The Pandemic: Experienced by a Junior Doctor
12th March 2020
This is the day when it finally became real to me.
It was just a normal day to begin with. I was my customary five minutes late to work and wolfed down my overnight oats so I could start preparing the notes for the ward round. The consultant that day emerged from the office with a crease between her brows. “I’ve been talking to a colleague in Milan” she said. “He says the situation is terrible over there... I thought he was a strong man. Now he’s a broken man”.
There was a strange silence between the doctors as we felt her words wash over us. And then we went back to work. Because that’s what we do.
Later, I headed for the meeting we had been emailed about that day – The Hospital’s Strategy for tackling the emerging pandemic. Clinical staff and administrators from the whole hospital crammed into the ‘lecture theatre’, to learn about the details of our impending War on a virus about which we had little knowledge and no experience. At the time, we had no confirmed cases in our hospital, though two patients were sitting on my ward awaiting their swab results. We had no idea what was coming.
Friday 13th March
You will have heard the term ‘on call’ if you’ve ever watched a medical program, but it is one of those nebulous, undefined things doctors say, like “we need to run some tests”. Being on call, at least in my hospital, means a thirteen hour shift where you carry a bleep (pager) and out of normal working hours people will bleep you to do all manner of jobs for patients all around the hospital whom you’ve never met. This is different to your normal 9-to-5 day job where you take care of the same patients every day.
I was on call that Friday, and was part-way through looking up some blood results when I received a bleep. I could tell he was tired from the strain in his voice. “I need you to chase some scans, urgently” he said. One was to check the placement of a feeding tube in a lady who had not eaten in days. The other was to check for an infection in the brain of a patient with uncontrolled HIV. It turned out both of these patients had been in the intensive treatment unit (ITU) until today, when they had been stepped down to the wards to make place for the new COVID-positive patients who needed ventilating. Ventilating a patient (inserting a tube down the windpipe and attaching it to a machine that pumps air in and out to breathe for them) can only be done under close supervision in a few areas of the hospital. So now, these other very sick patients, who would usually be one of few under the care of intensive care physicians. were the responsibility of the medical team. The doctor calling me had stayed three hours past the end of his shift to make sure these patients would be safe overnight.
I went to handover that night with a long list of jobs I had simply not had time to do. In my 13th hour at work I had begun to lose focus, and I drifted in and out of the conversation going on around me. I heard snippets of discussion about a patient who had been confirmed to have coronavirus but had a lot of comorbidities. “The thing is, we’re going to have to be making life and death decisions every day, and some people aren’t going to make the cut. This lady is one of them”, I heard one of the Registrars say. “Yes” said another, “but she’s only 59”.
Wednesday 18th March
It is the calm before the storm.
We are discharging every patient who can feasibly do without constant hospital care. It is strange to see a ward with so many empty beds. I can almost see premonitions of the future patients in those currently crisp, clean sheets. I am imagining the noise and the tears. I am trying to enjoy the current calmness.
I am writing this at 23.34, having come home from my on-call shift, late. It was very busy on call, leaving the relative relaxation of my own ward to see patients on the busier wards where we are cohorting those with suspected or confirmed COVID. My brain is working sluggishly but I wanted to write things down now before everything changes tomorrow.
We have been told that tomorrow the junior doctors are going to be moved around the hospital according to need. I relish this as I felt impotent today looking after so few patients when I knew that elsewhere people must be firefighting. This means saying goodbye to my team, my usual patients, the nurses on CCU, and potentially trying to care for the most ill, most heartbreaking patients in the hospital.
