Heart Wrenching Decisions Jagtar Pooni

United front: BMA members respond to the COVID-19 pandemic

Life at Work
Jennifer Trueland, Peter Blackburn, Tim Tonkin and Keith Cooper

Coronavirus is the greatest challenge the NHS has ever faced. BMA members talk about the problems they have encountered during the pandemic and how they are fighting back.

Heart wrenching decisions

For many doctors, such as for West Midlands intensive care consultant Jagtar Pooni (pictured above), it does not end when they return home after a long shift. Even the human instinct, at times of stress, to hold one’s family close has to be overridden.

He said: ‘When I go into my house there’s a pathway for me to take off my clothes and get to the washing machine and then shower upstairs without touching anything else – we have gels and we practise social distancing even in the same house.’

The West Midlands had, as of late March, one of the highest numbers of COVID-19 infections and deaths in the country. At the time of speaking to The Doctor, Dr Pooni’s unit was treating between 16 and 20 patients who had contracted the virus.

Although the number of cases was forecast to grow, he said difficult treatment decisions were already having to be made.

‘We are using admitting criteria because we don’t want to get to the Italian experience where we started admitting everyone. These are prolonged-stay patients, so we are admitting those we are confident are going to get better. We have pulled away from those people we might usually give a trial of treatment to.’

Dr Pooni said the aim in his trust, which had been very supportive, was to meet an initial surge to 48 ICU (intensive care unit) beds. His principal concern was finding enough staff to run them.

‘I can say to the silver command, I have this amount of ventilators, I can expand into this area or that area, we can get equipment from the stores, but when it comes down to staffing those beds and escalating this care to less-qualified individuals looking after the patients, and them being supervised by more senior nurses, that is a big challenge.

‘There is lots of activity stopped in the rest of the hospital and what we have to do is train those people up and see if they can provide the basic level of care that we can supervise, but that is a challenge in itself.’

Achieving the surge to 48 ventilated patients will be challenge enough but, as he understands it, the Government’s plan is for his trust to accommodate at least 80.

Dr Pooni, who is a member of the council of the Intensive Care Society, said: ‘We can’t staff 80. The only way to do that is literally to put somebody on the ventilator and not have bedside care. You would have one person looking after maybe three patients and that is a massive deviation away from normal practice.

‘If there’s another person who needs ventilating do I say, I can’t take you, which means you are going to die or do I accept that I take you and the staffing level is unsafe – that is where the real decision making and ethics come in. It is going to be very difficult. What do you tell that person’s family? What about the impact on the rest of the patients?

‘I am experienced, but I’ve not been caught in those scenarios before. Usually our staff can flex up and we can pull one or two nurses in from elsewhere if we really need more capacity or someone will do an extra night shift at the last minute to tide us over, but on this point it would be challenging. I am just not thinking about it. I can’t, I don’t want to and it’s a coping mechanism. I will worry about that when it happens, I’ve got plenty else to worry about in the meantime.’

We are using admitting criteria because we don’t want to get to the Italian experience where we started admitting everyone.

Intensive Care Consultant, Dr Jagtar Pooni

An early perception of COVID-19 was that serious harm would be confined to those patients who were older and had relevant underlying conditions. But Dr Pooni said that not only had he seen more younger patients than he expected, but the older ones had tended to be fit and active.

And Dr Pooni, speaking just before the first two UK doctors died of COVID-19, said it was vital that all NHS staff were adequately protected with proper PPE (personal protective equipment).

‘There is a big concern among doctors obviously with us at the front line – at my trust we are very lucky here on the ITU that we are supported by hospital management that there are adequate masks and equipment but there’s still a very big concern among doctors that it is not a matter of if, but a matter of when we contract this virus.

'On intensive care there are more high-risk procedures of course –  for example on Sunday I was examining a patient and before I had put the stethoscope on the patient the ventilator became disconnected so that it was then blowing COVID-19 infection into the ICU – I picked it up instantly and reconnected but in theory while I had the PPE on there is still that risk.

‘The reality is that just because you have got it on you are not absolutely safe, with moving about and the mask moving and the pressure of the situation and the discomfort of the mask. You are exhausted and if the mask slips a bit you could be exposed. That causes concern.

‘We do other procedures like tracheostomy to help patients get off the ventilator – there’s a time where there is a possibility of the ventilator ventilating because you have disconnected the patient for this virus to be sprayed around the unit.

‘Not many ICUs around the country have had one tracheostomy so far in this – we have done five. That is not without its risk to the consultant. There is absolutely a lot going on in your mind.’

