18th September 2020
UK COVID Deaths - Daily 27 / Total 41,732
James Cook Hospital – Total COVID deaths – 257
All COVID cases within South Tees Hospitals Trust – 13
James Cook Critical Care COVID cases – 2 (1 ventilated)
I’m back at work after a week off. The admission of two COVID cases to the ICU before my holiday had caused some consternation throughout the department. It had been all too easy over the summer for us to forget that a second wave might be coming. We very quickly had settled into our old ways, treating patients with familiar problems and rapidly forgetting what it was like to spend days in PPE. We have also got used to our mortality rate returning to something near normal. It goes without saying that ICU is a much more satisfying place to work when far fewer of your patients are dying.
However, whilst I’ve been away, one of our COVID ICU patients has sadly died. The patient was a gentleman in his sixties who had, like many of our patients, been very careful during the first wave of cases. Unfortunately the relaxation of restrictions and the opening up of society inevitably led to a higher likelihood of contact with the virus. The loss of a patient is always upsetting but it has also suddenly brought the return of COVID-19 into sharp focus.
Many staff are becoming increasingly anxious about having to return to the dark days of the first wave. Most of us knew it was coming but we had hoped for a longer respite. The frustration at what appears to be the general public’s complacency is also keenly felt. In the coffee room, the latest example of disregard for social distancing that the nurses have witnessed is discussed at length. There is growing resentment and anger at the realisation that we will be the ones left to deal with the inevitable consequences that will result. We all know that this particular buck stops with us.
Over the last 48 hours there have been a number of new patients admitted to the hospital with respiratory failure due to COVID-19. Today I was called to the ward to review a lady in her early fifties who had been admitted only an hour earlier. She had classic COVID symptoms and was developing worsening breathing problems despite receiving high-flow oxygen. She had no underlying health conditions and had not been able to work out where she could have contracted the virus.
When I arrived I was suddenly struck by how familiar it all seemed. I was taken back to late March when I first started seeing these patients. Her symptoms, her clinical signs, her blood tests and the now all-too-familiar chest X-ray appearance all screamed COVID. It was an easy diagnosis to make. There was no chance her test was going to come back negative.
So, like a well-oiled machine the Critical Care Outreach team transferred the patient to the High Dependency Unit. Once there, the plan was to try CPAP and to get the patient to lie on her front to see if that will help her breathing. This so called ‘self-proning’ technique can help to by altering chest wall mechanics and improving the amount of the lung that is available for the transfer of oxygen. We are hopeful that the patient will respond to these measures and avoid mechanical ventilation.
Of course our treatment of COVID pneumonitis is now more refined than when we first started. We have more experience in using CPAP, improved ventilation strategies, more knowledge on likely outcomes and we now give our patients the steroid dexamethasone which improves mortality. We were doing this before in a significant number of patients but only as part of one of our research trials. We also have a relatively limited supply of the anti-viral drug remdesivir, which has been shown to reduce the overall length of hospital stay in COVID patients. However, the evidence for the effectiveness of remdesivir is weak and there is no evidence yet that it affects your chance of surviving.
So, despite the influx of new COVID patients, we are still far from being over-run. We continue to hope that things will be different this time; we are still hoping not to see the rush of cases that we saw in March or as many elderly, vulnerable patients being infected. However, all of us increasingly feel that we are staring at the tip of a giant COVID iceberg. Unless there is a change in everyone’s behaviour or new restrictions are introduced, we will once again have to prepare for the worst.