Thursday 21st May 2020
Figures for 20th May
UK COVID Deaths 363 / Total 35,704
James Cook Hospital – Total COVID deaths – 220
All COVID cases within South Tees Hospitals Trust – 50
James Cook Critical Care COVID cases – 8 (5 ventilated)
James Cook Critical Care non-COVID cases – 32 (15 ventilated)
Time for another update about my friend Gary. Gary contracted COVID-19 and was ventilated in an Intensive Care Unit in a London hospital for six weeks. Against all the odds he has survived and was discharged to the ward a week ago. For those who don’t know the story I will list the relevant blog entries at the end of this post so you can catch up.
Gary and his family have found the move to the ward more difficult than they expected. This is a difficult time for Intensive Care patients. They are moved to a new environment with unfamiliar staff and the levels of nursing and medical staff on the ward do not come close to those on ICU. Families often find the more rigidly enforced visiting times difficult when compared to the ICU. Of course, this is not an issue at present whilst routine visiting is no longer allowed due to the pandemic.
The transition to the ward can be made a lot easier for patients and staff if the hospital has an Outreach nursing service. I have talked about our team before and their role in assessing and assisting the ward staff in looking after their critically ill patients prior to admission to HDU or ICU. One of their other roles is to follow-up patients on the wards once they’ve left Critical Care and provide useful support for the patient, their family and the ward staff. They can ensure that any issues are identified and dealt with appropriately.
One of the problems Gary has is a weak voice. This is not unusual following an ICU stay, especially a prolonged one. We are ventilating our COVID patients for much longer than usual and having a breathing tube sitting in your larynx for 5-6 weeks will cause swelling, inflammation and sometimes scarring. It can also cause damage to the nerves supplying the vocal cords. Gary had a CT scan which ruled out any of these which is good news and his voice should continue to improve over the next few weeks.
Gary is also very weak. This is due to critical illness polyneuropathy and critical illness myopathy. I have spoken about these before and explained how his physical recovery is going to be slow. He continues to work with the physiotherapists to speed his rehabilitation but has been disappointed in the provision of the physiotherapy service on the ward when compared to the one available in ICU. He is able to stand with assistance now but has numbness and loss of sensation in his feet. He is also having problems with ‘foot drop’ in one of his legs. These symptoms again, are not unusual in ICU patients and are most often due to critical illness polyneuropathy. Occasionally it can be due to isolated nerve damage and Gary will be undergoing specialist nerve conduction studies to investigate whether this is the case.
Gary’s biggest problem however, is his swallowing. Again, difficulty swallowing is very common after a prolonged period in ICU and is proportional to the amount of time spent intubated and ventilated. The reasons for the swallowing problems are many and include inflammation of the lining of the mouth and oesophagus, wasting of the muscles involved in swallowing, a loss of proprioception (a patient’s awareness of where food is in their mouth and upper oesophagus) and damage to the nearby larynx as discussed above.
Swallowing problems can also be caused by damage to the part of the brain or the nerves that co-ordinate swallowing. This may be due to complications of an ICU stay, such as a small stroke. Gary is going to have an MRI scan at some point to determine whether this has happened.
The Speech and Language Therapy team (SLT) are experts in swallowing, especially in the ICU patients. They can arrange investigations to look at why swallowing is poor and plan any appropriate treatment. They can also arrange therapeutic exercises to improve swallowing over time.
In the meantime, Gary has to be fed by a nasogastric feeding tube that is inserted through the nose and passes into the stomach. This is not proving straightforward. The hospital protocol requires that the position of the tube should be checked before feeding just to make sure the tube has not moved out of the oesophagus and into the lung. Putting feed into the lung would cause pneumonia leading to respiratory failure and can be fatal. The position of the feeding tube is checked by sucking up a small amount of stomach contents through the tube and checking that they are acidic. Unfortunately, Gary’s tube whilst working well enough for feeding, appears to be blocked just enough that this can’t be done. The protocol dictates that if this is the case, the tube needs to be x-rayed.
The end result is that Gary has been having an x-ray every day for a week. As well as the obvious undesirable effects of this, such as glowing like a Chernobyl fireman, it delays the start of his feeding for hours so that he has not been getting enough food. Luckily, I have learnt today that common sense has prevailed and they are no longer having to do this if the feeding tube’s external position hasn’t changed.
Reading this, you can start to get an idea of the legacy that a visit to the Intensive Care Unit can leave you with. Access to good rehabilitation services are key to making the most of the huge effort that has gone into ensuring a patient like Gary survives. Spending tens of thousands of pounds on Critical Care is poor value for money if a lack of rehabilitation results in a poorer outcome than might otherwise be the case.
Rehabilitation services are not what they should be, be they found in acute hospitals, specialist rehabilitation centres or in the community. We are trying to improve these services for our patients within our own hospital and improve their outcomes. We want to develop an ICU follow-up service to allow for this both whilst the patient is in hospital and once they have been discharged.
It would be quite easy for Gary to become despondent given what he has been through but when I was FaceTiming him today, I saw no sign of that. He was looking so much better than the last time I saw him and talking to him is a lot easier as his voice has improved significantly. Whilst he still has a long way to go and will have many low moments, it’s still a joy to see him answer the ‘phone and smile at you.
Earlier blog posts that tell Gary’s story: