What is it like to be a doctor in Covid -19 season? I came in to work today at 8AM to get a handover of patients from the night registrar (fellow). One of our colleagues a thirty something fellow had been admitted overnight with severe pneumonia, tests awaited but almost certainly covid-19. The ward I am working on used to be a burns unit, but has been taken over to be a high dependency unit for patients with Covid-19. Part of the ward is now a clean area, where we keep the notes and all the kit we need. After getting the hand over from the night registrar, and reviewing the bloods and observations We (me and the consultant) suit up in PPE. Gowns, gloves, visors, and masks. The latter are the most critical given Covid-19 is airborne, we pinch the mask tight over our nose and pull it well down on our chin. If the visor fogs up you clearly don't have your mask tight.
The entrance to the clinical area is through an airlock. heavy plastic sheeting with a zip down the middle has been installed. For those familiar with diving the procedure is familiar, you check your buddy (in this case my boss), to make sure our PPE is on properly, then we unzip the outer plastic sheets, turn round and zip it up again. A newly installed A/C unit keeps the pressure in the air lock positive. We unzip the inner door and go in to the clinical area. All the patients on this ward have severe lung disease and are on assisted ventilation. Half way between a normal ward and ICU. They are awake and receiving some form of assisted ventilation. This is classified as high risk aerosol generating, the machines that we use potentially produce a spray of infected material so we need to wear high level protection.
Most of our patients are receiving CPAP therapy, we have repurposed machines designed to treat sleep apnoea to treat patients with severe viral pneumonia. Every day we learn how to look after the patients a bit better and the guidelines change. The CPAP machines provide what is called pressure support, air is blown in at a higher pressure than room air, by a tight fitting mask, we attach oxygen to the mask so that while the fan from the sleep apnoea machine provides the pressure most of what the patient breathes in is oxygen. all of this is us just winging it, as hundreds of others are doing round the world. The equipment is designed for this use nor certified. One of the consultants has been trying different machines and circuits on himself. Some machines burn out after a few hours because they are not designed to work for hours on end, others can't cope with the rapid breathing that happens in pneumonia, but we now have a set up that works.
So we round on our patients. Nothing comes out of the infected zone(except the staff), so we make notes on the computer which we will later transcribe onto paper (in case the computer system crashes we keep a paper record for in-patients). The first patient is critically dependant on pressure support and this is day three, he can't come off for long enough to eat so we need to pass a feeding tube to ensure nutrition is maintained. This involves a change of mask as the mask currently being used is not compatible with a feeding tube. The physiologists (respiratory therapists) who used to look after the sleep apnoea service and home ventilation service are now coming in every day including weekends to help troubleshoot issues with mask fitting and ventilators, essential because the nurses having to look after these patients have had no experience with this equipment before now. The physiotherapists are in to try and optimise breathing, a critical issue in covid-19 since a big problem appears to be collapse of areas of the lung, and optimising 'lung recruitment' is essential to survival we have discovered.
The next patient's oxygen levels drop hugely just with the effort of sitting up so we can listen to his chest. The oxygen levels need turning up to the maximum we can deliver. The ICU team have seen him and will take him for mechanical ventilation if needed, but if we can keep him his chance of living is 70%, if he needs to go to ICU his chance of dying is 70%.
The next patient is a success a thirty year old who is off supported ventilation, we will keep him one more day and if he remains well then to the general ward.
For each patient we visit we put a second pair of gloves and an apron on so we don't transfer any infection between patients. one patient sent here turns out to have had flu pneumonia, we don't want them to catch covid, and we don't want to spread flu to people critically ill with covid-19.
the there is the blood round, we try and minimise people exposed, so my consultant goes out of the ward prints off the blood forms and labels the blood bottles, then leaves thenm in the air lock. Once the outer door is zipped up. I collect the pre labelled blood bottles and take the bloods. These are then bagged, and left in the air lock, my boss, dressed up in PPE then enters the air lock 'double bags' the samples in clean bags with the request forms and brings them out changes out of PPE and sends the samples to the labs. Even such a routine process as taking a blood test from a patient is now hugely complex and uses up multiple sets of PPE.
Unlike the nurses who have to remain in the high risk area in PPE (hot and sweaty, not in a good way) for an entire shift, having rounded, done the bloods and written up the notes I can leave and have a team coffee (at a safe social distance). We meet up more than normal, but in a rapidly changing situation this is important, the gossip is all about what we have learned about this illness, a better way to wean off ventilatory support, what trials are ongoing, and changes in our rotas.
I take the chance of skyping my partner mid day, she is shielding due to taking immunosuppressive therapy for colitis , and I am working in a high risk area for infection, so this is the closest we'll get for months.
there are referrals from the ED (Emergency Department) about patients with bad breathing that might have Covid-19 and need assisted ventilation, neither seem likely to have Covid-19 and both have complex ling disease that need specialist treatment. The problem is that it is all too easy to label anything as covid-19 and not think about things in the same way as one would six months ago. However, the truth is anyone with any problem could be carrying the virus at the moment and we need to do our best not to put any other patients at risk and not to put any staff at risk. Our hospital is an old institution, most of the wars our open ward and we have relatively few single rooms, so we are constantly having to think about who can go to which bed.
I can't claim that at the moment we are really busy, we have empty beds, people are avoiding coming into hospital. Everyone is having to learn new skills, things are constantly changing and for some people this can be immensely upsetting. But everything now takes much longer, takes more people and has to be done with scrupulous care not to endanger anyone else.
Nominated.
