Reasons to be Cheerful?

9th February 2021

UK COVID Deaths – Daily 1052 / 7-Day average 834

Total UK COVID Deaths within 28 days – 113,850

Total UK Deaths with COVID-19 on the death certificate – 121,674 (up to 29th Jan)

James Cook Hospital – Total COVID deaths – 547

All COVID cases within South Tees Hospitals Trust – 149

James Cook Critical Care

COVID cases – 22 (13 ventilated)

Non-COVID cases – 38 (12 ventilated)

For once I have some better news to report. The last few days have seen a significant reduction in the number of COVID patients within Critical Care. We have been waiting for our case numbers to drop and we are hoping that this is the start of an ongoing trend. The total number of COVID patients within the hospital has also fallen and is now slightly below the peak we reached during the first wave back in April last year.

One of the COVID ICUs has been re-designated as a regular ICU in order to cope with an increase in non-COVID patients. This increase in ‘regular’ patients is similar to what we saw during the latter phase of the first wave. Back then we attributed it to people who had avoided seeking medical attention due to a fear of catching COVID. We wondered if such people were becoming seriously unwell after presenting days or weeks later than they should have done. This resulted in an increased demand for ICU beds and this could be what we are starting to see again. However, I also suspect that the recent bad weather has played its part in driving up the usual winter caseload.

Unfortunately, this increase in non-COVID patients means we have not been able to close any of our Surge ICUs just yet. We remain spread out across a wide area, which at times means stretching our pool of doctors and nurses thinner than we’d like. However, the hospital is currently admitting fewer COVID patients each day and if this trend continues we might soon be able to think about abandoning at least one of these satellite units.

It looks like this reduction in Critical Care COVID patients is primarily due to lockdown decreasing the number of people who are becoming seriously unwell. I don’t believe that vaccination has yet played much of a part. We currently only have three COVID patients within Critical Care who are over the age of seventy. We also don’t have many patients in the COVID units who are classed as ‘clinically vulnerable’. This has been the case for much of this second wave. It means that the vast majority of the patients we have been admitting do not fall into a group who would have been vaccinated and protected by now.

It’s also important to stress that many of our ventilated patients will spend weeks on the Intensive Care Unit, even if they do not ultimately recover. The end result is that Critical Care numbers may fall slower than the public are expecting. This is important because, Critical Care bed availability is an important indicator of the degree of stress that the nation’s hospitals are under. Once the country began to run out of Intensive Care beds at the end of December, the case for imposing another lockdown became irrefutable. Critical Care provision had to be guaranteed to avoid the death rate rising to a level that would be unacceptable whichever way you looked at it. Likewise, the improvement in Critical Care capacity will be an important metric that determines how fast restrictions are lifted.

Whilst the situation is undoubtedly improving, there are times when it’s difficult to see that things are getting much easier. We are still watching a significant number of our patients die. Many more are desperately unwell and are requiring high levels of nursing and medical care to ensure that they are given the best chance of survival. I have spent the last couple of days on one of the COVID units, surrounded by some very ill, ventilated patients who we are struggling to keep stable.

We are constantly attempting to improve oxygen levels by adjusting pressures, oxygen concentrations and ventilator timings. We are also able to turn the patients alternately prone and supine in order to ‘recruit’ or open parts of the lung. Lung dynamics work better in the prone position but turning our COVID patients is both time and labour-intensive.

We have been greatly helped by our medical colleagues from other parts of the hospital. In particular our anaesthetists, surgeons and paediatricians have come to our aid and formed ‘proning teams’. These teams visit the various ICUs regularly in order to turn patients for us. Each team is made up of up to seven people, one of whom is responsible for looking after the airway. This is always either a senior ICU doctor or an anaesthetist for good reason; in the unlikely event that the breathing tube becomes dislodged whilst the patient is being rotated, it must be reinserted within seconds to avoid catastrophe.

The proning teams have ultimately become very slick at flipping patients. The teams have created a league table so they can keep track of just how many patients they have turned. Naturally, our surgical colleagues began to get competitive and we now have various surgical sub-specialities competing with one another to see who can prone the most patients. Often, two specialities will work together in order to get ahead of the competition, making for some interesting team-ups. I'm not sure whether we should be offering a prize for the winner – maybe some sort of trophy might be in order? A golden ventilator perhaps?

The league table. It’s reassuring to see that the General Surgeons haven’t yet grasped the concept of the tally chart…