The Wry Observer’s Covid-19 update (8)

Here we go!  Spain and Italy are lifting their lockdowns, at least in part, and there’s an immediate clamour in the British media to do the same. But (1) we are a few weeks behind them on the curve – though ours does seem to be flattening and we have only used 19 beds in the giant Nightingale Hospital in London – and (2) has it occurred to the clamourers that it might be worth waiting to see what happens rather than rush in prematurely and get a horrible rebound?

It seems that the highly imaginative reconfiguration of our existing hospitals, albeit at the expense of closing some services, has kept the lid on ICU capacity.  If indeed that is so, how long, I wonder, will it be before the mediafolk start screaming about the ridiculous overprovision, what a waste, all those unused and therefore useless ventilators, why didn’t you start making these wonderful CPAP machines sooner, they are much cheaper, money could have been spent better elsewhere etc?  Not long, I suspect.

Come on, mediafolk.  At least try to understand that hindsight makes everything clear when it isn’t at the time.  What we medics call the retrospectoscope is a highly dangerous instrument.

Perhaps there is one mistake that was made.  Perhaps testing in care homes should have begun earlier. The point was made by one of the medical advisors that the management of serious infections such as MRSA has improved dramatically, but even they seem to believe that most of it was hospital acquired.  I don’t.  Most of that was hospital identified, not acquired. It actually came in from the community (the bacteriologist in my hospital did a study proving this). Likewise in care homes the original introduction must have been from somewhere else in the community.  It cannot just have appeared by magic.  The numbers of Covid-19 deaths are sad, but pneumonia has always been the old person’s friend; flu epidemics carry off the elderly and infirm; while each case must be taken on its individual merits I believe it may be morally unjustifiable to subject an elderly and infirm person to ICU management when the overall outcome is likely to be an inevitable death anyway.  But that applies to all old people who get very sick.  As I have written in my book “Mad Medicine” when my 94 year old mother was admitted to hospital with a broken arm following a fall, the surgeons wanted to fix that and also replace her arthritic hip.  Part blind, mostly deaf, suffering from a chronic and untreatable urinary infection, doubly incontinent, wishing to die (and having signed an advance directive) one’s only response could be “You cannot be serious”. Not least because she was a retired doctor and knew all the ins and outs.

What has been awful if that old and unsaveable folk have died without their relatives being there.  That has now been relaxed; one might say that is the first easing of lockdown, and very humane it is.  It would be nice if funeral services could resume, but only as long as those attending understand that there remains a risk.  But as I have said repeatedly, just because we can treat something does not inevitably mean that we should.

Reinventing wheels etc

In the BMJ of 23rd April are listed the finalists for the BMJ Neurology team of the year awards, which include the Multiple Sclerosis team of UCLH for its integrated service.

Reinvention of the wheel? Failure of institutional memory? Left hand not knowing what right hand is doing?  All three possibilities come to mind when I read the nomination which “to everyone’s surprise” showed that urinary infections were the commonest cause of admission in patients with MS.

I am certainly surprised it was a surprise.  Indeed when I read this I was almost speechless.  I have known, and taught this for nearly 30 years.  I took over a Young Disabled Unit in 1985.  Over the next ten years I and my multidisciplinary team turned it from a long-stay unit with 15 residents to a dynamic rehabilitation unit with some 300 clients, the majority of whom had MS.  We provided a regular inpatient respite service, a helpline and regular outpatient review, which was supplemented in later years with bladder ultrasound.  The superb nursing staff were also alert to admissions of our clients to acute beds, from which they would be extracted as soon as possible – or at the very least they would make a trip to the acute ward to advise.  I taught all the trainee doctors that patients presenting to A&E with a sudden deterioration in their MS had an infection (usually urinary, but sometimes chest) until proved otherwise.  While deterioration was rapid, so was recovery if effective treatment was instituted rapidly.  I might add that, as a clinical point that will save some lives if anyone reads this, some patients with an acute infection regularly developed severe hyponatraemia which we attributed to acute adrenal insufficiency, and recovered with hypertonic saline and hydrocortisone; whether this phenomenon was related to previous high dose steroid treatment for relapses we never did determine.

We also provided an effective pressure sore service. Regular physiotherapy helped prevent contractures and maintain mobility.  Occupational therapy home visits were a sine qua non. Our service was entirely integrated.  Our local district nurses involved in home care regularly exchanged information.  If a patient “went off” suddenly then infection testing was arranged at home.  Not infrequently I would write the antibiotic prescription.  Unit emergency admissions were organised not by GPs but by family or the district nurses by direct contact.  In this way we actually kept MS patients out of acute hospital beds.  All of this was done without any input from neurologists.

To return to my opening paragraph it appears to me that the UCLH team have reinvented the wheel.  I regret that my teaching in a suburban district general hospital never permeated to the centre to provide a lasting institutional memory, but perhaps the most damning indictment is that, until relatively recently, it was rehabilitationists who dealt with long-term MS patients and not neurologists, who concentrated on diagnosis (once made, there was little treatment, so many, though not all, lost interest). So the crossover of information from left to right hand was as limited as in a patient whose corpus callosum has been transected.  It is thus encouraging to see the growing interest and enthusiasm of neurologists in integrated long-term management.

Though our model was highly effective, and much appreciated by patients and their families, it was expensive.  The Unit kept afloat as much through my political lobbying as through its care success. Within a year of my retirement it had been closed down.