Thursday 28th May 2020
Figures for 27th May
UK COVID Deaths 412 / Total 37,460
James Cook Hospital – Total COVID deaths – 228
All COVID cases within South Tees Hospitals Trust – 37
James Cook Critical Care COVID cases – 8 / 5 ventilated
James Cook Critical Care non-COVID cases – 32 / 10 ventilated
I was working overnight last night. There hasn’t been much of a change in the overall numbers of COVID patients but nearly all of the patients we do have continue to improve. Three of them have been extubated and have had their breathing tubes removed since the last time I saw them. All three are now breathing entirely by themselves and look like they stand a good chance of remaining off the ventilator.
One of referrals I took last night was from the ward. The call was about an extremely elderly gentleman with a urinary tract infection. The patient didn’t speak English very well and had been living abroad for many years. The only history appeared to be that he had one testicle and was on some hormone replacement medication. There was puzzlement when I asked the ward doctor if the patient had been living in Argentina. He wanted to know why this was important. I explained that I just wanted to make sure we hadn’t admitted the Führer. He didn’t get the joke.
In the end, that patient was doing quite well on the ward and didn’t need our help. The next referral was a patient with what looks like COVID pneumonitis but the picture is not entirely clear. He had confirmed COVID-19 a couple of weeks ago and tested positive. He didn’t need admission to hospital and gradually got better before developing worsening respiratory failure today and presenting to A&E. We have tested him again today and he remains positive. This is not that surprising as we know that some people continue to test positive for a few weeks after they have recovered. There are reports of some patients testing positive for much longer.
His chest x-ray shows dense shadowing throughout both lungs. This could be due to COVID pneumonitis or equally, a secondary ‘traditional’ bacterial pneumonia. He has undergone a CT scan which has ruled out pulmonary blood clots but the CT shows features that could be pneumonitis and pneumonia. I suspect that the CT shows recovering COVID changes with new pneumonia on top but the clinical picture is not typical for either.
It’s at times like these that our lack of experience with COVID-19 is frustrating. We know what changes occur on your chest x-ray following COVID pneumonitis because we will repeat x-rays as a patient recovers. What we don’t tend to do is repeat the CT scan if a patient is improving because it involves transferring the patient and irradiating them much more than a chest x-ray. The end result is that neither I nor my colleagues know what a chest CT looks like some two weeks after COVID pneumonitis. This means there is some doubt about the exact diagnosis.
Of course, you could argue that it doesn’t matter – you can just treat for both conditions can’t you? You can give oxygen and CPAP to help the respiratory failure. You can give intravenous diuretics to dehydrate the patient slightly in order to improve some of the effects of the COVID pneumonitis. You will also want to give antibiotics and use chest physiotherapy to treat any bacterial pneumonia and if there’s any wheeze or asthma-like symptoms you can give nebulised salbutamol to open the airways. Easy. Just give it all, right?
The trouble is that we doctors don’t like not knowing exactly what is going on and this treatment plan is like firing a blunderbuss into a flock of ducks at point blank range in the hope that you'll bag a few. It feels unscientific and, dare I say it, lazy. Of course, there are many times when acute medicine is like this, but it makes me feel like a junior House Officer again and I don’t like it. I like to try and pretend I’m cleverer than that.
But, there I go again, making it all about me, when to be honest the patient seems to be doing well for now. This is after all, what is important. Sometimes the blunderbuss might just be the right tool for the job.