of the children do a weekly bathroom-cleaning round, my eldest son mows the lawn, and one child has started to teach the other how to play the piano. I have ended up in bed poorly with (likely) COVID19 and needed to be in strict isolation for seven days, as one of our children is in a more vulnerable health category. During my recovery, my family delivered meals, cups of tea and even wonderful reading material to my door. Wifi had yet to be installed in our new home, and without all my books fully unpacked, my 17-year-old kindly turned his own collection into a lending library for me as I recuperated. What joy to discover we share a love for good fantasy novels! 

I honestly have no idea how I would be managing without my husband and children during this time of quarantine. Sure, life might be a little quieter, and food supplies would last a lot longer. It would also be much less fun. That is why, Thursday nights at 8pm you will find me clapping for my home team until this dreadful pandemic is well and truly over. 

NHSdoctor957

 

 

24th April 2020 

Work-life balance 

While the debates around adequate supplies of personal protective equipment (PPE), optimum mechanisms for the test-track-trace strategy, and clearer details regarding exiting the lockdown period continue nationally, a drive for optimised hospital productivity persists locally, requiring high degrees of flexibility. Currently, we are starting to consider how our department might re-introduce some level of normal working practices over the coming weeks, whilst factoring in the impact COVID19 will continue to have. A mountain of work awaits us. 

Away from work, life continues relentlessly for us all. For some of my colleagues this has meant juggling two medical careers - several are married to anaesthetists who are now rostered into exhausting ITU shifts. Despite school provisions for families containing two key workers, of course no school day matches the 12-hour shifts most doctors are now working. Impressive, acrobatic shift-swapping acts have taken place to ensure home life can go on safely. Not an easy task, on top of the underlying, no doubt gnawing worry regarding a medic-partner’s health due to the regular exposure to COVID19, despite adequate PPE. Some of these double-doctor families have been re-writing their wills in preparation for a worst-case scenario. Sobering times. 

Meanwhile other doctors live on their own. Due to the way our rota works, we no longer regularly overlap with colleagues we might normally see quite frequently. It has taken me until this week to notice that some colleagues have been coming into work on their days off to beaver away at lengthy research projects in a quiet corner away from the rest of the hospital hustle and bustle. These are naturally hard-working doctors, but I now realise there might be a significant degree of loneliness going on behind the scenes. Short of buying buns to share at a distance over chats during breaks, I am finding it hard to know how to help. 

Achieving some sort of work-life balance is often tricky for doctors but has now become a challenge for most adults in our country. For me, our current, longer shift patterns mean I rack up weekly working hours faster. Although I now work significantly more weekends than normal, I also have more days off in between. Suddenly, and quite unexpectedly, I find myself with an improved work-life balance: I have more time to help with home schooling, cooking, gardening and other home chores. My 19-year-old commented the other day that - pandemic or no pandemic - I no longer have hobbies, I have kids. There is nothing quite like a child reminding you of the realities of your life, even if you might not fully agree. Either way, it looks like it may be time for me to redevelop some hobbies…     

NHSdoctor957

 

 

21st April 2020 

Resilience and open-mindedness 

My attempted blog entry for yesterday was hijacked by a long and busy shift at work. Suddenly there was nothing left of my day or evening. I had wanted to write about the psychological impact of quarantine and how, reportedly, having three or more children proves beneficial in reducing the psychologically detrimental impact periods of isolation can have on an individual. I have four children! Unbeknownst to them (and me), it turns out they have been giving me the resilience edge - psychologically speaking - during this lockdown. However, and perhaps for the best, I did not get very far with turning my smugness into a readable blog entry… 

Instead, my shift found me working alongside our clinical lead (CL), a much respected, fun, highly skilled surgeon with seemingly boundless energy and an open-minded, inclusive, yet determined approach to leading our team. Our dialogue focused on the new format we have for urgent clinics, also known as ‘hot clinics’. Before I knew it, a simple chat grew to multiple conversations also involving other staff members, and then turned into a revamping of our hot clinic service. Let me tell you, this CL knows how to work his people! We now have a wonderfully streamlined approach for any urgent ENT reviews required during the COVID pandemic:  

