Intensive Care Page 2
Looking back through history, it’s easy – or it was, at least, in January – to pity our ancestors, at the mercy of forces they barely understood, and awash in misinformation. Epidemics were once thought to wax and wane at the whim of the gods or the heavens, and the word ‘influenza’ derives from the perceived ‘influence’ of the stars. But they’ve also long been associated with a more familiar series of changes: the flux of the seasons. ‘In all cases so far described,’ wrote Hippocrates, ‘the spring was the worst time and most of the deaths occurred then; the summer was the easiest time and few died then … For the coming of winter terminates summer diseases, and the coming of summer shifts winter diseases.’
Compare this with a World Health Organization statement on the novel Wuhan coronavirus: ‘Currently the northern hemisphere (and China) is in the midst of the winter season when Influenza and other respiratory infections are prevalent … countries need to take into consideration that travellers with signs and symptoms suggestive of respiratory infection may result from respiratory diseases other than Covid-19.’ In other words, when it comes to epidemics, seasons matter as much now as they ever did.
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On 29 January the first cases of the new coronavirus were confirmed in the UK: a Chinese couple staying in a hotel in York. The following day, 30 January, the WHO announced a global health emergency as the death toll reached 170 in China, and the cases in that country alone reached almost 8,000. Cases were also confirmed in India and the Philippines.
I also received my first instruction to tell patients to ‘self-isolate’ even if they had no symptoms. It was from Lothian NHS Board, and asked that anyone coming from Wuhan city lock themselves away for fourteen days, even if they had no symptoms. They were to
inform NHS 24 of their travel history and symptoms when they call. If they become symptomatic they should not leave their home until they have been given advice by a clinician. That coronaviruses do not usually spread if people don’t have symptoms, but we cannot be 100% sure – so this is a precautionary measure.
This would later be shown to be wrong – one of the reasons SARS-CoV-2 is so devastatingly effective as a virus is its ability to spread without triggering symptoms of illness. The instructions also informed us that masks ‘and other personal protective equipment’ would be sent to us shortly. We didn’t have a great deal of faith in NHS procurement, particularly for workers in general practice, and the instruction prompted jokes among my colleagues that we’d be sent a paper bag and some of those cling film gloves you get at petrol stations. But we were wrong: some surgical masks did arrive later that week, and tear-off plastic aprons.
During the week I work at my small Edinburgh practice, but at the weekend I work evening shifts at an ‘out of hours’ (OOH) centre in the city covering a much larger population, with a different team of doctors and nurses. I had an email from the clinical director of the centre, Sian Tucker, advising me to tell any patients from mainland China outside Wuhan that they would only need to self-isolate if they had symptoms, adding that those symptoms did not include a sore throat. Until then I’d been assuming that a dripping nose and a sore throat would be the herald of coronavirus infection, the way those symptoms are the manifestation of most respiratory viruses. My practice started a WhatsApp group to keep one another updated. It proved as helpful for sharing joke videos as for divesting the latest governmental advice.
In my routine clinic in Edinburgh’s city centre, Monday to Friday, my three colleagues and I began slowly to orientate ourselves towards the changes this virus might make necessary. I had worked as a GP for fifteen years, having moved to that role after six years in hospital medicine focussing on surgery and on emergency medicine. I was drawn to general practice for the way its work is balanced between clinic and home visits, young and old, the mundane and the life-threatening. There are many things to love about the work: the variety of different encounters with people who flow through the clinic doors each day, the breadth of their concerns, the intimacy of the private consulting space with its ethical codes of confidentiality and candour, the strange mingling of science and kindness, the intuitive leaps made necessary by the constraints of time and resources. The work is satisfying because it is, at its heart, about listening to people’s stories and offering modest, practical advice.
