DISCLAIMER: I do not intend for these blogs to be seen as giving clinical advice nor as judging public health policy but rather to recount the lived experiences of physicians from across the world. I recommend you still follow your local guidance.
The narrative of COVID-19 has centred around the virus’ preponderance for the elderly and has been perceived publicly as a death sentence for anyone over the age of 75. In this climate, I could imagine that the geriatricians all over the world were braced for the biggest challenge in their career. Much like family medicine, geriatricians are generalists and, alongside the respiratory physicians and ITU doctors, this pandemic was going to be their time in the limelight.
In this setting, I talk to Dr Lucy Abbott who is a consultant in the care-of-the-elderly specialty in a hospital just outside of London. Pre-COVID, she spent half her time doing acute geriatrics in the emergency department and the other half working in the community looking after a rehab ward – one half of the spectrum to the other.
When COVID was reaching our shores in the UK, Lucy was called back to the hospital to work as a general physician, something she had not done for over a year. She recounts her experiences with some bemusement as she describes the evolution of her practice as well as her confidence in managing COVID-19. At the beginning of the pandemic, she could feel her juniors’ eyes boring into her as she was trying to make heads or tails of the new disease but, by week four, she had found her feet again and was able to triumphantly regain her status as consultant as she grilled her juniors on the clinical and radiological findings of her coronavirus patients. She was really surprised on how little she could predict which patients would do well and actually how many did so well with some oxygen and some fluids and empirical antibiotics. Patients, who were so frail that she was anticipating watching them for a few days before the inevitable would happen, would suddenly perk up and rally home. Not as miserable as the popular press would make you think. She did note that many were more exhausted than your standard viral illness and more needed to be shipped off for extended rehab before making it home.
I try to imagine what it is like in hospitals at the moment and I wonder if I would have enjoyed it. No one likes to feel insecure in their knowledge but this must have been the time where all doctors had to get comfortable about knowing nothing. There was no text book to refer to and even the tiniest rash could be an unforetold COVID-related complication. I also wonder if it could have been quite fun as we have all had to work from first principles and try to figure out what was happening or would it not? It reminds me of the time I worked in the back end of nowhere in Uganda where there were we had limited investigation capacity and all decisions had to be made based on clinical findings. Furthermore, management had to be calculated with what was available and I would spend ages calculating what medications would be reasonable given their mechanism of action within the pathophysiology that I was working with. I believe that medicine is an art but it can be really fun tapping into the inner geek when it is stripped right down to the naked science. If only it was in better times.
From our conversation, I really sense the over-cautious fearful atmosphere within the hospital at the beginning of the lockdown and Lucy describes the minimisation of investigations to avoid cross-contamination between departments. However, once numbers of potential COVID patients increased, this was not tenable and the hospital adapted to have hot and cold zones. As we all know, we had a national shortage of testing and Lucy remembers the first week when they ran out of reagent in the hospital so they couldn’t do any COVID testing. Everyone just had to remain flexible and open-minded as things unfolded and evolved. She said that, at the peak, it felt a bit crazy and it felt like every patient had COVID but now there may only be one or two on the take list now. More worryingly, she’s noticed a spike in mental health presentations – suicide attempts and decompensated liver disease secondary to alcohol – more than she has ever witnessed on one on-call. They are starting to see the collateral damage.
During the pandemic, her hospital, like many others in the UK, started delivering seven-days-a-week care which meant that Lucy had social workers, physios and other members of the discharge team readily available even on the weekends. Furthermore, there were significant changes to how health and social care was being funded which meant that when a patient was ready to be discharged, they were discharged immediately without the need for quibbling over whether this was coming out of the NHS or social care budgets or from the patient’s own pocket – a process that could typically take two weeks for complex discharges. Lucy is a bit worried about what is going to happen in the future as this funding is not available forever but it has truly given her a taster of how hospitals can function when fully funded and fully staffed. She has really noticed how everyone from the hospital, the CCG (NHS bodies responsible for the planning and commissioning of health care services for their local area) and social care have really pitched in in positive ways, not bound by their traditional roles or by their traditional geographies. This is what it feels like to work when these silos are broken down and these artificial barriers have evaporated. But, as you can imagine, the current delivery of care is unsustainable financially and emotionally as many of the staff have had their annual leave and study leave cancelled. There was a naive Blitz spirit back in March where everyone got together to “beat” coronavirus but now people are exhausted and are facing the stark reality that this is a long game. Working in a hospital that functions at over a 100% capacity in pre-COVID times (like all NHS hospitals), Lucy is really worried about the winter pressures that are looming with the potential for a concomitant second wave in this COVID-present world. We know this completely depends on individual population behaviour and we are taking solace in the fact that not all countries coming out of lockdown before us have been hit by a second wave.
