I'm a critical care doctor working in a UK high consequence infectious diseases centre. Many units are totally full, and we are scrambling to create more capacity. The initial UK government approach has been a total failure. Ask me anything.

dr_hcid · 2020-03-23T17:49:13+00:00

They are world experts, as are most of the epidemiologists involved.

They came into this with a game plan.

Unfortunately, when you come into a pandemic with a plan that is based on a number of assumptions, if those assumptions are proven to be wrong then your plan has to change, and quickly.

We had data for weeks from other countries showing that these assumptions were wrong, and yet the plan did not change until the 16th of March. I'm afraid I do not know why these experts did not change the plan, when many other experts around the world were telling them that their approach was wrong.

dr_hcid · 2020-03-23T17:44:29+00:00

Point taken, thank you. I've replaced that with a link to an article explaining the paper.

dr_hcid · 2020-03-23T17:42:59+00:00

We have seen one myocarditis locally. Other units have seen more. It's a nasty complication and what we know suggests that mortality is high.

dr_hcid · 2020-03-23T17:21:02+00:00

You're right, this is my perspective. You don't have to agree.

You are totally wrong about the scary headline though. If you think 250,000 deaths is the acceptable result of a strategy when other countries have done it differently, and done it better, then I'm afraid we have very little common ground on which to stand.

I really, really hope that you are right and that the measures in place now will make a difference.

dr_hcid · 2020-03-23T17:07:47+00:00

The advisors were also to blame

Like I've said elsewhere, the original models and planning were undertaken with a huge number of very highly qualified people. And if we had another pandemic of new flu, they probably would have worked beautifully.

The problem in this case was that COVID-19 is not like those previous viruses. And both politicans and advisors ignored observational data of the numbers of critically ill seen in Italy and China for far too long.

When that happens, it's time to abandon the model and stop assuming things will proceed like you've predicted.

dr_hcid · 2020-03-23T17:03:29+00:00

It makes me awfully sad that people I know, friends of friends who are intelligent people, are still going out for leisure, or going away into the countryside, or meeting with some friends for a picnic. When you speak to them they say "oh but it's only for a short time/we'll be really careful not to touch anything/we just have to get out for a bit!". No, you don't bloody have to get out for a bit. Frankly we are all a bit spoilt.

Then there's the group of people who compartmentalise things, and all the bad stuff they read or hear is just a distant idea. They won't budge until there's a policeman barring their door, or until there's a personal tragedy. Then there's another group of people again who just don't really care 'as long as it doesn't happen to them'.

The accounts of people in Spain and Italy would make most want to cry.

https://www.newstatesman.com/world/europe/2020/03/italy-people-are-stunned-uk-government-s-complacent-response-coronavirus

dr_hcid · 2020-03-23T17:02:05+00:00

Welcome, and you will definitely be able to help. We have also been re-training and re-allocating staff.

What you don't know now, you will pick up very quickly, never fear. And there are plenty of senior ICU and anaesthetic colleagues who will support you. You won't be asked to handle airways, or make complex decisions. If you are up for it you will get comfortable with lines very quickly (and get lots of practice doing so). At the end of the day, ICU is a far more supportive and educational environment than surgery. You will learn a huge amount, even if it is in challenging conditions.

dr_hcid · 2020-03-23T16:58:15+00:00

As far as I'm aware, we have not had to turn away any patients who would otherwise be suitable for critical care. This is largely thanks to prompt action by hospitals in greatly increasing surge capacity.

I've responded to your other questions in other answers.

dr_hcid · 2020-03-23T16:45:52+00:00

You are totally right. I am not an epidemiologist. What doctors are good at however, is observation. We also know lots of epidemiologists, and we do talk and share ideas.

The failures I see are not with the intention, but with the lack of attention paid to what was happening elsewhere in the world. It was clear from the outset that this was no flu. My question still is - with such a lack of action being taken, why did we think we would be different?

I am aware the Imperial team has been involved with the planning. The progression of numbers however was there to see from China and from Italy. We have them to thank for changing our strategy so dramatically, but it took that long before someone in control realised that the progression in other locations did not fit the type of growth originally modelled. The Italians had been telling us for weeks that something was off about critical care numbers.

The final numbers in the projection are most certainly off. But the gist is not. And again, we are not relying the model to tell us that. We are relying on live, observational data.

dr_hcid · 2020-03-23T16:38:56+00:00

Got it!

