COMMENTARY

COVID-19: UK Emergency Department Diary

Dr Dan O'Carroll

Disclosures

March 23, 2020

As we draw towards the end of the second week since the first cases of COVID-19 were diagnosed in the West Midlands, much has changed. The crisis that we once hoped to avoid now seems to have taken grip. Previous worries of many unexpected and early deaths, potential loss of life of colleagues, a health service about to be tested and stressed like never before, and a huge socio-economic impact, have now become a reality.

Dr Dan O'Carroll

As more and more countries world-wide were gripped by the pandemic, we'd anxiously observed the impending crisis and wondered what lay in wait for us here in the UK.

The UK Government's policy as we entered the delay phase was to try and ensure that the peak of demand caused by the illness did not exceed the NHS capacity for treatment. It now seems clear that this will not have been successful.

Many of us, well used to dealing with adversity, working in overburdened and under-resourced departments, are genuinely fearful of what lies ahead of us. The tone of conversations amongst colleagues changed, anxieties were expressed along with a grim determination to do the best that we could for the maximum number of patients.

Hot Zones

Nationally, it appears that most Emergency Departments (EDs) have tried to keep cases of suspected or confirmed COVID-19 away from the on-going normal ED workload. Many departments have managed to develop two completely separate streams, with patients being directed into a 'hot zone' if they are presenting with any respiratory symptoms.

The previous 'contain phase' of the Government's plan recommended that full PPE (including the FFP3 masks, disposable gowns and eye protection) should be used whilst assessing and swabbing the community cases.

In the delay phase, this advice changed. Once in the hot zone, a member of staff wearing a surgical mask, a disposable apron and gloves would take a history and decide whether the patient needed admission, and if so, they would be swabbed for the COVID-19 virus. If they were well enough, and even if COVID-19 was suspected, they were sent home and advised to self-isolate and to return if their condition deteriorated. Swabbing for patients that were being sent home was not available. 
 

PPE Supplies

Rumours of shortages of full PPE circulated on social media, and the Government quickly released new guidance suggesting that the full PPE only be used for certain high-risk procedures (mainly those associated with aerosol generation). This level of PPE was not mandated even in those patients that were confirmed COVID-19 positive. 

This has caused much confusion amongst staff, and seniors have had to reassure them that the Government's new advice was evidence-based rather than based on any supply concerns. It is hoped that this new advice does not result in large percentages of the health care work force contracting the virus requiring, at best, absence from work, and likely to result in further burdens on an over-stretched work force. 

I believe questions will need to be asked regarding this change of advice regarding PPE, particularly against reports of several front-line doctors dying in Italy and reports emerging of health care professionals in the UK already becoming critically unwell and needing intensive care treatment. Discussion forums amongst hospital consultants seem dominated by the perceived lack of appropriate PPE, although there are no apparent shortages of the basic equipment advised in the current national guidance. There are suggestions that the health care workers that have died had been exposed to high viral loads at the time of their infection, which justifies the staff's ongoing concerns.

Some local departments and GP surgeries discovered that the standard surgical masks that had been issued had actually gone past their manufacturer expiry date, which had been covered with stickers. Assurances were offered to staff that they remained safe to use.
 

Testing

The capacity for testing for COVID-19 was stretched and even on those patients being admitted, a 72-hour turnaround time was to be expected, with the obvious problem that these patients would need to be managed as if they had the virus until the result was known. Local care homes were refusing to take back their clients until the results of the swabs were available, which put further pressure on the system.

The Government's advice about suspected COVID-19 in those well enough not to need hospital treatment threw up interesting problems for maintaining the workforce. If we were to exhibit the features mentioned, (cough, fever etc) we're being told to self-isolate for 2 weeks. Surely testing these clinicians should have been made a priority so that they could return to work if negative?

The way the Government communicated its plan changed, with daily formal press briefings being made by the Prime Minister and scientific advisers, and changes in policy being enacted on an almost daily basis. This was to be commended, rather than the drip feeding of information from 'anonymous Government officials' or announcements being made behind favoured newspapers' paywalls.
 

Ventilators

Appeals to UK industry were made with great fanfare, that if any company could produce mechanical ventilators the Government would buy every single one that was made available to them. This was done against the background of the virus appearing to cause Adult Respiratory Distress Syndrome, and mechanical ventilation being the mainstay of treatment. It is worth noting that Italy had roughly double the number of ventilators at the start of the crisis compared to the UK, and one would have hoped that these appeals to industry had actually been made several weeks earlier, when the clinical features of the disease in China were being discovered, rather than only last weekend.

Many of us have had nightmares about the tough clinical decisions we're going to have to make due to demand for ventilators outstripping the availability, and it seems inevitable that some patients will not receive the care that they could normally expect to.

Cancelling Elective Surgery

Hospital trusts begin switching away from elective work, to free up in-patient capacity and to increase availability of clinicians, and all of this was done against the background of relatively quiet EDs. It seems the local populations had taken heed or were too scared to come to the ED in their usual numbers. But as numbers of confirmed cases begin to accelerate, front-line clinicians are seeing more and more poorly patients with atypical pneumonia features, dry coughs and respiratory examination findings, in some cases similar to childhood bronchiolitis (widespread wheezes and crepitations).

The deal made with private hospitals to make their beds, ventilators and staff available to the NHS during this crisis is to be commended, although one would have thought that they would have been very quiet and unused during this crisis anyway, so one hopes that the associated costs would reflect this.

The effects of the pensions crisis still linger over hospitals: many doctors withdrew from the pension completely to avoid the eye-watering tax bill [they might otherwise receive], and are concerned at having foregone the substantial 'death in service' benefit. Those of us that reduced our hours, will also have reduced this benefit. Maintaining safe staffing levels remains one of the biggest concerns, and I have made it known that I would be happy to go back to full-time during this crisis, when it is needed. How long this crisis will last is unknown, so whatever plans we make need to be sustainable in the medium term: the most optimistic estimate would be that it will have peaked by 12 weeks.

'Irrational Population'

All of this is going on whilst observing a general population that seems increasingly irrational and panicked. £1 billion extra food was bought over the last 3 weeks and stockpiled by citizens worried about a lockdown. The Prime Minister's earlier advice about staying away from pubs and restaurants was not embraced by enough of the public, and last week he announced that these types of public venues, including gyms, need to close to prevent further spread of the disease. This resulted in several reports of people going out for one last 'knees-up' and many pubs advertising themselves as such. And although I have every sympathy for the business owners, this seemed very much at odds with the reasons behind the announcements.

Weekend news reports show many beaches and public areas busy like a sunny bank holiday, as it seems the general public is unable or unwilling to grasp the importance of the social distancing measures, leading the Prime Minister again to urge people to respect them, to protect the vulnerable from the disease and protect the NHS. It seems to me that much more draconian measures are required as the public don't seem to be taking this as seriously as it warrants.

Tomorrow is my scheduled hot week. I will be working until the early hours of the morning each day of the week and likely dealing with the most critically unwell. I'd be lying if I said I wasn't nervous or even a little afraid of what it's going to be like. It seems almost inevitable that I will be infected by the virus by the end of the week, but as several colleagues have said in more morbid moments, if it is inevitable that we're going to catch it, we'd rather it was early whilst there is still ITU capacity if required.
 

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