3/5/20

The war drum begins to beat. We array ourselves on the field of battle, semi-ordered phalanxes waved onwards by our political overlords barely visible on the hill behind us.

A few of us are in full battle gear with glistening helmets, sturdy sharp spears, thick shields and appropriate footwear.

Many are not so lucky. Some are using inverted pots and pans for head protection. A few are making do with pikes and hoes. Others just have sticks. Still more are holding dustbin covers. Several are wearing beach sandles. Whatever we’re clutching the knuckles are white.

Our collective anxiety over imminent engagement is not much reduced witnessing the worried faces of (usually unflappable) anaesthetic and intensivist colleagues as they are pushed forward onto the front rank.

Rightly they fret that the beads of sweat on their brows will soon be replaced by aerosol droplets of virus-laden saliva spewed forth on intubating Vesuvian-like tracheas. We know that we too will find ourselves doing similar risky procedures in time.

The horn sounds. The drum beats louder. We shuffle forward together, peering into the murk.

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.

25/3/20

I’ve just finished my first shift back at the small community hospital where I work four days a week. And things have definitely changed.

The hospital is being radically reconfigured for the coming Covid tsunami. As I was going in the main entrance at the start of my shift I was accosted by our reception/triage team who have now been relocated to a room just to the side of the foyer at the front door.

Their job was to now screen and assess all those seeking to enter the hospital for signs/symptoms of Covid-19, be they patients or visitors. The visitors are no longer allowed in, except for imminent death of loved ones. Patients not in extremis are being turned away. This of course makes a lot of sense.

Everybody is now dressed in scrubs whereas before we could wear uniforms or civvies. There are plans to separate the hospital into Covid and non-Covid sections. The final plan from the bigwigs is to be finalised in the next twenty four hours. We all hope there is enough PPE.

The shift was eerily quiet today and all the more unnerving for being so. I think many of would-be patients are staying away and hopefully looking to take on more self-care. GP practices locally have been switched exclusively to telephone triage. This might mean their capacity to manage minor illness has increased, so the patients are less likely to come to us. I’m sure some pateints are simply staying away out of fear.

We did see some of course. Several minor injuries requiring imaging and treatment. I also saw a couple of patients with serious illness – one with a rip-roaring pancreatitis, the other with suspected appendicitis – both required onward referral to the main hospital.

I had the luxury of admitting them today. But when soon there are no more beds to be had, these patients will come to represent the collateral morbidity and mortality to Covid-19. These numbers will not be in the headline daily Covid fatality reports, but will deserve to be just the same.

It begins to hit home the difficult, if not impossible, decisions that will have to be made in the near future. There is no doubt about it. Patients presenting with conditions that would routinely have been urgently conveyed to the main hospital by ambulance will be simply be sent home with the next best option to take their chances. “Minor” heart attacks, suspected PEs/DVTs, severe headaches with absent neurology……… the testing facilities and investigations of these patients will not be available and it is inconceivable that deaths will not occur in this group too.

There is consideral angst amongst colleagues what this will mean for us medicolegally when this is done. The GMC is making reassuring noises that the exceptional circumstances surrounding these risk-laden clinical decisions will be considered in mitigation in the future. No-one is comforted by this. When this event passes, and it will, for how long will relatives be in a forgiving mood? How long before they pick up the phone in response to the no-win-no-fee legal service advertised on daytime TV?

A colleague I worked with today is heavily involved in the current frantic reorganisation. She tells me the current projection is that we are in week two of twelve. It is going to get “very bad” in the next three weeks. It will then get “unspeakably bad” for another three weeks, before hopefully just getting back to “very bad” again for the following three weeks. The numbers expected to die in our area are truely staggering, but it is also that they will do so in an incredibly short space of time.

I’d like to finish by saying something pithy here. But I can’t.

22/3/20

So it’s Sunday the 22nd of March. I feel completely recovered from what I suspect to have been a mild bout of Coronavirus. I can’t be sure of course as I haven’t been tested. That said I’m 90% certain it was as it had some of the expected symptoms.

