22nd September 2020
UK COVID Deaths - Daily 37 / Total 41,825
James Cook Hospital – Total COVID deaths – 257
All COVID cases within South Tees Hospitals Trust – 25
James Cook Critical Care COVID cases – 5 (1 ventilated)
I missed the NHS Spitfire flying over the hospital today. I had been outside over lunchtime in order to try to spot it but I got called back just before it arrived. It was a shame as it was a lovely day and I had been informed that it would be flying down Linthorpe Road, strafing anyone who wasn’t social-distancing with its machine guns. I must confess that I didn’t hear any gunfire so I guess that everyone must have been behaving themselves.
New COVID-19 restrictions have been announced today due to the recent sharp rise in cases. These include table service at all pubs and restaurants which must close at 10pm, more mask-wearing, and working from home where possible. Whether these measures will be enough to stop the inexorable march of the virus remains to be seen. I should imagine that the Spitfire would be more effective but I guess it can’t be everywhere at once.
At the hospital we have seen a significant, sustained rise in the number of COVID admissions over the past 36 hours. The designated hospital COVID ward is now chock-full of patients. We have admitted another three people to ICU, two of them with confirmed COVID pneumonitis and the other suspected. The youngest patient is 50 and the oldest is 67. They all have some underlying health conditions such as angina or a previous heart attack. Luckily none of them currently need ventilating and we are hoping to manage to treat them effectively with CPAP.
This brings the total number of COVID cases within Critical Care to five and there is a real danger that we will run out of isolation rooms very soon. As a result we have decided to ‘cohort’ all our COVID patients together in one unit. Intensive Care Unit 2 has been given the honorary title of ‘COVID ICU’ and we have erected a partition to separate it from the non-COVID ICU next door. Putting this 'wall' back in place has been rather sobering. We all remember the early days of the first surge and how we moved quickly into one cohorted unit and then quicker-still into another one. The partition has remained in the corridor ever since the first wave, waiting to be used again but we really hadn’t reckoned on needing it so soon. We have also quickly reverted to wearing full PPE again which is not at all welcome. Morale is quite low as a result. Everyone knows that unless the number of COVID patients being admitted to the hospital slows down we could be in trouble a lot sooner than we expected.
As if to underline this fear, my last few days at work have been busier than usual. Our ventilated COVID patient remains very unwell. He has developed a recurrent pneumothorax. This is a collapse of the lung caused by a rupture in one of the small airways. It can cause worsening respiratory failure and sometimes cardiovascular collapse. A pneumothorax is not uncommon in ventilated COVID patients and is caused by a combination of the inflammation present in the lung and the high ventilator pressures required. The treatment involves insertion of a chest drain or tube through the ribs to decompress the thoracic cavity and allow the lung to re-expand. Our patient required two such drains before his lung was re-inflated.
We are continuing to see a significant number of young patients dying from the complications of alcoholic-liver disease. These are people who have been drinking for some time before lockdown and already have cirrhosis but have clearly upped their alcohol intake during the past few months. They are all presenting to hospital with decompensated cirrhosis and end up with multiple organ failure as a result. We have had a number of such deaths recently and it has been disheartening to have tell their young families that their mother or father is dying. The undesirable effects of lockdown on health are many but this is one that is increasingly worrying us.
Another young patient caused us a great deal of angst after developing septicaemia from an unknown source. He had streptococcal septicaemia, or what people classically call ‘blood poisoning’. This is a life-threatening infection caused by bacteria that live in your throat, nose and skin. Rarely, these bacteria can enter the bloodstream and produce an immune response which can be deadly. I have seen a number of such cases over the years and they have been some of the sickest patients I have come across. Often you are powerless to halt the rapid, fulminant organ failure that can develop despite the rapid administration of powerful antibiotics. You are simply trying to maintain a blood pressure using any means possible in order to buy time for the immune response to subside. Cardiovascular drugs that constrict the blood vessels in the arms and legs in order to drive blood flow to the heart, brain, liver and kidneys are used in large doses. The blood flow to the limbs can be so compromised as a result that survivors sometimes require amputations for gangrene.
We had done a good job of maintaining our patient’s blood pressure but were conscious that the blood flow to his arms and legs was not looking good. By now, he was experiencing a lot of pain due to the inadequate blood supply to his limbs. As his condition worsened it became clear that intubation and ventilation would be necessary. Complete cardiovascular collapse and cardiac arrest is not uncommon at this point and Kay, my registrar and I exchanged nervous glances as we prepared. The initial intubation went well with no undue calamity but poor Kay then spent a torrid hour trying to keep our patient alive as the effects of the sedating drugs tried to cancel out those of the cardiovascular ones.
By this stage our patient’s kidneys had failed and so we transferred him to the non-COVID ICU in order to commence dialysis. By the end of my shift, his condition had stabilised and we had managed to stop the situation worsening. To be honest, this is all we can hope for and represents something of a victory. Time will tell whether it is enough.
In the midst of all this chaos we discovered that it was the birthday of one of our junior doctors. Salma had been keeping fairly quiet about this and to be honest, probably didn’t feel like celebrating much. However, Kay snuck out to Marks & Spencers, got hold of some cake and decided to turn the late afternoon bed-meeting into an impromptu tea party. It was a little subdued; there was no pass-the-parcel and the Boris piñata I had asked for failed to materialise but it was still fun. Everything’s better with cake.
The Wailing Wall