Dr Pooni said shifts were longer and more intense, with the arduous donning of uncomfortable PPE contributing to an overall sense of exhaustion.

Student support

Hundreds of medical students have offered to play their part in the struggle against COVID-19.

Sheffield medical society president Hasnain Khan is running a portal to link fellow Sheffield Medical School students up with hospitals, surgeries and doctors who need volunteers. ‘A lot of our students have had placements and lectures cancelled and they want to help in any way they can.’

Working with Lucy Pinder and Leah Lam, also third-year students, they created a database of 400 students and had requests for help from hospitals and surgeries across South Yorkshire.

‘We have had three or four hospitals get in touch and are talking to Sheffield teaching hospitals about setting up a proper induction process so students know what they can and cannot do,’ he said.

Third- and fourth-year students have already started volunteering at GP surgeries and hospitals. Those in their earlier years of training look in on older people in the community, shopping for them and helping doctors in work with babysitting. Some 40 parents have asked for such help so far. ‘We are still looking for more volunteers because of the demand out there,’ Mr Khan said.

Hard months ahead

Insufficient access to PPE has put many doctors at needless risk, and the BMA has been pressing the Government urgently to ensure supplies.

BMA junior doctors committee chair Sarah Hallett said that while access to PPE had not been an issue at her own workplace, she had heard disturbing reports.

Sarah Hallet Junior Doctors Committee
BMA junior doctors committee chair Sarah Hallett

‘I have heard reports from some of our [JDC] reps that they have run out of PPE even on COVID positive wards, so there are still problems with the supply chain that need to be rectified. We need it on the front line now.’

Everyone that I’m aware of and coming into contact with is preparing themselves for a hard couple of months.

BMA junior doctors committee chair, Dr Sarah Hallett

Dr Hallett, a specialty trainee in paediatrics in London, went into isolation having experienced symptoms associated with COVID-19. On returning to work, she said: ‘Our entire trust has been completely reorganised.’

Dr Hallett said: ‘We have a lot of patients with COVID and we are having to turn lots of areas of our hospital into critical care areas. Many of our staff who would normally deal with surgical or medical issues are being redeployed to intensive care.

‘All of the resources of my trust are now going into ensuring that we’re in the best position we can be to deal with lots of very sick patients.

‘Everyone that I’m aware of and coming into contact with is preparing themselves for a hard couple of months.’

Massive change in general practice

In general practice, there have also been profound changes to how doctors work.

Derby-based locum GP and medical director of Derbyshire’s GP taskforce Susie Bayley said: ‘We’ve been under a huge amount of pressure.’

Dr Bayley said that a number of practices across the county had reported staff absences of up to a third of their workforce, clinical and non-clinical, either owing to people self-isolating or because of underlying health conditions which put them at greater risk.

She credited NHS England, her local clinical commissioning group and the BMA for the support they had been providing, and for the understanding around relaxing normal working practices to free up capacity for urgent-care services.

‘There was a bit of dragging of heels but now there’s been a massive understanding that we need to stop things that aren’t urgent face-to-face care,’ she said.

‘General practice has been massively galvanised by this – we’ve seen practices working together and making seismic shifts in the way that they work within a very short space of time.

‘Practice teams have been amazing in the way they’ve come together despite being short-staffed.

‘We’re doing everything we can to make sure we can cope with the demand and at this stage I think we’re on top of things. How long that will last is difficult to say.’

While her practice has made as many changes as it can to its working practices, such as moving to a telephone-only triage service, making physical changes to the patient waiting room to maximise social distancing and converting rooms into self-isolation areas, continued external support was vital.

On 19 March Dr Bayley put out a request on social media asking schools whether they could donate science-lab goggles to supplement PPE supplies.

‘We do have PPE in stock, [however] the adequacy of that PPE is slightly questionable so we’re looking at innovative solutions to try and make sure we have got the stuff and are as protected as possible and able to continue in the day job.

‘We also need to get the testing of healthcare workers sorted. There are people off work who do not have coronavirus and don’t need to self-isolate – getting these people tested and back to work will help the workforce.

‘We are also still uncertain with regard to what is happening with childcare for key workers as there seems to still be a lack of clarity and clarity will help our staff with workforce planning.’

Read the BMA COVID-19 toolkit for GPs and GP practices 

A lifetime’s planning put into action

For Richard Jarvis, this is something he has been preparing for ever since his first pandemic flu exercise, six weeks after becoming a public health registrar in 1996.

