Wednesday 13th May 2020
Figures for 12th May
UK COVID Deaths 627 / Total 32,692
James Cook Hospital – Total COVID deaths – 213
All COVID cases within South Tees Hospitals Trust – 60
James Cook Critical Care COVID cases – 12 (9 ventilated)
James Cook Critical Care non-COVID cases – 35 (13 ventilated)
Nicky was at work last night. When she arrived for her night shift things seemed busier than they have recently. There were quite a few patients in Accident & Emergency that needed review, another undergoing surgery in the operating theatre and another couple on the wards.
This is typical of the feast or famine workload often seen in ICU. It can be quiet for a few hours, or sometimes even a day or two and then you get called about five or six patients all at the same time.
During the day there had been two COVID positive patients admitted to Critical Care and another ‘suspected’ patient. These are patients who have not yet had a coronavirus swab result returned from the lab or they have had a negative test but the clinical features and test results are suspicious for the disease. A negative swab result can be a ‘false negative’; this is a result that is returned as ‘negative’ even though the patient is positive. The false negative rate for a laboratory test is probably around 10%.
We have certainly had patients who have only tested positive on their second or even third swab. Obtaining samples from deep within the lung improves accuracy significantly but is only possible on ventilated patients.
The risk of placing a patient who has a false negative test in the non-COVID ICU and having them unintentionally infect their critically ill neighbours is easy to understand. In order to prevent this, we admit every critical care patient into an isolation room first until we can be sure which ICU they need to go to. Because of the rapid turnaround of tests, anywhere between 3-5 hours, this can involve playing a decidedly un-entertaining game of ‘musical beds’ where a patient can be transferred back and forth between units during their first few hours.
The patients down in A&E are all recreational drug overdoses. They appear to have all taken opiate containing drugs. Exactly what, we will never know but they include drugs like heroin, Tramadol, codeine, Oxycontin, fentanyl and others. The end result is unconsciousness, which can of course lead to failure to protect your airway, choking, aspiration (inhalation of your stomach contents) and ultimately, if severe enough, respiratory arrest.
Fortunately, all three patients responded, at least partially, to an opiate antidote called naloxone which reverses the effect of the opiate overdose, sometimes leading to Lazarus-like scenes when the patient wakes up. This is wonderfully portrayed in that scene in the movie ‘Trainspotting’ where Renton is taken to hospital by taxi and wakes up abruptly on the hospital trolley.
It’s difficult to know the effect that lockdown is having on recreational drug use. Some predict it will decline amongst ‘social’ drug users, others believe that in some groups it will increase due to a deterioration in their mental health. Certainly the population appears to be drinking more alcohol than ever before and I suspect we will be seeing the consequences of this for a few years to come.
There is also great concern over the effect that the lockdown will have on vulnerable people’s mental health. The social isolation, breakdown of existing support and coping mechanisms coupled with a media-driven rise in anxiety does not make for a good recipe. Many people will face education, job and income worries. Others may be in abusive relationships and find themselves isolated with their abuser. On top of this, existing mental health services have been cut-back or stopped and so support may not be available when it is needed the most.
The title of this post is a slogan used by the Royal College of Psychiatrists and the World Health Organisation amongst others. It sums up the issue quite nicely.
We have already seen a number of suicide attempts, mostly overdoses and the occasional self-inflicted stabbing but I suspect we will begin to see numbers rise over the next few months.
The wider health effects of the lockdown are not to be underestimated. It is important now that we begin to reinstate important NHS services, for both physical and mental health in order to prevent worsening collateral damage.