Timely Reminder

14th December 2020

UK COVID Deaths – Daily 232 / 7-Day average 424

Total UK COVID Deaths within 28 days – 64,402

Total UK Deaths with COVID-19 on the death certificate – 73,125 (up to 27th Nov)

James Cook Hospital – Total COVID deaths – 368

All COVID cases within South Tees Hospitals Trust – 78

James Cook Critical Care

COVID cases – 10 (7 ventilated)

Non-COVID cases – 41 (14 ventilated)

Over the past few weeks I have tended to look after our non-COVID patients within Critical Care. This weekend, however, I have been looking after patients on the two COVID units and have been reminded just how awful a disease COVID-19 can be.

Over the past few weeks we have accumulated a collection of COVID patients who are every bit as sick as the ones that we saw during the first wave. They are also younger than those we were looking after a few weeks ago. Most of our current patients are in their 40’s and 50’s with the remainder in their 60’s. There is no-one that I would call elderly and many of them have surprisingly little in the way of existing medical problems.

One of the perplexing things about COVID-19 is the seemingly random way that some individuals develop severe, life threatening infections whilst others have minimal symptoms or remain asymptomatic. Clearly age, sex, ethnicity and underlying medical conditions are important but exactly what causes these people’s immune response to COVID-19 to spiral out of control is unclear. Whilst it will be a long time before we come to fully understand what is happening, there has been a long-held suspicion that genetics play an important part.

Nature magazine published the results of the GenOMICC (Genetics Of Mortality In Critical Care) study a few days ago. This study looked at 2244 patients across the UK and examined the effects of an individual’s genetic makeup on their susceptibility to the life-threatening complications of COVID-19. James Cook Hospital was one of many that took part and I believe we were the biggest recruiting site in the country.

The study has discovered five genes which, if present, increase your chances of being ventilated and dying from COVID-19. These genes were responsible for two processes – antiviral immunity and lung inflammation, both of which are obviously vital in the body’s response to COVID-19 exposure.

It’s important to emphasise that the overall chance of becoming severely unwell with COVID-19 if you have these genetic variations is around 6.5%. Whilst significant, this risk is smaller than many other risk factors such as age. There is a hope that, rather than simply predict who may be at increased risk of death, this information can be used to develop targeted new treatments in susceptible individuals.

Unfortunately, none of this is much help to our current batch of ICU patients, a lot of whom are very unwell indeed. Many of them have been ventilated for weeks. A number of them have gone on to develop secondary bacterial pneumonias which, coming soon after COVID pneumonitis, is a life-threatening complication. Antibiotics can be used to treat the new infection but the extra damage that occurs in an already injured lung can sometimes be too much for these patients. We lost a young patient to such a complication this weekend. We had been struggling to keep him alive for the past month and his death is very disconcerting and upsetting. His family have been through so much during his ordeal that I cannot imagine how difficult it is for them to come to terms with this tragedy.

Amongst all the ventilated patients, we have two gentlemen who have been on CPAP for the best part of two weeks. We have always been worried about them; they were transferred from the ward to the ICU in order that we could keep a very close eye on them. They have, at times, struggled to tolerate CPAP. This is perfectly understandable; most patients find it difficult to put up with a CPAP mask for a few days, let alone a fortnight. Unfortunately, they too have now both developed secondary pneumonias. Over the past two days we have seen an increasing number of episodes when their oxygen levels would dip alarmingly. We had been holding our nerve and desperately hoping for improvement but, as time went on, it was looking increasingly likely that we would have to place them on the ventilator.

By the time the clock ticked over into the early hours of Sunday morning it was clear that neither of these two patients could manage much longer. My registrar, John and I made the decision to intubate and ventilate both of them. We progressed from one patient to the other, reassuring them before putting them off to sleep, passing the endotracheal tube into the trachea and placing them on the ventilator. After a quick fiddle with their ventilator settings, we soon had two sedated, stable, well-oxygenated patients. What struck me was how much more routine this had become compared to when we started intubating COVID patients back in March. Not a hint of fuss, drama or worry was evident. Whilst we never like having to intubate any patient, it was great to see the whole team, doctors and nurses alike, working so efficiently together.

John remarked that it was a strange coincidence that both these patients had arrived in hospital at almost the same time. They had been placed on CPAP and transferred to the ICU, hot on each other’s heels, on the same day. Now, some ten days later, they had both developed the same complication and deteriorated at the same time. We then intubated and ventilated them within minutes of each other. Hopefully they will both recover together too.

This was not a great finish to a fairly exhausting weekend. Fortunately, earlier in the day I had taken some time out to remind myself that it wasn’t all bad news. One of our patients, a gentleman just out of his 50’s has begun to make a recovery. He has been very unwell with COVID pneumonitis for the past six weeks but has improved to the point where he is awake, intermittently breathing without the ventilator and is now able to talk to us. He still has some way to go but he is streets ahead of where he was last week. I had a bit of chat with him and, to be honest, it did me the world of good. Sometimes the COVID ICU can feel like a pretty gloomy place. Every so often it’s important to park your pessimism and remind yourself that people do get better.