ENT hot clinics continue to take place in our normal clinic rooms. We have 11 in total, all on the same corridor, with five rooms equipped with couches, microscopes and suction apparatus. Our hot clinic service will use five clinic rooms as follows:  

• Room 1 is for the initial assessment of COVID-negative patients; no aerosol-generating procedures (AGPs) are performed in this room; 
• Room 2 is for donning personal protective equipment (PPE); 
• Room 3 is for COVID-negative patients requiring AGPs; 
• Room 4 is for suspected or known COVID-positive patients; AGPs can be performed here if required; 
• Room 5 is for doffing PPE. 


We will perform an early audit to assess the effectiveness, efficiency and overall use of these clinic rooms in an attempt to further refine our approach to seeing urgent patients while the pandemic continues. As with everything at the moment, a good sprinkling of flexibility and open-mindedness is required to achieve the best possible outcomes for our patients and colleagues alike. Some may argue that this may precipitate uncertainty which, during a national pandemic necessitating lockdown measures, may have psychologically detrimental effects on individuals. I wonder whether having a large family helps here too…? 

NHSdoctor957 

 

 

17th April 2020 

One month on… 

It has been exactly one month since I had my last day of ‘normal’ clinical activities. Since then I have had no routine clinics or elective operating lists. Instead, I have learnt when and how to use different types of protective equipment, and have started to get my head around some of the regularly-updated management guidelines. I do this on a needs-must basis: there are way too many new guidelines to remember all the minutiae after the first read-through, so now, when an issue arises, I go back to the relevant guideline to consider an appropriate approach.  

I have begun to work an emergency rota shift pattern, consisting of two teams: a dedicated tracheostomy team, and an ‘on call’ team covering all other emergencies. I am on the latter. Thankfully, our rota has an inbuilt contingency plan: one person per grade is always on ‘back-up’, available to fill gaps left by colleagues needing to self-isolate. If no back-up is required, those team members are then available for redeployment around the hospital. Other specialties have members of staff on ongoing redeployment, some available for the local Nightingale Hospital. Our team is too small for this to be feasible. 

Our ENT ward has been cleared of patients in order for it to become a step-down COVID-ward for patients that are discharged from intensive care. In view of the lag period between patients entering intensive care and being discharged from there, our ward has remained uncharacteristically empty. Other ENT inpatients are on a separate ward and discharged as early as safely possible. Face-to-face handovers now happen with the minimum number of colleagues present, the rest is done via phone calls or messaging. Emergency clinics are more richly staffed than normal: one SHO, one middle grade and one consultant are available for 12 hours during the day to see urgent ENT cases, in an attempt to lighten our emergency department’s workload. 

Daily, the trust emails us outlining any salient COVID19-related issues relevant to all members of staff. Separately, I also receive some of the summaries of the daily briefings for medical staff. For medics and allied front line healthcare workers, bank holidays have been scrapped and turned into normal, working weekdays for the foreseeable future. Additionally, usual junior doctor contract restrictions regarding hours worked have been set aside now that everyone’s rota contains far too many weekends to allow compliance. Appraisals and revalidation procedures have been postponed.  

An astounding amount of changes have taken place in my workplace in the past month. In a system that normally contains rather a lot of red tape, it has been almost refreshing to see how easily things can be revamped when required. Of course, we all wish the circumstances were different. Nevertheless, I am hopeful that there may yet be a few positive things we will be able to extract from this extraordinary time.  

NHSdoctor957

 

 

14th April 2020

Reinforcements

For the last nine months, I have taken on a teaching role within the trust I work in. I have been assigned four groups of fifth year medical students; three students per group. The task has been to provide weekly tutorials to supplement their 15-week module on ‘Managing the acutely ill patient’. Of course, none of us had any idea of quite how soon this part of the syllabus would become so incredibly pertinent.

