27th September 2020
UK COVID Deaths - Daily 17 / Total 41,988
James Cook Hospital – Total COVID deaths – 259
All COVID cases within South Tees Hospitals Trust – 24
James Cook Critical Care COVID cases – 5 (1 ventilated)
Nicky is at work this weekend but things remain under control. She has admitted another COVID patient to the ICU today, but has mostly been kept busy with ‘routine’ work; cases like diabetic emergencies, heart failure, alcohol-related gastro-intestinal bleeding, abdominal aortic aneurysm ruptures and the like.
Fortunately the rise in COVID cases that we saw earlier this week hasn’t continued. Whilst the hospital is continuing to admit small numbers of coronavirus cases, a few patients have recovered and a couple have sadly died, meaning overall numbers have remained fairly static.
On the ICU, our single ventilated patient remains unwell. He has been with us now for over 20 days as a result of severe COVID pneumonitis and continues, at times, to be difficult to ventilate effectively. Amongst the other patients, I am pleased to report that the lady that I admitted nine days ago has improved to the point where she has been discharged back to the ward. Her pneumonitis responded slowly to CPAP and she avoided mechanical ventilation.
Not surprisingly, the recent increase in seriously ill COVID admissions has been seen throughout the northern region. As of two days ago, there were just short of thirty COVID positive and suspected positive patients within Intensive Care Units in the North of England Critical Care Network (the area north of Leeds). This increase in ICU patients is to be expected but none of us know how quickly cases will continue to rise or for how long. Predictions and forecasts are notoriously unreliable and can be quite frightening but it is important to plan for the worst. Well, as much as you can.
NHS England has made it clear that the response to a second surge of cases will be different from the first that we saw back in March. Whilst it’s obviously essential to plan for a sharp rise in the numbers of hospitalised COVID-19 patients, there must also be plans to maintain hospital services for other patients in need. With regard to the provision of routine surgery, it is not expected that everything will grind to a halt as happened before.
This presents a major problem for hospitals: How do you keep non-COVID patients safe whilst in hospital and protect them from becoming infected during their hospital stay? This was relatively straightforward during the summer when viral transmission in the community was at a low level but it is now more difficult. Preventing such infection is vital; patients undergoing surgery after contracting coronavirus are at greatly increased risk of postoperative death.
The hospital has colour-coded pathways to try to minimise nosocomial COVID-19 infection (meaning an infection occurring in hospital). The red pathway is for patients who have tested positive for the virus. They must remain in a red (COVID) ward for the duration of their hospital stay. The amber pathway patients are patients who have been admitted urgently and have tested negative on admission to hospital. Unfortunately it’s still possible that they may be incubating the disease and so they too have to be separated from at risk patients. They will be swabbed again on day five but even if negative, must remain with other amber patients. The only way to become a green patient is to self-isolate for 14 days prior to admission to hospital for your operation or procedure. Staff looking after green patients must also only look after green patients in order to minimise the risk of cross-contamination.
So Critical Care is either a red area (our COVID ICU) or an amber area (the non-COVID ICU). Our patients are receiving treatments such as CPAP or ventilation that are classified as aerosol-generating procedures. This means that all of our staff must now wear full PPE in order to protect them from inadvertent exposure to a potentially high viral load. This has caused a big slump in morale, especially amongst the nursing staff who have to wear the loathsome costumes for nearly all of their long shifts.
We see all these changes as a march toward the inevitable, prompting recollection of what we all went through back in March. Everyone is beginning to worry. I am pleased to report that the hospital’s Clinical Psychology Team have returned to the ICU in order to offer their support to all staff who will have to cope with the increased workload that a second surge will bring.
Finally, for those who would like to believe that the virus is only affecting the young and that as a result, new cases are less likely to require much in the way of medical care, it’s worth emphasising that so far, over 20% of the hospitals current cases have required admission to the Intensive Care Unit. Not a reassuring statistic.