To ease some of the mental load on the NHS, and show their appreciation, some companies – Pret a manger, Leon, Dominoes, McDonalds – are offering discounts and even some things free to NHS workers. I wanted to take a moment here to talk about some of the NHS workers who are thankfully included in these perks, and deserve more recognition for the work they do. I’m talking about the cleaners, the porters, the catering staff, and many other people who are integral to the working of the hospital – I can’t possibly list them all. They are often a little forgotten because they are not burdened with the responsibility of care or difficult decisions. But, at the moment, they are being exposed perhaps more-so than many of the clinical staff, through serving food to infected patients, cleaning their rooms, taking them for scans. I made the choice, when I accepted my place at medical school, to put my own health and wellbeing at risk to help those more vulnerable than I. I know that I am more at risk of catching TB, or that one day I will accidentally give myself a needlestick injury at 2am on a night shift when I can‘t think straight. I am not sure that non-clinical staff have necessarily had to take that into consideration before. And yet have seen none of these people complain or shirk responsibility. They continue diligently, and I am so grateful for their work.
As I write this, I slip a lozenge into my mouth to sooth my slightly sore throat, and convince myself that the cough I’ve had for weeks is not getting worse.
Friday 20th March
Yesterday and today, I was working on the COVID positive ward. We’ve cohorted the positive patients into the same bays or we would run out of side rooms, and it means they are much easier to care for as you can see them all at once without having to continuously don and doff the protective equipment.
It was fine yesterday. We managed to discharge a lot of patients. Today I feel beaten. The ward I am on has a side room which opens up into the doctors’ ‘office’. A COVID-positive patient who was on non invasive ventilation was transferred there from another ward. The guidelines are that if a patient is either COVID positive or negative, but having an ’aerosol generating procedure’ (meaning that the virus is flung out into the air a long way, rather than droplets which are bigger and don’t travel as far), then we have to wear ‘full FFP3 PPE’ (PPE is personal protective equipment, FFP3 is one of the more fancy types of protective mask). Non-invasive ventilation produces lots of aerosols. And were we told that the patient was being transferred? Were we given time to don any protective equipment? Were we fuck. So today I was exposed to aerosols from a person we KNOW has coronavirus. And it happened again and again, every time someone opened the door. I wish I had just worn a mask continuously.
A friend of mine who works in Leeds sent me a photo of her at work with some sort of futuristic plastic mask with external filters covering her face. This is the provision for them when they see anyone COVID positive. And what is it for us? A normal surgical mask. Or nothing, as was the case today with the debacle with the patient in side-room 2. And this is the reason I sat and cried before writing all this down. When I see that other places in the NHS will spring the money for their staff to have good equipment I feel so abandoned by my own hospital. It’s like they don’t care if we get sick. And I know that’s not true, of course it’s not. But one of the things which makes that hard to keep believing is that the guidelines keep changing almost daily. At first, the only people we were allowed to wear basic PPE to see (i.e., the basic surgical mask, a simple plastic apron and gloves) were COVID-suspected patients with no aerosol-generating procedures (AGPs). Now that basic PPE is sufficient to see people with confirmed COVID (and no AGPs) ‘unless they’re coughing’. I mean, you can’t tell that someone’s going to cough on you until they cough on you! What kind of guidance is that? It seems like the sort of guidance which allow them to use the cheapest stuff for as many people as possible, rather than fork out for equipment that will keep the staff on their feet for the longest. Are we dispensable to them? Are we just names to put into a rota? I have always been so sure this was not the case, but when you see the PPE worn in Italy, and China, and even in other UK hospitals, compared to that provided in a little district general hospital in a deprived corner of London that nobody cares about, it’s hard to keep convincing yourself of that. It makes me not want to go to work on Monday. Or perhaps even after that.
Monday 23rd March
Received a message through a work whatsapp group:
“...my colleagues are being mugged for their NHS ID badges at knife point for all the freebies given by shops and cafes at the moment”
What is wrong with people? All for a free coffee at Pret?
