26th October 2020
UK COVID Deaths – Daily 102 / Total 44,998
UK COVID Deaths with COVID-19 on the death certificate - Total 58,164 (up to 9 Oct)
James Cook Hospital – Total COVID deaths – 277
All COVID cases within South Tees Hospitals Trust – 64
James Cook Critical Care COVID cases – 10 (3 ventilated)
I’ve just finished working the weekend and have experienced two very different days. The hospital has continued to see an influx of COVID patients and when I arrived on Saturday morning I discovered that we had filled the eight-bedded COVID ICU. This left us with only the isolation rooms on the High Dependency Unit to admit COVID patients into. We have been close to this position before over the last fortnight but never with so many COVID patients on the wards.
An increasing number of these patients are receiving CPAP. We no longer have the capacity to admit them all. Some of these patients would not be suitable for ventilation if CPAP fails and so it is appropriate to keep them on the ward. Such patients are usually very frail and elderly with significant, debilitating medical problems. There is often very little more that can be done for them if their respiratory failure continues to deteriorate despite CPAP.
We currently have two younger patients with worrying COVID pneumonitis who we are hoping will avoid ICU admission. They are in their 30’s and 40’s and unusually have no underlying health problems. Such patients can often deteriorate very quickly and leaving them on the ward always worries us a little. This is a dilemma that we face all the time. We would like to be cautious and admit any patient with the potential for deterioration but if we do this then we will have no beds available for anyone who might arrive in the hospital in extremis. We are continually making judgements about who to admit and who not to. We must balance clinical need against bed availability and the potential for deterioration. Over the course of the day, the constant re-evaluation and revision of this decision-making can become exhausting.
The two registrars on-call this weekend, Tomy and Katie were taking most of the calls from A&E and the wards. Tomy had spent most of his day pin-balling around the hospital seeing COVID and non-COVID patients alike. Every half hour or so, he would ring to inform me of the progress of a host of patients or announce the arrival of a new one.
Halfway through the afternoon we had a patient who went straight to the top of the ladder. Katie and I were summoned to the Coronary Care Unit where there was an elderly patient who had developed severe heart failure and was rapidly deteriorating. She was unable to breathe properly as her heart failure had led to pulmonary oedema - an accumulation of fluid within her lungs. It was clear that we needed to arrange transfer to ICU in a hurry.
Whilst I called the Unit to let them know of our imminent arrival, Katie and the nurses did what they could to stabilise the patient.
I returned to the patient’s room just a few minutes later to find that things were not going well. A quick glance at the monitor revealed an ECG trace that was anything but healthy. The patient looked like she was suffering a large heart attack and by the time I reached the bed, she had collapsed and arrested.
I immediately started CPR and was promptly told off, albeit good-naturedly, by the nurses. I wasn’t wearing full PPE you see and so was in breach of the COVID-19 resuscitation guidelines. During the pandemic, resuscitation (chest compressions and bag-mask ventilation) has been classified as an aerosol-generating procedure and so could inadvertently lead to viral exposure. Resuscitation training teaches you to look for hazards before commencing CPR but this is more appropriate for an out-of-hospital scenario. We are supposed to check for oncoming traffic, falling masonry, electrocution risk or all manner of unlikely hazards such as frenzied wild animal attack that may pose a risk to our own health whilst resuscitation is in progress. The small chance of contracting COVID-19 from our patient hadn’t registered on my ‘hazard radar’. I apologised and let one of the nurses take over.
Unfortunately, it soon became very clear that our patient was not going to survive and we were sadly forced to abandon our resuscitation efforts. Katie and I returned to the ICU to catch up with Tomy and the rest of the patients under our care.
By the end of Saturday, the hospital contained a grand total of 69 COVID patients. Kerry, our Outreach nurse reported that, fortunately, the patients on the ward were relatively stable and no-one was currently looking like they would need ICU admission. However, we had very few ICU beds left. Worse still was the fact that the ICU Consultant taking over from me was Ian. Ian is perpetually’unlucky’ when it comes to attracting patients and has a tendency to fill any remaining ICU beds whenever he is on-call. For his sake, we thought it best to come up with a contingency plan. We identified patients that we could send to the ward if push came to shove and calculated that if we used the designated COVID operating theatre as a makeshift ICU overnight we could continue to admit should the need arise. I left for the night, wondering what carnage I would be greeted with when I returned in the morning.
Sunday dawned and it was a glorious sunny morning. Because the clocks had changed, I wasn’t setting off to cycle to work in the dark for a change. I arrived to a surprising air of calm; Ian hadn’t ruined everything after all. In fact, he hadn’t admitted a single patient overnight.
Jane, the Outreach nurse reported that there had been no further COVID admissions to the hospital and that there was still capacity on the wards to provide CPAP if necessary. It looked like we had dodged a bullet. We had expected to be implementing our ‘surge’ plan. This involved closing the Female Surgical Admissions Unit (SAU) and converting it into a High Dependency Unit. We could then move some of our non-ventilated patients from the ICU, allowing us to create a second COVID ICU. This would give us a total of sixteen COVID beds and allow us to cope with the ongoing rise in COVID admissions.
We discussed whether we should implement this plan on a Sunday or whether we could wait until tomorrow. Our Sister in Charge, Jo, cautioned us regarding the amount of time it would take to transfer patients, clean beds and move equipment with the number of nursing staff we had available. I asked if there was anything we could do to speed up the process. “Yes”, she said sarcastically, “you could roll up your sleeves and help me clean the beds…?”
In the end we decided to postpone the move for 24 hours. We were betting on a quieter day and we were not disappointed. In an opposite replay of the day before, we weren’t referred any new patients. We had time to complete thorough ward rounds, review patients, have a coffee break and the whole team even managed to sit down for takeaway pizza together. It was the calmest day we’d had in many weeks and everyone was thankful for it. I even found time later on in the afternoon to customise my new PPE hood system.
So, a day that very much felt like the eye of the storm to be honest. Come Tuesday we will have opened our second COVID ICU and had to expand into another part of the hospital. The expansion of Critical Care will have knock-on effects on the hospital’s ability to perform routine non-COVID work. It’s becoming increasingly easier now to look to the horizon and see a situation similar to that which we saw during the first surge in March and April.
PPE: Piranha Protective Equipment