CRITICAL CARERS
Seriously ill Covid patients arrive at emergency terrified and struggling to breathe. This is the journey they will take from the doors of the hospital to ICU
As the wave of cases crested on the Gold Coast, as daily death numbers from Covid rose to levels Queensland had never seen, an elderly man sat in the emergency department’s triage zone, struggling for breath. A doctor, one of the tribe of medicos who has studied and practised and devoted themselves to saving every life possible, told the unvaccinated man he had severe Covid pneumonia. The man looked at the doctor and said, “Well, that’s your opinion.”
The doctor kept working. Kept talking the patient through the next process in lifesaving treatment for a disease ravaging the patient’s body, even if the patient wasn’t convinced. It’s what doctors on the Covid frontline do.
For more than two months, medical staff at the Gold Coast University Hospital have tended to thousands of patients with Covid. As the border opened in mid-december, ushering Omicron into the popular tourist city, one of the least vaccinated regions in the state, the Covid caseload spiked.
At the peak, about 40 per cent of patients arriving at the emergency department, or an average of about 120 a day, were Covid cases.
Some were vaccinated, some not. But the chances of ending up in hospital with Covid if you have not received a booster vaccination are nine times greater, according to Queensland’s chief health officer, Dr John Gerrard, a former long-serving doctor at GCUH.
Dr David Green, the head of the ED, says he’s witnessed a lot of fear about Covid – and quite a bit of denial. Unvaccinated patients who do not believe they have Covid have been “relatively common”. Green finds it hard to understand why people who could be vaccinated don’t get the shots. “It’s incredibly sad that you’ve got all this research out there, creating a lifesaving vaccine that they refuse to use and it’s free and available”.
But as Green’s colleague, Dr Hayley Frieslich, makes clear, the ED is open to all.
It’s been a rugged couple of months but with the surge on the wane, the staff at the Gold Coast University Hospital take us on a virtual tour, detailing the treatment, the monitoring, the care that is provided when a patient’s Covid symptoms bring them to their door.
The journey begins at the emergency
department. It looks a little different at the GCUH in these days of Covid, with two airconditioned Covid triage tents erected in the grounds; one for ambulance arrivals and the other for walk-ins. The staff inside look different, too: dressed in personal protective gear of masks, visors, gowns and gloves.
And the patients? They’re in all manner of conditions. Some arrive gasping for air and incoherent, the lack of oxygen causing confusion.
If a patient has a mild case and no extra risk factors, they are sent home, equipped with information about how to care for themselves and monitor symptoms for deterioration. Some will go home but be admitted into a virtual clinic. Severe cases go straight to the main ED. Others with moderate disease or comorbidities are admitted to a Covid ward.
To make that call, the doctor assesses the patient’s respiratory function, their level of fatigue and medical history. “If you’re an elderly patient who has active cancer or chronic respiratory disease or morbid obesity or diabetes and you’re unimmunised, even if you present with relatively few symptoms, you need to be carefully assessed because your risk of dying of Covid is much higher,” Green says.
“The other thing that is tricky is that the deterioration of patients doesn’t happen the day they get diagnosed with Covid; it’s often five to seven to 10 days later.” Conversely, some people may look reasonably well on admission but the next afternoon, they’re on a ventilator in ICU. And while young, fit people tend to cope well, “there are occasions when they don’t”.
Omicron has been deadly. Its severity is less than Delta but it transmits more readily. “Because it’s such a big caseload, even if
2 per cent of the case load is seriously ill … that’s a heck of a load when you’re getting thousands of cases each day,” Green says.
His colleague Frieslich says the surge has meant a lot of double shifts and overtime, particularly among nursing staff, with shortages due to Covid diagnoses or being close contacts.
For a long while, Frieslich says, as they watched their colleagues in Victoria and NSW slog it out, week in, week out, many Queensland medicos felt something akin to survivor’s guilt. Now they’re in the tents, in the PPE, dealing with a pandemic that has challenged the world.
“It almost feels right now that we’re taking our share,” she says.
EVEN IF
2 PER CENT OF THE CASE LOAD IS SERIOUSLY ILL … THAT’S A HECK OF A LOAD WHEN YOU’RE GETTING THOUSANDS OF CASES EACH DAY
Rare soil infections were the out-of-the-box
type of disease Michelle Kimmins thought she’d be dealing with when she became the nurse unit manager for infectious diseases in August 2019.
