Truly, I never imagined it would be this bad.
Once again Covid has spread out along the hospital, the disease greedily taking over ward after ward. Surgical, paediatric, obstetric, orthopaedic; this virus does not discriminate between specialities. Outbreaks bloom even in our ‘clean’ areas and the disease is even more ferociously infectious. Although our local tests do not differentiate strains, I presume this is the new variant.
The patients are younger this time around too, and there are so many of them. They are sick. We are full. There can be no debate: this is much, much worse than the first surge.
We start the morning with 10 new patients to be concerned about. These are just the worst of them; we cannot worry about those who, though less unwell, would have had us scared in days gone by.
They are scattered on general wards around the hospital, being given as much oxygen as possible through a standard mask. Most are lying prone on their fronts, breathing rapid, shallow breaths, too breathless to talk, blood oxygen saturations alarmingly low.
The eldest is in his 70s but most are much younger. All urgently need respiratory support. This is ideally given non-invasively using a Cpap mask or very high oxygen flows through the nose. Like most hospitals we have set up a new respiratory-led breathing support unit for this purpose, but it filled up with patients weeks ago.
Our intensive care unit, able to deliver these therapies as well as invasive ventilation for the very sickest, is also full despite being stretched and pushed way beyond its previous capacity. Our neighbouring hospitals are under the same pressures, or worse; even if patients were well enough to transfer out safely there is no space to receive them.
We divide and conquer. Some of us rush through the morning ward rounds on the breathing support and intensive care units, desperately hoping to find patients that have improved enough to step down on to a normal ward or could be swapped between the two units according to their needs.
Some of us go to assess the new referrals. We make sure that everything possible has been done to avoid the need for more support but our colleagues have already been thorough. They need to come to us, and soon.
We initiate difficult conversations with some patients who were frailer before catching Covid and would therefore have less chance of benefit from additional breathing therapy. We no longer have the luxury of “giving it a go”; we have to ensure that we select only those with the best chance of survival.
Getting it wrong may occupy a precious high dependency bed for many days, often ending in a difficult and symptomatic death while preventing other patients from receiving the correct therapy. Conversely, identifying those who will not survive will allow us to ensure better symptom control and a kinder end to life.
These conversations, often barely intelligible through our PPE, are draining, fraught, brutal. We must justify to patients and their families, and often our colleagues too, why we cannot offer these therapies to everyone.
There is a common misconception about ventilation and respiratory support. These are not treatments; they simply stop people dying while they hopefully heal. Dexamethasone, the steroid identified as effective at reducing mortality in the Recovery trial, is the single best treatment we have available for Covid.
It certainly stops many people dying, but it may not make them better, at least not quickly. This is a large part of our current problem: people who previously died within a few days now need respiratory support for weeks on end. Our mortuary is emptier than it was, but the hospital is much fuller.
We reconvene to discuss what to do with the 10, plus another two referred during the morning rounds. We feel that three have such a poor prognosis that we cannot justify offering more support, leaving nine to accommodate.
A couple of intensive care patients have died; two available beds. We step down a total of four others to normal wards, though two of these much earlier than we would like; we just have to hope they will not sicken again and need to come back.
That’s six accounted for now.
An alarm call goes out as another patient on the unit suddenly deteriorates. We peel off to assess him, gently remove the Cpap mask, transfer him to a side room, call in his family to be with him, administer medications to control terminal symptoms, help comfort the nursing staff who are in tears; they had got to know him and this has come as a huge shock. Still, it’s another bed. Seven.
There is no option for the last two but to further expand our breathing support unit, stretching it into yet another bay on scavenged kit with nursing levels way, way below what we used to consider safe. Problem solved, temporarily, but it has taken many hours during which the patients have not received the care they need. Our nurses are amazing but they are being stretched beyond breaking point on a daily basis now.
Meanwhile, maybe 30 new patients have been admitted through A&E, most of them requiring high levels of oxygen. We have no more beds in the hospital and barely enough staff to support the ones we do have. Our A&E fills up again and ambulances queue out the door.
There is barely time to process any of this; I go home and fall asleep. We have not even reached the peak of new cases in our area. The numbers arriving in hospital will peak some days after that and the death rate even later; it takes time for people with Covid to sicken and die. I have not heard of any credible central plans to relieve this pressure, yet already the system is about to fail. It is this that wakes me, anxious, in the small hours of the morning.
There is nowhere left to go.