Pasties at last. 02.06.20
Welcome to The Plague Pit – issue number 27.
Yesterday, regular operating lists started at my hospital for the first time in nearly three months.
As the newsreaders keep telling us, it’s not over yet. But if a graph can look beautiful, I think this one does.
SLACCN = South London Critical Care Network.
People are still dying, though.
A month ago I went to ICU to hear from the hospital’s pathologists. They were presenting the results from our first two COVID-19 post mortems. About twenty people had come to listen in a tiny, stuffy room. Everyone looked tired and dishevelled. Only just past the peak of the pandemic.
A guide to scrubs
Most of the audience were in ‘scrubs’. These cotton pyjamas are mostly associated with surgeons and the operating theatre. ICU staff wear them on duty, too. The patients they look after emit body fluids of all sorts, sometimes in a fairly uncontrolled fashion. Nobody wants to have that sort of stain on their shirt when they get on the bus home.
Back in the days before COVID-19, our hospital used to make quite a big deal about different coloured scrubs. Blue scrubs – ‘COBALT’, it says on the label – were strictly for theatre use. Purple, or ‘RASPBERRY’, were for general wear. Something you could use all around the hospital if you wanted to spare your own clothes from ruin. This policy had the same level of evidence behind it as ‘bare below the elbows’ (see issue 13). [1] It generated the same sort of resentment, too. Here’s why.
As an anaesthetist, you duck in and out of the theatre department a fair bit. You have to see patients on the ward, pre- or postoperatively. There are meetings with non-anaesthetist colleagues. Paperwork to tackle in the office, one floor down. Even proper coffee to buy in the hospital foyer – when you just can’t take the theatre vending machine stuff any more.
The blue/purple policy came in a few years ago, We quickly realised we couldn’t just nip out of theatres for a few minutes between surgical cases, as before. Every exit and re-entry now meant a change of clothes – and valuable time lost. So we tended to stay in our windowless theatres all day. Efficiency tumbled. Jobs were left to the end of the day. Lunch became a major organisational feat for anyone who could not face the limited institutional fare at Maureen’s, the theatre canteen.
My workmates and I mourned the loss of our freedom. Starved of variety, light, social interaction and anything more exciting to eat than lasagne, we became seriously demoralized. After a year, senior management promised an amendment – anaesthetists were to be excepted. This was blocked immediately by the orthopaedic surgeons, worried – in a non evidence-based way, of course – about the infection risk for their joint replacements.
So the offical blue/purple rule stands to this day, with no formal waiver for the gasmen. One COVID consequence, though, has been a slightly more anarchic feel about this sort of stuff. Blues now tend to be seen a bit more out and about in the hospital – a phenomenon occasionally assisted by raspberry shortages. With ‘bigger things to worry about’, there’s – gasp – even talk about abandoning the policy.
Cynical doctors sometimes suggest that scrubs of any colour, worn by all, degrade traditional hierarchies. They enforce inappropriate ‘democratization’ on healthcare teams, leaving patients less able to distinguish nurses from doctors.
There’s history here. In recent years, trained nurse practitioners have assumed several traditionally medical roles in the UK. It’s a process driven by economic imperatives and validated subsequently by a general failure to demonstrate that relevant clinical outcomes are operator-dependent.
Despite this – evidence suggests that patients like to be able to tell who’s who. [3] Perhaps that’s what identity badges are for.
Good relationships between doctors and nurses are fundamental to the safe and efficient delivery of healthcare. Anyone contemplating a medical career could do worse than look at this page on ‘The Prospective Doctor’ website:
Whistle and flute
I’ve written before about patients’ possible preference for short-haired doctors. A recent comprehensive literature review shows how complex and context-specific are patient attitudes to physician attire. Often subconscious, too. [2] The review mentions the iconic white coat often, reminding me of a conversation long ago.
Until recently, white coats were for the ranks. Consultant surgeons typically wore a suit on their ward rounds. Mr X, the first surgeon I worked with at my current hospital, was Medical Director – the most senior clinical role in the management.
As such, he had to report regularly to the Board, none of whom were clinicians. Impeccably dressed, he would don a standard-issue white coat over his suit before every Board meeting. I wondered aloud that he didn’t want to intimidate the opposition with his Savile Row flair. ‘They can far better afford a good suit than I can’, he replied, ‘but I always like to remind them I’m the one with his hands in the patient’s abdomen.’
And with that, back to the post mortem.
In the old days
When I was a medical student, our pathology department held an open post mortem session on Wednesday lunchtime. Few people actually brought sandwiches. It’s a long time ago, but I believe I can remember the set-up – I wonder why. These pictures give a general idea of the style of the decor. No carpets……
I think the London Hospital must have repaired the air raid damage, because the room looks about right to me. In the 1980s, I think there was a ‘stage’ with a marble floor, projecting into the rectangular room from one side. The dissection table bearing the cadaver sat in the centre of this stage, which had a gutter round the edge. Behind the gutter, on three sides, were four rising tiers for standing spectators. Each tier had a rail in front to lean on – chest height.
