Heroics

10th March 2021

UK COVID Deaths – Daily 190 / 7-Day average 174

Total UK COVID Deaths within 28 days – 124,987

Total UK Deaths with COVID-19 on the death certificate – 143,249 (up to 26th Feb)

James Cook Hospital – Total COVID deaths – 596

All COVID cases within South Tees Hospitals Trust – 65

James Cook Critical Care

COVID cases – 14 (8 ventilated)

Non-COVID cases – 46 (24 ventilated)

My three children returned to school on Monday and are all pleased to be back. The youngest is in primary school and so was able to join her friends in the classroom for business as usual. The older two are at secondary school and so had to undergo lateral flow testing before they could be allowed to return. Fortunately, they both tested negative and so were able to start lessons yesterday. They now have to wear facemasks in class, rather than just in communal areas and on the bus. This is not proving popular and there is a certain amount of whinging going on. Having spent my working life in PPE for nearly a year now, I fear I may not be coming across as very sympathetic.

The news at the hospital is also good. The number of people being admitted with COVID-19 is falling as is the total number of COVID patients currently in the hospital. There are now a total of five wards occupied by COVID patients. Whilst we still have two COVID Intensive Care Units, we have far fewer patients on CPAP out on the wards and we are expecting that the number of ICU patients will continue to slowly decrease. It will be a few weeks before we know just what effect opening schools will have on case numbers and later still before any effect on hospital admissions might be seen.

I have spent the last few days working on one of the two COVID ICUs. The time off that I spent last week soon felt like a distant memory. Whilst surrounded by ventilated COVID patients, it was easy to feel like nothing had changed. Suddenly the rest of the world, where cases and deaths are falling and people were meeting up with a takeaway coffee to talk about summer holidays seemed very far away.

Our sickest patient was a gentleman in his 50’s who had been with us for nearly two weeks. He had initially managed on CPAP but had been ventilated after developing a secondary bacterial pneumonia. His respiratory failure had been deteriorating steadily over the preceding 24 hours and, overnight, he had developed a pneumothorax (a collapse of part or all of the lung due to air entering the lining of the chest wall). A chest drain had been inserted between the ribs to allow his left lung to re-expand. Whilst this had worked to some degree, it hadn’t led to the improvement that we had expected. A new chest X-ray revealed that the pneumonia had worsened with what looked like new abscess cavities within both lungs. There was also a suggestion that he still had a pneumothorax despite the chest drain but it was impossible to be sure of this given the multiple cavities on the X-ray. Inserting another chest drain in an attempt to allow the lung to expand further could lead to a significant improvement, but it was impossible to be sure exactly where to place it.

We needed to transfer our patient for a CT scan. This would enable us to fully understand what was happening and see whether another chest drain was indicated. Of great concern was that, by now, we were failing to achieve adequate ventilation and also struggling to achieve a satisfactory blood pressure. There was a real chance that he might die during the trip to the CT scanner. However, it was now certain that, if we did nothing, death was inevitable. We therefore made the necessary preparations for transfer.

Moving a very sick ICU patient, even a relatively short distance, is always worrying. The concept that a patient may be ‘too sick to move’ is a well-established one but the risks are all relative. They have to be weighed carefully against any potential benefit. This was undoubtedly the sickest patient I have ever transferred and what followed were a frantic few hours, during which all our effort was required to stop him dying.

The CT scan turned out to be even worse than I had feared; easily one of the worst I have ever seen. It revealed a terrible pneumonia with multiple cavities and abscesses in both lungs. Underneath all this was, of course, severe COVID pneumonitis. As we had suspected, there was a significant pneumothorax but there were also multiple, smaller pockets of air, all contributing to significant collapse of the lung.

We hastily returned to the ICU and inserted another chest drain into the largest pneumothorax. Whilst this led to some improvement, it was far from what we had hoped for. It was clear that, even with the pressure within the chest relieved by two chest drains, the lung was not expanding.

Our patient’s oxygen saturations continued to fall despite us turning him prone. We had re-started dialysis as soon as we had returned from the scan but he came dangerously close to arresting yet again as his potassium levels rose due to his worsening kidney failure. By now, the situation was looking bleaker and bleaker.

When younger, I might well have looked upon this as some sort of heroic struggle. After all, this is what happens on TV isn’t it? We have all watched, perched on the edge of our seats, as the valiant team of doctors and nurses battle against impossible odds to try to save their patient. They stubbornly refuse to admit defeat as they try ‘one last thing’ in order to win the day. Of course, the reality, experienced by the older, weary me was absolutely nothing like this. There was just an overwhelming feeling of desperation as things got steadily worse and worse. This slowly gave way to a sense of futility that grew as the hours passed. We treated every complication, narrowly averting catastrophe over and over again but, in reality, nothing we were doing was making our patient any better and we knew it.

We called our patient’s family to the hospital. I explained that, despite all our efforts, we could no longer stop him dying and that it was time to stop. Continuing support when all hope is gone is not something we wish to put any patient through and so we changed our priority to ensuring comfort and avoiding distress prior to a withdrawal of care. Our patient died a short while later.

Despite her obvious grief, our patient’s wife thanked us for all our efforts and, able to see that we were also upset, told us not to feel too bad. She was very keen to stress that none of the team were to see his death as a failure on their part. Time and time again, I marvel at people’s generosity of spirit. I am always surprised at the way some of us are able to think of people other than ourselves, even in the midst of such a devastating personal tragedy. Of course, this all just made me feel worse.

Later, thinking back on the day’s events, I realised that I am worried that I am not as objective as I used to be. I certainly wasn’t being objective during the many hours I spent with my doomed patient. A colleague of mine asked why I had struggled on for so long when it was clear that nothing we were doing was working. My reply could have been a complicated one. I could have talked about how I was becoming increasingly disheartened by the number of COVID patients I had watched die. I could have described my sense of impotence and how I wanted to feel that I was still able to exert some control over the situation. I could have tried to express how, just for once, I had wanted things to play out differently. Instead, I gave a far simpler answer, one that seemed to sum everything up - I just really didn’t want him to die.