Today ‘my’ 12 medical students, alongside a battalion of peers, will enter the NHS medical workforce. An initial three-week assistantship will quickly turn into an internship until their foundation posts start, as planned, in August. A quick written survey of my group has highlighted the following:

1. Almost all had made fun plans involving friends or family, and travel, for the last summer holiday before starting working life.
2. There is a real sadness that their university years have ended in this rather anticlimactic manner, with social distancing measures precluding any sense of, let alone opportunity for, celebration.
3. Some know where their assistantship placements will be and what they involve (for example, allocation to a ward to fulfil roles of “scribing, clerking and doing jobs, much like an FY1”), but others are still eagerly awaiting any information regarding location, let alone the roles they will be expected to fulfil.
4. Main concerns about starting work today include: “encountering something extremely traumatising”, “feeling unsupported”, “not knowing how to help”, “being judged the year group that got a free pass through finals”, “access to the correct PPE”, “will I be taken seriously”, and “will I cope with this premature transition from medical student to doctor?”
5. Using three words to describe their feelings regarding starting work today, during a pandemic, included sentiments of feeling “nervous”, “underprepared”, “surreal”, “daunted”, but also “eager”, “ready” and “privileged”.

Entering the world of fully-fledged medical professionals from student-hood has always been scary business. Insight into one’s own lack of expertise coupled with an overwhelming sense of responsibility for patients’ health and, ultimately, their lives, leaves most freshly qualified doctors with a feeling of imposter syndrome. As the years go by, expertise may increase, but not the wonder at how much there is still to be learnt. What changes is a growing realisation that we are all in the same boat - all of us are good at something, irrespective of years since qualification, we are just not all good at the same things, and certainly, no one is good at everything. At this time more than ever, those already in the medical workforce recognise how much we value colleagues whose brains we can pick when we are met with the unfamiliar. My group of fifth-year medical students, who as of today are my colleagues, will benefit from the same reciprocal privilege: to be able to ask for and provide help when it is needed.

I have no ounce of doubt that my group of new colleagues will rise to the challenge of this early entry into the workforce, bringing with them the same attributes I have observed over the last nine months: enthusiasm for the new, an eagerness to learn, bright minds that relish a challenge, a professional work ethic, insight into their own limitations, a team-working spirit, an ability to encourage others, and, perhaps most importantly, a great old sense of humour.

Those of us already in the medical ranks are delighted and immensely grateful to be prematurely joined by battalions of freshly qualified, keen and competent new colleagues around the country. In my opinion, medical graduates of the year 2020 will not be remembered as the year that got a “free pass through finals”. Instead, they will be known as the colleagues who set aside well-earned personal plans for celebration, travel and fun, to join the NHS early, in order to provide medical reinforcement during an unprecedented national health crisis. I say: Welcome!

NHSdoctor957

 

 

9th April 2020 

Behind the scenes 

Headline news this week has been that Boris Johnson has spent several days on ITU for close monitoring of his COVID19 symptoms. 

Meanwhile, behind the scenes, it turns out there is a small army of hardworking Design & Technology (DT) teachers and less-than-amateur DIY-enthusiasts who have been beavering away, quietly making face visors for front line NHS workers. Quite by chance, I stumbled on an internet forum of such a group of crafters a few days ago. They had some questions for medics who might be using the visors, so I joined the forum to help answer what I could.  

Entering a forum like this as a doctor is not as straightforward as one might think. I had to provide credentials to prove I was not a random charlatan wanting to meddle in the serious business they are undertaking to provide more resources for the NHS and keep those on the front line safe. Fair play to them! However, once accepted as the real-deal, I quickly found myself in the wonderful position of receiving extra visors for the ENT team I work with, as well as those around us. The first delivery arrived a few days ago alongside a small basket of fresh eggs - having just returned from another night shift and failed to find eggs in the local supermarket, it was hard to decide which sight made me happier! 
Meanwhile, my colleagues at work are delighted at the prospect of sufficient and, importantly, colourful new visors. Currently pink headbands appear to be trending. In stressful times, it seems, the small things still matter and cheer, perhaps, beyond expectation. The battle against COVID19 is not one fought with the usual weapons of warfare. Instead it is a battle characterised by care. The solidarity and care demonstrated by those working behind the scenes, such as these generous and hardworking DT teachers and DIY-ers, towards those on the front line continues to be humbling and encouraging beyond words.  