Thursday 26th March
Things have finally kicked off in the hospital. Until today I felt like we were waiting with baited breath for the start, sitting in the calm before the storm. I offered to help out on another ward which was COVID positive. All around us, patients were deteriorating and needing to have their care escalated. At 5pm we intubated a patient in their thirties. It was this day when I started doubting my abilities as a doctor. I’m only in my first year and have little responsibility looking after people who are acutely unwell. I know that there’s a lot of information in my head but through the many hours of paperwork it has been gathering dust. There was a patient violently vomiting up their lunch at one point today and I froze. I’m usually so calm in a crisis but I just didn’t know how to stop it. I’ve never dealt with it before. It’s these sorts of things which make me dread the new rota which is coming into place, where I will be doing night shifts. I know that nearly all first-year doctors do nights around the country and my area is one of few exceptions, but that’s because night shifts are difficult: you’re exhausted, you think at half-speed, and there are very few people to lean on. People always say “your job is just to make sure they live to see the morning”, as if that takes the pressure off. Sure, I don’t have to cure them, but I’m still responsible for them. The new rota will see us having one first/second year looking after 2 wards overnight, with a registrar per 4 wards. This is a far better staffing level than usual. But I’m still a little terrified.
Tuesday 31st March
Received a text from work today:
“Dear all We are running low on oxygen
*please can all patients requiring oxygen be reviewed.
− stop optiflow where possible
− Reduce from 15L O2 where possible
− consider stepping down from CPAP if possible …
This is a site emergency”
Saturday 4th April
My ward is now the high dependency unit (HDU), with many patients on CPAP (that is, both producing aerosols and very sick). And FINALLY, the hospital has developed a coherent plan and obtained sufficient equipment to deal with it. Today I am wrapped up in scrubs, upon which I have a full-length surgical gown, and a hairnet, goggles and FFP3 mask adorn my head. All of this is the baseline for being on the ward, and then we wear a plastic apron and gloves which we change between patients. It is hot in all this gear and after an hour or so the mask welds itself to your face, but I berate my colleagues who complain that their face is uncomfortable and the mask is too tight. At last we are being treated as if our health matters. At last we are being shown some basic level of respect. Having a ‘dirty’ ward has made everything so much simpler and more effective. I finally feel like I have the equipment to do my job properly. Plus, it makes for a very funny selfie.
Monday 6th April
To protect the patients, their families and the staff, we are not allowing patients to have visitors. This comes with a multitude of issues for all involved: the patients are bored, lonely and scared; the families are anxious and angry and upset; the staff have lost their translators, their patient’s advocates, and the end of each day involves a few hours of phone calls to families. Often the phone calls are exasperating, chipping away at the small amount of patience I have left to me at the end of a shift. Most annoying is when a family has been calling you all day and you’ve not yet seen their family member or you’re awaiting a test result and therefore have nothing to update them about at the time, and then when you ring them back repeatedly in the evening they do not pick up. Many families are desperate to work out where their loved one picked up the virus, sometimes blaming themselves, often blaming the hospital. But to me, updating the family is a duty second only to the wellbeing of the patient so I ring any and every number available to me.
The only exception to the ‘no visitors’ rule is for patients who are dying. For them, we allow one relative to come in and sit with them for a limited time each day. It is heartbreaking to have a whole family turn up, only to have to turn away all but one to the waiting room. You see the fear in their eyes as we teach them to don the PPE, and lead them into a ward full of faceless medical professionals and patients fighting for breath.
But even more upsetting than that is when someone is lying on their deathbed with no visitors. One of our patients had a daughter who was so scared of catching coronavirus that she dared not come to the hospital to be with her mother in her last days. The patient spent all of her last days staring at the other side of the room, unable to occupy herself in any way, her days filled with silence, awaiting the eternal silence. I thought often about her during the day, and wished to keep her company, perhaps to sing to her or talk to her. However, the patient was non-verbal and couldn’t tell me what she liked to hear, and I was scared to call her daughter to ask as I didn’t want her to feel guilty or inadequate. So I didn’t. I left that woman to die alone, drifting in and out of consciousness without even a stranger to hold her hand.