Nostalgia

Wednesday 20th May 2020

Figures for 19th May

UK COVID Deaths 545 / Total 35,341

James Cook Hospital – Total COVID deaths – 220

All COVID cases within South Tees Hospitals Trust – 55

James Cook Critical Care COVID cases – 8 (6 ventilated)

James Cook Critical Care non-COVID cases – 31 (16 ventilated)

Another relatively calm night shift last night. Numbers of COVID patients continue to fall slowly although we still have more patients than any other ICU in the Northern region. We have reduced our numbers of ‘surge’ beds by closing 2 beds on the Paediatric ICU (now used for adults) and another 2 beds on the Surgical Admissions Unit. We are no longer using the Neurosurgical HDU or the Cardiothoracic HDU and we have reduced the numbers of beds that we have access to on the Cardiothoracic ICU.

The idea is that we are now shifting our focus in order to be able to move toward ‘restarting’ the hospital and concentrate on the important non-COVID work that needs to be done. We are remaining flexible and so all these changes can be undone very quickly if we see a second spike in cases.

As the evening begins there is a COVID patient to review on the ward. Colin, my eminently capable registrar returns later saying that the patient is doing fine on high flow oxygen for the time being.

Meanwhile I do a ward round on the HDU. We have a couple of problem patients who need attention. The first is an elderly lady who has been transferred from another hospital with a complicated infection. She’s done well over the last couple of days and earlier had been ear-marked as a discharge to the ward. Just as the nursing staff are getting her ready she develops fast atrial fibrillation (AF). This is where the heart develops an abnormal rhythm and speeds up, becoming inefficient. This lady’s fast AF is really rather fast at 160 beats per minute. That’s way too quick for anyone but a younger athlete and she isn’t looking too well. We are able to control her heart rate with some medication and within half an hour or so she looks a lot better. Obviously we won’t be sending her to the ward now.

Most of the patients that we discharge to the ward do well but we do get a small number of re-admissions despite our best efforts. Unfortunately when you are recovering from critical illness, complications develop pretty quickly and without much warning so we may not see them coming. It’s not infrequent for us to talk to a patient and their family about discharge to the ward and for them to raise concerns about it being too early. Of course, we would love to be able to keep all our patients in a High-Dependency setting right up until they are ready to be discharged home but this would be a huge waste of resources.

So, often we have to bite the bullet and discharge the patient despite their (or their family’s) concerns. If, following that conversation, something untoward and unexpected happens, we usually get a look from the patient rather like the one I got last night. It’s the ‘See, I warned you this would happen but you wouldn’t listen. Now get me a proper doctor’ look. It’s one I’m familiar with...

Our other patient is a middle-aged man with heart failure. His heart has not worked well for years and it’s not entirely clear why. It may be a consequence of excessive alcohol intake when he was younger. Quite why it has got worse is not clear but we suspect that he may have been drinking heavily during lockdown and things have worsened. Lots of different intravenous infusions have been started in order to manipulate his heart and circulatory system. These are called inotropes (which make your heart contract stronger) and vasopressors (which constrict your blood vessels to improve your blood pressure). There are also vasodilators (which relax your blood vessels) and chronotropes (which speed up your heart rate). Just to make it more complicated, you can get drugs that combine different effects, such as an inodilator (improves the heart’s contractile strength and dilates blood vessels).

Sometimes this all gets a bit complicated. You can think and talk yourself into physiological knots trying to work out what is going on and which drug to tweak in order to get the desired effects. Often the best advice is not to overthink it. We go back to basics and attempt a more straightforward approach and it pays off. Come the morning the patient is in a better place, but heart failure is as worrying as it sounds and this may just be a temporary reprive.

We regroup in the coffee room just after midnight to hand-over the patients to each other. I take the opportunity to grab something to eat. I’ve managed to feed the kids before I left for work but I haven’t eaten. The hospital canteen is still delivering free food to the Critical Care units. When working a night shift this is a godsend. Tonight it’s NHS Beef Curry (NBC) which is a favourite of mine. Every single hospital canteen I’ve ever visited has always had a beef curry on its rotating menu. They taste the same whichever hospital you are in and I think the original recipe goes back to when the NHS was formed in 1948. I have very fond memories of eating it when I was a house officer. It would often be on the late night menu back in the days when the hospital canteen used to open into the early hours. It conjures up memories of when I was a young junior doctor, escaping from the wards for a while to hide away in the canteen to swap stories with my colleagues and unwind.

The other reason I am fond of NBC is that when each of my three children were born at the Friarage Hospital in Northallerton, I would wander over to the canteen for lunch after the blessed event was over. Stepping into the old Friarage canteen was like going back thirty years in time - in a good way. No surprise for guessing what was on the menu on every occasion.

Clearly, the best part of the night was now over, but luckily things began to slow down. Colin admitted another non-COVID patient overnight who had a pneumonia whilst our COVID patient on the ward had improved after ‘self-proning’ for a few hours.

I’ve talked before about how placing ventilated patients with COVID pneumonitis on their front improves their respiratory failure in the ICU. The same appears to be true for non-ventilated patients on the ward. We have seen significant improvement in some patients. Of course, this is not possible if you are on CPAP and it’s important that the patient has to be able to turn themselves back and forth or it could be very dangerous. It might be difficult to explain to the Coroner why you decided to place a patient face down into a pillow knowing they were unable to move.

I handed over to my colleagues in the morning and headed back to my office. The weather forecast says that today is going to be the hottest day of the year so I’m looking forward to having a nap in the garden.

Just before I leave I can’t resist having a cup of tea and reheating the last NBC in the fridge. Fantastic. Nostalgia for breakfast!