Monday, 6/04/20; An Australian Chest Physician’s Reflections on the Covid-19 Pandemic. “To be or not to be” or “Much ado about nothing?”
Letters from Australia. No.3 by Dr Roger KA ALLEN (www.sarcoidosis.com.au)
As I write my third article, I feel that the rate of change of the pandemic is difficult to keep up with as the amount of material coming in hourly is enormous. Most of us have witnessed the “codivisation” of the world media and most of us are suffering Covid-19 fatigue and overload. The daily news is generally the “Bad News” as there are few rays of sunshine to hearten us apart from the possibility that the curve might be flattening in some states or countries. The scenes of mobile freezer trucks set up as morgues in New York and with a procession of trolleys bringing the bodies covered in red plastic is but a “chilling” manifestation of this human catastrophe. What I hope to bring in my articles are my personal medical perspectives as just one of thousands of health workers.
As a chest physician, I have many patients with a variety of serious medical conditions and not just restricted to the lungs which put them at increased risk of dying from this virus. I too, am at risk, as is my family. We all are. So far we have had no cases of Covid-19 at our institution where preparation is being made for a possible influx of cases. The scenario looks Kafkaesque if we don’t contain this. I don’t want “The Italian Job” here! Cruise ships go home!
In the past few weeks I have seen patients including those on oxygen who have wanted to see me for an update on their current lung function and to get all their medical documents ready in case they get Covid-19. These patients suffer from lung diseases such as emphysema, COPD, severe asthma, pulmonary fibrosis, lung cancer, asbestosis and even young men with silicosis to name but a few conditions and mostly with other co-morbidities such as diabetes, heart disease, hypertension, sleep apnoea and obesity.
However, I have repeatedly had to tell such patients that we have been directed by health authorities and our own thoracic society (TSANZ) not to do lung function lest we spread the virus to staff as a significant proportion of cases of Covd-19 are asymptomatic; perhaps as many as 30-50% as we have also seen on the cruise ship debacle. It has been difficult but necessary for me to tell such patients that in the event of their developing a Corona viral pneumonia, it is unlikely that they would be offered treatment on a ventilator at a time of limited health resources. There will be a triage system as occurs for battle casualties in war and civil disasters; triage coming from the word,
“three” or three categories of patients; (1) the unsalvageable, (2) the urgent who need treatment ASAP, and (3) the walking wounded. As one who served in the RAAMC Reserve for nearly 15 years and as a medical specialist including running an ICU in East Timor in 2000, I speak from personal experience.
Generally, this has been greeted by and large by such patients with a mature sense of resignation and fatalism, even Australian black humour and irony, and I have told them that with limited resources and with the possibility that a younger patient may need a ventilator more etc., bla, bla….
This dilemma has confronted ethics committees and has put many a doctor in a no-win situation. There are no guarantees here and there will not be time for ethics committees to convene over each case, to pontificate one’s fate and the right allocation of resources. This is war, not the Old Boys’ Club with smoking jacket, cigar and glass of port. Nevertheless, as has been seen in the USA already, I have little doubt that celebrities, the bottom-dwellers, the “entitled”, with money and pull, will be allocated ventilatory treatment unjustly at least in some hospitals, somewhere, sometime. https://www.abc.net.au/news/2020-04-06/nsw-health-not-drawing-up-life-or-death-guidelines-for-doctors/12123406
I have therefore stressed the need for these vulnerable patients even more to stay at home, “bunker down” and sit this out in relative safety. It may also be that with our stay-at-home policy, influenza may be less prevalent provided we all have the influenza vaccine. It is not a given that anyone will be given ventilatory support if we are overwhelmed. This pandemic will only end when the herd immunity increases dramatically by both asymptomatic infection and illness and by eventual immunisation as I doubt that any medication will do more than reduce disease severity in those afflicted. We beat smallpox and polio. We can beat Corona, at least I hope.
