Frontline insights

Dr Rahma Elmahdi

Honorary Research Associate at Imperial and Junior Doctor in General Medicine. She has been working on COVID-19 wards at North East London NHS Foundation Trust.

“I usually work full-time in epidemiology research and was aware of the impact the outbreak was having in the UK. Once lockdown started, and we were advised to work from home, I decided that the most useful contribution I could make as hospital pressures increased would be returning to clinical work. It wasn’t a hard decision but simply what I was trained to do.

It’s been a really tough and unreal experience overall. There has been a great deal of solidarity among the staff on the frontline and I’ve been consistently inspired and proud of the dedication and energy of all my colleagues on the wards; everyone from the student nurses recruited in the last year of their degree to the consultants on Intensive Therapy Units (ITU) providing (re)training for us.

Although the sheer pressures and confusion coupled with the suffering experienced by our patients has been hard to cope with, the public support and video calls with my friends and family have really been essential for staying positive and going back and doing the same again.

Despite the challenges, there are some really lovely patient stories. My favourite story was seeing a married couple in their seventies, who were admitted one after the other onto our COVID-19 ward – despite the husband being very ill with the infection, he never failed to ask about how his wife was doing on the daily ward round. The team were delighted when he was well enough to visit his wife while they were both inpatients and when we were finally able to discharge them together after three weeks on the ward.

There are also painful stories, which are important to tell in memory of those patients. One man who was admitted to hospital from a care home told me how he wished to see his family before he passed. He tragically never had this opportunity as he deteriorated rapidly and the first time we were able to contact his family was to sadly inform them of his passing.

I’ve not been able to live at home with my family as my mother is in a high-risk group. I’ve been so grateful for the accommodation offered to me for free whilst I work on the wards and all the meals and cake that we’ve received to power us through our shifts. The real gems have been the hand cream we’ve had donated – fantastically useful for my dry and chapping hands after the constant washing.

The first doctors to die of COVID-19 were from Sudan, like me and my family, so this was felt acutely in our community. For anyone who works in health, the two to three-fold increased risk of death from COVID-19 in BAME colleagues is not surprising.

I suspect that a large contributor to this disparity is the racialised socio-economic hierarchy that manifests throughout our society. Sadly, no matter your seniority in the NHS, if you’re from a BAME minority group, your outcomes will be worse than your non-minority colleagues, and now the stakes are higher. Like many of my colleagues, I’m keenly waiting for the outcomes of the inquest led by Professor Kevin Fenton into this and hope for a recognition of the toxic impact of racialised inequalities in the NHS and real change that protects those of us who are most at risk and brings our voices to the fore in order to do so.”

Dr Ruud Nijman

NIHR Academic Clinical Lecturer at Imperial in Platform Science and Bioinformatics and Registrar in Paediatric Emergency Medicine at the London Deanery. He has been working at St Mary’s Hospital to treat COVID-19 patients in intensive care.

“I was greatly looking forward to a period of academic time and working on two large European studies called PERFORM and DIAMONDS, looking at biomarkers in children with acute infections. When COVID-19 happened, I started off working in the paediatric emergency department at St Mary’s Hospital. Then, due to a large reduction in children attending the emergency department, I was asked to support the team in the paediatric intensive care unit, which was repurposed to look after critically unwell adults with COVID-19. In the paediatric intensive care unit, we have all had to adjust our way of working and retrain. Although we had experience in intensive care medicine, most of us didn’t have recent experience of caring for adults.

There were some very difficult times in the unit with very sick patients but the team has been incredible; everybody has really pulled together to make things happen. Looking after critically unwell children is different to looking after critically unwell adults, but a lot of the basic principles of intensive care medicine still apply.

The structure of clinical approach and things like using a ventilator and inserting central lines remain pretty much the same, but other aspects are ’new’: adults are a lot bigger, which makes the clinical handling different. We are used to using very small cannulas and lines and different dosing and types of drugs for children and we need to think about different side effects and blood markers in adults. There have been e-learning modules and webinars offered by the Trust and resources from the unit itself. It has been invaluable to experience the logistical challenge of restructuring and have this additional experience of looking after adults in intensive care.

It has been really challenging to show empathy for each other and for patients and their families whilst working with our equipment on. That is something that will stay with me: how did we look after each other in these difficult times, when you can’t show facial expressions? It makes you realise how special the way we look after patients is without PPE.