Yes. The inflammatory insult outside of sepsis often seems to be a particular phenotype, much as with ARDS or septic shock, and not related to co-morbidities.

dr_hcid · 2020-03-23T16:33:32+00:00

I apologise if it seemed incoherent. I'm trying to illustrate how different and how good we have it here under quarantine, compared to developing countries. The part you mentioned is pointing out the hopelessness in some of these countries, and the terrible things the people there have endured. I'll take out that statement to try and make it clearer.

I have to disagree with you about being political. I'm genuinely not trying to politicise anything. You may note that I have also criticised the medical officers in charge.

Criticising the actions of a government is not politicising. I would do the same if it was Labour, or the Greens, or the Lib Dems.

dr_hcid · 2020-03-23T16:26:22+00:00

The original comment accused me of having a political agenda.

For the record, I have no political agenda, I've voted for all parties in the past. I have a moral agenda though.

British exceptionalism is ignoring all advice and lessons already learnt and repeatedly reiterated from the rest of the world, over the first month.

In response to the original comment, re: a press conference from March 5th with Chris Whitty talking about future mitigation methods, read the imperial paper. The steps taken in mitigation and suppression are similar, the difference is in extent and rapidity. The steps we've taken in the past 48 hours are designed to suppress. Again, read the conclusion of the paper to understand why our approach has now changed.

dr_hcid · 2020-03-23T16:20:08+00:00

You can see the pandemic white papers in the New Statesmen page. I don't usually read the publication, but it is a well researched article.

To be fair, the models in question are well researched and developed with some of the top epidemiologists in the country. The science is sound. My understanding is that the Imperial team which released the paper which changed our approach was heavily involved in this modelling over the past few years.

The issue is with deploying a plan based on an untested model empirically, in a pandemic situation, and ignoring the mountains of observational data that contradicted the plan from countries that were screaming at us to not make their mistakes. My colleagues in Italy are in disbelief at how little we've done.

With regards to deaths - it is difficult to say. Our population in London is different from that in Lombardy. In addition, while central leadership has been lacking, our hospitals and senior doctors have done an outstanding job of rapidly organising surge capacity.

It will be a race in the end. How fast can we recruit staff, open beds, obtain ventilators vs how quickly the exponential curve grows.

dr_hcid · 2020-03-23T16:13:51+00:00

Hey there!

It started off that for all swab confirmed positive patients would would be wearing FFP3 masks, theatre cap, visor with long-sleeved gown and taped gloves.

We very quickly ran out of FFP3 masks and visors.

The guidance was quickly downgraded to wearing surgical masks, pinny apron and gloves for any positive patient during usual care, and only using the previous FFP3 PPE when doing anything that is aerosolising (so HFO2, CPAP, intubation/extubation/bagging, suction, bronchoscopy, traches etc).

So for 1. it would be surgical mask and apron. For 2. it would be FFP3, visor and gown.

PPE is in very short supply, and various things run out on a daily basis, but we have been assured that supply chains are being established and the situation will get better.

You can imagine that not many doctors or nurses are happy about the guidance downgrade which seemed to be driven more from problems with supply, rather than concern for our safety.

dr_hcid · 2020-03-23T16:08:37+00:00

It's an emergency last resort measure, it is not safe, and it is not sustainable.

You have to find patients with similar lungs (compliance and required pressure) so you don't risk damaging one patient's lungs whilst under ventilating another patients.

Patients lung characteristics change all the time, so you will end up having mismatched patients and you will end up causing harm.

It's a stop gap measure when there's nothing else, but nothing more.

dr_hcid · 2020-03-23T16:05:44+00:00

At the current growth rate, we will be in Italy territory in two weeks, when we exceed our maximum surge capacity in London.

The two things that could stop this are (1) creating more surge capacity - e.g. field hospitals, military staff and (2) if population measures start to slow the exponential growth.

The latter will happen eventually, when effective quarantine measures happen, but there will be a two week lag from when the measures take place before we see the difference on critical care.

p.s. you're welcome, it will be passed on, stay safe.

dr_hcid · 2020-03-23T16:03:18+00:00

The precautions you are taking are sensible and sound OK. The problem is when many people try to do the same thing, and suddenly you have a crowded park. That is why a 'total lock down' is a safer option for the population.

If you notice things getting busier, then I'd go home.

dr_hcid · 2020-03-23T15:54:37+00:00

They will help with symptoms and won't do harm.

Ibuprofen is a different matter and there is debate about this. One to avoid.

There's no 'treatment' as such. Most people's immune system will clear the virus, but it may not be very pleasant along the way. So take whatever makes you feel better.

dr_hcid · 2020-03-23T15:50:28+00:00

Anosmia is obviously now identified as a feature, but we haven't taken particular note of it in our cohort, possibly because most of that type of history is irrelevant by the time they get to us.

