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Hot Topics Blog

A GP’s COVID-19 Diary

Dr Siobhan Becker - 7 May, 2020

It is Friday evening and I joke on our partner’s WhatsApp’s group ‘ I am trying to pretend I don’t have a sore throat, I think a gin will help’. I keep ignoring it, but by Saturday I can’t deny it anymore, coupled with the burning sensation in my chest. We have spent the last 3 weeks or so working at full tilt in the practice to clear our backlog, reverse our way of working and minimise face to face contact; we have split our sites into ‘hot’ and ‘cold’, we are all set up for working from home, and we are ready. I just wasn’t ready to be ill…

I am still sure it is just a cold but I switch to working from home to self-isolate for 7 days. Day 5 and I am feeling undeniably below par. I am logged in from home and doing my surgery by phone; I start to notice how long each phone call is taking me, and how my sentences are getting shorter and shorter. Finally, after a particularly voluble patient that I struggle to keep up with, I check my sats…90%. I am no intensivist, but I am pretty sure that is not good. My fabulous colleagues all sweep in remotely and take over my surgery and I crawl to bed where my sats recover. Each trip to the loo brings an alarming tachycardia and a drop in sats. But also sometimes just lying in bed, an episode of breathlessness for no apparent reason. I have a consistent RR of 24, but as long as I am not active my sats are maintained.

Constant chest pain and breathlessness become the default. Circulating on the WhatsApp groups are stern warnings of how patients with COVID can go from being pretty fine to pretty dead in a few hours, so when day 7 brings a sudden unprovoked, unexplained episode of acute breathlessness, I end up in an ambulance to respiratory ED, crying all the way with guilt that my children have seen me like this and I am leaving them with a good chance that I am going to die.

Luckily my sense of doom is misplaced; I don’t die, and after bloods and a CTPA, the episode settles back to down to my ‘usual’ level of breathlessness and I can go home. The next 7 days are spent in bed, breathless, and with the sensation of a burning bowling ball sitting on my chest.

And then begins the recovery…at a worse-than-snail’s pace. Patience is a virtue I was never blessed with, and coupled with the guilt of being away from work for so long it’s a tough time. The breathlessness still creeps up from time to time and the exhaustion is grinding. Just trying to read 5 of the seemingly ten thousand emails that have built up is too much. My capacity to do anything other than watch trash sitcoms has vanished. Slowly things improve and finally, the day comes when I can leave the house and walk around the block. It is a triumph and restores my spirits.

4 weeks from day 1 and I am working from home, on a light schedule; I am still exhausted, it is so boring, but I am heading back to normality after the oddest 4 weeks. I am incredibly lucky. I have had huge support from friends, family, and my beloved work colleagues. I had exemplary care from paramedics and the ED. And now I have no worries about how effective my PPE may or may not be…

Siobhan

Siobhan Becker, GP Oxford & NB Medical Hot Topics presenter

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COVID-19 and the potential cancer time bomb

Dr Kate Digby - 14 May, 2020

I am sure you will agree that in the last 2 months life has become somewhat strange. Within the space of a week, we redesigned our way of working, discovered IT skills we never knew we had, and began to work remotely as much as possible. Herculean amounts of planning and an unprecedented volume of email traffic followed to ensure that not only were we looking after our staff, but we were also looking after our patients as best we could while the Covid-19 pandemic unfolded. As the pandemic continues to unfold, the collateral damage is starting to emerge and at the forefront is the time bomb of missed and delayed cancer diagnoses.

For example, at the start of the pandemic, I had a call from a 50 year old chap who was feeling very itchy. He had been lucky enough to have squeezed in a holiday just before the lockdown began. We agreed his symptoms were most likely due to dry skin/dermatitis and I advised he buy some OTC emollients. The next call he made was to a colleague 2 weeks later, the problem persisted and the itching was driving him crazy. In addition to the emollient, an antihistamine was advised and a steroid cream prescribed. The 3rd call to the practice came 2 weeks after that….his skin looked yellow and his urine had turned brown…cholangiocarcinoma has subsequently been diagnosed mid-lockdown.

The Government’s clear message of ‘Stay Home, Protect the NHS, Save Lives,’ went down well. Our patients have been brilliant, doing as asked, and staying away from the surgery as much as possible. We have become more confident in telephone consulting, video consulting, and managing problems remotely. But there is a flip side to this new way of interacting with our patients…what about the un-done work? Just because there is a pandemic going on doesn’t mean that all other problems have decided to take a break. Cancer did not receive a memo at the start of the pandemic asking it to stop developing for a while whilst we address the Covid-19 issue. Yet urgent (2WW) referrals to secondary care for suspected cancer have dropped by 75% since the pandemic began. This is in part due to fewer people contacting their GP with new symptoms and partly due to a reluctance on the part of healthcare professionals to refer patients to secondary care for investigation, or reluctance from patients to visit their local hospitals for fear of catching the virus. Cancer Research UK (CRUK) estimate that this dramatic reduction in referrals will miss over 2,000 new and as yet undiagnosed cancers per week in England alone.

Couple this with the fact that screening services for bowel, breast, and cervical cancer have been paused during the pandemic. Over 200,000 people per week are not being screened, reducing the chances of early diagnosis whilst asymptomatic. The C-bomb is ticking and we will be counting the costs of the COVID pandemic on our early diagnosis and survival statistics for years to come.

So, what can we do? The NICE NG12 guideline & Scottish Referral Guidelines for Suspected Cancer both provided clear symptom-driven recommendations on when we should consider referral or investigation. Even in these strange times, it is worth remembering those recommendations to prompt early referral or at least a discussion of your concerns with your patients.

Your clinical IT system may support the use of a cancer Risk Assessment Tool such as Q-cancer. If it is not embedded into your clinical system, the Q-cancer tool is available for use online. It is also worth checking with your local departments to see if they are still able to process diagnostic tests such as a FIT tests or XR requests, which could help in your diagnostic quest.

Of course, we all know that in practice many patients present to us with vague, undifferentiated symptoms. If improving early diagnosis/referral rates for suspected cancer was tricky in conventional times, it is a massive challenge when working remotely. Finding that elusive needle in a haystack has never been more complicated.

There has been a lot of research published on how we can better manage these vague presentations (in non-pandemic times) and one consistent recommendation is the use of careful safety netting measures. At least this is something that we can still do during remote consultations.

Re-assessing patients if their symptoms do not resolve, documenting clearly the advice that you have given, and explaining the likely time to resolution of symptoms (and the need to call again if they persist) are key parts to safety netting. Trying to avoid the false reassurance of normal results (CXRs are normal in about 20% of lung cancers) and ‘seeing through’ the co-morbidities that may be masking the sinister symptoms are other considerations. I am a firm believer of the ‘3 strikes and you are in’ approach – if a patient presents with the same problem 3 times, it is time to ask someone else for an opinion.

CRUK Insight have several useful advisory publications on managing vague symptoms and safety netting. Most recently CRUK has published recommendations for safety netting during the Covid-19 pandemic as well as a useful resource for patients, both are worth a read.

The later diagnosis of cancer with its prognostic implications is going to affect our patients for years to come. If we can mitigate the impact and reduce the number of cases where we feel that opportunities for earlier diagnosis were missed, it would not only be good for our patients but would be great for us and our mental wellbeing. I firmly believe we are all doing our absolute best at the moment. We now need to consider how we can sustain this way of working going forwards whilst resuming some of our key diagnostic duties such as increasing the referral rates for suspected cancer.


Dr Kate Digby

NB Medical Education, Cancer Lead

GP in Gloucestershire

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