Over the past few weeks, we have seen some really sick children and initially we could not quite relate how they presented with the typical Coronavirus symptoms in adults. Most did not have respiratory symptoms, but they had multi-organ involvement and ended up needing specialised care from our infectious diseases team or even intensive care. This arising clinical syndrome, a hyperinflammatory response that we believed might be related to Coronavirus, was escalated to NHS England and the Royal College of Paediatrics, leading to national efforts to try to understand what was happening.

The paediatric infectious diseases and paediatric intensive care team have been instrumental in formulating a case definition of this Paediatric Inflammatory Multisystem Syndrome and driving recommendations for the clinical management of these children. The DIAMONDS study, led by Professor Michael Levin, is now recruiting children across sites in the UK and Europe and the team is undertaking essential research to better understand this new inflammatory condition in children. I am truly humbled to be part of these world-leading teams, both clinically and academically, where studies are integrated into day-to-day clinical care.

It is fantastic how everybody has rallied behind the NHS and how Imperial Health Charity has coordinated the charity efforts. I have not had a shift where I was not offered a hot lunch and often there is food to take home as well. Sometimes it is difficult to get the shopping done or you don’t have the energy to cook, so knowing that when you go to work that that has been provided has really helped.”

Dr Rohini Sharma

Reader in Clinical Pharmacology and Medical Oncology at Imperial and a Consultant Medical Oncologist at Imperial College Healthcare NHS Trust. She has been managing cancer patients.

“As an oncologist, I deal with a very vulnerable group of patients many of whom are shielding and are not able to travel to hospital for their routine appointments. These patients are often scared both about catching COVID-19 and about their cancer getting worse during the pandemic. I feel that it is really important to try to support patients through this difficult time both clinically and emotionally.

My typical role within the NHS is to manage liver cancer and neuroendocrine cancer – a rare tumour that can develop in many organs of the body. Additionally, I lead the research efforts in liver cancer and I’m responsible for allocating patients to clinical trials. Since the onset of the pandemic our entire way of working has changed. It has become necessary to manage our patients remotely and conduct my clinics via telephone, something that has been challenging but to which we have had to adapt. A number of treatments have also had to stop as service provision has focused on allocating services to COVID-19.

My hospital-based clinical care has involved caring for inpatients and on-call provision for the oncology wards at Charing Cross Hospital. The remainder of my time has been spent off-site, which has allowed me to focus on my research, both within oncology and particularly the impact of COVID-19 on patients.

During the initial phase of the pandemic we had to have difficult discussions with patients regarding palliative therapy instead of chemotherapy – as chemotherapy can affect the immune system. These patients were most vulnerable to catching the virus. Surgical lists were also cancelled which obviously meant that many cancer patients could not undergo any surgical treatments during this time.

I found these discussions very difficult, particularly as it became necessary to have a number of these conversations via telephone rather than in person and without the ability to directly support patients faced with such life-changing decisions.

A number of my colleagues have also been infected with the virus, some with significant symptoms and prolonged courses of sickness. It was very difficult hearing how sick they were and how little there was that could be done for them. Though thankfully for them and their families, they have managed to recover, it has been a very frustrating situation and I look forward and hope that we gain control of the pandemic soon.”

Professor Sonia Saxena

Professor of Primary Care at Imperial College London and a GP at Chartfield Surgery in Wandsworth, is supporting primary care services.

“I feel my first duty is to the community I have served as a GP for over 25 years. Everyone has risen admirably to the challenges COVID-19 has thrown at us in our practice in south-west London. I am seeing both ‘hot cases’ in our practice and continuing usual care.

At the same time, I lead the Child Health Unit at the School of Public Health at Imperial. The initial weeks were difficult for some of my staff and students to grasp what was really happening. I think they variously went through shock, anger, denial and eventually some form of acceptance. We quickly organised ourselves with weekly crisis meetings, mid-week tea time catch-ups and morale-building activities.

We have launched the Imperial Child Health COVID investigation working group. Our focus is to ensure that children and young people’s health is not compromised during the pandemic and its aftershocks. Especially with containment and school closure, they have lost their voice and become invisible to much of the research and policy agenda.

The main thrust of our work was to deploy our existing team to brainstorm priorities for urgent child health research, apply for real-time data to inform our hypotheses about health impacts and link with UK and European partners to join public health efforts to combat the virus' effects. So far, we have published several thought pieces on policy, and hope to continue with several projects in progress.

