This evening, someone at church asked me if I were okay.
"Yah".
"Really?"
Actually, no. I'm not okay. And I probably won't be okay for a bit longer. But I didn't say that.
I asked what his week ahead was looking like.
"Strategy meetings, planning for Christmas..."
We exchanged another look as he trailed off. We both knew we were not okay. No one is these days. I remember when we were both also 'okay' back in February when we last saw each other.
February
I'm keeping track of the number of coronavirus cases on a daily basis, but things seem alright. I go to work, and nobody's behaving like we could be hit here in the UK. Sure, the number of cases are rising in Italy and France... but nahhhhh we will be okay.
Still February
At work, we are all asked to get fit tested. There's a bit of a state of panic when we get multiple emails from the medical director asking us to get fit tested -- urgently -- and to inform the team as to which masks fit.
So I go along to this 'fit testing'. It's a bit of a joke. I put a large specialised hood over my head and stick out my tongue. My colleague squirts a spray into the hood. I taste the spray. It's bitter. Good.
Off I go and return 30 minutes later. We repeat the entire process, except this time, I'm wearing an FFP2 mask. I can taste the bitterness after about eight squirts. Oh dear. That's not supposed to happen now that I'm wearing a mask. Alright let's look for another mask.
Three masks later, I can still taste it every time. I don't even need the spray to tell me that the masks don't fit me because my glasses fog up every time I put it on. What does this mean? Does it mean I can't look after Covid patients?
I'm on call as a medical registrar and A&E refers a patient who has just returned from South East Asia with a fever. I can't see the patient since I've not passed the fit test. Hmm.
After many phone calls later to the microbiology registrar, we have an action plan. The poor A&E SHO who saw the patient initially will continue to review the patient while they are in A&E to minimise the exposure for the rest of us. The patient is kept in our only Covid cubicle in A&E, and the nurse and A&E SHO looking after the patient gown up and wear full PPE. In the end, we discharge the patient (from A&E) as the patient improved on their own and did not need any oxygen or IV medications.
MARCH
5/3/20
I turn up to my ward and there's a patient in a side room with ?covid ("?" is used by medical teams to communicate possible, but not confirmed, diagnoses). He has a pre-existing chronic lung condition and turned up to the hospital with breathlessness and a fever. The impression is that he has an exacerbation of his lung disease (which is common and expected). This patient hadn't travelled out of the UK recently, nor has he been in contact with anyone who has. Nevertheless, we follow protocol and treat him as if he has got Covid, although none of us really believed that he could have it.
At this point, we have zero Covid patients in our hospital.
At 4.45pm, my SHO calls me and tells me that the virology registrar needs me to go to the ward to have a word with him. Oh, this must be about the patient with acute hepatitis B that I saw earlier.
Turns out it wasn't. One of my other patients has Covid. Shit. Okay.
I ask the virology registrar, "So I guess you guys do all the contact tracing and we just have to tell the patient?"
"No. There's now too many Covid cases so we aren't contact tracing anymore."
Wait what???
My SHO, FY1 and I frantically try to find other masks. We get fit tested by the nurse in charge but we all fail testing. Didn't get to tell the patient he was positive until Monday, when another colleague who passed fit testing was at work.
16/3/20
I turn up to handover on Monday as I am on call. My fellow colleague who worked the weekend looks drained and shell shocked. He runs through the admission lists from Friday to Sunday.
It consists of patients positive for Covid, patients with results still pending, and patients with negative Covid tests, but still highly suspicious. Okay, there's the odd malaria case too. I learn from him that they had many peri-arrest calls over the weekend as the staff have been panicking when patients with Covid desaturated.
I start my shift, and the medical take, so far, is pretty quiet. Patients seem to have stopped coming into hospital. Hmmmmmmm.
At about midday, I get a text from a colleague saying that PPE has been 'downgraded'. Now, according to the new regulations, all we need to wear is a surgical mask when seeing Covid-positive patients, and FFP2 masks when aerosol-generating procedures are involved (e.g. if patient is on non-invasive ventilation (NIV)).
