A step-down facility in Dublin is helping to rehabilitate patients who have been severely impacted by coronavirus using physiotherapy, occupational therapy and psychological support.
The last thing Ann Keelan remembers before being placed into an induced coma in intensive care was a mask going over her face. Just two days earlier she had been admitted to Beaumont Hospital in Dublin with a sharp pain in her stomach; she had been unwell for a week and suspected it could be appendicitis.
From Donabate, north Co Dublin, the 57-year-old mother of three adult children was tested for coronavirus with the results coming back positive a day later on March 19th.
“I was shocked. I didn’t have a cough, I had a temperature but none of the other symptoms, no tightness of chest,” she tells The Irish Times. She has asthma but has not had a serious attack in over a decade.
Sitting in her hospital bed things began to move very quickly as her condition deteriorated. Her doctors told her they wanted to move her into the intensive care unit and put her into an induced coma on a ventilator, in an effort to stave off the worst impacts of the virus.
“They did tell me some people don’t wake up. I said if it’s for the best then you have my permission to go and do it . . . I’m a fighter,” she says.
At the back of her mind was the fear she would become a statistic, one of the scores of Covid-19 fatalities announced each evening.
“You try to acknowledge but ignore it. It is scary, all you hear about is the people who have passed and the deaths each day.”
Intubated on a ventilator for a week, when she woke up she could not speak or sit up. She had survived coronavirus, but the trauma of intensive care had taken its toll and severely weakened her muscles.
“I couldn’t talk, because I had had the tube down my throat, that was frustrating . . . I couldn’t even hold a cup, I picked up a cup and spilled it all over me,” she says. Breathing with the help of an oxygen mask, she was moved from intensive care to a Covid-19 ward in Beaumont.
The ward was “hectic,” with staff “run off their feet” caring for large numbers of patients, their medical gowns often sticking to their bodies with the sweat, Keelan says. Despite the intense pressure, the staff “tried their best to brighten your day”.
The journey to full recovery after ICU can be a long and frustrating one. At first even sitting upright could lead Keelan to faint. Several times standing with the assistance of two nurses her legs gave way, but slowly she began to recover her strength.
Step-down
On April 8th, Keelan was moved to Clontarf Hospital, north Dublin, which has now opened two wards to rehabilitate patients who have experienced severe cases of coronavirus. The step-down facility has capacity for 48 Covid-19 patients, where physiotherapists and occupational therapists will work towards their rehabilitation.
Carmel Curran is a consultant geriatrician in Beaumont who also works with patients in Clontarf Hospital. The aftermath of intensive care can be "huge" on patients and "some need to learn to sit again, to stand again and walk", she says. The patient's lungs will be injured and they will quickly find themselves short of breath during simple tasks such as walking to the bathroom.
It is not uncommon for patients to experience post-traumatic stress disorder after intensive care. One thing Curran has seen during the pandemic is a heightened psychological trauma among Covid-19 patients post-ICU. She says that being treated in hospital by faceless staff wearing full PPE (personal protection equipment), masks, goggles and gowns, and the absence of family visiting adds to this trauma.
“A lot of people leaving ICU will have the elation, but then in the weeks after the nightmares and flashbacks will start.” So much so that Clontarf Hospital is looking to introduce psychological support for patients who show signs of post-traumatic stress.
The age of Covid-19 patients recovering in Clontarf ranges from people in their 20s to their early 80s.
“If you’ve had severe Covid-19 you’re very deconditioned, your muscles are weak,” Dr Curran explains. Rehab work begins shortly after intensive care, with patients first working to sit up in bed, then in a chair, moving up to standing with the help of two staff, and then walking with a Zimmer frame.
Caroline Daly is the senior physiotherapist on one of the Covid-19 wards in Clontarf. She starts her day with a socially-distanced meeting in the gym with other physio staff, before donning full PPE gear and heading on to the ward where she will stay for the day.
During her rounds she will run through a chart of physical exercises with each patient, constantly assessing their progress.
“These patients are complex, they will potentially have ongoing pulmonary scarring on their lungs,” she says, which means they fatigue “very easily”.
The aim is to build back up strength in the thighs and legs and work towards everyday mundane tasks such as putting on a pair of socks.
The sudden loss of independence can be difficult for younger patients, while older patients who had completely lost their mobility while in hospital were often “very apathetic” at the start, Daly says.
“Some patients can be quite good one day and then you come in and they’re very sick, almost to a critical level. There have been a couple we’ve had to transfer back to hospital.”
She has worked in Clontarf Hospital since 2011, previously providing lighter orthopaedic care often to elderly patients recovering from hip surgery, but work on the Covid-19 ward is significantly more intense.
Keelan is currently practicing how to walk up stairs again.
“I couldn’t put one foot in front of the other [when I came in] every little bit I do is closer to home.” She is no stranger to a difficult recovery; in 1999 she suffered a serious spinal injury after falling down stairs and was in hospital for several months.
Back then her daughters were aged two, three and nine, and she “had to get back up” to care for them. This time around “they’ll be taking care of me” upon her expected return home in the coming days, she says.
After several weeks working on strength, movement and balance, patients are discharged. Previously they would be referred for community healthcare support, but the current crisis means the same level of aftercare is not available, Daly says. To bridge the gap she has been checking in on discharged patients via WhatsApp to run through exercises.
Sharon Trehy, director of nursing, says while the facility was providing rehabilitation to Covid-19 patients after critical care in hospital, it was also dealing with outbreaks in non-coronavirus wards.
In late March the hospital had its first cluster of Covid-19 infection and the virus was a “nightmare” to contain, she says. Once there is a confirmed case in a congregated setting it is “very hard to dampen out that fire” and prevent it spreading. At any time 50 of the 270 staff will be out of work with symptoms awaiting test results or self-isolating with the virus.
“There seems to be no rules around this virus, the rules are always changing,” Trehy says.
