An interview with emergency department consultant Andy MacNab

THE more coronavirus patients emergency department consultant Andy MacNab sees, the more he learns.

And he is picking up new information from other sources all the time.

“We discuss all the cases we get – particularly the ones who go to the intensive care unit – and what went well or not so well,” said the Morriston Hospital consultant.

“We are looking at every little change of information from around the hospital and from around the world, and thinking, ‘Can we make it work here?’

“We are thinking of doing more positional changes for conscious patients – trying to get them on their side or front for quarter of an hour.

“They are connected to a lot of stuff, and emergency department trolleys are relatively narrow compared to intensive care beds.

“For patients who are unconscious, it can take a team of eight to roll them.”

Changing patients’ position, he said, helped get blood and oxygen to different parts of the lungs.

For it is respiratory problems – created by the virus and the body’s immune response to it – which characterise Covid-19’s grim profile.

Dr MacNab and his emergency department colleagues operate at the very front of the frontline.

He said around 60% of patients coming through the front door had Covid-19 symptoms; the other 40% were more conventional emergency cases, such as cardiac arrest and stroke.

These two types of patient are treated in separate areas – and mild to moderate coronavirus cases go to a new respiratory assessment unit nearby.

Dr MacNab and fellow staff wear full personal protective equipment (PPE), which he described as hot and “almost oppressive”.

He said: “You can’t exhale as much as you normally would.

“You tend to do half a shift – four hours – in PPE. Then you have a drink and cool down.

“Mentally it’s challenging – you’re thinking, ‘Don’t touch this – don’t touch that.’

“And the communication side is really tricky.”

The human touch, he said, was part of being a doctor, especially when children were involved.

“If children come in with fevers, we still have to protect ourselves,” he said.

“With a toddler, a smile or a reassuring facial expression goes a long a way.”

Dr MacNab said PPE was continuing to arrive but that he and his colleagues would feel more reassured if they could see four, five or six days of supply in the cupboards rather than less.

“As a high risk area, we are prioritised,” he said. “And bringing in the Army has helped.”

He said “one or two” emergency department colleagues had been off sick, but that generally the unit had been pretty well protected.

Dr MacNab explained the key differences between Covid-19 and winter flu.

“The number of people it is affecting is different to standard winter flu, which predominantly affects older people,” he said.

“That is not necessarily the case here.

“In some ways, Covid-19 is reminiscent of swine flu (a virus which caused an outbreak a decade ago).

“But the number of people needing to go to intensive care is more significant than either (swine flu or winter flu).”

He added: “Why do some patients with Covid-19 have this lung inflammation? That’s something we would love to know.

“It’s likely to be a combination of pre-existing conditions and genetics.”

If you could predict this, he said, you would better know which drugs to trial.

Dr MacNab said the interaction between the virus and the immune system was very complex.

“It’s hard to separate the two things,” he said.

“It’s not usually the bug itself but the way it stimulates your body to fight it that’s the problem.”

He said he and fellow medics welcomed a new study of 20,000 households in England which aimed to better understand infection and immunity levels.

“We don’t know with any accuracy yet what proportion of people catch the virus but only get mild symptoms,” he said.

Knowing this, he said, would enable health experts to better plan what hospital resources were needed.

Some people requiring hospitalisation don’t pull through, and Dr McNab said he and his colleagues tried their best to allow relatives to visit in the final hours, where safe to do so.

“It’s really difficult to balance that risk,” said the 53-year-old. “You don’t want people who come in to become unwell.

“We consider every case on an individual basis.”

Computer tablets are also on hand for patients to keep in touch with their families.

Tragically, health workers throughout the UK have died after contracting Covid-19, including at Swansea Bay University Health Board.

Asked how this affected staff, Dr MacNab replied: “You try to protect yourself mentally coming into work, and think it happens to people who are different from you.

“It hits you when it’s someone your age, or someone like you at work.

“And if it’s someone you know, then that makes it that bit harder.

“That’s really difficult for us all.”

When he’s at home in Llanmorlais, north Gower, Dr MacNab said it could be difficult to switch off.

“It’s hard not to think about it (the virus),” he said. “Firstly, when you have any sort of news channel on, you’re constantly being reminded what’s going on.”

He also said he and his colleagues would let one another know when the latest scientific paper on Covid-19 was published.

“You do decide that for a couple of hours you’re just going to watch a movie with the kids – but knowing you’ve got this drive to know more,” he said.

“We’re used to pressure, and you learn strategies to relax.”

According to NHS chief executive Andrew Goodall, around 47% of Wales’s acute hospital beds are empty at present.

Health boards have created extra capacity due to Covid-19, postponing a number of routine operations and services as well as creating new field hospitals.

Dr MacNab urged people who were “properly ill” – for example those experiencing the breathlessness and chest pain associated with a heart attack, or those with the symptoms of a mini-stroke – to attend their nearest emergency department.

“That’s the thing that’s worrying us,” he said.

“We have seen a drop-off in TIAs (transient ischaemic attack), which can be the precursor of a large stroke to come.”

Dr MacNab praised the public for its very visible support of the NHS, and for the food which was being supplied to Morriston Hospital staff.

And he thanked people for adhering to the social distancing and self-isolation measures.

“If they had not done that, rather than the figures levelling off we would have have seen that big peak which would have totally overwhelmed the resources of the health service,” he said.

“We are really grateful.”