‘We learnt so much about Covid in so little time’
A multidisciplinary approach has been the key to winning the fight against the disease, doctors tell Victoria Lambert
The announcement that a cheap steroid called dexamethasone can save the lives of people with Covid-19 has come as a relief. But it is also a reminder that – in medical terms – we have travelled a long way in a matter of a few months when it comes to dealing with this coronavirus.
Back in February when cases first began occurring in the UK, scientists warned steroids had no effect on the disease. Now, an Oxford University trial has found that dexamethasone cuts the risk of death by a third for Covid-19 patients on ventilators.
Meanwhile, in March, French doctors warned that ibuprofen and other anti-inflammatories could make symptoms worse. Today, London’s Guy’s and St Thomas’ hospital and King’s College are actively exploring whether ibuprofen could be used to treat breathing difficulties.
At first, Covid-19 was talked of as a bad type of flu, at worst a serious respiratory disease – now we know it can cause a lethal inflammatory response, affecting every organ. Certainly, it was believed to be the kind of disease that one could develop a robust immune response to, leading to those theories on herd immunity.
Now, as we all know, it is not yet possible to say how long immunity might last or to predict if Covid-19 will mutate every year, making a vaccine and lifelong immunity still a dream.
Yet infection and mortality rates are tailing off due to the huge leaps of knowledge. Doctors have been on a steep learning curve, agrees Dr Matthew Knight, consultant respiratory physician at Watford General Hospital. “The science has improved massively,” he says. “We know so much more about what does and doesn’t work.”
For a start, he points out, it was thought hospitals would need far more ventilation than they did. “We used all the capacity we had,” he says, especially at the height of the crisis in March and April, “but the Nightingale hospitals were never needed.”
Part of the reason for that has been improvements in diagnosis, helped by the quantity of cases: doctors quickly learnt to recognise Covid’s presentation (as opposed to other respiratory illnesses). With time, says Dr Knight, that has been finessed. “We know now that those coming in initially with lower levels of oxygen are likely to get sicker and need earlier intensive care.”
The public understand the symptoms better too, says Dr Tom Wingfield, honorary consultant physician at the Liverpool School of Tropical Medicine. “People are more aware of what to do: when to selfisolate,” he says, “and when to go to hospital.” He adds: “We also know that some people get silent hypoxia – a shortage of oxygen that doesn’t show up in normal ways like breathlessness.”
Crucially, there is also understanding of who is at greatest risk for severe disease based on age, ethnicity and existing conditions. Dr Wingfield explains: “If we have a second wave, senior clinicians could meet patients at the front door and assess how ill they are.” This will mean they are put at once on the best personal Covid-19 pathway.
The use of radiology and imaging has increased too, as identifying telltale lung damage can also reveal if a patient has Covid-19 and to what extent.
The disease’s very infectiousness has also been a catalyst for change. Within hospitals including Watford, zones were created to reduce the chance of transmission, not just between patients but also between staff. These zones had full multidisciplinary teams, meaning that staff were not moving around the whole hospital site as much, thereby improving infection control.
Covid has also shown up the value of enhanced care, says Dr Alison Pittard, dean of the Faculty of Intensive Care Medicine. She explains: “Many patients need a level of monitoring and care which is below that of intensive care but more than that offered on an ordinary ward. These patients have usually ended up in critical care when they didn’t need to be, taking up a bed.”
Covid has seen more staff from all backgrounds trained up to offer this level of enhanced care – where patients may be monitored more regularly without needing organ support, freeing up ICU for more urgent cases. Dr Pittard says these staff would make the basis of an excellent reserve force for future crises. “This would be a win-win for patients and the service.” And maintaining enhanced care “wouldn’t just work in an emergency, but could help with surgical patients every day”.
It’s fair to say that new lines of communication have also sprung up. Dr Knight says he now has the hospital engineers on speed dial: “You can’t double the amount of continuous positive airway pressure (CPAP) you use without getting the team to increase the overall oxygen supply.”
CPAP is thought to be particularly valuable itself. Dr Wingfield says: “The research hasn’t been published yet but we are seeing groups of patients who benefit from CPAP, meaning they can avoid going into intensive care.”
One of the most important lessons has been in terms of what happens inside the lungs. Dr Wingfield explains: “There is the inflammation caused by the body’s immune response. In extreme cases, a cytokine storm.” This is when the body overreacts to a virus and causes internal damage.
A third of people in ICU will develop a blood clot on the lungs, he warns. “We are exploring the value of blood thinners. But we are not sure how much to give and for how long yet.”
The use of proning has also been cited as a good lesson – this is when patients are turned on to their front to increase the amount of oxygen getting to the lungs through gravity.
“This has been shown to be important for those severely unwell with Covid,” says Dr Wingfield, “but as part of the treatment. It doesn’t improve the outcome on its own.”
Fears of viral spread have also led to the creation of virtual hospitals. Patients with suspected or mild Covid-19 are given the same support and treatment at home as they would be in a ward, with daily contact from a doctor or specialist nurse.
Dr Knight estimates that Watford saw about 1,500 people pass through the virtual hospital, with about 10,000 outpatients monitored by remote consultations. Tele-health has also revolutionised patient and family communications, and after discharge, there have still been improvements in care. “Covid doesn’t stop,” says Dr Knight, “when you are no longer infectious to other people.”
That means some hospitals are giving full holistic assessments on not just physical but mental recovery.
“The vast majority feel back to normal health within a few weeks, but about five per cent of those who have been to hospital may have a lifestyle-altering change in the way they feel. They may have fatigue and muscle aches. At Watford, we’ve even seen two cases of appendicitis due to immune reactions,” says Dr Knight.
Sue Houston, head of nursing at post-acute rehab specialists the Christchurch Group, says that drawing on existing practices for patients leaving intensive care helped them design a pathway very quickly for Covid patients. Even so, she admits “every day is a learning day”.
She adds: “Everyone thought it was respiratory, but it is not, it is multifunctional. So, patients have individual programmes depending on whether they need recuperation or more intensive recovery after being weaned off ventilation.”
The long-term takeaways for Dr Knight start with a suggestion that every home should have an oxygen monitor in the first-aid kit. “If patients have these, we can check their health at home doing simple exercise testing like climbing the stairs.”
But he has also had confirmed the value of the true multidisciplinary approach. “It’s been a pleasure – in this awful time – to see hospitals really working together.”
Dr Pittard agrees: “One of the things that came out of the early stages was the natural delineation between specialities being abolished. Using enhanced care encourages a team approach and now it’s been tested by Covid. We have learnt what can be achieved.”
And the innovation goes on, says Dr Wingfield. “We are all quite tired now, but we’re also reading reams of papers. We are keeping up with all the information coming out.”
You could say that the prognosis for Covid care is good.
‘It’s been a pleasure – in this awful time – to see hospitals really working together’