I feel privileged to work alongside my practice team and I am proud of my research teams for pulling together and being productive in difficult working conditions. I feel a great optimism for the lessons that we all have learned about ourselves, our values and priorities. Above all, this sharp shock will teach the next generation how to be resilient and bounce back."

Professor Mark Thursz

Director of NIHR Imperial Biomedical Research Centre and Consultant in Hepatology at Imperial College Healthcare NHS Trust.

“Normally, I supervise the infrastructure for delivering clinical research across the Trust and across every speciality, but most of this research had to be closed down at the beginning of the outbreak, apart from a few studies with specific exemptions. All of our focus and resources needed to be used for dealing with the current epidemic. It is my role to participate, help coordinate and ensure the smooth running of any COVID-19 research.

It has been extremely busy, both clinically and from a research perspective. There have inevitably been tensions between the delivery of research and the delivery of clinical care because we anticipated being very short of resources. It became clearer, probably more than at any other time, the need for the two parts of NHS work to be integrated hand-in-hand. It is a completely new disease, so research is absolutely vital to our ability to fight this epidemic and reduce mortality. For example, when clinical services were overwhelmed, we encouraged research nurses to undertake phlebotomy and clinical observations – that level of integration mitigated against conflicts.

Communication is probably one of the key factors in any kind of success. We have managed to keep a good dialogue between the College side and the Trust side of the partnership.

As a clinical academic, I have done my own time on the wards and have been running clinics remotely. Being on the wards is great in some ways; there is an excellent camaraderie amongst the clinicians, with people trying to help each other out and support each other. On the other hand, it is very frustrating not to have a specific therapy for the patients that we have been admitting.

We have had a number of patients with liver disease admitted during this COVID-19 crisis. Some were admitted for the usual complications of cirrhosis but unfortunately, some of them got infected while in hospital. This underlines what we have seen in the national and international statistics: people with co-morbidities, particularly in this case with cirrhosis due to obesity and diabetes, are incredibly susceptible to very severe COVID-19 infections. It is very sad that the transmission rate even within hospitals is very rapid.

We have been one of the largest recruiters to the platform trials analysing different treatments for COVID-19, with over 2,700 patients recruited into research studies. I have seen clinicians and academics across the Imperial College Academic Health Science Centre (AHSC) coming forward with mostly very sensible ideas, hypotheses, therapies and interventions.

The support both inside and outside the hospital has been wonderful. However, if I had a choice between public adulation and having PPE, testing and a proper policy for dealing with the pandemic, I’d go for the latter. What the public can do to help most now is to hold the government to account, working through their MPs to question why we have had such appalling mortality statistics.”

Mr Martin Lupton

Vice-Dean (Education) of the Faculty of Medicine at Imperial and Consultant Obstetrician at Chelsea and Westminster Hospital Foundation NHS Trust. He has been conducting virtual clinics with patients.

“Contributing to the NHS response to COVID-19 is a visceral thing. When you work in a team in a hospital you develop a very close professional relationship with your colleagues. These are the people that you have telephoned for advice at 2am or asked to help you with difficult cases. They are people who you have shared tragedy with and a lot of joy. When the chips are down you would literally do anything to help them.

As an obstetrician, the way I do my work has been turned upside down. Virtually all my clinical work is now conducted over the telephone. It is an entirely new skill and requires an extraordinary focus on listening. I am learning to hear anxiety, hear uncertainty and make sense of pauses and silences. It is exhausting and fascinating.

My experience at Chelsea and Westminster Hospital has been extremely good. It has been managed with great professionalism. I worry about a number of things, some of them about the well-being of the staff who have been on the frontline for many weeks now. I think for some there is an element of shell shock, and I am not sure how well the system is geared up to manage this.

As far as the public are concerned, I would ask that they reflect on the value of expertise, science and balanced judgement. I would also ask that they reflect on how we support the University sector and science in the future and consider what level of taxes they are prepared to pay to support the NHS so that it is better prepared for the next pandemic. Most importantly, I would ask that they reflect on the contribution that medical, nursing and other key workers have made to their safety, in particular those who are recent immigrants from the European Union and the rest of the world. We cannot use these people during times of crisis and try to ignore them in times of calm.”

Frontline insights

Words: Maxine Myers, Ellyw Evans and Siobhán Stack-Maddox

Photography: Giles Duley, Imperial College Healthcare NHS Trust | Ben Pruchnie, Imperial College Healthcare NHS Trust | Thomas Angus, Imperial College London | Andy Pritchard, Imperial College London