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In the Dark

Test, test, test.

Dr Tedros Adhanom Ghebreyesus, WHO Director-General

I won’t soon forget the handover meeting on my final morning.

“There is a patient with a cough and a fever on the ward who is being treated as query COVID-19,” one of the on-call doctors said to the ward team, exasperated after a long shift.

The ears of everyone in the meeting pricked up. The junior doctors looked uneasy. The ward consultant’s eyes narrowed. The team was mute as they considered their options. The evolving pandemic had already established itself as a major public health emergency.

The on-call doctor sighed and shook his head. “He’s isolated in a side room, but we don’t yet know if he’s tested positive. The porters weren’t even using PPE when he was transferred from A+E. Nurses were doing obs without any protection.”

The consultant slapped their hand on their forehead. “This is just chaos. It’s crazy.”

Now, the threat was as proximal as it could get.

Public Health England has guidance for clinicians which says that patients like with a ‘flu-like’ illness like this should be treated as query COVID-19. This means isolation in a side room, full PPE for people entering the patient’s room and sending off samples for testing.

But here’s the problem: there are lots of patients in hospital with a cough and fever at any one time. What do you do with all of them? Think about how many people would need isolation, how much PPE would be needed, how much disruption this would cause to the staff’s usual work (which isn’t exactly easy to begin with).

The COVID-19 case definition according to PHE is (you’d hope) very sensitive (picks up most cases) but not very specific (people with other respiratory illnesses, like the flu, also fall into the case definition).

From a health protection view, having a sensitive case definition is good because it picks up most of the cases you want to treat. Indeed, Professor Andrew Morris from the University of Toronto provides justification for the broad case definition:

At this time in our history, I would say that anyone who comes in with a fever or any of the common respiratory complaints – whether that’s cough or shortness of breath in particular – you should absolutely be thinking of COVID infection. And I say that because this is so widespread, that it’s largely overtaken – in terms of its epidemiology – many of the other common respiratory infectious diseases we see…

He continues:

That doesn’t mean we aren’t going to see Influenza. In fact just in this past week we had a patient come in who we strongly suspected COVID-19 infeciton, but infact ended up having Influenza B. We’ve had another patient who we also suspected as having COVID-19 infection who ended up being a bacterial pneumonia. So, it can be very difficult and even though there are some heuristics that we can now use to help us at least increase our suspicion that it may be COVID-19 infection, I think because of the current epidemiology we have to assume it’s COVID-19 infection until proven otherwise.

Professor Andrew Morris, Emergency Medicine Cases podcast, Ep. 137

What does this mean? Because lots of patients fall into the case definition, it means LOTS of people will need stringent infection control measures put in place. LOTS of PPE will be required. LOTS of tests will be needed.

Here’s the crux of the issue: the patients that fit the case definition just weren’t being tested fast enough. If you’ve got a very sensitive – but not specific – case definition, you need to triage the patients with a test that is VERY specific. That allows you to filter out any false positives which result from using the case definition alone.

There is a test that fits the bill: RT-PCR. This test picks up the specific sequence of coronavirus (more specifically, SARS-CoV-2) RNA. This is the gold standard test. If this come back positive, there’s a very high degree of certainty that the patient has COVID-19.

blog4-filter

The two filters in a simplified COVID-19 diagnostic pathway. Filter 1 is the case definition, which removes lots of patients without symptoms consistent with COVID-19 (such as people with strokes and heart attacks). Filter 2 is the gold-standard RT-PCR test, which is much more specific to COVID-19.

In an ideal world, with plenty of testing kits, a doctor should be able to send off a throat or nose swab from a query COVID-19 patient and get the results of the PCR on the same day. But it just wasn’t happening. In some cases, the results were taking five days to come back. That’s just not acceptable when there’s a pandemic raging.

Why the delay? Too many samples, not enough testing capacity. In addition to the usual delays in transport and processing, queues of samples were already building up because the testing facilities couldn’t deal with the influx of nose and throat swabs needing testing. We often hear about the ‘surge capacity’ of the health service in terms of the numbers of beds, numbers of ventilators etc. but the same is true in the laboratories. Contrast the UK’s situation with South Korea, where they had built up big testing capacity in their public health laboratories following on from the SARS outbreak in 2003. Their early, extensive and rapid measures worked.