Ventilators may just be unavailable but this idea does not seem to have sunk in to those still flouting social distancing and other preventive initiatives. For example, the beach at the Gold Coast this weekend was so well patronised that the authorities closed the carpark at The Southport Spit last night. Dumb-arses abound still. Yesterday in Brisbane 150 cars turned up for a car rally “social petrol-head love-in” (lots were heavily fined) while the Powerhouse food market in Brisbane was awash in humans with a death wish much to the dismay of the State Premier.
I tell my chronically ill patients that their Covid viral pneumonia would be managed by “best supportive care” which is a euphemism for palliative care. Morphine alleviates breathlessness, pain and cough as well as puts one to sleep. It will not be a “warm and fuzzy” end though, as patients die alone, without relatives and friends, attended by nervous and exhausted staff in PPE looking like space-men and whose gentle touch is through a double rubber glove. Even funerals will be lack-lustre, graveside burials solitary and wakes limited to a few unless they happen online. Crematoria in Italy are working 24/7. To avoid this gruesome scenario, we all must do our bit.
In the British NHS, there have also been directives about not doing CPR on Covid patients who have had a cardiac arrest unless staff are in full PPE or if the patient is in an ER where staff area also wearing full PPE (BMJ 2020;368:m1282). This is an unprecedented move. The British Medical Association stated that medical staff are still at considerable risk from a shortage of PPE despite government assurances to the contrary. (BMJ 2020; 368:m1316). It is all case of “To be or not to be, that is the question.” We, the public make the choice, the doctors make the choice, the available health assets make the choice, and the virus dictates the choice.
As one who daily reads the news media daily from several countries in five languages, I observe quite different approaches by different countries depending on their national temperament, political system, health system and capacity to deliver. As mentioned in previous letters, the USA was too slow to get off the mark as was the UK, while Sweden has been following a fairly lay-back approach only to find this deficient this week. This was the “Much ado about nothing” approach of President Trump (“all back to church on Easter Sunday” approach) and of PM Boris Johnson who has been admitted to hospital today. Italy let it get out of control and a large football match may have been the time-bomb of their apocalypse. Iceland whose population is about 364,000 has had the highest proportion of citizens tested and shown that of the 1% who were positive, half had no symptoms which has implications for healthcare professionals who are concerned that they may be unwittingly transmitting the infection as well as succumbing from the infection contracted from asymptomatic carriers. This also agrees with a report from Seattle where they found 50% of 24 critically ill patients (not mild cases) at presentation had no fever and that to rely on fever as an indicator of disease was regarded by the authors as simplistic. (NEJM, March 30).
For example, at the Wesley Hospital where I work, there is now, sensibly, one entrance to the wards and this is supervised by staff including some taking random temperatures to cull out those who might be infected. However, as mentioned in my last article, a temperature less than 37.5 may still be significant if you baseline normal temperature is in the low 36 and as a significant proportion of infected people may have no symptoms and as 44% of 1099 Chinese as mentioned had no fever on presentation, we are probably not picking up a significant proportion of infected people. This is an epidemiological nightmare. Indeed I asked the nurse taking the temperatures what was the commonest temperature and she replied that it was in the low 36 range and that in 24 hrs she had seen only person with a fever and that person had been sent home. This is like enemy soldiers being admitted to a castle in disguise wearing the uniforms of the “friendlies.”
We clearly need a rapid test for this infection such as we have for influenza (takes a few hours) and a reliable test of whom has been exposed e.g. an antibody test. Currently it takes about 48 hrs for a throat swab (NPA) test result to come back and this is too long as the patient may be sick while the medical and nursing staff are left in a limbo waiting.
This virus has once again reminded us of exponential growth of both virus and cases, but this idea is not well understood by the general public but applies to many things in nature including an atomic reaction and the growth of bacteria and viruses. For example of exponential growth, if you start off with just one dollar and double it each day, how long does it take to reach over $1 million? No, it is not ten years, but 30 days! Thus, we now see that the number of confirmed cases in the world has doubled from 500,000 cases to 1 million in just eight days. It is going “viral”.
