At the very beginning, before there were any confirmed cases in the UK, Covid was a source of morbid fascination for us junior doctors. We’d sit in the office over lunch and guess the number of reported daily cases in Italy. As these numbers rose we soon began to count deaths instead. We were shocked when the daily toll reached 100. It just didn’t feel real; it was some scary and abstract thing that was happening to other people in other countries.
But as the first cases emerged in Britain, a huge gulf developed between those staff members terrified of the new virus and those who didn’t believe it to be any more than a normal flu, if it even reached Britain at all. I was in the “terrified” camp.
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It’s easy to forget that we had no data on how severe this infection was, how it was transmitted, who was at high risk and what — if any — its long-term impact would be. We relied on anecdotes read online, initially from Wuhan and later from Italy.
I’d like to say that as a doctor I was always only concerned for my patients, but in truth I was mostly worried for myself and my family. I didn’t want to be responsible for the deaths of my parents or my partner as a result of going into work each day.
Then in early March it began to feel far more real. We’d had one confirmed Covid case in my hospital so far when I went to review a patient in Accident and Emergency. He’d had a fall here in England while on holiday from Milan — the epicentre of Europe’s outbreak — and needed an operation to fix a fracture.
I asked the A&E consultant if he had screened the man for any Covid symptoms and he laughed, admonishing me — semi-jokingly — for my “racism” against Italians. I suggested that we should isolate him until we had tested for the virus, to be on the safe side.
At this point I was told sharply “whatever next? We test everyone who walks through the doors for covid?” Looking back, that comment feels entirely absurd — today, of course, every patient has a rapid Covid swab before they are admitted to the hospital — but a year ago such an idea didn’t even occur to anyone.
While it was not within my powers to question a senior A&E doctor, I was able to suggest to my surgical consultant that the patient should be isolated “just in case”. We moved him from the open ward, alongside all of the other elderly patients with fractures, to a side room.
At the time tests were hard to get and results took 48hrs, although our hospital had developed a more informal 24-hour test which was “not yet clinically validated”. The result came back negative, although in block capitals underneath the result was written DO NOT DEISOLATE PATIENT UNTIL FORMAL 48h TEST. And so… we deisolated the patient immediately, because, so I was told, “He has a fracture that we need to fix. He’s got no symptoms anyway!”
The following day the result of the clinically-validated second test came back — the patient had coronavirus. By this point he had already been intubated and ventilated in theatres, itself an aerosol-generating procedure, and on several separate open bays full of patients. It’s hard to know how many infections resulted; how many deaths.
It’s worth remembering at this stage that masks were strictly Not Allowed when reviewing patients, unless they had either tested positive or had symptoms, and had also recently returned from China, Italy or Iran. When we were assessing our Italian patient in A&E, we were told sternly to remove our masks, lest we “scare the patients and other staff”.
My colleague, who had reviewed the patient with me, developed a cough several days later. Initially she stayed at work, since she had neither shortness of breath nor fever; when she called in sick the next day, many of the consultants laughed at how she had clearly been scared by her Covid contact, and was being ridiculous to not work through her “mild cold”. She was later admitted to our hospital with moderate “Covid pneumonitis”, as we would now say, requiring oxygen to help her breathe.
Available workspace had become tighter in the hospital in recent years, with old doctor’s offices making way for patient bays. Our shared office was now — quite literally — an old cupboard, roughly two metres by two and a half. It had no windows, let alone windows that opened; six junior doctors shared that office as the coronavirus epidemic hit Britain.
Our team raised the issue that we had shared an office with our now-sick colleague, but were told that since none of us had symptoms we should continue working as normal. We called down to the hospital housekeeping department to try and at least arrange a deep clean of our office, but were told that hospital housekeeping teams are not responsible for doctors’ offices, since they are “non-clinical areas”, and that if we wanted it cleaned we’d have to do it ourselves, on top of 13-hour days on Covid wards. And that was that. We had always joked that the office looked as if it hadn’t been cleaned in five years, but that turned out to have been an accurate observation.
