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  • Richard Cree

Three Strikes

Updated: Apr 15

Tuesday 14th April 2020

COVID Figures for 13th April

UK Hospital Deaths 717 / Total 11,329

James Cook Hospital – Total deaths – 100

James Cook cases on wards - 129

James Cook cases in Critical Care – 22 / 13 ventilated

I'm back working on one of the COVID units today. Not a lot of change in the overall number of patients within Critical Care; we have some new admissions, some patients have recovered and some have not survived.

Most of the patients I encountered today were fairly stable and didn’t require an awful lot of attention on my part. However, three of them were not very well at all. Only three days ago I wondered whether we were going to see some very sick people who had tried to avoid hospital. I also wondered why we hadn’t seen more overdoses. It seems that the Gods had heard me.

Our first sick patient is a gentleman in his 40’s who has taken various substances before being brought to hospital. The only thing we know is that some hours earlier, back when he was still able to talk, he admitted to taking amphetamines. We suspect other substances were involved as well but it can often be difficult to work out exactly what someone has taken. There is a chance that his ‘overdose’ has been staggered over several days.

He is now very poorly. There are lots of ways recreational drugs can make you unwell. Often they don’t cause too many problems but taking too many can render you unconscious, give you heart or kidney failure, cause muscle damage or simply make you really, really annoying.

Our patient had moved quickly from the annoying phase to the trying to die phase. He now had multiple organ failure and required ventilator, kidney and cardiac support. We didn’t know whether this was a complication of a pure drug or whether someone had been cutting his ‘Bolivian Marching Powder’ with ‘Mr Sparkle Washing Powder’. Over the course of the day, we tried, in vain to prevent his continued deterioration. Little seemed to work.

The second patient was a middle-aged lady with typical coronavirus symptoms. She had been unwell for a few days and then got very I’ll yesterday. By the time she was admitted to hospital this morning she was close to cardiac arrest. She was rescued by the Anaesthetic Emergency Airway Team (the Thunderbirds) and brought up to us.

Arterial blood gas analysis revealed one of the worst results I had ever seen. There was a huge amount of acid in her blood (pH 6.5) due to kidney failure and the accumulation of lactic acid due to heart failure. Now, it will come as no surprise to find that, unless you are hunting Sigourney Weaver in a Ridley Scott movie, having lots of acid in your blood is not a good thing. It was extremely unlikely that we would be able to stop the inevitable decline that was coming.

One of the hardest things about Intensive Care Medicine is the feeling of futility you get when you have tried everything you can to salvage a dreadful situation, knowing that nothing will work. This was one of those times. It gets easier as you get older but no matter how experienced you are, you just can’t shake that voice at the back of your head telling you ‘there must be something you can do’.

Our third patient was another COVID pneumonitis. He was a gentleman in his 70’s whose respiratory failure had been fairly stable up until today. Now there was some new shadowing on his chest x-ray and it was difficult to provide enough oxygen using the ventilator.

When patients are difficult to ventilate, sometimes placing them on their front will dramatically improve the situation. This is not easy when the patient is ventilated. We had tried this before a few days ago, but this patient had failed to improve. However, it was my opinion that he had now entered a second phase of his COVID pneumonitis and that he may respond to ‘prone ventilation’ this time.

What did I know? We flipped him over and watched as once again, the situation failed to improve, and then got worse. Within 30 minutes I called my colleagues to let them know he would need to be quickly returned onto his back.

Strike three. I’m out.

I hand-over to the night team and apologise for my spectacular failure to improve any of the patients before cycling home.

Tomorrow is another day.

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