Covid 19: A primer on ICU care for the non-intensivist. St Emlyn’s

In the coming weeks and months we are likely to see clinicians working in areas that are previously unfamiliar to them. Here in Virchester we’ve identified that emergency medicine, acute medicine, and intensive care medicine (ICU) are likely to be the areas with the highest numbers of redeployed staff.

Of these the one that appears to be causing the greatest concern is intensive care and with good reason. You cannot simply grow an intensivist overnight! In the UK it’s a highly competitive, high tech, high demand speciality that attracts some of best and brightest clinicians who deliver a consultant based service. However, we may very soon be in a different situation where we will not have enough fully (or partially) trained intensivists to go around all the beds that we are currently creating/making/knitting 😉 . Here in Virchester our escalation plans involve using our wider anaesthetic team (docs/nurses/ODPs/EAPs) to staff beds in the first instance (who may have completed blocks of ICU training in the past), but if that resource is exhausted we may call on other clinicians to work under the supervision of a senior clinician with ICU training.

This blog and podcast are here to try and start answering some of the anxieties that we have heard in recent weeks. It’s not a complete guide, but hopefully a reassuring starting point to learn, one that will guide you to do further online learning and at your place of work with face to face lectures and workshops (Ed – if they are not happening yet, they probably should be). There are some great links at the bottom of the page to get you started which I will try and keep adding to as more resources come online. Start by listening to the podcast below. In this we do not underestimate the concern and worry that is genuine and real for many people who face taking on new skills and roles. ICU is far more than twiddling knobs on the vent (a phrase which woefully underestimates the complexities), but it is also something that you can help with, so long as you can access good training, guidance and supervision. That’s really the main message of this blog and podcast. No-one can turn you into an intensivist in the time frame we have, but we can help you support the service and our patients. If in doubt about the way that intensivists/anaesthetists value education you can always pop onto twitter and follow some of the amazing clinicians out there who exemplify a supportive, education focused, evidence based approach. There are many such people whom I hope typify who you might work with in the next few months.

The bottom line is that NOW is the time to identify and train clinicians who may have to work on ICU, but who may have never worked there before, or who worked there many years ago.

Dr. Sarah Thornton is an anaesthetist and intensivist in a hospital somewhere NW of Virchester University Hospital, who together with colleagues has put together an aide memoire for ventilation and general ICU management which you can download and adapt below (this one was designed by @jplomas based on designs seen in Salford and Cardiff). She has also agreed to join our podcast to talk through how we see the expansion of critical care beds working in the UK (we suspect it will be similar elsewhere too). We encourage you to develop a similar resource in your local units and to use this and other resources to start training staff now. Remember that you need to train a multiprofessional workforce and not just doctors.

The idea behind this is that we can use ARDSnet strategies for Covid patients in the first instance.

An additional daily ward round aide-memoire is the FASTHUGS system which we employ on the Major Trauma Service in Virchester. I find this also helps me remember the routine, but vital aspects of care for our more severely injured patients.

All these systems are designed to make critical care a structured and systematic approach where the basics are completed in a regular and reliable way. For clinicians like myself this is absolutely the approach that we need to work efficiently under the guidance of a (proper) intensivist.

You should also look out for some materials coming out of the Royal College of Anaesthetists soon to support e-learning on this issue. We’d also recommend you finding out about the escalation policies in your hospital and availing yourself of any local learning opportunities. You can also look online for guides, such as this excellent examples below, but be aware that strategies may differ between countries. More are listed at the end of this blog.

Best I’ve seen so far (but not actually done myself) is an online course form University of Cork as highlighted by Andy Neill. Link here https://ucc.instructure.com/courses/22984/pages/modified-basic-icu-course-13-03-20

Lastly, and perhaps most importantly, never, ever forget that critical care nurses have incredible knowledge, expertise, skills and wisdom. They will probably be looking after other nurses who may have been redeployed just like you. However, that’s not how your hierachies should work. EM and Crit Care thrive on flat hierachies and total respect for all the different tribes and teams that work there. Your nurses will save you and your patient if you work well with them. Work with them and listen to them, not only will the patient get a better deal, you’ll also learn loads.

If you haven’t already, don’t forget to read and listen to our other Covid-19 resources here. Good luck everyone and we’ll see you on the other side.

vb

Simon Carley and Sarah Thornton

Addendum: In the first podcast released we were unclear about the 6L/min issue. This relates to patients getting high flows as part of their RSI, especially if via devices such as nasal cannula which may be used in these patients on wards and also as part of a no-desat approach. It does not specifically relate to face mask delivered oxygen. This is a local practice and as far as I am aware is not part of national guidance.

Other resources

EMCRIT – The Internet book of Critical Care https://emcrit.org/ibcc/covid19/

EMCRIT – Dominating the vent part 1 https://emcrit.org/emcrit/vent-part-1/

BroomeDocs – Airways, Safety and Strategy for SARS-Cov2 https://broomedocs.com/2020/03/airways-safety-and-strategy-for-sars-cov2/

Free lectures on Continulus (needs registration) https://www.continulus.com/covid-19-free-lectures/

Royal College of Anaesthetists page on Covid-19 https://icmanaesthesiacovid-19.org/

Critical Care Northampton has an amazing site with loads of relevant resources for new ICU clinicians https://criticalcarenorthampton.com/

AliEM https://www.aliem.com/paucis-verbis-ventilator-settings-for-acute-lung-injury-and-ards/

University College Cork Basic ICU course https://ucc.instructure.com/courses/22984/pages/modified-basic-icu-course-13-03-20

Covid Quick reference guide https://www.saferinsulin.org/

This book has a cost, but I am assured that royalties go to charity (I’ve not personally checked https://www.amazon.co.uk/dp/1138035785/ref=cm_sw_r_cp_api_i_fVKEEb869GKZ4)


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Posted by Simon Carley

Professor Simon Carley MB ChB, PGDip, DipIMC (RCS Ed), FRCS (Ed)(1998), FHEA, FAcadMed, FRCEM, MPhil, MD, PhD is Creator, Webmaster, owner and Editor in Chief of the St Emlyn’s blog and podcast. He is Professor of Emergency Medicine at Manchester Metropolitan University and a Consultant in adult and paediatric Emergency Medicine at Manchester Foundation Trust. He is co-founder of BestBets, St.Emlyns and the MSc in emergency medicine at Manchester Metropolitan University. He is an Education Associate with the General Medical Council and is an Associate Editor for the Emergency Medicine Journal. His research interests include diagnostics, MedEd, Major incidents & Evidence based Emergency Medicine. He is verified on twitter as @EMManchester

  1. Great review. Dr Thornton stated that peak pressures should remain below 30 cmH2O on a couple of occasions. Did she mean plateau pressures? This is what I have heard over a number of other resources

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  2. The flow rate >6 being aerosol generating was news to me. Where’s this from? Nothing on PHE that I can see and would have huge implications. Otherwise great work thanks
    Jo

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Thanks so much for following. Viva la #FOAMed

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