Coronavirus doctor's diary: Making rapid life-and-death decisions

In his first diary for the BBC, published on Monday 30 March, Dr John Wright of Bradford Royal Infirmary reported on his hospital's preparations for the coronavirus storm. In the last few days, the storm has begun, putting all involved under great strain.

Not that long ago the hospital had just a few Covid-positive patients, isolated inside rooms. By the start of this week we had two full wards designated as "red" or infectious zones. And two more turned red a day later.

One of the most overused phrases that we use as doctors is, "It's just a virus." It reassures our patients, and it covers up our own uncertainty. So for many the devastation that the coronavirus has wrought has been so unexpected.

By Wednesday, 14 of our patients had died.

This is one of the big issues around Covid-19 - its high death rate. So while less than one in a 100 of those who get it will die of it, when you get into hospital that goes up to one in five, or one in six patients.

We are used to people dying in hospital, because it's often a place where people die. But normally we are reflective in our practice, we give time, and time is a great instrument for us in health care. But in the hospital today we are making rapid decisions about life and death - decisions about ventilation, about escalation care and when to make the decision about end of-life-care.

As palliative care consultant Dr Clare Rayment says, none of us wants to get it wrong.

Prof John Wright, a medical doctor and epidemiologist, is head of the Bradford Institute for Health Research. He has looked after patients in epidemics all over the world, including cholera, HIV and ebola outbreaks in sub-Saharan Africa. Over the next few weeks he will be reporting for the BBC on how his hospital, the Bradford Royal Infirmary, copes with Covid-19.

"There's a lot of worrying about making those rationing decisions because it's not something we are used to in the UK," she says.

"I think in other countries it's something they might be more used to having conversations about. We are used to people dying in hospital but we aren't used to saying, 'You're going to die because I can't give you this ventilator because someone needs it more.'"

Many of us have got parents, and we may worry that these decisions like these are going to be taken on the basis of the patient's age.

But age is only one factor.

"We should recognise this as a society, that so many 80-year-olds are actually in better physical and mental shape than some 65-year-olds. That 80-year-old shouldn't be written off," says Dr Alex Brown, a consultant in elderly care.

Another feature of Covid-19 is that people are dying alone. Hardly anyone is allowed into the hospital now to visit.

So the challenge is "thinking about how best we can make sure those people have good deaths in an environment where their family members are likely not to be," Clare Rayment says.

Technology is part of the answer.

"If someone wants to be there when someone's dying, can we do that in a video call? It's out of everyone's comfort zone, but actually it might be very important for a patient, if they're awake enough, to be able to see their wife or whoever on the phone," she says. "And also for that wife, husband, daughter, whoever it might be, to see that their loved one is comfortable, isn't distressed."

Emma Barnes, the senior sister for the respiratory wards, tells me that even though family members cannot enter the hospital some are still driving in to be near their loved ones, and sitting in their cars in the car park.

She has also noticed the emotional strain that staff are under - people crying in a corner, or admitting that they cry when they get home and have to hide it from their children. She has raised the idea of designating a room as a "wobble room" where hospital staff can go for a moment if they are feeling emotionally wobbly.

I think there is a mass insomnia among the staff, because our normal routine has suddenly been totally disrupted. I've taken to waking up through the night thinking about it myself.

So many things have changed so quickly. It's barely two months since the first Covid-19 patients were diagnosed in the UK. And yet the number of cases has now exceeded 30,000.

In the 16th Century, measles and smallpox were spread by Spanish Conquistadors to entire communities who had no prior immunity. Those viruses took 100 years to conquer the Americas. Covid-19 has taken 100 days to conquer the world.

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