Lana Spawls talks to Thomas Jones about working on a paediatric ward during the Covid-19 pandemic, and the ways hospitals have changed in response to the virus.

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Lana Spawls: How to set up an ICU

Adam Tooze: Shockwave

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Thomas Jones: Quaresima


Thomas Jones: Hello, and welcome to the London Review of Books podcast. My name is Thomas Jones, it's Tuesday 14 April. Over the weekend I spoke with Lana Spawls, who's a paediatrician in London. Lana wrote her first piece for the LRB, a diary about what a junior doctor does, in 2016. Her piece in the current issue describes how to set up an intensive care unit. She talked to me on Saturday between shifts (she was back at work on Sunday evening), about the ways hospitals have changed in response to Covid-19.

Hello Lana, thank you for joining us. In your piece in the current issue of the LRB you describe what it takes to set up an ICU, an intensive care unit? But you're not actually working in ICU yourself, is that right? Because you're a paediatrician, so you're still working on the paediatric ward.

Lana Spawls: Yes I am. Many of my colleagues have been moved over to the adult side to look after patients with Covid. I'm not one of them myself, but there has been a lot of reshuffling within the hospital to kind of move people from areas that are less busy to areas that are more busy. So that includes moving people, doctors, out of paediatrics and also out of community services and things like dermatology or allergy clinics that aren't running at the moment. They've all been pulled into the hospital to treat all the adult patients with Covid.

TJ: But you're not because you work with newborns and obviously some things can't be put on hold and can't be stopped.

LS: Exactly. So babies are still being born the whole time and so we still need a service to treat them and look after them. And the whole maternity service obviously still needs to be in place. 

TJ: But there have been changes to it, haven't there? Because for example, what happens if you have the mother who's tested positive for Covid and has a baby, what happens then? How does that change your working?

LS: So obviously it changes what you wear in terms of the PPE and the masks you have to wear, and the gowns. And you also treat them differently. So if the baby's well, they stay with the mum and they get looked after. If the baby's unwell and has to come into the neonatal unit, then we have to ban those parents from coming in because they're positive and they might spread it to other people.  And the babies are kept isolated until we can be sure whether the babies are negative or positive.

TJ: In terms of testing, so if a mother comes in with symptoms she'd be tested for Covid? Or they all are? Or only only symptomatic?

LS: So mostly it's only the symptomatic people who are tested, but they're all presumed positive until we get the negative tests back. So you'd treat them as if she is positive until proven otherwise.

TJ: And is the baby tested, then as soon as it's born? It's sort of part of when they get their vitamin K  jab and they have a Covid test.

LS: So we tend to test them a couple of days after they're born, so there's time for them to develop enough of the virus to pick up, and we do a couple of tests and you wait until all of them are back and negative before you consider them not to be Covid-positive because amongst the test there is already quite a high false negative rate. I think lots of places said it's up to about 30%. So you want to do, particularly with these babies, you want to do a couple of tests to be sure they're definitely negative before we allow them to be in the same room with babies who we know don't have it.

TJ: Sorry, is that a 30% false negative for everybody, or for babies?

LS: Everyone.

TJ: And how many times do people get tested then? So, if you test negative because of the high false negative rate, does that mean you try and test everyone at least twice, or is that just not possible?

LS: I think if you are really strongly suspicious that they do have Covid, you probably would test them again a couple of days later, and definitely from all the reports in China they were saying they had a lot of people that tested negative, but they could see signs on the X-Ray or the CT scan that they did have Covid, so then they retested them and then they were positive.

TJ: And is that something that you've found – I was talking to Rupert Beale at the Crick Institute last week, who was saying that doctors are getting much better at diagnosing it without the tests, and that, as it were, it's just the experience of seeing enough patients who have it, doctors are getting better at diagnosing and knowing who needs testing because you can tell who's got it.

