The plight of nurses in Covid treatment units

At Mulago National Referral Hospital where most of the critical cases end up, nurses had to be transferred from other departments to serve at the treatment units. 

Those transferred had undergone a week of training when a few asymptomatic patients were admitted at the Covid Treatment Unit (CTU) from March  last year. 

A refresher training for a day ushered some of the nurses whose services were much needed in CTU, especially from October. 

Joining CTU is on a voluntary basis but also depends on the nurses’ health condition. One must be healthy and physically fit. 

The treatment units shifts are tight. Those who begin at 9am finish by 2pm, the next shift joins from 2pm to 9pm or 10pm depending on how the next shift keeps time.  The night shift starts from 9pm to 3am before another from 3am to 9am depending on how the colleagues keep time. There must be no gap or else a patient can die trying to help themselves. 

“They are 100 per cent dependent on oxygen. If you remove (the oxygen) and allow them to use the toilet, someone can collapse and die. So they do everything from their beds,”  Ms Akite  (not real name) , a nurse who has been working at the CTU since March 22 last year when Uganda announced the first case,  says.

Caregivers

Since the patients in HDU and Intensive Care Unit (ICU) are not allowed to  leave their beds, nurses have to also do bed baths, clean those who ease themselves and change their bedsheets. 

They also have to feed the patient, change position for those who cannot turn on their own, ensure they have taken their medication and be on standby should a doctor or any other specialist be needed to attend to the patient. Some patients require transfer from HDU to ICU or vice versa, and that requires utmost care.  

Ms Acii (not real name) joined the team of about 100 nurses at CTU at Mulago two months ago. 

She has adjusted to the five-day work routine, which is exhausting and stressful.

Ms Acii leaves her house at about 8am, attends the morning meeting and dons her PPE to begin her 9am shift. Breakfast is served during the meeting. After the meeting, about 30 minutes is left for donning, preparing to enter the wards. 

Before she dons the PPE, she has to ease herself to be able to stand the six to seven hours of attending to Covid -19 patients in the high dependency ward without answering nature’s call.

“If you feel like your bladder is full, you hold (the urine). Once you get out, you do not go back in. But when you feel dizzy, you are advised to doff (remove PPE) and leave the red zone,”Ms Acii says. 

Dr Paska Apiyo, a physician and the officer-in-charge of the case management unit at Gulu Regional Referral Hospital, says:  “You cannot remove the PPE then wear it again. You can get infected. If you are badly off, you do it (urinate) in your PPE. But we train you (the nurse) so that you learn to hold (urine). Once it happens and it becomes frequent, whoever finds themselves in such a situation, you are advised to report [it].” 

“Someone can be diabetic. You cannot force yourself to continue with the work. It becomes a health risk for you as well,” he adds.      

Medical experts say dizziness is a warning sign as it can be caused by dehydration, hyperventilation (gasping for breath), elevated carbondioxide levels in the blood, low blood sugar, and anxiety, among other things.

Particular features of PPE can impose a physiological (how the body normally functions) burden on the healthcare worker which can be exacerbated by long work hours without adequate breaks for eating, hydration and self-care.

“It is not easy staying in that PPE for more than six hours without a break. When you enter, you find patients calling for help (from their beds, on oxygen),” says Ms Acii.

Dr Apiyo says no medical personnel is recommended to stay in PPE for more than three hours.  

“This is not right. It can affect the physiological functioning of the healthcare worker. Heat stroke can be very dangerous to some people if they stay in for too long. The PPEs are hot and you need to get used to it. Some people stay in it for ten minutes and they are already touching their bodies. It is risky (in terms of infections),” Dr Apiyo says. 

He says when dealing with infectious diseases and epidemics, one has to be trained and prepared to fit in the treatment unit. 

The three HDU wings, male, female and main wards at Mulago CTU can have four or five nurses attending to more than 60 patients depending on admissions and transfers to other units. 

