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The hospital sector is undergoing a very public transformation as it races to build capacity ahead of the spread of Covid-19. New facilities, dubbed NHS Nightingales, are being commissioned in disease hotspots such as London. Beds in existing hospitals are being emptied wherever possible; oxygen pipework is being installed in newly created clinical areas; and ventilators are being begged and borrowed, if not actually stolen.
The pace and scale of change in general practice is less obvious, but every bit as far-reaching. We are the waterfront against which waves of Covid-19 patients are beginning to break. Our job is to manage as many as possible in the community, while simultaneously identifying and admitting those who require hospital care.
Working for our out-of-hours service, which covers a population of 934,000, I am now regularly talking to patients with symptoms of the disease. In order to reduce the risk of virus transmission, we are assessing everyone by phone, and only arranging face-to-face contacts where absolutely necessary. Doctors are said to make around 85 per cent of our diagnoses on the basis of history alone – the combination of the person’s symptoms; how they have evolved over time; things that make them better or worse – so telephone triage should in theory work well. One problem with a new disease like Covid-19 is that we are suddenly encountering people whose stories don’t match patterns we’re familiar with, which makes confident assessment that much more challenging.
There is feverish activity to get up-to-date information out to support the front line. Take the issue of chest pain. Ordinarily this would be an alarm symptom, suggesting significant heart or lung problems, and Covid-19 guidance published in the British Medical Journal just ten days ago flagged it as a marker of moderate risk. Having spoken to numerous patients with this symptom whose clinical condition has been otherwise stable, it has become clear to me that chest pain is actually a common feature that doesn’t, on its own, mean much. We’re all learning as we go; the last shift I worked, a colleague was still bringing these people in for examination, understandably anxious about something that for the duration of his career he has treated with great caution. Updated Covid-19 guidance now reflects our evolving experience and normalises the presence of this particular pattern of pain.
The crucial Covid-19 complication is fulminant viral pneumonia, the hallmark symptom of which is shortness of breath. Again, cumulative experience of the disease is putting this in context. Many patients experience breathlessness; the key sign is deterioration, typically around seven to ten days into the illness, and often over the space of as little as six hours. Pulse rate, respiratory rate, and oxygen saturation in the blood all assist in evaluating this, but all have traditionally entailed physical examination. The race is on to find ways of assessing these parameters remotely. Few doctors had heard of the Roth test before last week. The patient takes a deep breath, then counts from one to 30. Failure to count for at least eight seconds before needing to draw breath again is said to be associated with significant oxygen desaturation. It hasn’t been properly evaluated in this situation, though. Even so, finding that a patient can get to 30 before running out of steam has been reassuring for me that they are clinically stable.
In our smartphone era, much attention is being paid as to whether apps can help. It turns out that for measuring heart rate, several can. But although at least three apps claim to be able to measure oxygen saturation – two by using the built-in camera as an oximeter – the results are essentially useless.
That statistic that doctors make 85 per cent of diagnoses based on their patients’ history seems to me to ignore a crucial fact, which is that visual clues and non-verbal communication are just as important to our assessments as the words a patient actually utters – and these are difficult if not impossible to gauge over the phone. A partial solution may be video consulting, which gives the clinician the chance to eyeball the patient’s general condition. Practices and out-of-hours services are scrambling to install and incorporate software to allow direct visual contact between doctor and patient.
Back at my daytime practice, where we look after just 5,000 people, numbers of Covid-19 cases are still proportionately small, but predicted to surge in the coming fortnight. We are using the narrow window to prepare. We already have one doctor and one nurse out of action, having gone into self-isolation. By the time you read this, we should have completed preparations with our neighbouring practices to pool manpower resources so as to be able to continue to offer a service whatever may come.
We are also, at the behest of our local clinical commissioning group, hastily reviewing our “at risk” population. These are the elderly and those with multiple co-morbidities, who are currently being “shielded” or advised to follow stringent self-isolation. In the event they contract Covid-19, this population is highly unlikely to benefit from hospital care. We are being tasked with identifying in advance for out-of-hours and the ambulance service those who should be discussed for admission. And those, as a corollary, who should be kept at home for palliative care, accepting that this disease will be their final illness.
The gravity of the situation was underscored for me last week. I was contacted by a long-standing patient in his mid-fifties, unwell with what appeared on the face of it to be just an exacerbation in his chronic lung disease. This was someone who was still working, still with a family to support. Two days later, he was dead. The first Covid-19 fatality among my patient population.