The Wry Observer’s Covid-19 update (3)

Daily blogging has never been my scene until now, when house arrest means there are no distractions and I cannot stand another game of Spider Solitaire.  But Covid-19 is a fertile source of material, not least because I am getting irritated by the continual sniping of people against the government.

So far we have had lots of criticism that it has done too little.  How anyone was supposed to predict how much would be enough is beyond me; accurate prophecy died with Cassandra (though I confess arrogantly that many of mine have come to pass – but then, if you are vague enough, that’s hardly surprising).  So there hasn’t been enough testing, there aren’t enough intensive care beds or ventilators, PPE etc etc.  I point out that if you hold huge contingency reserves that you may not ever need that’s a waste of scarce resources.  In fact it now transpires that the government had stockpiled shedloads of PPE but it was so long ago they have passed their sell-by date.  So- do you renew the shedloads, or wait for something actually to happen?  Likewise the dire prediction of intensive care beds running out has failed to happen (yet – it may do in a couple of weeks) and there is now capacity, with the new Nightingale hospitals, for management of a worst case scenario.  Indeed because of creative creation of new ICU beds in operating theatres and so on they may never be needed.  If so, then I prophesy that there will be a media outcry; how could the government have done so much too much?  What a waste! And so on.  Those who were most critical of inaction will be as critical of over-action.  Be prepared, government, and hold your nerve.  Whatever you do will be wrong to somebody.

Some years ago a new arthritis drug hit the market.  When doctors were cautious about using it they were slammed by the media for withholding “new hope”.  Partly as a consequence the drug became widely used – and then its serious side-effects began to emerge.  The very media that pressurised us to use it suddenly asked how we could possibly have agreed to use such a dangerous drug.  Opren was its name.  So the principle that whatever you do will be wrong is a real one, not just an invention of my fertile imagination.  My book “Mad Medicine” contains more details.  At present there is a huge outcry about the possible denial of resuscitation to some people.  This has always happened; there is no point, medically or morally, in practising futility medicine (a concept also in “Mad Medicine”).  Just because you can do something does not mean that you should.  So why raise it now, except to pad out the news with yet more Covid-19 hysteria?  There’s enough already, much of it repetitive, some of it ill-informed or wrong.

Today I read in “The Spectator” a splendid piece by a pathology professor, John Lee (https://www.spectator.co.uk/article/The-evidence-on-Covid-19-is-not-as-clear-as-we-think).  You might think that my previous posts have plagiarised his work.  The similarities in our arguments are amazing.  But though the issue came out on March 28th my copy comes to me second-hand, usually too late to beat the deadline for the competitions, but I suspect my generous friend has also more time than he knows what to do with, and so is cracking through it quicker.  No, I haven’t borrowed his arguments; quite simply great minds think alike..  Except his is far greater than mine, and his elegant exposition is clearer than I have achieved.  His concluding remark is “We must keep an open mind – and look for what is, not for what we fear might be.”  He makes several important points: we are recording Covid-19 deaths, but not respiratory deaths from ordinary flu so it might appear to kill more simply because of the way deaths are recorded (and as I have said, is it death “from” or “with”; the growth of deaths is no different from those from ordinary flu, should we bother to attribute them; recording varies between countries so you cannot compare data; one must balance the benefits of lockdown against the (substantial) ill-effects.  In essence – we may be overstating the risks.  No reason to not stay at home (yet) but as I have said before it’s likely that huge numbers of folk have already had Covid-19, and we need to know who they are so they can stop self-isolating and get back to normal work and life.

 

The Wry Observer’s Covid-19 update 2

Oh how the sands keep shifting.

Every day there’s something new to read about how the government should have done this, should not have done that.  Please, everyone – abandon the retrospectoscope until the dust has settled.  There is no conflict in history where mistakes have not been made.  Anthony should not have fought Octavian at Actium; the Persians should not have thought that numbers would win Salamis; Napoleon and Hitler should not have invaded Russia; The Prince of Wales and Repulse should not have been sent to the South China Sea without air cover.  In each case hindsight exposes the flaws in the executed plan.  These things happen, but until they happened no-one had a clue that it might go belly-up, and why..

The latest little eruption involves contact tracing and why the UK abandoned it, thus allowing an underestimate of spread.  In the same breath it is suggested that Covid-19 got among those who went to Cheltenham for Race Week.  About 60,000 of them.  From all over the world. They have all dispersed and some get symptoms.  Are you seriously going to try and trace 60,000 people and test them all, before even they have had a chance, those of them that have got it, to pass it on?  Get real, guys – that’s a busted flush.  And anyway what will it tell you, when you have tested them all?  Some have it, some don’t, some you don’t know.  What use is that?

