‘We thought we were facing a catastrophe’
CONSULTANTS’ concern for the welfare of their private patients is at its most acute now over those without symptoms of chronic diseases, for which they would have been treated successfully.
Patients with the least to moan about are potentially at greatest risk of silently developing complications while the virus dominates the healthcare agenda, in one of the ironies of the strange new world of COVID-era healthcare.
But those presenting symptoms are being admitted publicly if their consultants deem it urgent and essential.
Consultant Respiratory Physician at the Bon Secours in Tralee Dr Alan Mulgrew told The Kerryman this week that he and the vast majority of his colleagues are still taking scheduled appointments, albeit virtually.
Meanwhile, as it became clear Ireland would not be spared the global pandemic, private consultants ramped up their contact with patients in a frantic bid to ascertain the exact degree of urgent need among their charges – in anticipation of the public contract.
“What we’re almost all doing now is that anybody that had scheduled appointments are still receiving them in a virtual clinic,” Dr Mulgrew told The Kerryman. “Very few of them were fully cancelled, and in the case of cancellations those patients were phoned up and asked if they were okay with the cancellations to make sure they were not symptomatic.
“Most are thankfully well. The patients you would worry about are those who are not symptomatic. Endoscopy has been really curtailed as we haven’t been able to get the turnaround on the screening. Before Leo Varadkar made the announcement of the deal we knew would come, we obviously consulted with every single patient on our waiting list. I went through everybody on my waiting list, double-checking each one, and if I was anxious about anything we brought them in. We are not curtailed from seeing people or bringing them in or getting them tested now, but we obviously don’t want to put them in harm’s way.”
Timely screening is crucial to optimise safety for patients and staff and ensure as high a degree as it is possible to ensure in the shadow of COVID-19. “At the start, the huge difficulty was their ability to test and get a result back in any kind of efficient manner. Patients don’t come in wearing a badge showing they have the virus, and when it was taking six to seven days to turn around a test, it was very difficult to operate.”
Test results are now back within the day from the Bon Secours’ lab – at a time when the State has reached the target of 15,000 per day – helping minimise risk. Suddenly, even the most straightforward diagnostic examinations are now potentially hazardous for the medics. Exercise stress tests and other breathing tests of the type Dr Mulgrew would have routinely administered are now no longer recommended as the devices allow for the aerosolisation of the virus.
“In anything involving endoscopy, it is hugely advantageous, therefore, to be able to screen the patients for any procedure that represents high risk to staff. All surgical patients, respiratory admissions, anyone presenting any symptom that could be construed as on a COVID pathway but isn’t an emergency is now pre-screened, with the results back within the day. If, for instance, you are one of my COPD patients and you are on antibiotics but not really improving, we will bring you in for a COVID screening, and if we think you are going in the wrong direction will act accordingly. What we don’t want are patients who are going in the wrong direction but end up becoming an emergency and in the other hospital,” Dr Mulgrew said.
It was the first Cork case that gave Dr Mulgrew and colleagues in Kerry grave concern: “Given the first case in Cork seemed to be one of community transmission without a definite source identified, we thought we were potentially looking at a catastrophe. We were, by then, actively planning for how many patients we could ventilate while busily trying to source masks for non-invasive ventilation. The conventional CPAP, IPAP masks would allow the virus to vent, so we needed specific non-ventive masks.
“That was a major source of stress initially as the whole world wanted them. But as we work with an awful lot of CPAPs in terms of our sleep apnoea clinic, we had the advantage of great contacts and managed to source them early without having to try to establish new relationships with suppliers.
“As you’re waiting you are, of course, trying not to get caught out while managing so much extra pressure at the same time. But just as it took off, we had a patient who turned out not to have COVID, but had very similar symptoms. There was a realisation that if this patient had proved positive for COVID that a number of things were done sup-optimally. So there was massive learning, and almost immediately a COVID expert group sprung up on WhatsApp, started by one of my friends in Cork, and quickly reaching the 250 maximum number of members. We started sharing extraordinarily detailed material on it as new understanding of the disease came to light.”
The notoriously tricky nature of the disease caused by the virus was certainly noted in Kerry. The symptoms run the gamut from breathlessness to gastrointestinal pains and conjunctivitis, and no one can say for certain which COVID patient will deteriorate.
“I think the curious parts are the myriad of presentations. The breathless patients are obvious, the ones with funny xrays and CT scans are relatively easy to pick up. But I had one patient come in with weight loss we discovered through questioning was as the result of loss of taste. That patient ended up having a CT scan that looked highly suspicious, and then you start putting it together and the swab was positive. The hazard in all of that was there was exposure at a time when we were cognitively biased that the patients didn’t have it.” No staff got sick from contracting the virus in that instance.
Asked as to the likelihood of a second wave, Dr Mulgrew said he doesn’t fear it later this summer or in the autumn: “It’s in the scenario of COVID plus winter viruses peaking in January.” That could easily overwhelm the system if suppression is not adhered to.
Accurate and rapid contact tracing and testing will be essential if the country is to succeed in staying the ship, Dr
Mulgrew said. As will another measure not heretofore standard: “I fail to understand why face masks are not being recommended much more strongly. At the start there were PPE challenges in terms of the hospital needs. But reusable masks, cotton masks are easily come by now and the data is very clear: in countries where there is widespread use of masks, the virus is much better suppressed. If you wear a mask, the likelihood of you transmitting the virus is much reduced. Also, the social distancing ruling pertains to people who are not using PPE. If everyone is using a mask then the difference between one and two metres is less important.”