Alumni nurses respond to Covid-19 pandemic: Inside the ICU

Registered Nurse Suresh Rajasekaram (BSN’16) at the National University Hospital’s medical intensive care unit.

Suresh Rajasekaram: As a healthcare worker, I have many reasons to be grateful. Even though the circuit breaker has impacted many aspects of our economy and has been tough for those who’ve had to stay home, it has kept community transmissions low and helped the healthcare system manage our patient loads. As a country, we should be proud of our response. Our mortality rate has been low at 0.07% and healthcare workers here have the necessary PPE to care for infected patients without having to risk our lives. Being small, we have an edge in keeping the spread in check as our economy opens up in phases. I think it’s essential for everyone to remember that we all have a part to play; it’s a new normal and an imperfect world we live in now, so let’s be patient and help one another get through this!

I was a student during Singapore’s last pandemic, the H1N1 outbreak in 2009. This is very different: the SARS-CoV-2 virus is new, and many questions on how it spreads remain unanswered. To safeguard ourselves and our colleagues, we’ve had to take the highest form of precautions when caring for infected patients. This has meant learning to put on and remove PPE without any shortcuts or complacency, including donning and doffing N95 masks, goggles, gowns and gloves, and in certain instances, Powered Air Purifying Respirators.

Another characteristic of handling this virus is that our workflows change very rapidly. At the ICU, we have many workflows, such as obtaining and despatching specimens from COVID-19 patients, transporting them out of the ICU for scans or transfers to another unit, and bed allocations once the unit hits a certain percentage of bed occupancy. Initially, these would change every few days, if not daily, as new evidence and knowledge emerge. The nurses in the ICU have had to keep current with updates almost daily. 

Most of our patients are severely ill with serious lung injury leading to Acute Respiratory Distress syndrome and multi-organ dysfunction. They are intubated and heavily sedated to allow for rest and recovery, while the ventilator takes over their breathing and regulates gas exchange. A few others need Extra-corporeal Membrane Oxygenation (ECMO), which is the last stage of full life support to give them the best fighting chance of a recovery.

We perform a long list of tasks! The scope of our care for COVID-19 patients focuses heavily on reducing the spread of transmission by isolating the patient in a negative-pressure single room. It includes receiving handover from the nurse from the patient’s previous location, physical assessment and monitoring of the patient, preparing and assisting to sedate and intubate the patient for mechanical ventilation, and insertion of invasive tubes and lines. We also prepare, assist with and perform portable chest x-rays, obtain blood and fluid specimens for tests, and initiate at least four to seven infusions and medications to stabilise and treat the patient.

It’s rougher performing these duties for COVID-19 patients. Nursing is a team-based profession and I would usually have a team of colleagues helping me to carry out these procedures simultaneously. With COVID-19, we’ve had to manage with a leaner team.

Furthermore, extremely good planning of care is necessary. Once I enter a patient’s room, I would want to perform all my duties at the same time to minimise the number of times I leave and re-enter the patient’s room to conserve precious PPE supplies and decrease the time taken to put on and remove them. Many times, I find myself staying in the room longer to monitor the patient, titrate the medication infusions and ensure everything is completed, which may take two to three hours at one stretch.

We have seen one death so far and a few patients who remain critically ill. But at the same time, we have also seen miraculous recoveries, including a patient who was clinically dead for six minutes. He was revived and subsequently made it out of the ICU to join his wife and children in a community isolation facility. At one point, he was so severely ill that all of us thought it could be the end of the road for him. There was also another patient whom I did not have the opportunity to care for but was also severely ill and was on ECMO. He too made a splendid recovery and is now back in the community.

Their recoveries renewed our confidence in the meaning and quality of the care we provide our patients.