28/3/20

My first day back in the local out of hours service did not get off to the best start. I usually do car shifts, which means travelling around visiting patients in their homes if they can’t make it into designated treatment centres. We do this in a customised car fitted out with medical supplies, devices and therapies – a mobile health clinic in essence. If there aren’t any visits I do telephone triage, where I ring back patients who are calling in with problems and need to speak to a clinician.

But in the room where I normally triage at the local base the computer screen has disappeared. I ring a dispatch co-ordinator at the head office and she is surprised at the news. She promises to look into it and get back to me. She never does. I’m left twiddling my thumbs for a while as other colleagues are busy triaging in the rooms next door. There are plenty of possible Covid calls on screen apparently.

This state of affairs just doesn’t seem right during a pandemic. That said some visit requests come in so we’re on the road before long.

It is the last visit we make that gives an idea of some of the newer challenges arising from the coronavirus outbreak. An elderly lady becomes more breathless in the last twenty four hours. Her carers ask us to come and see her.

She is ninety four and was recently discharged from hospital. She had fallen and broken her right forearm before her last admission. Essentially bedbound now she lives with her equally frail husband. Their carers are vital and attend four times a day to help them with washing, cleaning and cooking. They could not cope at home without this support. They have no family locally.

I go into the house in my PPE regalia (Personal Protective Equipment – mask, apron and gloves) as it is not clear at this point whether the patient has coronavirus or not. Her carer, in the form of a very pleasant young lady employed by a local agency, does not have access to any surgical grade fluid resistant masks. Used correctly these confer benefit in reducing transmission to people working closely with infected patients. They have no benefit in reducing transmission if wearing them walking down the street or on the bus. Especially if eating crisps.

In the end I suspect a lobar pneumonia and prescribe some oral antibiotics. She had a productive cough with yellow/green sputum with focal chest signs in her right lower lung. These findings are not typical of coronavirus – at least we think at this stage. But it is early days and there is much we don’t know about the virus. Presentations of many illnesses in the very elderly can often be atypical. I’ve read reports of some elderly patients testing positive for coronavirus presenting with confusion and diarrhoea only.

A conversation was had about the ethics of allowing carers with no proper PPE to continue to do their very up-close and personal jobs in patients who may have coronavirus, but in whom in cannot be confirmed clinically. Even if performed, a test (if it were an option, which it is not in the UK currently for patients in the community) would take days to be processed. Who would or could care for them awaiting a result, nevermind after a positive test? I advised the carer that she needed to raise this as a matter of urgency with her agency.

To be fair I’m sure her agency is already aware of this. The truth is that there is a shortage of PPE – not just nationally, but globally – and they are simply struggling to obtain it like everybody else. Even the supply in my car today extended in total to about three patients.

I strongly suspect this will not be enough from next week.

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