Much of March 2020 was terrifying; some of it was exciting. One morning our seniors seemed to click just how bad the pandemic was going to be. We stormed around the ward, discharging every post-operative patient who wasn’t actively dying, much to the dismay of the physiotherapists who lamented that they hadn’t yet passed their stairs assessments.
We told them that their patients had a higher risk of catching Covid and dying in hospital than being discharged early and risking a fall at home. It felt like being in the beginning of a post- apocalyptic film, both incredibly real and surreal all at the same time. At this point there was no denying that we were in the middle of a catastrophe; we were part of history.
And we were completely unprepared for dealing with an infectious disease of this scale. Sure, at the hospital we were used to occasionally isolating one patient with TB in a side room, but not to questioning every patient who walked through the doors. It was all new to us. Doctors also aren’t involved in deciding where patients are moved — mysterious “bed managers” are in charge of that — and often arrive in the mornings to find that patient A6 has inexplicably switched with C4, and D3 has been moved to another ward entirely. This turned out to be rather a serious issue when C4’s test result returned positive, adding to the number of covid-exposed patients who would require isolation.
Initially, isolating potentially-infected bays was an endless cycle in which patients testing positive would be removed from the bay and the bay isolated. We would then immediately test other patients in the bay. This is what happened with our first Covid patient, the Italian tourist: we immediately tested everyone, and when those tests came back negative we then deisolated them, allowing the patients back. Several days later, one of those patients developed a fever. We isolated her and she, of course, tested positive for coronavirus. Whoever was making the isolation policy didn’t seem to understand that the incubation period was an average of five days, and a negative test immediately after exposure is next to useless.
I can make many excuses for our policies in the early days, but this one seemed idiotic — even at the time — for anyone with the most basic knowledge of virology.
I was soon placed on a ward for patients deemed “not for escalation”, which meant that if they required ventilation on the high dependency unit (HDU) or intensive care (ICU) they wouldn’t get it. These patients were generally 60 or over, but often otherwise fit and healthy until Covid struck. Occasionally we’d get called by the nurses to assess a patient when they deteriorated, and we’d ask if they were on maximum oxygen and then we’d leave again. What more could we do? There was no real treatment for the virus; it was a lottery and some got unlucky.
And soon it was my turn. My mother had developed a fever and a cough. I tried to instruct my father over the phone on how to assess her, so I could have a better idea of how unwell she was. I ordered them a pulse oximeter from Amazon — just before they sold out — and eventually, I became so concerned that I felt unable to avoid assessing her in person. There was no other way.
I had accepted at this point that I would inevitably catch the virus from her. I felt great guilt over that decision; I knew how much stress my colleagues were now under, and how my absence would impact on them if I became symptomatic. However, much as I cared about my patients and colleagues, I selfishly cared about my own mother more.
I arrived home after work that evening, and immediately made the decision to drive her the hour and a half journey to A&E. Understandably, the hospital didn’t allow me to stay with her — I was, after all, another source of infection to other patients and staff. So I sat and waited in the hospital car park for hours, until at 2am I decided to drive home. Two hours later the hospital phoned — my mother was ready for discharge and needed to be picked up now, even though she still had Covid. The nurse on the phone suggested that I should order her a taxi, since “taxi drivers don’t know if their passengers have coronavirus anyway”. I drove to the hospital and picked her up.
This was a common theme in the early days: Get The Patients Out Of Hospital At Any Cost. It was the same thinking that led to tens of thousands of preventable deaths in care homes via infected hospital patients. Some of the thinking seems justifiable, or at least logical: we didn’t know how full the hospital was going to end up, so how could we turn seriously unwell patients away at the door because we hadn’t been able to discharge Mrs Jones back to her care home with a mild case? Yet we did this for some time even after we knew what was happening as a result.
I emailed my consultant the next day, informing him that I had had close contact with a Covid positive patient and should self-isolate for 14 days. I was told that since I did not have any symptoms myself, I should continue to go to work. So I did. Five days later, I was eating lunch when I complained to my partner that they must have changed the recipe for the soup we were eating, because it tasted of absolutely nothing.
