Going Large

6th July 2021

UK COVID Deaths – Daily 37 / 7-Day average 21

Total UK COVID Deaths within 28 days – 128,268

Total UK Deaths with COVID-19 on the death certificate – 152,725 (up to 25 Jun)

All COVID cases within South Tees Hospitals Trust – 30

James Cook Critical Care

COVID cases – 7 (5 ventilated)

Non-COVID cases – 46 (24 ventilated)

Yesterday, the Prime Minister announced that almost all COVID restrictions would be lifted on July 19th. Boris has decided to ‘go large’ and end social-distancing, working from home and the legal requirement to wear face masks. It’s an impressively brave decision given the ongoing rise in cases and the rest of the world will be watching us closely. We are the first heavily-vaccinated nation in the world to remove restrictions at a time when the incidence of the virus in the community is high. However, Boris acknowledged the growing sense of expectation and justified his decision by asking “If not now, then when?” It is a valid question. The decision to remove restrictions is a complicated one. Many factors have to be considered – the risk to the NHS, the economic consequences, the health effects of ongoing restrictions, issues around personal liberty and, of course, the effect on the Prime Minister’s popularity.

Time will tell whether the decision is bold or reckless but I will confess to being surprised at the decision to completely remove the requirement to wear face masks. I was expecting that they would still be required in some enclosed public areas with poor ventilation such as on public transport and within essential shops. The government is leaving the decision whether or not to wear a facemask up to the individual but this seems rather disingenuous to me. Unless we are talking about the sort of masks we wear in ICU, the widespread wearing of facemasks is designed to act as a source-control measure. One could spend a lifetime arguing over the effectiveness of standard face masks and the evidence-base for their use. What is certain though, is that such masks are worn to protect others rather than the wearer. This is something that a lot of people don’t seem to understand; I suspect that a lot of people wearing masks after July 19th will be doing so in a mistaken belief that they are protecting themselves from infection.

Whilst it’s clear that vaccination has severely reduced the risk of developing serious illness and admission to hospital, it hasn’t completely stopped it. Sadly, it also looks like our current vaccines are not able to prevent the continued spread of infection amongst the population; the concept of herd immunity may remain elusive for a while longer. The PM is gambling that the numbers admitted to hospital will remain manageable over the next few months and, to be honest, there is a reasonable chance that he might be right – hospital admissions are still only increasing slowly despite a high prevalence of COVID within the community.

Here at James Cook we are inevitably starting to see more COVID patients. Over the last two days, the hospital has admitted 22 COVID patients which is more than we were expecting to see at this point. Fortunately, very few of these are becoming unwell enough to be admitted to Intensive Care but we have admitted enough patients that we have run out of isolation rooms and have had to turn ICU 2 back into a COVID unit again. We did have to briefly open the temporary ‘surge’ ICU for a couple of days but this was due to the need to separate COVID and non-COVID patients whilst we prepared ICU 2 for its new role. The trusted temporary partition that we first hastily erected during wave one has been dusted off, given a lick of paint and is back in place, separating ICU 2 and ICU 3. Whilst still demoralising, the situation isn’t as bad as it might sound as we have fewer non-COVID patients than we did. We still have room for everyone for the time being.

We find ourselves looking at the current batch of COVID patients in ICU and rationalising their reason for admission. Some have refused to be vaccinated, either due to a reluctance to accept that COVID was a threat or even that it exists at all. Others have worried about vaccine side-effects and have delayed getting their second jab. Those who have been vaccinated twice all have a potential ‘explanation’ for the failure of the vaccine to protect them. Most often this is because they have a medical condition that causes them to be immunosuppressed or have to take immunosuppressive medication, such as steroid tablets, to keep an existing medical condition in check. Finding such explanations makes us all feel a little better. It reassures us that people without underlying risk factors, such as ourselves, colleagues, friends and family members are still very unlikely to become ill with COVID-19 and end up needing Critical Care. It’s also very common for ICU staff to try to rationalise what is happening around them in order to make sense of what, at times, can be a very chaotic environment. Being able to analyse, explain and justify why a particular patient has ended up in ICU gives us all the illusion that we still have some control over what happens in our lives. We don’t want to believe that any of it is simply down to bad luck.

We have also seen cases of vaccine ‘failure‘ amongst our own staff. There are a number of doctors and nurses who have become infected with COVID-19 despite being vaccinated twice. None of them is seriously unwell but they are obviously unable to work. There are other members of staff who are currently self-isolating after having close contact with someone who is infected. The number of staff off work has not caused too much disruption yet but with cases still rising there is clearly more of this to come.

The other route for staff to become infected is through contact with patients. There is now an increasing chance that any patient arriving at the hospital may be infected with COVID without realising it. As a result, the hospital has decided to re-introduce the Red-Amber-Green pathway system. This means that you can only be labelled ‘green’ or ‘definitely not COVID positive’ unless you have isolated at home for 14 days prior to elective admission. All other patients who are admitted and test negative are classified as ‘amber’, meaning they could still potentially be COVID positive. ‘Red’ patients are those who have tested positive for COVID-19 before or on arrival to hospital. This means that we will soon be back in full PPE when we are in ICU, as using CPAP or ventilating patients aerosolises viral particles in infected patients. Without the protection that full PPE provides, this creates an unacceptable infection risk, both for us and other patients. The prospect of being back in all the necessary protective gear is quite depressing even though we have known for a while that it was coming.

There are other signs that the incidence of COVID in the community is rising. My eldest daughter is distraught at the news that she will have to start wearing a mask at school again. My son would also be upset were it not for the fact that he and his entire school year are currently self-isolating. Sadly, this is not an uncommon occurrence at the moment. He plays rugby at Middlesbrough Rugby Club and his team-mates attend different schools within the local area. Every day their WhatsApp group announces that yet another of his team-mates has either tested positive or is isolating due to a close contact at school. This picture is being repeated across the land and more than 640,000 English children were absent from school last week as a result of COVID.

Clearly, this is a huge concern and there was no way that the Government could continue to allow this number of children to repeatedly miss school. It would be irrational to have a test-trace-and-isolate system that continued to operate once the country had officially abandoned attempts to stop the spread of the virus. With this in mind, our shiny new Health Secretary, Sajid Javid, today announced that from August, anyone who is in close-contact with a COVID case will no longer have to self-isolate as long as they have been vaccinated twice and undergo COVID testing. Those under the age of eighteen who have not been vaccinated will also be able to avoid self-isolation and remain at school or college using the same system.

We are about to enter a new phase of the pandemic, one which few of us predicted would happen quite the way it has. I had always imagined that when the end of restrictions came around we would be in a better situation than we are now. It is very difficult for anyone to try to predict just what will happen in the next few months. Eventually, we should see the number of new cases start to plateau and the number of hospital admissions will begin to slow down, but at the moment, no-one seems to have an idea when that might be.

I read yesterday that the Queen has awarded the George Cross to the NHS in order to honour everyone’s hard work over the past sixteen months. Obviously, it’s a very kind gesture but it’s not clear yet whether any of us will ever get to see the medal. I have worked out that if all 1.4 million NHS staff were allowed to wear it whilst they took a selfie, it would take the best part of 32 years to let everyone have a go. I won’t be holding my breath.

ICU 2 - A COVID unit once more