/1 year of COVID-19 in a critical care department

1 year of COVID-19 in a critical care department


As we reach the 1st anniversary of the COVID-19 pandemic, Medical News Today contacted a number of healthcare professionals. We asked them to provide an insight into the last 12 months. In this feature, we hear from Dr. James Evans, a consultant in critical care and anesthetics in the United Kingdom.

What follows is Dr. Evans’ description of life as a consultant during the COVID-19 pandemic. For readers in the United States, a consultant is roughly equivalent to an attending physician.

Dr. Evans covers the changes that took place as SARS-CoV-2, the virus that causes COVID-19, began to spread out from China, his experiences working with people with COVID-19, COVID-19 denial, and more.

The text is a lightly edited version of Dr. Evans’ first-hand account.

I have been a doctor since graduating medical school in 2002 and have worked on the south coast of the United Kingdom since 2008, with an 18- month spell in Australia.

Since February 2016, I have been a consultant in critical care and anesthetics. The anesthetics department is fairly large, with approximately 45 consultants across two sites — Eastbourne and Hastings — of which only 14 of us focus on critical care.

I am also a critical care lead for East Sussex Healthcare Trust (ESHT). [In England and Wales, a trust is an organizational unit within the National Health Service (NHS), which serves either a geographical area or a specialized function.]

This means that I have a management role within my job plan and time allocated for the administrative tasks and meetings that come with this role.

I took over as critical care lead in 2019. I was just settling into the role when we first heard about the new virus emerging out of China. Before this, my clinical duties were a mix of anesthetics and working in the intensive care unit (ICU).

Before COVID-19, I would work a week in ICU every 7 weeks and was on call 1 in every 10 days and 1 in every 10 weekends. The rest of the time would be general anesthetics and regular private work as part of a consortium. I was allocated roughly 1 day each week management time for my role as lead.

The trust is busy, and the population is diverse and challenging. Eastbourne has a relatively elderly population; Hastings has a slightly younger group of patients but with different issues, and there is a noticeable difference in the socioeconomic status of the two areas.

Thrown into the mix is the surrounding countryside that contains expensive properties and a more affluent population. Like most coastal towns, there are the usual problems of drug and alcohol abuse and suicide in younger people.

On a typical pre-COVID-19 day, we would have 19 critical care beds in ESHT — eight in Eastbourne and 11 in Hastings. We would run at about a 75% capacity, which is usual for similar departments throughout the U.K.

There were also predictable seasonal variations: busier in the winter — the so-called winter pressures, and relatively quiet during summer.

The critical care beds would be filled with a mixture of general medical patients and surgical patients (emergency and elective). We tended to manage the majority of patients within the trust, occasionally needing to transfer cross-site for bed or staffing pressures.

However, we rarely needed to transfer out of the trust unless it was for specialist treatment.

Essentially, we would be busy, but with a good mix of interesting patients, and we were usually well-staffed: the trust and location make it a popular and desirable place to work.

All of the above is an attempt to paint the picture of “normal” everyday life in a busy coastal district general hospital. I spent a lot of my time as lead managing the staff and rota issues, liaising with the critical care matrons, ensuring correct policy and guidelines were in place, recruitment, and all the other things that keep you busy but leave you wondering, “why am I dealing with this?”

We are a strangely cohesive group, and I would say a strong and supportive team, which was important with what was to come.

It became apparent in January 2019 that the “new virus” was going to be a problem. I can’t remember the timeline of spread exactly, but I do recall the daily reports of cases in Europe, then, eventually, York in the U.K.

We had all seen the television reports and pictures coming out of Italy in particular, and the path of destruction that was heading toward the U.K. It was an odd time — I do remember that.

Suddenly, I was being asked to attend numerous meetings with strange abbreviations and would frequently find myself in conversation with the CEO and numerous others in the management team.

Critical care was emerging in the press as a specialty that had previously been unknown. Everyone seemed obsessed with how many ventilators we had and where we would put all the patients we were expecting.

I soon realized that my job description was rapidly changing, and there was an increased amount of responsibility being thrown my way. It was clear people were scared already; bear in mind we were only in the preparation stage.

The tales emerging from Europe did not bode well for the U.K., and we were particularly concerned for our vulnerable elderly population on the south coast.

By mid-March, we were seeing the first hints of staff sickness associated with COVID-19, and the meetings were endless. I had rapidly become something of an expert on COVID-19 and took a new-found interest in the trust’s oxygen supply and personal protective equipment (PPE).

I remember walking in slightly late to a departmental clinical governance meeting in March. I was due to present something, and, as I walked in, I realized that not only was it the best-attended governance meeting I had been to, it was also full of surgeons and was video-linked cross-site.

The most worrying thing, though, was that they all seemed to be waiting for me, and I proceeded to do a question and answer session on COVID-19 for the next few hours.

By no means did I think of myself as the right person to be doing this, but I guess I was the most appropriate person at the time, and I was amazed at how much preparation we had already put in at this stage and how willing everyone seemed to be to help.

We were seeing how badly London had been affected, and there were the daily pictures of nurses in tears and families grieving.

The trust was taking this all very seriously, and pretty much all elective work had been canceled, with just provision in theatres for emergencies, obstetrics, and trauma.

Vulnerable staff were shielding, and anesthetics and critical care had moved to a ‘surge’ rota, which essentially puts more senior hands at the coal face day and night but left us working a horrible shift pattern.

By this stage, we had managed to expand our intensive care units on both sites to provide extra capacity to ventilate patients. We experimented with various sites in Eastbourne, taking over the endoscopy department, theatre recovery, and eventually settling in the pediatric ward, which is opposite the normal ICU. We are still utilizing this area.

