ONLY a few weeks ago, SARS-CoV-2 (the virus which causes COVID-19) was something few of us had heard of. It was a distant problem, in an obscure metropolis, somewhere in China. It was not our problem.
Most of us assumed it would come under control. As it moved to Italy, people started to take notice.
Even then, the reality didn’t hit until lock downs started. I count myself amongst the naive masses who even went as far as taking my first ski holiday in the Dolomites in the second week of March. On the second day the ski resorts closed. The penny dropped.
On arriving back in London, I checked my work emails. I saw the deluge.
I realised COVID-19 had made its grand entrance in my very own backyard. It had hit hard and fast in south east London.
With each passing day, there has been directive upon directive of how we must shut down all our routine work to manage the crisis. Meeting upon meeting and protocol upon protocol to be written and rewritten.
And then, there was the plea for help from our respiratory colleagues for help in looking after the patients – they can’t cope with the volume of patients coming through.
As a consultant in HIV medicine, I felt that I had a role to play in combating this novel virus. As I write this article, the number of positive inpatients being cared for in our hospital is 417. This is an increase of 105 from Friday.
I took up the challenge and did my first weekend on the ‘Covid wards’ last week. I walked onto the ward with a sense of apprehension. I am aware of the statistics of who gets milder disease, who gets seriously ill and who dies.
As a 38-year-old man with no known health issues, perhaps naively, I figured the odds of surviving COVID-19 are in my favour.
But the odds of me avoiding COVID-19, are not in my favour. As I changed from my regular clothes into scrubs and walked onto the ward, my first impression is how basic the personal protective equipment (PPE) is: a pair of blue nitrile gloves, a flimsy pink pinafore apron and a loose fitting surgical facemask by a company called ‘Tiger’ (should you wish to google an image).
This is clearly at odds with WHO guidelines: we all know this but higher authorities insult our intelligence by suggesting there is no evidence base for needing higher standard PPE.
I’d respect a truthful response – there isn’t enough proper PPE to go around.
As I leaned over one of my first patients to hear him speak through his oxygen mask, he coughed in my face. I realised how wholly inadequate the protection was.
As the morning progressed, the tension in the air dissipated and gave way to normal chit-chat amongst the doctors, nurses and other healthcare professionals. With this, a sense of complacency, you get used to the lack of protection and hope for the best.
Make no mistake: COVID-19 does not just cause a ‘bad flu’. This is a nasty illness and people are very sick, febrile, myalgic and most distressingly, short of breath.
In a proportion, a syndrome of hyperinflammation develops with diffuse lung infiltrates giving rise to a phenomenon known as ‘acute respiratory distress syndrome’ or ARDS.
Increasingly high oxygen requirements ensue. Treatment is supportive, revolving around oxygen support, careful balance of fluid management (to ensure patients don’t become fluid overloaded and worsen the respiratory distress) and antibiotics for potential superimposed bacterial infection.
There are no direct acting antivirals against SARS-CoV-2. As a physician attending these patients, the next decision on the list is ‘would we, should we ventilate if they deteriorate?’.
Whilst these decisions are always made, it is now more urgent. There aren’t enough ventilators to go around.
Treatment escalation planning – the phrase doctors use to describe proactively how much medical intervention you would wish for in extremis – is now at the forefront of discussions amongst multidisciplinary teams and with patients and relatives.
Whilst there may well be a shortage of ventilator beds, these discussions are also about making sure the person most likely to survive artificial ventilation gets the ventilator bed.
Most of the patients are frail and elderly. But if it were your mother or father, you’d want everything done.
And if there were an infinite supply of ventilator beds in our intensive care units, would we be having these discussions in such an upfront manner? Probably not.
Dr Cillian Ó Coinn is a consultant in HIV medicine from Armagh and has been working on the frontline against COVID-19 in one of London’s central teaching hospitals. He has since tested positive for the virus, but he is mending well.