COVID has had many unpredictable effects on healthcare and working life. One such impact has been the delayed presentation of unwell individuals to hospital. These patients stay away for a number of reasons: to protect the NHS; for fear of contracting coronavirus from hospital; or due to being wrongly diagnosed with coronavirus and actively advised to stay away from hospitals. As such, operations have been cancelled or postponed, cancer care has been delayed and poor outcomes have resulted. Today I will discuss a cases of delayed presentation due to the coronavirus pandemic.
An unfortunate case of delayed diagnosis
A 20-something-year-old patient, let’s call him John, presents to Accident & Emergency with fever, cough, shortness of breath and with a painful left arm and right leg. John had been displaying these symptoms for over a week. During this time, he had been taking his mother’s codeine tablets for the pain which had worked with some effect. He had called his GP for advice and was prescribed a further supply of painkillers without actually being seen. His GP had mentioned that John should stay at home, as he might have COVID, and John was triaged over the phone. The patient took the advice of the GP and self-isolated for four days before calling NHS111, the government hotline, to ask for advice due to worsening symptoms. Once again, the hotline advised John that his symptoms were likely due to COVID and that he should stay at home. John obliged with this advice for three days further.
About a week after initial symptoms appeared, John awakens ablaze with pain in his arm and leg. He can barely breathe and he feels hot, sweaty and shivers until the bed shakes. He is brought in by ambulance to the resuscitation area in the Accident & Emergency department at the Royal Infirmary of Edinburgh. Blood tests and scans are done on arrival. John is in septic shock. Septic shock describes a severely infective state where the body is unable to meet its own oxygen requirements due to low blood pressure and a falling output from the heart. This is a critical junction as without immediate help John will die.
John is whisked off to the Intensive Treatments Unit (ITU). The scan results show a large right-sided lung abscess. COVID swabs come back negative—it seem that this is a bacterial infection. Aggressive resuscitation is required and thankfully John survives a difficult first night in ITU, one of many. It is noted in ITU that he has patches of red skin around his left armpit and right lower leg. These areas are tender to touch and require high doses of painkillers for John to move normally. The Orthopaedic team are asked to review the patient for a potential soft tissue infection. However they feel that the primary source of infection is in the chest and that the soft tissue infection is nothing more than a cellulitis.
John spends a further ten days on ITU receiving high dose intravenous antibiotics. Despite this, he makes only minimal improvements and there is some blistering and worsening pain noted in his arm and leg. Further scans are required, which show fluid in between the muscle layers in the leg. This is a worrying sign for a life-threatening soft tissue infection. The patient is rushed to theatre for an urgent surgical exploration of the two areas. John is noted to have significant muscle and fat necrosis, or dead tissue, in both the left arm and right leg due to a rare and life threatening necrotising soft tissue infection. He requires the biceps muscle and one of the calf muscles to be removed as they had rotted. John loses 3.8L of blood in theatre and requires 11 units of assorted blood products, replacing almost his entire circulating volume of blood. However, John pulls through.
He is transferred back to ITU and will undergo four further operations within the space of five days to save his life. He spends 34 days on ITU and is eventually discharged 10 days later having made a good recovery and starting the process of learning to walk again.
Maybe it was our similar age, his fantastic attitude to his recovery or the length of time he spent under our care, but I became relatively close to John during his admission and his case struck a chord with me. So much so that I decided to write his case up with the hope of publishing his case in an academic journal, which has taken up a significant proportion of my time in recent weeks. This has been an interesting endeavour as it allowed me to work closely with John to really understand the delays to his treatment. In the case report discussion I discuss the importance of early diagnosis and the difficulties associated with this. Earlier diagnosis and treatment would have improved John’s outcomes and reduced the length and intensity of his treatment. The unfortunate delay due to a period of self isolation prior to hospital admission increased the severity of John’s disease and contributed to the near fatal illness that occurred.
However diagnosis is a difficult game as it is part science and part art. A diagnosis is a living beast, continually evolving with new information from laboratory tests, scans and examination findings. The healthcare staff, the GP and the triage team at NHS111 did the best that they could with the little information that they had at the time. There is no escaping COVID in the media and as such COVID is on the minds of clinicians at all times. We are on the lookout for coronavirus infection in all of our patients and therefore we can incorrectly diagnose a constellation of symptoms as COVID infection simply because we are looking so intently for it. This is an example of recency bias, a systematic flaw in the thinking of humans. As clinicians we should be aware of these biases particularly when judgement, as in the case of diagnosis, is concerned.
How we fail frontline staff
Last week there was an outbreak of coronavirus on the ward, requiring the ward to shut completely for three days. No new admissions, cancelled surgeries and staff off sick—14 staff members to be precise. The higher powers in the hospital decided that we should swab all the patients in the ward to ensure that there were no remaining infected individuals on the ward: a good idea. However they also decided that they would not swab the staff members: not a good idea. Infected staff members, especially asymptomatic individuals, would continue the cycle of infection by acting as a reservoir for the infection. All the doctors and nursing members could not understand the decision not to swab staff members and remain perplexed to this day. Should we not know if we are infected? By being unknowingly infected we are putting our patients and loved ones in harm’s way. We suspect that this decision was made as it might reveal additional infected staff members and further cut down the number of available staff members to work. However there has been no indication from management for their reasoning. This is a failing of the management on behalf of its staff. Should serious injury or illness result of it, management would be partially to blame. We should hold our seniors accountable for their decisions. Our patients are important, and our staff are invaluable. We should care for them equally.