Man down. & typical A&E resumes...

Suspected Covid-19 is my very justifiable excuse.

From what was  idealised to be a weekly reflection and documentation of a ‘frontline’ medical experience, it has unfortunately passed a month since blogpost numero 1.

I apologise to those who were interested in seeing my updates!

MAN DOWN.

No summit these 2 weeks, that's for sure!

8^th April I was on a late shift in our ‘blue’ Covid bay, aka ‘Blue-han’, when I noticed I had spent the past hour coughing. It was an irritating dry cough, co-existent with an irritable dry throat (which I recalled I’d taken painkillers for the preceding night). 

When I arrived home after 3 further hours with this dry cough I realised the weight behind acknowledging this symptom. I indeed, had a new, persistent cough. According to national guidelines, I must inform my employer immediately and self-isolate for 7 days. Not only that, but my poor nurse housemate must also isolate, and not work at all, for at LEAST 14 days. Ouch.

Maybe this is nothing? I haven’t coughed for a while now? I can’t stop my housemate from going to work for 2 weeks!! I’ve also only done 4 shifts back in A&E, I’ve barely helped! What if they think I’m lying/taking the pee?!

Despite this overall feeling, the cough is unmistakable. So yes, I ‘called it’. My housemate’s face at being locked indoors for 2 weeks was (!). But in reality if I had ignored it, and gone to work, everything I'd lay my hands on: doors, tables, chairs, every colleague I stand closely to and discuss patients with, not least every PATIENT that I am close to, I would risk passing on my likely virus to.

Did I get tested?

No. I did not. 

Occupational testing at that point was accessible only after a referral from a ‘line manager’, something which was unfortunately missed by my department.

Contacting occupational health to find this out and ensuring one got sent, lead to a call to me on day 7 (when I was still symptomatic) which went something along the lines of, “You’re past the point of testing. We only test on days 4-5 with the hope of returning people who are negative back to work before 7 days, as you’re already day 7 we can’t help you. You return to work. If you are sick, you call yourself in sick and call your own GP if you continue. Bye.” 

My housemate nurse being taken from our healthcare system for a further 7 days, perhaps needlessly, did not matter to them as she works for a different employer. Oh well.

The flowers are still blooming.
Nature and the outdoors have been saviours to many.

What was my illness like?

I was unable to function mentally for a solid 14 days. That feels like a long, long time.

It also makes me angry at the insinuation in our UK guidance that “7 days” is a thing: what is 7 days?! The WHO acknowledge mild Covid-19 lasts 2 weeks, so by giving the air of ‘you are well enough to work and don’t shed the virus after 7 days if you are symptom free’ not only perpetuates the return to work of sick and infected staff, but adds a moral load to the return-to-work decision.

Every day come late morning I was suddenly smacked with a dense head-fog,drowsiness, and a tight throbbing cerebral band, which would render me unable to manage ANYthing other than lying on my bed. Eyes closed. Hoping it would pass by the next day. And the next day… and the next day… 

But it’s after 7 days, I should be at work. Today I should be on a twilight, maybe I should give it a go? Tomorrow I’m on nights, I should be there, maybe I could try?

Some of my friends are the most thoughtful and caring people. I love you!

Neaha and Daisy honestly - this made my month. :'D

As nothing changed and I was nearing week 2, I succumbed a few times to helpless ‘surrender’. 

What is going on with me?! Am I even unwell? Is it all in my head? Maybe I’m developing chronic fatigue… maybe I’ll never get better!? 

I broke down on the phone to my mother, “I have stuff to do, mum. I can’t do anything. My head hurts all the time. What if it never goes away?”

In fact, this illness marked a point in my personal family history: the first time in my life my mother has telephoned me! HA, YES, SHE DID IT!!! Sorry mum, I had to. This comes from a mum who when her daughter texted her out of the blue with a “I love you”, responded with “I think you’ve texted the wrong number”.
I’m sure she loves me really, she’s definitely softening up in her old age!

Tough love, made me who I am! :'D

Anyway to the point - I got over it. And you will most likely be the same!

Day 15, the head thing didn’t happen! The sniffles and intermittent throat-clearing cough had waned, and I decided I could be fit enough to try a bike ride. Now, if I’m fit enough to try out work I’m definitely fit enough to ride my bike! It was SHEER BLISS, and I felt back to normal!? Hallelujah!

Be forewarned all, including those of you currently suffering with Covid-19 esque symptomatology: this thing is very ‘relapsing-remitting’, aka it affects your mind and body very variably both throughout a day, and between days. You may feel fully normal, your hope may return and you try to return to normal, then suddenly you feel horrendous later the same day and can’t move. This is startling and scary for many, but it is to be expected. Ride it. The majority of us will be fine.

Ride it out.

RETURNING TO THE EMERGENCY DEPARTMENT, HAVING MISSED THE ‘PEAK’… (ha, some Covid-fighting Dr I’ve been. I should be ashamed!)

I worked a day shift into few late shifts, into a few night shifts immediately on my return. Not the ideal work pattern post illness, but there is little choice when ‘thems are the shifts’, and I immaturely lack the patience to wait and ‘make sure’ my body is ready. Also a day shift is a rare gem, and a good tester shift to return to.