Ventilators were an early concern, but, somewhat fortuitously, we had received our order of new ventilators — which was placed a long time before COVID-19 — in January. So all we did was keep the old ones, which provided us the capacity to ventilate about 30 people without the need to use anesthetic machines.

So, we had expanded our bed base, and hence our physical footprint within the trust by transforming medical wards into intensive care units. The work that went into this was a phenomenal effort, and we have forged relationships with staff from electronics and medical engineering, estates, procurement, and housekeeping in the process.

It made me realize what an amazing group of people work in the trust, people I wasn’t really aware of before, or would most likely not have come across day to day.

I actually have a list of “awesome people” who have helped critical care above and beyond the call of duty and have proved themselves exceptional under pressure — one day, I hope to be able to buy them all a drink!

So we found ourselves in lockdown and essentially completely occupied by COVID-19. That was all we talked about and thought about at work and at home.

The wave hit, and critical care became busy. Both sites filled up, and for a long period, we only had COVID-19 patients in ICU.

We often wondered what had happened to the “normal” ICU patients because we didn’t really see any for a few weeks.

Support from redeployed nurses was great; for example, we had nurses from the out-patient eye clinic working on critical care. There was a real camaraderie, and we managed, but it was tough.

The PPE was not great back then; nurses and doctors could not spend longer than 2 hours wearing it without becoming exhausted.

I remember seeing a young ICU nurse in tears, collapsed, surrounded by her colleagues at the end of her shift. She was having an asthma attack, and it turns out she had been in full PPE for 5 hours with no break.

We tried to stay up to date with treatments, National Institute for Health and Care Excellence (NICE) guidance, Public Health England guidance, and staff well-being.

Clearly, my job plan had changed somewhat, but it was a unique time, and we were not as badly hit as anticipated. The massive influx of patients never came, and our mortality figures in the trust (critical care) were excellent compared with the rest of the country.

There remained a trickle of COVID-19 patients as we came out of the surge rota and started to work a bit more like “normal,” pre-COVID-19 times.

I was always very aware that we hadn’t seen the last of COVID-19 and continued to be sent scary-looking graphs predicting a second wave over the winter months. This would be devastating on top of the usual winter pressures.

We continued to plan for the second wave and maintained our new, enlarged critical care footprint within the trust. At the same time, we seemed to be doing more elective surgical work than we were before the pandemic — I guess to make up the backlog.

In ESHT, we were particularly bad at the end of December and the whole of January. Both critical care units filled up rapidly. This time, the population we were dealing with was noticeably younger, most with overweight, plenty of healthcare workers, and some staff members.

It was much busier than the first wave. Much, much busier. The problem was, this time, we had fewer redeployed staff to help out. Not as many people seemed as keen to return this time. Also, staff sickness was a greater problem.

The situation resembled the images we saw in Italy during the first wave. Nursing ratios were stretched, we were at the absolute limit of what beds we could provide, and we had to transfer patients out of the trust. We also had to request extra ventilators from NHS England.

The trust oxygen supply was also an issue. There was a danger that we would lose supply to some areas, so we were using oxygen concentrators on the wards to try and spare the main supply.

We had around 13–16 patients on each site on critical care with COVID-19. We were seeing multiple referrals on the wards, and our nurses were at breaking point. It was the most stressful and difficult time I have ever worked in. The last 2 weeks of January were particularly horrendous.

I have to say, the critical care nurses were absolutely amazing. I mean, what a bunch of people.

They displayed superhuman ability to cope and work in the worst conditions I have seen in the U.K., and they kept coming back, shift after shift.

They would leave at the end of the day in tears but turn up the next morning to manage multiple ventilated patients with minimal assistance and few breaks. I am in awe of them and can’t express my gratitude to them enough.

We have started to see light at the end of the tunnel now. The rate of infection in the community seems to be improving, which obviously reflects in reduced hospital admissions, and eventually reduced pressure on critical care.

I remain cautious and worry we have not yet seen the back of this. This time around, it seems a lot more people know someone affected by COVID-19, but there are still non-believers who seem to think this is either a hoax or a government conspiracy.

Well, COVID-19 is very real. It is caused by a nasty little virus that can spread very easily. It affects the young and the old, and there is no clear reason why some people are more badly affected than others. It does not discriminate.

We have seen patients die in critical care far too often from COVID-19, and it takes its toll on the staff, the nurses, the doctors, and, of course, the relatives. Young families. Elderly couples. Members of staff. It is truly heartbreaking stuff.

I tend not to worry too much about the day-to-day things I see in the hospital, as in – I don’t think it will happen to me. However, with COVID-19, there is a lingering doubt.

The variations and the mutations are worrying, the younger population is being affected, and its seemingly relentless nature makes this scary. I don’t currently see a way back to normal; maybe I am just cynical and grouchy and have spent too long in the hospital in PPE dealing with this.

I am not particularly interested in politics but find it difficult to blame the government for any of this, really. It is an unprecedented time, and I hope everyone is doing the best they can, but I do feel members of the public could really help by listening to advice.

The third lockdown did not seem to make much difference to people’s behavior. I know everyone is fed up with being at home and the pubs not being open, but we will be like this for another year unless we do something significant now.

We definitely saw the effects of Christmas gatherings in the hospital and this increased pressure on beds. I hope the vaccine will make a difference, but we may not see these effects for a while.

In summary, it has been a difficult year. Sadly, I think it will be commonplace in the future — new viruses, PPE, masks in public, and physical distancing. We need to find a way to deal with it quickly; we need to accept a new normal.

Staff involved in this recent wave will have been irreversibly affected by this traumatic experience but have also shown a great strength and compassion that has astounded most of us.

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