‘Stay at home. Save lives. Protect the NHS’. We’re all familiar with the UK government’s message during lockdown. But what was it like to be on the frontline itself? Josh Eves reflects on his experience from the last few months as a trainee surgeon at a large London hospital.

Coronavirus came as a shock to many of us. Reports and pictures of people in masks from China felt very distant, and I was guilty of taking vague comfort in having seen it all before with SARS and Ebola. Sick people far away; poor them. Myself and a few of my colleagues felt it was an exaggerated media ploy. Fear sells only slightly less than sex after all, and Brexit was becoming tedious. Early on, I attempted to reassure a worried scientific but non-medical friend not to listen to the media hype. Since then she compared me to the current American president (now there’s a compliment.)

In late February reports flooded in of a dire situation in northern Italy, and the first cases had dribbled into hospitals around London. The reassuring hum of hospital routine faltered; all junior doctor rotations, interviews, courses and exams for the foreseeable future were cancelled. Normality continued dreamily for a few days, in what we dubbed the ‘phoney war’. Increasingly aware of the unseen enemy, daily business was curtailed to prepare us for battle. With elective surgery cancelled and A+E admissions down by 25% in the first week after lockdown, we junior surgeons often found ourselves with less to do than normal. At times we felt like frauds. Instead of sick patients we were faced with a barrage of adulation and free coffees. With WhatsApp groups sharing the latest NHS discounts, as surgeons we were able to enjoy these perks more than some of our colleagues facing the first wave in the emergency department, medical wards or in intensive care.

After the calm

Under the calm façade, our management had been lit like a match. In a hospital where a reported faulty computer may go unfixed for the whole rotation of a junior doctor, the management system sprang to life with military conviction. Advice was taken from Italian hospitals, and impressively quickly our emergency department had been divided into the expectantly large ‘red’ (COVID) and much smaller ‘green’ (non-COVID) areas. Our intensive care unit was expanded in a matter of days, with staff and space purloined from cancelled elective surgery. Already described in terms of soldiers on the front line by the media, wartime concepts of medicine have crept into our approach to patients. Rather than prioritising the sickest, resources were increasingly reserved for those most likely to survive. 

A poignant example was a delightful 91-year-old gentleman who presented with a rupture of his aorta, bleeding out into his abdomen. This is a medical emergency, and in our hospital a relatively fit man like him would have had a bed on ICU with little questioning. Under the new COVID circumstances, was denied a bed because of his age and other medical problems, and with no time to waste, he underwent a life-saving minimally invasive procedure. Relining his aorta with a stent, under only local anaesthetic, he survived. We were able to discharge this charmed man after two days later to reduce his chances of catching the virus.

Hospitals, usually infested with nasty microorganisms, have become more dangerous than ever. Transmission of the virus to inpatients was unfortunately common at the beginning. The first cases of COVID-19 we encountered were patients known well to us – sick people unfortunate to be in the wrong place at the wrong time. In particular we began to see daily declines in one man only just beginning to show improvement after long illness post-surgery. We watched helplessly as he was increasingly unable to get enough air into his lungs, gasping furiously for hours to stay alive. He passed away alone, unable to share these last days of suffering with his wife because of concerns for her own safety. For many of my colleagues, the helplessness and limitations of what we can do for our patients has been difficult, all the while denying them the most basic therapy: human contact.

A pandemic, and more

Early on, however, especially as looking after COVID patients was not yet my role, the patients I saw in A+E were as much a product of lockdown as of the virus. Unexpectedly, our trauma case load only slightly decreased despite the whole city being on lockdown. On my first night we saw a number of road-traffic accidents. One 45-year-old gentleman died in our department, having been hit at high speed by a drunk driver enjoying empty roads. In addition to RTAs, there has been an alarming rise in cases of domestic violence, with a 25% rise in calls in the two weeks following lockdown. Intimate partner violence is presumably exacerbated by enforced proximity, but it is known to be increased in times of financial stress, and strategies to support victims will be vital in the years to come. Violence is not limited to partners however during lockdown, and in emergency theatre I assisted the case of a man who was stabbed seven times during an altercation with his housemate.

For medical professionals, another alarming side effect of the pandemic has been a shocking reduction in people with almost all other medical conditions coming into our emergency department. The good-hearted British public have been staying home to ‘protect the NHS’, but sometimes to their own detriment. Early on, a 25-year-old lawyer presented very unwell, having stayed at home for four days with abdominal pain. He required emergency surgery to remove an outpouching of small bowel, a ‘Meckels Diverticulum’, which had perforated, leaving bowel contents contaminating the rest of his abdomen. We were aghast that this bright man had waited at home so sick with his family. This virus has made a scenario where wealthy western patients are presenting in ways more expected in poorer countries. 

Cautiously lifting lockdown

The reduced hospital throughput has made my experience of this pandemic a contrasting one. On the one hand I went through the anxiety of the impending rush, fear for my own safety, and I had a few days of feeling pretty rough with the virus. I (and to a greater extent some of my colleagues) have dealt with the dying and the infected sick. We have explained to appalled family that they cannot see their dying relative or risk being infected. On the other hand, following marvellous work by my doctor and nursing colleagues in medicine and in intensive care, recent weeks have been some of the quietest that I have ever experienced in hospital. 

These experiences led to interesting feelings while being clapped by the great British public, or scoffing kindly donated curry and cake in our mess. While some of us surgical doctors sit in quiet moments enjoying auntie Gladys’ finest carrot cake, gossiping, performing no surgery but the dire emergencies, I wonder if she really meant it for us. Perhaps when icing those buns she was thinking of my colleagues in A+E or in ICU (although their workload has also vastly decreased). Maybe she was thinking of carers in the community looking after the elderly with minimal PPE, or shopkeepers organising the irate public into spaced lines. Luckily having kept my sense of taste and smell intact; I certainly appreciated it either way.

The good news for Londoners and the wider British public is that hospitals are quieter, there are less admissions and the Nightingale hospitals have either been quiet or stood down altogether. Thanks to a rapid response, quick planning and lockdown, we are over the first peak. Staffing, previously very difficult, is now improving with many of us who tested positive now fully recovered from the virus. The NHS machine has been tweaked to fight the pandemic, with postponement of a lot of regular care including cancer screening, elective surgery, regular medical appointments, scans and mental health follow-up. Cancers are growing, vulnerable people unsupported. Challenges remain with COVID on the scene for the foreseeable future, but creative thinking and sound planning is required to treat this backlog of sick people. To quote our heavily tanned friend over the Atlantic, “the cure must not be worse than the disease.” It is not only for the sake of our economy that we must cautiously and judiciously come out of lockdown, it’s also for our health.

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