Author: dr. Wolter Paans & dr. Wim Dieperink

Hanze University of Applied Sciences, Groningen, The Netherlands

This blog or opinion peace is written by dr. Wolter Paans and dr. Wim Dieperink during the peak of the corona crises in April 2020 in the Netherlands. Dr. Wolter Paans and Dr. Wim Dieperink are nurses and nursing researchers within the intensive care sector and have written this opinion piece in their personal capacity. Now the Netherlands is facing a second wave and therefore the blog becomes again relevant. A part of this opinion piece consist elements of the Dutch situation about nursing, the position of nurses and nursing leadership.

Picture (posed by model): iStock

ICU nursing in the corona crisis: Intensive care in bizarre times

We would like to contribute to the information on the corona outbreak with a letter on a specific subject that is quite prominently highlighted these days in relation to the COVID-19/Corona outbreak. In addition to the many expert reflections from microbiology, virology, specialised medical disciplines and economics, we would like to take the opportunity to highlight more specifically the perspective of the nurse. We do this in order to illustrate the reality of an intensive care nurse in COVID-19 crisis time, so that the plastic abstractions that are sometimes spoken about – for example, in journal entries about the number of infected people, respiratory cases and numbers of deceased patients – can be reduced to more tangible, palpable consequences of the coronavirus. We try to describe a real image that may seem intrusive. It is our intention to describe objectively what the corona outbreak brings about behind the scenes, and that keeping a distance from each other and washing hands is worthwhile.

The role of the nurse in the care process of the corona patient
In addition to the intensivist, who is the patient’s primary care provider at the intensive care unit (ICU), an ICU nurse is also a diagnostician who focuses on the consequences of the disease; the symptoms that characterise the course of the disease. In addition to targeted patient observations, nurses have various sources at their disposal with which, among other things, vital functions such as blood pressure, respiratory frequency, breathing pressure, body temperature and oxygen saturation can be monitored. Laboratory results, such as blood analyses, are also of evident importance. A nurse is not so much someone who focuses primarily on determining the disease itself, or on prescribing certain medication and medical policy, but they do work to ensure that this policy is established and implemented. Nurses and doctors work very closely together in an ICU, they trust each other’s information and count on the accuracy of each other’s actions. They now do this in ‘dedicated teams’ specially formed for this crisis, in which the necessary expert capacity is distributed as good as possible among the various teams. All teams have a fixed formation so that team members can get attuned to working with each other and work more efficiently and effectively. This creates a professional, interdisciplinary team that can work with a particularly high level of commitment, with the aim of stabilising a patient in such a way that they can breathe independently again and recover from the serious lung infection caused by the corona virus.

The seriously ill COVID-19/Corona-patient and basic nursing care
The COVID-19/Corona patient who ends up in the ICU is generally respiratory insufficient (cannot breathe independently), which in some cases makes switching to ventilation in the prone position necessary. Ventilating patients in the prone position results in a better ventilation-perfusion ratio (roughly speaking, the amount of air that reaches the lung vesicles and the exchange of CO2 and O2). Unfortunately, abdominal ventilation also has a number of potential complications, such as rapid entanglement or dislocation (disconnections and dislocations) of intravenous and arterial infusion lines and/or the endotracheal tube (breathing tube to secure the airway). Acute hypoxemia (immediate lack of oxygen in the tissues) due to sputum mobilisation (mucus moving in the lungs), disrupting the ventilation-perfusion ratio can also occur. Also reflux of the stomach contents (reflux of tube feeding from the stomach) is a possible complication. In the longer term, decubitus (bedsores due to shear and compression forces and poor skin perfusion) can occur in the face (mouth, chin, ears, nose, cheekbones), breasts (especially for women), genitals (especially for men), knees, toes and at pressure points of infusion lines. But also eye damage, pointed feet (permanent forced position), luxation of joints and oedema (formation of fluid) in the face occur.
Under normal circumstances, many of these complications can be prevented with protocol-based medical and nursing care. In a crisis situation, however, in which older, vulnerable patients often have to be given artificial respiration for a longer period of time, this is unfortunately, most probably, not always preventable.
Together with the doctor, the nurse must change the patient’s posture every four hours, whereby in some cases it is only possible to move the head and an arm in a posture similar to a kind of slow ‘breast crawl’. It is important that the patient lies comfortably in a position where the abdomen has space and does not make ventilation more difficult. Turning only the head of a respiratory patient requires the cooperation of a doctor and two to three nurses at the same time.