It’s also hard to put into words but the experience, on some level, was as if my immune system was slightly baffled and at times didn’t know what to make of what it was it responding to. The kind of response a virgin immune system might have to a novel virus perhaps.

Like as if you’re walking down the street and some guy comes out of a shop in front of you walking on his hands. Visually and socially odd, but processable. It thankfully did its job however and I personally hope it was Coronavirus – if that was my lot I’ll take it.

I’m looking forward to going back to work. It sounds odd but I feel better knowing (probably) that I’ve had the disease and that I can now do my job without looking over my shoulder. I’ll still take the necessary PPE precautions of course, but I will be happy to put myself forward to see suspected patients if other colleagues are not so sure of their status. Pretty soon I don’t think any of us will have a choice however.

During my week off the organisational Covid emails and whatsapp groups are ramping up their activity and number as the NHS locally seeks to get ready. The root and branch changes to the local structure that are happening are truely staggering. And being done in record time.

I take some heart in that even if we ultimately get completely steamrollered as they have been in Italy, then we will have done so in an organised, rather than disorganised, fashion. Time is not on our side however.

In addition to working in the community hospital I also do a day a week in a GP practice, although I’m not back there for another couple of weeks. I have some time off coming up as all previously booked holiday plans are scuppered. I can’t imagine it will be difficult to fill these with work dates going forward unfortunately. Any days I do have off will be for downtime. This will not be a sprint but a marathon.

18/3/20

I’m at home self-isolating having I picked up what I suspect to be Covid-19 starting on the Sunday just gone. I registered a very mild transient temperature which was short-lived that evening. The penny dropped on my way to work the following day when I developed a very minor cough and a sense of nasal catarrh. I did not have a congested nose, sneezing nor a sore throat.

I immediately rang the small community hospital (one of the places where I work) to let them know of my suspicions and that I felt I couldn’t come to work. They readily agreed. Of course I don’t know for sure whether I do indeed have it or not as the UK government at this stage are not routinely testing in the community.

The mood of the nation is increasingly sombre and anxious. The 24/7 news cycle is in full coronavirus mode with flashing blood red headlines against a backdrop of graphic and uncountable viral particles shedding ad infinitum on one particular channel. For once the fear-mongering may not be commensurate with what is to come.

The country is slowly but surely beginning to shut down. People are beginning to ponder and come to grips with all of the ramifications – not just with regards to personal health, but also financial, economic and social.

The government are ramping up their actions and rhetoric, but they just give the impression of being a little bit behind the curve. This is not where you want to be when you look at the harrowing images and numbers coming out of Italy, where there is what can only be described as a geriatric holocaust.

On a personal level I’m trying to steel myself mentally and emotionally for what is to come as best I can. This involves visualising actual battlefield conditions (imagery supplemented from war movies – my life’s only visual frame of reference). I have a feeling I will be spending a lot of my time either palliating patients, or trying to get them admitted to non-existent beds, and then palliating them.

I bumped into a colleague last week during a change-over at an out of hours shift. This was before I became unwell. She is quite religious. She is a very decent person but her religiosity can sometimes be a little bit intrusive.

We were discussing the impending crisis. As we parted she said that she would pray for me. She then looked at me and said “God didn’t cause this”, and that she knew this for certain. However her eyes betrayed a sense of not being as sure as her words implied. I had to refrain from suggesting that if it wasn’t caused by God then perhaps it was caused by another supreme being with the same name.

In truth I feel sorry for her as her faith is going to be tested in ways she could never have possibly imagined. It will not surprise me if she feels differently when this is over. In that sense I feel glad I’m an atheist. That is one particular cross I will not have to bear.

And so it begins……

I am an NHS doctor in the Southwest of the UK. I hope to keep a regular blog of my experiences as we enter a uniquely foreboding time due to the Coronavirus Pandemic in the coming weeks and months.

Selfishly I’m mainly doing this for myself in a bid to help sustain through what is about to come, but if others find it interesting or somehow helpful than that is all to the good.

I will be doing this as regularly as I can, but will also be doing so in a strictly anonymised form to protect all identities involved.

Best regards,

PV