Many Covid-19 patients continue to need care at home, once they leave hospital. The story of Mary Blessington illustrates how the path to recovery can involve U-turns, writes Dr John Wright of Bradford Royal Infirmary.
We've already had our second spike - in care homes - and we know the third is waiting impatiently in the wings. Epidemics often have long and bumpy tails.
If you catch Covid-19, your risk of death if you're over 80 is 15%. If you are under 50, it is less than 1%. We were late in protecting our care home residents and far too many have died far too early. But most of our older people live independently, many of them alone.
Our new Covid-era NHS will have to adapt quickly to care for them, whenever possible keeping them out of hospitals, where the virus abounds, but also looking after them when they are discharged as survivors.
In Bradford we are fortunate to have an innovative team called the Virtual Ward, who've been fulfilling this role for the last couple of years. It's almost as though they knew Covid was coming.
It was a member of staff on the Virtual Ward that noticed all was not well with Mary Blessington, after she was discharged and returned to her loving husband, Michael.
Mary and Michael were both admitted to hospital with Covid-19 on the same day, having most likely caught the virus at the funeral of one of their sons on 16 March. They have been together since the age of 13 and, coincidentally or not, it was when they were placed side by side on the same ward that they began to recover. (I wrote about this here.)
Michael was discharged first, and the family was overjoyed when Mary was allowed home a few days later.
But Elaine Martin, a trainee advanced clinical practitioner who visited Mary at home, noticed that she was still having difficulty breathing, and that she was deeply worried both about her husband's health and her own prospects of recovery.
"She was still having symptoms, she still felt breathless and chest tightness but I think a lot of it was anxiety. She felt she was going to die, and her husband had recovered but has an underlying condition, so there was a lot of anxiety," Elaine says.
The decision was taken to bring Mary back to hospital - which was fortunate, because that night her condition worsened.
It was thought she might only have hours to live, so Michael and the couple's two surviving sons came to the hospital early in the morning, put on PPE and sat with her, saying their goodbyes.
But I am glad to say Mary recovered again. She remains very poorly, and is receiving help for her anxiety, but we hope she is on the mend.
Mary is only 67. We have had numerous older parents who have recovered on our wards from Covid-19, but there is a good reason for keeping older people out of hospital if we can and sending them home as soon as it is safe to do so. For elderly patients, every day in hospital leads to "deconditioning", a loss of physical and mental functioning. For some, the strange environment can cause delirium - a condition with symptoms ranging from drowsiness, confusion and rambling speech to hallucinations.
The Virtual Ward allows elderly patients to remain instead in familiar surroundings, or to return to them quickly - perhaps enjoying the company of a spouse, children or friends - while also continuing to receive complex clinical care. Staff are on call 24/7, and patients remain the responsibility of the doctors who referred them.
"There are really important clinical reasons for people to be in hospital, of course, but for multiple reasons, elderly people just do better at home," says Kate Moore, an occupational therapist trained to understand what equipment and adaptations frail people need at home after being discharged from hospital.
"People get weaker when they're in hospital, there's incontinence, not eating and drinking, all those things seem to get worse for people when they're in a hospital bed, and especially in a world where people are wearing masks and they might feel very disorientated. So we try to replicate the care of the ward but in people's own homes."
Front line diary
Prof John Wright, a doctor and epidemiologist, is head of the Bradford Institute for Health Research, and a veteran of cholera, HIV and Ebola epidemics in sub-Saharan Africa. He is writing this diary for BBC News and recording from the hospital wards for BBC Radio.
- Listen to the next episode of The NHS Front Line on BBC Sounds or the BBC World Service
- Or read the previous online diary entry: Did VE Day parties cause a spike in Covid-19 cases?
With an ageing population in the UK, many living alone with chronic health problems, there are many people who need more help than local authorities currently provide - all of the political parties accept that. Reform has been promised for years. And now we have Covid to contend with as well. The virus has been disrupting the support networks that some frail and elderly people rely on, and increasing their isolation.
"There's a huge problem and growing one around depression and loneliness, because people are doing less with family members. They probably aren't walking as far as they used to. People that we would normally refer to a group for group exercise aren't going to group exercises. So people are getting weaker. So we're going to see more falls," says Kate.
One of her patients, 81-year-old Phyllis Holmes, fell and broke her wrist several weeks ago. More recently she developed a cough and diarrhoea and was admitted to hospital with suspected Covid-19 - two warning signs seen in many elderly patients - but her swab came back negative. So she is now back at home, but coping alone is hard.
"I can't open my front door or turn on the taps properly - I tried turning them on and nearly flooded the place," she says. "I haven't been able to wash my hair since March. I can't open my pills because I can't get the grip on the bottle - my neighbours would help in the past but they're staying away because of Covid."
Before the lockdown, Phyllis also got help from her daughter, but she too is now staying away in case she picks up the virus at the supermarket where she works. The rest of Phyllis's family are isolating for their own health reasons.
Kate says she will practise some wrist exercises with Phyllis and help her to find ways of opening the door and getting out into the garden.
Another patient on Kate's calling list is Vernon Fearing, who is in his late 80s.
Vernon came to Bradford from Jamaica in the 1960s to work on the railways. He has diabetes, and recently had a minor stroke. A couple of weeks ago, when his blood sugars plummeted, he was taken to hospital by ambulance treated and discharged. A week later, when he developed a high temperature, he was admitted to hospital again with a suspected urine infection. But when he was tested, it turned out he had Covid-19.
Vernon has been sent home to recover but he is still infectious and this has to be carefully managed.
"What we're desperate to try and do for him is just make sure that he doesn't get any weaker than he already is. He's upstairs in his house. He can't come downstairs so I'm taking him a walker to see if that helps him at least get up from bed," Kate says.
"I'm going to try to educate the family a little bit on exercises they can do, partly for physical stimulation, but also mental stimulation because obviously, with Covid sometimes people get a hypoactive delirium, which means they get less active, they become very, very drowsy."
If that happens, there's then a risk that they will lose interest even in eating and drinking.
The person who will help Vernon with his exercises is his granddaughter, Jodie. His wife, Carmen, is in her room, coughing - she is waiting for a test result that will reveal whether she is also Covid-positive.
Vernon has trouble speaking. He says he wants to see the sun from his bedroom window so Kate helps him get up and suggests that he dresses each morning. She's going to try to get him re-tested to find out if he is still infectious - which is a concern for Jodie, who has a condition that requires her to take drugs to suppress her immune system.
"I can just count my blessings because I know there's a lot of other families that are going through even worse, where they've actually lost members of their families," Jodie says. "And I've just got to be grateful. I'm thankful, even though it's not the best situation."
Apart from the two days she spent at home, Mary Blessington has now been in hospital for six weeks. It's not only patients admitted to intensive care - like Mohammed Hussain - who need prolonged treatment for Covid-19. Mary is also not alone in having had return to hospital after being discharged.
When Mary is feeling better she asks her son, Craig, to bring her food - a prawn salad, a fruit salad with melon, or crisps - which he leaves at the entrance of the hospital to be taken to the ward. I heard good news on Saturday morning that Craig was en route to the hospital with a big lunch order.
When Mary eventually leaves hospital for the second and hopefully final time, she is likely to need further care at home for many more weeks. It will be the Virtual Ward that provides this, until her recovery is complete.
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