LS: Yeah, I think the more that you see the patients with it, the more you pattern recognition, when the symptoms, you know, the kind of pattern symptoms go through, but there is still a lot of variability amongst patients and some people, it seems that there's a big number of people who have no symptoms at all or some that, you know, some follow a more traditional pattern, but others – like we see a lot of children that have diarrhoea as their main symptom which, conventionally, you may not have thought of that as being part of Covid, but actually now people are kind of recognising more that might be their presentation. So they’ll probably get tested more routinely now.

TJ: And in terms of treating children who do test positive, what do you do with your patients who have tested positive? Does it complicate their own health, if that's even the word? With a newborn baby who has Covid-19, what’s –?

LS: I've not seen any myself, but from the literature and reports they're normally completely, and at most, they're just a bit, you know, have a bit of a snuffly nose, but they're otherwise completely well in themselves, and that applies to the majority of children. There obviously are some children that get more unwell, but they tend to be the ones who do have more underlying health issues. But you would treat them ultimately similarly to the way you would treat adults.
So that means giving things like oxygen or any sort of breathing support. If they're really unwell, then sometimes you have to incubate them and put them on a ventilator. And then obviously the usual things, paracetamal and fluids and just basically supporting their body to fight off the infection.

TJ: And is the paediatric ICU separate from the adult one, or the children go into the adult?

LS: Yup, so normally they're completely separate and they're run by completely separate teams. They're often in different buildings. But across the UK, there's a lot of movement to have a few designated paediatric ICUs in a few hospitals, and then the other paediatric ICUs can be turned into adult ICUs. So they're kind of centralising it so that patients, you know, if you have a hospital that they might normally be admitted to, and that normally has a paediatric ICU, but that's now shut and they'll be transferred to another hospital, which is now like the designated paediatric ICU. Does that make sense?

TJ: I think so. It's quite complicated. So, the levels of reorganisation among hospitals and between hospitals have been quite significant. I haven't they?

LS: Exactly. There's been a lot of coordination and trying to transfer patients to a lot of different hospitals in order to make the room where you need it.

TJ: And in terms of the Nightingale, the specialist, dedicated hospital that's been set up in the Excel centre, is that taking patients yet, or is that still waiting for when –?

LS: So apparently they have started taking patients. I don't know how unwell those patients are or what level of care they're actually given at the moment, I think they've only taken a small number. 

TJ: Because it isn't actually an ICU is it? It's a high-dependency unit.

LS: So they claim it can be an ICU. I think it's a little bit difficult when I don't know exactly how it's going to work in terms of – obviously you normally have a lot more things on site in terms of labs and x-rays and things like that. I don't know how well that is all set up there. But I think it sounds like their plan is that it'd be patients who've been admitted to hospital, need an intensive care or high dependency unit care in one of our normal hospitals, and then they would get transferred to there once they're stable on whatever ventilator settings you've got them on.

TJ: I saw on the news today that Holby City has donated it's working ventilators.

LS: I didn't know they had working ones. I thought they’d have fake ones.

TJ: And in terms of doctors getting sick and being tested, you had, I hope it’s alright to ask about this, you had symptoms yourself, didn't you, a couple of weeks ago? A few weeks ago?

LS: Yeah.

TJ: So what do you do when you think you have it as a doctor?

LS: So obviously as soon as you think you've got any symptoms, you obviously have to let your team know that you're not going to be coming to work. And like everyone else, we have to stay at home for the seven days from getting symptoms or 14 days if it's someone in your household that's got symptoms. At the point when I was unwell, we didn't have any staff testing. It is now coming in, but a lot of the centres – there's designated centres that people can go to, to be tested. And some people's own hospitals are also testing them. But often most of the centres are drive-through, so that kind of limits it to people who can drive already, and have a car.

TJ: So it is literally drive-through.

LS: It’s literally drive-through. You open your window, someone in PPE comes and sticks a sawb in you or gives it to you to do yourself, and then you pass it back out your window, and they send it off.

TJ: Do you drive?

