This transcript was automatically generated using speech recognition technology and may differ from the original audio. In citing or otherwise referring to the contents of this podcast, please ensure that you are quoting the recorded audio rather than this transcript.
Jessamy: Hi, my name is Jessamy
Gavin: and I'm Gavin,
Jessamy: and today we're going to be talking to some doctors in the UK who have been redeployed. So that means that they've been reassigned from their usual roles into different roles. And first of all, we speak to Mr. Phil Tozer, who's a colorectal surgeon in a hospital in North London, who is now coordinating the intensive care unit.
And then we also speak to a junior doctor who has been reassigned and is using her skills I
Gavin: think this is a really fascinating state of affairs, which is why we wanted to do a podcast, not only to hear experiences, obviously, from from doctors who are in the midst of dealing with this pandemic. But the way in which skills can be reassigned and people put into different roles as something like this.
Threatens to overwhelm the health system.
Jessamy: That's actually, I think there's a lot of collegiate feeling, people all over the world in every healthcare system are keen to help each other. But obviously with that comes some anxiety because you might be a doctor who. Hasn't really done any general medicine or respiratory disease medicine for 15 or 16 years, or perhaps you're a junior doctor who Doesn't have that much experience and for the most part when you're not able to have that experience you're able to rely on either senior clinicians for advice Or on set guidelines and a really heavy body of research and in this situation there may not be the same availability of access to senior clinicians because everybody's very busy and there certainly isn't that sort of very clear cut guidelines on how to be dealing with these patients because we're learning so quickly.
Phil: So I'm a colorectal surgeon. I work at St Mark's, which is one of the hospital's at Northwick Park as part of the London North West University Healthcare NHS Trust and the bulk of the work that we do is elective colorectal work and of course there's very limited call for that at the moment. Our cancer surgeons are continuing to do elective work and It is all the urgent expedited work that they can do within the very constrained circumstances.
So without wanting to go into that in any detail, really, that means that there's a lot of surgeons around at the moment, and I'm one of them, who are having to fulfill quite a limited role at the moment. So we really only have to cover the emergency surgical work. And that means that there's lots of time when we don't have to do any active clinical work, and we can't, much as we might like to, we can't.
Jessamy: Exactly, because of the restrictions on trying to keep patients out of the hospital. Exactly,
Phil: exactly. So we've done some telephone clinics and that kind of thing, but the bottom line is there's only so much you can do without actually being able to lay hands on a patient.
Jessamy: Particularly for their specialty of surgery, more than any other specialty in a way.
Phil: That's exactly right. And in combination with that relative redundancy, there is the massive increased demand that's taking place within the critical care services and medical services. And so there is a big move to redeploy very many people. into an area where they are more useful. And this is something that everyone is familiar with.
Jessamy: But now you're fulfilling some other roles. So how did that come about?
Phil: I'll tell you how it started. Surgeons, you will know that surgeons develop really close relationships with their anaesthetists.
Jessamy: Yeah.
Phil: And My, my anaesthetist is one of the intensivists here as well, and he, in the two or three weeks that ran up to the Tuesday that I think of as the crunch day, he was telling me how tough things were, how bad things were getting, how we were going to have to stop elective operating, and so on, and then this particular Tuesday night, I was in doing an emergency case, and we finished at, I don't know, midnight or just after And I came out of that case and found an anesthetist who I knew wasn't on call drawing up drugs in the anesthetic room.
And then I looked out of the anesthetic room and saw another three anesthetists, one of whom was mine, who were also not on call. And it, that had happened because suddenly there was a big influx of COVID positive patients who needed intubation. And that was the moment when. Everything changed. And by the end of that night, there were patients being ventilated in theatres and anaesthetic rooms here.
The first thing to say was that there was this kind of remarkable, immediate answer to the call that went out for help from the anaesthetic team. And as a collegiate bunch, they are really brilliant at doing that. And they were just, they all descended and helped. And having come out of this operating theatre, I took the view that I couldn't exactly go to McDonald's and head home as I would normally do after a late case like that.
