Perspectives: Redeployment and new roles

Redeployment to intensive care: A viewpoint from an Obstetrics and Gynaecology trainee

Kate McCallin is an Obstetrics and Gynaecology trainee (ST1) working in the South Yorkshire area.

COVID-19 may well provoke permanent changes to healthcare delivery in the UK. From video consultations with patients and online multi-disciplinary team meetings, to extensive phone based triaging systems – we have had to adapt national practice significantly to reduce face-to-face contact and help prevent virus spread. As for my personal role, seven months into my speciality training programme of Obstetrics and Gynaecology, I was redeployed to the unfamiliar territory of Intensive Care. To say the workload was different is somewhat of an understatement. No longer was I helping to deliver new-born babies by caesarean section, the new focus was to prevent death in critically unwell patients. Daily life now consisted of a prompt eight o’clock morning handover led by the night senior registrar and attended by the full cohort of doctors working that day. Each patient was discussed in minute detail, ordered logically by organ system and cardiovascular status, blood pressure support medication requirement, respiratory system and ventilator settings and so forth. Initially, I felt as though I was listening to a different medical language. The vast majority of the patients on the unit were COVID positive, sedated and requiring a ventilator to breathe. Most had been on the unit for days and some up to four weeks. It was difficult not to blur patients all into one. Following morning handover, it was time for the daily patient reviews. We donned our stiflingly hot personal protective equipment (PPE) including surgical gown, sterile gloves, non-sterile gloves, surgical hat, FFP3 mask and visor and entered the unit. After being assigned a patient, the in-depth analysis began. Each system was closely evaluated using detailed charts meticulously kept up-to-date by the nurse looking after that patient. Ventilator settings were monitored. The three or four drug infusions that the patient was on were carefully assessed. When was the patient last proned? When did they open their bowels? What were their most recent blood oxygen levels? Proning was new to me. I had never before come across this in my ten years of being at medical school or a doctor. It involves turning the patient, complete with central line, endotracheal tube, and arterial line onto their front in order to improve oxygen levels. Patients remained prone for approximately sixteen hours per day. Coming from a specialty where patient communication is of upmost importance – breaking bad news of a second trimester miscarriage or metastatic ovarian cancer diagnosis – not being able to talk to patients was one thing, but not even being able to see their faces? Proning was not the only barrier to effective communication. Wearing a voice muffling FFP3 mask which covers half your face also effectively conceals the majority of muscles used for facial expressions. Dressing all staff in identical outfits also provides issues. Each worker had a sticker placed on his or her surgical gown detailing that person’s name and job role. These small additions to enable cohesive team working in a new, stressful environment should not be underestimated. There were tough days. And this was despite the amazing support of the intensive care consultants, anaesthetic trainees and experienced nursing staff. To watch a previously fit and well man in his fifties die despite the consultant giving him every last drop of available treatment possible is hard. To watch the grieving relative in full personal protective equipment (one family member allowed only) say goodbye after not seeing her husband for three weeks was harrowing. Towards the end of my time there, I saw a patient that I had become familiar with over the past few weeks, walk unaided out of the unit with staff providing a poignant round of applause. He no longer had to communicate via miming nor breathe through a tracheostomy. During his stay he told me of the mental struggle he had struggled to overcome. He felt imprisoned in his single room with no daylight and much to his annoyance, a clock that showed the wrong time and could not be fixed. His mental and physical recovery provided the much-needed moral boost that the wearied staff needed. For many specialties within the NHS, particularly surgical based, work may be currently less busy than usual, with many elective surgical lists cancelled. However, at a time like this, spare a thought for intensivists and anaesthetists, working tirelessly for each critically unwell patient. My contribution was miniscule but it has taught me the importance of adaptability, resilience and teamwork in the face of the unknown. I hope that the lessons we learn during the COVID crisis will continue to benefit the National Health Service (NHS) for many years to come.

