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Covid – difficult moment when the answers are not straightforward

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Yesterday we ran a Zoom session for care home staff in Rotherham.

We had originally planned for this to be a rapid-setup ECHO, like the ones I have described before; as with everything in Covid we didn’t have the time, resources or I guess ‘cheyshek’ as the Yiddish word goes, to pursue all the governance, paperwork and coordination to do it officially; we therefore ran a Zoom training session for care homes in Rotherham focusing on infection, prevention and control, the use of personal protective equipment (IPC & PPE) and a little bit from me gabbing-on about whatever seemed relevant at the time.

We put-aside concern about the ‘security’ of Zoom – accepting that if someone wanted to bomb our call, so be it (this is apparently where during an Alcoholics Anonymous session a hacker from Belarus photobombs/gate-crashes the meeting).

Anyway.

We had 45-odd people tune-in (my estimate, although difficult to determine as not everyone had their cameras turned-on) (Something I recently learned to be a ‘thing’ in Zoomland, in that turning your camera off is kind of acceptable to younger people who prefer to watch but not be watched; kind of weird to me though, a little like joining a party via a one-way mirror).

Getting to the difficult moment.

We ran through the talk; when and how to don and doff, what to touch, how to clean, wipe, isolate and so on.

Lynn, our wonderful Care Homes Team nurse ran a demonstration of how to put on and take off the kit;

Then someone asked about The Guidance.

I put this in capitals as it is, like one-way mirrors, another ‘thing’.

You see, since Covid began in earnest, in the UK, round-about the start of March those of us working in care have been receiving daily updates of the guidance from the Department of Health or Public Health England (I am not that clear what the difference between the two is, although I guess the DoH is full of bureaucrats and managers directly influenced by politicians and PHE is full of doctors, nurses, social workers and managers indirectly (or not) influenced by politicians) (I may be wrong).

As an example, yesterday I received 14 updates with different items of guidance and, it is like this every day. If we have been running this for, let’s say, 30 days, that is something in the region of 400 documents.

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Yes, a lot.

Too much in fact.

I actually started the talk yesterday with the comment that initially there was too little information which wasn’t helpful, now there is too much information which is equally as useless; no happy medium, or, perhaps I am just never happy with what I have got.

We, that is the doctors, nurses, health and social care managers do our best to keep-up; it is impossible (particularly when the guidance comes-out and it is obviously wrong e.g. the first discussions about only using PPE when you thought someone had Covid (was illogical) or the more recent guidance about family members verifying the death of their husbands or wives (immoral/wrong).

So, I guess, I have to hold my hands-up and say, I am not reading most of it.

I am not back where I was after the last election where I deleted my Facebook, Twitter and BBC News apps, but possibly getting there (I still haven’t reinstalled the BBC).

I appreciate I am getting off-topic although it is kind of relevant;

You see, Lynn, after her donning and doffing, explained that if you are caring for a patient (resident in social care (these people have retained some elements of their identity unlike the anonymising process of turning into a patient)) who likely has (or has been tested for and definitely has) Covid and is actively coughing, they are likely to be releasing multiple (i.e. trillions) or particles of Covid Virus into the air; some of this might land on your goggles and facemask and pinnie and after caring for such a person, it is reasonable to take the gown and mask off and use a new one before you move-on to the next resident.

Kind of makes sense.

Yet, the most recent advice (according to the managers who challenged us) was to keep the same mask on for a shift; we use a new word for this ‘sessional’ i.e. the time between coming on shift and taking a break, which for some people can be many, many hours.

So, Lynn advised to change the mask if someone was coughing away, the government to keep the mask – the two managers even had the guidance printed out which they showed us on the call.

How do you reconcile conflicting advice?

Well, if you are human, which is most of us, you tend to ignore one and listen to the other, even if one is more logical; we call this cognitive dissonance – when dealing with two conflicting pieces of information, you go with the one that seems most familiar.

My response, in trying to chair the discussion was to do what felt right at that moment in time for that patient/resident.

Although there is guidance it is guidance.

As my colleague Professor Burns says, these are guidelines not tramlines; they don’t say what to do in every specific situation – they can’t; they are finite, and the world is infinite.

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I’m not sure if this came across.

I pulled-out the old trope of, ‘Let’s move on to something else and we will find-out the facts and share the current guidance with everyone later’ (met with the managers flourishing the piece of paper aka latest guidance on the screen) – I hope I at least convinced some people.

You see, I don’t, indeed I never have followed guidance (OMG says my medical defence union), more, I take each patient, situation and event at a time on face-value and decide what is best then and there;

Each patient encounter is unique, either because the patient is unique (they all are) or the situation (they all are), the condition (some similarities) or I am (my relationship or interaction with each person is different).

I therefore don’t do what I want, I do what I believe to be right. In the best interests of my patient and I at that moment in time.

I know doctors are lucky, we get to bend the rules more than anyone and sometimes this works, sometimes not.

All we can do in the Time of Covid is to do our best and act in good faith.

Whether we read the latest guidance or the one before that, we can only act with the tools we have before us (mask, goggles, gown) and the information and time and capacity available.

We are finite and also, infinite.

We are a paradox.

Try getting that across in 60 minutes of Zoom-time.

We are running another care home Zoom next week followed by a call designed for home-care staff (aka ‘domiciliary’) – the forgotten backbone of care and support in the UK; if you want details please email me r.kersh@nhs.net

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I dedicate this blog to my colleague, Dr Medhat Atalla who died Wednesday the 22nd April from Covid-19.

I worked with Medhat for many years during my time as a medical registrar then consultant in Doncaster.

Medhat, a quiet, reserved guy who always arrived early and left late would spend hours reading notes, supporting doctors and nurses and communicating with patients and their families.

It was always odd when we would arrive in work in the morning on the Gresley Unit, with my, ‘Morning Medhat,’ and his, ‘Doctor Kersh’

He always kept this formality.

Perhaps a reflection of his heritage.

At one point Medhat and I even shared patients; taking half a week each running one of the original winter wards, which subsequently became Kingfisher and Kestrel.

He had a great smile;

Take care.

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