You’re fighting a fire blindfolded if you don’t know which patients are positive and which ones are negative. You need to know who’s got coronavirus and where, so you can isolate, treat and divert resources appropriately.

Being in the dark has huge consequences – in the hospital, it creates an atmosphere of confusion and panic. In the case I witnessed, it became apparent that the correct PPE hadn’t been used because the case had not been confirmed COVID-positive. No PPE in A+E, no PPE in the transfer to the ward and no PPE in any ward care as of yet. So many points of transmission had already occurred.

I want to emphasise: there was a LOT of confusion. You would’ve thought that any query COVID-19 case would warrant the use of PPE, but for one reason or another, it just wasn’t happening. In some instances, there was delayed recognition. In other cases, there was a lack of communication as patients were transferred from A+E to the wards.

Back in the handover meeting, the team re-assessed and the ward consultant highlighted the need to wear PPE. But there are widespread shortages. of appropriate PPE, and that was being felt here on the frontline. Only flimsy aprons and gloves were available.

“I’m worried about getting this myself because of my asthma,” one nurse pleaded. “How is a flimsy apron, crappy mask and wrist-length gloves going to protect me. I can’t even get the right size gloves.”

The lack of testing compounded the problem with PPE. If you’re waiting for days to get a result back from the lab which could turn out negative, it could mean resources like PPE are being diverted from where it’s needed most.

Doctors, nurses and other healthcare professionals (HCPs) are a high-risk group. They are exposed to more potential cases and are more likely to receive high viral loads during transmission, which predicts worse outcomes. The problems patients were facing with a lack of testing also extended to the staff. Although the government had announced widespread testing of HCPs, it just wasn’t happening quick enough (or in some cases, at all).

If HCPs aren’t tested, there are two issues: firstly, HCPs who are actually infected with coronavirus and don’t know it can act as superspreaders in the wards. Secondly, it creates staffing problems, because if a doctor, nurse or one of their family members develops symptoms they all need to self isolate for 14 days. HCPs are often married to one another, so this could knock out two staff members at once. It’s a non-sensical situation; when the NHS needs staff the most, they’re faced with lots of staff taking sick leave for two weeks or more.

The testing of healthcare professionals needs to be prioritised, and it needs to be done fast. If they aren’t tested, they could be self-isolating for no real reason, and they may have to self-isolate more than once. Each time they or a member of their household has a cough or temperature, they need to self-isolate again.

The problems extend to GP practices too. Now consultations were being done via phone. If GPs spoke to someone who reported fever or a cough, they needed to tell them to self-isolate. But the patients weren’t getting tested since RT-PCR tests had now been reserved for hospital inpatients – it often wasn’t clear at all whether they had coronavirus or not. After the period of self-isolation, if they developed symptoms again, they would need to self-isolate… again. You can see the problem: it becomes chaos. The enemy is lurking in the shadows and you don’t have a flashlight.

In primary care, staffing issues were, again, a problem. In one GP practice I had previously been to on placement, almost a quarter of staff were quarantined because of a sick family member. Primary care – the most critical part of the health service responsible for 90% of patient interaction – risked grinding to a halt.

My story is not unique. The crisis national. There is widespread lack of testing and there are PPE shortages across the board: the fifth-largest economy in the world, unable to provide critical healthcare staff with the basic protection to keep them safe. The situation is beyond belief and the duty of care owed by the government to the staff has been breached.

The whole situation has made me incredibly anxious as a final year medical student. I would be overwhelmed starting as a junior doctor – a complete rookie – in a system where the veterans are struggling to cope. If there’s not enough PPE, I’d get sick and even potentially spread it. I’d feel like a burden. My FY1 job is in St Thomas’, one of the hospitals at the epicentre of the UK’s coronavirus crisis. Several patients are on ECMO to support their heart and lungs because of this bloody virus.

We aren’t even at the peak of the coronavirus crisis yet – by most estimates, we are two weeks behind Italy – and the NHS is beginning to crack under the immense pressure.

To the public: stay at home. To the government: save our staff. To healthcare workers: you are heroes.

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