NHSdoctor957

 

 

6th April 2020  

Doctors and patients 

As of last week, our whole department has been working according to a new emergency rota - pretty much 12.5 hours on for three to five days (or nights) in a row, then several days off. My turn was to start with night shifts at the end of last week. In ENT, the corona-wave is now palpably close. Most patients I dealt with during my shifts were COVID19 positive, diagnosed either directly from symptomatology or indirectly via, for example, incidental scan findings.  

The guidelines I mentioned last week have started to become more applicable. Somewhat surprisingly, my discovery this weekend has been that previously straightforward to manage ENT conditions have become a little more challenging to deal with. Take, for example, the case of tonsillitis we managed in a 20-something-year-old patient this weekend. The new guidelines suggest swift treatment, aiming for discharge within hours of hospital attendance, where at all possible. This makes sense - who would want to be admitted for any length of time to an increasingly COVID19 populated hospital? In order to be able to send a tonsillitis patient home again, they need to be able to drink fluid and swallow their medication. To achieve this, we would normally give a cocktail of antibiotics, analgesia, steroids and rehydration. In COVID19 patients, however, prescription of steroids and non-steroidal analgesics requires considered caution.  

The patient we were treating had classic findings of tonsillitis, which included a raised temperature and deranged inflammatory markers. Confusingly, these signs overlap with those seen in a COVID19 presentation. This is where the dilemma begins. Suddenly, a simple case of tonsillitis requires careful thought - can I prescribe ibuprofen, or do I go straight to an opiate analgesic if paracetamol has been insufficient? Elsewhere, deaths have been reported following young COVID19 sufferers having taken ibuprofen. Can I prescribe dexamethasone, or will this worsen the subsequent course of illness if my patient develops more serious COVID19 symptoms further down the line, as has been reported with some corticosteroids? You can see the new issues we are facing in ENT. At five in the morning, this made for interesting thought processes. 

In the end, I decided to opt for what comes fairly naturally to surgeons - a frank discussion of the aims of treatment, including the options available, with an explanation of risks versus benefits, acknowledging the lack of sufficient, conclusive evidence to allow easy decision-making. Most patients value honesty, even if it precludes clarity. My tonsillitis patient was no different. In the end, simple topical and systemic analgesia, with some advice did the trick and enabled an early discharge. In the COVID19 era the content of our discussions may have to change, but not the underlying nature of the doctor-patient relationship. This will always remain a thing of deep beauty. 

NHSdoctor957

 

 

2nd April 2020

The show must go on

563 deaths from COVID19 in England in the last 24 hours. Two weeks ago we started noting the number of deaths per 24 hours on our wall calendar at home. Initial single figures that rapidly jumped to ever higher numbers have been telling their own story - similar, albeit delayed, to the one unfolding in Italy. If I were an epidemiologist, mathematician or even microbiologist, I might find this evolving pandemic fascinating. From the vantage point of ENT, however, the tale feels too real and too macabre. Tragically, this week the first ENT surgeon in England died after being infected with COVID19. A devastating loss for the family, and one that also leaves a large hole for our profession.

Over the last few weeks, fresh guidelines and newly reported evidence relating to COVID19 have been hitting my inbox relentlessly. The frequency is at times overwhelming, and occasionally mind-numbing. In parallel, there is an ongoing discussion between my direct colleagues on social media regarding COVID19 issues. Keeping abreast the ever-changing suggestions of how best to protect oneself, team members, and patients, let alone the own family, on top of work commitments and home responsibilities, has been time consuming and, at times, absolutely exhausting.

