The Bittersweet Return

'The Bittersweet Return'

Pre-tsunami calm, figuring out this new beast, PPE, & teamwork

Pre-covid scramble up the 'Llech Dhu' spur in Snowdonia

La Introduccion!

Hey folk, thanks for your kind interest in my experiences and thoughts.

I'm Alaina, a slightly manic, adventure-loving "squeeze-every-drop-out-of-life" kind of  gal based in Sheffield, England. I moved here 18 months ago to start my training to be a General Practitioner. But also to live near the Peak District National Park - allowing me to fill any spare time with cycling, running and climbing amongst impeccable outdoor beauty. :)

In love with my backyard!

How did I end up and A&E right now?

I'm just over halfway through my GP training, and after enjoying a 4 month post in 'obstetrics and gynaecology', I was due to move to my last hospital job rotation. The coronavirus pandemic started being taken more seriously by our man Boris, and it was then announced that all doctor job rotations/training would be cancelled, to minimise service disruptions. Aka, we must all stay in our current jobs, but probably expect a mass movement of staff across the hospitals to places in dire need when the impending crisis hits big style.

A slow onset reality check began to seep in: public health mitigation measures were being instilled in a gradual but clear-cut manner (the schools, then the pubs...); there was a building  news flurry of rising global cases and deaths; and even closer-to-home, there were updates from my best friend trapped in her flat alone in Madrid for weeks already. I was overcome by a tidal surge of powerful feelings, "I MUST DO SOMETHING!"

Being a vegan in this crisis is a sure-fire way to guarantee your survival!

A film-reel of passionate thoughts and emotions begun spinning through me: this thing is going to change our society and people's lives forever, let alone make seriously ill or kill hundreds of thousands in the UK alone. At this point nothing else is important. How can I be most useful? How can we all help as many people as possible?

I thought of contacting local research groups to aid even small tasks like data collection, I searched through as many community charities I could find (I even thought/and briefly created one for my local vicinity). Whilst obstetrics and gynaecology had been lovely, and to be honest was now slightly quiet due to the pre-emptive cancelling of all non-essential services (clinics and operation lists), as a GP trainee I felt my general medical skills could serve people best in an 'acute' or A&E setting during this crisis.
I emailed the leads of GP training and whoever I could in A&E, where I had worked over a year ago to see if I could be transferred.

FYI - the A&E rota is infamously awful. I remember 3 weeks straight of 65 hours - with shifts mainly until 01:30am or nights, and a lot of weekends. But to be honest, none of it matters when we need to be helping with something much greater than ourselves. AND since everything in 'normal life', socialising and sporting events are cancelled anyway, I may as well devote every minute to the cause!

SO, here I am, after 3 shifts back in A&E. And bloody raring to go.

Now is the time: keep on keeping on.

"PPE" (or the lack of)

ho ho, now this is a contentious topic isn't it!
PPE = Personal Protective Equipment.
In the UK, our health bosses and guideline-writers state that we only need the definitive and evidence-based 'FFP3' masks for procedures which put you most at risk of inhaling aerosols. These 'aerosol-generating procedures' include when a patient is intubated. So, if you work in critical care or in an operating theatre, these are a must. Ideally they need to be 'fit-tested' to ensure your masks doesn't leak.
However in the initial covid-mania, guidance (in the form of daily altering email communications) changed from "everyone must have an FFP3 mask and must be fit-tested, make an appointment in your own time - your responsibility!" to, "we have no masks and you don't need them anyway unless near an intubated patient". This also seemed to occur soon after our mask delivery at the maternity department got stolen. Yes, stolen. Someone earned a few bob on Ebay for that one, I'm sure. Thanks for that, mate.

My new A&E bud Fleur, demonstrating our covid PPE

Anyway, so now we're told we need plastic aprons/gowns, gloves, some eye-cover and a normal 'surgical' mask for every patient contact.
I'm not sure on the evidence for surgical masks, other than they should prevent YOU from coughing large droplets onto people. Although they get wet with your water vapour after around 20 minutes, at which point they are no longer supposed to be effective. We definitely don't have supply to change our minimally stocked masks every 20 minutes per staff member, per day.


My A&E

We've split the department into the 'Covid' and 'Non-Covid' sides. The difference being that you must wear the above 'PPE' throughout the covid side, plus an extra apron and glove set for a new patient. It gets damn hot in there, I tell you!
In the non-covid side, where anyone not-reporting any covid-likely symptoms go, we only wear gloves/mask/plastic pinny when we see a patient.

