COMMENTARY

COVID-19: UK Emergency Department Diary Part 2

Dr Dan O'Carroll

Disclosures

April 12, 2020

I feel I need to apologise in advance. I like complaining about stuff, I moan a lot (see previous articles). I'm a middle-aged man, this is what we do. Unfortunately, I don't think I can bring myself to moan this time. I have been inspired and humbled in equal measures by acts of kindness and generosity from the general public and so many examples of people, whether NHS workers or not, going above and beyond what is expected, that I am left with nothing other than admiration

Dr Dan O'Carroll

As the COVID-19 pandemic takes its grip on the UK and the world, the Emergency Departments (ED) across the UK are becoming increasingly concerned about a very unexpected phenomenon. Where has the normal ED workload gone? Surely the general public are still having their heart attacks, strokes and other acute medical and surgical problems? But if they are, what is happening to them? They do not appear to be coming to the EDs, many of which are reporting attendances as much as 50% lower than predicted on usual days.

This has coincided with the apparent exponential growth of infections, admissions, and subsequent deaths, of COVID-19 patients.

Talking to colleagues across the region and further afield, many of us are surprised about how quiet our departments have been. Overcrowded and borderline unsafe departments had become the norm for most of us. We had forgotten what it's like to be able to concentrate on what we're best at, as we had become used to the multiple other demands needing our attention. Although the acuity of many of the patients that are now coming in is higher, the overall workload, at this moment, appears less. Colleagues have even commented that the EDs at the moment are much more manageable and in a better position than every winter day for the last 5-10 years, and also better than much of last summer. The reports of colleagues, friends and acquaintances being very poorly and even dying from the illness makes us appreciate the quieter departments so that we can concentrate fully and manage our own personal risk. I dread to think how we would be coping if we were dealing with the COVID presentations as well as the normal workload.

Cold and Hot Sides

Most EDs are now running two parallel departments. One cold or blue side, for presentations that are unlikely to be COVID, and another hot or red side for anything that might be COVID. The relative size and ratios of these two streams is dynamic, and the red zones are much larger than the blue in many departments. ED clinicians are identifying at the earliest opportunities which patients will not likely benefit from hospital admission and are involved in trying to facilitate the discharge of these patients back to care homes, sometimes on end of life pathways, with anticipatory medications prescribed. We are also identifying those patients whose pre-existing frailty and/or heath conditions would mean that intensive care admission would be futile and not in their best interests. Finally, long overdue public discussions are being had about DNACPR decisions, but it remains a difficult discussion and some well-meant and sensible approaches have been pilloried within the media, although admittedly they possibly were somewhat insensitive or clumsy. 

Clinicians are becoming adept at spotting the COVID presentations and seem to be able to predict those that will do badly and go on to need intensive care. Patients are presenting with incredibly low oxygen saturation levels, with examples of patients self-presenting and walking with Sats as low as 65%!

Although the virus seems mainly to be a minor illness for most, those that are needing ventilatory support and intensive care are needing it for long periods and many have not been successfully extubated.

Underfunding

How on earth have we got to this position, which seemed impossible, never mind unlikely only a couple of weeks back?

I can tell you how. It’s because the NHS has had to borrow from the Conservative Party's election manifesto to have its 'potential unleashed'. The NHS has suffered from years of crippling financial restrictions, which have led to huge short falls in medical and nursing numbers, further exacerbated by the loss of many EU health workers. As the seriousness of this crisis became apparent finally the taps were opened, and funding followed - the NHS more or less being given a blank cheque to prepare as best it can. Secretary of State for Health, Matt Hancock even going as far as to write off £13.4 billion of NHS debt. This is a great soundbite, but of course is nothing like as generous as it seems, as it just represents the chronic underfunding that is being redressed.

The transformation across the whole of the NHS over the last 3 months has been staggering. Whole hospitals have been built and staffed from scratch in a matter of weeks and the Nightingale units continue to open across the country. ITU capacity in many trusts has increased by a magnitude that would have been unthinkable previously. Ventilators have been globally sourced and hospital Electrical and Biomedical engineering teams have given up their Saturday nights to have them ready for use within a matter of hours of arriving in the country.

Speciality colleagues have changed the way in which they work to rise to meet the challenge, eg, orthopaedics taking responsibility for the minor injury attendances to the ED. Paediatricians seeing all children presentations directly, completely bypassing the ED.

The expanded ITU capacity nationally was always going to represent a challenge for staffing. Traditionally ITUs run on a 1:1 nurse to patient ratio, and it would seem obvious that this would be impossible to maintain. ITU nurses are overseeing and supporting other nursing colleagues to look after a number of patients that would be too high for traditional ITU numbers. And surgical colleagues have undergone crash courses in looking after ventilated patients to ease some of the burden on ITU colleagues.

The whole system has pulled together and what has been achieved is a testament to all of the NHS staff, from management to domestic and cleaning staff. Everyone has contributed.

Clap for Carers

I'm sure I wasn't the only NHS worker initially reacting cynically to the idea of the 'clap for carers' initiative, but as this tribute seems to have grown in scale over the 3 weeks, and as the death toll of the population at large and health care workers rises, the clapping seems even more poignant and emotional. It is nice for the NHS to finally feel valued by the public and Government.

Hospitals have been overwhelmed by donations of food from local businesses which surely must be struggling to keep themselves afloat financially during the lockdown. Individuals have raised money to be donated to NHS organisations. Some parties have even gone as far as to source and provide PPE independently.

Schools that are essentially closed, have continued to look after and provide care for the children of 'keyworkers' and this has been a great help to many of us, and great fun for some of the children involved. Other schools have taken practical measures to aid the NHS staff, including production of PPE. Many local businesses have taken practical measures to help the staff and have purchased or built many pieces of PPE to help to protect the staff. A friend made the great analogy of this to the little ships of Dunkirk. He was also at pains to point out that although he was pleased to learn of the Prime Minister's on-going recovery, he is, by no means, a Winston Churchill.

It seems that a national crisis has brought out the best of so many people within the country with 750,000 volunteers signing up to help.

PPE

The issue of personal protective equipment (PPE) is well documented elsewhere, and despite several public assurances from the Government it appears that many health care workers are still experiencing a shortfall in supplies. It seems that Government's latest approach though is to castigate health care workers for using up the equipment.

I am certain that the issues of PPE and appropriate testing for staff and public will need to be looked at in great detail after the crisis has passed. The UK guidance for this has changed several times, and I suspect this is down to issues of supply chains rather than any changes in actual evidence. These are questions for another day though.

Let me conclude by saluting every single one of my colleagues and friends. Having seen what's been achieved in such a short space of time, I have never been prouder to work for the NHS and with its truly exceptional workforce. Let's hope that when this is over, this is not easily forgotten.

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