Saturday 16th May 2020
Figures for 15th May
UK COVID Deaths 384 / Total 33,998
James Cook Hospital – Total COVID deaths – 216
All COVID cases within South Tees Hospitals Trust – 56
James Cook Critical Care COVID cases – 10 (7 ventilated)
James Cook Critical Care non-COVID cases – 37 (18 ventilated)
A very mixed day today. It started badly with some very sad news. One of our COVID patients who had been with us for the past three weeks died overnight. Nicky and I and the rest of the staff had got to know him when he was first admitted and had required CPAP. We had all grown fond of him and were upset when his condition worsened such that he required intubation and ventilation. We did our utmost to try to ensure his survival but sadly, despite all our efforts, his condition ultimately continued to worsen. His death has upset many of the staff, myself included. I cannot imagine what his family have been through over the past few weeks and my heart goes out to them.
Having got off to a bad start the day was not getting any better. I was on-call for emergency admissions to Critical Care and the emergency ‘phone that we have ironically nicknamed the ‘bat-phone’ rang incessantly all day. The 'phone itself is a nasty cheap 1990’s style Nokia mobile. It is impossible to hear the caller clearly, especially when in PPE and you have to ask them to ring you back on a landline or your own personal mobile to ensure that you don’t miss anything important. Worse still, it has the most annoying ringtone. It’s almost as if it has been designed with the sole purpose of annoying me.
The first call was to Accident & Emergency where an elderly gentleman had severe respiratory failure due to what looked like bacterial pneumonia. For a short while it looked as if we would have to intubate and ventilate in order to prevent respiratory arrest but we tried non-invasive ventilation (NIV) and things began to improve. Non-invasive ventilation is a bit like CPAP and uses the same tight-fitting mask. Where CPAP uses continuous low pressure to keep airways open, NIV uses higher pressures to help patients inhale deeply. It is useful if the patient’s oxygen levels are acceptable but they are accumulating carbon dioxide due to shallow breathing. We transferred him up to the High Dependency Unit to continue this treatment. He subsequently tested negative for coronavirus.
Another patient was brought to A&E by ambulance after suffering a cardiac arrest at home. He had been successfully resuscitated by the paramedic crew but was not surprisingly, very well when he arrived with us. He was a diabetic who had developed diabetic ketacidois (DKA). When a diabetic runs out of insulin, the body cannot use sugar for energy and starts consuming fat instead. This leads to the build-up of harmful substances called ketones. These are acidic and eventually coma, shock and cardiac arrest will occur. DKA is often triggered by a concurrent infection in a susceptible diabetic and this would appear to be the case here. Again it looked like the likely culprit was a bacterial infection rather than the virus.
The patient required urgent intubation and so the Anaesthetic Airway team were called. We transferred the patient to CT scan to rule out other causes of a cardiac arrest such as a stroke or a pulmonary embolism. The patient’s lung CT did not show features of COVID pneumonitis but we still needed an isolation room until his swab result was back. I had arranged a bed in one of the cubicles on the COVID ICU because all those on the High Dependency Unit (HDU) were occupied. All new patients need to be isolated for a few hours until their coronavirus swab result comes back to ensure that we do not miss atypical COVID cases. Unfortunately we simply do not have enough isolation rooms for this. The anaesthetic team duly took the patient up to ICU only to be told when they arrived that there was no room in the inn and there had been a change of plan.
Things change pretty fast on ICU but I was feeling very guilty after promising them a bed. We quickly drew up a plan to take the patient to one of the empty operating theatres and set up a little ICU there. This is far from ideal for many reasons but, unflappable as ever, Cat, Kate and Patrick got things under control and set about trying to stabilise the patient. By the time an isolation room was free a couple of hours later, the patient was starting to improve.
There then followed multiple calls from different wards asking us to review lots of patients who were not poorly enough to need Critical Care but were at risk of doing so if they weren’t managed carefully. I barely had enough time to get to grips with one problem before being called to another. By the time my shift was over I was more than ready to call it a day.
However, the thing I shall chose to remember about today is not the tragic loss of a patient, nor the sometimes chaotic nature of Critical Care in a big hospital but the hour I spent over lunchtime reuniting one of our patients with some of his family.
One of our success stories is a gentleman in his 30’s who was desperately ill with COVID pneumonitis. There were many times when it did not look like he could survive. Against all odds he did and is now on the HDU with a tracheostomy, very close to breathing by himself. He has been with us now for seven weeks and he has not been outside or seen his family in that time. We decided to kill two birds with one stone. We arranged to take him outside where he could meet his wife (whilst respecting social distancing).
Taking recovering patients outside is something we have done for a few years now when we can but we have not been able to secure approval for this since the pandemic began. Michelle, our director obtained the necessary approval a couple of days ago. The benefit to the patients is enormous. Only people who have spent an appreciable period of time in hospital as a patient can understand how big a step it is for sick patients to recover to the point where this is possible and the uplifting effect that even a short period of time outside can have. We would dearly love to have our own garden for this purpose but in the meantime we are using the Emergency Cardiothoracic entrance. It’s far from a scenic beauty spot but it’s the best we could do.
Sadly, only a few patients are suitable given the need for stability and a minimal ventilator requirement. This was the first time we were taking a COVID patient outside and we had to wear PPE in order to transfer the patient through the hospital. His nurse, Lucy, Healthcare Assistant Nicole and I arranged for the patient’s wife to meet us outside. It was an emotional moment and was by far the most enjoyable time I have spent at work since this whole business began. And it wasn’t just because I was able to get rid of that bloody 'phone for an hour…
The Great Outdoors