A soccer game in Milan, Italy, according to ABC News on February 19 had 2,500 Valencia fans (from Spain) and a total attendance of 45,792 people. I leave the rest for your imagination and for you to read for yourselves but the potential mathematics here are staggering. It is a chain reaction like in an atomic reactor where the graphite rods slow it down and prevent an explosion or melt down (e.g. Chernobyl) and social distancing does the same. If you start off with 2,000 infected people rather than 1, the growth is scary.
Why does this virus kill you so easily you may ask? As we have no prior immunity to this virus, it is as if it has come from outer-space for our immune system which has developed and continues to develop a repertoire of recognition of bad guys of what is out there and how it best can confront it. It is like it has a filing cabinet of files of bad guys and what is the best weapon to take them out. Our immune system is made up of a complex array of cell types each of which confront “bad guys” with a primed set of responses which we develop from our mothers and even in the colostrum before breast milk comes on line. The immune system exists within us independent of our own will and control. It is an automatic system a bit like having armed soldiers, mine fields, drones, artillery and air support around us wherever we go. To us they are invisible but when they do work, we notice them in the form of fever and tiredness. For some people, the virus is combatted effortlessly and silently, often with few or no symptoms. It is not that they are better but just fortunate. It is a myth that anything reasonable you can eat or take can improve this apart from certain medications. It is also a myth that vitamins such as Vitamin C have any benefit in the common cold other than two studies which showed that at best, it might reduce the length of the illness by a few days. However if myth becomes embedded in societal belief, they soon become dogma and then dogma is accepted as fact as we see in religion.
In a lot of people the illness is mild but in people, the virus excites an exaggerated immune response resulting in all the troops and air support hitting the target e.g. lungs all at once and in so doing, releasing a lot of collateral damage to your tissues e.g. lungs from the release of inflammatory chemicals from cells we call “cytokines”. This is known as a “cytokine storm” and is accompanied by a whole range of cells, antibodies etc. like dropping napalm on a friendly village; collateral damage par excellence. In the process, the lungs become stuffed with cells, proteins and the lung tissue becomes leaky with fluid exuding into the air sacs and parenchymal tissues. This may produce an acute respiratory distress syndrome we call ARDS. As result the ability of the lungs to exchange oxygen from the air diminishes and the ability to deliver oxygen to vital organs such as heart, brain and kidneys fail with eventual multi-organ failure and death.
In addition, the patient’s lungs are full of virus so that every time they breathe out or cough, an aerosol of virus enters the air with the potential of infecting those around; hence, the need for proper masks and PPE. That is why a ventilator helps but when it all goes “pear-shaped”, even a ventilator will not save you. Nebulisers such as for salbutamol and CPAP pumps have also been show to spread the virus in the air and thus these have been banned in Covid-19 patients. In a minority of patients there is a hyper-immune phase where their immune system goes into overdrive, damaging the lungs and leading to death often as has been described by Italian intensivists. Overall, your chance of survival if you need a ventilator is about 50% (heads or tails); a game of “two-up” with not two pennies but one.
There was some information going around that the virus can affect the heart, causing a viral cardiomyopathy, arrhythmias etc. but this has been refuted by recent reports. https://healthmanagement.org/c/cardio/news/cardiac-complications-in-covid-19
However, if you have significant heart disease, hypertension and diabetes, you are at greater risk of dying.
This virus takes no prisoners, respects no age, no credo, colour, race or political persuasion, prime ministers, queens or princes. It is all very sobering but the take home message is still that prevention is better than cure as there is no cure yet; only prevention and the recent flattening of the infection rate curve in all Australian states is confirmation of this and should give us reassurance to stay the course even though you might be bored or feel cooped up. Better bored that dead and after all, the eternal afterlife could just have its boring moments too. Stay home whenever possible.
Disclaimer: I have attempted to provide objective information from many sources in good faith but if any errors in this article are found, I apologise in advance and would be pleased to amend the mistakes.