Little green men. 26.05.20
Welcome to The Plague Pit – issue number 24
Most of what I have written in The Plague Pit so far concerns doctors. What we think, what we do, what we wear – and so on. For this issue, I’d like to start instead with some first-hand accounts of the ICU experience from recovered COVID patients. I think these paint a striking picture of how extraordinarily unpleasant intensive care, and its aftermath, can be.
I’ve written before about patient confidentiality. It’s something that doctors take seriously. In any hospital, the usual rule is that identifiable clinical information about a given patient should be accessed by, and shared with, only those staff directly concerned with that patient’s clinical care.
These are special times, though. The accounts were circulated to several hundred ICU staff by our Critical Care Recovery Clinic (CCRC) – evidently with patient consent. As the Clinic hoped, many staff were heartened to see ‘how greatly appreciated [our] hard work is …. during this impossibly challenging time’. For this article, I have removed the picture from each account and changed several personal details and all names and dates.
The CCRC sees former ICU patients for a virtual check-up once they have been discharged from hospital. Several of the COVID patients below recollect hallucinations and paranoia during their ICU stay. Most have ongoing problems that affect their daily lives – physical, psychological, financial . These experiences are not uncommon [1,2]
I have left medical acronyms and abbreviations unaltered. It really is how clinical staff communicate. For the sake of completeness, though:
T1RF = type one respiratory failure, CXR = chest X-ray, SOB = short of breath, PTSD = post-traumatic stress disorder, MSK = musculoskeletal, Lupus = systemic lupus erythematosus (an autoimmune inflammatory condition).
If you don’t know what ICU, COVID and PPE stand for by now, you may be on the wrong website.
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Patient A
Patient A was admitted to ICU on 15/3/20 for T1RF due to COVID Pneumonitis, requiring 4 days of ventilation which was relatively straightforward. Patient A has memories of having to call the police whilst in ICU because he thought that the nurses had stolen all his belongings.
He has returned to work for his local council and is hoping to be able to help other patients who have been affected by COVID. Patient A says he keeps lots of PPE in his car so that he is always prepared in case someone needs him. He reports feeling very well, he is sleeping well, eating well and his walking is back to normal. He describes his memory as ‘very sharp’. Patient A would like to say a huge thank you to everyone who helped him to get better, and specifically remembered Nigel and Janine who he said were very kind and helpful.
Patient B
Patient B presented to his local hospital on 02/03/20 with 6-day history of COVID-like symptoms. He was intubated for T1RF on 06/03, and transferred to our intensive care unit for capacity issues on 12/03/20. Patient B required 6 days of muscle relaxant for desaturation and ventilator dysynchrony, and was then successfully weaned from his ventilation and extubated on 15/03/20.
He was repatriated to his local hospital the following day, where he spent a further 6 days as an inpatient on the ward. Patient B’s progress has been excellent – he has returned to long walks although he does admit to using to needing a stick for the uphills.
Patient B had significant delirium whilst on ICU but does not have flashbacks and is not troubled these memories. Patient B had a weak right arm after ICU which was significant enough to make him believe that he had suffered a stroke, which he hadn’t. Initially he was unable to hold his shaver up to his face, but the strength is coming back to his right arm and hand with regular physio and exercise.
Patient B is struggling with concentration. He says he becomes irritable watching TV as he cannot concentrate for a whole program. He has taken to listening to music instead for entertainment. As a retired city worker who previously played competition bridge, we were concerned about the change to his cognitive baseline, and Patient B will be followed up in our Neuropsychiatry Clinic to investigate this further.
Patient C
Patient C presented to this hospital on 10/3/20 with malaise and fevers, and shown to have CXR changes consistent with COVID Pneumonitis. He deteriorated 2 days later on the ward and was intubated due to increasing oxygen requirements. He required 3 days of ventilation whereby he was then stepped down to the high dependency unit and soon after went home to his wife.
Patient C is a local cab driver, and has not returned to work as his friends have told him that there is not much business at the moment, and his wife is keen to have him at home for further rest and recovery. He is struggling financially as he is over retirement age and has been told he is not eligible for financial support. Occupational therapist Jimmy has advised him on this further, as his finances are his biggest concern currently.
Patient C feels very resolved about his hospital admission, which is helped by his Christian faith and he described feeling very lucky to have been cared for so well by this hospital and by Jesus Christ. Whilst in ICU Patient C remembers dreaming of how England’s roads were built, which he found very interesting! He described some mild forgetfulness, for example going around looking for his keys while he was holding them, but this has not impacted on his life and function significantly. He describes being back with his wife and sons as ‘marvellous’ and is grateful to everyone who helped him return home.