So let’s talk about care homes – a heavily contested area in the British response to coronavirus. The UK government has been heavily criticised about excluding care home deaths in the total death count, although this was not exclusive to the UK. The message that was being portrayed was that residents in nursing homes did not count. Certainly, as a GP, I received agonising phone-calls from care home workers, many from the BAME community, who had not received adequate PPE. Lucy also noticed this and really struggled witnessing the outbreaks in nursing homes due to the lack of protective equipment. Due to the lack of tests, patients were sent back to nursing homes without being swabbed on discharge to save tests for patients who needed to be admitted. There just wasn’t enough tests to do both. Now, things are a lot better and all patients need to be swab-negative on discharge and supply chains of PPE seem to have become more efficient. If we could have our time again, we should have protected our staff and residents in care homes with more testing and PPE although was this really possible in a global pandemic when everyone was scrabbling for the same resources? I appreciate the beauty of the retrospectoscope but we perhaps haven’t appreciated fully on a public scale what it must have felt like working in these conditions anonymously whilst your NHS colleagues were being lauded as heroes.
Like us in GP, and like in paediatrics, there has been a real drop in footfall of patients over 75 coming to the hospital which is a little unnerving as they will have to turn up sooner or later. Lucy feels that this is because there is a real fear amongst elderly patients turning up to hospital but she also is aware that GPs, nursing homes and admissions avoidance teams are doing their best to keep patients at home. In response to this, Lucy went out to look for her patients and is now working with the Rapid Response Team (a team consisting normally of OTs, physios and carers who receive referrals from GPs and paramedics) and seeing patients in their home. This seems to be working well and Lucy hopes to continue this service into the future. Interestingly, she feels that the geriatric specialty is going full circle. In the 60s and 70’s, geriatrics was mainly practised in the community in the UK and only really became a hospital specialty in the 80s and 90s. Will coronavirus encourage more community-based care? She hopes so and also feels that there will be better awareness of the inappropriateness of managing elderly patients in the hospitals where usually they get “stuck” due to social care reasons. One of my hopes here is that we can finally start demedicalising non-medical problems and that we can support our elderly patients holistically.
Another innovation that Lucy has been loving recently is the remote consultations. She openly admits that she did not imagine that it would work for her patients cohort who are often suffering from dementia or are hard-of-hearing or with visual impairment but it appears to have been really popular with her patients and their relatives. She is able to involve relatives who don’t live nearby (which is far more inclusive and may reduce the “daughter-from-California” syndrome) but also, for many relatives, means that they do not have to bring their frail parent to the hospital, pay for parking, look for a wheelchair and sit all morning in outpatients. I’m not surprised that this has been a popular move!
Geritatricians, like family physicians, are the voice of vulnerable and often forgotten people in our society and I can only imagine that lockdown and the response to COVID-19 would have been frustrating for many geritatricians across the world. Social isolation is worse for your health than smoking and can be a precipitant to depression and cognitive impairment. When we know that social interaction is a massive protective factor, lockdown is predisposing our population to health issues in the future. For Lucy’s population in particular, the little trip to the shops could be their only exercise of the day, and without it, the loss of muscle mass could be the beginning of the downward frailty spiral. She also points out how COVID-19 has unearthed the deep British discomfort in talking about death. The narrative in the media has been about patients being denied treatment and ventilators when it should be about giving appropriate care. There has been a lot of negative press about end-of-life care discussions. Lucy is not sure if our society is ready for these conversations although we all know the importance of having them.
What is becoming apparent to me here is that medicine is only a small subset of the COVID experience for our patients. What happens in the wider society – the conversations about death, the following of the rules – it will all impact our workload directly and indirectly. As we move out of lockdown, I sense that COVID is no longer a medical problem and more a social problem. I share Lucy’s concern that, after the initial first wave is over and the public and governmental interest wanes, we will be facing our usual winter pressures in the COVID-present world without the support. As the usual patients return to general practice, I worry about the future of medicine. Have we done enough innovation in the last 12 weeks to have lasting efficiency so that we can cope with the double burden of COVID and everything else? Will there be public funding cuts that will impact the NHS thus squeezing more blood out of the NHS workforce? When we entered lockdown on the 23rd March in the UK, I remember the wave of anxiety rippling through the medical community on whether we were going to survive the peak. And we did. As we come out officially of lockdown, I can feel a similar rising sensation about the second peak. Figuring out the long-game with well-rested well-nourished staff is essential both in primary and secondary care and we all need to recognise our limitations.
Thank you to Lucy for a wonderful interview and I am grateful for all the fantastic work that you do for your patients both in the hospital and in the community.