LS: No, so I don't own a car, so I wouldn't be able to be tested in this way, in which case I'd have to be off for a week.

TJ: And you can't ride your bike to the drive-through?

LS: I don't think for the main drive-throughs you can. I think some of the hospitals are letting people cycle there. But also the question is, if you're cycling through a major city, I know there's obviously less people around than usual, but there’s obviously the risk that you might transmit it, and obviously you can't get public transport there if you think you've got symptoms.

TJ: So the point of the car is that in your car, you’re still –

LS: You’re still isolating in your car. 

TJ:  And then the question of PPE, because it's something that I saw out on my daily walk yesterday, that there were a couple in a car and they were in their car, windows up, they were both wearing masks, they were both wearing gloves. They were readjusting their masks with gloves on in the car. And that’s not best practice, for PPE, is it?

LS: No, so you’re meant to be very cautious not to touch your face with the mask on because then you can kind of break the integrity of the mask, and you might then pick up something that's on the outside of your mask onto your hands and transfer it to your face.

TJ: And you are having to wear more protective equipment then you would have done a year ago.

LS: Yes. So we're now at the point where you're assuming everyone in hospital might have Covid, regardless of whether they've been tested for it or not.  So for every patient you’re normally wearing at least a surgical mask, gloves and an apron. And then, for people who are actually confirmed, you'd probably also, depending on what – there's also a lot of stuff about when there’s aerosol generating procedures, and these procedures, that might include things like doing CPR or intubating someone, you have to wear more high tech mask, which are these FFP3 masks, because the thought is that those procedures expel the virus into the air that you can breathe in, rather than being just droplets that have landed on surfaces, that you might get by touch.

TJ: Do you have  enough equipment? Just speaking for yourself in your ward, do you have the equipment you need?

LS: Yes. We have so far from what I've seen, but I know that a lot of other hospitals have been struggling to get it, and there's obviously been a lot of news reports about it and about people having difficulty getting all the PPE they require.

TJ: And if, for example, without thinking or by mistake, you touch your face when you’re wearing gloves or you adjust your mask and you break the seal, then do you throw it away and put on a new one?

LS: Yeah, so you’re meant to clean your hands, throw that one away, clean your hands again, put on a new mask.

TJ: Matt Hancock wouldn't think that's –

LS: I don’t know if he thinks that’s wasteful or not, but you have to be safe.

TJ: Yeah, of course. You're saying that obviously procedures  that can be postponed or delayed, have been, or things that can be done in the community – but presumably there are also some people, or there have been news reports of people who needed to go to hospital, but either because they're scared themselves, haven't been, don't go in and have got much sicker than they otherwise would have been. In terms of of A&E admissions for children, have you noticed that going down significantly?

LS: Yeah, so there's definitely been a massive drop off in attendances to A&E, both in paediatrics, but also a drop off in adults. The majority of the people that are coming into adult A&E are Covid, but they’re still less busy than they probably, for lots of them, than they would be on other normal days  And there’s obviously a big worry that people are not coming in when they have their heart attack or their stroke or something, they're just carrying on at home for as long as they can because either they don't want to come in, because they're scared of catching Covid while they’re in hospital. There's also some concern that 111's advice for anyone who has a temperature is immediately just stay at home, isolate, don't go to hospital. But for a young baby that's coming in, that might be a sign that they have sepsis and normally we'd be doing blood tests and starting antibiotics on these babies, and they might be getting missed because they may be advised by someone that, ‘Oh, it's probably Covid, day at home’. So I think there is ongoing work with 111 to be trained more about trying to pick up those nuances. And obviously they've had a massive increase in their workload in quite a small amount of time. So I think obviously there’s probably a lot of pressure on the 111 system at the moment, but there's definitely concerns that we are missing these patients and that they are coming in later and sicker. And I think even with Ebola there was some evidence that there was a higher mortality from other conditions at that time because people weren't coming to hospital, because they didn't want to catch Ebola or any of the other outbreaks like SARS and things. And there's also some concerns as well that pregnant women aren't coming in as much as they normally would. So most of them are now having remote consultations over telephone or video calls with their midwives. But also that some of them might not be coming in as soon as they normally would do if they felt the baby wasn't moving as much, or all these kinds of little things in pregnancy, which might be a sign of something that's actually quite significant. If more of these women aren't coming in as early as they normally would, therefore we're not able to intervene in the way we normally would.