Strictly speaking, UK general practice clinics are not part of the NHS; they’re small businesses run by the doctors who are for the most part ‘partners’ rather than employees. But they’re odd businesses, in that they have essentially only one customer: the National Health Service, which ‘buys’ healthcare for a defined population, paying each practice through a complex and historically convoluted set of mechanisms that have somehow stood through seven decades with only minor adjustments. The distinction of being theoretically independent brings freedom, autonomy and agility, but it also brings administrative hassles and money concerns that pass hospital specialists by: surgeons aren’t obliged to own and maintain their operating theatres the way many GPs have to own and maintain their surgery premises, for example.
Just as the funding mechanisms of general practice hadn’t changed much in seventy years, so too the model to which many of us worked: a reception, a waiting room, a series of clinical offices in which each doctor spent two or three hours in the morning, and again in the afternoon, seeing between twelve and sixteen people and talking to them about their problems, one after the other, in short, often pre-arranged appointments. At busy times the waiting room would be full, and for flu jab clinics in the autumn the corridors would be crammed as, between us, the doctors and nurses of the practice would vaccinate about a quarter of the practice population in the space of a few weeks – those whose age or infirmity meant they were more susceptible than the wider population.
Lunch was often skipped or hurried, the time between morning and afternoon clinics filled with home visits, and with reading volumes of correspondence from hospital colleagues: advice; letters on anyone who’d been recently discharged from hospital; reports on X-rays and ultrasound scans; results of blood tests we’d taken ourselves; summaries of specialist reviews on everything from audiology to urology. Some doctors find reading through correspondence a chore, but it has never felt like that to me: diagnosing illness can feel like being set a series of intricate and cryptic puzzles, and reading correspondence from specialists can be like turning to the back page solutions. There’s satisfaction in having my questions answered and, when no answers are forthcoming, there’s a comfort in knowing that sometimes even an expert trained for thirty years in their chosen organ or disease can be as baffled by a patient’s symptoms as I am. Doctors are far more fallible in their judgements and their diagnostic abilities than they are usually prepared to admit.
After reading the correspondence I’d make a few telephone calls to people who simply wanted my advice, or whose correspondence had thrown up anomalies and questions that needed resolution or a change in treatment: an alteration in antibiotic for one; a reduction in the dose of water pills or blood pressure meds for another. Then, after that, it was out on my bike, not in Lycra but in smart trousers tucked into my socks and often, given the Edinburgh weather, waterproofs, visiting people too frail or fearful to be able to manage to visit the GP practice itself. In slums and in mansions, in high-rise apartments and disability-adapted bungalows, GP work offers insights into how people really live in ways that many hospital colleagues envy. On a home visit I’m acutely aware that I’m not on my home turf, but invited into someone else’s space – that invitation shifts the dynamic of the medical encounter in subtle but powerful ways, towards the patient’s agenda and away from the doctor’s.
31 January, a typical Friday. The first patient is a 4-week-old baby, a third child, who’s apparently been screaming the house down but is tranquil now. Screaming for babies of course isn’t unusual, but there’s a harshness to the cry, and the mother, being experienced, has been alarmed by it. There must be something wrong, she says. The baby
vomits, too, that’s new, and every time she starts screaming a bulge appears in her side. Where? I ask. There, I can show you. She takes out her phone and plays me a video, and there on the crystal screen I can see the bulge appear with each scream. As I watch I place my hand on the infant’s belly, pushing gently, trying to feel through the skin with my fingertips towards the baby’s tiny pebble kidneys, the convex spleen, intestines as thin as bullrushes. But I can’t feel anything untoward. The baby is tranquil, feeding from her mother – such peace some spend their whole lives trying to rediscover – and I know that in seconds she will be screaming as if disembowelled again, and that mysterious swelling will rise again from her side. She needs an ultrasound scan of the belly, and I speak to the paediatricians to arrange it.
