By Dr Heer Shah
THE Covid-19 crisis has placed us all in unnatural circumstances and we are slowly adjusting to the new normal.
As a 24 year-old newly qualified junior doctor, I have seen the virus impact some of the most vulnerable members of our society and have watched as the NHS faces its largest challenge to date.
As junior doctors, we follow a clear pattern or rotation for two years following graduation from medical school. This gives us an opportunity to work in and experience six different specialties, each four months long.
Having started in August 2019, I was finishing up my second placement in nephrology as the coronavirus pandemic gained strength. Although the first Covid-19 death was reported on March 5 in the UK, the true course of the disease had not yet been fully understood. As the days went on, it became clear that this was a unique condition – the ease with which it was being transmitted and the degree to which it was affecting people made it much deadlier than the flu virus that it had been initially compared to.
In early March, we saw a few Covid cases. Given the demographics of the surrounding area, many elderly locals were at high risk of contracting the disease and had been self-isolating. Unfortunately, those who did develop symptoms often presented to our A&E breathless and in need of oxygen. These patients were often given antibiotics, anti-virals and put in a side room in any medical ward throughout the hospital, which helped contain the infection to that room.
However, having side rooms dotted in wards in the entire hospital allowed the virus to quickly spread. As weeks went on and cases continued to rise, there was increasing pressure on the need for clear treatment guidelines as well as recommendations for PPE (personal protective equipment).
I remember sitting at a handover meeting where the night doctors finishing their shifts meet the day doctors to inform them of the previous nights’ events, ill patients and any unforeseen deaths. This is a routine practice across all hospitals, repeated at the end of a working day.
However, on this day, the mood in the room was different. The constant barrage of Covid-19 headlines and social media posts had clearly taken its toll in our ever-connected worlds. The news stemming mainly from our colleagues and partners in London was a warning of what was to come, and we had to be better prepared. If what they said was correct, our hospital in Essex was approximately 14 days behind those in central London and, given the rate of spread and infection, it would take merely a few days for our hospital to be operating at maximum capacity.
That long day shift on Sunday, March 22, would be my last ‘normal shift’. From the next day, all junior doctor rotations were paused, all specialties were gradually phased out to other central hospitals and the entire medical workforce embarked on a Covid rota.
A usual week would involve working days from 9am-5pm in your own specialty, in my case, nephrology. Once a week, you work a late shift where, from 5pm to 9pm, you are on call helping with jobs from different specialties that the day team has handed over. Every four weeks, you would be asked to work an on-call weekend, where you see sick patients across all specialties and carry a ‘bleep’ to tell you which patient needs your attention next. This would normally account to 44 hours on most weeks and 60 hours once every four weeks.
The Covid rota changed all this. The entire hospital was split into ‘hot’ and ‘cold’. Hot doctors were designated to treat only suspected or confirmed Covid patients, whereas cold doctors would treat patients presenting with other problems, from heart attacks to abdominal pain.
Unfortunately, as the ‘hot’ patients had initially been placed throughout the hospital in various side rooms, doctors had no clear base ward and were instead running from one side of the hospital to the other to see their next hot or cold patient. As all doctors were now always on-call and there were no longer any normal working days, we were all asked to work four 12-hour day shifts followed by a two-day break, then four 12-hour night shifts and a one-and-a-half-day break. After this the cycle would restart and doctors would oscillate between night and day shifts.
As cases continued to rise and side rooms began to become scarce, entire wards were converted to Covid wards and the designation of ‘hot’ and ‘cold’ was eventually scrapped. Doctors were once again placed on a single ward for their four-day period – whether hot or cold – and would see all patients on that ward. Every two weeks doctors would rotate between a hot ward and a cold ward to minimise the overall exposure to the virus and keep the viral load low.
The changes have had a considerable impact on our lives and mental health, and have pushed us to adapt to the new challenges. The hours have been tiring, the relentless switching from night to day is not easy – on some days we survive on fewer than four hours’ sleep before starting a new shift.
