Lets Go To Work
Updated: Apr 2
Monday 23 March 2020
Night shift. First one in many, many years.
I've been taking part in an 'on-call' rota for the past 17 years I have been a Consultant but it's rare that I find myself in the hospital all-night. I have junior staff for that sort of thing. However, we have just implemented our 'surge' rota and I have the honour of being the first of my colleagues to work a resident night shift.
We know what's coming. We have known it for months. We try to pretend that it will not be as bad as we fear. We have seen the reports from Wuhan, Northern Italy and now Spain and there can be no doubt. We have been planning and our intensive care unit is as ready as it can be. We are on the cusp of planning fatigue. I am not sure that this is true for the rest of the hospital. Some of my colleagues in other specialities don't seem to appreciate what's ahead of them. It's horribly clear that the public don't!
We have too few ICU beds as it is. We have been labelled as 'unsafe' during our latest CQC inspection, predominantly because we have been trying to do too much with too few resources. This looks deeply ironic in light of what will happen over the next few weeks.
I cycle in for the start of my shift. It's a lovely Spring evening, but it's dark by the time I set off. I arrive early for once (I am habitually late) after making a real effort to get the kids fed and ready for bed in good time before I leave. My wife is also an ICU Consultant in the same department and it will be a couple of hours before she gets home.
It's far busier than I had thought it would be. We have 4 ventilated COVID-19 positive patients who are cohorted in one of our two general Intensive Care Units. These patients have all arrived in the past 24-48 hrs. We reckon we are 2 weeks behind London so based on their experience, we are about to see our first surge of COVID patients in the next few days.
Our first patient was a nurse from our sister-hospital nearby. She is fit and well and has no 'underlying health conditions'. This has scared a lot of staff. We know we are more at risk of death than the general population but this has made the threat seem real. However, there seems no question of anyone not doing their duty. There is a growing sense of camaraderie amongst everyone. Trite phrase like 'we are all in this together' are now seeming strangely apt. I am an old and deeply cynical bastard but to my surprise, I find that I am fiercely proud of all the staff around me.
It's still taking 24 hours for testing results to come back. We have more suspected patients in isolation rooms. We need faster testing. We have to suspect that anyone with respiratory failure is COVID positive as the pattern of presentation can be variable and many colleagues elsewhere have been caught out.
There are a lot of non-COVID patients that are pretty sick. Myself, Tim, my consulant colleague and Matt, the ICU registrar, divide and conquer. A few hours later things are more under control but there is a patient in their 50‘s in A&E Resus. He is pretty unwell with respiratory failure and jaundice and is becoming agitated. The chest X-ray suggests heart failure. We are wearing full protective PPE gear as there is a chance he could be COVID-positive although I suspect he has an underlying cancer. We need to run him through the CT scanner to be sure. However, his agitation gets worse, as does his breathing and soon it's clear he needs to be intubated and ventilated before we can think of doing anything else.
He is rapidly transferred to the A&E decontamination room that has been converted into a COVID intubation room. It is essentially a big shower and normally has no equipment it it whatsoever. I am concerned about how badly things could go wrong. I have not got around to watching the video simulation that was posted a few days ago and now wish I had.
We quickly re-don our protective gear and enter the room. We hastily check our equipment and discover the video laryngoscope system is missing. There has been some talk that this may protect ICU staff when intubating as it avoids you getting too close to the patient's mouth and getting, what is in effect, a face-full of virus. However it takes more time and a low-tech oldie like me can put a tube down with a standard laryngoscope far quicker. No choice anyway now so we crack on. He is anaesthetised and is an easy intubation. So far so good.
Then things go south. Very quickly. His ECG complexes widen horribly and he loses his cardiac output. We start CPR. As a result of his kidney failure his potassium is too high. We can fix that so we do and his ECG starts to return to something vaguely normal. But then he develops ventricular tachycardia. We shock him and get restoration of a weak pulse.
The arrest is going well in some ways. Things are not looking good for the patient but everyone is calm and working well. I still think we might be able to recover the situation but then he starts to develop bradycardia and is clearly in cardiogenic shock. We do what we can but nothing seems to work for very long. We are not going to win this one. I don't know why but I carry on for far longer than I know I should. This is not like me. I am a pragmatist and normally pretty good at knowing when the game is up. I feel that somehow this is a sentinel case and that if I lose this patient this early then somehow it is a bad omen for what's coming.
Asystole supervenes and I instruct the team to stop. Everyone is in agreement. I talk to the patient's daughter and explain what has happened. She is devastated. She has not seen her father for weeks and is now not allowed to see the body because of the risk of infection. I am surprised by how upset I feel about this. My entire working life seems to be spent telling people that their loved one is dying or has died, but this new element makes her grief and hopelessness palpable.
I return back to the ICU and spend the next few hours getting on top of everything. Things are calming down and I leave Matt to it and grab a couple of hours sleep in the on-call room. I feel like I am cheating but am worried about how tired I'm going to be tomorrow night unless I get some rest.