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MIRROR How can I imagine the condition of a Covid patient who comes to the intensive care unit?
Vögeli: The impressive thing about the clinical picture is that the patients are very sharp, very bad. You have great difficulty breathing, but, and this is interesting, it does not manifest itself through restlessness, fear, or panic. Instead, they shut up very quickly, at least that’s how we observe it. It is as if there is simply no gas exchange in your lungs from now on.
Svenja Vögeli30 She has been working as an anesthesia and intensive care nurse for almost eight years, currently in a maximum care clinic in Bavaria. Due to a previous illness, she doesn’t care about Covid patients, but she experiences everything very closely. Here she describes the experiences of her colleagues in her neighborhood.
MIRROR What does this mean for treatment?
Vögeli: As soon as they arrive at the intensive care unit, patients must be intubated immediately, that is, artificially ventilated. This is different from many other patients with shortness of breath, who show signs of worsening, but can often still save a little time. That is one of the most significant differences.
MIRROR How do you prepare for it?
Vögeli: In all rooms, which are intended for Covid patients, there is a respirator equipped with all tubes and checked, as well as materials for various supply and discharge lines, such as catheters. Otherwise, this is only done when patients are there and actually have to be intubated.
Intensive care bed in a room of the Dresden University Hospital: to the left of the bed is a heart and lung machine, above are the monitoring monitors, to the right of the bed is a respirator and infusion technology
Ronald Bonß / DPA
MIRROR How busy is your station right now?
Vögeli: Our currently specially designed Covid intensive care unit has 12 of 16 beds. However, we still have ventilation spots on our back.
MIRROR In view of this, would you make it all clear to him?
Vögeli: No, it is too early for that, also because the disease is not palpable. We still know very little, the courses may differ greatly. For example, we had a patient infected by her 90-year-old mother. The 90-year-old man was in the normal room from the beginning. But her daughter was in very poor condition for days and had to be artificially ventilated in the intensive care unit in the late 1950s and early 1960s.
MIRROR What happens when a Covid patient arrives at the intensive care unit?
Vögeli: It is first connected to monitoring, for example to record pulse and blood pressure. Intubation then generally occurs. Then, patients are connected, as we call it, given a central venous catheter, for example, to administer medications that stabilize circulation. And an x-ray is taken of his lungs.
MIRROR How much do patients notice about all this?
Vögeli: Often there is only one head shake or one head shake. Of course, we explain what happens to the patient. Tell them that we are going to put them to sleep and we will help them breathe so that their lungs can recover. Most of them just nod and appreciate being helped. In this state, they really couldn’t say no, even if they wanted to.
MIRROR How important is psychological care in such a situation?
Vögeli: It is one of the most important tasks in nursing. The doctor often has to consult again or make phone calls to family members, at this time we do not leave the patient alone, we explain everything to them again in simple words, maybe we just hold hands. Even if patients fell asleep soundly to breathe artificially, we spoke to them. For example, let them know when we enter the room, when we leave the room, or when we change positions. You never know what the subconscious will notice.
MIRROR Do some patients react to this?
Vögeli: Sometimes, you see an increase in blood pressure or an increase in heart rate. However, as a general rule, Covid patients are very sedated to tolerate the breathing tube and the prone therapeutic position.
MIRROR Why are you turning the patient upside down?
Vögeli: The goal is to improve circulation and ventilation of the lungs, and thus gas exchange. But it does with every lung failure, not just with Covid patients.
MIRROR What does it mean to care for a patient receiving artificial ventilation?
Vögeli: At first, we do blood gas tests almost every hour and adjust ventilation pressures, respiratory rate, or oxygen, if necessary, so that the patient has optimal ventilation. We also administer medications, wash and care for patients, and regularly change their position in bed to avoid pressure ulcers. Once in turn they receive eye, nasal and oral care, the breathing tube moves to the other corner of the mouth. And of course we control the values on the monitor, the pulse, the blood pressure and the oxygen saturation. We always set the alarm limits of the devices at the beginning of the service so that we are informed in time if one of the values deteriorates or if the patient begins to breathe, for example.
MIRROR Can that happen?
Vögeli: Yes, it shouldn’t. Especially when patients are lying on their stomach, they must sleep so soundly that they will not notice anything and can be ventilated without problems. To ensure this, we also pay attention to all common waking signs, for example movements.
MIRROR Can you leave such a patient alone?
Vögeli: You must leave the room before, for example, to take medicine or to obtain missing materials. However, we have a central monitor on which we can see the values of all patients. In addition, a kind of baby monitor is installed in the hallway of the Covid room so that we can react immediately if, for example, a respirator sounds an alarm or the medicine runs out.
MIRROR How many seriously ill patients can a caregiver care for at the same time?
Vögeli: There are currently a maximum of two for Covid patients. But nothing else is possible. On the one hand, because at the most there are intensive care patients; On the other hand, because you have to dress up every time you enter the room. That is time consuming and working with FFP masks and safety glasses is extremely tiring. If you wean a patient from artificial ventilation, you would actually need personalized attention, even without Covid. Unfortunately this cannot be done.
MIRROR How does this weaning work?
Vögeli: There are different starting points. Most of the time, he begins to cut down on his sleeping medication, and waits and sees. Does the patient show wakefulness? Are you starting to grimace? Do you have your own breathing drive? The goal is often to find a balance: the patient must be awake enough to be able to breathe independently, but at the same time he is sufficiently protected by the medication so that he is not stressed.
MIRROR How do patients react when they wake up?
Vögeli: Often unable to wait for a specific response, patients are not immediately awake from now on. Some are stuck in a kind of intermediate world for days because the body first has to break down the medicine. Many react with high blood pressure, high heart rate, begin to sweat, press against the vent, or reach for the vent hose. A very demanding phase in nursing.
MIRROR At the same time, patients have to learn to breathe independently again.
Vögeli: Exactly We try to put the patient in a special mode of spontaneous breathing of the ventilation machine, that is, to restore independent breathing.
MIRROR What role does the psyche play in this?
Vögeli: Many patients with, for example, a surplus of medications simply need someone who is in bed and encourages them to breathe. I call it cheerleaders, you have to have a calming effect on others. It is particularly difficult when patients do not speak their language and cannot explain to them where they are and what is happening.
MIRROR How long does this phase last?
Vögeli: That largely depends on the age and duration of ventilation. With young people without significant pre-existing conditions, this is often done in a day or two. But for older people who are previously stressed at all levels and whose respiratory muscles become even poorer, this can go on for days and sometimes unfortunately for weeks. Many also fail to independently breathe permanently or have to be intubated again due to other complications, which we have also observed in some patients with Covid-19. Many also go on dialysis since the kidney is often the first organ to fail due to extreme oxygen starvation.
MIRROR You can hardly care for a patient with more effort.
Vögeli: That is usually the best, but it can also be fun as a specialist. And there are success stories. As far as I know, the youngest Covid patient was 35 years old. We relocated her to acute lung failure and she’s back now and no longer needs ventilation.
