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Inside a COVID-19 ward: My Experience at the Nightingale Hospital

I work as a digital GP for Babylon Health. As the COVID-19 pandemic spread to the UK, I was in the position of being able to help with the NHS response as a healthcare professional. Part of this response was to build a field hospital for critical care patients, in case the hospitals reached their capacity. With the support of the Babylon team, I put myself forward to work at the Nightingale Hospital in the ExCel Conference Centre, London."My time at the Nightingale Hospital only lasted a few weeks but I saw and learnt so many lessons about healthcare, humanity, compassion, and life in general that I will undoubtedly carry with me forever.

On April 13th 2020 I walked onto Bedford B ward for the first time*. It was overwhelming the first time I walked in. The enormity of it was astounding; it engulfed me. I walked past multiple long wards to get to the one that was fully functioning and saw numerous anonymous people behind masks and gowns, diligently working by patients’ bedsides, with many machines dispersed in between. There was so much going on but no commotion. It felt calm, collected, and that everyone had been working here for a long time.

My role as a ward doctor consisted of stepping back into hospital medicine as a junior in the Intensive Care Unit (ICU). Having only left hospital medicine two years previously, it didn’t feel that far removed from what I know, however I had not had much ICU experience during that time. The ethos at the Nightingale was to instil a ‘flat hierarchy’ where there would be no significant division of roles. The staff at this field hospital would be coming from all different backgrounds, and undoubtedly be experts in their fields. Before arriving at the Nightingale I undertook many hours of reading, e-learning and discussions with my experienced friends who were kind enough to offer their time to teach me, and I felt well versed in the theory. This, however, doesn’t prepare you for the reality of stepping foot on an ICU ward, let alone in the unknown of a global pandemic, in a hospital that was a conference centre just three weeks previously.

Within hours of being on Bedford B ward, I knew the roles and backgrounds of many of my colleagues, the situation with some of the patients and how the hospital was functioning. There was a lot to learn, and I would spend whatever time I had to learn from others or take in what was around me. Those that were more experienced within the ICU setting would use their ‘spare’ time to teach you what they could. This was one of the things that I took away from this experience - the generosity of all those that I interacted with. One of the ICU consultants who was phenomenal, would use his very precious free time to impart his knowledge to help you feel more comfortable in this new environment. Not only would he encourage you and lead you as a colleague, he would then tell you that we ‘need people like you’ to help in this current climate. The feeling of camaraderie was there from the beginning. In between these teaching sessions, he would be managing multiple critically unwell patients, making decisions and having conversations with families that would be thinking about for days afterwards.

The first week consisted of many hours on your feet (in extremely uncomfortable mandatory wipe-able shoes), constant questions and reinforcement of learning, a surprising amount of free drinks and chocolate (and Ben and Jerry’s ice-cream), and understanding more about COVID-19. The management of ICU patients is basically learning a whole new language. In GP land we are used to talking about feelings, pets, hobbies, medications, family history etc. In ICU you talk about PEEP, gas exchange, tidal volumes, po2, fio2, RASS scores, FLATCHUG, and Penlon vs. Dragers to name just a few. The list doesn’t stop! The feeling of handing over to another doctor in these acronyms was absolutely terrifying. The first couple of times I did this, I would look for reassurance that I was in fact making sense. It took a few shift changes to get used to it but when you finally got the knack of it, it was a good feeling.

I realised that the feeling of working here would not leave me even when I went home at night. I would constantly hear the machines beeping while I tried to sleep, I could feel the phantom PPE mask on my face, and I would be dreaming about my experiences from that day. I also unfortunately felt physical repercussions on my body from the medical gear and the long shifts. I noticed that my body was aching more, my skin was dry, I had the beginnings of pressure sores on my face from the masks and I was in a constant daze of tiredness. Despite this, I thought that I was handling the night shifts much better than expected – given that it’s been over 2 years since my last! I also was eager to get back on the ward, see how my patients had been overnight and try to do what we could for the day. Every day, you would come in and check on the patients you knew. Your stomach would drop when you saw an empty bed as you didn’t know what this meant. Sometimes this meant that your patient had been successfully extubated (come off the ventilator), and had been moved down to the other end of the ward. The feeling of elation when this happens is hard to describe. I remember the first time this happened to one of the patients I was looking after. I went to try and speak with him. This didn’t go very well as he didn’t really speak English, but to see him alert, talking, breathing by himself was just a great feeling.

Of course, this wasn’t the case with all of our patients. There is an overall understanding of how devastating this disease is. You often don’t know which way patients are going to go, but it does come to the point when you know someone isn’t going to improve. The first time I experienced withdrawal of care for a patient on the ward was tough. The most devastating part of it was that the family couldn’t be there by their loved-one’s side. One of my most poignant memories will be of the care that was given to this patient towards the end of her life. Two of the clinical support workers (who would have been of various medical backgrounds from student nurses to optometrists), took it upon themselves to ensure that she was cared for as best as possible at the end of her life. Medically, there was no more that could be done. At this point, she was being kept artificially alive with the help of the ventilator, and as far as we could tell she wasn’t in any distress or pain. She was also heavily sedated, so it was difficult to know whether she was aware of her surroundings. She was religious, so they took out their own phones and placed it in a plastic bag by her ear with readings from the Quran. They washed, combed and braided her hair so that she looked presentable when her family came in to see her later that day. They spoke as quietly as possible so they didn’t disturb her, and took care not to mention anything about dying, just in case she was able to comprehend this.

