Experiences from the COVID Intensive Care Unit – Interview with Speech Therapist Sarah Stierli

Speech therapist Sarah Stierli at SPC, Nottwil, talks about her experiences in the intensive care unit during the COVID-19 pandemic

In early 2020, photos of overcrowded intensive care units, severely ill people and exhausted hospital staff were broadcasted around the world. Back then, they seemed far away and yet we were shocked and worried.

Soon after, also the intensive care units of Swiss hospitals started to treat people who were infected with SARS-CoV-2 – the “Corona virus”. Also here in Switzerland, some hospitals reached their maximum capacities. There was hardly any time to report about it and pictures of Swiss hospital wards treating COVID patients are rare.

Still, one might ask oneself what the people experienced in these units. How was it to be a severely ill patient in complete isolation? How did staff deal with the risk of exposing themselves to getting infected?

This blog post provides insights into the intensive care unit (ICU) of Swiss Paraplegic Centre (SPC) in Nottwil during peak times of the pandemic. It also sheds light on the question why speech therapists, in addition to ICU nursing staff, were exposed to particular risks.

In the first part, speech therapist Sarah Stierli talks in an interview about her work in the COVID-ICU at SPC. In the second part, Zeljko Raduljevic, who was severely ill from COVID-19, reports about his experiences in this - literally isolated – world.

March 2020: State of emergency at Swiss Paraplegic Centre

In March 2020, the Canton of Lucerne asked SPC for support in coping with the pandemic. Aside from the Cantonal Hospital of Lucerne, the St. Anna Clinic and the RehaClinic Sonnmatt Lucerne, SPC became the fourth cantonal medical treatment center for COVID-19 patients. The SPC gym was set up with 200 emergency beds as well as several care units for admission of COVID-19 patients were set up. Among them also the ICU. In the following video shot in March 2020, the former SPC Director, Hans Peter Gmünder, informed about the course of action.

Deputy Head of Logopedics, Sarah Stierli, explains the state of emergency back then in the ICU: “The regular ICU at SPC has 16 beds where each patient is separated by a sliding door from the hallway. Normally, standard hygiene is sufficient, sometimes individual rooms are isolated. We are usually dealing with droplet isolation; i.e. a protective coat is required and the face mask has to be exchanged upon leaving the room.”

“In case of an aerosol isolation”, Sarah continues, “that’s a different scenario because aerosols are smaller than droplets and move freely through the air. Therefore, the area in which we have to protect ourselves is much larger. Furthermore, the familiar FFP2 masks which protect us from breathing in aerosols are required. Only few illnesses require this level of protection. Therefore, the situation was quite extraordinary. SPC had to take structural arrangements to be able to isolate part of the ICU through separating walls and ports – the COVID-ICU.”

“They simply need our help right now.”

Sarah Stierli

The situation was quite tense at that time, describes the speech therapist. “Only little was known about the virus, little on how to best protect oneself. This was very stressful in the beginning.”

Nevertheless, says Sarah, it was clear to her and the entire logopedics team: “We are simply needed right now. This is our main task, virus or not.”

Swallowing exercises and speaking despite machine ventilation – logopedics in the ICU

In fact, logopedics was providing the same services as usually, explains Sarah. “Normally we work with patients who are on a ventilator due to severe accidents, intensive surgery on the spine or high quadriplegia. Now, the patients were in intensive care because they became ill with COVID-19.”

What exactly are the services provided by a speech therapist? “In all patients who were intubated for more than 48 hours, sensitivity of the pharynx was reduced”, Sarah explains. “This creates a latent risk that they develop dysphagia. That means that they are not able to swallow their own saliva easily. Also eating and drinking and taking medication can become challenging.”

Therefore logopedics assesses patients who were on a ventilator through the mouth (intubated), swallowing and dealing with saliva and secretion. Some are able to breathe on their own at this point while others continue to be dependent on mechanical respiration and are therefore tracheostomized. That means direct access is gained to the respiratory tract through tracheotomy and a tracheostomy tube is inserted through this hole. The respiratory tube can then be attached to the tracheostomy tube as shown in picture 1.

Picture 1: A patient who is ventilated through a tracheostomy tube in the ICU of SPC. A green speaking valve is integrated in the respiratory tube so that the patient can speak despite being ventilated.

“Aside from swallowing, logopedics in the ICU also ensures communication”, says Sarah. “To enable swallowing exercises and speaking, we set the patients up with a valve so that they can talk while being ventilated.”

The respiratory tubes have to be separated for a short period of time to insert the speaking valve. On pictures 1 and 2, the green valve is visible on the respiratory tube. Picture 2 shows Sarah in protective gear on the COVID-ICU while performing the described adaptation. The respiratory tube on the picture is separated from the patient and lies on his abdomen.

Responsibility and maximum concentration – daily routine in the COVID-ICU

When separating the respiratory tubes, the ventilator releases contaminated exhaled air of the patient into the room. This explains why speech therapists are exposed to particular risks. “All logopedic measures on a patient generate aerosols”, Sarah confirms.

Understandably this task was highly respected during the first wave in 2020. Risks and benefits for the treatments in the COVID-ICU had to be weighed carefully. It was a group decision to provide logopedic therapy while adhering strictly to the protective protocols.

