For Sonosite’s ongoing series of interviews of physicians working on the frontlines of the COVID-19 pandemic, Chief Medical Officer Diku Mandavia, M.D. interviewed Dr. Justin Kirk-Bayley in Guilford, England about his experiences fighting the coronavirus. You can watch the interview on our COVID-19 Ultrasound Resources site.
Dr. Mandavia:
As you know, we're in the middle of a global pandemic, and we have been trying to get viewpoints from around the world. As the pandemic continues, right now we're about 2.7 million cases around the world and nearly 200,000 deaths. Today we are interviewing Dr. Justin Kirk-Bayley, who is an anesthetist and an intensivist consultant in Guilford, England. He's going to give his vantage point and his experience with COVID-19. So Justin, welcome and thank you for joining us here at Sonosite.
Dr. Kirk-Bayley:
Thank you very much for having me and giving me the opportunity to talk to you.
Dr. Mandavia:
Justin, why don't you tell us a little bit about where you work, your background?
Dr. Kirk-Bayley:
So I work in, as you said, in Guilford, which is in the southern part of England between London and the sea on the south coast. I work in what we call a district general hospital. A medium- to small-sized hospital with about 500 beds in their critical care unit there. Our critical care unit is slightly larger than average in that we've got 24 beds because we're a major cancer center. And I'm right at the forefront of dealing with COVID right now. So we are about four weeks in. There’s a lot of planning, but now we've got three or four weeks of experience of just what's going on under our belt. We're seeing patients change, practices changes, and we're just waiting for our numbers to change as well, for the influx of patients to diminish somewhat.
Dr. Mandavia:
So tell me a little bit about that. Tell us about how things have changed in the hospital. Have you experienced your surge yet, or are you expecting more?
Dr. Kirk-Bayley:
We've had our surge already. So we maxed out at about 20 patients in our intensive care unit. And we've got down to about 15 or 16 at the moment. But my hospital has just changed beyond all recognition. If you'd spoken to me 12 months ago and told me what would be going on in my hospital right now, I would have looked at you quite quizzically and probably wouldn't have believed you. I could've believed that there would've been a pandemic. The way it would've affected our daily working lives, our practices, the practice of medicine, and just the general operating procedures and the way we conduct ourselves at our hospital each day, I wouldn't have believed it. It's been like nothing I could've thought of. We've cleared out the hospital effectively. So all but the most essential, life-saving surgery has ceased. We have stopped everything apart from all of the immediately-required cancer surgery. Orthopedics, for example, outside of trauma has stopped. All of the other lumps and bumps and things. And so the patients that we have in our intensive care unit now as we speak all pretty much have COVID. There was a period where there were some patients who might have had COVID, but that period is very much two weeks in the past. Apart from the people who are having the cancer surgery who we've screened who are coming up for post-operative intensive care recovery who definitely don't have it. Every single other patient is currently troubled by having the virus.
Dr. Mandavia:
Well that seems like a pretty overwhelming situation. In my conversations with physicians elsewhere, as you know, there's been a significant resource limitation. Whether it's around PPE or ICU beds or ventilators. Any comments on that?
Dr. Kirk-Bayley:
I think we've been lucky so far in that we've not experienced acute shortages of PPE or ventilators, but we know that there's definitely brinkmanship. We have been teetering on the edge of having to make do, do without and things like that. So we will arrive of a morning and just discover that a delivery of PPE has just arrived because we are running out the day before. We have gone backwards and forwards with having patients on anesthesia ventilators. Just one or two as part of our expansion plan but we're back down to our usual ventilator stock. And we're just riding that edge now of hemodiafiltration and renal replacement therapy machines as well. The thing that has been loitering in the background quite a lot and something that I've been involved with a fair bit is the drugs. Because our usual critical care sedative drugs, we are burning through them as well. As well as our filtration fluid. And so we can't do much about the filtration fluid other than trying to decide what we're going to do there. But the drugs are a bit of a problem because we're never quite sure when we go out for supplies, where we're going to get it from. But thankfully on a day-to-day basis, the people who are there, the nurses and the junior doctors and other people, they don't notice that this is going on in the background. So as far as they're concerned, when they turn up they're never quite sure what color their PPE is going to be, but they're lucky they've had it.
Dr. Mandavia:
Tell me about the morbidity and mortality that you're experiencing locally or in the UK.