Six months later, Covid-19 arrived and she’s been riding the rollercoaster of a pandemic ever since. “That was on no one’s radar, was it?” says the nurse with more than three decades’ experience.
The original admission of the tour group from Wuhan in January 2020 gave way to the arrival of hospital-quarantined travellers, many of whom weren’t sick. Some were abusive, arguing they were being kept against their will. Then came the Indooroopilly cluster of August 2021, which saw a few patients at GCUH. But this Omicron wave has been the most intense period of seriously ill patients.
At the peak of the Gold Coast’s surge, on January 20, there were 202 patients across eight Covid wards – some in the GCUH’S sister hospital, Robina and the ICU. Kimmins is in charge of D5 North, the original Covid ward, which has negative pressure rooms and is reserved for more serious cases.
The science of healthcare still captivates Kimmins, especially with the emergence of a novel coronavirus, but her great passion is “the difference you make to (patients) emotionally”.
She knows it can be disorienting for patients to arrive at a Covid ward to be greeted by nurses dressed in PPE. “About all they can see is our eyes,” Kimmins says. “So, it is challenging for them. And sometimes those frustrations do boil over into anger.” Nurses have experienced the gamut of emotions from patients – from gratitude to tears to abuse.
Kimmins says the abuse has never turned physical and was more prevalent during the mandatory hospital quarantine period than now. “As our patients are getting sicker, they’re getting less aggressive towards us,” Kimmins says.
Each patient is admitted to a private room, and visitors are only allowed if a person is dying. “We’ve had lots of scared patients and they do feel isolated and they’re vulnerable,” Kimmins says. “As much as we’re there to treat them, we can never comfort them like their friends or family can.” Nurses will help patients navigate social media apps to stay in touch.
Reassuring the patient that they’re in good hands is the main aim as the nurse and a sanitation officer take a new arrival through the layout of the room and the way the ward runs. They’re told that while they may not see a nurse or doctor as often as in other hospital stays, their condition is being monitored.
The reduced contact is partly due to the need for medical staff to change their gown, gloves and eye covering every time they go into another patient’s room. “It’s a bit of a slow process,” says Dr Katherine Garnham, an infectious diseases specialist based on the Covid wards. But when a doctor does visit, it’s a comprehensive consultation. “When you do see someone, you’ll see them for 30, 40, 60 minutes,” Garnham says.
Oxygen is the most immediate requirement. Less severe cases will receive regular flow oxygen through nasal prongs while other patients need high-flow oxygen. In most cases, those patients will be in the high acuity D5 North ward “because you need to have regular monitoring and maybe a bit more extra help with proning”.
Proning – the simple act of lying on your stomach – has been a revelation in Covid treatment. “Proning is almost better than anything to stop your Covid from getting worse,” Garnham says. Turn on to your stomach and oxygen levels rise dramatically.
Physiotherapists are on hand to help patients prone, easing the load on nursing staff. In some cases, particularly if the patient has an underlying lung condition, physios will do chest work to shift mucus that is clogging the airways.
Three main medications are used, as dictated by national and Queensland guidelines. Dexamethasone, a corticoid steroid, is the standout medication shown to make a “big, proper difference” in Covid patients.
Those who have had Covid for less than about six days might also receive antiviral drug, remdesivir. Its job is to inhibit the virus replicating, making it useful in the first week of infection. And a low, prophylactic dose of an anticoagulant blood thinner, enoxaparin, is given as an injection to ward off blood clots.
Blood clots in the lungs’ arteries are “something unique to this particular coronavirus,” Garnham says. If a clot is found after a CT scan, the dose of enoxaparin increases. “Part of the body’s response to the
PRONING IS ALMOST BETTER THAN ANYTHING TO STOP YOUR COVID FROM GETTING WORSE
virus … is that you are 10 times more likely to develop a pulmonary blood clot.”
It’s in the second week that deterioration is most likely to occur. “Covid is what’s called a biphasic illness so you have your first viral symptoms and viral pneumonia symptoms early on; most people get a bit better and then if you are going to get worse, it’s that second week with all the lung inflammation that does the damage.”