And so I drew up some drugs and undertook some other relatively straightforward tasks that bears of little brain like surgeons can do. And was part of that team and hung around for a few hours and just helped out fetching and carrying and getting stock. I searched the hospital for a thing called an IVU, which is a particular type of intubation equipment, which I hadn't ever heard of before and now suddenly I find myself in the storeroom in A& E digging through their boxes to see if I can find the right one that's got the spare ones in.
And then one or two of us did that same kind of thing over the subsequent few days. And it became really clear that the ITU team was so desperately busy intubating patients, assessing them, deciding what they could do, that they didn't really have the opportunity to organize things from a a coordinated point of view very effectively.
They were just so deeply involved in the clinical work that it wasn't so easy for them to step back and do things like organize their list of patients and work out who could be transferred and then act on that and so on. And so we developed this role, the Surgical Support Coordinator role, which is a rotor of consultant surgeons.
otherwise unemployed. So colorectal orthopaedic and urology consultants who have come off their own specialty emergency rotors in order to staff this rotor, which we do 24 seven, two people during the day, one person at night to help coordinate the ITU work, which is now across five different wards within Northwick Park.
Although they are co localized into two broad areas, helping them understand who's. who's where, helping with communication within the trust and externally, organizing transfers and all that kind of thing. And so we're acting as their kind of dog's body, PA, coordinator, organizer, and so on, communicating in and out of the dirty areas and all that kind of thing, so that they can concentrate on the really difficult bit that they're so good at, clinically managing the patients, and we're helping in this kind of coordinating regard.
Jessamy: Yeah, and of course Northwick Park has been one of the real hot spots in London. Where are you now with things?
Phil: Yeah, we remain a real hot spot and of course a lot of what we've done, as is always the way with these things, is admit a bunch of new patients and then transfer out the most well ones that we can and they go off to other hospitals and hopefully get better.
But it, it obviously leaves us with the patients, many of whom are at the highest risk. And we remain a net contributor of patients into the network rather than receiver because we are almost full all the time, we, as soon as beds empty with transfers out, we're filling them up again.
Jessamy: And how are you finding this new, slightly managerial, coordinating role?
Phil: It's been really interesting from my point of view. The first thing I have to say is that the intensivists and the ITU nurses are the ones doing all the hard work. They're the ones who are spending hours and hours in full PPE, looking after patients in the dirty areas and so on. And the work that I'm doing and we're all doing by comparison is very straightforward.
And. Less hazardous and less uncomfortable and so on. So it really is them who are doing the hard bit. But the thing from our point of view is that it is incredibly interesting working with this very different group of doctors and doing a very different role. And there are some fascinating things here to think about.
I'm sure any psychologist could spend you know, could write a PhD about the stuff we're learning at the moment in terms of the way that they work. So for example, I mentioned earlier how collegiate the anaesthetists are and what that meant was that as soon as the call goes out that there is trouble, then there's a dozen anaesthetists saying, I'm here, how can I help?
They're just absolutely brilliant at that. Rather than being competitive, they are collegiate. The flip side of that is that they, when we do the handover. Twice a day. We say who's in charge today? And there's a sort of general reluctance, not because they're not willing or able to take charge, but because they don't want to be the guy who stands out or, or, to upset their colleagues because they're used to just working as a collegiate group.
Jessamy: Yep.
Phil: And that's fantastic in lots of ways, but it doesn't lend itself quite so clearly to, to the kind of didactic leadership which is required at this moment. And so we're helping them with that in the sense that we're helping them coordinate who is in charge and who does which role, and providing communication between those groups.
And I should also say that, We're a few weeks into all of this now, and of course they're now brilliant at it. But we're still able to help them.
Jessamy: And what about some of the skills that you're having to develop in this new role and position of kind of obviously there's a lot of leadership skills that you have anyway, when you're a surgeon, just doing your day to day clinical job, but this is again, a slightly sort of higher level coordinating position.
Has that been strange or different?
Phil: Yeah, it's definitely different. There's a it's very unusual for Surgeons to have a large number of patients that they don't really know that they're looking after we I know most of my patients. I know them really I meet them in clinic and then I operate on them I look after them after the operation if they're an inpatient see them again Talk to them on the phone, you get to know them really well.
I'm not even seeing some of these patients directly. And so we're suddenly looking after this big cohort of names. And that's a very different feeling to the one that I've had before working as a surgeon, where you are up close and personal with patients all the time. So that's very odd. It's also necessary.