He looked confused. I went around sniffing at all the strongest-smelling things I could find — vinegar, mustard, garlic — but I couldn’t smell a single thing. I’d read online, and heard via friends, that Covid could cause anosmia and ageusia (loss of sense of smell and taste), but it was not yet a recognised symptom. I Googled and found some mentions of the Covid association in other countries, but it wasn’t in the UK guidance until 18 May, long after doctors knew about it.
Again, I emailed my consultant, asking if I should isolate, but was told that since I had none of the “three major” symptoms (at that time: cough, fever, shortness of breath) I should continue to work. So I did.
At the time, the situation was desperate and elective surgery was being cancelled, and medical staff brought in from doing academic work. During the worst days of April 2020 even our oxygen began to run out, and a doctor came round every ward asking us which patients were on oxygen and whether any of them could reduce their intake. So saturation levels for patients were turned down to 92% as oxygen was rationed.
Likewise with PPE, where we were totally ill-prepared for the coming onslaught. In the beginning, FFP3 masks were required for confirmed positive patients and no masks were needed for other patients. Later, surgical masks were required for even asymptomatic patients. However, supplies started to run low, and we often had to go to several different wards to find a box of masks in order to start work in the morning.
We were given stash of masks left over from the stockpiling for the 2009 swine flu epidemic, with stickers over the “use by” dates. We didn’t mind as long as we had something. But when even those stocks began to run low, the guidance on mask requirement changed — it’s funny how masks are suddenly “required” in fewer situations when supplies run low.
While this was an ongoing problem, we’d crowd round a phone — which seems strange in a time of Covid but in our tiny office we had no choice — to watch the now daily Covid briefings, with politicians claiming that there was no shortage of PPE.
TV cameras were always directed at ICU, where PPE was prioritised, and whose teams ended up with the lowest infection rates as a result. We on the regular Covid wards were never shown on the news with our flimsy plastic aprons and surgical masks.
There was a disconnect between what we knew on the front line — about how there was not enough PPE, about how poor patient and staff isolation was — and what we heard being said by politicians.
We had the feeling that both staff and patients were being viewed as expendables, and the most important thing was to avoid headlines about ICUs overloading. This is why we discharged Covid-positive patients to care homes, and why we also handed out huge numbers of Do Not Resuscitate orders for older-but-healthy people, who once might have been given a fighting chance but who now risked overwhelming the system.
Some mistakes are understandable; we were in a pandemic, with a system facing a new type of disease, but if we junior doctors were readily recognising these errors, and learning from them, then policy makers could have responded faster.
We learned from some errors; we got better. We learned to move patients to “Covid contact” wards, and only deisolate them if they tested negative on Day 5. Our ICU unit was the first to catch on to the fact that proning helped, even though the anecdotes had come from Italy before we even had our first patient — another thing we should have learned more quickly. We didn’t start proning patients on the ward routinely until well after the first wave. We stopped discharging infected patients to care homes — but it took thousands of deaths before this happened.
Some mistakes we still haven’t learned from. From the start, there was always a focus on touching contaminated surfaces, while countries like Japan emphasised the three Cs: closed spaces, crowded places, and close contact. We still focus on aprons and hand washing, even though we know of virtually zero confirmed cases of fomite transmission. So little is still done to ventilate rooms. Indeed in my wards, built in the post war era, we cannot even open our windows, where they exist at all.
We have learned many things since, but throughout last spring we continually under reacted and failed to update our policies rapidly enough. We under reacted when PPE was required, we under reacted with patient isolation, and with staff isolation. In every way we were underprepared and often underprotected, a group of young people some straight out of university sent out to fight the biggest threat facing Britain since the Second World War. Many of our older colleagues died doing so but for the junior doctors who lived through the epidemic, March 2020 was a month we can never forget.
But I wonder if we’ve learned enough over the past year to not make the same mistakes next time. Because of the nature and size of the NHS, it’s difficult to tell if the lessons we juniors learned so hard were also absorbed by our superiors. We’ve got to hope so.
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