Heating Up

Friday 27th March 2020

COVID Figures for 26 March

UK Deaths 115 / Total 578

James Cook Hospital Critical Care - 11 cases (3 suspected) / 7 ventilated

I didn't sleep very well last night. Body-clock changes following my two night shifts will have played a part but I blame ITV for their thoughtless scheduling of the movie 'Contagion' last night. And yes, I do know I shouldn't have watched it!

It was Nicky's second night shift last night. Things are steadily getting busier at the hospital with progressively more COVID patients being admitted. It's still not too busy within Critical Care however, but Nicky admitted another patient overnight.

He was a gentleman in his 60's who had come into hospital via A&E a few hours before. He was pretty overweight and was deteriorating fast so had been transferred up to one of the High Dependency isolation rooms whilst we waited for his COVID test results. The team tried using CPAP but he couldn't tolerate it and rapidly required intubation and ventilation. As a result of his obesity, his facial anatomy and his big, bushy beard he was a tricky intubation. He was already hypoxic (short of oxygen) but during intubation his oxygen level plummeted alarmingly. Fortunately, he improved quickly and he was placed on the ventilator and transferred to the ICU in a more stable condition. The obese patients appear to deteriorate rather more quickly than others and according to data from China and Italy, have a significantly higher morbidity and mortality rate.

There were other non-COVID patients requiring critical care during the night. One of them was a stabbing that presented to A&E. The patient had been stabbed in the neck. Nothing unusual there for a Middlesbrough hospital but the patient's partner was currently self-isolating with COVID symptoms. The patient therefore had to be treated as COVID positive himself.

The patient needed exploratory surgery to assess the damage done but there had been much anxiety amongst the surgical teams in the last 72 hours about their exposure to the virus whilst operating. There have been 45 doctors who have died in Italy, many more than in China and understandably, this is worrying staff who may be exposed (sometimes inadvertently). The potential risk during some operative procedures may well be very high.

Thankfully, new guidance published yesterday - The "Intercollegiate General Surgery Guidance on COVID-19" provides some reassurance. Key recommendations for emergency surgery include:

1. All non-essential surgery must stop. High suspicion and testing of any patient needing acute surgery.

2. Use the simplest, shortest techniques.

3. Minimal number of people in theatre. Full PPE protection for nearly all cases unless sure the patient is COVID negative. Remember that a significant number of tests can be false-negative.

4. Do not use laparoscopic techniques (no keyhole surgery) as the potential for aerosol transmission of the virus is high.

5. Only emergency endoscopies to be conducted.

6. Remember that even placing a nasal feeding tube can be an aerosol-generating procedure.

Theatre was arranged and afterwards our patient would join the other suspected COVID patients within critical care. We are fortunate to have had a retired virologist return to work in our labs and are now able to offer in-hospital COVID testing, obtaining a result within a few hours. This is helping enormously with the efficient use of beds.

My friend Gary is now ventilated in ICU down South. However, it sounds as if he remains stable and in single-organ (respiratory) failure. Hopefully he will be one of those patients that come off the ventilator within a few days rather than a few weeks. His chances of survival remain high at this stage.

I'm off for my daily exercise in the sunshine now whilst Nicky recovers.