Let me remind you of what testing in its different forms allow us to determine, with the following little table.

Test	Positive	Negative
Antigen test (swab of throat/nose)	You’ve got it	You haven’t got it You might have got it but it isn’t positive yet It’s a false negative You’ve had it, and it’s over
Antibody test (blood test)	You’ve had it	You haven’t had it You’ve got it but it’s too soon for antibodies to have been raised

Look at this and see if you can work out which tests, and which results are useful.  Then read on…

Have you got it?  The answer that is, silly, not Covid-19.  Well done if you have worked out that the only test that is unequivocally useful is the one that gives you a positive.  From a negative test you can draw different, indeed opposite conclusions which are useless in your management either of individuals or on a population basis.

I have said in previous posts that I wondered if I had had Covid-19 back in December and it now seems that there is a growing acceptance that it may indeed have been around for much longer than we first thought.  If I have had it, I could postulate that I got it off one of the many hundred Chinese tourists who frequent Rye (not right now, of course, but we are on the tourist circuit as a quaint medieval town, not too far from London – or Dover, for that matter; it appears the big cruise ships have been offering a day excursion to Rye). But what we need to know are the following:

• Who has symptoms and is positive, because they may be at risk of respiratory failure.
• Who has symptoms but is negative (and on a repeat), because they may be safe to go out (they may spread whatever it is they do have, but it isn’t Covid-19).
• Who has had symptoms, and has had it without knowing, because they are also safe to go out once the symptoms have gone, because they can neither catch it nor spread it.

Thus we need to provide antigen tests for those with symptoms and for NHS staff, and antibody tests for all.  At least, we need to do those at a suitable interval, once it has been determined how long it takes for the antibodies to appear.  We won’t, of course, need to do the antibody test on those who we tested positive with the antigen test (except to use those people to work out the delay in antibody appearance, but that’s a trial thing).  We don’t need to worry about how long immunity lasts, because it will be months or longer and by then there will be a vaccine.

Let’s ramp up!  I want to escape from house arrest, please.  I have to say that the good citizens of Rye are, on the whole, extremely good, and our local shopkeepers have been amazing.

Keep well, everyone.  More to follow when needed.

The Wry Observer’s Covid-19 update

In today’s papers the growing hysteria over NHS failures is widely reported.  While I would not wish to downplay the seriousness of Covid-19 I believe that some of the comment is alarmist and unnecessary.  It seems to presuppose that when the nation is confronted with an unprecedented emergency due to an organism about which little is known, it expects a kneejerk reaction to produce instantly measures that will work.  Life is not like that.  You have to analyse a problem carefully to work out what to do.  Let’s look at some of the issues.

1. The supply of protective gear (PPE).  It’s needed. Everybody in the whole world wants some.  Supply cannot keep up with demand.  Therefore there are shortages until manufacturing gears up.  Then there are the logistics of delivering it. Then there is the calculation of re-supply.  It cannot happen all at once.
2. The availability of ventilators.  They are needed.  As yet supply (and availability) exceeds demand.  Therefore there is time to get geared up.
3. The availability of intensive care beds.  They are needed.  As yet supply (and availability) exceeds demand.  Therefore there is time to get geared up.  The NHS Nightingale Hospital in the Excel conference centre is ready now, but no-one is a patient there yet.
4. The availability of testing.  It’s needed.  But what testing?  It’s hopeless to rush out thousands of tests if they are not reliable.  Experience in Spain suggests that some tests are – not reliable.  What could that mean?   In my view at present the only safe antigen test result is a positive.  Those who test positive will isolate for the requisite time, whether they need to or not. Negatives, on the other hand, are a nightmare.  If they are false -the subject could infect others.  If they are real do they mean that the subject has had Covid-19, and has recovered, or that they have not yet had it, and are thus at risk?  This has serious implications for letting healthcare staff back to work.  The roll-out of mobile testing stations has been hampered, it is fair to say, by bureaucracy; it may result in queues, but why not let all staff drive in so long as they are clearly healthcare employees?  But on the basis of my argument about negative tests the roll-out may be a huge waste of resources, as the results cannot be properly interpreted.  What we really need is antibody testing (again, that is reliable) which tells us whether a subject has had Covid-19.  They will be safe; even if immunity is short-lived it is immunity.  Getting the antibody tests up and running will also enable self-isolating people to know if they are safe; positive, and they are, negative, they are also so long as their antigen test was positive (for then their antibody test will turn positive later).