Much of this progression is due to what is called the “cytokine storm”, an overactive inflammatory response in which the body attacks itself. “The lung involvement in that second week can be anything from a mild cough that won’t go away, all the way up to such severe inflammation that your lungs are full of fluid and your heart can’t pump anymore,” Garnham says. “It’s a real spectrum.”
Garnham says most people tend to pick up within 48 hours but if they continue to deteriorate once put on high-flow oxygen, a patient may be moved to intensive care.
The main determinant of ICU admission is if you need oxygen beyond what can be safely provided on the ward, which is up to 40 to 50 litres a minute.
But for some patients, every intervention is not enough. That’s where nurses such as Kimmins come to the fore. “They may or may not have gone into ICU but the treatments that we have to offer them aren’t working,” Kimmins says. “Then the focus shifts to making them comfortable and giving them the best end of life that we can.”
Every so often, as intensive care specialist
Dr Jon Field details his work, his hospitalsupplied phone lets off a beeping alert. That’s a notification to staff that a Covid-positive patient is being moved through a part of the hospital and to stay out of the corridors.
If someone needs moving to ICU, Field is often part of the decision-making team. Needing more than 50 litres of oxygen a minute is the main criteria but other signs include an inability to speak and exhaustion.
Intensive care admissions of Covid patients peaked at 15 patients on January 15. For those who need intensive care, the first stop is a CT scan of their lungs. When healthy, the lungs are shaded black. In some Covid patients, they are completely whited out, a sign of serious Covid pneumonitis.
“The virus process in the lungs is causing the lungs to silt up and they can’t carry out their normal duty of absorbing oxygen and excreting carbon dioxide,” Field says. “They have horrendous looking scans when they have bad Covid.”
Bacterial, or secondary pneumonia, might also be detected but is less common. Blood clots are not. “We’re finding that about a third of patients seem to have blood clots in the lungs,” Field says. “Quite a high frequency.”
Once in the ICU, a patient is hooked up to cardiac monitoring and pulse oximeter blood pressure monitoring. Oxygen supply may be switched to non-invasive ventilation; a tightfitting mask fitted over the face to deliver oxygen under high pressure
The patient is monitored, continuously, with one nurse dedicated to their care. Proning continues, for between eight to 12 hours a day. Medications continue, with the possible addition of some monoclonal antibody treatments. Then it’s a matter of waiting to see if the patient improves or deteriorates.
Globally, doctors have learned that noninvasive ventilation and proning are so beneficial for Covid patients that intubation and mechanical ventilation is delayed. “They’d have to be moribund, unable to speak, exhausted,” Field says. But for some patients, intubation and ventilation is necessary. A general anaesthetic is administered and a plastic tube put into the windpipe. “Then we can apply oxygen, positive pressure, through it again.”
Patients tend to need some sedation to tolerate the tube and will continue to be proned, as well as receiving physiotherapy. They are fed via a tube through the nose into the stomach.
X-rays of patients are taken nearly every day. “The primary thing we look for each day is the requirement for oxygen and how your lungs look on X-ray,” Field says.
Some have died of Covid in ICU. “If we can’t deliver oxygen despite maximum treatment, they die of oxygenation failure. You’re on a respirator, you’re on 100 per cent oxygen, all the treatments have been given, everything’s turned to maximum and despite maximum effort and maximum treatment you’re still not oxygenating. Those patients slip away.” About 30 Gold Coast residents have died with Covid.
But more survived. Once you start to need less than 40 per cent oxygen, discussion turns to removing the ventilator. Blood pressure, heart, kidneys, lungs all need to be working reasonably well. Then sedation is reduced, you are asked to follow simple commands, have a good cough. “If you have enough oxygen with the ventilator turned down, then we’ll take you off and see what you look like without it,” Field says. And their reaction when the tube comes out? “Relief,” Field says. “Enormous relief.”
The journey doesn’t end there. More time in ICU, then the ward, is likely before being discharged. Some will have organ damage and need ongoing specialist care. Others will battle Long Covid. But they’ve made it, thanks, says Field, to a staff across all disciplines that has been willing to step up, learn new roles and care.