Another change is that every staff member wears a set of scrubs (or medical-style PJs), which we're meant to take a fresh set of each day, from the department.

At least I have a lovely daily commute!

El Ambiente...

Ok, let me use a brush, to sweep colour across the light and dark patches of this situation, and how it initially felt to be here.

Teamwork

Having not worked here for a while, a chord of warm familiarity was struck within me, seeing faces from the past. There were a lot of lovely "welcome back! It's good to have you back again"', which was so nice. It felt as though nothing had changed.

The fact that every single staff member has to wear an identical uniform - from the cleaners, to the ward clerks, the nurses to the doctors - unifies us.

I looked around me in blue-bay (the 'Covid' side, also now affectionately known as Blue-han), to see a sea of masked faces in scrubs. sharing patient tasks, thoughts, advice.
We are all the same. We are all equal. And we are all here for the same reason: our patients.
It made me so proud to be a part of it.

A last rock climbing evening outdoors before 'lockdown'

The pre-tsunami calm

Picture this:

• The government tells the entire population to 'stay at home'
• They add to that, the sentiment that if you don't you will be risking lives and the NHS
• The population are battered with news of a deadly virus which no one can see, but which is transmitted even by touching objects (this thing can survive days on various surfaces!), which is currently killing up to 1000 people per day in some countries

Now, do you think people would dare pop to their local A&E to check out that broken nail? 

Not kidding, that has definitely happened. 

Or perhaps, that niggly chest pain they've had for a few days which will 'probably be alright'?

Says every elderly person with blocked arteries not wanting to make a fuss...

This has resulted in an unknown silence in some of our hospital areas. Add to that the massive ongoing deployment of more and more staff in preparation. "It's coming", we all keep uttering, in an apprehensive ignorance of what is about to hit.

We all need to be aware of the indirect public health effects the above is going to cause.

All of those patients who actually have significant disease who will now NOT be seeking health advice. If this continues for months, which is very likely, we are later going to be hit by a wave of serious other disease which have been festering away in the community. Cancers, missed heart attacks, sepsis.

And finally, by cutting all 'non-essential' services, meaning outpatient clinics, elective surgery, and many face-to-face GP appointments or disease monitoring nurse appointments - we are effectively cutting OUT primary health care. We are stunting our disease prevention strategies. The bedrocks of a healthy population and the mitigation of severe disease and emergencies later on.

All of this is going to emerge in a future tidal wave of pathology.

It is an interesting time for public health.

'Cut the waffle! How have your first few shifts been!?'

Sorry yes, I'm not great at being brief. But this is the ending summary for my first post, you'll be glad to read.

At first, looking around me at frail elderly folk with masks, fighting to breathe, writhing around uncomfortably and looking helplessly in discomfort...I felt sick. 

I felt horrified, and an instant pain for these innocent people who must be feeling such fear.

This virus delivers a strange affliction. It bestows the most common-known symptoms on its victims, which thanks to the news and social media every Tom Dick and Harry can tell you about. However, it also is a great deceiver... we have had cases which you would label as 'classic' presentations of other diseases, for example abdominal ones, only to find that no, no, it is indeed Covid !

By and large it is interesting to see and learn from these cases, to help us understand this still relatively new beast. The commonest hospitalised people have been forced to present due to the inability to breathe, 1-3 weeks after initial symptoms. And we find them looking relatively ok despite having about 60% of the normal level of oxygen being pumped around their bodies!

The sad reality is that the only way to treat a very severe covid lung disease will be putting people to sleep and having ventilators do their breathing for them. This is reserved for people who are likely to be fit enough to be able to wake up again. We have to be making these decisions now, at the front door, on initial assessment. Obviously internationally we are trying to up ventilator numbers - our own hospital is planning an increase from 18 to 250 ventilated beds. Although reports from London are that not many have been 'woken up' after being ventilated yet.

This is why, guys, when people talk about 'flu causes a similar number of deaths, what is the fuss about!?' we need to realise that it's not just the death number, it's the level of morbidity or severe disease that it causes which is the problem. This is what will overwhelm our healthcare systems to breaking point.

