Ema Swingwood

‘One of my abiding memories of the year has been coming out of the changing rooms to go into ITU, and seeing a line of consultants in personal protective equipment (PPE), all from paediatrics who had volunteered to form a proning team, waiting to go in and turn patients every morning and late afternoon. It was really upbeat and quite a sight to see these amazing consultants. It really highlighted how everybody was supporting each other.’

So says physiotherapist Ema Swingwood, the respiratory pathway lead at University Hospitals Bristol and Western (UHBW) NHS Trust, whose year on the Covid-19 frontline at the Bristol Royal Infirmary was marked with the award of the Order of the British Empire (OBE) in the New Year’s Honours in January, for her “services to physiotherapy”.

As chair of Association for Chartered Physiotherapists in Respiratory Care (ACPRC), Mrs Swingwood, led on the speedy development of UK specific respiratory physiotherapy advice and guidance for CSP members during the pandemic. She was also the clinical lead physiotherapist for Bristol’s 301 ITU bed Nightingale Hospital – which was, thankfully, never required for Covid patients.

But she describes her OBE as a “total surprise” and, although it is a personal award, she says: ‘I couldn’t have achieved any of this without the support and efforts of so many wonderful colleagues’.

Looking back, she says the past 12 months have been “amazing but brutal”. The onset of the pandemic saw her shift away from management to clinical work due to the sheer number of patients across so many clinical areas.

‘Initially my role was as a Covid floater, putting plans and risk assessments in place and organising teams. UHBW changed lots of working patterns to make sure that staff were OK. It’s all very easy to get swept away with it all and before you know it eight weeks have passed and you haven’t had a day off – so it’s about focussing on the wellbeing of staff.’

Demon virus

The first reports respiratory professionals were receiving from China made it clear to Mrs Swingwood and ACPRC colleagues that the virus much more dangerous than flu.

‘We put plans in place as a result of the learning from China and Europe but we found that our patients were presenting differently in terms of respiratory needs so therefore we needed to change our approach to fit those in front of us.

‘It’s a respiratory virus but it affects many more things than just the respiratory system. We had to use neuro and rehab skills, but there is no way that Covid could have been dealt with without us working as one element of a multidisciplinary team.’

She says the high incidence of serious respiratory problems associated with Covid are due to the way the virus attaches to receptors in the lungs. 

‘However there are also receptors in the gut which is why we have seen patients with diarrhoea, but they are located elsewhere which is why you get a multitude of symptoms. 

‘There is definitely something going on from a clotting perspective; patients were throwing off quite a lot of microemboli – clots which cause blockages – which impacted on cognition, memory and agitation. It’s a demon of a virus.’

Part of the task for the coming 12 months is to developing Covid follow-up clinics for the management of the fatigue and other symptoms associated with long Covid. 

Mrs Swingwood says it’s interesting to observe that many patients who were not hospitalised are the ones that are struggling with long-term symptoms.

‘At the moment we only know what a post-Covid patient looks like up to a year post-Covid. This time last year we were seeing the first patients, so it’s really hard to make sure that the pathways and services we put in place for this group are right -  so our plans need to be flexible.’

At the start of the pandemic, the ACPRC started getting queries about how to treat patients presenting with Covid. 

‘We said, “we don’t really know, we’re learning just like you are”’, Mrs Swingwood explains.

At the moment we only know what a post-Covid patient looks like up to a year post-Covid, so it’s really hard to make sure that the pathways and services we put in place for this group are right.

Given the ACPRC is the biggest respiratory group in Europe it was clear that new guidelines would be of great value to a great number of people. 

The guidelines were established in collaboration with the CSP, which Mrs Swingwood says has been a “massive support”. But they also made sure patients voices and those of occupational therapists are heard.

The guidelines set out to show where the role of, initially respiratory, physiotherapy fitted in Covid-19 treatment. 

‘We were looking at how our treatment and assessment skills could be used for this patient group and how they could be adapted for Covid to make sure that they are safe for patients and staff. That includes what PPE to wear, and whether things like extra filters were needed.’  

The ACPRC also provides a forum for discussion and runs courses and evening webinars to give clinicians an opportunity to get information and ask questions on Covid-related topics. 

‘We wanted to make sure there was this network of people where you could access relevant resources from our perspective. It’s now open access* you don’t even have to be a member to access the Covid advice.’

Reducing viral load

While Mrs Swingwood never experienced problems accessing appropriate PPE, part of her work was also ensuring physiotherapy had “appropriate seats at appropriate tables”, significantly linking with Public Health England (PHE) on PPE, which she says was and still is a “massive job”.

‘The problem from a respiratory physio perspective is that there isn’t the research out there to say whether our techniques are aerosol generating or not. I think they are and we have put information in place to highlight that with people, which is why we are working with PHE. 

‘Some of the problem is a lack of understanding of what respiratory physio is – it’s not just about using certain devices, it’s about the fact that we are in such close proximity to patients and that adds to the risks. If we’re making a patient cough then that cough could have a viral load which may increase transmission.’

Risk of transmission is reduced by “very simple tweaks”. 

‘When we are really up close and rehabbing a patient, getting them to put on a surgical mask reduces the risk. It’s about keeping things simple, thinking about what is happening from a physiology perspective and adapting as required.’

The pandemic saw Mrs Swingwood pause her National Institute of Health Research (NIHR) Clinical Doctoral Research Fellowship PhD.’To be honest as a respiratory physio in the middle of a respiratory disease pandemic you don’t want to miss that. This is what we trained for.’

She says it was hard putting so much planning into the Nightingale - something that was never used.

‘Keeping people on board with that was difficult as there was some negative press – but we said if we end up like some of the health services in Europe we will really need them.’

Looking back Mrs Swingwood reiterates that past months have been “brutal” but also offered “amazing opportunities” and “inspiring teamwork”.  

‘We have lost patients of course but on the flipside there are patients we have worked with for months who are now back to work or playing football with their grandchildren. That beats any pay packet.’

Find out more about the The Association of Chartered Physiotherapists in Respiratory Care here