What did I notice?

I mainly worked these shifts on the ‘normal’ side of A&E, owing to a large number of doctors, a lessening flow of Covid patients, and a hotting influx of regular A&E patients. 

It has to be said that we’ve done an excellent job at doctor staffing to cover this crisis. Even when a lump of patients present, there would be enough of us there that each patient would be soon ‘picked up’ and dealt with. 

The mainstay of presentations in my experience have been either: 

a) Mental health problems, or physical problems presenting through the former; 

b) Injuries, unsurprisingly via DIY incidents (come on guys! *face palm*) 

c) Delayed or more advanced disease (through fear of coming to hospital) 

Without too much detail, to give you guys an idea and for your own interest, I’ll give some examples:

• Patient with cancer who had experienced THREE new and massive seizures at home over 3 weeks, but had been avoiding hospital due to Covid risk. They were physically ‘vulnerable’, so, to be fair to them, had been weighing up the risks of exposing themselves to a potentially lethal virus, or having further seizures and suffering the consequences of those.
  Awfully, we found a few new brain tumours.

• Fingertips cut off with a chainsaw
  
• A nutmeg overdose
• Yes. Really. Hallucinogenic, apparently. Please don’t all try this at home
  
• Intoxicated on ?substance.
• Person, refuses to give any information away. Now, if they have overdosed on paracetamol, it can be insidiously lethal… taking a number of days to inflict its permanent damage: it therefore needs urgent level measuring and appropriate treatment. I asked this person, “do you think you may have consumed PARACETAMOL at all today, then…?” they responded glaring at me, with an exaggerated shrug. I then tested their paracetamol level to find they had indeed! AH GOT YA! Admitted and treated. Geez, that could’ve been close.
  
• Half a broken pencil and a radio antennae stuck up a rectum
• This patient is a regular, and we discussed their management very ‘matter of factly’. Patient: Oh silly me, what have I put up my bum this time! Ho ho
  
• Unable to urinate. Patient then takes selfies of their arm with gauze on it after having blood taken, and runs away not waiting for the blood results.

 Yep, saving lives here, people!

To summit one Peak, only to face another...

Any more experience of Covid-19 patients?

Yep, so I’ve not had much more time in ‘blue-han’, but I’ll detail what I’ve experienced there recently.

Firstly let me remind you of the chap I discussed in blogpost 1, with the classic kidney stone presentation. He did indeed have a blood clot in his lung, in fact, on BOTH sides. With absolutely no risk factors. His Covid-19 swab was negative. But I think it’s quite clear, as did the haematologist who followed him up, that this was likely the doing of the coronavirus. The poor man was anticoagulated, and I hope he makes a full recovery.

COVID-19 CASE 1: Gastro-Covid, and an emotional DNACPR discussion.

You may be aware that this illness can actually present like a gastroenteritis. The posh name given to a vomiting and/or diarrhoeal illness, often triggered by a virus or from contaminated food.

Well, I saw a lovely older lady who had suffered a drawn out 2-3 weeks of varying symptoms, but culminating in constant diarrhoea and vomiting, so much so that she was unable to consume anything orally at all. A sign which heralds the need for a hospital admission, always! 

Her husband and son had been unwell 2 weeks prior but purely with a cough and cold-like symptoms, and had both fully recovered. Again, they had avoided sending her to hospital fearing her picking up the virus. They had hoped she did not have it. Her tongue was extremely dry, it was awful to see her so dehydrated, and I was just so glad that her body had been compensating so well up to this point.

The next steps feel and can seem extremely clinical and cold, because we have to get into a habit of doing it, but they have an important rational behind them, not least morally. I had to bring up with her the ‘resuscitation question’. Not only did she break down with fear at my explaining her likely diagnosis, stating through her tears that she didn’t want to end up on a ventilator, but I then had to (even hypothetically) move her thoughts to the scene of her heart stopping.

DNACPR – Do Not Attempt Cardio-Pulmonary Resuscitation

The truth is that CPR is often unsuccessful, with between 10-20% of patients (and that’s your average patient) surviving after it to leave hospital. And in what state? Many ‘survivors’ are actually permanently disabled either from brain or other organ damage, after those moments of lost oxygenation from the heart. Of course, on top of that is the physical effect of the CPR: crushed ribs and other organ injury = punctured lungs, more time on machines to help the person survive from the ordeal.

CPR is less likely to restart your heart or enable you to survive if you have other medical problems, or are older. SO, crushing your ribs in a traumatic manner, for you to pass away anyway, or ‘live’ but in a severely disabled state, NEEDS to be clear to people. This is WHY we need to discuss this with more patients and at earlier points of healthcare contact. So that a ‘DNACPR’ form is created, which can always be revised if the patient so wishes or their chances of success happen to change, but so that if the worst were to happen, a patient may pass away naturally in a dignified and appropriate way. If it is obvious an attempt would not be likely to work for that patient, the decision can be put in place by the medical team, but should still be explained to a patient and their family. Let me finally be clear by stating that ethically unless there is a visible DNACPR form available, we must start CPR.