The Cheshire and Merseyside consultant in health protection and communicable disease specialist said: ‘Once you realise this is a global emergency you remember you have been planning for this for a long time – we got the plans out to become familiar and it gave us the confidence to take those first few faltering steps to begin to deal with this.’

It has been a relentlessly busy time since the first news of the dangers of this coronavirus became clear in January this year. Dr Jarvis has been helping to organise the response – bringing specialty registrars into positions created to help respond to the outbreak, training them up and backfilling the normal public health jobs, which have not gone away, such as monitoring other illnesses.

There are around 50 staff working in health protection in Cheshire and Merseyside and Dr Jarvis says the secondments could increase that figure by up to 70 per cent, with a further 15 or 20 recently retired public health doctors also potentially coming back into the fold.

I sense that there may have been a political reluctance to move on this quite as early as might have been useful but that is said in hindsight and I wasn’t making those political decisions.

Dr Richard Jarvis

Initially, Public Health England’s work focused heavily on tracking and isolating cases of the virus – monitoring movements and trying to halt the spread. But once cases come into the hundreds that sort of work with current staffing levels is ‘near impossible’, Dr Jarvis says. Other countries with greater resource and more data monitoring of citizens have been able to do more.

More recently the work has been largely moved from contact tracing to ‘incident and outbreak management’, managing and shutting down transmissions and outbreaks in hospitals and care homes.

For Dr Jarvis, the responses of the health system’s institutions and organisations have been excellent, but there is a feeling that the political response may have slightly missed the mark.

He said: ‘I sense that there may have been a political reluctance to move on this quite as early as might have been useful but that is said in hindsight and I wasn’t making those political decisions. If we had started the ramp up [of restrictive measures] two weeks earlier than we did I think that would have been very useful.

‘The next thing is the speed of the changes in the social measures has been quicker than I would have anticipated – if you put something in place to say “we are all going to be social distancing now” then you would normally want to give it enough time to see if that measure is working in and of itself.

‘Some of the things that we put in place, we haven’t been able to see the evidence on whether they were working or not – that isn’t necessarily important now but it will be when we start to step back because we won’t know how far we can step back.’

There are also concerns about how 10 years of austerity politics will affect the outbreak. Dr Jarvis identifying a total ‘lack of slack’ in the NHS and widening health inequalities – with life expectancy stalling, and childhood poverty soaring.

‘It’s bad for their health and social equity and all of those things combine to weaken the country as a whole at a time when we need to respond to something exceptional,’ Dr Jarvis said.

Back on duty

One of the most striking features about the pandemic has been the willingness of thousands of doctors and other healthcare workers to return to help deal with the crisis. Since leaving general practice almost seven years ago, Hugh Tooby has been a ‘citizen scientist’, conducting nature surveys for organisations including the British Trust for Ornithology.

Now, however, he wants to use his skills, knowledge and expertise to contribute to the pandemic effort.

‘I’ve never regretted getting out of medicine at all – people ask if I miss it and I always say I don’t,’ said Dr Tooby, 58, who lives in the Forth Valley area of Scotland. ‘And then we arrive with an international health emergency. I think the time out has cured the “burnout” and now I feel that if there’s something that I can do, commensurate with the residual skills that I still have, then that would seem to be a very sensible thing to do.’

Dr Tooby’s 28-year medical career spanned working as a GP in Bradford, a three-year stint in the Army (with tours in Kosovo and Germany), some time in medical management with GP out-of-hours cooperatives, and locum GP work in remote parts of Scotland.

He decided to retire at the very early age of 52 partly because he felt worn out, but also because he wanted a more outdoor life.

In a time of crisis, given that I’ve got that medical education and experience behind me, it would seem the entirely natural thing to do to see if there was some way that can be brought back into play.

Retired practitioner, Dr Hugh Tooby

So why does he want to come back now?

‘I think on a general level as a human being, and perhaps the way I was brought up, I feel we all have a duty to contribute to society; we’re not here just for ourselves. For human life to carry on, we have to act collaboratively.

‘But more specifically, I’ve always fought a little bit with guilty feelings about retiring early. Rationally I know that I did 28 years in the NHS, including three in the Army, but that still doesn’t stop you having that little bit of a “hum” feeling about it.

‘I know that what I’m doing now as a volunteer is providing valuable data that’s important for the health of the planet, but in a time of crisis, given that I’ve got that medical education and experience behind me, it would seem the entirely natural thing to do to see if there was some way that that can be brought back into play, given that we know that the NHS is going to be very, very pressed very, very soon.’

