*Any names and locations in this have been changed* *This account is based around my personal experience with Covid-19 and may differ from descriptions you've read elsewhere - these are my impressions an experiences*
In the past ten days there's been a subtle ramping-up of activity at [redacted] hospital. We've gone from three 'hot' wards to a total of six now, with one ward specifically geared towards surgical patients with covid-19, the 'positive' patients are slowly but surely achieving parity of numbers with the 'suspected' and 'negative' patients(interestingly enough, several of my medical colleagues have noted on more than one occasion that tests only appear to be picking up positive results 70%(if there's time, I may go back and check how accurate national testing has been) of the time with several patients who have a clinical picture strongly suggestive of covid-19 but a negative test result. This has, on occasion led to repeat tests and one or two individuals even moving from 'hot' to 'cold' areas and then back to 'hot' with all the implications for infection control THAT entails.
So, what are seeing on the coalface then? (trigger warning: from here on in, there may be some frank and potentially upsetting details. Proceed with caution if you, your family members or friends are unwell currently).
I've often thought I might experience many emotions during The Apocalypse but a a resigned shrug of 'here we go again' isn't one of them. Managing covid-19 has gone, in ten days from a sort of appalled fascination to low-level tedium for a lot of us.
Presentation follows a depressingly familiar path for our inpatients.
Generally people pitch up at ED with a 5-7 day history of the by-now well-known Covid symptoms of high temperature, dry cough, lethargy and 'feeling like sh*t'. They've usually been sent/brought to ED because they have been becoming breathless. Chances are, pneumonia is trying its damnedest to set in at this point.
In ED, we'll take bloods, start oxygen therapy(and likely antibiotics if there's evidence or suspicion of pneumonia), a chest X-ray and the patient will then be reviewed by the med reg, one of his/her FY2's as part of their initial 'clerking' and the ED plan of 'scrape up and stabilise' will be expanded upon and fine-tuned. At this point, someone will usually decide the patient's 'escalation status' - in simple terms the 'are they for resus?' question(in practice it's slightly more nuanced at the moment, some patients can be not for resuscitations but for certain ITU-based treatments that fall short of intubation, I fear this level of nuance will not last).
The chest X-Ray will look like a variation on this, rather extreme example(I've chosen a particularly 'filthy' example of a chest X-ray, as if you're not familiar with them they can be tricky to interpret. I personally rate myself as having 'blagger's X-ray' interpretation skills - I can spot the obvious and have a decent stab at most things, particularly if others have already ruled out other things or I have a good history to draw on):
For reference, a normal chest should look like this, without the labels, obviously:
Th patient will then transfer to one of our 'hot' wards to undergo the delightful procedure that is the covid swab. It goes something like this:
After this, observations are checked regularly, medications are given and the patient is reviewed on a daily basis by a senior doctor(usually a consultant, but a registrar at the very least) and, at the risk of over-simplifying, the y either get better or they don't. If they improve, they will go home as soon as they are fit to do so. In practical terms, this means 'off oxygen and able to self-care/live at home with support safely'. If they are not improving, a number of things are likely happening.
- their temperature remains high - oxygen requirement increases - respiratory rate increases(a sign of increasing respiratory distress) On testing further we're likely to find that CRP(check your list of abbreviations, kids) is increasing along with white cells(another infection marker) and an ABG is likely to indicate a worsening hypoxia(oxygen starvation) despite ever-increasing levels of supplementary oxygen.
As general rule of thumb, this point can be described as '60% oxygen(room air is 21% O2) and struggling'.
Here's where it starts to get scary. These patients will frequently look reasonably well(all things considered) and will quite often be able to speak in full sentences(I'm generally used to those in respiratory distress as severe as this being unable to speak or being extremely breathless on speaking). Why is this scary? It's scary because if you're just doing a cursory look at a patient(an 'endofthebedogram', if you will) it's very easy to be fooled by the appearance of the patient and think 'o they're OK and not escalate your concerns/investigate further.
If we're at this stage of things, there's going to be likely two outcomes:
1. The patient is 'for escalation' and we call out the ITU team - they will decide if the patient could benefit from admission to ITU and likely intubation and mechanical ventilation. Sometimes they will admit immediately, other times they will suggest further tweaks to the plan of care and the Outreach team will monitor and report back.
2. After careful consideration, its decided that admission to ITU is not in the patient's interest. This may be for a number of reasons - multiple chronic conditions, patient age and frailty. Sometimes the patient may, on having what an ITU admission entails may even decline admission themselves.
If the patient if for ITU, a member of my team will facilitate the transfer - this is an involved process which is not without its risks - so we will transfer the patient with full heart, oxygen saturations, pulse and blood pressure monitors attached, portable oxygen and full PPE. Despite this, an 'into ITU' transfer is usually a fairly straightforward(if occasionally hair-raising if the patient is very sick, or you've a long way to travel).
Normally, I am very pleased to transfer a patient into ITU. I usually tell them 'you're coming into the safest place in the hospital'. After 12 years of working there, many of the people there are close friends and I enjoy a good level of professional understanding and team working. Now, the ever-present PPE, constant flow of new faces(not that I can see them under the PPE) and the fact that we are expecting a 60% mortality rate amongst our sickest of the sick, the place itself feels alien, diseased and hostile. This is no longer a place of safety, it is the last resort. You'll notice that I'm not going into details about what the 'lucky' ones who get into ITU will go through. That's because I don't at this point have enough experience of looking after this group. I suspect that in the weeks to come, this will change.
For those who are not suitable for ITU the likely outcome is even grimmer - the dread phrase 'EOL if continues to deteriorate, update family'(or a variation thereof) will soon be seen in the notes. We will continue with our current management and if the situation become irretrievable we will 'switch to best supportive care', 'palliate' or 'seek to make comfortable'. In short, if this patient shows no appreciable improvement over the next 24-48 hours, they will die. The 'update family' bit will almost always come via the phone. On the one occasional I've been able to do so in person, social distancing means simple human contact that makes these occasions easier to deal with, like a hug, a hold of the hand are off the table and it feels impersonal, mechanical and like the imposition of a death sentence.
We will try to mitigate respiratory distress with medications such as high doses of morphine, dry any sputum on the chest with a drug called hyoscine(usually by this point, the pneumonia is well-established and it will have a limited effect) and ease agitation with sedatives.
A significant number of patients have apparently suffered with appalling levels of agitation which the wards struggle to control and even the palliative care specialists have experience difficulties. This is all made even more upsetting for all involved by visiting restrictions. ONE nominated relative can spend an hour a day(at a time agreed with the nurse in charge) with their loved one.
As long as they are not self-isolating as well at this point.
Whilst we're suffering a lot less out here in rural East Anglia, I fear the worst is still to come. The wave is yet to break on us.
Despatches From The Front Line Part Three: What We Do With Covid-19 on 23:07 - Apr 6 by NthQldITFC
Thank you. I don't know you personally, but I feel a hell of a lot of love and respect for you right now.
This one was the hardest one so far to write. There's at least three members of staff(former and current) members of staff as inpatients in various locales at the moment. Sh*t is pretty real right now.
These people are called idiots and BB is their leader.
It is more about the antibody tests which will, if they work, show whether someone has had the virus. The bit about specifity versus sensitivity is important.
The antibody test will be a big game-changer. It'll get us people people back on the shop-floor quicker, people more safely berthed and hopefully manage some of the anxiety on the wards(I've seen a LOT of inappropriate mask-wearing in the past few days).
These people are called idiots and BB is their leader.