Each day would bring new surprises, and also new pleasant interactions. I would never have thought that one day I would be having lunch with the medical director of the Nightingale and an ICU consultant. On another occasion, a fellow Nightingale colleague - an ophthalmologist of 20 years who had minimal elective work due to COVID-19 – told me, ‘I didn’t want to sit at home doing the gardening, I even offered to be the cleaner’. A consultant cardiologist, would perform echocardiograms* on patients because he had spare time, and talk us through the whole procedure (something that would rarely happen on a hospital ward). An anaesthetist, who needed to be taught how to use the computer system. A war journalist, who ended up working in the morgue and cleaning patients. Painters and decorators, who volunteered to be porters. Religious figures, who were called in at any time in the day to be by patients’ bedsides as their family could not be.

After a week on the ward, I started to feel more confident and comfortable with what I was doing. The initial adrenaline rush had worn off and there seemed to be some kind of (albeit odd) routine. As I was on the same weekly rolling rota as others, I started to get to know people from all different backgrounds. I continued to learn about ventilators, spending hours just looking at them and trying to understand their settings. Unfortunately, each machine had different acronyms (just to make it even more confusing), and the Nightingale had multiple different machines as they had been sourced from different places. I also started to admit patients and make some management decisions on their arrival. No matter how small these were it was extremely satisfying to have got to the point where I felt confident about doing these tasks within the space of two weeks!

I think in the week of 27th April I started to feel morale drop slightly within the team. There had been some negative news in the media about the hospital, and to be honest for everyone who was putting their heart and soul into the care on the ward, this was devastating. I remember speaking to one of the Clinical Support Workers, who was really upset about this. She had an argument with someone in a supermarket queue, which had obviously had a very negative impact on her and appeared genuinely upset about it. I tried to reassure her that she was doing a good job. Unfortunately, it felt as though we were being drawn into the nasty political-media rigmarole, which was coming at the cost of our emotions, as well as the patients and the relatives that were involved too. From where I was standing, these patients continued to receive outstanding care. I just hoped that the relatives still had confidence in what we were doing. This was difficult to gauge, as we didn’t have direct contact with them. There was a family support and liaison team appointed. They were all medical professionals (doctors and nurses) who would update the families based on our reviews for the day and from speaking to the ward team. In ICU there would be at least four reviews by doctors per day (these are formal reviews but the doctors/nurses would be in close contact with their patients 24/7 and making adjustments to their settings). From what I could see, this team had an extremely difficult job. Even though I have communicated with families throughout my whole career, it had never been in this kind of setting.

The best way to go forward in these situations was unfortunately to paint an extremely bleak picture. The patients had multiple lines/tubes in them, their faces were swollen, and they didn’t look like themselves. There were pictures of them by the bedside which are hardly recognisable to me. It’s hard for a family to understand this unless they see it. And it’s even harder for them to accept it unless they see it. If you start using terms such as ‘stable’ or ‘no change’, this to a family member gives them hope. Over time I realised that even when patients started to show a glimmer of improvement, this could rapidly change in the space of minutes to hours. I saw patients who seemed like they would be extubated one day, who then died the next day. The course was so unpredictable. This was reflected in the fact that over the course of one weekend early on in my time there, we had more deaths than successful extubations, and we began to realise that the longer they were on the ventilators, the harder it would be to get them off.

When it came to the point that we knew the Nightingale was going to close, we still kept going to take care of the patients we already knew and were there. With the uncertainty of where things were heading, I was trying to make the most of the experience. I already felt that Nightingale was part of who I was at the time, and it would help shape me in the future. I wanted to keep going back to learn more, and help more patients. I wanted to use the skills I have already harnessed over the years, and continue to develop. The first time we had an overstaffed shift, I opted to go home so that the newer doctors could get more experience. It felt really unusual. I was in my scrubs, ready to go, and when we didn’t go on to the ward I couldn’t bring myself to leave. It was a very strange attachment and had become my whole life at the time, that I didn’t know what to do. When I eventually had to leave because it was weird that I hadn’t already, I took a few of the free chocolate Easter eggs, went home, had a glass of wine and had my first ten-hour sleep in a while.

On the last day that I was there, the atmosphere remained the same, although there were much fewer of us. We still had extremely sick patients on the ward that we needed to manage to our best capacity. Two patients, whom I had got to know and of whose lives I had learnt a lot, left to be transferred to their local hospitals. They were doing better, and this gave me hope. I said goodbye to them and wished them luck, although they probably had no idea who I was or what I looked like. Towards the end of our shift, we started to reflect and say our goodbyes to each other. We were grateful that this was a sign that the pandemic was slowing down, but we were also emotional to be leaving this post that we never even imagined a few weeks previously. Even though we went to try and help, we didn’t know that it would touch us and give us so much. Following the closing of the Nightingale, we have since had a reflective day about our combined experiences. We all now share a bond that it is hard to explain to anyone else. It felt like going back to see friends that I had known for years but in reality, only worked with for a few weeks. A few weeks, that may even be forgotten in the future by many, but would always remain with us.

If the time came and Nightingale was forced to re-open would I go back? Of course, yes. Some changes would definitely need to be made to the whole process, but given the speed at which we were rostered in, I appreciate that this wasn’t possible at the time. Now that I have learnt what to do and what needs to be improved for next time, I would feel more prepared, but I wouldn’t think twice about it.

*An echocardiogram is a jelly scan of the heart and surrounding blood vessels, like a pregnancy scan.