I think the NHS has done a magnificent job of gearing up.  Of course there were and are teething problems.  Nothing like this has happened before; one cannot load up with stocks of stuff that may never be needed (even PPE has expiry dates); one cannot constantly maintain thousands of empty intensive care beds just in case something big happens; one should not stockpile ventilators that go rusty if nothing big happens.  When the chips are down, quite clearly the NHS, its staff and even its past staff, can jump.

So calm down, everybody.  I am beginning to wonder whether the government’s daily press briefing is necessary.  The same questions are being asked and the same answers are given; in many cases, the honest answer is “We don’t know yet”.  We might know what we need to do, but doing some of it cannot happen yesterday, no matter how loudly people shout.

I say maybe because we need to put this into perspective.  There is another important factor in relation to deaths.  The number of Covid-19 deaths is given daily – panic and hysteria when it goes up, but daily figures do not show the important long-term trend (and anyway as deaths follow a week or two after infection, we might expect them to drop off a week or two after the infection rate drops).  But are these really deaths from Covid-19, or deaths with it but due to something else?  Is it possible that some deaths from December to February 2020, reported as “pneumonia”, were actually Covid-19 related?  And lastly are we seeing an excess number of deaths over what we would normally expect, and if so, how many?  The answer is – well, actually we don’t know yet but the current overall figures for March do not look that different from those in 2018 and 2019 – around 42,000 in England.  And what of previous epidemics?  Look up the swine fever epidemic of 2009, and you will find that in some months the number of deaths exceeded 50,000.  So it may be that the overall death rate doesn’t change much, and “normal” deaths (which clearly happen) are attributed to Covid-19.  We won’t know the answer to that for several months.  So for the moment let’s continue to socially distance and wash our hands, and try to take the panic out of pandemic.

If you make a diagnosis and administer the treatment, and the treatment fails to work, it’s the diagnosis that’s wrong.

I once had a 17 year old patient with low back pain referred after the GP had become exasperated by his failure to improve – oh, and by the way, his ESR was 57 (for the non-medical reader, a high ESR is indicative of inflammation, infection or malignancy).

He was very stiff so I made a confident diagnosis of ankylosing spondylitis, not least because his SI joints looked fuzzy on the X-ray.

After two trials of different non-steroidals for a month each I put him on phenylbutazone. This didn’t work either. It now became apparent that his pain w as quite localised to the L2 region – which was just off the top of his original pelvic X-ray – and further investigation confirmed that he had osteomyelitis in L2 and L3 presumably from the discitis between. Common? No.

Corollary: if a physical sign doesn’t fit the diagnosis, reconsider the diagnosis.

An Indian gentleman in his 70s presented with typical symptoms of polymyalgia (pain and early morning stiffness across the neck and shoulders) and a high ESR. His son said he had just returned from India and had been investigated for an intermittent fever, but his malaria tests had proved negative.

I gave him some steroids (prednisolone-EC 10mg daily) for a fortnight; he did not improve at all. I assumed I had not started him on a high enough dose, and doubled it for another fortnight. Nothing.

So I followed the corollary and wondered whether this was some sort of malignancy (myeloma and prostate cancer can both masquerade as PMR) and did some further tests – bloods and a bone scan. I was inspecting the latter when a message came round from A&E that he had been admitted with a paraparesis; he had lost power and sensation in both legs..

Have you remembered the fever?

The liver tests were right up the Swanee and the scan showed a hot spot at T3. Osteomyelitis (probably tuberculosis) was the diagnosis on biopsy at the neurosurgical centre.

Patients with polymyalgia respond dramatically to steroids and the ESR comes shooting down; if this does not happen, then either we have some other unrelated pathology (as above) or we are dealing with some other sort of inflammatory joint disease. Medicine is like buses, not trams. You need to be able to make detours when things are not right, not just grind to a halt.

While this is a rather medical post, I am prompted to add it having just read “The Monogram Murders” by Sophie Hannah – it’s a Hercule Poirot story in the spirit of Agatha Christie.  Poirot tries to make the nice-bit-dim policeman, Catchpool, do some thinking for himself, pointing out repeatedly that facts are facts and you cannot ignore them when they don’t fit the theory.  You must make the analysis fit the facts, not the other way about.  In both these above cases I failed to do that.  As a corollary to that I estimate that every doctor will make at least two mistakes a year that result, or might have resulted, in serious harm to the patient.  I have.