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2nd Place winner of the Covid Challenge: Before, In Between, After - Peter Endicott

1.


Before Covid, there had never been a routine. I worked on weekdays and weekends, on evenings and through the night. It wasn’t long before I realised you could pick any hour of any day of the week and there would be an iteration of that hour when I would’ve been walking the hospital’s long corridors. Typing at its thousands of computers, taking samples to the lab, or phoning specialists to get their advice. Sitting in the doctors’ lounge on the greasy faux leather sofas and sipping the free instant coffee from the Styrofoam cups. The activity and the stress and the joy from any day to another was completely changeable, and completely dependent on what happened to the patients who came into the hospital.


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The hospital was a big grey brutalist building of twelve stories, sitting above the Victorian red brick houses of a fancy part of London. A public park rose as a hill alongside it, giving views of deep green forest and lighter meadows from the windows of the higher wards. The best view, of course, was from the private wards on the top floor. Of spinning rows of houses whose roofs and parallel streets formed strange abstract shapes from such a height.


If the day was quiet, there was time to escape out onto the closest portion of the park for lunch, and sit under the shadow of one of the oak trees that lined the path. I’d stare across a pond of murky blue at the multimillion-pound mansions that stood to attention, with their narrow gardens and opaque glass windows.


After work, I could often get away in the mid-afternoon and meet friends who would come to a part of London that is easy to converge on. We would drink beer from cans and stare at the monolithic structure of the hospital in front of us. With music and the taste of beer in my mouth I could forget about it.


Sometimes, early in the morning after finishing a night shift, I would ignore the waiting barriers of my usual station and take a path around the first of the ponds and through the cool shade of a small wood. It led to an open field that contained an orange four-hundred metre track. Sometimes runners would be there, doing loops.


I’ve been thinking about these things because they were things I did with no pattern. The result of one of the people I was working suggesting a trip for lunch. Or a text on my phone from a friend asking to meet. Or just the tired decision of a brain that wasn’t ready to sleep yet. Spontaneous things. After the hospital had to change, to accommodate the crisis that was the first wave of COVID-19 infections, there was no longer space for such spontaneity. I would’ve thought a crisis would bring up many strange moments. But we quickly settled into a routine so regular that time passed without us even noticing. Every doctor came in for three days, worked for twelve hours, and then went home for three days. They did this from eight a.m. until eight p.m. for two sets, and then went eight p.m. until eight a.m. for two sets more. And then it started again.


At the start, I had even thought of keeping a diary. But eventually it seemed like there was nothing to write. At least, nothing stood out in the days as I experienced them. At the time everything that came seemed to go very quickly. I looked forward to the days I had off and then I worked the days I was scheduled to work.



2.


Before the crisis sunk into this regularity though, there were moments that stood out. In the space between everything that made up ‘before’, and everything that came after.


In late January, a registrar – a senior doctor who is almost a consultant – and I were doing rounds of the acute medical ward. We came to a side room and saw on the computers we wheeled round with us that a patient had coronavirus. This was not COVID-19. Just the old version that caused the common cold. At that point, the disease that would become the pandemic was spreading around Wuhan, a faraway place. My registrar, who had recently come back from working in the US, who had practiced all over the world, said that she thought it would soon be rampaging through UK hospitals. She looked at the masks that were stacked up outside the side room, as they were outside all respiratory isolation rooms. She mused aloud about taking one for her elderly dad whom she often visited, in case supplies were to run out. At the time I was too wrapped up in my first year of medicine. The thought that anything more could happen than was already happening to me was unimaginable. I told the registrar that I was sure it would be fine. That it wouldn’t spread that far in the end. Italy was days from reporting its first case, announced on 31st January. By April 17th, UK Government guidance related to PPE advised healthcare staff could wear long-sleeved patient gowns, if regular PPE was not available.


By February 27th, fifteen people had tested positive for COVID-19 in the UK. The hospital I was working at was a specialist centre for infectious disease and so a number of those fifteen had been transferred there. You didn’t see them. The transfers often took place at night and the infectious disease team were working twenty-four-hour shifts looking after them so that the medical team was never really involved.


Soon there were enough patients with COVID in the hospital that the infectious disease team couldn’t look after them all. Oncology patients were moved or sent home from the ward across the corridor, and the medical team was in charge of the new beds that had opened up. Both wards were on the eleventh floor, penultimate stop in the lift. I was asked to do extra shifts to cover the new patients. I received glances, small steps away, when I pressed the button marked ‘11’ each morning on the way in. The first week I met COVID patients, I was with a specialist in respiratory medicine. We did ward rounds together. Looked at blood tests showing by-products suggesting the blood was thick and clotting, chest x- rays where the black shadows of the lungs were covered by spectral white opacities. Each of the main bays had four patients and hissing oxygen flowing from the walls. I asked the respiratory specialist if it was normal to see such high clotting numbers, such terrible chest x-rays. He told me he didn’t know, he didn’t know, how could he know what was normal?