Grandmother 1, 95yrs old and happily independent. I just hope she stays safe
(photo taken by me whilst I waved at her through the lounge window)

I will just mention one interesting patient to you.

An extremely fit older man had developed an excruciating pain in his left loin/lower ribcage area a day ago. He could barely move. If you tried to lower him from sitting to lying he was brought to tears. He had also had a 'flu-like' illness for a few weeks: weakness and muscle aches mainly. On further questioning he had also lost his senses of smell and taste.

This guy had a spotless medical history. His heart rate was a bit quick, his blood pressure a little low but not much else was going on.

He was actually a classic presentation of kidney stones - possibly brought on by dehydration after he stated reduced drinking and urinating during his recent illness.

When I listened to his chest, his lower lungs were pretty quiet - not an unusual finding in older folk.

BUT, I got a chest x-ray to ensure it wasn't a hidden left lower pneumonia causing the pain, or who knows, maybe some splodges of hidden Covid...

Yup, CXR = scattered infiltrates, worse on the left, possibly covid in my opinion, plus a secondary pneumonia.

Very severe pain for a pneumonia... on top of that his CT looking for kidney stones revealed a flawless intra-abdominal area. What was going on!?

There's perhaps a link between covid and blood clots in the lung, which can also cause sharp pains. I will find the result of that when I look up his results on my next shift...

Grandma 2, again 95yrs, blissfully enjoying life in her nursing home.
I pray for her safety in such a high risk environment. I hope I get to see her again.

Reflections

The recent experiences of this 'only just beginning' local epidemic, are making me feel different. At odds with the rest of the 'normal' world. We are actually all so shielded from this: the majority of us being shut up in our homes. I know of people still meeting loved ones but 'at a distance'.

The sad reality, especially in this very lax "lockdown" the UK has employed, is that if you go out and touch something, and you are carrying this invisible killer, you may potentially cause the death of an innocent person. You may be the reason that my lovely, innocent man now can't breathe or move due to a potential clot in his lung.

Is it really worth it? 

Please, there are things much bigger than ourselves and our small little world right now.

Not only that, but there are so many ways to unify our society currently and help those at risk, or people who are trying to self isolate.

Those of you with spare time on your hands, please, give yourself a vital purpose, make yourself part of the team. I'll list a few places to start at the bottom of this post.

Let's fight this beast together

Healthcare worker risk

I have no doubt that the majority of us working with covid-affected patients will become infected.

Yes I wear the gear as advised, but to hear a patient properly, and to show that I care for them in this moment I am getting closer to them. The very sick ones pull their masks off to breathe, or their masks fall off around the oxygen masks/tubing. One guy coughed all over my face before proceeding to projectile vomit. Thankfully, the majority of splashes missed me.

I've not thought about a risk to me, but what I worry and feel awful about are my colleagues who have families they must return to. Who may live with older or more vulnerable people that they will now spread the disease to. It's horrendous that they have to be put in this situation.

A new way of practising medicine: back to the old days

Not that I worked in the old days, although I am getting on a bit.

We've been advised, quite sensibly that to listen to a patient's chest, or say, examine their throat we'd be putting ourselves at a great risk.

We've been told we shouldn't even listen to a chest, as if they describe likely symptoms or are clinically unwell they'll be admitted to hospital anyway! Fair enough. We also will only do a chest X-ray, and a diagnostic swab, if they need to be admitted.

So basically we'll be taking a more 'hands-off' approach to medicine at the moment, and only doing things thought to be necessary or that will alter management in that moment.

This is quite refreshing, and will require better history-taking skills. Not just throwing needless tests and resources at people for no reason.

I think I'll still find it hard to not examine someone thoroughly, or put a hand on their shoulder to show I care about them when they're fearing for their lives.

Right, that's all for now

It's a sunny day in England and I've got today off. I'd love to go for a ride but will have to find somewhere quiet. I expect, and secretly hope, that we may be in for a more stringent lockdown imminently. 

We're going to have to take this thing more seriously. 

Please, think of all these innocent people, and do what you can. We're stronger together.

Lots of love,

Alaina X

Let's look forward to future, happy times, with the people we love the most <3

Volunteering resources:

• https://covidmutualaid.org/ - find local groups to support your community
• https://www.vas.org.uk/ - for Sheffield residents
• https://www.ncvo.org.uk/ncvo-volunteering/i-want-to-volunteer/volunteering-coronavirus