This case study has been republished here following kind permission from the University of Cambridge.
As hospital wards fill up with COVID-19 patients, many senior academics are finding themselves returning to the frontline, working alongside NHS colleagues to prevent existing services becoming overwhelmed. For some of them, it may be several years – decades, even – since they last did regular ward work. This is the case for Professor Paul Fletcher, who finds himself readjusting from being a senior academic to being, in practical terms, a relative junior.
“When the whole crisis hit in mid-to-late March, it became very apparent that the existing services would be stretched, and so I felt, as a lot of academics did, that we should use our existing skills to try and help out, though mine are perhaps rustier than most,” says Fletcher.
Ordinarily, you would find Fletcher in the Department of Psychiatry, researching mental health and psychiatric conditions such as psychosis. (He was also Mental Health Advisor to the BAFTA-winning videogame Hellblade). But since March, he has been back on the wards, helping assess patients with psychiatric conditions at Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust and Cambridgeshire and Peterborough NHS Foundation Trust. He continues to lead his research group, though his ‘day job’ is mainly carried out at the weekend, after working in the hospital on weekdays. (Fortunately, Wellcome, who fund his research, have been very encouraging, he says, as have the members of his research team.)
Returning to full-time clinical practice after so long was daunting at first. “I’m rusty in a number of areas if I’m perfectly honest, and it’s a very different setting. The last time I wore surgical scrubs was decades ago. Being in a situation where I’m seeing people with masks, gloves, gown, hat – it’s very, very different, but fortunately my colleagues have been incredibly supportive.”
The Liaison Psychiatry team, to which Fletcher is attached, provides assessment, advice and treatment to people admitted to the Addenbrooke’s wards for a variety of medical and surgical reasons. Sometimes the patients have pre-existing psychiatric illness or they may be suffering psychological symptoms as a consequence of their medical problems. For some, the situation may be compounded by infection with the SARS-CoV-2 virus, leading to the disease COVID-19 – in severe cases, individuals need to be placed on a ventilator, which can be profoundly frightening and disorientating.
It is less than four months since the first case of COVID-19 was reported to the World Health Organization (and less than three months since it received its official name). The pandemic has spread so rapidly that scientists are still trying to understand what the virus does to the body. There is growing evidence that the virus can cause symptoms that reach beyond respiratory and cardiovascular problems, profoundly affecting brain processes in some patients.
“The picture can be immensely complex,” says Fletcher, “but [working on the wards] is extremely interesting and rewarding, and provides a constant reminder that drawing rigid distinctions between physical and mental ill-health is far too simplistic.”
For the safety of both staff and patients, healthcare workers wear personal protective equipment (PPE), which can range from mask, gloves and apron on the non-COVID wards through to full PPE when working in higher risk situations, for example intensive care units. But this can pose a real challenge to establishing a rapport between the clinician and patient.
“For example, one of the principles of looking after people with delirium, which can be a part of the infection, is to try to create a calm and steady environment with familiar faces. This is very difficult when the entire staff are wearing PPE.”
While this might not be the ideal situation in which to carry out psychiatric assessments, occasionally it is unavoidable. “In that setting, you just have to make the best of a very strange psychiatric assessment. When the patient can only see your eyes, there’s an awful lot of nonverbal communication that gets lost.”
There are concerns, too, about the lasting psychological or neurological implications for these patients.
“We know that viral illnesses in the past have been associated with longer term psychiatric problems including depression, anxiety, possibly even psychosis. So there’s an anticipation that there will be a wave of new psychiatric illnesses emerging as a consequence of [the coronavirus].”
The psychological impact of the pandemic is not restricted to those who are infected, either. Britain, as with many countries, is in lockdown, with businesses closed and people forced to isolate themselves from friends, even from loved ones.
“I’ve seen some very sad cases of people who have had the rug completely pulled out from under them by the lockdown,” says Fletcher. “They’ve lost their financial input, their job, their support and may be completely isolated. And the consequence of that has been that they’ve become extremely depressed and even suicidal.”
Despite being particularly vulnerable during this time, many people who experience physical or mental health problems may be reluctant to seek help, worried about burdening a clearly over-stretched health service or afraid that hospital admission will lead to them contracting the virus. This has led to a reduction in the number of people visiting accident and emergency departments and in the number of planned admissions. “I think it’s worrying that some people are staying away, when actually they need treatment.”
Working on the wards has made Fletcher acutely aware how physically and mentally demanding the job can be for staff who are working day in, day out dealing with patients in challenging situations. “There’s the challenge of working with somebody who’s very ill, and the physical challenge of working in [PPE] gear. I’m astonished at the level of physical exertion that the full time staff on those units must be putting themselves through – long shifts, hour after hour, wearing very cumbersome gear and acting in a very cognitively stressful environment.”
Added to the physical exertion is the mental strain that this work is putting on healthcare workers. “It’s a frightening thought that there’ll be some people working long shifts who aren’t really getting much time to think about themselves, who are undoubtedly exhausted and who are seeing a significant proportion of their patients die.”
And yet, Fletcher says he never ceases to be amazed by his colleagues, many of whom he says are “managing it with extraordinary fortitude. I’ve been struck by how people who are facing a very physically and mentally demanding challenge, are meeting this with unerring professionalism and compassion.”
He gives an example of when he was about to see a patient on an intensive care ward for the first time, having been trained how to use PPE, though admitting to being “obviously not terribly competent”. He was spotted by a nurse heading out on a break who then spent almost her entire rest period ensuring his gear was on correctly. “By the time she got me dressed up, her much-needed break was pretty much over, but it didn’t stop her prioritising the safety of her colleagues and patients and doing so with great patience and consideration.”
On another occasion, he ran into a paediatrician whom he knew on the hospital concourse. “She was shocked to hear that I didn’t have protective goggles, so she took me over to her department, where they had just received a delivery. She ensured that I had a pair and that they fitted and has since followed up to check that I have all I need. I see this all the time: lots of people looking out for each other. I feel very well cared for by my colleagues here who can see that I’m essentially a very junior member of the team.”
Returning to the full-time clinical work after decades in academia has been a real eye-opener, he says. “It’s a reminder of just how limited my skill set is. I have a research programme that I very much enjoy, but to see that placed within a much broader setting, within the bigger clinical perspective, is salutary and humbling.”
He has quickly learnt to accept that when he is in the hospital, he is no longer the group leader, no longer the senior team member. “I realised very early on that there are people in the nursing and medical staff and allied professionals who are much more experienced and competent than I am. I may be the oldest but, in effect, I’m a junior and my best bet is to just shut up and listen.
“In return, my new colleagues have gone out of their way to support me and so far, nobody’s told me that I’m completely useless!”
Paul Fletcher is Director of Studies in Medicine (Pre-clinical) at Clare College, University of Cambridge, and the Bernard Wolfe Professor of Health Neuroscience