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180 degree shift

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In an essay published by The Lancet Respiratory Medicine (and reproduced here with permission), Adam Nolan and Ethan Singer – who graduated from Brunel University London last year, and are now Chartered Physiotherapists – wrote about how the onset of the pandemic propelled them to have placements as clinical assistant practitioners, helping to rehabilitate COVID-19 patients.

Sat in one of the many lecture halls of Brunel University London, in December 2019, the concept of prone positioning seemed far detached from our reality. As we built up towards our final year physiotherapy exams, we knew this would be the last formal assessment before our final placements. Our physiotherapy lecturer, Dr Mandy Jones, discussed the PROSEVA trial and we listened attentively, knowing it could be assessed in the exam. However, what we did not know is that 4 months later, teams of health professionals termed “proning teams” would run from ward to ward turning patients onto their stomachs.

During March, 2020, student physiotherapy placements were cancelled. This meant we were faced with the question “will we finish our degrees?”, followed by “will we ever be qualified physiotherapists?”. Our anxiety was fuelled by the fact that the Health and Care Professions Council stipulated that due to the risk involved in treating patients with COVID-19, student physiotherapists had to be employed by a Trust for their final year placements. This was to provide students with additional employment rights and protection, but it highlighted the hazards that all health professionals were facing during that first wave.

Fortunately, we were offered the opportunity to return to our previous placement at one of London's leading centres for cardiorespiratory care. This would allow us to obtain the 1000 clinical hours we required to finish our degrees. Our makeshift role of clinical assistant practitioners meant that we were able to support the physiotherapy team as they rehabilitated patients with COVID-19. This modified student role allowed us to assist with rehab doubles and lead sessions for medically stable mobility patients. The aims of the rehab sessions were to reduce functional limitations on discharge. We saw many more intubated and ventilated patients than on a traditional placement, and this gave us the opportunity to develop our treatment skills, including the suctioning of sputum from patients' chests and hyperinflation techniques to assist in the re-expansion of collapsed lungs.

Interviews for physiotherapy posts commonly feature a prioritisation scenario—”how would you cope if all your team were off sick and you were left in charge of the ward?”. This scenario is never straightforward as it is centred around having few staff and a busy caseload. The apprehension of being asked this question in a potential job interview was soon replaced by the fear of having to cope with this situation in reality. During the first wave, our daily caseloads mirrored that of a qualified therapist, and were now in excess of ten patients—we were having to cope with many staff members off sick or self-isolating. Like Steven Gerrard in the second half of the famous “miracle in Istanbul” where Liverpool were three goals down to the Italian giants AC Milan, we refused to be defeated in this high-pressure situation. However, unlike Steven Gerrard who was at the top of his game, we were amateurs with ongoing deficits in knowledge and performance. In spite of our student status, we found that merely carrying on and attempting to maintain calm was the best remedy.

The experience of stepping onto the intensive care unit (ICU) for the first time felt like a blur. The “donning station” was like an MI5 operation with nursing staff ready at each station to ensure we were wearing personal protective equipment correctly. In retrospect, the strangest part of this ritual was downing a bottle of water in 5 s flat in order to prevent dehydration. Although reassuring, the nursing staff's presence did nothing to prevent the constant panic of making sure our mask had a seal, the pain of the mask straps digging into our ears nor the inevitable steaming up of our visors after a particularly physical rehabilitation session. This experience was something we never expected to happen to us and something we will never forget.

Our critical care lecturers, Alex Harvey and Mandy Jones, joined us to work clinically on ICU. The experience of seeing our lecturers walk into the office in the morning was surreal. Seeing your lecturers in scrubs working clinically (something we forgot they actually did) was a real surprise. There was a feeling of anticipation and nervousness. Similar to watching your friend who recounted how good they are at football turn up to have a game of five-a-side with you on the weekend. Furthermore, there was a feeling that at every opportunity we would be tested on our knowledge of ventilator settings. This was not necessarily the case and instead we saw the gap between academic and clinician bridged.

What we would like to see continue is the collective team effort we were exposed to during the pandemic. In a health-care system that sees patients evaluated and treated across a range of disciplines simultaneously, priorities are subjective. For instance, balancing essential rehabilitation with weaning from mechanical ventilation. The specific roles of each health professional are typically represented as discrete with limited overlap. In contrast, our experiences of the management of patients with COVID-19 showed us that the blurring of professional boundaries is useful. Indeed, the willingness of therapists experienced with artificial airways to help previously ward-based nurses, enabled patients to be managed safely in our makeshift ICUs. We hope in the future that this ability of multidisciplinary teams to work together in order to meet patient-centred goals continues.

Throughout our physiotherapy education, we have been taught to try and get the most out of patients. However, during the pandemic, we departed from this common belief as our paradigm shifted. Indeed, joint rehabilitation sessions with the psychologists highlighted the need to end these sessions on a high allowing the patient to feel positive about physiotherapy, in what would otherwise be a very negative and alien environment. Short-term sacrifice for the long-term goal was how we viewed it. Initially it felt wrong not to push patients to their absolute max. However, it was a strategy we used in order to build rapport and motivate our patients. Making real-time adjustments to our session plan, to push patients or not to push patients was a conundrum we often wrestled with. The experience of giving constant praise and positivity to our patients kept morale high, allowing us to achieve our mission of getting patients home.

The period between our enrolment at university and our lecture on prone positioning gave us the opportunity to learn the basics of respiratory physiotherapy. During the pandemic, we remember seeing a patient being put into the prone position for the first time. To us, this was a watershed moment. Much had been made about the virus in the media, in academic publications, and by our university, but actually seeing someone prone really emphasised how unwell some of these individuals had become. At the same time, we recalled our lecture months earlier. This lecture taught us the theory and evidence base around prone positioning, but what it couldn't teach us was that the process of proning a patient required coordinated teamwork, communication, and clear leadership.

The act of taking off our scrubs and putting them in the trademark orange bags that lined the hospital became symbolic, representing our departure from health care into the real world away from ventilators and the constant bleeping of alarms. In June, 2020, when we were finally awarded our physiotherapy degrees, we closed the chapter that began with 80 students learning about prone positioning tucked away in a quiet borough of London.

Physiotherapy at Brunel University London helps people lead more fulfilling lives, through illness and recovery. Find out more at www.brunel.ac.uk/physiotherapy.

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