TJ: And are more women having babies at home. Are there more home births since this started?

LS: So I'm not sure if there is definitely, yet, but I think there'll be a lot of people trying to encourage those women that are safe to have a baby at home, to have them at home because it just reduces the number of women coming into the hospital and the number of people that are in the hospital and potentially could be exposed to Covid.

TJ: While on the one hand it's obviously worrying that people with more serious conditions are not coming into hospital, there are some things which, as it were, people who would go to A&E when they really didn't need to. I mean, they're not going either. And I presume, there's some things that can be done in the community.

LS: Yes. And I think we are trying to do much more in the community than we used to do. So things like whether people can have blood tests done at the house by a midwife or a community doctor or nurse or someone who can come out and do some of those procedures, to save people coming into hospital, going to the phlebotomy service, mixing with other people. So there's a big move to get people as much treatment as they can at home, which obviously for the patient, actually a lot of the time, is better than them having to come into hospital. If someone comes to your house and does the blood test, that saves you a trip into the hospital and that kind of stress associated with that 

TJ: And is there any work that you do that you as well you can do from home rather than doing in the hospital? Paperwork or any of that?

LS: So we've started  – there's doctors who are home either because of their own health needs, so they need to, you know, anyone who's got bad lung disease or immunosuppressed might have to stay at home for their own health, to not be exposed to it, and also there's a lot of people who are on call at home that can come in if needed, but actually when they're at home might do other work. So lots of hospitals are setting up doctors with remote access at home, and you can just do the paperwork that you would normally do on your shift  from home. So things like writing discharge letters for patients and ordering routine investigations and things like that.

TJ: And has your workload gone up? Are you having to work more hours, longer shifts? 

LS: For me at the moment, it's probably about the same because I'm isolated in the neonatal unit, and you still have the same number of – we're kind of a protected service, so we still have a good number of staff to meet our needs.
But I know obviously in the adult side of it and the people looking after Covid patients, that they're obviously working hard and longer hours and a more irregular pattern. Normally you’d get six months at a time for your rota to lead you up until the summer or something. But at the moment, most people are getting it week by week or only a couple of weeks at a time because everything keeps changing, and staff are moving and staff are off sick. So everything just has to be really flexible.

TJ: And the other thing, that relatives or fewer relatives are allowed in hospital at the moment, aren't they? There are severe restrictions on visitors?

LS: Yes, at the moment, all adult wards are not letting anyone come in to visit, which obviously means for the patients who are unwell in hospital, they don't have the support network, they don't have people to provide comfort and care for them. And then that also puts extra toll on the doctors and nurses and healthcare assistants and everyone who's there, because, you know, obviously then there's a need to provide a lot more emotional support for patients and to be the person who's there if they're otherwise dying alone or they're unwell and they need someone to talk to. So I think it's very difficult both for the patient who's in the hospital, but also for their relatives who are sitting at home. Often the relatives are having to self isolate completely because they've been in contact with their relative who is now admitted for Covid and it means they're just waiting for a phone call from the doctors to say, good news or bad news or whatever.

TJ: And it must be extra pressure on the doctors and nurses who are having to provide that level of, or trying to provide that level of emotional care, as well as their other professional care.

LS: Exactly. And I think it obviously puts an emotional toll on the doctors and nurses as well because you feel you want to do more for these patients than you can in terms of emotional support. Because often, as you say, you have all your other duties that you have to do and sometimes you can't spend as long talking then still have a long list of other jobs you need to do, and then pulled in all different directions. And I think that's quite stressful and upsetting for a lot of the doctors and nurses on the wards at the moment.