Having been out of practice for more than three years, Dr Tooby does not fit the criteria for the first wave of retired returners but talking to friends working in the health service has convinced him that it is only a matter of time before the categories are expanded.

He is aware of his limitations – he is not up to date with the latest prescribing protocols, for example, and has not performed physical skills, such as inserting a cannula, for a long time.

Nevertheless, he believes his years of experience would bring benefits to the NHS, partly by freeing up doctors performing more ‘back-room’ functions, such as triaging out-of-hours calls, so that they can be redeployed.

He also believes that retired doctors will complement the contribution of medical students, who have the up-to-date knowledge and physical skills required on the front line, but don’t have that depth of experience to call on.

'In June it will be seven years since my last day of actively seeing a patient, which is quite a long time. Not everything is like riding a bike – it won’t all come back immediately. But there are skills like taking a medical history, talking to people on the phone, being able to reassure people – these are all the things where experience tells.'

Desperate to help

Other doctors are desperate to help, but are stymied by bureaucracy.

Priyadarshini Bhattacharjee is stuck in limbo, unable to offer her skills to health services either in the UK or at home in Kolkata.

On 10 March she travelled from India to Manchester in preparation for sitting her Professional and Linguistic Assessments Board 2 exam in April, so that she could realise her dream of working for the NHS. Despite assurances from the GMC that the exam would go ahead, on 17 March she was told it would be postponed until July. Meanwhile, India announced its borders would close from 18 March.

‘I frantically tried to get on one of the last flights, but I wasn’t able to get a ticket,’ said Dr Bhattacharjee, 27, who hopes to enter specialty training in internal medicine.

‘So I’m stuck here, unable to work in the UK, and unable to get back to India.’

It’s particularly painful for her being unable to take part in the enormous medical effort to mitigate the effect of COVID-19.

‘I’m a doctor and have worked in critical care in my country, so if I could be of any help, I’d like to extend it to the NHS, but I don’t think the law permits that. Even so, if I could help by offering support by telephone, or social media or even WhatsApp, if someone is experiencing any problem.’

Dr Bhattacharjee has set up a support group with doctors in the NHS and friends from India, Nepal, Sri Lanka and Myanmar, some of whom are in the same situation as she is. The aim is to share information and help each other cope with the situation. But it is still frustrating for her not to be able to do more. ‘I’m missing home,’ she said simply.

‘And if I was at home I could be useful, because India is also facing a crisis right now and they also need doctors. I can see my friends working in the isolation wards. It’s very hard for a doctor to just sit at home, see situations go from bad to worse and not do anything. I know I have the knowledge and the training to help people and I just wish there was any way I could do that, either back home or here in the UK. It would have been at least something.’

Doctors manage a ‘micro-wedding’

While the pandemic rages, lives have been put on hold, plans radically altered.

When they realised that their wedding plans coincided with the likely UK peak of COVID-19, medical couple Dominique Thompson and Simon Bradley knew they had two options.

‘We got engaged on New Year’s Eve, and were planning the wedding for 13 June. It wasn’t going to be massive, but we would have had family and friends at the registry office, and a nice big lunch at a local restaurant in Bristol. We had people coming from Orkney, France – all over the place.

‘Last week when we were looking ahead, we realised that in 12 weeks’ time we would be hitting the peak of the pandemic in the UK. So we thought we could delay the wedding, or, because we just wanted to be married to each other, and these are difficult times, we can get married now and then we can focus on what’s going to be needed from us personally in the next few weeks.’

While her partner is still working as a GP, Dr Thompson had swapped general practice for other roles, including as an author and a speaker and specialist on child mental health.

With the advent of COVID-19, however, she is one of the many, many doctors who have rushed to offer their services, and expects to hear shortly what her duties will be. This did, however, leave a small window in which the wedding – now a ‘micro-wedding’ – could take place.

‘I called the registry office, who already knew we were going to be married, and they had two slots available. We knew we couldn’t have many guests, but we had our 10-year-old son, Jack, and one of my stepsons was one witness and a friend was another witness. We sat six feet away from each other.’

Mindful of infection control, they didn’t even take taxis, and the wedding cake was a ‘Colin the Caterpillar’ effort from Marks & Spencer.

Wedding over, she can now focus on working for the NHS once more. ‘We all have to do our bit – we really are all in this together,’ she said.

This article is taken from the April 2020 issue of The Doctor magazine.