How Covid treatment in the NHS has changed in a year
- Credit: AFP via Getty Images
Our understanding of Covid, and of how to treat it, has grown enormously over the past year. But mortality hasn’t significantly fallen.
In the early weeks of 2020, the NHS prepared for the pandemic however it could. Wards were labelled red and green to keep active Covid cases away from those not infected, where possible. Some hospitals built new A&E facilities to receive patients arriving with the virus. Yet doctors knew very little about what it was or how they should treat it.
A year on, intense pressure, medical skill and research produced at an unprecedented pace have meant people contracting Covid are now less likely to die. But there’s no silver bullet.
In the first wave, most patients who arrived at a hospital had a cough, shortness of breath and chest pain. An A&E doctor would assess their case. Oxygen was the primary treatment available, but doctors had to decide how much they needed. Some of those with severe symptoms would be sent to ICU; others would not.
The decision – one that doctors make outside pandemics too – rested not on a person’s age, but their frailty. Intensive care, which in the case of Covid often means ventilation or intubation, is physically traumatic. Patients have to be sedated, renal failure is more common, and there is a risk of pneumonia on top of the Covid. Doctors had to decide whether a patient was so sick that they needed intensive care or too weak to survive it.
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During the first wave, people were sent to ICU and ventilated much more rapidly than normal because the alternatives could cause the virus to spread. Continuous positive airway pressure, or CPAP, ensures a person’s airways remain open by delivering 50 litres of high-pressure oxygen every minute. “It is pretty unpleasant – like a reverse vacuum cleaner or sticking your head out the window of a speeding car all day,” one medic says.
This option is the most intense form of non-invasive ventilation given on a normal ward, but there was a problem. It creates a high volume of aerosols – infected droplets that could be spread by the fast-flowing air. One doctor recalls adjusting a patient’s CPAP mask and feeling the air rushing onto their face. In an ideal world, hospitals would have been able to separate CPAP patients into side rooms, but there was not enough space.
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As a result, weaker patients in some hospitals ended up in intensive care. The decisions did not necessarily improve their odds of survival. “I can think of patients when we have stretched limits of who we will generally admit, and those patients have almost all died during their intensive care stay,” one intensive care doctor explains.
Besides oxygen, doctors had few proven treatment options available. “Effectively, when we just started, we had no definitive therapies. We were just supporting the body in its ability to knock back an infection,” one doctor says. Remdesivir, an anti-viral used to treat ebola, was initially presented as a possible treatment. Yet randomised control trials eventually failed to show that it saved more lives than standard medical care.
In the past year, there have been four main breakthroughs in Covid treatment:
1. Dexamethasone, a steroid, has been shown to cut the risk of death among ventilated patients by a third, and patients on oxygen by a fifth. It works by calming extreme immune system responses to a Covid infection – known as cytokine shock. “It is the one drug about which there is very little doubt that it is very helpful,” one doctor says.
2. Non-invasive ventilation. More patients are kept out of intensive care and are instead given non-invasive ventilation, like CPAP. “There’s definitely been a move to not intubate some people who would have been intubated in the first wave,” the intensive care doctor explains. Hospital trusts do still have different policies on the point at which a patient should be ventilated, but doctors say greater provision for non-invasive ventilation on the wards and more confidence in the effectiveness of PPE makes CPAP more feasible.
3. Proning. The technique of proning – turning patients onto their front – increases blood flow to their lungs. Proning is heavy manual labour, requiring multiple doctors and nurses, but it helps maximise the oxygen getting into the blood.
4. Clot prevention. Halfway through the first wave, doctors began doing more to prevent blood clots. Normally, all intensive care patients are given anticoagulants to thin the blood and prevent clots forming as they lie in bed. After doctors regularly found blood clots in people’s lungs, and some younger patients died suddenly of strokes, they began giving all Covid patients higher doses of anticoagulant. All patients with severe cases of Covid now get multiple CT scans which are carefully examined for signs of clots.
Other treatments are still being tested. Steroids, used in intensive care for years to tackle conditions like sepsis, may prove useful. Tocilizumab and Sarilumab are thought to calm inflammation. Yet intensive care doctors remain sceptical.
“If someone’s on a ventilator and they’re not looking good, we check their white cell count and other blood markers to see if we think they’ve got a bacterial infection. The problem with Tocilizumab is that it stops those markers going up,” an ICU doctor says. “It may or may not have some benefit in terms of the actual Covid disease but it does have some real negative effects on our ability to care for patients in a wider sense.”
During the 12 months since the UK’s first recorded coronavirus death, doctors’ hard-earned experience and research into existing medications mean a person’s odds of surviving the virus have improved – but not as much as might have been expected.
“So why has mortality not significantly dropped? That’s the question,” says a doctor with a national oversight role. “And the answer is because the health service has been running so hot that it can’t deliver [the expected] standard of care.” It’s like a restaurant for 20 people trying to squeeze 60 in and keep them happy with an extra-special starter, he suggests, and the burden is falling on its staff. “It’s like we are setting ourselves on fire to keep people warm.”
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