A direct continuation of; https://watchitdie.blogspot.com/2020/04/the-pox-on-all-your-houses-pt2.html
The practice of medicine is really a series of Risk/Reward calculations.
Take for example Ibuprofen.
Ibuprofen can cause shortness of breath, wheezing and an erratic heartbeat. All symptoms of ARS.
However the Risk of Ibuprofen causing those symptoms is very low. While the Reward of Ibuprofen relieving inflammation and pain is very high.
So Doctors are happy to use Ibuprofen as a medicine. They're even happy for it to be sold to the type of idiots who panic buy toilet paper to use at home, unsupervised.
At a time when demand is outstripping supply medical professionals may need to accept more Risk in the Risk/Reward calculation than they would normally.
For example by delaying putting a patient on Oxygen Therapy for longer than they would normally.
Another example could be with the use of ventilators.
Rather than talking about ventilators I referred to; "Ventilator Beds." This is a logisitical unit made up of the ventilator and a bed. Along with all the things needed to operate the ventilator. Trained staff for example.
A Ventilator Bed also includes a lot of plastic tubing. Endotracheal Tubes.
In non-invasive ventilation an endotracheal tube runs from the ventilator to the patient. Where it connects to mask which fits tightly over the person's mouth.
If you are doing invasive ventilation then there is an endotracheal tube which goes down the patient's throat into their lungs. This is connected to a mounting which sits over the mouth. Another endotracheal tube then connects that mounting to the ventilator itself.
Between patients all of these plastic tubes need to be changed.
In order to prevent a opportunistic infection from one patient spreading to another. If you're already sick enough with a virus to need a ventilator the last thing you want is a fungal lung infection as well.
Most of the endotracheal tubes on the market these days are single-use. They're intended to be thrown away after one use.
The high number of patients requiring ventilation means that some hospitals are going through far more of these plastic tubes than they would normally. Making it had for them to get fresh supplies. Without this USc35 piece of plastic a US$10,000 ventilator stands completely useless.
Under these circumstances medical professionals may have to run the risk of cross infection by reusing things like endotracheal tubes.
Obviously they would still attempt to minimise that risk by sterilising these tubes between patients. Along with increasing the prophylactic broad spectrum antibotics and antiifungals they give the patients.
I'm not sure how you would go about sterilising them though. It's unlikely plastic would survive steam, autoclave, sterilisation. Without knowing the specific type of plastic involved I can't even comment on how it would detoriate on exposure to alcohol.
I suspect the manufacturers of this type of equipment do know though. They could perhaps help by switching production to reusable versions of their products.
As I've said the medical profession has a deeply engrained culture of excellence. Something which has developed over more than 2,000 years. Dating back to Hippocrates.
The most famous thing the medical profession has inherited from Hippocrates is the Hippocratic Oath; "First do no harm."
Essentially don't carry out a treatment unless you are sure that the Reward far outstrips any Risk.
So asking medical professionals to accept more Risk in a Risk/Reward calculation is going to be difficult. It's something that goes against almost the DNA of the profession.
Probably a lesser factor in medical professionals aversion to risk is the possibility they may get sued for malpractice.
Particularly Doctors have to pay out of their own pockets for malpractice insurance. Every time they get sued, even vexatious cases, those insurance premiums go up.
So I wonder if it would be possible for the government or state to act as the insurer for medical professionals treating COVID-19 patients. In instances where they have been forced to accept more risk than they would normally be comfortable with.
One thing which shows the medical profession's culture of excellence is the Mortality & Morbidity (M&M) Conference. If a patient dies unexpectedly a M&M Conference is convened. Even when there are no ambulance chasing lawyers or suggestions of malpractice involved.
An M&M Conference sees all the Doctors in a department, sometimes even in the hospital gathering together. They look at every aspect of the deceased patient's medical history along with the care they recieved. Not so much to indentify what went wrong as much as to identify what could have been done better.
I envison lawsuits resulting from COVID-19 patients going before an M&M Conference. If that concludes that the medical professionals merely accepted more risk than they would normally the government/state acts as the insurer in the case. The usual insurer cannot use the case to calculate future insurance premiums.
If the M&M Conference concludes that actual malpractice had been a factor the government/state no longer has a responsibility. If a medical professional has enaged in serious malpractice it's unlikely they're going to have to worry about paying insurance premiums in the future.
I know this sounds like a good idea. However it also sounds to me like an extremely complex legio-financial instrument to create in a short space of time.
It would be made easier if the Fever Clinic strategy was fully adopted. Meaning that COVID-19 cases are treated only by designated medical professionals in designated sites.
While talking about Risk/Reward Calculations I should also briefly touch on some of the experimental COVID-19 treatments being suggested.
Particularly the Murdoch Children's Research Institue in Australia's study using the Bacillus Calmette-Guerin (BCG) vaccine as possible treatment for, rather than vaccine against COVID-19.
