The Covid-19 pandemic has many untold stories and has touched everyone in different ways. From children missing out on key education, office-workers adapting to home working to small business owners forced to close their shops due to profound reductions in footfall. We are beginning to see the impact of the economy and undoubtedly this will have a secondary effect that we will only determine in hindsight. As the country moves into the next phase of the Pandemic (which by no means is over, but has certainly changed), I wanted to provide some high level reflections and a personal viewpoint.
A change in our working lives
For us, as Doctors, we have been on the same journey but with some additional hurdles. Like many Key Workers, we have worked throughout the lockdown period, and as everything goes back to normal, there is a huge backlog of work that needs to be cleared.
My wife, a frontline Doctor who saw patients in Emergency Departments and Urgent Care Centres was seeing unwell patients with fever and breathlessness with very little support or protection. Thankfully this improved over time but she has spent many hours in tiny rooms with barely a few inches between her and the patients. Her Hospital actively removed masks from staff as the advice from central Government waxed and waned. We had worries about her bringing home the virus, and as many people have had to do around the country, we avoided all contact with family members. Both of us had a system of complete ‘detox’ when returning from work: a complete strip and immediate shower. We stuck to old clothes – all now disposed of!
As an Interventional Cardiologist, I was asked to be in the Cardiac Catheter Laboratory every day to help deal with those having heart attacks triggered by the virus. Compared to the re-deployment experienced by others, this was relatively easy for me to adapt to. Rather than performing procedures two days a week, it become a more frequent affair. On-calls continued but these changes as well. There was reduction in the number of patients presenting with classical heart attacks and when they did, they were often sicker and less easy to treat. We rapidly adapted to wearing full protective equipment, and while it was uncomfortable, I was grateful to my Hospital system obtaining the best equipment that it could. The Hospital developed one-way systems and converted all the theatres into ITU space. While much was made of the Nightingale ITU unit in East London, we were unable to transfer any of our patients to them. Our wards became increasingly closed off and the removal of family members meant the public spaces within the hospitals seemed eerily empty.
I saw a whole spectrum of illness – those who only had trivial or no symptoms, to those with fulminant illness and severe life-threatening disease. All the cases I saw, because of the change in the work-pattern, were those who needed an emergency procedure. Our experience and assessment of the current research data has now been published by Heart, part of the British Medical Journal.
As an Interventional Cardiologist, I am used to dealing with critically unwell patients. Those having heart attacks and needing primary angioplasty (acute unblocking of their heart arteries) can be very sick with severe fluctuations in their state. While this invariably causes marked fluctuations in our own adrenaline levels and blood pressure, it means we can appear unfazed by the most dramatic changes in the patient’s condition. We are also well versed in performing emergency procedures with complex equipment and we have a number of ‘tools in the box’ we can draw on the reverse a patient’s decline. However, despite our hardened shell, there is a deep-cut into our psyche which manifests later and I am still processing some of the carnage I witnessed. Many others have written about what happened on the wards. My personal experience was that we managed in a safe and appropriate manner.
Healthcare workers became infected
The risk to the medical staff was real and easily appreciated. All levels of healthcare workers were exposed and a number of healthcare workers had well publicised deaths following Covid-19 illness. Despite all that we have learnt, why some are more prone than others is poorly understood. There is racial component (more common in minorities) and gender bias (more common in men). There was also a greater chance of catching it if the viral load (the amount of virus you are exposed to) was high. But why some exposures had a higher viral load is also still unclear. Were these staff members coughed upon directly or spend a very prolonged period in close proximity to an infected individual.
Many of our Registrars (the level below Consultant) became infected, as did some of my Consultant colleagues. This may have been because early Hospital policies denied the routine use of face masks when caring for patients that had not been proven to have Covid-19. As the diagnostic turn-around was 4 days, it can be seen it was a ludicrous approach but one supported at high levels. I was appalled to hear one Consultant was demanding the junior staff remove their personal masks as it conflicted with ‘policy’. Infectious Disease specialists told us we were being “melodramatic and anxious” when we asked to have the appropriate protective equipment. This was while a junior colleague of ours was needing a machine to help support his breathing. I appreciate that they were falling policy, but it felt tone-deaf. With hind-sight, we can see they were entirely wrong but we still haven’t had an apology or even just an admission that they were wrong. Now, everyone, including the public, are wearing masks the entire time. Back then, those dealing with unwell patients, but without the magical confirmation, were not allowed to wear.
Quiet or Busy Hospitals
The emergency departments, which are normally full of patients suffering from full-blown life threatening events to much minor issues, also became empty. This was quite unexpected but perhaps reflected the strong political messaging about “Stay At Home” and “Save the NHS”. People undoubtedly had medical issues that they simply did not present with to the Hospital, or their General Practitioner. It appeared the only condition that existed was Covid-19. It also seemed as if every patient had it. Even the patients we didn’t think had it, had it on swab testing. Those patients that didn’t have positive swabs, had the clinical features (high temperatures, breathlessness, unable to smell) leading to the diagnosis. We started off with woeful testing systems but thankfully this has evolved into rapid-turn around systems.