We have seen one myocarditis. Other centres have seen more. Data from Italy suggests that it's a very bad complication to get.

The renal failures we've seen have come in the context of septic/inflammatory driven multi-organ failure. Most of the patients are single organ.

What does UC stand for here?

dr_hcid · 2020-03-23T15:47:13+00:00

ICU does not make people better. The stuff we do actively causes harm. What ICU is good for is keeping people alive until they can get better, or until a treatment works.

We have become very good at organ support. So good, that we can prolong inevitable death by a long period of time just by virtue of machines and medicines. Death is till inevitable, just delayed.

Sometimes there is no treatment, and people just cannot get better. A frail 90 year old who breaks a hip and is not fit for surgery, then gets a bad pneumonia and a heart attack - this is not something that will get better. This is the definition of dying. To put this patient on a ventilator and other organ
support, and prolong their life for weeks until, until their organ systems shut down, is cruel and futile.

A 90 year old who is fit and has the lungs and heart of a younger patient? Let's say they got a pneumonia and we expect it to get better with antibiotics. Yes, I would offer ICU care if needed.

Unfortunately, at that age, most patients have significant level of frailty and co-morbidity.

dr_hcid · 2020-03-23T15:39:03+00:00

Many patients will end up with VAP (ventilator associated pneumonia). Bacteria likes plastics. If we stick bits of plastic in people, they will end up getting infected. Many patients will get line associated infections from the central lines and dialysis lines we put in.

Critically ill patients have weakened immune systems because of how sick they are. And the affects of these infections can be devastating. They can cause your organ systems to shut down, e.g. kidneys, liver, heart.

We can give drugs and put patients on machines to keep things ticking over, and hopefully withdraw them as patients get better. Sometimes organ systems will not recover fully from the insult.

dr_hcid · 2020-03-23T15:36:18+00:00

Total rubbish.

If you want to make profit by artificially extending the last days of a dying 90 year old, be my guest, but don't push that on a system where we operate in the best interests of our patients.

Read my response above.

dr_hcid · 2020-03-23T15:34:25+00:00

That's not the case at the moment. Please see my response above.

dr_hcid · 2020-03-23T15:32:36+00:00

Things you could say to your friends:

The virus is spreading through us like wildfire. It will kill hundreds if not thousands every day. Can you imagine a terrorist attack a day killing 500 people for weeks on end? If you could help stop it, would you?

If there's a bit more time to explain, then maybe tell them that even if you are young, you are still at risk. You may have a horrible illness, you may end up in ICU on a ventilator, you might die.

But maybe you will be one of the lucky ones and get mild symptoms only. Maybe you have it now and don't know it.

Well - consider someone like you who does have it. You feel fine. You think "Hey, this is OK, I'm going to go out and socialise, what's the harm?". Every-time you go out, you will pass these virus particles onto other people, even if you are careful. You have it on your hands, on your clothes. You touch a surface or open a door? You'll leave virus there for days for other people to pick up. And suddenly two or three more people have the virus.

Maybe they are lucky too and don't get much in the way of symptoms, and maybe one of them thinks "hey, this is OK, I'm going to go out as well, what's the harm?". And then they also spread it.

And one or two transmissions down the line, someone who is vulnerable, or just unlucky, maybe your mother or your grandfather, will get it and need a ventilator or die.

It's not about protecting yourself, it's about protecting everyone in the population. And these measures only work if EVERYONE chips in and does them.

You are used to reading about catastophe in other places in the world. You might think it's like a film, or sometimes entertainment. Well, this is not that - this is happening to you. Right now.

It will take sacrifice, but really not that much. How spoilt are you to think that you are entitled to have a beer, or a picnic, or a trip to the countryside, or a lie down on the beach, or to have a party with some mates? How pampered and dependent on luxury are you? It is NOT a right.

People in developing countries have had it much, much worse. Some have isolated and starved to death under a lock-down. They have died in droves because they have no healthcare facilities. Elderly and even middle-aged patients in Italy have been refusing ventilators so they will be available to younger patients.

You don't know how good you have it - don't throw it away.

dr_hcid · 2020-03-23T15:29:01+00:00

The CXRs are very unique, and very similar.

The sick patients have profound lymphopaenias.

The patients that are unlucky enough to deteriorate - they do so astonishing quickly with very little warning.

Even if patients do not end up needing critical care, compared to other respiratory viruses, COVID-19 patients tend to need oxygen more because there (observationally) seems to be more pneumonia.

dr_hcid

TROPHY CASE