The BCG vaccine works by injecting a person with live Mycobacterium Bovis. This is very closely related to Mycobacterium Tuberculosis. Which causes Tuberculosis (TB) in humans.
However because Mycobacterium Bovis has evolved to infect cattle it doesn't cause TB in humans.
What it does do is trigger the immune system into fight the virus. In winning this easy fight the immune system develops blueprints for specific antibodies to fight Mycobacterium Tuberculosis.
So if and when the person does get exposed to Mycobacterium Tuberculosis the immune system is there, ready to go to fight it. Meaning that the Mycobacterium Tuberculosis is destroyed before it is able to take hold and the person develops TB.
Obviously the immune system doesn't immediately know how to fight Mycobacterium Bovis. So what it does first is launch a massive response to fight the infection with sort of general purpose antibodies. To stretch the military metaphor this is something like the immune system's Quick Reaction Force (QRF).
Not only does the immune system retain the blueprints for Mycobacterium Tuberculosis. It also retains blueprints for how to quickly deploy a largescale QRF.
That QRF then gets deployed against every infection, bacterial, viral or otherwise, which enters the body. Meaning that those infections also can't take hold and develop into illnesses.
The theory being tested is that this QRF also prevents, or at least reduces, COVID-19 infection.
The Australian study focuses only on frontline healthcare workers treating COVID-19 patients.
As I've said how sick COVID-19 makes you depends of the amount of 2019nCoV virus cells in your body. The Viral Load.
Frontline healthcare workers are treating the roughly 10% of COVID-19 who go on to develop SARS-CoV-2. The people who have got the most sick, the ones with the highest viral load.
Being constantly surrounded by huge amounts of the 2019nCoV virus frontline healthcare workers themselves rapidly develop a high viral load.
I does annoy me when the general public assume that healthcare workers who've become infected and died are typical of COVID-19 patients. So feel they've got to copy the infection control measures that fronline healthcare workers have to take. Such as wearing gloves or masks.
Frontline healthcare workers are an extreme, anomalous, high-risk group for COVID-19. So they have to take special precautions which are utterly meaningless to the general population.
The general population could perhaps show their support by not buying up all their gloves and masks.
Some people have pointed out that it is exactly these infection control measures, Personel Protective Equipment (PPE) etc, which will make the Australian study ineffective. In Australia frontline healthcare workers have access to large amounts of high quality PPE.
This makes it hard to tell whether COVID-19 infection has been prevented by that PPE or by the BCG.
On April 2nd (2/4/20) two French Doctors caused controversy. By suggesting that mirror studies of the Australian study be carried out in Africa. Where frontline healthcare workers have nothing like the PPE available to their Australian counterparts.
They were instantly condemned as racist. Tedros Adhanom, the first African head of the WHO has since said that BCG studies wouldn't be used in Africa. Which, along with the naming issue, has further fuelled speculation that he's more of an Affirmative Action hire.
Not expanding BCG studies to Africa and elsewhere strikes me as foolish. Particularly if the BCG is being donated for free.
In any study you want to test against as many variables against a control group. So here; no BCG, BCG with PPE and BCG without PPE.
What would be unethical would be to create the BCG without PPE group. As would deliberately infecting people with COVID-19.
However as the BCG without PPE group already exists in many African nations. Or is about to. It would be reckless not to collect that data.
It's the same as the issue of when to start Oxygen Therapy for SARS-CoV-2 patients. Which I mentioned in my previous post.
The overwhelming majority of medical professionals will treat their patients according to existing guidelines. However some those with the resources will try treating earlier. While those short of resources will be forced to treat later.
With these variations in treatment happening anyway it's important that data on the results is shared. Not just to improve our understanding of SARS-CoV-2 but of ARS and SARS more generally.
The BCG has been used as a vaccine against Tuberculosis (TB) since 1921. Its risks are well understood, including for imunocompromised (HIV/AIDS) patients.
The only added Risk using it to treat COVID-19 is that it won't work.
Even then though you still has the big Reward that people recieving the vaccine will be immune from contracting TB.
If someone's already sick with SARS-CoV-2 the last thing you want is for them to also catch a serious bacterial lung infection like TB at the same time.
It is also particularly important that the BCG is tested widely. It is known that its effectiveness decreases the closer you are to the equator. Although no-one really knows why.
One theory is that the closer you are to the equator the more sunlight you get. Creating the warm conditions that bacterium really thrive in.
This means that people living closer to the equator will likely have been infected with some strain of Mycobacterium before they recieve the BCG. Learning and remembering how to rapidly deploy an immune QRF.
Meaning that when they do recieve the BCG the immune system's QRF defeats it without having to develop the specific antibodies needed to fight TB.
Once again proving the lesson that health 'experts' seem to have forgotten in the face of COVID-19;
There are actually some infections that you want people to get.
Another potential experimental treatment being discussed for COVID-19 is Chloroquine/Hydroxychloroquine.