The testing process was an experience in itself. Initial swabs were performed incorrect as staff had not been formally trained. Many placed the swab just in the front part of the nose. What is required is a deep swab – with the near entirety of the stick passed through the nose, into the deep nasopharyngeal area. Even when done correctly, a negatively swab can be falsely negative. The likelihood of false positive was much lower. Later in the pandemic, we moved to staff testing on a frequent basis. This makes sense as it reduces the risk of staff members acquiring it and spreading it to other vulnerable patients.
There were plenty of difficulties posed by the slow testing. Patients were moved around the Hospitals according to their Covid-19 status: those with the condition were housed together, while those without the virus could be within ‘clean zones’. But because it took time for the diagnosis to be made it was inevitable to make mistakes and we were concerned about cross-infections between vulnerable patients.
While there were certain departments that were rushed off their feet, there were some specialities with little to do as all elective work was cancelled. While many were redeployed it did not make sense for everyone to be exposed simultaneously. The fear was that an extension of the first wave would mean staff would needed later. Junior staff kept their spirits up with TikTok videos. Some raised eyebrows about this but I don’t blame them. There was an unrelenting atmosphere of concern and stress. 15 second videos of fun and japes built camaraderie between teams that were thrown together.
Routine Work
In addition to the altered working patterns, all of my NHS clinics were switched to telephone-only. This was a new way of working as this had previously been perceived as an ‘unsafe’ way of working. With some practice, we developed new pathways to deal with both new and long-term follow-ups in the safest way possible. A major limiting factor was the sudden lack of routine testing. Patients could not have echocardiograms or be booked for elective procedures. Bar a few notable exceptions, patients were very understanding. The vast majority of the public
Those that genuinely needed urgent treatment got it. In fact, the removal of all routine work meant that urgent and emergency work was suddenly easier. I was able to discuss with a patient about their sudden change in symptoms and bring them into the Hospital for the procedure within a few days (once their swabs had all been processed).
Learning on the go and optimal communication
One major issue is that we needed to learn about Covid-19 but we couldn’t get together and all conferences were cancelled (I lost a fair amount of money on missed conferences). The real issue was the transmission of credible and meaningful information and traditional modes of learning were broken. This was helped by online learning, webinars and in some cases, spread of information via social media. It was through social media that we refined our treatment algorithms in place at one of our Hospitals. It was through social media that we spread the message of view on best practice for personal protective equipment.
There were some major pitfalls in the early part of the Pandemic. Information was coming out of China and Italy and yet our own systems were not responding to the information. Doctors that were active on social media were more informed about key issues than some senior decision makers. This lead to a feeling of inertia and disgruntlement amongst the younger members of medical circles.
In some quarters, the learning from both China and Italy were dismissed entirely out of hand. Many of our own medical circles descended into angry arguments based on very little information or data. This felt very destructive and unhelpful.
Social media discussions have also become aggressively politically partisan. The issue was that initially the data was limited and quite biased – because it was collected from the sickest patients. Then, the data became plentiful but quality also appeared to deteriorate. There was scare stories and there has been a progressive increase in what appears to be fabricated or manipulated. This is horrifying that this has happened and the reasons behind it are complex.
An additional concern was that many Doctors were asked to work in departments or divisions that were outside their area of training or expertise. This was not so difficult, there are clear hierarchies in medicine and, with the All-Hands-On-Deck approach that was common during the pandemic, meant that learning on the wards wasn’t so difficult.
Communication between Hospitals has always been weak in the UK but suddenly we needed to communicate continuously and share clinical data through methods that were previously banned or considered unacceptable. While this may seem trivial, health care workers have been removed from their posts or even their professional bodies for sharing patient data through means which is now considered entirely acceptable. Hospitals have started sharing patient data in easier and more efficient ways. In many ways, huge technological barriers within the NHS have now come down and this should lead to improvements in care in the future.
Protective Equipment
While we are used to sterile working conditions, the additional need for protective equipment was a challenge to many healthcare workers. There was the well publicised shorted of protective equipment. Many of my colleagues established import / export companies to bring the needed equipment into the country. We did this using our own funds as the Hospitals were constrained to use normal established pathways which were not fit for new New World we had entered.
It is also worth noting that Doctors had to learn to treat a new condition while information about it was rapidly evolving. There was a lot of misinformation across the Internet and a huge political bias or spin on Public Health decisions. Hospital management often had to be seen to follow Governmental advice, even if we all recognised that the advice was wrong. It was a challenge to deal with critically unwell patients while trying to critically appraise rapidly published research data. Some of our teams immediately established new research projects to advance our learning.
Conclusion for now
The story continues to evolve and this represents a summary of a few thoughts I’ve had over the last few months. I will continue to share my thoughts but I would also value to hear from you. If there is anything you wish to discuss, please get in touch: info@drnijjer.com.