Of course we are all grateful for the rapid and candid information provided. However, the evidence is not for the faint-hearted: ENT surgeons comprise one of the most at risk groups of medics in terms of COVID19 infection; infection, and severity thereof, are directly proportional to viral load; many ENT procedures (let alone operations) are classed as ‘aerosol-generating’ (for example flexible nasoendoscopy, aural microsuction, and even examination of the oral cavity), which, in an infected patient, can expose the ENT surgeon to very high viral loads; where possible aerosol-generating procedures should be avoided. The list of findings and recommendations goes on. My personal conclusion is that as the pandemic spreads, and until universal testing of patients and staff is freely available, all patients presenting to ENT should be considered COVID19 positive. In order to maintain as intact a workforce for as long as possible, the most obvious solution would be to use full PPE, including eye protection and FFP3 masks for any and every patient dealt with by ENT surgeons. However, and for whatever reason you might like to suggest, this is not (yet) the official recommendation. Until it is, I will need to continue seeing ENT patients as per the guidelines. In some instances, I will just have to live with the cognitive (and emotional) dissonance this creates for me, as, after all, the show must go on.

NHSdoctor957

 

30th March 2020 

A word about face masks 

In the end, the session I attended last week on donning and doffing PPE kit was a rather mixed experience. Contrary to what I had imagined, there was no chance to practise, only a demonstration of how to put the protective gear on and remove it again (think emergency oxygen and life jacket demo on airline flights). Is this because the hospital is having to ration PPE kit, saving it for the ‘real deal’, rather than wasting it during practice-runs? No explanation was given. Added to the press reports discussing a national shortage of PPE gear, you begin to understand how healthcare workers’ confidence in their workplaces providing adequate protective equipment begins to erode. How much this affects each individual is, ultimately, down to personal levels of paranoia, hyperchondriasis, and risk-taking behaviour. 

Of course, the approach of “demonstration only, no practice allowed” in itself is rather questionable - no amount of kit will adequately protect if not donned correctly. To mitigate this, there should be a ‘Donning Officer’ to hand, checking everyone is clothed correctly before they embark on treating COVID19-infected patients. Very reassuring while not many wards in the hospital are segregated as COVID19 wards. However, as the pandemic spreads across our country, bit by bit all wards will fill with infected patients. At that point, will there be enough ‘Donning Officers’ to check our donning and doffing practices? And so we return to the question of health versus infection, life versus potential death. A recurring theme. 

If this is all sounding rather negative, then let me reassure you, there was a silver lining to the donning and doffing session I attended: quite by chance, I discovered the hospital had switched to a different type of FFP3 mask since I had originally been fit-tested. The outcome?  I needed to be fit-tested once more. Again, I hunted down the fit-testers, and got re-tested with the new mask. Again, to my great delight, my face is boringly standard and I fit the FFP3 mask we will now be using.  

While I may feel sorted (albeit temporarily), this is not the case for many of my colleagues around the country. Down in the South West, a junior doctor friend working in one of the larger hospitals has found they are running low on FFP2 masks, despite all non-emergency surgery having stopped. I dare not ask what their situation regarding FFP3 masks is. Closer to home, a GP friend reported their surgery had 100 FFP2 masks for the whole team. Once those run out, they are planning on somehow converting disposable nappies into masks. In times like these, we are grateful for those amongst us who, with extraordinary creativity, go to great lengths in finding solutions for those around them. Inspiring? Definitely. Reassuring? Almost.

NHSdoctor957

 

25th March 2020

On doffing and donning…

Just over 10 days ago I found myself doing a normal day of double clinics. The virus had made itself known in the UK by infecting some and killing few. It seemed remote, but more real. When I was informed by junior colleagues that fit-testing for FFP3 masks was happening in the hospital, I decided to briefly abandon my clinic room (things were quiet), in search of the location where fit-testing was taking place. I went on the equivalent of an adult treasure hunt around the massive hospital I work in but was glad to ultimately find the ‘fit-testers’. Luckily for me, the queue was short (in hindsight perhaps a reflection of how distant the viral threat still appeared).