There's no point in me becoming another member of the clinical team. The intensivists are doing that. They're brilliant at it. They don't need my help with that. What we can help them with is that. Being that person who's a step away from the patients directly so that you can do all of that organization.
And that, you're exactly right, that is not what surgeons are used to. However, what it requires is organizational ability and any surgical registrar or SHO or indeed medical. Registrar or SHO will know exactly what it's like to have to create and order a list. And that's quite a lot of what we're doing.
Keeping this list up to date with patients in several different locations. That's skills that we have all developed as junior doctors. And the rest of it is coordination and communication, all of which we're very comfortable with. And the other aspect of it, which is really crucial, I think, is willingness to do basically anything.
There are some people around who wouldn't be willing, for example, to go and dig through a storeroom to find a box of equipment that's required in another location. There ought to be a porter or someone else who can do this. There isn't. There isn't anybody. There's you. So get on with it.
And that kind of Attitude is the one that a lot of the NHS is currently displaying so brilliantly. There is a job to do, I'm going to do it. I can do it safely, so I'm going to get it done. And I don't care that I might in the past have considered that beneath me. Nonsense. Those rules no longer apply. And so that kind of thing is what the is the willingness that people who are on the road So I'm describing are showing and very many people in the NHS currently are showing although of course As with all things not quite everybody
Jessamy: How are you dealing with some of this kind of psychological toll of it or some of the anxiety that you may have around?
You know being in this environment
Phil: It's a really good question. Normally when I leave work It's And I've really enjoyed what I've done that day, and I'm looking forward to coming back the next day and doing the thing that I'm used to and that I enjoy very much and so on. And that isn't always how I feel at the end of one of these shifts.
I'm very often very keen to get home and see my family, and I'm glad when I've got a day off the next day. And as I said earlier, it is as nothing compared to what the intensivists and ITU nurses are going through. But it is such a high paced environment that, that doesn't have a very good outcome for quite a lot of the people who we are looking after because the patients in ITU are the ones who, by selection are going to do the worst or are at highest risk of doing the worst.
That is quite. That is quite difficult. And I come in one day and there are a few fewer names on the list than there were the day before. And some of them have been transferred, but not all of them. And that is quite hard. And the surgeons, we're not really used to that very much. Some of our patients die, but it's unusual.
I'm pleased to say this is a different group. That's quite difficult. What we don't have to deal with in the same way is the Up close and personal physical and emotional misery that the ITU nurses And intensivists see and I have to tell you that one of the hardest parts of this Is to see these guys when they come out of the dirty area Their faces are red.
You can see the indentation of the FFP3 mask on their face. They're sweaty and they look Miserable. Utterly miserable. And one after another, I have seen nurses go home in tears after their shift. It's not clear whether they're just upset, or whether it's relief that they're out of there, Or the fact that they're upset about having to come back the next day, that particular group of individuals are really up against it psychologically and physically.
And the other group who have real potential difficulty are the junior doctors who are being asked to work as ITU juniors, either. either as doctors or nurses. And that that is also very stressful. And I came on two mornings ago, Saturday morning, to find an SHO just on the verge of tears, about to don for the first time and go into one of the dirty areas.
And took her aside and had a conversation with her and all those kinds of things. And she was fine. And at the end of the shift, she was okay. She was ready for her next shift, but for those. For those people, that toll really is massive. I think I wonder whether that's the other benefit of having made this a senior role.
Because, there was an option to say, Hey, look, the best people at making lists and organizing things are F1s and F2s, right? They're doing it every day. But actually, I think some clinical and emotional maturity is probably of value in this. Because we're able to be a smiling, reassuring presence as we charge around the hospital to all the other people who are having a harder time.
And I think being senior probably helps with that.
Jessamy: Yeah, extremely difficult situations. Is there anything formal for you to get through some of the mental toll that this might be taking?
Phil: Yeah, there are there are one or two groups within the hospital who have set up some kind of support network for people who are struggling and want to make use of that.
So such things are available. As with all of these things, they're never quite as Obvious and available as you would hope but yeah, they do exist here, and I think the Trust has tried very hard it's certainly recognized all of that stuff and has tried very hard to provide some kind of supports for that.
