8 July 2020

The reckoning

A patient’s progress

This is what coronavirus looks like, from early symptoms to ventilation and beyond

By Jonathan Williamson

I’m both an anaesthetist in a London hospital and a photographer. This gives me and my camera a unique view on the coronavirus pandemic – but it is not a straightforward one. The windows for taking photos in hospitals are extremely limited: patient care cannot be interrupted or delayed, and the breaks from my medical work are short and sporadic. There are technical issues, too: hospital lighting is varied and often poor, while the use of a flash can be disruptive and is therefore avoided.

This photo essay shows how a London District General Hospital – my hospital – met the challenge of Covid-19. It also shows the incredible journey of one of our staff members who became our patient. Of course, all photographs were taken when clinically appropriate and safe for both staff and patients. And they were taken with a handheld Nikon Z6, without extra equipment which could increase the risk of contamination.

Raquel, a senior nurse with 20 years’ experience in the NHS, working as a site practitioner, would normally be busy coordinating the hospital’s response to unwell inpatients, allocating resources and liaising with the medical teams. We’d see each other at the night-shift meeting.

But then she caught the coronavirus, and we saw each other in different context. Here, as her condition worsens, she wears a CPAP mask, providing high oxygen levels at a pressure designed to help keep the lungs open and ventilated.

This image demonstrates her stoic attitude and resolve, even when exhausted from the infection and short of breath. We joked about how she was the most stylish patient in the bay, with her embroidered pattern on her top.

The next day, Nurse Raquel’s condition deteriorated further, and the decision was made to intubate and ventilate her on intensive care.

Nurse Raquel’s two friends and colleagues, who are also both Site Practitioners in our hospital, check on their friend during their night shift.

Entering the ICU. Colleagues look on to ensure that PPE is worn correctly – it is all too easy to miss something, so a “buddy system” was set up.

A consultant looks into one of the negative pressure isolation rooms in intensive care, which is being used for intubating Covid-19 cases. Inside, the Anaesthetic Registrar communicates with the outside team using a walkie-talkie wrapped in packaging made from gowns, to prevent contamination.

An anaesthetist communicates through his walkie-talkie wrapped in plastic.

Nurse Raquel is intubated – meaning that a tube is passed through the mouth, the voice box, and into the windpipe at the top of the lungs. A patient’s breathing can then be taken over completely, or supported, with a ventilator.

Here, she is heavily sedated, or in an “induced coma”. Infusions of various agents, all carefully balanced against each other, are used to support her blood pressure and ensure adequate sedation.

Dr Vino, an anaesthetist, checks the breathing tube of a Covid-19 patient before turning them back over from the “prone” position, by which they lie on their front. This procedure requires meticulous planning, due to the risks of disconnecting vital equipment, making it hard to ventilate and support the patient.

At least seven members of staff are required to turn this patient safely – rising up to 12 staff for patients who weigh over 100kg.

Dr Finn emerges from the ICU. He has removed his visor after two hours of turning over patients. A bead of sweat trickles down his temple – a testament to the physical, stressful job work he has had to do.

Nurse Raquel showed improvement after a few weeks in the ICU, so the breathing support was decreased. Her vocal cords were swollen and a tracheotomy was created: a hole in the skin, below the vocal cords, through which a tube can be inserted. This allowed her ventilation to be supported and her sedation significantly decreased, as there is no irritating tube going through her vocal cords to make her reflexively cough.

While her ventilation was supported, Nurse Raquel was unable to speak – and so a pen and paper became her voice. After, she described how she knew what she wanted to say, but how it became muddled on the way out.

In my first few minutes with her, I was unsure we’d be able to communicate. She was writing a response to me, illegible at first, and then it came together: “This is happy, I still live.”

Nurse Raquel laughs as we tell her how, when she was delirious, she was asking about the number of hospital beds that were available – part of her job as a nurse.

Patient diaries are put together, in part, so that patients can discover what happened during any time they were unaware. This is a valuable part of recovery, helping a patient to process a monumental event in their life.

At this moment, Nurse Raquel has no recollection of what happened during her hospital admission – and couldn’t remember me or my colleagues treating her on the ward. This is a very normal phenomenon, although it can be very unnerving for patients.