SHIT. Are they serious right now? I'm terrified.
It's now 5pm and I get referred this man with what was described to me as "likely Covid". Oh dear. I had just discharged him from A&E a few days ago because he didn't meet criteria for admission. Now he's got oxygen saturations of 80%. This is not good. The A&E registrar puts him on CPAP and calls the ITU registrar as well. A few hours later, he's been intubated and is in ITU.
17/3/20
I was previously speciality-based, but wards have now been categorised into Covid-positive wards, Maybe wards, and Covid-negative wards. We will now be based on single wards to prevent cross contamination. I'm moved to a Covid-positive ward.
My boss comes round to give us a pep talk. We really need it. My registrar colleague and the two SHOs who worked the weekend now have a fever and a cough and are self-isolating at home.
"We are learning from Italy. We are about four weeks behind. We think we may run out of oxygen in four weeks but we are working on it," he said. He said a lot of other things too, but the "running out of oxygen" bit was pretty much the only thing that stuck.
21/3/20
I feel a bit achey, so I take my temperature and the numbers "38.0" beep back at me. Oh no no no no. We're all going down one by one like flies. It could be the level of PPE we use. Or it could be my tube journey to work. Or it could be one of my colleagues. At that time we weren't wearing masks around each other.
I self isolate for two weeks with fevers and myalgia. I'm sleeping most of the day. I'm so tired and scared.
2/4/20
A hospital nearby has had to declare a major incident because of oxygen pressure issues. I thought we had four weeks??? OMG.
6/4/20
I'm back at work! Woohoo!!! I'm still feeling tired, but I'm glad I'm back. I felt like I'd let the team down when I got sick.
We are now on a three-long-days-on, three-days-off rota. Thank God! My colleagues had been struggling out of hours with very sick patients prior to this rota. (For some reason, the Covid bus hits us badly in the afternoon. People start to desaturate and get sick then. We really need more doctors after 5pm and at night.)
Food in the canteen is also now free. Wow. This makes a HUGE difference. I work 13 hour shifts but I get to eat three meals.
But things are tough. I've got to re-train as now I'm looking after patients on CPAP. I learn about CPAP settings, how to get the patients on the machine, etc. Sure, as a medical registrar, I know how to start non-invasive ventilation (NIV). But I usually tell the nurses the settings the patients need, and they set it up. With Covid, nurses are busy and overworked, and some patients are too sick to wait. This time, I learn about the different types of machines so I can put my patients on it myself.
12/4/20
A patient of mine, Mr C, is claustrophobic and couldn't tolerate the CPAP mask. We keep him on a non-rebreather mask (NRB). He seems okay for now.
Another patient, Mr S, is also on a NRB and seems okay. But when I get back from lunch, I see he's taken off his mask. I check his sats and they are 70%. He tells me he had taken the mask off as "the oxygen tank had run out of oxygen". OMG. I get a new tank and his sats go back up. Note to self. I have to be more vigilant with these tanks!!
13/4/20
Mr C now is desaturating on the NRB. He cannot be persuaded to go back onto CPAP. We prone him and he seems to be doing okay.
After lunch, I do my sats and oxygen tank checks. (Oh. Is it normal for patients to be on oxygen tanks? Not really. Oxygen usually comes from the wall behind the bed, but because I'm in a ward which used to be a surgical ward (before it was converted into a Covid-positive ward), not every bed has walled oxygen. I know.)
Mr S now needs CPAP. Despite being on NRB, his sats are now less than 90%. I call the ITU registrar. He asks me if I can wait an hour as he is trying to get a patient transferred to another hospital for ECMO. Yah, we can wait. In the meantime, I call the bed manager and request they get a bed ready for Mr S on the CPAP ward. But when the ITU registrar turns up, they decide that Mr S is probably going to need intubation soon so they whisk him straight to ITU.