A new role in COVID: Experiences of a retired returner

Anthea Mowat is a recently retired Associate Specialist Anaesthetist in Lincolnshire. She is Honorary Secretary of the Medical Women’s Federation. She has a strong interest in supporting doctors, having been a Chief Offi cer of the British Medical Association, as past Chair of the Representative Body. She is former Chair of her Trust Local Negotiating Committee (LNC) and was Lead Appraiser until her retirement.

When the COVID-19 crisis hit, there were 2500 recently retired doctors who answered the call to assist the NHS. Frustratingly many who came forward to volunteer did not end up back in the workforce, some due to departments having sufficient resources that they managed to redeploy staff, but others who were stymied by bureaucracy, in both primary and secondary care. Having retired in the latter part of 2019, I was keen to help, but also aware that a recent health issue would put me in a higher risk category. Nevertheless, when I applied using the necessary link, NHS England assured me I could have a useful role. The day the General Medical Council (GMC) announced they would be granting temporary registration to returners, I also had a phone call from my old department and a generic letter from my old employing Trust, both asking if I was prepared to come back. Due to enquiring about a non-patient facing role, I was asked by the Trust if I would consider being a driver, porter or domestic (which is where I started my original job in the NHS as a student so a certain symmetry there!). Though it did puzzle me that these roles were seen to not have interaction with patients! Meanwhile, NHS England suggested NHS 111 as a possibility. Having provided identity checks, health declaration and other paperwork for NHS England they assured me it would be forwarded to my old Trust. I was pointed to the hours of online learning expected (dutifully completed), and also used online learning provided, with impressive speed, by my Royal College and specialist associations. More Continuing Professional Development (CPD) done within a week than normally done in a year, it was an emergency after all. Then nothing seemed to happen! Frustrating, as I was ready and raring to play my part. Having heard nothing for nearly three weeks, I contacted my previous Medical Director to ask how I could help and, with no hesitation, was offered the role of Medical Examiner, to do the amended role permitted under the Coronavirus Act 2020. There were 26 necessary online modules to complete before the role could be done. So, even more CPD undertaken. Trust induction specifically for returners was planned. Mine was held on a bank holiday with some necessary departments not there (IT and occupational health). I was the only person on it, and the trainers who were there were all staff I had trained when they started in the Trust: we were surprised and amused by the role reversal. I was also required to confirm my identity (ID) again to three different departments despite having NHS England approval. However, I soon acquired the all-important ID card, had departmental induction for the new role, alongside three other retired returners, and off we go! Only one short delay when occupational health would not accept the health declaration done for NHS England and wanted their own format, but we got there in time for me to start. The role has been both rewarding and poignant. It was based in bereavement services, and involves completing Medical Certificate of Cause of Death (MCCD) after scrutiny of the whole of the final admission for all deaths, irrespective of cause. Having not been involved in the care of the patient, it required detailed scrutiny of all the results and entries by any professional in the notes to determine cause of death but also to look for any clinical governance issues. It also involved speaking to the bereaved relatives, to check their understanding, give them the chance to ask questions, and also to find out if they had any concerns. This was a sad privilege as so many were stunned by the speed of events but also their grief was magnified, as in many cases they had not been able to visit and may have only had a facetime call with their loved one. We also liaised with the coroner and completed the initial forms necessary for cremation. This took pressure off all the amazing clinical staff who no longer had the pressure of doing this work at a time when new rotas, long shifts, redeployment, use of Personal Protective Equipment (PPE), and sheer exhaustion were taking enough of a toll. It has been a fascinating role using professional skills but very different from being in my former clinical role seeing patients. As things gradually started to return to restoration phase, I and my three new colleagues came to the end of the fourth month of the role and were stood down, and while we will miss the all wonderful staff who welcomed and valued us in our return, we all hope we will not be called upon to return. I was lucky I have been able to help, albeit this quiet background role, but also feel for the many retired doctors who wished to come back but have not been enabled to do so.