“I see in your eyes the same fear that would take the heart of me.
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.
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
As you may have guessed from my Lord of the Rings and other war references, I am writing this from the ‘calm before the storm’ period. That period of preparation and anticipation as we can see “the water receding before the oncoming tsunami”. However, given my usual pace of writing these posts, coupled with the exponential graphs of cases that I keep seeing, the storm may have already arrived. Indeed, even now I am already hearing about the increasing load of cases that are arriving at hospitals throughout the country, and I don’t doubt that the intensive care units will be next. Whilst I have been impressed by much of the efforts in preparation, I feel we have the mixed blessing of being further down the line of countries being hit by the disease. This gives us some extra time to prepare (where possible) but also time to look at what is unfolding, particularly in the north of Italy, and shudder a little. This is a wealthy region, with intensivists that have literally written the books on critical care (I definitely stole that from someone on Twitter, but can’t find the reference, sorry), but is being decimated by the sheer volume of patients. They are the frontline spearman, being overwhelmed by the sheer number of onrushing orcs, whilst it is time for us in the second line to draw our own swords (I’ll get bored of this analogy eventually).
For those of you wishing to learn more about this epidemiological aspect, these were some useful resources that I have found:
- 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/
Preparation
This delayed onset feels like it has gone on for months now, such has been the volume of information that has been distributed. There has been intensive information provision and training in personal protective equipment (PPE), as well as guidance on ways to safely manage ‘routine’ interventions in infected patients, such as intubation. The challenges this results in are surprising, and the opportunity to undertake simulation has been invaluable. Some of the larger scale organisational stuff has been less available to me currently, with the feeling of great movement going on behind the scenes, yet not fully manifesting itself on the frontline. Some of the numbers are quite mind-blowing though: I have heard talk of some big hospitals planning to increase their ventilated patient capacity by 10-fold!
Otherwise, in my free days this week I have been making the most of the opportunity to educate myself on the nature of the foe that approaches us. The information is understandably new, but there is an increasing volume of it, and much of it is invaluable. I have endeavoured to summarise some of it in my own note form here:
There is also an excellent collaborative resource available here:
To summarise what I think are my key take-home messages thus far:
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:
- 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
Onwards
To wrap up, I think I will return to my wartime analogy of the start. Importantly, we will be the frontline soldiers here and it is going to be tough. I have always felt blessed by the camaraderie that our specialty displays so clearly, and I am especially aware of that within my own region. It therefore comes as no surprise then that they have put together excellent support guidance for us in these challenging times. I will endeavour to return to writing here as things unfold, to hopefully provide some writing of use. For now, I will expand on our opening quote for a powerful call to arms. I hope Tolkien and Peter Jackson will forgive my (mis)appropriation of their art:
"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.
Tom
"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.
Tom
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