14/4/20
Mr C is now VERY breathless and is looking like he is going to tire out. His family have been speaking to him on the phone and he finally agrees to have CPAP. By now, he's really quite ill. We don't have time to wheel him to CPAP ward. Me and my boss get the CPAP machine and masks from the CPAP ward, put him on it, and wheel him to the CPAP ward with full PPE. ITU team also comes to see him as he may need to go to ITU.
15/4/20
I am on my first day off after the last three days of working long days. I really need this break.
17/4/20
I'm bored out of my mind. I can't wait to get back to work.
18/4/20
I'm on the night shift today. The day team hands over a woman in her 40s who needs CPAP imminently, a man in his 20s with a GI bleed, and a man with Covid who may have had a stroke.
ABCDE
Airway, Breathing, Circulation, Disability, Everything Else
I go review the patient with the B problem, send my SHO to see the man with the C problem and my FY1 to manage the man with the D issue.
Great. The patient needs needs CPAP like NOW NOW. I call the outreach team. They are busy. Thankfully, the night bed manager is helpful. She gets the bed ready on the CPAP ward. I get the mask and CPAP machine ready (Yes, I know. This sounds like this is all I do). It takes me ages to hunt for a machine. It looks like we're running out. My FY1 tells me she saw one on a ward so I go get the last machine.
My patient is terrified. We wheel her to the CPAP ward. The lovely nurse on the ward holds her hand while we get the mask on. Her family is also on the phone with her to reassure her.
Her oxygen sats responds beautifully to the CPAP. PHEW.
Okay let me go see how my SHO is doing. He's done a good job. He's done the ABCDE assessment, organised a blood transfusion, started some PPI, and spoken to the GIB consultant. The patient is now stable and can wait 'till the morning for an endoscopy.
And my FY1 managed to get some help from another registrar who heard how busy we were on our side of the hospital and came to help.
We finally get some rest after dinner and a quick round on the CPAP ward. All is good. Everyone's sats are fine on CPAP.
19/4/20
Nothing major was handed over to the team today. Hmmmmm. Okay. I guess we can't always be busy.
At 5am, a patient (Ms A) gets quite ill. ITU comes to review and literally said, "Yes, start CPAP. What are you waiting for?"
Well, Ms A looks remarkably well if not for her sats. But okay. The SHO, FY1, and myself wheel her to the CPAP ward. (For a bit of context, CPAP is aerosol-generating, so you don't want someone to be on CPAP whilst being wheeled across the hospital. The team moving the patient may be wearing full PPE, but we also need to protect everyone else in the corridor from getting exposed to the aerosolised Covid particles. Usually, the porters will go ahead and make sure the corridor is clear before we go -- all the more reason to have a porter doing the moving. Also I'm not a good driver. I don't know how the porters wheel the patients in this huge bed single handedly... kudos to them!)
Anyways, we have full PPE on, but the patient looks okay, so we wheel her on her NRB to the CPAP ward. I put her on the machine but the machine keeps beeping. Her sats are now going down with every moment she is not on oxygen from either her NRB or a working CPAP machine. At one point, it was down to 37% (Side note: People say the sats reading cannot truly be that low. All I can tell you is the panic I experienced watching the sats decrease, knowing the CPAP machine wasn't working, because her sats were dropping and the machine was beeping).
I put her back on NRB and her sats come back up. What do we do now? This is the last machine! Fortuitously, it's now breakfast time and the nurse takes the man next to my patient off his CPAP machine to eat. I borrow his (temporarily freed) machine, used a different filter, tubing mask etc., and try it on Ms A. She looks better on the CPAP. This is why Covid is silent. Patients look well with really low oxygen sats. This patient looked so well but she was, in actual fact, very ill.
Now, I task myself with looking for a machine for the man having breakfast, Mr B, who I've stolen the machine from. He's gonna finish breakfast soon. The chap next to him, Mr C, is using his CPAP only at night, so I borrow that machine.
