16th February 2021
UK COVID Deaths – Daily 799 / 7-Day average 621
Total UK COVID Deaths within 28 days – 118,195
Total UK Deaths with COVID-19 on the death certificate – 129,498 (up to 5th Feb)
James Cook Hospital – Total COVID deaths – 571
All COVID cases within South Tees Hospitals Trust – 121
James Cook Critical Care
COVID cases – 27 (17 ventilated)
Non-COVID cases – 38 (20 ventilated)
To be honest, I had thought that things might be a little better by now. The number of COVID patients within Critical Care has actually increased over the past week and the decrease in the number of COVID patients admitted to the hospital has slowed a little. We still are admitting a significant number of patients into our various ICUs and we are still sometimes finding it difficult to staff enough beds to put them all in. I suppose it shouldn’t come as too much of a surprise that things are not as good as they should be. The case prevalence rate in Middlesbrough is only falling slowly and the town remains the second worst affected area in the country.
The number of non-COVID patients who require Intensive Care is also growing. Only last week, we flipped ICU 3 back to a non-COVID unit to allow for this. However, this weekend we decided to go further and turn our largest 17-bedded COVID unit (the General High Dependency Unit) back into a non-COVID unit. This meant that the newly-converted ICU 3 had to become a COVID unit again. The newly-erected partition between ICU 2 and ICU 3 was therefore torn down again - for the umpteenth time.
Moving ICU patients around on this scale is not something to be undertaken lightly. I could go on to explain why this was necessary and describe the complex logistical nightmare that ensued. However, I’m pretty sure it would make for some dull reading. Instead, imagine speeded-up footage of the patients being moved backwards and forwards from one unit to another, set to the theme tune from the Benny-Hill Show and you’ll begin to get an idea of what the weekend was like.
If I’m honest, the end result was not that much different from before but it did mean that we were better equipped to admit non-COVID patients. We had all been expecting a fall in the number of COVID patients and a concurrent rise in non-COVID admissions. However, no-one had expected that we would continue to admit COVID patients at a faster rate than we had the week before. We coped, as we always do, but things got so tight that we had to transfer one of our stable COVID patients to Newcastle in order to accommodate everyone.
Of course, in amongst the organised chaos, there were still patients to see. It took me four attempts to enter the Cardiac ICU to conduct a ward round before I was successful. Each time I would don my protective gear, enter the unit and begin to review a patient when someone would telephone, requesting my presence somewhere else in the hospital. I would then have to remove (or doff) my PPE before heading off to the wards, A&E or another ICU to deal with whatever crisis was occurring. I’d then return to Cardiac ICU and repeat the process all over again before once more being summoned elsewhere.
Now, I don’t mind being busy, but being repeatedly needed in several places at the same time is extremely frustrating. It can also be difficult to prioritise patients given the sometimes limited information you are given over the phone. I’ll admit that I was getting irritated at having to deal with so many requests and so, when I arrived at one of our surge ICUs, I was very much in a hurry. I had been called to assess one of our COVID patients whose condition had been worsening over the past few hours. They were now desperately unwell and there was nothing more that we could do. The patient’s family had been called to the hospital and I needed to explain all this to them.
It was only when I arrived that I began to realise just how awful the situation was. The patient who was dying was a young man. He was known to some of us, having been our patient in the past. His mother had already arrived and was sitting by his bed. I learnt that his father was also suffering from COVID pneumonitis and was a patient on one of the wards downstairs. Over the past few days he had been receiving CPAP and so we arranged for the Outreach team to bring him to the ICU and give him high-flow oxygen so he could be next to his son.
It was a dreadfully sad situation. I explained that all we could do now was ensure that their son was comfortable and pain-free whilst we withdrew respiratory support. I watched his mother and father together at his bedside and time seemed to slow-down as I witnessed their grief. I was angry with myself; my earlier irritation and hastiness felt selfish and petty in the midst of this tragedy.
It wasn’t long before the ‘phone rang again and I was needed in the Accident & Emergency department. To be honest, I was thankful for the distraction and spent the next couple of hours seeing three patients who needed admission to ICU. One had COVID pneumonitis and needed CPAP, one had suffered a stroke and the third had septicaemia following a prolonged period of alcohol intoxication.
As I was returning to the command room to inform them of the new admissions I bumped into Sister Pugh. Because we are all working odd shift patterns and are spread out across multiple units, I hadn’t seen her for a few weeks. Janet was returning from a cardiac arrest call and was wheeling a trolley full of resuscitation equipment. Now in my day, if you were on a cardiac arrest team you simply had a couple of IV cannulas tucked into the pocket of your white coat, and maybe an inhaler if you were asthmatic. I knew that, a good few years ago, we had started taking a large backpack to arrests and that over time it had become bigger and bigger but I had no idea that we now needed a trolley to cart it about. To be honest, if you tried to put that much kit on Janet’s back she’d fall over and be unable to pick herself up. She’d end up like some sort of resuscitation-turtle, desperately trying to right herself. She didn’t seem to find this idea as funny as I did.
Later that afternoon I finally managed to finish my ward round on the Cardiac ICU. My Cardiac ICU colleagues had kindly done most of the work whilst I had been elsewhere but I was needed to help them perform brain stem death tests. The patient that we were testing had suffered a cardiac arrest at home as a result of a large heart attack. During the resuscitation, their brain had not received enough oxygen and catastrophic brain damage had occurred.
Brain stem death is a condition where there is no evidence of brain activity. The person affected remains in an irreversible, profound coma, is unable to breathe and has no chance of making any recovery. Brain stem death can occur following a lack of oxygen, haemorrhage, stroke or trauma. The brain stem is located at the bottom of the brain where the brain joins the spinal cord. Damage can occur directly or follow damage to other parts of the brain. When the brain is badly injured, it can swell and this swelling can ultimately lead to compression and death of the brain stem.
If brain stem death has occurred then the patient can be legally confirmed as dead under UK law. This requires brain-stem death testing. The process involves a thorough neurological examination by two senior doctors looking for signs of brainstem activity. There has to be evidence on a CT or MRI scan of the damage to the brainstem and other causes of coma must have been ruled out. The most important part of the test is when the patient’s inability to breathe is confirmed. The tests are performed twice and after the second set of tests the patient is declared legally dead. After brain stem death, organ donation may be possible if the patient or their family had expressed a wish for this to happen.
It can be confusing and difficult for some families to try to come to terms with the fact that a patient whose heart is still beating is no longer alive. The situation did not exist before the dawn of intensive care medicine and the use of ventilators. Brain stem death is very different from what is sometimes called a ‘vegetative’ or minimally-conscious state where patients can often breathe by themselves and show some signs of brain activity.
Brain stem death testing is never a pleasant part of any ICU doctor’s role. In nearly every case, it has occurred suddenly and more often than not, unexpectedly. Families are usually grief-stricken and may be struggling to come to terms with the sudden news that their relative can no longer survive and may, in fact, already have died.
The remaining few hours of my shift were spent checking up on various patients I had seen earlier in the day and handing over to my colleagues who were working the night shift. I now have a couple of days off. It’s half-term and so there’s no home-schooling to be done either. Woo-hoo!