“The severely ill COVID-19 patients underwent logopedics each day at least once, sometimes even several times. We did everything possible without exposing ourselves too much to the risks”, Sarah explains.

Picture 2: Sarah Stierli in protective clothing at work in the COVID-ICU: When the respiratory tube is briefly separated from the patient, things need to happen fast.

Each day, one person of the logopedics department was assigned to the COVID-ICU. Everybody was able to decide freely how often they wanted to be in the ICU. Sarah remembers: “The team always came together to see who wanted to and who could take over how many shifts. When doing so, we were honest with each other, which is very important – and still so today. Everybody should always be able to say where the personal limits are.”

“The constant question: When do I touch what? This is an enormous challenge for the brain.”

Sarah Stierli

Before the shift, it was important to familiarize oneself with all patients’ records in as much detail as possible. Above all, it was important to perpare supplies well. “Everything that you take into the COVID-ICU must not come back out. At the same time, you can also not quickly get something”, Sarah explains.

“Then you pass the outer port, put on the protective coat, cap for the head, FFP2-mask, protective goggles and gloves. The goal is to have as little bare skin as possible”. She even attached the protective goggles with tape to the cap so that nothing could move, she further explained. Then you were allowed to enter the COVID-ICU through the inner port.

The work wasn’t comfortable. “I drank little so that I would not have to take off the mask but also because it was complicated to go to the washroom with all the clothing. Most of the time, I did not take any breaks, only during lunch”, Sarah said. Meals were taken in a separate room in the COVID-ICU. There you were allowed to free yourself from the protective gear for a short period.

“At the end of the day, you took off your clothes in the port and you could take a shower directly in the change room. This felt really good from a hygienic as well as psychological perspective”, says the speech therapist. Back in the office, she then documented her work or made important phone calls.

Every single move in the COVID-ICU was considered in detail. Sarah underlines: “The constant question: What do I touch when? This is an immense challenge for the brain”. It also requires you to have great trust in the actions of the others. “In the COVID-ICU, everyone is in the same boat”, she explains, “you also carry responsibility for others”.

Fear and gratefulness – emotions in the COVID-ICU

This was also Sarah’s responsibility outside of the COVID-ICU. During the first lockdown, she isolated herself and her husband and their two children to protect others. “The kids were not allowed to play with other kids because I did not know what I would bring home. I absolutely did not want the virus to spread from my kids to other families”, she explains.

“Suddenly you also become the only contact, for a woman or a child, replacement for everything.”

Sarah Stierli

In addition to the concerns about the virus, what worried her the most was the solitude of her patients in the COVID-ICU who were not allowed to see anyone for months. “It was not even clear whether they would see their loved ones ever again”, says Sarah. This was a big burden on all health professionals in the COVID-ICU.

“Suddenly you are also replacing family members, for a woman or a child, replacement for everything”, she explains. During therapy, the task was often to ensure that the speaking valve would allow communication with family members. She often facilitated FaceTime calls and was then in close contact with the family members. She comments: “This is a huge emotional burden but also rewarding because you notice how much you are needed.”

Picture 3: Sarah is communicating with a severely ill patient. Behind the protective gear, communicating with the eyes is especially important.

The meaningfulness of her task was also what kept her going, says Sarah. Through logopedics making the first attempts to swallow sorbet or finally being able to speak is generally a very valuable experience for patients. Due to the particular circumstances, however, she felt especially appreciated in the COVID-ICU.

Whether she was able to take something positive out of the difficult situation? Sarah mentions the even stronger connection among her own team and among all employees of SPC. She learned a lot professionally. SPC’s unofficial motto “Doesn’t work, doesn’t exist” was lived much more intensely.

Picture 4: Without COVID, this is what it looks like on the ICU of the SPC.

Scientific work instead of recreation

After the first wave, she should have taken some time off, Sarah says. But then there was the opportunity to write down her experiences from the COVID-ICU in a scientific paper. The article has meanwhile been published and here is the link.

“It was only work, eat, sleep.”

Sarah Stierli

She was therefore hardly able to take her overtime and recover as much as she should have, she says. And then the second wave in fall 2020 arrived much sooner than expected. “I briefly thought that I could no longer do it. And it was indeed a massive burden throughout the winter and used up all my energy. I was tired, exhausted and hardly able to recover. It was only work, eat, sleep”, she says.

In the meantime, however, she has recovered well. And she sincerely hopes the situation will stay like this with the vaccine “and the suffering of so many affected people, irrespective of their age, finally passes”.

We share this hope.

That the situation on other COVID-ICUs was similar, becomes clear through the impressive pictures by Fabian Fiechter. As ICU-nurse, he documented the work through photography of severely ill COVID-19 patients before and after his shift on the ICU of the University Hospital Basel. Here are a few of his photos:

The second part of the blog series is about patient Zeljko Raduljevic who became paralyzed from the neck down since his severe course of disease of COVID-19.

Raduljevic has been in rehabiliation at SPC Nottwil since February 2020. He openly describes, how he experienced the time and how he deals with the situation – and talks about a “small wonder”. The second part will appear soon here on Community.