The Long Road to Recovery
Tuesday 28th April 2020
COVID Figures for 26th April
UK Hospital Deaths 360 / Total 21,092
James Cook Hospital – Total deaths – 172
Nicky and I now have a couple of days off together before one of us is back at work. I thought I might update you on the progress of my friend Gary down in London. We have known each other for many years now. We are both enthusiastic mountain-bikers and despite being a good 10 years older than me, Gary can give me a good run for my money on the bike. As I have said before, he is the fittest person I know who carries a free bus pass.
Gary became unwell due to a Coronavirus infection at the end of March. He developed a fever, followed by a cough and then became short of breath. He was admitted to Hospital three days later with respiratory failure due to COVID pneumonitis. His condition worsened despite high-flow oxygen and CPAP and he required admission to the Intensive Care Unit.
Once in ICU he was monitored closely but his breathing continued to worsen. The following day he required intubation and ventilation. He remained sedated and ventilated for the next week.
His ventilation was complicated by a pneumothorax. This is a well-recognised complication of ventilation where the pressure used to inflate the lung cause the rupture of the lung alveoli (air sacs) and an air leak. As a result, air from the ventilator fills the lining of the lung (the pleural cavity) and causes the lung to collapse. The air can also leak into the cavity containing the heart and up into the tissues of the head and neck. This requires treatment with a chest drain, where a tube is inserted into the pleural cavity to allow the air to escape and the lung to re-inflate. The ruptured alveoli then heal up spontaneously and after a short while, the chest drain can be removed.
Eight days after admission, Gary developed kidney failure. He started dialysis on his birthday. Far from the best present he has ever received.
Over the next few days, he developed recurrent fevers. Secondary bacterial infection was suspected and he was treated with antibiotics. His condition slowly began to improve.
The sedation was reduced and his respiratory failure improved to the point where he was able to take over some of his breathing by himself. An attempt was made to remove the breathing tube a fortnight after he had first been ventilated. Unfortunately it did not succeed and despite CPAP, he required re-intubation and ventilation.
There followed another fever and ongoing infection requiring further antibiotics. Despite this, there was some improvement in kidney function and dialysis was temporarily stopped. Unfortunately this was short lived and dialysis had to be restarted a few days later.
Gary’s progress continued to slowly improve despite these setbacks. There was another attempt to remove the breathing tube with some initial success. Unfortunately due to a combination of residual drowsiness from the kidney failure and residual lung effects from the pneumonitis, he required re-intubation the following day.
It was now clear that tracheostomy would be necessary and this was performed the following day by the ICU team. It was now 25 days since admission to the ICU.
The tracheostomy allowed for a slower wean from the ventilator, allowing communication and reduced sedation requirements. There followed another episode of fever and probable infection due to an infected dialysis line which was removed. This was a minor setback and within a few days, his kidneys had recovered to the point where dialysis was no longer required. The pace of recovery was starting to accelerate.
A week later, Gary had improved to the point where he was able to breathe by himself for a few hours each day and things were looking brighter. Sadly I have heard today that it looks like he has another infection. Most likely this is from his chest and is to be expected given his troubled course. I am hoping that this is another small setback and that his progress will continue shortly.
It has been hard hearing all this from a distance. His course in Intensive Care has been typical of many of my COVID patients. With my Intensive Care hat on, I know all too well how poorly he was, and still is. I knew the statistics and his likelihood of survival. I have wanted to stand at the end of his bed and check everything; to review his blood results, chest X-rays and CT scans. However, despite all this, I know how it is possible for some of our patients to overcome these odds.
Gary is as strong as an ox. It is why he is still with us. He is far from out of the woods but the edge of the forest can be seen in the distance.