‘wear a mask and don’t lose hope... we just need to get through this winter’
Dr David Hepburn, an intensive care consultant at the Royal Gwent Hospital in Newport, has been on the frontline in the fight against the virus and even contracted it himself. Here, he gives acting political editor Will Hayward an insight into the crisis
What is the current situation in the ICU?
If you remember back in April and May time we were in a pretty desperate situation. We were several times overcapacity with patients, many who had Covid-19, and we had to expand out our normal footprint which had an impact on lots of other services.
This time we have stayed within our footprint, but there is a lot of the winter to go.
We are still pretty full and it is a mixture of patients with Covid-19 and other things because it is winter and people get sick with other reasons.
In March we had had time to prepare and we had emptied out all of the parts of the hospital to get ready for Covid. This time we have been going ahead with routine surgeries.
It is quite difficult to keep Covid patients and those who do have Covid in different areas. We are doing better than a lot of the units around us.
Cwm Taf is having a really hard time in Merthyr because the incidence over there is much higher and they have been hit a lot harder this time than they were last time.
There are a lot of people in the nonICU parts of the hospital with Covid19 this time, though less seem to be coming to intensive care.
This is a good thing because it means that some of the new treatments we are giving people seem to be working. Plus the patients that we have had with Covid in ICU who have been very poorly seem to be bouncing back more quickly. This echoes the experience of a lot of my colleagues around the country.
In the first wave people would be sick for about a month. Now they seem to be turning around in seven to 10 days. This is not to say that we haven’t had some patients die, sadly.
But what we are seeing at the minute is not on the scale of what we saw earlier in the year.
Everything can change and we’ve got to get right through January and February before we know the full impact.
Is part of the challenge of capacity in ICU not just beds, but also staffing?
Yeah, absolutely. Because ICU is a specialist area, generally those ratios of patients to staff is 1:1.
For example, if you had a patient in what we call a level three bed they might be on a kidney machine and strong drugs. Those patients need one-to-one nursing. I know recently in England they made an official announcement that they were going to allow people to be nursed on a 1:2 basis.
We are not having to do that, really, which is good. Because these patients need so much continuous attention, 24 hours a day, if you don’t have your eyes on them all the time you do start running into complications – things like lines coming out, etc. It is a very intensive relationship.
In Italy when they were in real trouble they were having one nurse looking after between four and six patients. Then it starts to affect people’s ability to survive. A bed is a small part of capacity, it is the human resources that is most vital.
What is a typical Covid-19 patient in your ICU? Are they all over 60 and have pre-existing conditions?
A typical Covid patient around here is a typical South Walian patient, basically.
We have had a big range of age groups. We have had people in their 20s before and had people in their 70s and 80s. The vast majority are between 40 and 60. The peak is probably around 55 to 60 years old.
There’s been a lot of talk about preexisting conditions and the theory that the people getting sick are people that are unhealthy and have other problems, but actually, in our experience, any pre-existing conditions that people have are very, very mild. So many will have high blood pressure and Type 2 diabetes and a lot of them will be carrying a little bit of extra weight around the middle.
But these are not morbidly obese people with badly controlled diabetes.
They are the sort of person who lives down your street and who you will meet in the pub. Most people over 40 have a bit of high blood pressure and these things are incredibly common.
What condition are people in when they arrive in ICU?
We find that a lot of our patients have been at home with Covid for a while before they present at the hospital. Usually they are a good week into their illness and then things start catching up with them. In terms of the average day of being ill enough to come into intensive care is most common at day 10 or 11.
How do you respond when you hear people say conspiracy theories like this is no different to the flu and our health system isn’t really in danger?
It’s a horrible situation. The pandemic and the lockdown, all of it has been awful. There is no right way through this.
This is the first time we have faced a global pandemic since 1918. We know how damaging lockdown is and we know how damaging the disease is. We can see that we are getting towards 70,000 deaths now in the UK.
I can understand why people are trying to find an explanation and find a meaning behind this. Some people are leaning on the hope that actually all of this is a big scam, the hospitals are all in on it and there is plenty of capacity.
There may be spare beds in a few hospitals and I don’t know apart from my own hospital what the situation is. But what I do understand is that once you have a big population of people inside a hospital with the virus it starts to spread.
Once you have 60% of the patients in hospital having Covid, the risk of bringing people in for routine work massively increases.
Are you worried about the amount of people who have had their operations cancelled?
I think that’s one of the things people have been struggling with. There was a period between June and September where we really got cracking again on the surgery that we had put off because of the first wave of the pandemic.
Around October time it had become incredibly risky to do anything because you are putting people in harm’s way. Unfortunately the way hospitals are built, especially the Gwent, it’s very difficult to isolate people. A lot of the hospitals have been built piece by piece on a Victorian framework so it’s very difficult to cut through corridors to even adjacent wards. It has a huge impact on routine work; cancer screening has been hit massively.
