Thread by @doctimcook

The pandemic & ICU

There is questionable value of conversation with an individual who is either misinformed or intentionally misrepresenting recent history

However a thread to correct the record/explain apparent inconsistency in data that may lead others to honest error

1/n

March 2020 was a time of uncertainty & fear.

The evidence from Wuhan & northern Italy is that we would be engulfed by an unprecedented number of sick patients many needing ICU

Doing nothing was never an option

2/n

Early modelling suggested our 13 beaded DGH ICU would expect >500 ICU patients in a few weeks.
About 8 months work in one.

Three things reduced actual numbers
-voluntary public behaviour to reduce social interaction
-lockdown
-the predictions were likely too high

3/n

At this time the expectations were that all likely to benefit from care would be offered it
-hospital mortality was around 15-20%
-ICU mortality about 50%

Both serial fold higher then for ‘normal illnesses’

There were no known effective treatments

4/n

Hospitals were asked to immediately increase ICU ‘capacity’ 200-300%.

This requires redeploying
-space (usually operating theatres)
-staff (anaesthetic, surgical, theatres)
-stuff (fluids, drugs, pumps, beds, ventilators, storage etc etc)
-systems

None of this is easy

5/n

Healthcare does not run with a lot of ‘fat’ so expanding ICUs necessitates cutting or stopping something else.

What had to stop was routine surgery (& much of other routine care)

Based on surge 3 I estimate surgery reduced by up to 50%. Paediatric surgery up to 90%.

6/n

Fear & personal risk were huge issues

-epidemic outbreaks were typical on wards
-frontline hospital staff were 3-4-fold more likely to be infected (& those they lived with 2-fold) than their community
-risk disproportionately affected junior frontline staff

7/n

Protective equipment to counter increased infection risk was limited & the wrong design

Healthcare workers died: with risk restricted to frontline workers

Those who died were disproportionately
-from ethnic minorities
-first generation immigrants

8/n

The fear of infection was huge for ICU staff. In SARS & MERS ICU staff had high risks of infection & death.

It is no exaggeration that in surge 1 it was an act of bravery just to go to work (as I was acutely aware while working from home)

9/n

ICU personal protective equipment was unpleasant, restrictive & prevented communication

This hampered clinical care, communication & human level interaction with patients & colleagues

ICU was not comfortable for anyone

On wards PPE was inadequate

10/n

The number of ICU patients was only one factor

In addition
-each COVID patient stayed an average of 12-14 days on ICU. Many > 1 month.
So each COVID admission equivalent to ≈4 normal admissions

-no visiting was allowed.
A massive burden on patients, families & staff

11/n

Elsewhere respiratory, general & geriatric medical
wards were owerwhelmed by COVID

-huge numbers of cases
-high staff sickness rates

Most deaths were not in ICU
-1/10 of all COVID deaths and 1/7 in hospital were on ICU

12/n

In one ward where I work - normally a routine surgical ward where death is uncommon - there were more then 40 consecutive days when a patient or patients died.

None had visitors & dying support delivered entirely by ward staff

Not normal
Not comfortable

13/n

To minimise infection of patients in hospital (many at high risk of harm if infected) hospitals had to
-close up to 20% beds
-effectively run two segregated hospitals side by side
-change routine care fundamentally

Despite this many thousands were infected in hospitals

14/n

Respiratory wards undertook as particularly high workload
-delivering treatments that in many hospitals are restricted to ICU (effectively a further expansion of ICU services)
-triaging who should/would come to ICU if they deteriorated

15/n

Throughout all this prinary care took on an enormous workload including
-care of COVID patients & outbreaks in nursing homes
-triaging who should go to hospital (or not)
-delivering the care hospitals could not

All with minimal protection & resource

16/n

The question of triage is a highly controversial one

When demand exceeds capacity not all can have the care they need

Restricting access to hospital, treatment, ICU more than would be normal is population triage.

This can be explicit or hidden.

I believe this took place

17/n

The psychological impact of working in these conditions (primary care, ED, wards, ICU) all different but all hugely impactful

Witnessing
-deaths
-suffering
-all without family support

The burdens of PPE, personal risk, family risk, exhaustion, uncertainty

18/n

The surge of March/April 2020 was bedevilled by uncertainty, fear, poor PPE planning/execution, staff sickness & a sense of isolation

The surge of Dec/Han 2020/21 was notably more widespread & an even greater burden on healthcare

But that’s for another thread

19/n

My personal setting

I work in a DGH in region with lowest numbers in surge 1 (also region with fewest ICU beds per capita)

I was working from home in surge 1 & involved in professional national responses

Then back in work

I believe others suffered much worse than me

20/n

On one level denying that all this happened (& I’ve only scratched the surface) is dumb & offensive.

Equally importantly, we need to learn the lessons of what has happened in the last two years. If we don’t we are doomed to repeat the errors.

Denial doesn’t help.

21/21

For clarity in surge 1 some of the things UK ICUs ran out of included
-ICU beds
-ICU staff
-oxygen
-basic sedative drugs
-dialysis
-breathing machines (CPAP & ventilators)

All more so than PPE (though they too was a struggle)

& all again in winter 2020/21
#4Ss