Next a man in his eighties, a retired schoolteacher who always wears a tie to our visits. He’d fallen and cracked a bone in his back. He’s sorry to trouble me, but could I just help him with his pain, with the side-effects of the painkillers, with advice on how long the healing will take? In a conversation of courtly politeness we circle the plastic skeleton that hangs in my consulting room, discussing the anatomy of the spine. Then a woman of late middle age who couldn’t hold on to her urine; the exercises I’d suggested were ‘useless’ and a brief trial of drugs had desiccated her mouth. An ultrasound scan of her bladder, when full and when empty, had added nothing, and I referred her for consideration of surgery to her pelvic muscles. A woman of twenty scratching at her skin – she had picked up scabies from a flatmate. A girl whose mother said she had food intolerances; from her bag she pulled a colour-coded list three pages in length, grouped together by symptoms and food groups, and asked me to go through it with her. A man whose birthday it was that day: ninety years! A tiny avatar of a cake with candles had appeared in the bottom left corner of my screen. At my congratulations he beamed, told me he’d meet his grandchildren for lunch, and I went back to explaining the purpose of all the new medications he’d been given since his stroke. A 50-year-old archaeologist, a badminton enthusiast who wore a beard like Trotsky and whose shoulder injury hadn’t settled despite three months of physiotherapy. With a long, sterile needle I breached the hidden space between his shoulderblade and humerus, and injected a vial-full of steroids. A 6-year-old with tonsillitis, who opened her mouth for my inspection with the enthusiasm of a hippo having its teeth cleaned. A 92-year-old retired postmistress with memory loss, together with her son; every example of forgetfulness the son offered was forcefully denied by the mother, with a pout of indignation; together the son and I coaxed her towards accepting a formal assessment at a memory clinic, and a CT scan of her brain. A 74-year-old widow, a retired lollipop lady, unsteady on her feet. A fifty-something nurse with a chest infection. A feverish toddler who lay in her mother’s arms, blotchy and panting, having vomited up her breakfast. She watched me with malevolent distrust as I pushed on her belly, testing for pain. A man in his sixties with chronic depression, his face demolished by age and sadness. That was the morning clinic over with.
There were three phone calls: to check in on a marketing executive who’d been measuring his own blood pressure at home; to a woman whom I’d been treating for joint pains, to see if her tablets were working; and to a young man who’d been cutting himself – the psychiatrists had recommended mood stabilisers, and I was relieved to hear that they’d been helping.
Then three home visits: to a woman recovering from breast cancer surgery, who lived alone and isolated in a high-rise apartment, and who before her surgery rarely left the home. From her window we looked out over the city, its industry and traffic, the windows catching brief shafts of sunlight, each building shining like a cage of light. The second was to a care home which was once a baronial mansion. I locked my bike to a tree trunk in the garden and rang its bell, then was led by a Filipina nurse to see my patient, Miss Nicol. She’d been refusing food and lashing out at the care staff. I watched as the nurse, Nenita, succeeded with great skill in calming her, then coaxed her to accept sips of water and her medications. Miss Nicol was aged 94 and the survivor of many years of dementia; her closest relative, a nephew, lived in Australia. As I examined her with care, trying not to provoke her, I remembered an afternoon the previous summer when the nephew, in Scotland for a holiday, came to my clinic to talk about his aunt. ‘No heroics,’ he’d told me, ‘she always said she couldn’t bear to depend on anyone, and now look at her.’ I told Nenita I had little to add, and that if Miss Nicol wouldn’t eat, I didn’t think we should oblige her to, and we certainly shouldn’t admit her to hospital. Many conscientious and caring nursing home staff have a fear of being accused of neglect, so being able to document ‘no action’ after medical review meant that Nenita and her colleagues could get on with doing what they were so good at: caring for this old lady with dignity, in a place she knew well.