As mentioned in blogpost 1, our hospital starts a ‘Covid form’ where we detail amongst other things, the presence of a DNACPR form, any discussions with the patient about this, and about their wish and whether they would likely survive being put on a ventilator. If the worst were to come.

This is practising rational and ethical healthcare. We should all be doing this.

Any more for any more?
Or can I get back to my Zoom pub quiz??

Ok ok, I told you brevity was never my forte!

A couple more interesting ones with learning points…then, the end!

 

COVID-CASE 2: young and (understandably) anxious

I saw a young man who had actually been seen by a colleague the preceding night. He was in his 2^nd week of symptoms, a lot of vomiting, fatigue and feverish episodes. The night before he had been unable to tolerate oral fluids, and had obviously seemed dehydrated so was given a ‘drip’ before going home.

He had come back to me that evening in a panic. The morning had brought with it a new lease of energy, perhaps, a return to good health? His appetite was improving and he hadn’t vomited. (Note what we discussed earlier people!)… the late afternoon thrashed his infirm body with hot sweats, nausea, and a heart rate reaching 115bpm. Not surprisingly a call to 111 lead to him being sat there again before me.

He was young, fit, and by now with entirely normal observations: heart rate, blood pressure, respiratory rate, oxygen levels and temperature. A ‘clinical’ assessment by me, of observing him, visibly gauging his hydration status and examining him, lead me to believe his body was holding onto his fluids well. The only thing a miss, were the crackles I could hear in one lung. Often you can hear the inflammatory fluid caused by Covid-19, but it would be wise to sometimes give antibiotics on the rare off chance a bacteria has jumped on that vulnerable already-unwell person and caused a pneumonia.

The important thing to note here was that this guy doesn’t need to be in hospital. Despite how awful he felt, and his fears, his body will likely, and was, fighting it off. How is he to know, and to feel comfortable at home, suffering day after day?

Distractor from large text blocks...Make someone's day - the biscoffi cupcake way!
(What I did after a night shift, before hitting the bike, naturally)

This is where ‘ICE’ comes in handy. A consultation model taught to us, mainly in training to become a general practitioner. You need to address the patients’ ‘ideas, concerns and expectations’, to really understand why they have come. To meet what they’re worried about so they feel their plight has been answered. SO, when your doctor says to you “ What do YOU think is going on with you?” it’s not because they’re an idiot who relies on google to do their daily doctoring (despite what you all may think! :p) , it’s because if we know what you’re REALLY worried about, we can actually explain to you why it IS or ISN’T that. To help you!

I did indeed explain to this poor chappy that his relapsing/remitting illness was to be expected, after he explained his main fear had been that he was getting sicker all of a sudden. And focused on explaining to him how well his body was coping with his hydration, when he should worry and come back to A&E, and that I would give him some antibiotics to be extra sure about the crackles I could hear in his lung.

I hope I helped him to understand, eased his anxiety a bit, and that he’s recovering well at home!

The positives of commuting to a night shift in Sheffield <3 #theoutdoorcity

I was going to mention another interesting case, but to be fair I bet 90% of you already dropped off after the first 100 words.

I’m sorry I’ve taken up so much of your time, but hope it’s been useful and eye-opening to some of you!

 A bit of joy in this mishmash period of unknowns, lonliness, economic-difficulties, sickness and fatalities

Remember grandmothers 1 and 2 from blogpost 1?

Well, they both just turned 96 years old!

Grandma 1, in a nursing home, has now lost 12 of her fellow residents to the Covid-19 virus. Reliving that number draws tears for me now, for those people, their families, and the high risk to my beloved grandma. But, against average statistical odds against her, she has lived to reach her 96^th birthday on Sunday 3^rd May. I spoke to her briefly on the phone walking down a hospital corridor, as I rushed to another shift. The warmth in my heart bubbled over the edge as she repeated her usual phrase, a phrase which her wonderful self with very mild dementia likes to say every single time we speak, “Yes, I’m still here to annoy you all!”.

My other grandmother, the maternal side, worried me during my sickness due to a fall at home, a hip dislocation (5^th time… yes, this prosthetic hip REALLY isn’t working well for her *face palm*), and a hospital admission. Even better, after she coughed whilst sipping a tea in their A&E she got put onto a Covid-ward pending a swab result. Brilliant! Way to infect my grandma!!!

Thankfully she got released back home, where she lives alone about 1h 15min away from any family members.

My delightful return to full health sparkled brighter when it meant I could pair a long bike ride with surprising her with a ‘window-visit’. Including on her 96^th birthday yesterday!! Her neighbours also joined forces to sing happy birthday to hear, socially distanced on her front lawn. After I attempted to help her with her daily crossword through the window, the bouquet from London I’d pre-ordered arrived. Yay!

The essence of being human, and part of a community is currently highlighted. Look after yourselves and your loved ones. Show people you care about them. Do things to help others, and to brighten up someone’s day. Continue to follow social distancing rules, minimise interactions with others, take symptoms seriously, and please if someone is seriously unwell come to hospital!

PEACE OUT

Alaina X