First Steps

Thursday 4th June 2020

Figures for 3rd June

UK COVID Deaths 359 / Total 39,728

James Cook Hospital – Total COVID deaths – 238

All COVID cases within South Tees Hospitals Trust – 26

James Cook Critical Care COVID cases – 3 / 1 ventilated

James Cook Critical Care non-COVID cases – 41 / 20 ventilated

The numbers of COVID patients both within Critical Care and the hospital as a whole have fallen a little over the past couple of days, so I thought I’d try and keep the good news theme going whilst I can and update you on my friend Gary’s progress.

Gary contracted COVID-19 at the end of March. He developed COVID pneumonitis and needed ventilating in an Intensive Care Unit in a London hospital for six weeks. Despite being horribly unwell, even by Intensive Care standards, he has survived and was discharged to the ward three weeks ago.

I wrote last time about his swallowing problems. These have not improved significantly in the last fortnight and in order to avoid ongoing problems with nasal tube feeding, Gary underwent a Percutaneous Endoscopic Gastrostomy (PEG) a week ago. A PEG is a small procedure carried out using an endoscope in which a flexible feeding tube is placed through the abdominal wall directly into the stomach. This allows convenient feeding without the problems associated with a nasal feeding tube. The hope is that Gary’s swallowing will improve over the forthcoming months and the PEG tube can then be removed.

Gary underwent a brain MRI scan last week in order to rule out a small stroke as the cause of his swallowing problems. Fortunately, the scan was unremarkable but this does not rule out nerve damage that can have occurred locally in the areas close to the mouth and neck that could be contributing to his swallowing difficulty.

Gary’s voice continues to improve slowly. To further investigate his speech problems, a nasendoscopy test was performed the other day. This is where a thin endoscopic camera is inserted through the nose whilst awake in order to study the back of the mouth, neck and vocal cords. It revealed that one of his vocal cords wasn’t working properly. This is an uncommon but well-recognised complication of prolonged intubation with a breathing tube. Once again, natural recovery can take many months.

I wrote last time that Gary had also developed a foot-drop whilst in ICU. Once again, this is another complication that can follow a long ICU stay. Foot drop is usually part of a generalised nerve weakness called Critical Illness Polyneuropathy (CIP) that affects critically ill patients. He has undergone nerve conduction studies which have shown that as well as the CIP, he also has some locaised damage to one of the nerves in the leg responsible for controlling his foot. This too, will have to await improvement over time.

The nerve conduction tests could not be carried out at the hospital that Gary was in and he had to be transferred to another hospital nearby. This meant he had to be brought out on a trolley and loaded into an ambulance for the transfer. This gave an opportunity for his wife and daughter to briefly meet him outside the hospital. This was the first time they had seen each other in nearly two months.

I’m delighted to be able to report that a few days ago, Gary took his first steps. He was aided by his physiotherapist and he didn’t go far but this was, in his own words, ‘a major milestone’. This accomplishment had been made harder by problems with his blood pressure. When he has been standing, he has been experiencing low blood pressure, resulting in dizziness and a feeling that he’s going to faint. This is not helpful when you are already as weak as a kitten.

I joked that this was likely due to a lack of moral fibre on Gary’s part but, in reality, this may also be due to critical illness polyneuropathy. As well as affecting sensory and motor nerves, the nerves that control your autonomic nervous system can be affected. This part of your nervous system is responsible for controlling heart rate, blood pressure and blood flow to where it’s needed. In some patients, they have ongoing problems regulating such things resulting in low blood pressure when they stand up. Hopefully this should improve reasonably quickly.

There are plans to try to arrange transfer to a specialist rehabilitation hospital but this is more complicated than it should be. I have written before about how poor rehabilitation services are for ICU patients throughout the country.

I have been sent a video yesterday of Gary walking the length of the ward with only minor support from his physiotherapist. Talk about a picture being worth a thousand words - it was impressive to see how well he is doing. To my mind, it looks like he may not need to be in an acute hospital for very much longer. In fact, if community rehabilitation could be arranged, he may soon not need to remain in any hospital for long. Fingers crossed!