Nurse Raquel received amazing support and care from her colleagues – and a card!

Now stepped down to the respiratory ward, the ongoing emotional and physical challenge of recovery is shown on Nurse Raquel’s face. No longer requiring support with ventilation, she is only receiving humidified oxygen through her tracheotomy via a special mask.

Specialist Nurse Zoe explains to Nurse Raquel how we are going to change her tracheostomy tube.

The team prepares to switch to a smaller size of tracheostomy tube. It was thought if we decreased the size, the extra air flow around the outside of the tube, up through Nurse Raquel’s vocal cords, would enable her to speak.

The tracheostomy tube and windpipe are suctioned prior to changing the tube. Patients’ breathing muscles are weakened, and therefore coughing up phlegm, something we normally take for granted, can be hard or impossible. “Suctioning”, which removes mucus from the lungs, is a frequent occurrence – and a very important one, as it also helps to prevent the tube from blocking, which can be dangerous and distressing.

The procedure is uncomfortable, irritating her windpipe considerably. The specialist Nurse Practitioner provides support to the patient, whilst holding the new tube in place.

Nurse Raquel holds up her hand and lip-speaks from “one” to “ten”. This is to calm the panic that can easily set in when mucus gets into the tube. With the thumbs-up given, staff continue to secure the new tube in place.

We hear Nurse Raquel’s first clear words in weeks, crackling like an analogue radio message.

Dr Finn, an anaesthetist, is preparing to review a Covid-19 patient on the ward, after just being told he may have to intubate the patient for intensive care. In order to set about his work, he constructs a pair of disposable eye shields, having pressed a mask to his face.

A surgical tracheotomy is underway for another ICU patient. The allocated theatre staff “runner” comes to the end of the corridor to communicate with the team on the outside for equipment.

Now that she’s able to speak, we pause and talk about how she is getting along. Her memory of events is now returning, and we discuss my visits to review her on the ward before intensive care. She’s put on a brave face for everyone for so long, but we reassure her that’s its okay not to be okay.

The tracheotomy was removed yesterday, and we are able to have a long discussion about Nurse Raquel’s journey – and how it has changed her outlook on life.

She is, of course, eager to get home to her 17-year-old daughter who is sitting her A Levels. But she is also eager for other things. She wants a holiday in the Phillipines. And she is going to learn to ride a bike, starting by borrowing her daughter’s.

Beyond that, having worked for 20 years at the hospital, Nurse Raquel is looking forward to achieving her 25-year badge.

But there’s a new and deep understanding there, too: that it’s okay to ask for help. She never used to do so and was always running around at work and at home. Now it’s time to slow down.

This is a medical recommendation, as well as a change of outlook. Loss of muscle is very common from being stationary in intensive care, and provides a real challenge for a patient’s recovery. Nurse Raquel has gone from 56kg to 49kg during her admission.

After an online meeting with the respiratory counselling service, Nurse Raquel has made a diagram of her goals, which is put on the wall next to her cards. As she adds more and more details, we joke that she’ll soon be taking over other patients’ walls.

Nurse Raquel still has a nasogastric feeding tube, to ensure that she is meeting her nutritional requirements. A dressing can be also been seen on the front of her neck, where the tracheotomy passage is healing – this hole will close by itself over the coming days.

As he removes his personal protective equipment (PPE), Dr Finn’s face tells the whole story. To prevent contamination, he must pull the mask away from his face.

Despite the PPE’s raw imprint on Dr Finn’s face and the work he has had to do, he still manages a smile. The bond between teams combines with our knowledge and practical skills – and helps us to combat the pandemic day by day.

In an intensive care spotlight, both physically and metaphorically, Dr Badacsonyi, an ICU consultant, was one of those under unprecedented strain to care for patients such as Nurse Raquel – and has had to help lead a department at over twice its normal capacity.

 

J D Williamson is a doctor specialising in anaesthetics, training in London, with an interest in expedition medicine and photography. Recent medical photography projects have included internationally distributed educational material with the University College Hospital London. More of his work can be seen at https://www.jdwilliamson.co.uk/ or on Instagram @drjdwilliamson

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