Opinion
I'm an NHS consultant. We're exhausted – and a second surge is on its way
We have learned a lot about coronavirus, but UK hospitals face huge challenges ahead
by AnonymousNow that the dust has settled and we have time to reflect, what have we learned from the first peak of Covid-19? And how will we cope with another one?
We now understand this illness a lot better than we did. We know what it does to people who are sick enough to need to stay in hospital. For a start, it kills almost 40% of them, more if they are elderly. Many of the survivors suffer horrible lung damage and “storms” of inflammation, often needing weeks on a ventilator.
It makes the blood unusually sticky and causes clots all over the body – particularly in the lungs – and may do so for weeks after even mild infections. It is a cruel disease.
But we have adapted. Protocols have been written, pathways set up within the hospital to try to cohort patients. We now know which parts of the building have the best oxygen flow rates, something I never thought I’d have to consider, and we have become adept at turning patients on to their fronts so they can get more oxygen into their damaged lungs.
We are working out how to use blood thinning medications in the best way. The hospital has become more efficient; social care has improved greatly and the phenomenon of stable patients waiting weeks for discharge or placement seems to have been smoothed out. The Nightingale hospitals will be ready to step up again and hopefully faster this time. There is no question that we are better prepared now.
However, while we may be more efficient at keeping people alive while the disease takes its natural course, we still do not have any effective and available treatments. Clinical trials are under way, but right now these studies are standing still, waiting for more patients to enrol since infection rates have dropped.
And if any proof were needed of the importance of being guided by the evidence, just look at hydroxychloroquine, which may actually increase the risk of death. So while in many ways we are now better prepared for another peak, we still have no ways to actually treat the disease.
Although I have little faith in the muddled thinking and confused messaging seeping down from the top, my personal guess is that we won’t see as savage a peak again. I certainly hope not.
It seems more likely that the virus will linger in the population, returning periodically to cause smaller, intermittent surges. Nonetheless, the NHS functions so close to maximum capacity even in normal times that this could still cause another crisis. And when? Have we just kicked the can down the road until winter, when we’ll be at our busiest anyway?
There are other problems that we did not face, or did not recognise, first time around. There are logistical, strategic and emotional obstacles that most likely mean our services will not return to normal for a long time, whether we have another peak or not.
Firstly, we have our usual caseload of emergency and elective (planned) work. All clinics and planned operations were mothballed as soon as the scale of the response needed became clear. Provisions were made only for the very unwell and those with cancer; everyone else would just have to wait it out.
In addition, people were told to avoid hospitals unless it was absolutely essential. They listened; our non-Covid work during the first peak was a fraction of what it usually is. This was probably the only reason we coped at all.
The problem is that we are already seeing the results of this. Patients are not doctors; they cannot reasonably be expected to reliably self-diagnose what is essential and what isn’t. After two months of neglect their symptoms are becoming intolerable and, unable to seek help through the usual channels, they are coming in later in their disease course than we’d expect and often in a terrible state.
We have had people with undiagnosed cancer arriving only days from death, people with strokes and heart attacks presenting days after their symptoms started. This is reflected in the national figures for excess deaths; you don’t have to catch Covid-19 to die because of it.
Maybe we could get away with all this first time around, but for patients with life-threatening non-Covid disease these effects will be even more horrific after three months of standstill. We urgently need to provide for these people and there is no guarantee they will be able to stay away in the same way during a second peak.
Furthermore, we don’t really have answers yet as to how to keep Covid and non-Covid patients separated well enough to prevent cross-infection. It has become clear that during the first peak many patients acquired the infection while already hospitalised for other causes, and so we are tying ourselves in knots to prevent this. The logistics become baffling, requiring two separate areas for all aspects of care: “clean” and “dirty” X-ray departments, CT scanners, inpatient wards, A&E departments.
This is only made worse by the ongoing lack of rapid bedside testing for Covid-19 and the delay in the antibody tests to suggest whether people have previously had it.
So for now we must quarantine them in a third area, in individual rooms, until we know whether they even have the disease. This is hugely inefficient and often delays patients getting the care they need in the correct area. I can only hope we get these tools urgently and before the next wave hits.
The best approach would of course be to keep people with non-emergency or long-term medical problems away from the hospital in the first place. But for this we need our routine outpatient services running. Whilst we are honouring as many appointments as we can by telephone, without our usual diagnostic tests available all we can really do is work out who we need to see urgently and who can wait another few months.
In respiratory medicine we also have the enormous new burden of follow-up for the many hundreds of Covid patients already discharged from hospital. All this represents a hugely increased workload and we need more support.
This point brings me to my last key concern: we are exhausted. At the beginning, although there was the fear of the unknown, there was a purity of purpose that united us and drove us on. It was obvious what we needed to do; there were patients in front of us, gaps to plug, new skills to learn; fuelled by adrenaline, we got on with it. In many ways that was the easy bit.
This new phase is difficult, uncertain, draining. There are endless planning meetings and constantly changing advice. Many of us still struggle with insomnia and then there’s the toll on our our mental health; just like everyone else in lockdown we struggle to turn off when away from work. Goodwill to our government and our employers is beginning to fray, and I fear for the resilience of our workforce – whether a second peak hits or not. Mentally, we are not the same as we were at the beginning.
So I am guarded about our readiness for another peak. We know what to do and we will do it better next time. But this disease is causing massive collateral damage; this will only get worse the longer this goes on.
- The writer is an NHS respiratory consultant who works across a number of hospitals