Thread by @adavies4

‘There was a terrible feeling of dread’

Dr David Hepburn @apnoeaboy a month on from our last interview

The ICU consultant’s latest compelling account of treating Covid-19 patients.

Rarely have I interviewed a better communicator in any field of work

In my latest interview with David Hepburn, from @AneurinBevanUHB Royal Gwent Hospital:

• How patients are ventilated
• Physical toll of ICU
• ‘Intensive care delirium’
• Relative youth of patients
• ‘Constant fear that one day it might be one of us’

This extended version of the interview was filmed by @daibaker & produced/edited by @c4marcus

THREAD: Some extracts from the interview with Dr David Hepburn, consultant in critical care at @AneurinBevanUHB - where they've admitted more than 70 Covid-19 patients into their ITUs since the outbreak began...

David Hepburn:
[In early March] ‘We had an empty ITU essentially ready to take any incomers… but there was a terrible feeling of dread and anticipation because we knew it was coming... But it was a question of when’.

[With Covid] ‘a lot of the usual rules don’t apply. So with people with ARDS [Acute Respiratory Distress Syndrome] they get v leaky lungs, wet lungs, so we try and keep the amount of fluid that we give them down to keep the lungs dry. That doesn’t always work in Covid patients’.

‘Average length of stay across most intensive care units is somewhere around 3-5 days. The Covid patients we’ve seen have all been in, for the most part, a good 2-3 weeks…so the progression of the disease is much more protracted than we’ve seen before’

On ventilating patients: ‘when heavily sedated, you don’t move around, you’re unconscious basically, so you become very weak very quickly because you’re not using any of your muscles, & that includes your breathing muscles...

'...The longer you’re heavily sedated - or sometimes we use a muscle relaxant to actually paralyse the patient to stop them from coughing - the weaker they become...'

'After approx. 10 days if you’re still needing invasive ventilation the best option then is to do a tracheostomy – a small cut in the front of the neck & the tube goes directly into the windpipe… It reduces the risk of secondary pneumonias’

'The stay in intensive care is really a very small footnote in the full story of the patient’s recovery'

'Having been paralysed or deeply sedated for weeks…you get really dramatic muscle wasting…and a lot of them can’t actually do sufficient breathing for themselves so they’re incredibly weak and vulnerable and rebuilding that muscle takes an awfully long time’

'Mentally there’s a huge amount of things you need to recover from. Lots of factors contribute to ‘ITU delirium’ characterised by disordered thinking & an inability to concentrate. And that can cause v frightening hallucinations & very intrusive thoughts'

'Patients can slip into a fantasy world where essentially there’re haunted by sort of persecutory delusions……so that they think there are gangs of gunmen after them or nurses conspiring to kill them, and this is very, very common'

Dr Hepburn: 'They say that if you develop ICU delirium your baseline IQ will drop by between 10-20 points from its normal…so it’s almost akin to having a slightly mild dementia or some long term cognitive defects afterwards'.

'There are huge body image issues because you’ve changed beyond all measure and, coupled with the delirium, that can cause depression in a lot of the patients. PTSD is common. We have a team of psychologists providing a huge amount of support to patients'.

'The NHS has done an amazing job at getting these people through such a terrible illness, but it needs centralised acknowledgement of the [rehabilitation] burden & it needs some v good policymaking to ensure that it’s a service that’s available in every area'. @apnoeaboy

'What's stood out to me? The relative youth of the [#COVIDー19] patients. Our cohort of patients has ranged from early 20s to mid-late 70s. But the vast majority of those patients are in a bulge in the middle between the ages of 40 and the mid 60s'.

On caring for a young patient who was dying & whose family the doctors couldn’t get in to ICU in time:

'With the nurses & junior doctors we sat with this patient & did what we think we would want for our relatives. We held hands, cwtched them up in bed and we were all there...'

'.. so this patient wasn't on their own. They were there with the loving touch of some people.

Unfortunately it will happen again'.

On psychological toll on staff:

'Not everybody expresses themselves in the same way. So some of us are demonstrative, I will tell everyone if I'm in moral distress, but others will just keep it under their hats'.

'We are used to people dying in intensive care. It's part of the deal, but we've got lots of staff at the minute who work with us, ie the theatre nurses, working In ITU for the first time & this is not their area of expertise. So they're the people I worry about the most'.

David Hepburn: 'The permanent ITU staff - this is what we do and we are used to this but the volume and the numbers of deaths, and the relative youth of the patients makes it much more difficult than normal'.

'A lot of my colleagues are the same age, the same ethnicity, the same weight as a lot of our patients. I think that makes it all the more frightening for people and we have had some healthcare workers come in, we've had a couple die. And that just hits home...'

'So I think it's that constant uncertainty and that constant fear that one day it might be one of us. I think that's probably one of the reasons why there's such trauma and moral distress'

On health inequalities & Covid-19:

'There's always been massive health inequality here [in South Wales]. It predates Thatcherism, but it certainly was made worse during the closing of the mines...'

'You drive away from Cardiff & the Vale of Glamorgan and you head up towards Merthyr. It falls in terms of life expectancy by about four years as you go up the valleys, in terms of total life expectancy for men and for women'

'I think COVID is just highlighting that because in those areas with poor socio-economic backgrounds, & chronic health problems, who've always been disadvantaged, it's really shown very starkly now by the death rate there – the death rate's much higher'

'It's something that needs to be looked at very, very carefully…I'm not a policymaker, but if I was, we should be doing something to address that divide'

On the challenges now facing the NHS:

'I think the biggest, trickiest thing that we need to wrap our heads around now is how we can safely restart elective operating...'

'Just as the impact of the pandemic started we did a few urgent cancer operations because we wanted to get them done. And a couple of the patients got COVID while they were in the hospital, and although they've all gone home now, they had a very rough few weeks...'

Hepburn: 'There are lots of people out there we can't forget about. We can't let COVID be the only headline. And there are lots of people waiting for really urgent operations. We need to be able to get them going again. But it's finding a way to do that as safely as possible'

'Maybe putting everybody into a clean site, possibly, or opening different sections of the hospital for different things. I think that's going to be our next big challenge. And I'm not sure what the best way of doing that is'

If you’ve got this far, thanks for reading!

Link to the YouTube #c4news interview at top of this thread.