Dr. Kirk-Bayley:
Locally I can tell you, we're running our units slightly differently. And that's no big secret. So, the way that people decided that we're going to do it in the UK is that we're going to follow on pretty much from some messages that came out of Italy—which was that people were going to have pretty low thresholds for intubating people.
So we were seeing people in hospitals and metropolitan areas who had a much bigger surge much earlier on were intubating patients with an oxygen requirement of about 40%. And then discovering that that had a significant resource burn and told them about what they were going to do about it. So when we saw these things were happening, we got together as a group of intensivists and thought, “Are we going to do that? Are we going to see what we can do with non-invasive ventilation, with CPAP?” Mitigating for the risks of aerosolization of the virus, of course, and seeing what we can do. And the only way to do that would be to try and get it so that we have the very sickest of patients in our intensive care unit. So we can really focus on those people who needed our expertise. Whereas ordinarily you might have three, four patients on CPAP in their intensive care and work with our physicians and acute medics outside of the hospital. And get them with our support and expertise to run CPAP.
And they've run with that, and it's been fantastic. What that has meant is that for us and our expenses is that we've actually had people who have not come to intensive care. They've had CPAP, they've got better out on the acute medical wards, and then they've gone home. And then the patients that come to the intensive care unit are, without a shadow of a doubt, the sickest patients that myself and my colleagues have seen. And we've all seen sick patients, one or two. And we can all remember those particular cardinal patients you get on the intensive care unit. But to have a unit with 15, 20 patients who are all very similar but also have unique problems, and are really just at the threshold of life really taking every ounce of your intellect to think about what to do, how to manage them to stop them from deteriorating is emotionally, psychologically, and physically exhausting. And when we've put people on ventilators, it's taking a long time as every other country and every other hospital is experiencing for us to get them off. But we are, we're slowly getting them off and I think the number of patients that we're managing to recover from ventilation, be that with tracheostomy, without is mirrored unfortunately by the mortality level. So we've got a small recovery rate and a small mortality rate.
Dr. Mandavia:
Tell me about the demographics of the patients you're seeing. I know the initial experience illustrated was a disease that was affecting the elderly more. But since that experience has expanded, we're seeing it into younger patients. Any comments on that?
Dr. Kirk-Bayley:
The typical COVID patient that we're seeing is going to be an older man with comorbidities. So the ratio of men to women is definitely much higher. That's quite noticeable but when people come in maybe in their 50s, the first thing we go looking for is to decide if they're on medication. It's almost invariably that they're hypertensive. And we've noticed that they may have a slightly elevated body mass index as well. So those are the people that are being hit hard. But also, you can see how the patients are behaving. And obviously the older they are, the more comorbidities there are, the iller they are and the less likely they are to make it through. But actually, when they are younger, it's still a bit of a slog. It's a bit of a marathon that we're having to run. And we're seeing the things that other people are seeing with the unbelievable levels of pro-coagulant factors that we're measuring as well and the morbidity that that's causing. So pulmonary emboli and when they're getting onto renal filtration, we're seeing circuits just clotting off really quickly. When we're measuring the blood levels, we're seeing levels of fibrinogen and degradation products that we've just never seen before. And when we go to then heparinize them, we're finding that they're resistant to that. And we're just seeing that there's a phenomenon there across the board. But there's no doubt that the older you are, with a more disease burden that you have before you come into it, the worse you are and the less likely you are to pull through.
Dr. Mandavia:
Tell me about your staff. How are your staff holding up? Have they been, and how have they been affected?
Dr. Kirk-Bayley:
So as I speak today, I think my staff are in pretty good shape. Winding back right to the beginning to having to adjust to the terrible conditions of four, six hours in PPE, where we've expanded into our intensive care unit areas because we wanted to try to cohort in isolation and take out our base that we could just get all those patients together. Not a day went past for the first 10 days or so where we wouldn't see staff in tears or having a quiet moment to themselves. But having left work yesterday, morale is good because it's brought in amazing teamwork. We're seeing people who are coming from other areas. And it's boots on the ground to be able to bring us manpower in terms of nursing staff, physiotherapists, and allied health professionals to try and get things going.
But actually in the UK, the NHS [National Health Service], we've been really valued, and we've been really lucky. If you go into the coffee room, we have literally seen from floor-to-ceiling mountains of chocolate Easter eggs and smoothies filling every fridge. People have been giving us cosmetics, bath balms, clothes, and all sorts of things. So when people are having their down time, they're actually feeling quite valued. They've got prepared food that's being brought in for us. And actually it's making it a bit easier.
