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Frontline experience managing Respiratory complications of COVID-19


Experience from a secondary care respiratory specialist

This is a personal account of events and the views expressed within are not necessarily that of GSK.

I was working as a Respiratory specialist trainee coming to the end of my training and looking forward to starting work as a Consultant when in March it became clear that the hospital I was working in would need to undergo significant changes in estates, workforce and service structure to cope with the oncoming Covid-19 pandemic. These changes would pose many different challenges, both on an operational and a personal level, but ultimately, they would bring many different teams much closer together to work towards a common goal. 
 
A specialist Covid combined HDU/ ICU was created at the hospital in order to provide a place to care for those severely unwell patients with Covid 19, whilst also allowing the non-covid ICU to remain open - essential to the functioning of the hospital. The dedicated Covid unit was to be staffed by Intensivists, Physicians and Anaesthetists. Volunteers were asked for and a team was quickly assembled to staff the Covid rota - resulting in many of my more senior Consultant colleagues working a first night shift for many years! The modelling had made clear that our previous number of level 2 and level 3 beds would soon be overwhelmed if changes weren’t made. As physicians we would be involved in day to day management of these patients, as well as playing a key role in decision making regarding escalation of care. The plans talked about - providing hundreds more ventilated beds across the region - were daunting but inspiring. The word unprecedented was mentioned in the media a lot at that point and this really was how it felt to me, but I was impressed by the planning from the senior medical and management teams and also by the eagerness of people to step up and step out of their comfort zones in order to make this necessity happen. 


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As a physician normally managing the acute medical take I understood resource limitation in terms of bed numbers - usually restricted by workforce; i.e. the amount of doctors and usually the amount of nurses available, however, very quickly things that I had never even considered in the running of a hospital became of paramount importance. Awareness of oxygen flow rates came into the public realm when a teaching hospital in London had a critical incident where they came perilously close to a critical loss of oxygen flow1, but issues such as these were needing to be considered up and down the country. Oxygen had become a resource that needed to be managed with the utmost care. Other more simple things became important too, plug sockets and electrical supply to power ventilators and drip pumps, space to don and doff PPE, clean scrubs, alcohol gel and, of course, supplies of PPE. I was very fortunate that the supplies of FFP3 face masks and other key PPE was never really an issue on our unit, but I read the reports of the difficulty other areas experienced and of healthcare workers becoming very unwell, some losing their lives, with trepidation and great sadness. 

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Box 1
Patients started to trickle in at first, then they became a steady flow, the hospital quickly needed several wards to treat covid positive patients, some patients came in extremely unwell at the front door and these were the patients that we would generally take straight from A&E. The spectrum of patients coming into the hospital was broad - many elderly patients came in ‘off legs’ or ‘generally unwell’ but not requiring respiratory support, whereas anecdotally there was a particular type patient we would admit onto the unit (features in box 1) - typically from clinical presentation only as Covid PCR swab results had a 24-48 hour turn around and many had not yet been tested in the community (especially at the start on the pandemic when testing capacity was limited). A decision making process was developed so that ceilings of care decisions were made by at least 2 senior clinical decision makers (3 in those borderline cases) and although undoubtedly there was some difficult conversations, I found that on the whole patients and families were really receptive to our explanations and understood the limitations of our management - especially early on in the pandemic.  A common feature of our discussions with families was the fact they were undertaken over the phone, this posed new challenges as the normal non-verbal cues and communication was missing. This, I think, coupled with the relatives physical distance from the hospital and their loved ones must have added to their worry but we endeavoured to give daily updates to try and alleviate this.

Working in the unit in full PPE was hot, humid, claustrophobic and tiring. Communication between team members was also challenging through two sets of FFP3 masks and visors, however i really felt for our patients who were hypoxic and often delirious. I can't imagine how confusing and scary it must have been to be whisked up to the unit and then surrounded by noisy machines and people covered head to toe in PPE.


We’ve continued to learn as we have moved through the last few months. The experiences from China suggested that early intubation and mechanical ventilation was initially seen as optimal in severe Covid 19 pneumonitis, but as time went on we started to try and avoid invasive ventilation if we could. Equally we quickly realised the high clot burden in these patients and had a very low threshold for fully anticoagulating those who came in very unwell.  
 
It has been inspiring to see the role that research has taken in fighting this disease and I’ve been so impressed with the work that intensive care units have done up and down the country to drive down the mortality from this disease from ~60% to ~40%2. On our unit we recruited patients to two studies initially; the RECOVERY trial which had a positive outcome with the Dexamethasone arm3 and the RECOVERY-RS trial which aimed to compare efficacy on non-invasive forms of oxygen delivery with the end point to avoid intubation (the results of this are still awaited). I hope that these trials, along with the excellent work being performed on finding a vaccine will help us to manage a second wave, if we have one. 
 

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Throughout this pandemic, as is always the case in medicine, is the simple fact that good palliative care has been as important as good active management. Unfortunately, despite the advances made, we have seen a lot of deaths as the result of Covid-19. Some of the hardest parts to the last months have been seeing those patients who are too unwell to leave hospital but have only been able to have very limited contact with their family due to the risk of onward transmission. In our hospitals the nurses and palliative care teams have been exemplary in giving care and support to our patients and their families, I know that our colleagues in the community have worked tirelessly to provide excellent care and allowed so many people to live their last days in the familiarity of their own homes. They should all be proud of what they’ve done over these past few months. 
 
Numbers have now fallen and the hospital is now starting to open up non-covid services again, a crucial development if more indirect deaths from this pandemic are to be avoided. I can’t see healthcare returning back to normal for many months to come - indeed I hope some of the changes we have seen over the past few months are here to stay. Different teams have come to work so closely together, with a razor sharp focus on the patient’s care at the centre of everything. Within teams we are kinder to each other with a realisation we need to look after each other’s mental and physical wellbeing, as well as our own. The way I’ve practiced medicine has become less defensive and my relationships with patients and their families more frank, honest and empathetic. 
 
The toll of morbidity and mortality, economic damage and social upheaval from Covid-19 has been great and is ongoing, but I’ve been proud to work alongside so many outstanding colleagues throughout the whole of our healthcare system, proud of the way people that make our NHS have responded and grafted, proud to have offered my own contribution to the effort.  


References

 
(1) https://www.theguardian.com/society/2020/apr/02/london-hospital-almost-runs-out-oxygen-c oronavirus-patients
(2)  https://www.bristol.ac.uk/news/2020/july/covid-19-icu-mortality.html
(3) https://www.recoverytrial.net/news/low-cost-dexamethasone-reduces-death-by-up-to-one-third-in-hospitalised-patients-with-severe-respiratory-complications-of-covid-19

Dr Paul Whittemore has received an honorarium from GSK for developing this article/content.

PM-GB-RS-WCNT-200045 July 2020

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