TJ: And obviously some of those, a number of those, patients who are dying are themselves doctors, aren’t they, and that caring for colleagues –

LS: Yes. There seems to be quite an unfortunate number of doctors and nurses and pharmacists who have all died from Covid. Obviously we'll have to investigate it further once this is over, to know how much is related to their exposure at work and whether it was related to them not having enough PPE. I know one of the doctors had been posting on Facebook a few weeks before complaining about the lack of PPE in his hospital, and so there obviously are big concerns about whether there's enough supply of PPE in all hospitals, and also that the guidance has changed a lot, and there are some differences between the WHO guidance as well as our Public Health England guidance, which I think leads to a lot of anxiety for staff members as to which one they should be following. And obviously, it's very scary for those that are working directly with patients with Covid, it’s the risk that that poses to you and to your families back home when you come back each day from work, and a lot of people are doing quite complicated routines of cleaning their clothes and making sure when they come into the house, they immediately undress, shower, clean everything, to ensure that they don't risk passing anything to their family members.

TJ: You say that shifts are now being planned a week or two in advance, and rather than six months ahead, do you and your colleagues look beyond the next few days at the shift to how this may end, or is it just too early to start thinking about it? 

LS: Yeah, I think we're all very cautious and kind of assume that it's actually going to be months and months and months of disruption. It's going to be probably quite a while before we all completely go back to normal. And I imagine any kind of return, and stopping the lockdown would obviously have to be a very staggered, gradual approach. And I think amongst medics, there's obviously also a big worry that once you get rid of the restrictions on people, that then will have a massive new surge again and we’ll be back where we were, back where we are how.

TJ:  I saw there were reports that around 90 people in South Korea who had been positive and had thought to have got better, have now tested positive again, and they don't know if that's being reinfected or if they've never actually fully recovered. 

LS: Yeah, and I think that's part of the concerns. And there's obviously been talk about antibody tests and whether that means, if everyone gets an antibody test and they've shown that they've had it before and they've got an immune response and then they can all go back to work and everything could be fine. But I think there are lots of concerns about whether we're sure that people develop proper immunity to it and whether you can catch it again, or whether you might be able to still pass it onto other people. Even if you're immune yourself, if you can – some bugs like MRSA you can just carry in your nose. So whether you can carry it on you and pass it still to other people, then obviously you’re still at risk to other people.

TJ: And presumably someone, even if they were immune, could still carry it on their hands as it were. So that way of passing it on, it makes no difference if you have antibodies or not. It's not as if you're magic antibodies on your finger are going to zap the virus.

LS: Exactly, yes, you can still pass the virus in droplets on your hands to people or objects.

TJ: But more positively, people are getting better and are being discharged. And  at the moment, ICUs have not been overwhelmed. And, as they say, the front line has not been breached. So, I mean, it's working. The doctors are doing an amazing job and most people who get it are getting better. 

LS: And actually the majority of people who have it are sitting at home with their cough and never get tested so they never know for sure, but actually loads of people have it and are completely well and never need to go to hospital at all. And there obviously are quite a lot of people that go to hospital with it and recover and get better and go home. So there are a lot of positive stories that are, and we do still have capacity in ITU to look after these patients. So, in some ways it is amazing how hospitals have managed to create a lot more ITU space. And I’ve found it really positive to see amongst all the other staff members, everyone's so willing to help in any way. You know, you have people who've only ever worked in paediatrics who are willing to go work in adults. You have people who normally work in the community nursing teams and are willing to come into the hospital, work in that environment, with the risks, you know, acknowledging that there's a risk to themselves that they otherwise wouldn't be at because everyone wants to help and everyone's kind of coming together. And there's been much more interlinks amongst different hospitals so that everyone really is working like a big team to try to do the best that we can for the patients.

TJ: Thank you, Lana, very much.

LS: Thank you.

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