It's not easy, don't get me wrong. I think the longest I've spent in the last 10 days in the room was about an hour and half, and I really wanted to rip my mask off my face and get out. The nurse I was working with was going to have to spend at least another couple of hours or so. It is hard work, but I think we've adjusted, we've changed our ways of working. We know that we have to work hard, and we have to value our downtime.
And of course, the lockdown has affected things as well. So when people are going home, it's just them and their families and people are doing video conferences and Zoom and all sorts of other things like that, just like this, and life has very much changed. And the commute to work is an awful lot easier right now.
Dr. Mandavia:
Yes, that’s been a strange but beneficial effect of the pandemic. Getting back to the staff, as we know there's been a fair number of healthcare transmissions within the hospital to healthcare workers. Tell me about that. And I understand you had your own experience around that.
Dr. Kirk-Bayley:
That's something that we live in fear of. There's no doubt about that. And that's something that breeds a healthy degree of paranoia and people following PPE guidance. There's a strong risk of hermitic transfer that it will sit on the surfaces in one of those rooms where the patients are in. And you just have to be really careful about what you do donning and doffing your PPE. We've been reasonably lucky that in our hospital, we have only had a handful of people who have had it. But that's taken its toll on the staff because of course, it's quite difficult looking after somebody that you know that you work with. And there's always that nagging doubt in the back of your mind, “Did they pick it up in the hospital?” A proportion of my colleagues have had it as well. And we never know if you pick it up in hospital, from a patient or you pick it up in the community from friends and family. And obviously that's less likely now that there's lockdown, but you still have to get out and about and do your groceries and thinks like that.
But we're just having to be really careful and still socially isolate within the hospital as well. So if you do an electronic ward round, a board round, we have people go to the rooms trying to space people out into the corners. Because you don't want to give it, you don't want to extend it out to the families of the people that you work with. Give it to them, and then pass it on with the older and potentially more infirm people that they live with
With my own personal experience of having had COVID, I had mine right at the beginning of when it swept through Europe. I'm pretty sure I picked it up whilst I was away on holiday. It wasn't pleasant. And I've spoken to other colleagues, and they're fit and healthy, and I'm lucky to be fit and healthy as well. And you just imagine that it inhibits your ability to go to work. The people who've been away with it have felt quite guilty, too. Because they've had a week off, 10 days or so. They've been unwell and they know that it's not getting any easier day-by-day at work. And they really want to be back and helping and playing their part and feeling really ready to come back when they're allowed to come back as well.
Dr. Mandavia:
I'm really happy that you did well and you got through that COVID-19 experience yourself. Now you're also a point-of-care ultrasound expert. And you're in the middle of a pandemic. You're at an ICU that's full of critically ill patients with a highly unusual disease. How are you using point-of-care ultrasound in these patients?
Dr. Kirk-Bayley:
Our use of point-of-care ultrasound has changed as we've gone on. We did loads of preparation trying to get as much information as possible, of course. We looked at the webinars that were coming out of China. Learning from trends in Italy about what they've been doing for a point-of-care ultrasound. Learning all the diagnostics that could be had with lung, discovering what could be picked up on echocardiography, and just getting really prepared. So when it actually hit and we were starting to think about making diagnoses with patients coming in, it started off that we were looking at the lungs.
And I did a whole lot of tutorials to people not really knowing what the size of it was going to be. I had to teach anesthesiologist and intensivist skills that they hadn't quite picked up yet for looking at potential impact on lungs. So for diagnostics and then doing the second part there about for thinking those patients who may need to go onto proning and the consolidations, things you could pick up there. And then of course, there's the manifestations of cardiac implications as well. And I think it would be fair to say that whilst this carries on, 2020 is going to be the year of the right side of the heart. Because what's going on now is that with pretty much every patient who has COVID, I'm just seeing the IV lines and alveoli interstitial syndrome everywhere.
And there are patients who are on ventilators who are almost invariably transitioning into fibrotic phase. That still means B lines when I scan their lungs as well. But the things that we've been looking at—and I can remember recently when I spent 90 minutes by the bedside with a colleague—was those cardiopulmonary interactions and just trying to get that balance between getting optimal ventilation and also trying not to have too much of an impact on the circulation. So I had a colleague making adjustments with a ventilator whilst I was performing a cardiac ultrasound and really looking on that impact on the right side of the heart and the left side fill-in. And when patients have been actively deteriorating, we've been looking at it and of course, it's quite difficult because they're on ventilators. They've got the lung signs everywhere. And trying to get decent scans of the heart has been quite hard. But there's no doubt that as things have gone on, we've still maintained the application of point-of-care ultrasound. It's just that heart focus has changed. But it still is useful as it ever has been because you can pick up things that you can't get from just looking at waveforms, just laying hands on the patient which of course, is increasingly difficult because you've got layers of gloves and gowns between you. But point-of-care ultrasound for that visual impact of what's going on with the physiology of the patient has been just as valuable as it ever has been.
