How is the pandemic affecting non-covid services?BMJ 2021; 372 doi: https://doi.org/10.1136/bmj.n215 (Published 22 January 2021) Cite this as: BMJ 2021;372:n215
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The SARS-CoV-2 pandemic is impacting non-covid care to a greater extent than reducing normal in-hospital care for cancer and urgent cardiac surgery. It is associated with excess deaths in the community from diseases that would normally be diagnosed and treated by GPs and emergency hospital doctors. Pathologists performing medico-legal autopsies see these: Pell et al identified acute myocardial infarction, diabetic ketoacidosis, alcoholism and suicide in this category. I add to this list falciparum malaria, venous thromboembolism, and maternal death following self-delivery at home, as consequences of fear of attending hospital and, possibly, inappropriate telephone advice on isolation.
Such data will not be identified from ONS cause of death certification alone, and many of these indirect deaths from COVID-19 will not be inquested. Epidemiologists must examine the detailed autopsy reports to identify and quantify these deaths as the collateral damage from the pandemic. Coroners and fiscals should be making the reports available, rather than – as at present – confidential.
Pell R, Fryer E, Manek S, Winter L, Roberts. Coronial autopsies identify the indirect effects of COVID-19. Lancet Public Health. 2020 Sep;5(9):e474. doi: 10.1016/S2468-2667(20)30180-8. Epub 2020 Aug 10.
Competing interests: No competing interests
As outlined above, the pandemic is clearly having a huge effect on non-covid services. I am a junior doctor in the South West of England, and alongside the rest of the country I watched the case numbers rise sharply into January. Not just the national statistics recording the daily tally of new positive cases and deaths each day, but also on a more real, local level, as we play musical beds in our Intensive Care Unit to try and free up enough room for the deluge of hypoxic patients requiring ventilatory support that began to arrive. All elective operating has been cancelled as we overflow into theatres and recovery areas. I have watched as hospitals in other parts of the country have started to run out of oxygen, and hoped that we do not end up in the same situation. Like many others across the nation, I have reviewed people in their thirties, pleased to see that they do not imminently need Intensive Care support due to our lack of space and resources, only to find out they required intubation two days later.
But this is just one aspect of my job, as I am also a Clinical Teaching Fellow. This means that my role, alongside the clinical portion, is to teach final year medical students and deliver their curriculum this year ahead of their graduation. This cohort of students missed out on a large chunk of their education in the first wave of covid-19  and are now facing even more challenges on placement during this second, seemingly more brutal wave.
So how can we best prepare these students for the challenges that lie ahead? Ensuring they are fit tested for FFP3 masks and vaccinated so that they can gain experience in covid-19 ‘blue’ areas in the hospital is certainly a start. At my hospital we have also developed a simulation session on the resuscitation of a covid-19 patient in order to expose them to a scenario which they have never faced, in a safe environment, away from the wards. Additionally, we have provided teaching on end of life care for these patients, as well as practical skills and catch-up sessions as best we can.
For their clinical placements, the reality is that we are dealing with ever-changing goalposts. As case numbers rise, we want the students to be able to gain the most that they can from being in the hospital, but overrun wards, social distancing restrictions and large-scale staff redeployment are proving challenging. A flexible approach to the timetable, pairing students with a single clinician and increasing the out of hours placements will help in part, but in essence we are dealing with a rapidly changing landscape on a daily basis.
We are liaising closely with the local university to come up with innovative ways to examine the students. Clearly it is a fine balance between ensuring they are clinically competent despite the missed placement time and juggling the increasing demand placed on services. Furthermore, with some students unable to be placed in covid zones, we need a way to ensure standardisation of content delivery and examinations, and to prove that they are going to be ready alongside their peers in a few months’ time.
It is vital that these final year students remain on placement for as long as possible, to see the realities that the system is facing, and to learn how to do the job they are shortly going to be starting. They are our next generation of doctors after all, providing that the NHS is still standing in August.
1. Covid-19: Southend Hospital oxygen supply reaches ‘critical’ situation. BBC News [Internet]. 2021 Jan 11 [cited 2021 Jan 14]; Available from: https://www.bbc.com/news/uk-england-essex-55615591
2. Patterson C. No time to be a student [Internet]. The British Medical Association is the trade union and professional body for doctors in the UK. [cited 2021 Jan 14]. Available from: https://www.bma.org.uk/news-and-opinion/no-time-to-be-a-student
Competing interests: No competing interests