Physician to the President

6th October 2020

UK COVID Deaths - Daily 76 / Total 42,445

UK COVID Deaths with COVID-19 on the death certificate - Total 57,347 (up to 25 Sep)

James Cook Hospital – Total COVID deaths – 261

All COVID cases within South Tees Hospitals Trust – 21

James Cook Critical Care COVID cases – 6 (4 ventilated)

So, after three days in hospital, President Trump has recovered enough to be discharged home. It’s worth pointing out that ‘home’ comes complete with a small scale state of the art medical and trauma unit and Mr Trump will be surrounded by his heavenly host of doctors.

Clearly the president is not out of the woods yet. Should his condition deteriorate then he may well require re-admission to hospital. In a spirit of open co-operation I have written to Mr Trump offering to care for him here, in the James Cook Hospital ICU. I’m pretty sure that the Air Force One helicopter can fit on our helipad without much trouble. We have previously been approved by the Secret Service as a suitable location to deliver Presidential medical care back when President Bush visited Sedgefield in 2003. I can see no good reason why President Trump wouldn’t choose Middlesbrough as his preferred place of care.

Of course, even in the alternative universe where this might happen, it’s extremely unlikely that the hospital would choose me as temporary ‘Physician to the President’. Despite the fact that I reckon I’d look really good in one of those tailored white coats, I’m not sure I would want the job to be honest. I’m not sure it would even make my Mum proud.

Back in the real world we are continuing to see small numbers of COVID-19 cases admitted to the wards and to Critical Care. Some patients are recovering and we have had a few more deaths including that of another one of our ICU patients. Overall, our ICU numbers remain static although more patients are requiring mechanical ventilation. Four out of our six ICU patients are now ventilated whilst the other two are requiring CPAP. Our patients are mostly in their fifties and sixties but we do have one younger patient who is in their forties.

The fact that the number of patients has not risen greatly is good news given the continued rise in the number of daily reported cases of COVID-19. The recurrent failings of the omnishambles that is the National Test & Trace system mean that it’s difficult to know how accurate these daily figures are. However, the overall trend in case numbers is clearly on the rise.

The REACT-1 (Real-time Assessment of Community Transmission) study is conducted by a team at Imperial College London. They repeatedly conduct COVID-19 testing on people chosen at random from across the country. Last week they looked at the results of 80,000 people tested between 18 and 26 September. Overall, 1 in 200 of these people were infected with the SARS-CoV-2 virus but the rate of infection rose to 1 in 100 amongst the young and those in North West England . Big increases in the number of cases were seen amongst both the over-55’s and the over-65’s when compared to similar data from the beginning of September.

Despite the rise in cases, they concluded that the rate of growth had slowed and suggested that a combination of national measures and local lockdowns may have played a role in slowing down the spread of the virus. This was good news as their previous study had suggested that case numbers were doubling every seven to eight days. This is what gave rise to the not-so dynamic duo of Professor Chris Whitty and Sir Patrick Vallance presenting their ‘worst case scenario’ two weeks ago. They soberly warned that there could be 50,000 new cases a day by mid-October if social-distancing measures were not followed.

It does look as if it will take longer to reach that particular milestone but this does not mean that it’s all sunshine and lollipops. Cases are continuing to rise as are the numbers of people admitted to hospital with COVID-19 and those dying. There is no doubt that as we enter the colder months there is a real danger that these figures will accelerate. Transmission of other coronaviruses such as those responsible for the common cold becomes much easier during the winter. Outbreaks of COVID-19 in meat processing plants around the world demonstrate that the virus likes the cold and the wet. People also spend much more time socialising indoors when temperatures outside are low. The end result is that we are likely to see more and more cases finding their way to the hospital.

In many ways what we are anticipating is a slow-motion replay of what happened back in March. Back then, the number of coronavirus cases admitted to hospital shot up rapidly. Many of the patients required CPAP which was delivered on the acute medical wards. This was a conscious decision in order to leave our ICU beds free for ventilated patients. Despite this we quickly filled the beds we had and had to quickly turn our High Dependency Unit into an ICU. We then took over the Paediatric ICU and, to a lesser extent, the Cardiac ICU. Next we expanded into the Surgical Day Unit taking us to a total of 64 ventilated ICU beds instead of our usual nineteen. Just as we were planning to create yet another ‘pop-up ICU’ and wondering how on earth we were going to find adequate trained staff, equipment and drugs to run it, the effects of the lockdown kicked-in. Patient numbers stabilised before slowly beginning to fall over the next two months.

Unfortunately the journey this time will have to be a little different. As well as our COVID-19 patients, we will have to contend with the usual seasonal respiratory tract infections that are more common over winter. These may be due to bacteria or other viruses such as influenza. There had initially been a hope that we may see fewer of these due to social-distancing but it’s probably safe to assume that if we see a surge of coronavirus cases we will see more of the usual bugs as well.

The NHS tends to sail pretty close to the wind when it comes to dealing with winter bed pressures. There is not much spare capacity in the system at the best of times; there will be none going into the forthcoming winter. Understandably, we are being asked to attempt to continue to provide as normal a service as possible for those patients who need care for conditions other than COVID-19. This ‘normal service’ cannot grind to a halt as it did during the first surge. The provision of regular, elective surgery is particularly at risk and there is a danger that we may see widespread cancellation of operations unless we can preserve theatre capacity and beds for such patients.

So, what will be different for Critical Care this time around? Firstly we cannot plan on using the Paediatric ICU as the arrival of winter invariably means a rise in the numbers of sick infants and children. This is something of a relief in many respects as the Paediatric ICU is simply not big enough for adult patients. I also don’t like working under the watchful eyes of the Disney Princesses that adorn the walls. I always feel that they are judging me.

During the first wave we were helped by the arrival of extra staff from departments that were no longer able to work properly in a locked-down hospital. This time many of these staff members will be doing their best to ensure they can continue to treat their own regular patients. We may once again see the return of staff who were brought back from retirement to help out in April.

It’s likely that we will be looking at all the ICU beds in our region as a single resource rather than letting individual ICUs function in isolation. Should one unit approach their maximum capacity then they would look to transfer COVID patients to another nearby ICU that still had beds. This of course is not ideal but it will allow for more efficient use of all the ICU beds available in a given geographical area.

Our local plan is to expand again to a maximum of 64 ventilated beds. Should the situation worsen we would be expected to provide up to 100 ventilated beds under what is called our ‘Super-Surge’ plan. This is a big ask and it’s difficult to try to get across how desperate the situation would be were that to happen.

We have taken delivery of a whole load of extra equipment in order to be prepared. This equipment includes 52 extra ventilators, 30 non-invasive ventilators which can be used to provide CPAP, 54 patient monitors and over 450 syringe pumps for infusing medication. I hope and pray that all of this equipment does little more than grow dusty in a storeroom over the next few months.

Epidemiologist Professor Neil Ferguson stated today that he believes that the number of COVID-19 cases in the UK is doubling roughly every two weeks. The final REACT report involving volunteers tested between 18th September and 5th October will be published this week and will give a more accurate picture of where we are. The bottom line is that any normal healthcare services, be they emergency or routine will be completely disrupted if the hospital becomes overwhelmed with coronavirus patients. This is why we cannot let the growth in cases get out of control.

Should this happen, it is unlikely that any of our patients will come anywhere near to the sort of doctor to patient ratio that Mr Trump is currently enjoying.

The heavenly host. Their wings are folded behind their backs.