The third visit of the day was to a woman dying of a brain tumour who couldn’t walk, whose forefeet had swollen up like toadstools, and whose stomach had been bleeding from the inside. There’s a mysterious connection between the brain and the stomach as if the belly reacts in sympathy to any trauma endured by the head (it’s not unusual for the victims of severe head injury to develop stomach ulcers). Now the swelling in the woman’s head that threatened to blind her, that was slowly paralysing her limbs, had released some haemorrhage of the gut. I began to think that perhaps she wouldn’t die of the tumour after all, but of bleeding. I started speaking to her gently, watching her expression, talking of patients I’d known in the past who’d reached this advanced stage of cancer, who’d tired of hospitals and who couldn’t bear the thought of being processed through their bureaucracies for even a few of the moments they had left to live. I told her that to live like this, seeping blood into the gut, is to live with uncertainty – never knowing if the trickle might widen to a gush. Outside the patio doors, her grandchildren had arrived in the garden. They were waiting to come in and see their grandmother. I wondered if we should stop and let them in, but she urged me to continue.
‘But for some people, hospital is something they want to avoid so much that they’re prepared to take the risk just in order to stay at home,’ I went on. ‘For some people, their priority is to be home with their family’ – at this her husband at her side smiled, sympathetically – ‘rather than be admitted again to a series of wards; they want to take their chances to live the life they most enjoy, for the weeks left to them.’
‘What a stupid idea,’ she said finally. ‘What the fuck would someone do that for?’ And I reached for the phone, and silently typed out the number for admissions.
That was the job, in the first weeks of the year, before the pandemic hit. It felt timeless, as if it hadn’t changed much in a century, or had changed only in the specifics and not in the essentials, and wouldn’t change for a century more at least. But I was wrong about that: there were only weeks left.
2 – FEBRUARY
PRODROME
‘So the Plague defied all medicines; the very physicians were seized with it, with their preservatives in their mouths …’
Daniel Defoe
A Journal of the Plague Year
The word ‘prodrome’ refers to that period in the course of a viral illness when the virus first begins its work on the body – the incubation period is passed, the sufferer begins to feel a little unwell but is still able to function. The virus has not begun its multiplication through the tissues of lung, skin, or gut – those parts of the body most exposed to viral attack. The word is Greek: pro means ‘forward’, and dromos can mean running, a sally, an offensive. It’s a term from military history, co-opted to the lexis of medicine to describe that moment in the course of the illness when an infection is preparing its assault. The virus and the immune system are running towards one another across the battlefield of the body.
On 4 February I flew to New York to join a panel at the city’s Academy of Sciences and contribute to a discussion about curiosity and wonder in science and medicine
. United Airlines had been sending me a hail of text messages and emails for days, reminding me that if I’d been in China I would be turned back at the US border. Despite sporadic face masks among the travellers, the virus still seemed like a faraway problem; although one that, increasingly, I found myself thinking about with a nagging sense of anxiety.
There’s a masterful history of the 1918 Spanish Flu pandemic called Pale Rider, by Laura Spinney; a couple of years earlier I’d reviewed that book in a long essay for the London Review of Books, and a producer at Radio New Zealand had contacted me to ask if I’d do an interview about the piece, and also offer some perspectives on other pandemics. I thought about the Chinese travel ban and how the fear of the ‘other’ has long influenced how we describe diseases: in Madrid, ‘Spanish’ flu was known as the ‘Naples Soldier’; the Senegalese called it ‘Brazilian flu’; in Brazil it was ‘German flu’ – everyone had someone else to blame. The source of the 1918 pandemic is obscure, but of the three theories Spinney puts forward, the greatest likelihood tips towards an origin in China, it probably having arisen in communities where humans and poultry shared living and sleeping spaces.
The difference in time, logistics and other obligations all meant that this interview, via Skype, was the first thing I did when I reached New York. The absurd levels to which we’re all now interconnected came home to me as I sat down, cross-legged and jet-lagged, in a New York hotel room to talk to a radio presenter seventeen hours into tomorrow. He asked me for predictions on how far the new coronavirus would spread. I remember saying that I had no crystal ball, but what I’d seen of infection control measures in China seemed impressive – I hoped very much it would be contained as SARS-CoV-1 had been contained, and that isolation measures in China would be effective. That day it was reported that 425 Chinese patients had died, and infection rates, for those who’d been tested, stood at just over 20,000.