Dr. Mandavia:
How's your experience been with thromboembolism in these patients? Are you using ultrasound there?
Dr. Kirk-Bayley:
We've found that we've had a significant number of patients who have deep vein thrombosis. So it's nice, obviously with point-of-care ultrasound, then you can pick that up really easily. We've been, I would say, anticoagulating our patients early. Where they've got significant multi-system dysfunction, so renal failure, cardiac dysfunction, and obviously the restrictive failure that goes with it. They've got elevated, high levels of fibrinogen, so we've been deciding on the balance of risk versus benefit. We've actually been going for reasonable systemic anticoagulation pretty early on. But even despite that, we've noticed that there are signs and, indeed, using ultrasound that there are at least the smoking gun of thromboembolic disease.
Because for patients we've been who haven't necessarily had difficult ventilation, one of the things about COVID lung disease is that the lung compliance seems to be preserved. And so they're not really having to have high intrathoracic pressure, so that stress on the heart on the right side is pressures that you would expect with elevated levels of tri-gastric regurgism. And yet, you can see that the right ventricle's not happy.
And when we've been looking at patients who have been just gently going into renal failure, we've been looking at their hydration and making sure that we've got their free water deficit back up for their significant pyrexia that they've been having either when they've been with us or prior to us. We’ve been looking at the kidneys just to make sure that renal failure isn't caused by something that we weren't expecting, some other thing that might cause hydronephrosis or the standard things. One of the new tools of course that we've been looking at for point-of-care ultrasound is looking at the whole idea of vectors and looking at renal venous flows. And actually we've been noticing that the flows within the kidneys are not great.
I've been using this on and off. I haven't really discussed it a huge amount with my colleagues because not really many of my colleagues in my unit are up to the same level of scanning. But I've been discussing it with my great friends around the UK and certainly, it's difficult to try and prove these things because these are not transportable patients. As soon as you decide that you want to try and get a CAT scan on them and do a CT angiogram, or you want to go and get some sort of formal departmental scanning, you've got the whole risk of transferring a sick patient at the risk of aerosolization environs around the hospital. So actually anything that you can do at the bedside is useful. And certainly the clues are there other than finding a great big non-compressible clot in the femoral vein but the clues are there elsewhere in the body that there is a significant coagulopathy occurring.
Dr. Mandavia:
That's a pretty comprehensive view of these patients. And we're getting a consistent approach of a whole body ultrasound, and that's what you're describing. Any other final pointers for our viewers, whether it's around point-of-care ultrasound or your experience with COVID in general?
Dr. Kirk-Bayley:
I think that the thing to realize is that if it hasn't hit you yet, then it's going to be tough, and you can't plan enough. There's nothing that you can't put in place to mitigate for the sheer impact of the disease, both in terms of your resources and you personally as well. So you're going to have to realize that those days that you have off, you're going to have to be careful that you're not working too hard as well. But also for the rest of your workforce as well. You're going to have to try and get that work life balance. So knowing that when you're going into work, you're going to be absolutely up against it. You're going to be there, you're going to be in unfavorable conditions doing things that you're not used to. You're going to have to try and work around constraints that you've never even thought of before. And it's just going to be exhausting.
But actually, if you're working in a reasonably resource-critical care unit and you've got point-of-care ultrasound, it's not going to change. You're still going to use the tools that you have. You're just going to be using them in different ways. And so the skillsets that you've acquired over years of expertise are going to be just as valuable, it's just that you're going to find that you really are using them for a new disease that is doing things that we haven't expected. It is a long disease process as well, and as you go along, you're going to be using those skills in different ways throughout the patient's journey.
Dr. Mandavia:
Well, this is very helpful. It's been absolutely fascinating for me to learn about this disease from physicians all around the world. Your experience really contributes to our global knowledge base about this illness. So thank you, thank you for joining us here today. Thank you for your work in Gilford. On behalf of Fujifilm Sonosite, thank you for all your staff. So with that I think we'll end it, thank you.
Dr. Kirk-Bayley:
Thank you very much, a pleasure talking to you today.