Patient D
Patient D was admitted to the hospital on 12/3/20 with 5 day history of SOB having recently returned from abroad. She was treated for COVID Pneumonitis, for which she received 3 days of conventional ventilation. Patient D was working as an academic, she has not yet returned to work as she is still feeling SOB, forgetful and anxious. She loves to dance which she is currently not able to do to breathlessness.
Patient D had a session with psychologist Andrea to discuss her frequent and notable panic attacks and flashbacks to feeling like she ‘was going to die’. Andrea has provided strategies for coping with the PTSD and has advised Patient D to self-refer for local talking therapy to address this. Occupational therapist Jimmy is going to talk to Patient D further about a phased return to work when she feels fit and able to do this, and will advise on fatigue management in the meantime. Mike then did a demonstration of his dancing technique in case we needed to know what dancing meant.
Patient E
Patient E was admitted to the hospital on 12/3/20 with an 11-day history of non-productive cough and fevers. She had recently had a positive COVID contact abroad, and was intubated on 16/3/20 due to an acute desaturation to 40%. Patient E spent 3 days ventilated on ICU 1, and was then transferred to the high dependency unit after extubation, with a further 6 days on a general ward before she was discharged home. Patient E had 3 weeks off work before going back full time as a cleaner.
She works shifts and says she has been feeling a bit tired after a day of work, but is enjoying be busy again. Patient E’s main issue is that she has residual weakness and numbness in her left arm which means that she cannot lift a hair brush or lift arm up to put on a shirt. We will refer her to specialist MSK physio to look into this. As an ex-COVID patient, Patient E is keen to look into serum donation for antibody research to help other COVID patients in the future.
Patient F
Patient F works as a care worker and developed COVID Pneumonitis following a known contact at work. She was initially taken to her local hospital and was brought to our ICU on 11/3/20 due to capacity issues locally. Patient F spent 12 days intubated, and returned to her local hospital where she spent another week on the ward before returning home. She is in good spirits despite a number of physical problems, including debilitating new incontinence, poor exercise tolerance and poorly controlled hypertension which is causing headaches and dizziness.
Patient F is currently reliant on a lot of support from her from family, who feel that this event has made them all closer. Patient F has not been able to get back to singing which she loves due to poor voice quality – we have referred her to voice clinic for this, as well as made referrals to a number of other acute and community teams to address her extensive health issues.
Patient G
Patient G went into her local Hospital at the beginning of March with COVID symptoms and was intubated for T1RF on a background of Lupus. She was transferred to our ICU for capacity issues, and made a swift recovery soon after arriving with us. Patient G spent a total of 14 days ventilated, and suffered with stridor post-extubation.
Patient G has vivid memories of ICU and remembers creating stories of all the other patients around her which she adamantly believed to be true, for example being in a bed next door to a girl who thought she was a bird. Patient G remembers thinking that everyone had the word ‘guardian’ written on the top of their visors, and that they had plans to take all the patients on a plane and leave them to die on an island so that they wouldnt infect the rest of the population.
Patient G described many more florid hallucinations, which were distorted memories of her real experiences in ICU, for example teenagers torturing her by putting pipes up her nose, when in reality Patient G did require a fibreoptic nasoendoscope post-extubation. Patient G has not yet returned to her great love which is playing in a steel band. She has not yet gone back to work as a school teacher which she finds frustrating, but is planning to phase back to online teaching when she feels ready.
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Ventilation
I was going to write about mechanical ventilation this week – having intubated a COVID patient at the end of the last issue. The BBC beat me to it, though, with an excellent programme about building ventilators on Radio 4. https://www.bbc.co.uk/programmes/p08dytg4
This was especially timely. I had been speaking earlier that day to my clinical director, one of the main architects of our hospital’s highly effective COVID preparations. I asked him about the ventilator shortage everyone had feared early in the pandemic. He told me that the ones supplied to us at short notice were quickly rejected because they weren’t up to the job.
Instead, we used exclusively the ‘old faithful’ anaesthetic machine ventilators I showed in the last issue. There are a number of problems with them (they are designed to be used for hours, not days, for example) but these were overcome after discussion with the manufacturers and some truly ingenious fixes from inventive colleagues.
‘Medicine and Creativity’. Now there’s a topic for a future Plague Pit issue, right there….
COVID paper of the week
Only one, really. Lancet. Hydroxychloroquine. Looks like it may not work. Also, it may kill you. [3,4]
The Good Soldier
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[3] https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(20)31180-6.pdf
[4] https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(20)31174-0.pdf