The wait for people to go to the GP and get their first appointment with a cancer specialist should be two weeks, in some areas of South Wales that is being stretched out now to between four and six weeks. There is a huge amount of collateral damage. I can understand people’s anger and frustration. The problem is the two things are so intimately connected – you can’t carry on the routine work when you’ve got a critical mass of Covid patients.
Tell us about the new Hospital, Cwmbran.
The idea behind the Grange is that it’s going to be a hot site. It’s got a big intensive care unit in the middle of it and has a big accident and emergency department. All the unexpected emergency work will go to the Grange. If you need urgent surgery because you have a hole in your bowel or a strangulated hernia that would happen at the Grange.
Equally, people who come in medically very unwell with Covid will also go to the Grange because that is where the intensive care facilities will be.
You can define hospital work into either routine or urgent. Most of the urgent work will be happening at the Grange and that’ll include people having babies and sick children.
The idea is that now all the emergency work will happen in one place (the Grange) and that will free up Nevill Hall and the Gwent to do the routine work.
Grange
It feels like the coronavirus crisis has gone on forever. What is the morale like in the Welsh NHS?
I think there is a lot of uncertainty because there is a long period of time we are looking at where this could continue. It will be interesting to see what has happened with the firebreak and whether the cases start to fall off. We probably won’t see the effects of the firebreak in terms of the statistics for another couple of weeks because there is always a bit of a lag. With a bit of luck that will slow things down.
I think everybody is tired and nobody wanted to go through another wave, but we knew it was coming.
The things that keep me hopeful are the fact that in the spring the numbers will drop off because they always do with viruses as the weather starts to warm up.
We’ve also got the vaccine which is looking very, very promising as well. I don’t want to get too hopeful because it is very early days, but some of the data is very reassuring.
How hard is it with people not being able to visit families, especially for people who might not make it?
That has been the worst part for me.
And I’m sure my colleagues in intensive care in particular think this has been the most difficult part. We have a pretty open visiting policy – people can come in first thing in the morning and they can stay in the unit until about 10pm.
They are with their family members even when they are unconscious, they can see them getting better and see them getting worse as well as all the work that is going into looking after them.
The family is the biggest link we have got to knowing what the unconscious person is like. They humanise them and tell us their stories. Not being able to do that has been really hard for us. I can’t imagine what it is like to be someone’s relative who is so desperately ill in ICU and they can’t come in and see them.
We have used some workarounds. We have iPads that people can call on as well as a great communication team that phone patients families every day and give them a general update.
We can now allow families in for end of life which has made a huge difference.
Talk us through the treatments that are now available. Are there any that you are using regularly that you were not at the start of the crisis?
By far the biggest difference I think has been the introduction of dexamethasone. In the first wave we took part in a number of research studies, one of which was the Covid recovery trial. It looked at lots of different treatments. It was a very clever trial and is one of the biggest clinical trials that’s ever been done in the UK.
One of the findings was about dexamethasone which is a really cheap steroid you use for joint injections and for children with croup. It’s been around for years and it seemed to make quite a big difference to the survival rate.
The other thing we have probably done this time is to try and avoid putting someone on a ventilator. We have
been persisting with non-invasive ventilation which is a very tight-fitting face mask and that can make quite a big difference. It means you don’t have to put them into an induced coma and on a life support machine.
What lessons can we learn to make us better placed to deal with the next pandemic?
I think that one of the things that we need to realise is that intensive care in Wales in particular has always been the poor man of Europe. We always had less intensive care beds per head of population than almost anywhere else in Europe. I think Portugal also has a pretty low number, but we have in the region of four per 100,000. In Germany it is 12.
Increasing critical care capacity is probably the way to go.
We have been talking about it for a long time, but I think we have realised that if we had invested more we would not have been so overwhelmed and it would not have had such a knock-on effect on everywhere else.
Also, the way the Government react to another emerging viral threat will have to change. I think there’s got to be lessons learnt.
Look at New Zealand who locked down incredibly hard and sharp at the start at the start. This made a massive difference because they hardly had any cases at all. I think if you lockdown you need to lockdown hard and early. We weren’t quarantining people flying in from different countries. The problem is that the UK is a big bridge to the rest of the world. I think the Government was a bit slow in responding to that.
Whereas if you look at countries like Vietnam they had two weeks solid quarantine for everyone coming into the country. I think it’s getting a lid on it really quickly.
What is your message to people in Wales?
Wear a mask and don’t lose hope. There is a lot of hope for the spring, we just need to get through this winter.
I just want to say thank you. I know sometimes when I appear on social media I get piled on by trolls telling me that there is no Covid and it doesn’t really exist but the vast majority of people I think just want to get through this and not lose any friends and family as well as minimising the economic destruction. We had a huge amount of support and help and I think it has been a community wide thing.
The key to this is that it doesn’t work if you look at it from an individualistic or selfish approach. It requires the whole community to pull together.
I agree with how damaging lockdown is and if you don’t have lockdown the alternative is also terrible. People talk about letting the virus rip through communities; if you look at the deaths we’ve had even with a lockdown, if you let it rip through the community it would just be shocking.
We’ve all got to invest in doing the right thing like avoiding meeting people indoors because that is the killer.