It's time to handover and I leave relieved. The day team can find another machine for Mr C.
20/4/20
The patients are doing alright. No drama tonight. Yayyy!
21/4/20
Off again.
24/4/20
I'm back. I look up my patients.
Both Mr C and Mr S have been intubated.
The patient with the B problem has died. :(
The patient with the D problem is now on stroke rehab ward.
Ms Sats 37% (Ms A, rather) is being referred for ECMO.
Okay, they have names. They are not letters. But at this point I really cannot get personal. This is too difficult.
I go through this cycle of work and rest for a total of two months. I've gotten used to this.
JUNE
At the end of this Covid rota, I chat with my friend working in ITU in the same hospital. Only five patients who were intubated made it out alive from ITU. Okay, more than five survived, but we had moved a couple to another hospital for ECMO (Ms A survived!!!), a couple to the Nightingale hospital, and a couple to other hospitals when ITU ran out of beds.
I recognised the names of two of the patients who survived. They happened to have come from my ward. I guess there is some hope? At times, it did feel as if everyone died... like things were futile.
Lots of patients did do very well on CPAP. I learnt so much those two months while caring for Covid patients. So many people needed thrombolysis for pulmonary embolisms. We had a few strokes, and we had so many patients with low sodium. It was actually a thing.
Life went back to 'normal' in June.. except it wasn't. We weren't seeing patients in clinic. When I called them, many patients told me that they had started smoking or drinking A LOT during lockdown. Lots of people had lost loved ones. It was awful. On the phone, I would just listen to them tell me about their loved ones.
I also started to process what we had seen in the past few months. And it was tough. I've been a doctor for nine years. I'm a medical registrar. I'm used to breaking bad news, putting do-not-resuscitate orders (DNARs) in, and managing sick patients. What I am not used to, is managing so many sick people all in one go. Every single day. Seeing so many premature deaths. Seeing people suffer alone as their loved ones could not visit them in hospital. Women had to give birth alone. I saw many couples came into hospital, ill, together. And later, (because Covid, for some reason, tends to affect males worse) I saw many wives leave hospital alive without their husbands.
When I have meals together with my colleagues, we share our stories. In the beginning, we all started out a bit scared of catching the virus. Then, one by one, we all caught the virus. And then, we returned to work less scared because had some hope of (possibly) some form of immunity. Some stories I hear from my colleagues are simply horrific. I cannot imagine how my ITU colleagues coped. They are heroes.
JULY
I'm finding myself very irritable at work. I haven't slept properly in weeks. I think everything is okay, but one day, two of my bosses pull me aside and tell me I need to get help. I start crying and call the on call psychologist at work.
AUGUST
I've decided to give up my medical job. I don't think I can do this anymore. I've applied for GP training and managed to get in. I'm doing much better with therapy. And I've started my first placement in Paediatrics. Sigh. I'm back to being an SHO. But it's okay.
Work is offering the rapid antibody test so I get tested... I haven't got antibodies. What???
SEPTEMBER
I'm trying to get the hang of Paediatric things. I'm missing adult medicine. I miss patients who I can have grown up conversations with. Don't miss Covid, though!
OCTOBER
I tell one of my new Paediatric bosses that I am slightly traumatised by Covid. (Slightly? That's the understatement of the year.)
He tells me that he, too, has been affected by the pandemic -- not quite traumatised, as such, but affected. Children weren't too badly affected by Covid, but there were quite a few with delayed presentations. There were kids who turned up with a blood pH of 6.9 (very bad) from asthma attacks, there were kids with seizures that have been going on for longer than usual but parents were just too afraid to bring kids into hospitals, and there were the Kawasaki-like disease complications from Covid as well. But he found himself getting angry at others. Like people who wouldn't wear masks on the tube.
I get that. I, too, used to get angry whenever I saw people going around without masks. Or when I saw people coughing on the tube to work, who I thought should've been self-isolating at home (on reflection, they could've had COPD and a smokers cough).