The cadaver was prepared for display in advance. The skull cap had been sawn off and then replaced for easy removal and display of the brain. A long midline incision ran from the base of the neck all the way down to the genitals. Internal organs with something interesting to show were pre-dissected for rapid access. I recall there was a trolley with an enamel tray top near the table on which these could be displayed.
Two things come to mind in retrospect. The first is that it was just like a macabre cooking show – ‘Here’s one I prepared earlier’ – said with a conjurer’s flourish. The second is how quickly initial revulsion gave way to, well, boredom. I really was a terrible student.
Two tragedies
I was much more interested by the ICU post mortems last month. Like everyone else in the room, though, I felt confronted by ‘failure’ – by the limitations of modern medicine. Though our COVID-19 ICU survival statistics are much better than the national average, that’s no solace to the families of those who don’t make it.
The meeting was part virtual, with the pathologist calling in and displaying slides of the gross specimens (ie the whole organs), the microscopic sections and her written observations. Both deceased patients were middle-aged – one male, one female. The first died after more than thirty days on a ventilator, the second after a much shorter spell. She had a cardiac arrest in a different hospital when our ICU team arrived to bring her back to base for extracorporeal membrane oxygenation (ECMO). ECMO is the last resort for COVID-19 patients whose lung damage is so severe they remain hypoxic even when they are mechanically ventilated with 100% oxygen.
The appearances of the lungs, both gross and microscopic, were different in the two patients. Here’s the specimens from patient 1.
The lung is very fibrotic. Fibrin is a substance formed from blood components during the inflammatory process. As inflammation went on in this patient, it built up to change the texture and visible appearance of the lung, making the structures thick and rigid. Fibrosis badly affects the passage of oxygen from the microscopic air sacs in the lung (the alveoli) to into the small blood vessels nearby (the pulmonary capillaries). Once this stage is reached, there is little that drugs or clever ventilation can do.
The cardiac arrest in the second patient happened because of abnormal blood clotting. Inflammation makes blood thicker and stickier – and this is now known to be a particular problem in COVID-19. A large blood clot – a ‘saddle embolus’, carried in the blood stream from elsewhere – suddenly blocked the origins of right and left pulmonary artery, completely obstructing blood flow to the lung. An inevitably fatal event.
Baked goods
I promised to talk about Cornish pasties and COVID-19 in this issue.
The usual position for mechanical ventilation, in COVID-19 patients and others, is face up (‘supine’) – and slightly sitting up. Sitting up reduces the pressure of the abdominal contents on the diaphragm and lungs.
By adjusting the patient’s mechanical ventilator, an ICU doctor can set the percentage of oxygen in the inspired gas, the volume of each breath, the pressure in the lungs and the rate of breathing – along with a few other things. Modern ventilators allow patients to take back control of their own breathing bit by bit as their lungs improve.
Sometimes, if none of this works to improve the amount of oxygen getting into the blood, doctors will consider turning a patient onto his/her front, for ‘prone ventilation’. The advantages are complicated.
In short, prone ventilation allows secretions to drain out of the alveoli and small bronchi at the back of the lung by gravity. Also – in the supine position, the parts of the lung at the back are more compressed by gravity than those at the front. Turning the patient prone relieves this pressure, and allows the posterior alveoli to expand better. It may also work, when supine ventilation is failing, by directing pulmonary blood flow to parts of the lung with more oxygen
The beneficial effect is temporary, and there are risks (pressure sores can develop on parts of the body at the front, which normally don’t have any pressure on them). As a result, prone ventilation is used intermittently – so patients are only left prone for 16 hours, turned back supine for 8 hours, turned back prone again for 16 hours – and so on.
Turning very sick patients has to be done carefully, by a trained team of several people. If you pull out the endotracheal tube during the process, it can be a mortal catastrophe. During the pandemic, my hospital set up turning teams, made up of staff who were not working elsewhere. Their sole job was to go from bed to bed turning the prone patients at the scheduled time.
Here’s how it’s done. The patient, wrapped firmly in the sheet before turning over, is said to look like a Cornish pasty. Intensivists are known for their sense of humour.
https://www.youtube.com/watch?v=FMoVXcOvtzY
Nest week, the ‘Pork Pie’……
The Good Soldier
[1] Hee HI et al. Bacterial contamination of surgical scrub suits worn outside the operating theatre: a randomised crossover study. Anaesthesia 2014, 69, 816–82. https://onlinelibrary.wiley.com/doi/pdf/10.1111/anae.12633
[2] Petrilli CM et al. Understanding the role of physician attire on patient perceptions: a systematic review of the literature— targeting attire to improve likelihood of rapport (TAILOR) investigators. BMJ Open. 2015; 5(1): e006578. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4312788/
[3] Cheang PP et al. What is in a name — patients’ view of the involvement of ‘care practitioners’ in their operations. Surgeon 2009 Dec;7(6):340-4.
https://www.sciencedirect.com/science/article/abs/pii/S1479666X09801078