Today, the hospital was on ‘divert.’ It ran out of available beds for new medical inpatients, meaning the Emergency Department (ED) effectively closed to ambulances for a few hours. Instead, ambulances and their patients were re-directed to hospitals further away.
It’s not ideal: when hospitals don’t know a person’s medical history, it’s harder to get all the important details quickly, and being further from home can make it harder to arrange support when a person leaves hospital. However, being on divert did at least mean the team managed to sit down to eat lunch (albeit socially distanced), and so I have some energy to write this, now I’m back home. Only overload and incapacity give us time to talk about our work and what is going on.
It’s not unusual for hospitals to be on divert. During the winter—also known as the ‘winter crisis’—national hospital occupancy can often exceed 95 percent, leaving staff and resources very stretched. In this latest wave, there are more patients in hospital compared to April: medical problems that went unmanaged in the first half of the year got worse and people could no longer cope at home. In a way, it’s been almost a relief to see people with non-Covid problems coming to hospital again. It had been a huge worry that people with life-threatening illnesses did not seek medical attention earlier in the year.
While hospitals are open, they are losing what little capacity was available. This is in part due to social distancing between beds and segregating entire hospitals to triage patients between Covid, non-Covid and ‘pending’ – those patients who have been exposed to Covid in some part of the hospital chain, and who are awaiting their test results. One huge issue is the transmission of Covid within the hospital. In the first week of January, almost a quarter of the UK’s new daily infections were caught in hospital; when there’s an outbreak on a ward, patients can’t go home, and new patients can’t be brought in unless they are themselves Covid positive.
It’s hard to explain to patients about this triaging. I feel an awful guilt in telling someone that, despite their risk of severe Covid-infection from their underlying health condition, they were sat in the Emergency Department with Covid-positive patients for hours – sometimes far longer than the four hours we used to aim for. ‘I hope none of these people have Covid?’ someone asks while I’m assessing them. The hospital has euphemistically labelled the triaged areas ‘blue’ and ‘yellow’ zones, so as to not alarm patients. Which do you think is Covid?
It makes sense that someone with a fever, cough, or maybe new shortness of breath has to first be triaged as potential Covid – but for people who have hidden themselves away from their loved ones and endured months of isolation, this is a betrayal. As their doctor, I have now exposed them to the virus they have sacrificed so much to stay safe from. And it truly is a sacrifice for some: if your lung cancer was so severe that you had possibly months to live, would you have spent those months in isolation? It’s important that people know the hospitals are open, and operating as safely as they can. But no hospital has been designed for Covid, and lack of space makes it hard to eliminate risk entirely.
Capacity isn’t just about bed space. Tens of thousands of health workers are off sick or isolating due to family illness. We had emergency rotas reinstated in November, and we have been working long days, nights, and weekends in quick succession for months without respite. The emotional and physical toll is enormous, and people need to be rested and mentally prepared to provide good care. It just isn’t possible when the number of patients to care for or tasks to complete are too great to feel any sense of control.
In the first wave, a huge number of my colleagues contracted Covid. Most were lucky enough to have mild symptoms, and nearly all returned to work. In this second wave, colleagues are unwell, often with mild physical symptoms, but I’ve seen many who do not have the strength to return to work. Those intensive care nurses can’t be easily replaced in a district general hospital.
Some things feel like they’ve got better this year. At the front door to the hospital, there are people who are so unwell they will need to be moved to the respiratory unit or to intensive care. Some will need oxygen and a machine to help them breathe, either awake with a mask or asleep with a breathing tube. We have learned more effective ways to start these treatments in ED and then bring patients through the hospital. We have drugs that improve outcomes, like the cheap steroid dexamethasone. The hospital was reconfigured to ensure that there would be adequate oxygen supplies to the respiratory unit and ITU. There is a laminated protocol to follow in case the oxygen supply should fail: I’m very glad someone has planned for this, although equally unnerved by it.
But prevention is definitely better than cure. While the hospital can make contingency plans and reinstate emergency rotas, the reality is that that infection rates are so high in the community that we can only play catch-up. It’s demoralising to see politicians stupefied, failing to make decisions that would have reduced infection rates back in the autumn. Vaccination has not yet had any impact on slowing infection rates. It doesn’t help that the ‘second dose’ fiasco has caused an administrative nightmare, leaving many confused about what and when their doses are, and others more sceptical about vaccines at a time when public trust is absolutely essential.
We are awaiting the hiatus in admissions following this third national lockdown. At home, I am thinking of the frail, vulnerable people with severe Covid infections I’ve seen this week. When people are not strong enough for ventilation, they hang onto life with their oxygen masks. These people could have been better protected. I want the government to be held accountable for that.