Third Wave

9th January 2021

UK COVID Deaths – Daily 1035 / 7-Day average 894

Total UK COVID Deaths within 28 days – 80,868

Total UK Deaths with COVID-19 on the death certificate – 82,624 (up to 18th Dec)

James Cook Hospital – Total COVID deaths – 408

All COVID cases within South Tees Hospitals Trust – 157

James Cook Critical Care

COVID cases – 25 (14 ventilated)

Non-COVID cases – 32 (12 ventilated)

I’m not sure whether to call what we’re seeing the third wave or wave 2.2. It’s certainly the third lockdown we have all experienced but you could realistically describe the recent increase in cases as a continuation of the second wave following a small dip due to the November lockdown. You could also argue that the rise in new cases due to the emergence of the new variant represents a distinct third wave of cases. Ultimately, such pedantry is inconsequential; what is important is that the number of patients with COVID-19 being admitted to the hospital is beginning to rise alarmingly.

We are now admitting in excess of 35 COVID patients every day. James Cook Hospital is now treating more COVID patients than it did during the first wave. Worryingly, we also have twenty patients receiving CPAP on the ward compared with our first wave ‘record’ of fifteen. Our number of Critical Care patients has also increased to the point where we have had to open another COVID ICU. This is the second half of the Female Surgical Admissions Unit (SAU), known as the ‘horseshoe’ because of its shape. We can accommodate another eight COVID patients here alongside the eight that are already resident in the other half.

Most of the patients who are becoming very unwell seem to have been infected just before Christmas but we are starting to see an increasing number of patients who believe that they have caught the virus after mixing with their families on Christmas Day. It is now two weeks since the 25th December so it comes as no surprise that we are seeing such cases. Some families are being admitted together; the wives of three of our ICU patients have also been admitted with COVID pneumonitis and are receiving oxygen on the wards. Fortunately, they remain stable and have not required our help. My colleague, Scott, was able to visit the wards and update them on the progress of their husbands. It is clearly regrettable that we have to talk to them whilst they themselves are patients, but they are still grateful for a chance to communicate in person rather than over the telephone.

Cases of COVID-19 have risen sharply in the last fortnight and it is estimated that the true number of new infections across the UK is now well above 100,000 a day. How much of this rise is due to households mixing at Christmas and how much is due to the growth of the new variant of the virus is unclear. It is likely that both have played a part. The Office of National Statistics (ONS) reported that 44% of adults in Great Britain met up with up to two other households on December 25th. Those regions that were allowed to mix on Christmas Day (such as here in the North East) have seen steep rises in hospital admissions over the last few days. However, there is no doubt that the new variant of the virus continues to proliferate. Its incidence continues to rise in all regions of the UK and it is currently estimated to be responsible for over 30% of new cases in the North East of England.

Fortunately, the number of our non-COVID patients has not risen in parallel. We have seen a significant number of road traffic accidents as a result of the icy road conditions over the past week but we have seen fewer assaults and drink or drug-related admissions than we would normally do at this time of year. It looks like, just for once, there really was peace and goodwill towards all men on the streets of Middlesbrough over Christmas. Of course, it may just have been that the pubs were closed and everybody stayed at home, but I shall optimistically choose to believe the former reason.

Most assaults that we do see tend to involve knives or common blunt objects such as hammers or crowbars but we had an admission recently where the patient was unusually assaulted with a candlestick. One suggestion was that a live-action Cluedo game had been taken way too far but this seemed unlikely given the absence of any rope or lead-pipe injuries in A&E. I suggested that perhaps the patient’s butler had mistaken him for a home-intruder during the night. My idea was quickly brushed aside as being an unlikely occurrence in Middlesbrough and I was told I was being too ‘North Yorkshire’.

Amongst all the gloom and doom there has been some good news for Nicky and me. Nicky’s father, Gordon, has continued to recover from his COVID pneumonitis to the point where he has now been discharged home. As soon as he no longer needed oxygen, the decision was made to send him packing. It would seem there’s no convalescing in hospital during a pandemic anymore, not that Gordon is complaining.

Other good news is that the MHRA has approved the Moderna vaccine. This means that there are now three separate vaccines approved for use in the UK. Phase three trials suggest that the vaccine is 94% effective. Like the Pfizer/BioNTech vaccine, the Moderna vaccine is an mRNA vaccine that instructs cells to produce the virus spike protein. This allows the body to recognise the protein as foreign and produce antibodies and activate T cells to attack it, conferring immunity. Distribution is easier than the Pfizer/BioNTech vaccine as it needs to be kept frozen at between -25 and -15 degrees Celsius, meaning that specialist freezers are not needed.

Also bringing some cheer is the news that the REMAP-CAP research trial has shown that the anti-inflammatory drugs, tocilizumab and sarilumab improve survival in severe COVID-19 infections. These difficult-to-pronounce drugs, which are used to treat severe rheumatoid arthritis, have been shown to reduce death rates by 8.5% amongst the sickest COVID patients who are admitted to Intensive Care. This means that for every twelve patients treated, one would be saved. The trial also showed that patients treated with these drugs recovered quicker and were discharged from the ICU 7-10 days earlier. Like most Intensive Care Units, we have only been giving tocilizumab to patients as part of the REMAP-CAP trial but yesterday we were able to prescribe it to our first non-trial patient. It’s an expensive drug and currently in short supply but we anticipate that more will soon become available for us to use.

Even though the situation throughout the hospital continues to worsen, we are still able to admit patients and provide a high standard of care. How long this will last for is unclear. There is likely to be a significant impact on the hospital’s ability to provide routine, non-urgent care next week. Should we continue to admit patients at the current rate, there is a chance that the situation could quickly unravel. We are worried that we may ultimately find ourselves struggling to find beds, nurses and equipment. After last night’s on-call, I’m now not at work until Monday but I am worried about what I might find when I return.