“From the time you enter, you find someone is on 10 litres (oxygen) and it is not enough. You do not have another cylinder to be replaced so you have to roll an empty one and look for where you can get one to put on the patient. Others are crying in pain. Sometimes you fix the oxygen pots but it is faulty. You have to call for another one,” Ms Akite says.

However, Dr Rose May Byanyima, the deputy executive director of Mulago hospital, maintains that they have enough nurses, including some who have been interviewed, awaiting appointment as and when the need arises. 

The nurses say whoever doffs (removes the PPE) and comes out does not go back inside the ward because the PPEs are few.

Dr Byanyima could not clearly state whether or not inadequacy of PPEs or staffing is the reason for the six to seven hourly shifts. 

On Thursday last week, Mulago had 131 on admission with nine newly admitted, seven in ICU and 85 in HDU. 

Two had been discharged on December 30, seven on December 29 and 11 on December 28. 

The bulk of the work in caregiving before one is discharged falls in the hands of nurses. 

However, at Entebbe Grade B Hospital where Covid-19 patients are also being treated, health workers take less than two hours in. The hospital currently has 20 patients in ICU.

“They do not take more than two hours in the wards because the PPE is uncomfortable and hot. But when there is need, we can stretch to two hours. But we cannot take more than two hours,” says Dr Moses Muwanga, the executive director of Entebbe Grade B hospital.

Dehydration due to over sweating is one of the main challenges that Covid-19 caregivers wearing PPEs face whenever they get out of the wards.

But for the case of Mulago hospital, one has to minimise fluid intakes before entering the ward to reduce their chances of  answering nature’s call while inside the ward.

Dr Byanyima works with more than 100 nurses in CTU. But these nurses say they are overwhelmed with the workload since more patients are admitted. 

Last Thursday, Dr Byanyima confirmed to Daily Monitor  that there are nurses in the HDU working for between seven to eight hours and four hourly shifts for those in the ICU. 

She says the nurses are restricted from frequently coming out of the ward while on duty because some are lazy and give excuses so that they do not cooperate with the rest throughout their duty period. She also says if the next group delays to come in for their shift, they keep those already in the wards longer. 

“It is on you (the nurse) acting responsibly so that you relieve your colleague. They are trained as nurses on how to dress and be in there. There are those who are screened, like the diabetic, we do not want you to be in there because they have to take their meals in time, the blood sugar is out of range that is why they form urine very fast and they cannot hold it,”  Dr Byanyima says. 

For those who are healthy and can continue to offer the much needed comfort and counselling to some depressed and stressed patients, they must do so while ensuring their own safety.

“I have heard some of my friends say they urinate in their PPEs if they cannot hold it anymore because they fear getting other complications from over holding urine. I have never done it but I also hear it is uncomfortable because you have to continue working in that PPE soaked in sweat and urine,” Ms Akite says. 

Dr Frank Asiimwe, a senior urologist at Mulago hospital, says it is not problematic for a healthy person to hold urine. He adds that the body system can adapt to the situation if one is in an environment that requires them to once in a while hold it.

A typical case cited is of surgeons who can, once in a while, perform an operation for about 10 hours without going to the bathroom.

Urologists say if it is a younger person without any abnormality, holding urine for long once in a while is okay. But the older one gets, the more they strain their urinary system and it becomes more difficult and problematic to hold urine. In that case, one has to respond to the urge.

“But if you have underlying conditions, then that can make things worse. For instance, old men with enlarged prostates, which are blocking the system. Then older women you have had several deliveries (of babies), their systems are a little bit weak, that (holding urine) could trigger a leak (of urine). So depending on the age of the person and the underlying problem, in some patients, it can trigger an actual failure to pass the urine,”  Dr Asiimwe says.

Whereas holding urine will not be the immediate or direct cause of these complications, it will have triggered it because of the underlying problem. Failure to empty the bladder can also predispose someone to infections.