A day may come, when the strength of men fails,
When we forsake our friends, and break all bonds of fellowship.
But it is not this day!”
Aragorn, King of Gondor
As we enter the first days of the tempest that is the COVID-19 pandemic, it feels like a suitable time to put pen to paper again to document the landscape. It seems likely that we are living through a moment in history (a ‘once in a century event’ our health secretary has called it), and it is already starting to feel a little surreal from here. I can imagine that this might be what it was like in the early days of the great wars, or the worst days of the cold war: a sense of colossal forces moving throughout the world, whose potential impact is unclear, but almost certainly massive. A slight variation on this feeling is that we, as healthcare workers, are the footsoldiers in this upcoming battle, and with the knowledge that first contact with the enemy is imminent (I appreciate that, at the time of publishing this, the first contact has probably arrived for many of you). But enough over-dramatic build up for now, and time to do some more useful writing. Here, I hope to put down a few thoughts to entertain (or maybe just occupy) those who are stuck in self-isolation at this time, and also provide a reference point for posterity; to allow myself (and anyone else that is interested) to look back at the time before the wave hit, and recall what we were thinking.
The View From Here
- JAMA Network. Coronavirus in Italy - Report From The Front Lines. Youtube. 2020. https://www.youtube.com/watch?time_continue=1&v=TKS1pahoPRU&feature=emb_logo
- Covid-19 Podcast from Italy with Roberto Cosentini. St Emlyn’s. 2020. https://www.stemlynsblog.org/covid-19-podcast-from-italy-with-roberto-cosentini-st-emlyns/
- Johns Hopkins University & Medicine. Coronavirus Resource Centre. https://coronavirus.jhu.edu/
- Public Health England. UK dashboard. https://www.arcgis.com/apps/opsdashboard/index.html#/f94c3c90da5b4e9f9a0b19484dd4bb14
- Harris, S. Christakis, N. How should we respond to coronavirus? Making Sense Podcast. 2020. https://samharris.org/podcasts/190-respond-coronavirus/
- Harris, S. Adalja, A. Early thoughts on a pandemic. Making Sense Podcast 2020. https://samharris.org/podcasts/191-early-thoughts-pandemic/
- Information, guidance and resources supporting the understanding and management of Coronavirus (COVID-19). FICM, RCOA, ICS, AoA. 2020. https://icmanaesthesiacovid-19.org/
To summarise what I think are my key take-home messages thus far:
- A large number of cases are mild (and thus spreading it in the community)
- A smaller number will be very sick
- Hypoxia is the main challenge, although lung compliance and CO2 clearance mostly okay
- A small cohort will become critically ill, with multiorgan failure and potentially a myocarditis picture.
- The risk notably increases with age, with children being mercifully mostly spared.
- The focus on high quality supportive critical care is where the impact is.
These points have got me increasingly feeling that it is probably not really the nature of the disease that is the problem, but the scale. We manage these sorts of patients regularly, but the numbers from Italy are knee-weakening. And the current trajectory of our case numbers is not one of the reassuring ones (I’m getting sick of the exponential mathematical function). Again, for those of you wishing to learn more, these have been some of the resources that I think have been very useful:
- RebelEM. COVID-19: The novel coronavirus 2019. https://rebelem.com/covid-19-the-novel-coronavirus-2019/
- Osmosis. COVID-19. Youtube. 2020. https://www.youtube.com/watch?v=eup3_i_5uaw
- Hasudungan, A. COVI-19. Youtube. 2020. https://www.youtube.com/watch?v=jWMUBouaqb0
- McIntosh, K. Coronavirus disease 2019 (COVID-19). UpToDate. 2020. https://www.uptodate.com/contents/coronavirus-disease-2019-covid-19
- Public Health England. COVID-19: infection prevention and control. 2020. https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control
"I see in your eyes the same fear that would take the heart of me.
A day may come when the courage of healthcare workers fails,
when we forsake our colleagues and break all bonds of fellowship.
But it is not this day!
An hour of proning and broken PPE,
when the NHS comes crashing down!
But it is not this day! This day we fight!
By all that you hold dear on this good Earth, I bid you stand! Soldiers of the NHS!"
Keep safe everyone.