I had no idea what mask fit-testing entailed - roughly 10 minutes of breathing through the mask whilst performing different daily movements. During all this, the mask is attached to a machine via a tube to detect air leakage resulting from the mask not adequately touching the skin around its perimeter. The further you progress through the test the better, as it means the mask-to-skin seal is still adequate. The verdict? My face fits a standard FFP3 mask. This is possibly one of the few times in life to be overjoyed to have a boringly ‘standard’ face.

Today I am about to have a practical session on ‘donning and doffing’ PPE kit. I am prepared, having watched the videos sent to me earlier this week. Nevertheless, I am keen to practise - how efficiently I put on my protective gear could, after all, mean the difference between infection and health, between life or potential death. This is scary business.

Knowing how competitive (and at times black-humoured) medics, particularly surgeons, can be, donning and doffing might just be turned into a competition… I can imagine measurable parameters such as donning-speed, number of movements used, best body coverage and most appropriate fit. No doubt you will think of more. At times like these, there has to be some hilarity found in an otherwise dreadful situation. I will keep you posted as to how I fare.
Efficient donning and doffing of PPE gear, naturally, also throws up ethical considerations. For example, should only those best able to don and doff PPE kit be asked to look after COVID19 patients? Perhaps we will leave that question to some deep-thinking, wise philosophers.

In the meantime, COVID19 has sparked other donning and doffing in my life. Today, for the first time since getting married, I will remove my wedding ring before entering the hospital - COVID19 can last for up to 48 hours on steel, and while my wedding ring is not made of steel, I will need to assume similar properties. I have also doffed my usual leather phone case, and donned a clear plastic one that surrounds the entire phone to make it easily cleanable on leaving the hospital. I have started donning a face mask as well as a wide hair band for my daily commutes to work by train. The list will, no doubt, continue, all in an attempt to protect against a microbe whose true virulence is yet to be seen.

NHSdoctor957

 

20th March 2020

Two weeks ago today, I was attending the British Cochlear Implant Group meeting in Nottingham alongside many other British ENT and audiology colleagues. We enjoyed excellent keynote lectures, were brought up to date with some of the latest research in cochlear implantation, and were captivated by Dr Oakley’s fascinating overview of the UK government’s medium term strategy regarding science, and incorporating healthcare. Wine flowed freely over dinner in the evening, punctuated by Prof O’Donoghue’s fantastic after-dinner speech, and followed by dancing into the wee hours.  

Since then, the world has changed. COVID19 has gone from being a distant observation to becoming a palpable reality. Many of us now personally know (or know of) someone infected with the virus. Plenty of friends and colleagues are in self-isolation, and all of us are practising social distancing.  

Life suddenly looks different. Rapid changes will continue over the next days and weeks. 

This account, then, is a glimpse into one frontline worker’s story - NHSdoctor957, my story. It represents a mere fragment of the whole picture of individual jigsaw pieces put together to form one mega-puzzle. I shall not claim that my observations, thoughts and feelings are representative of all. However, they may provide an idea of some of what is occurring at (and away from) the NHS frontline today.   

About a week ago I heard an interview with patient74, Israel’s 74th patient to have been found COVID19 positive. It may seem odd, even de-personalising, to refer to an individual as a number. NHSdoctor957, nevertheless, somehow seemed appropriate - I am but one of a whole army of British doctors serving within the NHS. We are on a joint mission alongside our superb healthcare colleagues to prevent further spread of COVID19, and to treat those already suffering the consequences of infection to the absolute best of our abilities. None of us feel like heroes. Most of us feel scared. None of us understand what lies ahead, and at times our imagination runs wild. Join me on this journey and let’s see how it unfolds together. 

For now, I am off for a run to take my seven-year-old son for his ‘once a day outdoor exercise’.

NHSdoctor957