I can't give you details because I haven't looked. No, of
Jessamy: course, and I mean it's so difficult because it's such a fast moving area and there are so many things that need identifying and, things doing about them that it's These things which might seem slightly on the periphery, but are actually pretty key to the resilience and continuing care of doctors is, difficult to set up and difficult to make known, I'm sure.
Phil: As time ticks on and we get deeper into this and the initial stamina that everyone starts with starts to ebb. That will become increasingly important, I think, but so it will become increasingly available. I'm sure. And actually, everyone always grumbles about their own trust.
Don't they? Everyone does. Everyone always assumes that all the other trusts are in a better shape than their own with regards to communication and so on and so forth. I have to say that pretty much everyone that I've spoken to from other trusts and my own experience from this one is that communication has really been very good and the lack of information that exists is usually because that information is unknown rather than not finding its way down.
I think from that point of view, things have gone pretty well with regards to the hospital management as well. Trust management.
Jessamy: That's good and reassuring to hear.
Gavin: We also spoke with Nisrat Iqbal, a doctor at a hospital in North London, about the reassignments that are happening with her due to COVID 19 in London.
Nisrat: So my name is Nisrat and I'm I guess technically I'm a surgical trainee, a surgical registrar. At the moment I'm based in London and prior to the coronavirus outbreak, I was actually taking a break from clinical practice to do research. So I was doing a PhD in surgery and cancer. I'm now based at Norfolk Park Hospital and when the outbreak began I was redeployed to a role on intensive care and so I'm supporting the staff on the intensive care unit at Norfolk Park.
Jessamy: And it's strange, isn't it, because we've suddenly been faced with all this very military terms about being on the front line and being redeployed. And how did that feel to you?
Nisrat: In a way it was slightly, so we knew when this all started we knew that obviously something major is coming our way and this is going to change all of our working lives significantly for a period of time and so in a way hearing the military terms and hearing it described In these words was comforting to know that it was being taken seriously in that way in that it was having a very structured and organized response towards it.
But also in the same way it's something that's almost a foreign language to many of us who obviously aren't part of the military. Those aren't terms that we would use in our normal daily working lives. So it became a little bit slightly uneasy to use. To place our clinical lives in that context of being on war footing and being redeployed and and terms like that.
When to us, it's normally just, a normal day at work and suddenly this whole new aspect is being put onto it.
Jessamy: Yeah, exactly. And what. What exactly is your role being so far in the ICU?
Nisrat: So I've been placed onto an intensive care rota and it's essentially, it's very much a kind of award based role whereby I'm assigned a bay of COVID positive patients and I assess them fully and try and identify any issues that we might be having with the patients and then escalate those to, to a senior where necessary.
Essentially a, an SHO type role. And as a senior
Jessamy: house officer for people who aren't familiar with the UK training system, that's somebody who's out of medical school for, say, two years.
Nisrat: Yes, that's correct. Yeah, so identifying problems trying to remedy them where possible, initiating management plans.
As I said, escalation to senior members of the team, and then also there's the kind of the non medical aspects of care. So ensuring that families are kept up to date. So as you probably know, families aren't allowed to visit patients. So giving them daily updates with how patients are doing, relaying messages to them from their loved ones and then essentially organizing any.
Other kind of tasks that need to be done in terms of diagnostics or or treatments as well
Jessamy: Yeah, and I suppose what's interesting about this time is that you know The gmc is saying that trainees mustn't be asked to undertake activities that are beyond their level of competence And they should be advised about when they seek senior help.
But obviously we are in a crisis and when you're in that crisis, physicians all around the world are having to do things that they don't normally do and having to do things without clear guidelines. And that doesn't really change regardless of how senior you are. None of us really know exactly what we're doing with this new pathology.
What's been your experience with that?
Nisrat: So I, in terms of my background, I've never really had a formal intensive care role before. Although I have had exposure to patients requiring critical care in the surgical sense. So it's not a completely unfamiliar environment, but certainly some of the tasks that I'm doing I'm not what I'm used to.
However, I feel In medicine in particular, and maybe in surgery and intensive care in particular, there is quite a lot of overlap in terms of how we assess the patients and how we go about treating them. So I feel as though I have the basic knowledge of knowing how to manage the patients and manage the workload.