It's incredibly refreshing to hear someone else share that they, too, didn't quite get through unscathed. I thought I was on my own. I thought I was weak for quitting.
I was talking about the free counselling that was offered in the doctors' mess the week before, and I felt entirely judged for leaving 'med regging' for 'GP-land'. It's sad that there is still this massive stigma, even amongst healthcare professionals.
NOVEMBER
It's the second national lockdown. But it's okay. I'm still able to go to work and earn money. I've got friends who have been furloughed and it's tough since Christmas is approaching.
I've been given a book by Charlie Mackesy called The Boy, The Mole, The Fox and The Horse. I read it constantly but this one page resonates within me.
"Sometimes," said the horse.
"Sometimes what?" asked the boy.
"Sometimes just getting up and carrying on is brave and magnificent."
DECEMBER
I'm back at church. I'd been worried that I would pass Covid on to someone else at church, but I decided that, if I stick to strict social distancing, I won't really put anyone else around me at additional risk. Plus, I've not really looked after Covid patients since I left medicine.
It's the second week of advent. And at the end, the vicar says, "Maybe God wants us to find new friends in new places."
Yes, maybe He does. 2020 has been a tough year.
I'm not okay okay. My friend at church isn't a medic and he, too, isn't okay okay. He lost his police officer brother to Covid back in March.
None of us have escaped unscathed. I'm going to continue to talk about my experience and my journey to recovery. Because maybe God wants me to find new friends in this new place I'm in.
Addendum added 22/12/20:
London is now back in Tier 4. There is a new strain which is 70% more infectious. Hospitals in London are inundated with Covid patients and it is looking more and more like the second and third wave has hit us all at the same time.
But more than 500,000 people have been vaccinated and hopefully this will protect them. Until then, we live to fight another day.
Stay safe this Christmas. These dark clouds will go by. The blue sky above never leaves.
This was written by a London-based junior doctor working in the NHS. Some details have been altered to preserve the anonymity of patients and the author. All events are true.
If you would like to share your story, or have been encouraged by this, we would love to hear from you. Email dr.thestudentmedic@gmail.com.
If you, too, have been affected by the pandemic, some helpful resources are listed below.
Practitioner Health Programme: Doctors, dentists and medical students are able to self-refer to access fully confidential therapeutic and other mental health related support.
Frontline 19: Frontline 19 is delivering supervision, debriefing and emotional support to healthcare workers. Visit the website to be quickly matched with a professional psychologist, counsellor or psychotherapist offering free online sessions.
National NHS staff support helpline:
Phone: 0300 131 7000
Text FRONTLINE to 85258
Operated by the Samaritans providing confidential listening and specialist advice for NHS staff - including coaching, bereavement care, mental health and financial help (07:00-23:00, seven days a week).
Bereavement support: 0300 303 4434
Cruse Bereavement Care: https://www.cruse.org.uk/
Local Talking Therapies:
If you feel more anxious or your mood is lower than usual, you will be fast-tracked by your local talking therapies service – Improving Access to Psychological Therapies (IAPT) can be found by searching for “IAPT” and the name of the borough in which you live. They offer online materials, groups and/or sessions with a therapist.
Coaching & Support:
Project5 is a bespoke health service worker wellbeing service provides professional coaching and wellbeing support.
Trauma Response Network
TRN is a registered charity which provides free and anonymous trauma support by qualified EMDR therapists. They are currently offering therapy to support people online suffering from acute anxiety or PTSD due to Coronavirus
If you are suffering with your mental wellbeing/anxiety related to the current situation and the high number of “unknowns”. This is a perfectly normal reaction to what is going on and we would encourage doctors in this situation to access the BMA Wellbeing service 0330 123 1245. This is a completely confidential helpline which can also offer same day access to a counsellor and/or peer support. Doctors do not need to be a member of the BMA and it is also available to families of doctors.
The London deanery also provides online help and resources to London trainees.