The work itself has been novel and also challenging. Difficult decisions about how aggressively to treat patients, given our limited resources, are becoming a common part of our day. Not every patient who presents with breathlessness will be considered for intubation as the procedure itself carries risks. Furthermore, if someone is intubated and put on a ventilator, they will have to be transferred to the intensive care unit (ICU), but again there are only limited beds and despite my hospital expanding the ICU capacity by more than 100 per cent using the now vacant surgical theatres, not every patient will be suitable.
Another unfortunate common scenario has been death. It is almost impossible to write about Covid without mentioning the huge increase in deaths that we have experienced working in hospitals. There have been young patients who have been talking and even working just days before they deteriorate, unable to provide their bodies with vital oxygen.
The speed of deterioration in Covid patients has surprised me. Despite maximal oxygen therapy, patients continue to be deprived, using all their chest and abdominal muscles just to manage a single breath. Doctors are having to make more and more patients comfortable in the last stages of their lives, understanding that they are losing a battle by supplying constant oxygen. Conversations with families who are not even allowed to see their loved ones, explaining that there is likely hours or days left, has been one of the more desolate parts of these last few weeks. As we continue into May, the number of deaths has started to ease and the pressure on intensive care has slightly released, but we are far from the light at the end of the tunnel.
We have been fortunate that during the past seven weeks of this crisis, the hospital has had an abundant supply of PPE. Although the guidelines for what level of PPE to use for different patients has changed several times over the week, there has not been a shortage. As an example, if a patient is suspected to have Covid, but the swab test result is not back yet, a lower level of PPE has been warranted. If the test returns positive, which it often does, the level of PPE increases. This would pose the obvious question of whether a full course of PPE should be worn in all suspected, rather than just positive, patients. Doctors try to minimise contact with patients who are positive and infective, fortunately rely on blood test results and observations to make decisions about escalating treatments.
However, it will be the nurses and healthcare assistants who, I believe, will feel the full brunt of any disparities in PPE. Those who change, wash and feed patients, deliver drugs and take observations will be in much more contact than the majority of junior doctors and will carry a much greater risk. We have had generous donations from local businesses, helping supply scrubs and local schools creating masks and face guards for us to use.
The virus fight has undoubtedly had a huge impact on our mental health, with all healthcare staff, from doctors to pharmacists, feeling an increase in stress levels and panic within their workplace. The uncertainty about whether a patient will make it, whether we could be treating more aggressively, coupled with the lack of any true evidence-based treatments as well as the long hours and increasing social isolation is a challenge to our mental health.
We have also seen an increase in overdoses among other non-Covid related admissions, often related to an increase in anxiety and depression as a result of joblessness, financial issues and rise in domestic abuse. It is hard to see a quick fix to this, but there are some silver linings – the hospital has offered free coffee and discounted food for night staff. Many restaurants have generously donated food and other gifts and the weekly Thursday applause has helped bring the nation together. The staff at British Airways and Easy-jet have opened a wellness centre with free food for staff to relax and leave the stressful wards for some time to rest. Among doctors and staff there is a huge sense of teamwork which has considerably helped some of the longer, more arduous days this last month.
There will continue to be many ups and downs in this journey, but I am comforted knowing that doctors and other healthcare professionals throughout the country are on this journey together. I am proud to see people from all walks of life volunteer to help using their skills in new and beneficial ways and am thankful for society playing their part and social distancing despite the difficulties in doing so.
As I write this, I know that tomorrow I will restart my shifts and although I have begun to settle into this new on-call role, I am thankful to a number of people – my colleagues who have helped create a sense of togetherness, helping share jobs where they can and offering their advice around the clock. Unlike many of my fellow doctors, I am extremely fortunate to continue to live at home, surrounded by the unparalleled support of my family. I am grateful to have them beside me, and know they are with me through this journey.
The Covid-19 crisis has made me proud of the profession I have chosen and although I could not have possibly imagined this back in August as a UCL graduate, I believe it is often the role of medicine to prepare for the unpredictable and to use our knowledge to tackle novel problems.
Dr Heer Shah, 25, is a junior doctor working at a hospital in Essex, having graduated from UCL in August last year.