Tuesday 14 April 2020
My lockdown worries are over – they say vodka is good for disinfection (a_namenko)
You tell me what I should have said. Yesterday afternoon, a colleague telephoned me to say he formed part of a group working in a hospital at least a hundred miles away and a woman on his team had fallen ill. No fever, no cough, just unwell with a dodgy tummy. Several days ago, she had been slightly hot and sweaty but had not taken her temperature. Today she was feeling better. Should he worry or should he not?
If I am to believe guidelines, what I have described is not Covid-19, and consequently my colleague can relax. Covid-19, classically, presents with a fever and dry cough. Yet as each day passes so I learn of other symptoms – loss of smell, loss of taste, runny tummy, headache, tickly throat. What was initially a clear diagnosis has become more complex. However, to me the situation is straightforward. When my colleague’s team had started work a week earlier, each team member had been fit. Four days into their task, one member had become unwell. Four days is roughly the incubation period for Covid-19.
“Remember I am a surgeon,” I started. “You can ignore everything I say.”
“I normally do,” he laughed. “On this occasion, I’ll listen.”
“I’d work on it being Covid-19,” I replied. “The incubation period fits, tummy problems can be associated with the disease. Indeed in a few cases there have only been tummy problems and nothing else. Her hot and sweaty period was probably her temperature. She simply didn’t take it at the time. Can I prove it? I’m afraid I can’t. If you had a test, you would know.”
“I’ll work on it being Covid-19,” came the reply and with that the telephone went dead. My colleague has never been big on conversation.
The situation this morning – 14 April 2020 (courtesy Center for Systems Science and Engineering at Johns Hopkins University)
This case highlights the problem. His team member’s symptoms were not classical and could easily have been ignored. All that was required was a test and, in no time, there would have been an answer. But there were no tests. Without one, my colleague will have one team member self-isolating and everyone else on edge. Once testing is more widely available, events like this become simple.
I worry, too, about the testing, as it seems so many turn out to be negative. Roughly a quarter have so far appeared positive. I wonder how patients with a negative result were selected for testing in the first place? It suggests to me that the classic symptoms permitting the test are not so classic after all. Perhaps Covid-19 has many other presentations that the boffins will someday identify. Certainly, the list of symptoms grows by the day.
With the Easter break now over, the number of staff I am working alongside in my own hospital has increased and the systems we have helped set up have taken clearer shape. I only have to look at the smiles on the many, many faces who come through the hospital-inspired supermarket to know we are doing the right thing. It is interesting, too, how many people the supermarket is helping. We may have 1000 passing through us daily, often many more, but those 1000 are collecting for their loved ones at home. An average London household contains 2.47 people. That is nearly 2500 beneficiaries in a single day from a single project, based mainly on donations. You find me a project that offers better outcome for its buck. I doubt there will be many. After a lifetime of humanitarian activity, I cannot think of any that has been so effective. In silent moments I feel proud that I am a tiny cog doing this for my own country.
Being so happy with what I am doing has not made me any more tolerant of joggers. Still they hurtle here and there, dominating the centre of pavements, running side by side, while the rest of mankind is trying to socially distance. I see them regularly as I walk to work each day, and I see them again as I walk back. I am certain the joggers are spraying virus as they travel. I thought I was the only one to develop such a loathing for joggers, especially as in years past I was one as well. Maybe it is like a reformed smoker, who ends up hating smokers more than anything. Yet as I talk to others about joggers, I have found many who feel the same way.
The deaths in UK are still looking way over the top, each one being a personal tragedy. One, ten, a hundred, a thousand, a million, still the agony and distress is the same, multiplied a zillion times. Yet I must remind myself that, however unfortunate the fatalities, the death rate is not the figure I need to know. To me, the number of hospital admissions makes most sense. When the admission rate falls, the death rate will fall, too, but perhaps a fortnight later.
Anyway, even with the fatalities, the deaths outside hospital have not been included. Had they been so, the figures would rise by a further 11%. Care homes are being a particular problem with 2200 of them now affected by Covid-19. If there was any reason to keep my elderly relative in their own home right now it is hearing news like that. Close proximity to others, which is the way things are run in care homes, is a recipe for disaster, that much is certain.
In France, President Macron has extended their lockdown until 11 May. He has also been man enough to admit that he has no idea when normal life can return. The same also applies to UK. There has been much talk about when we are likely to release the lockdown, but the government will not be drawn. It is clearly worth being careful about such a decision. For example, Hokkaido, the northernmost of Japan’s major islands, has had to reimpose its lockdown as a second wave of infection has now occurred. They had declared a three-week state of emergency in February but then lifted it on 19 March. The relief did not last long.
Hokkaido in Japan has had to reintroduce a lockdown
President Trump is being challenged at every turn at the moment. Various state governors are looking to reopen their states for business, while the President has declared he has the authority to overrule them. I sense there will be an interesting few weeks ahead. His enthusiastic support for chloroquine is also under the spotlight after a small study in Brazil of 81 patients has suggested that taking a higher dose of chloroquine has resulted in irregular heart rhythms. This finding forced the researchers to cease using the drug altogether. I was not surprised to read this paper as chloroquine, rather than hydroxychloroquine, was used. Chloroquine is already known to have a higher complication rate than hydroxychloroquine.
More disturbing perhaps is a paper being circulated, unethically in my view, as it is under review for the New England Journal of Medicine (NEJM). The paper is from Detroit in the USA and states that the use of hydroxychloroquine in a hospitalised SARS-CoV-2 positive population is associated with an increased need for more advanced respiratory support. There were no benefits of hydroxychloroquine on mortality. I was not expecting to hear this. In fact, I should never have seen the paper until it appeared in the NEJM. Somehow the paper’s content was leaked. This may have been because it was rejected, and the authors felt aggrieved. Or, it may have been because they wanted to spread the message rapidly, and as widely as possible.
Russia, at long last, has entered the fray and is being more forthcoming with the world. From a position of appearing to claim they were exempt the mayhem encompassing the planet and were easily able to manage, President Putin has now said that the number of patients is rising while the amount of protective equipment for medical workers is falling. This is not a message you want to hear. To help it handle the crisis, the Russian population appears to have taken to the bottle. Rumour has it that sales of vodka rose by 65% in the last week of March. Somehow, I do not find this surprising.
Even less surprising is the claim by the Association of Alcohol Producers that the vodka was being purchased exclusively for disinfection. If you believe that, you will believe anything.
