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22 July 2020

In Westmorland for a short break, I’m asked, “How’s it been?” Well, how to describe it?

I have led my practice through the first wave, starting in early March when I realised the 25-year-old I was examining had Covid-19. It seems incredible now, but I had no PPE.

By Phil Whitaker

The holiday home sector reopened on 4 July. Suddenly, our week in a Westmorland cottage was back on – assuming none of us developed coronavirus symptoms in the meantime.

We’ve stayed there previously, which made the differences more noticeable. Hand sanitiser was mounted on a wrought-iron stand in the front garden. Inside the house was a checklist of everything that would be disinfected on changeover days. Books and games could not be, so scrupulous hand hygiene was advised. Charley and Mike, the couple who rent the place out, gave a socially distanced greeting from beyond the gate, and said it was great to see us again.

This was the first time off work I’d had since February half-term. Back then, the threat to our holiday had been Storm Dennis; Covid-19 had been only a remote concern. Over the months that followed, I have led my practice through the first wave. There has been the odd moment where I’ve been aware of being under strain, but on the whole I have taken things in my stride. Up there in Westmorland, though, it felt like a different world. I experienced a surprising reaction – a bizarre quality of unreality to memories that I knew to be real because I’d lived them.

The moment in early March when it dawned on me that the 25-year-old man I was examining – sent up by a 111 call- handler with a “chest infection not responding to antibiotics” – had Covid-19. It seems incredible looking back, but I had no PPE. That only became standard a few weeks later, by which time the faces of increasing numbers of nursing and medical colleagues were appearing on my social media feed, all of whom had succumbed to the disease. It was a chilling moment: my first encounter with the adversary. I rarely feel unsafe at work, and only then because of aggressive patients. But I felt distinctly exposed.

Later in March, as the NHS prepared, at high speed, for the predicted tsunami of cases, I was asked to submit availability for all doctors working with my surgery. There was no compulsion; people could opt out of “hot” work if they chose. Colleagues lodged their decisions with me in confidence. It was humbling, seeing those volunteering for the front line. Equally moving was the guilt expressed by those whose health or concerns for dependents meant they had to keep out of harm’s way.

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PPE was standard by then; I volunteered for “hot” work. The out-of-hours triage screen during the peak: reams upon reams of Covid-19 cases waiting for call-backs, new ones being added faster than they could be cleared. Trying to assess as many as possible by phone to minimise contamination of healthcare facilities. New information emerging daily about manifestations and complications of the disease. Trying to keep abreast of it. Trying not to get any case wrong.

The first patient I lost, late in March: Tom, mid-fifties, whom I had seen through numerous exacerbations of his chronic lung disease over the years. Days after contracting coronavirus, and not having seemed ill enough to warrant admission, he was found dead at home. There was no post-mortem; the rising mortality rate meant coroner’s officers were limiting autopsies to cases where there was no reasonable idea as to the cause of death. At that time we still thought of Covid-19 as a viral pneumonia. We now know it to be a multisystem disease provoking pathological blood clots, resulting in strokes, heart attacks and pulmonary emboli (PEs) – clots that form, typically, in the legs, break off into the circulation and lodge in the lungs. It will have been something like that which ended Tom’s life.

That was certainly what happened to Patrick, the fit, if obese, 23-year-old I admitted as an emergency in April. His Covid-19 proved mild in terms of changes on his CT scan; his acute shortness of breath was due to numerous PEs. He survived with standard blood-thinning medication. By May, the capability of coronavirus to provoke clots had become better defined: patients would even form them despite being on usual-strength blood-thinning regimes.

The CT report on Marcus, another patient of mine in intensive care on a ventilator in May: “Classic Covid,” the radiologist concluded. That stays with me. A few months in, and doctors throughout the NHS have seen so much of this new disease we have become intimately familiar with its manifestations. Marcus survived 50:50 odds, and is doing well back home. Thanks to the UK’s Recovery trial, a similar patient today would have markedly improved chances: a steroid, dexamethasone, would dampen the immune system overdrive that causes much of the pathology of Covid-19.

In common with all GPs, I have a handful of patients with a distinct variant characterised by ongoing debilitating symptoms. There are an estimated 250,000 of these “long Covid” patients from the UK’s first wave. No one knows when they might eventually recover, if indeed they all will. Supporting these patients, as well as the tens of thousands left with permanently damaged lungs, heart failure, or stroke, will challenge the NHS for years.

Charley and Mike, standing the other side of the garden gate at their Westmorland holiday home, remembered I was a doctor. “How’s it been?” they wanted to know. So I tried to give them some flavour of what we’ve seen; of what we have come to know. They nodded and smiled and said: “You’ll be glad of a break, then.”

They’re diligently observing all the rules for reopening. I still read commentators, even some academic scientists, pontificating about how Covid-19 isn’t that serious; how lockdown was an overreaction; decrying mandatory face masks as an affront to liberty. But you won’t find many front-line clinicians among them. 

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