And then when it comes to Issues and tasks that are not part of my my knowledge or my clinical experience. I'm lucky enough that I've been supported in having senior colleagues around who are easy to contact to be able to discuss cases with and to be able to discuss issues with.
And it's been really comforting in that way, in that it's So the seniors also understand that, we're taking on roles that we're not used to, and therefore they're always approachable, and I've not really felt out of my depth in that way in that sense. But I agree, it's, we're being asked to do something unprecedented, and the, and this, the entire environment is something that none of us have seen before in our clinical lives.
So therefore I think go above and beyond, and is necessary really to be able to provide. the right level of care for these patients.
Jessamy: And in terms of kind of the information that you're accessing, where are you in accessing your information? How are you dealing with the uncertainty?
Nisrat: Sure. I think our, representatives and societies have been quite good and quite proactive disseminating management guidelines to members. So the surgical societies and the societies that are in, charge of our surgical training have been quite good in communicating with us regularly with regards to issues to do with for example, pausing our training pathways or how we manage surgical patients in the, in these current circumstances.
But also the anesthetic and intensive care societies as well have disseminated guidelines quite. quite well amongst all trainees, I think of all specialties. But I think having come from a research background as well and generally in medicine, we tend to be quite self directed in terms of acquiring that kind of information to, to help us in our clinical roles and lives.
So I've also sought out that information myself in terms of reading critical care manuals and how to manage ventilated patients. And I think that's second nature to most of us clinicians. We do that a lot anyway in our jobs. So That didn't seem like something unusual to be doing and certainly for me it provided me with a lot of kind of reassurance when I was stepping into this role as well.
Jessamy: And how are you dealing with the kind of emotional toll potentially the anxiety about dealing with these patients and, just being in this very new environment that might be slightly scary at times?
Nisrat: So where I'm based at Norfolk park there's been a whole cohort of doctors who've been redeployed.
So it involves other research fellows and other general surgical orthopedic and neurology trainees who've all been. Placed in this unfamiliar environment, so it's been quite nice to be going into this together where we can all share our experiences And share tips as well with how to deal with this new working pattern so that's been really useful.
And also at a senior level a lot of the surgeons have been redeployed in managerial roles to deal with it transfers and critical care management in that way so having those people around who Understand this scenario and are also seeing it from my perspective is invaluable really. And outside of that, I'm quite lucky that my closest friends are actually intensive care registrars and ED registrars.
And just having them to talk to and bounce ideas off of and unload from the stress of the day has been really helpful as well.
Jessamy: That's great. Have you got anything else that you'd like to speak to?
Nisrat: It is an unfamiliar environment. And as I said, it's something that none of us have ever dealt with before.
It also came with kind of a sense of duty. So we as daunting and as scary as it is, we've been trained for this. This is what we've been prepared for medical schools. We put in unfamiliar situations where your skills are needed to do better. help people at their time of need.
It was, so whilst it also had that unfamiliar aspect to it, it was something that we knew we had to do. We, this is our time to step up and take on that responsibility. So it's also an honour in that way as well, to be working at this time.
Jessamy: That's nice words to finish on.
Thank you so much for all that you're doing. Okay. Thank you very much for having me.
Gavin: Jessica, I've got nothing but boundless admiration for all these medical professionals adapting so fast in these anxiety provoking environments. It's this real culture of pitching in, of making do, and this flexibility that reflects so well on everyone involved in these unprecedented circumstances.
Do you think, as Nisrat mentioned there, that all of these things derive from that sense of duty that medical staff have.
Jessamy: I think people do have a sense of duty throughout the world. Medicine is, and nursing is a vocation that people go into for specific reasons. And there is the kind of fairly nebulous aspect of professionalism and what that means to medical healthcare professionals.
And there is always a great sense of, being together and working together in all healthcare environments. And I suppose when we're faced with these enormous crises, then that is only amplified. And that sort of collegiate sense of working together and trying to do what's best for your patient completely takes over.
And it's very hard to see anything else other than what's directly in front of you.
Gavin: Thanks again for listening to this special episode of The Lancer Voice. You can subscribe to us wherever you get your podcasts. And we'll see you again very soon for another special COVID 19 episode. Take care.