COVID-19: One In One Out

The images coming out of Italy and Spain showed hospitals overflowing with the sick and dying. The patterns in the epidemiology were a warning that London was sitting a couple of weeks behind these countries. This warning set in motion a war plan. The reality is that (thus far) though our hospitals have been busy, we have not really seen hospitals in the UK buckle under the pressure. I thought I would share my observations as to possible reasons why. 

I can only really speak for my own place of work but I know from friends and colleagues around the country that their individual trusts have too not been overwhelmed. This mostly because of fanastic levels of preparation at the trust level. From increases in staffing and recuitment of final year medical students to reorganisation and growth of emergency departments and even telephone follow up clinics - the infrastructure was in place well before the exponential growth in COVID cases could throttle us. 

The majority of our patient load is still COVID related. As I mentioned in my previous post we are not seeing nearly as many other illnesses and pathologies. This is likely to be due to the amazing work primary care doctors are doing to keep patients well at home but also because patients who probably don't need a visit to A&E are more likely to access support via their pharmacist or online resources such as NHS 111. The lockdown has almost certainly meant we are seeing less injuries. Less children falling from climbing frames and less elderly patients tripping and breaking hips. We have however continued to see a lot of mental health presentations as a result of isolation which may exacerbate depression and anxiety. 

I also wonder how our attitudes towards community "Do Not Attempt Resuscitation" (DNAR) orders and treatment escalation plans compare with the rest of the world. These discussions set out what level of care is appropriate from patient to patient and whether or not an attempt should be made to restart the heart if it stops. These discussions are NOT simply age based. They take in to consideration a patients other illnesses (comorbidities) and also the patient's wishes. I think we have a very candid approach to these discussions which is extremely important. Our elderly patients' lives are just as important as our younger patients but the reality is that they do very badly after long stays in intensive care. They largely do not go on to have a decent quality of life and may require prolonged periods of rehabilitation. That is if they surive the stay. These conversations are had frequently by physicians when patients are admitted to hospital and also perhaps, even more importantly by primary care doctors who deal with huge numbers of elderly patient who reside in residential and nursing homes. I am sure that this must be contributing to a smaller burden from elderly admissions at this time with patients who are unlikely to benefit from admission, hopefully having more dignified end of life care in their own homes. 

Our intensive care beds are full but for the moment there is some kind of equilibirum between patients in and patients out. That being said - we really don't know whethere we have reached the peak or if this is all a false sense of security. I think many of us have an anxiety about what will happen when the lockdown is eased and we start to release people back to normal life. Could this trigger another surge which will hit when our guard is down? For the moment I think it is important to do all we can to continue to promote and encourage isolation and hope that this is indeed the beginning of the curve flattening. Though we are "coping" the rates of death remain high from a virus which is insidious in its infectivity - it will not take a lot to tip the balance. 

Written by Nadeem Crowe


Thank you for these posts. It is refreshing to hear a genuine real-world account, unaffected by what makes a better headline. I look forward to reading more, and the pressure lessening with the encouraging data suggesting lock-down is reducing new infections.

James on May 12, 2020

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