Monday, 27 April 2020

COVID19 - The Good Bad and Ugly

The Good:

Let's start with the good. Why not?

Despite the pain of lockdown, the advantages of isolation go beyond reducing COVID19 cases to a level the NHS can manage.  

Not only has the NHS, so far, been heroically successful in managing the workload, they are learning as they go along, and quickly. I wondered how this might play out when reflecting on my time looking after babies needing ventilation for Respiratory Distress (also due to lack of the lung surfactant needed keep the alveoli open) on Special Care Baby Unit in the 1980's. In terms of technology those days might as well have be in the stone age. There wasn't one computer in the hospital at that time, and a mobile phone was the size of a breeze block.

Nevertheless even during my two years of involvement there, techniques for ventilation moved on rapidly. Basically from energetic ventilation to keep the babies gas measurements normal, to carefully using the smallest pressures and oxygen for the least amount of time possible. This significantly reduced the damage done to the babies lungs. Might something similar be happening with COVID19?

The need for ventilators was predicted on the basis of the first experiences in China, and the procurement scramble reflected the assumption that many hospital cases would need them. It seems now that we are ventilating less patients that initially expected and learning fast that COVID19 is new and different from previous experience of viral pneumonia and Adult Respiratory Distress Syndrome. Patients, it seems, are less clinically unwell than their oxygen saturation levels would, in normal situations, imply.

The upshot of this is the good news. I suspect that more people, like Boris Johnson, will be getting by with close monitoring and support, nasal oxygen, or Continual Positive Airways pressure. (CPAP). This is rather like the sensation of breathing into a strong wind, which helps keep the airways open and can reduce the need for ventilation. If ventilation is needed, then I'm sure with experience, the outcome from this will improve too. Rather awkwardly for staff ventilating patients, the prone position seems to help.

In summary, there is alot of learning going on about this novel condition and the message to delay infection and get COVID ready by maximising health and fitness remains as important as ever. 

The Bad...

Never believe the hype! I had hopes that Remdesivir would offer treatment for COVID19, with lots of expectation and no doubt increased share price for Gilead, the American drug company who hold its patents. Early reports of its 'compassionate' use in France and the US led us to believe that the knights in shining armour might be on their way; only to be dashed once again by the harsh reality delivered by properly controlled randomised controlled trials.

There are shenanigans though. The report of its failure was posted by the WHO and then removed, as it had 'not been peer reviewed'. This won't detract from the reality that the trial failed to show any benefit.

It also turns out that the asymptomatic phase of COVID19 is significant enough for rapid spread outside the confines of lockdown or isolation, even in a skilled nursing home. Again this means that after the lockdown there are likely to be more waves of infection and so once again the message is to get COVID ready. 

The Ugly...

The Trumpster and Bolsanaro are making fools of themselves. Despite their power and influence, they seem not to understand the nature of responsibility. Their statements are verging on the comic, if it were not for their lofty positions.

They exhibit a deadly combination of ignorance and total self confidence. Surely these characteristics will not be affordable as we come out of this crisis, whenever that might be. I read so much high quality comment from genuinely clever people, health staff, scientists, reporters, and ordinary people which are in the main, so inspiring. Then there are these two!

Of course, Trump states that he was only 'being sarcastic". It didn't look like it at the time. This sort of evasion reminds me of school. Or was it pre-school. On second thoughts no. Pre-school children have far more dignity and composure.

Keep healthy! 








1 comment:

Thanks so much for your comment - I will get back to you shortly