A man in his fifties on the new ward had come in needing large amounts of oxygen, but for two days he was needing less and less. That first day I arrived he said he was feeling better and so we took his oxygen off. Visitors were still allowed in the hospital then, though not onto the ward, so I stood outside the double doors of the 11th floor and explained to the man’s son that he was doing better. I came in the next day and he was gone. I was told he’d gotten worse and was taken to ICU overnight. I don’t know what happened to him; I never spoke to his son again.


I was still covering shifts overnight through March as it became clearer and clearer that the medical team and infectious disease team couldn’t manage what was happening alone. There would have to be new and radical ways of thinking about how the hospital worked. In the meantime, patients were still coming in. Someone in their thirties was brought into the emergency department. They had a genetic condition that predisposed them to recurrent infections. They were now breathing heavily and so short of breath they could only answer questions with a single word. Eyes wide and hands trembling. A portable chest x ray showed the clouds of whiteness that were becoming ever more common. Sequential blood tests showed more and more carbon dioxide building up and less and less oxygen making its way in. I’d known patients to be transported to ITU from the emergency room before. I’d never seen someone intubated in the resuscitation bay of the emergency room, for their heart to stop and CPR to begin and then to fail, all in less than an hour. But that too would become common.


There are lots of ways of coping with the bad things that happen. One is to take the person you saw die and tell yourself just how different they are from you and your family and all the people you love and care about. I think most of us who were there when the person in their thirties died did that. Said oh-they-had-the-rare-lung-condition-it-wouldn’t-have-happened-otherwise-it-wouldn’t-happen-to-me. But as the days moved on it became harder and harder to maintain that distance from all the people you would see in a day. The same registrar I had worked with during the failed resuscitation attempt was still with me a few days later in the emergency room. I walked past as she was gazing vacantly at a chest x ray on her computer screen. It was all white. I didn’t think much of it; lots of the x rays were like that.


‘These are the ones that scare me,’ I heard her mutter to herself.


Later we went to one of the hospital’s conference rooms to let the night team know about the patients we’d seen, and those still to be seen.


We got to a man in his late thirties who’d come in with a cough and fever and shortness of breath. He worked in an office and ran ten kilometres a few times every week. Now he was in intensive care.

‘The x-ray. Bring it up, bring it up,’ she said to me. We didn’t normally go through imaging in the meeting – it would’ve taken too long – but I brought it up. It was the one she’d been looking at earlier.


‘These are the ones that scare me.’


It was bad. Hardly possible to see any dark patches of clear lung within the hazy mass of opacities. But I could still separate myself from it. Images like this were why I wasn’t going to see my parents or grandparents so that I didn’t pass on the disease to them. The registrar, I assumed, would find it harder to separate herself because she was a similar age. She was also very fit, cycling regularly. My lack of fear was simply selfishness. I’d retreated into it as a way to feel safe and to feel better about myself.


I was ignorant too. I’d only been working as a doctor for eight months by that point. Many of the things I saw seemed shockingly bad; there were very few things I’d gotten the chance to feel used to. The registrar was extremely experienced though. She was at a point where she could recognise this as something new and different. There are times in which ignorance breeds fear but I think this was a time when knowledge could do so too.


3.


By the time the hospital had been consumed by the virus, when every ward was host to patients needing so much oxygen that the building’s alarm system blared regularly to say there was too little to go around, there was a routine. By the time the surgeons had stopped operating and instead formed teams to turn intensive care patients onto their fronts to try and get just a little more oxygen in, the days were becoming the same. By the time the operating theatres had been turned into an intensive care unit, and the surgical recovery bays had been turned into an intensive care unit, and the paediatric nurses were helping gasping ninety years olds video call families who were not allowed to come into the hospital, nothing felt new.


Each morning we came in to the same ward to do the three twelve-hour day shifts, took the three days off, then did the three twelve-hour night shifts. We went to see each patient with the same illness and made the same decisions: the oxygen went up, the oxygen went down, the oxygen stayed the same. Of course, there was more to it than this, but there was enough of this that you got lost in it.


And things were organised to help this sameness. We were put into groups of doctors who were allocated to the same wards, attended the same shifts. I don’t think things were organised to produce this blurring of days – repetition was the easiest strategy when reorganising hundreds of people to work in hundreds of places – but it was useful to the point there seemed to be intention to it.


Something else happened too. Before, on medical wards, a round of six different patients could require knowledge of six different conditions. Even four months I’d completed in orthopaedics had raised the possibility of a hundred different injuries when I walked onto the ward each morning. Now there was just one problem. For the first time I would go to work knowing what to expect. Even as a doctor in their first year of work, I was comfortable treating every condition I saw. Another kind of selfishness accompanied this – relief that I was in my comfort zone. Finally, there was a routine to it.

 

Peter Endicott is a doctor and writer living in London

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