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  • Richard Cree

Old Dog

Updated: Apr 16

Wednesday 15th April 2020

COVID Figures for 14th April

UK Hospital Deaths 778 / Total 12,107

James Cook Hospital – Total deaths – 106

James Cook cases in Critical Care – 22 / 12 ventilated

Back again to pick up the pieces after yesterday’s disappointing day. I’m pleased to say that things are better today than I thought they’d be. The first half of the unit is full of patients who are all steadily improving. I’m struck by how many of these patients are overweight, hypertensive women in their 50’s. Only last week it was full of their male equivalents. It’s almost as if it’s now ‘Ladies Week’. One noticeable difference though, is that the women do not appear to be getting as sick as the men and relatively few of them end up ventilated.

The second half of the ward round features the sicker patients. The sickest three were the ones that I talked about yesterday. Of these three, two of them have shown a surprising degree of improvement.

However, the third patient who had taken the drug overdose has deteriorated further overnight. Despite valiant efforts, he was desperately ill by the time I saw him on the ward round and it was clear that survival was no longer possible. We decided to withdraw his treatment and change our priority to ensuring he was comfortable. He died shortly afterwards.

On a more positive note, the lady with the horribly acidic blood started to get better last night, just after I left the hospital. I steadfastly refuse to believe that these two events are connected.

Looking at things in the clear light of day, it looks as if part of the severity of her illness was due to her adrenal glands not working properly. These produce steroid ‘stress’ hormones during a severe infection. When they are not working properly, it can make a bad situation like a coronavirus infection an awful lot worse. This adrenal insufficiency could have explained her terrible blood results so we gave her intravenous replacement steroids earlier in the day. It was these steroids taking effect some hours later that led to her improvement. She remains extremely unwell but there is now hope that she could survive.

My third patient, the elderly gentleman with COVID pneumonitis was also better, now that he had been flipped over onto his back. He had not worsened overnight but I wondered if we could improve his ventilation somehow.

Now modern ICU ventilators are pretty fancy. Like any high-tech piece of electronic equipment, there are all sorts of features and modes that in reality, you never use. These are great selling points. After all, if you are going to spend £20,000-£40,000 on such a machine you want the one with the most whistles and bells and the thickest instruction manual, right?

Well, one of the ventilation modes that’s not used a great deal is called ‘Airway Pressure Release Ventilation’ or APRV. It is often used as a last ditch, rescue mode when patients cannot be ventilated adequately using more standard techniques. The concept has been around for longer than I have been working in ICU but it has become quite popular recently. In an attempt to ‘get down with the kids’ as well as improve my patients oxygenation, I start to fiddle.

It seems I have learnt nothing from the day before, when my meddling led to things getting worse. I seem to have temporarily forgotten the great advice that one of my senior colleagues passed onto me many years ago – “Don’t just do something, stand there.” I have practised his ‘less is more’ approach to ICU ever since but every once in a while I need to be reminded of this.

My attempt to use APRV does not produce results. After adjusting every conceivable variable on the ventilator I am becoming increasingly frustrated by the lack of improvement. Once things start to get worse I soon realise that ‘Airway Pressure Release Ventilation’ is an anagram of ‘bloody stupid ventilator not doing what I want and wasting everyone’s time’. Well, it is if you add a few letters and take some away…

I give up and go back to what was working before. Things get better. Lesson learnt.

Old Dog - 1 New Tricks - 0

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