During ventilation in the prone position, patients are generally given pain relief and sedation, so that they suffer less from the treatment. Patients are often completely asleep, but it is important that patients are properly informed before any actions are performed, because it is uncertain what they are aware of.
Another nursing aspect is that in the prone position, the eyes, lips and mouth are difficult to care for. The lips are regularly greased with a kind of Vaseline and, if necessary, the eyes are covered with an eye glass to prevent dehydration. You can imagine that oral care in case of lung infections and the associated mucus formation is particularly important, but that this is also often a complex matter, especially when large groups of corona patients require care with a scarcity of specialized personnel.
Furthermore, the patient has a feeding tube and a urine catheter with a urine meter and collection bag. Alarms regularly go off from respirators and infusion or feeding pumps to which a quick response is required.

Informing immediate loved ones
One of the nursing tasks is also to inform the family about changes in the clinical course. This will often be by telephone or through SKYPE, because visits are impossible. Great personal unrest, anxiety and sadness, with the accompanying expressions of (completely understandable) frustration, are things the nursing teams also have to deal with. The great insecurity and powerlessness experienced by most of the immediate family members are things the doctors and nurses will not easily forget, but no matter how intrusive, it certainly is part of the job.
Even with the prospect of an inevitable death, a visit is not desirable because of the infection risk. You can undoubtedly imagine the impact of this.
Research describes the traumatic effects of intensive care admission on immediate family members. This will certainly also be a recurring topic that will be addressed more specifically once society is ready to deal with this corona crisis.

The impact of corona care on the nurse
The current global, and increasingly regional, picture of care for corona patients is that this care, both physically and emotionally, places a heavy burden on the entire team of practitioners; doctors, nurses and all those who are involved in the care. All are severely affected by the serious course of the disease. Care providers involved wear protective clothing (i.e. mouth masks, aprons and goggles). This clothing is equipped to protect against a virus. That is to say, it is hermetic and downright stuffy. Glasses can fog up, generally you can’t eat or drink in between, and a sanitary stop is quite an undertaking.
The IC department is completely different; nurses work in a different environment and cannot rely on trained routines, which are important in life-threatening situations. The direct physical execution at the bedside actually requires maximum effort on all fronts and constitutes a stroke of exhaustion.
The emotional component demands at least as much. In many cases the ICU staff, who are in charge of the care, are used to it. After all, people die in intensive care, but in this crisis the extent of suffering and the extent to which people die is unprecedented. ‘It is the ultimate horror’, as one of the nurses called it. Another typical quote: ‘I have never experienced this and I will never forget this misery’.

The nurse and the appreciation of society
In an uncertain meantime, in which the course of illness of many people is still unpredictable, many feel dependent on a limited group of graduates, subsequently labelling them as ‘vital’ or ‘crucial’ professions. ‘Nurses and doctors are the backbone of society’, ‘Heroes in care await a warm welcome’, ‘Applause for heroes in care’, according to various media headlines. And rightly so, because these healthcare providers also feel insecurity and are concerned about their health; after all, they are on the front line.
Nurses recently demonstrated because they wanted a pay rise. It was a protest that was not only financially driven. Nurses experienced political misunderstanding because they were successively plagued by autocratic commissions that did not provide sufficient insight into the criteria they applied in the nurse re-registration.

Nursing at a political level
Today there are warm words for the nurses of the relevant State Secretaries, Ministers, the Prime Minister and other national and regional politicians who want to make themselves heard. That is nice in these times and certainly widely appreciated. The fact that nursing matters is now, more than ever, brought to the forefront of society.
However, at a political level, there has been an appalling level of amateurism when it comes to by far the largest professional group in the care sector. It is tragic to see how, time after time, ill-informed politicians with a presumptuous disdain, stating role-pattern supporting abstractions, try to charm the nurses with hollow generalities, out of electoral considerations, parrot moderately informed ‘Dutch celebrities’, only to come up with short-sighted, fragmented, visionless policies composed of weak compromises.

The fact that in the Netherlands, well before the corona crisis, many intensive care beds remained unoccupied was not due to a shortage of doctors, but to a shortage of specialised nurses; in fact, a shortage that was well foreseeable and therefore unnecessary. The underlying suffering in the waiting period and the uncertainty of patients and their immediate families has never been measured very hard, but of course it can be felt by everyone. Even now, due to this crisis, there is a growing group of patients on hold, until they can receive treatment somewhere after the crisis. The shortage of specialized nurses still exists and is more than palpable in this crisis.

Heart warming
This difficult time is also a time of heart warming togetherness, of willing helpers, of flowers for the caregivers, of balcony ballads; let’s hold on to it and keep it up until well after this corona crisis, because even then we will need it for a long time to come.

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