Interest in this really began with the big Pharmaceutical company Bayer donating quanities of Hydroxychloroquine tablets to the US government for free. With US President Trump singing the drug's praises at his daily press briefings other large Pharmaceutical companies following suit.
Hydroxychloroquine is intended to treat Malaria. A parasitic infection.
As the Malaria parasite attacks the body's red blood cells it actually creates an environment which is toxic to it. In order to survive it needs to build its own, almost, PPE.
Hydroxychloroquine stops the creation of that PPE. Effectively hoisting the parasite by its own petard.
As a side-effect Hydroxychloroquine ever so slightly alters the PH balance in the body's cells.
2019nCoV works by spearing itself into healthy cells. It seems to prefer those in the lungs. It then uses the healthy cells to replicate it's RNA to create many more 2019nCoV cells.
The slight change in that PH balance created by Hydroxychloroquine makes it more difficult for 2019nCoV to get its RNA into the healthy cell. Preventing, or at least slowing, the replication of 2019nCoV. Keeping the viral load down.
So it's well established that Hydroxychloroquine will have some effect in treating COVID-19, along with any other Coronavirus. However that can also be said about a host of other specialised anti-viral drugs. The question is over how much effect it will have.
As a potential COVID-19 treatment Hydroxychloroquine actually has two things going for it.
Firstly it is an extremely old drug. Developed in 1934. Meaning that there is very little that is not known about its effects on the human body. Therefore the Risk of using it properly, in a medical setting, is known to be negliable.
The other advantage is that it is extremely cheap. That though is largely because Hydroxychloroquine has been something of a victim of its own success.
The only strains of Malaria parasite that exist in the World now are the ones which are resistant to Hydroxychloroquine. The strains that aren't have long been destroyed by Hydroxychloroquine.
As a result there isn't really a market for Hydroxychloroquine anymore.
Although I gather that since President Trump has been shouting about it the commodity price has shot up from around US$100 per kg to US$1000 per kg.
The pharmaceutical companies which are donating Hydroxychloroquine are also in a race to develop a vaccine for 2019nCoV. This lockdown, stay-at-home, social distancing is largely driven by their fear.
Their fear that 90% of the population will become immune to 2019nCoV. Having contracted it and recovered after experiencing either mild symptoms or no symptoms at all.
Meaning that no-one will be prepared to pay them for the privilege of being infected with 2019nCoV.
The Influenza vaccine of course just seems to be a very expensive way of making sure you catch flu twice. Once when you get the vaccine. Then when the vaccine doesn't work and you get the flu anyway.
I'm sure that frontline healthcare workers know all about the Hepatitis B vaccine. How you have to book a week off work to recover from the 'mild' symptoms it causes.
Those pharmaceutical companies other big fear is that the US will invoke the Defence Production Act of 1950. That will prevent them from obtaining a patent for any 2019nCoV vaccine. Forcing them to provide it at a loss rather than a profit.
Donating Hydroxychloroquine seems to be the little bit of charity now which ensures massive profits later in the year. I'm sure the tenfold increase in the commodity price is helping to soften the blow for them in the meantime.
Hydroxychloroquine certainly makes for an interesting talking point.
As the name suggests it is derived from Qunine. The bark of Rubiaceae tree. Making it a form of herbal medicine. Although one which actual medicine has made a lot more potent.
As a treatment for Malaria Hydroxychloroquine has really been replaced by Artemisinin.
This is dervived from Arteminisia Annua. A type of wormword which is commonly used in traditional Chinese medicine. The traditional Chinese medicine that Chinese Premier Xi has been so aggressively promoting.
In fact the Nobel Prize winning paper that introduced Artemisinin to the world was entitled; "Traditional Chinese Medicine's Gift to the World."
President Trump has been insisting on calling COVID-19; "The Chinese Virus."
I think a lot of people really wish he wouldn't. It certainly doesn't inspire confidence.
But then neither does supposed health 'experts' forgetting the lesson that the pharmaceutical companies clearly haven't.
21:20 on 9/4/20 (UK date).
Thursday, 9 April 2020
Wednesday, 1 April 2020
The Pox On All Your Houses. Pt.2
A Direct Continuation of; https://watchitdie.blogspot.com/2020/03/the-pox-on-all-your-houses.html
In that post I looked at COVID-19. The virus that causes it (2019nCoV) and the illness it causes (SARS-CoV-2).
That reveals that COVID-19 is not a serious illness.
Even the worst case scenario envisioned by the British Government shows COVID-19 to be around 85% less deadly than Influenza is during a typical year.
Instead the threat posed by COVID-19 is that so many people will become mildly unwell at the same time society is no longer able to function properly.
As I covered in my previous post the first challenge is to build extra capacity within the healthcare system.
Once you have built capacity as much as possible you need to start using that capacity as efficently as possible.
Triage.
This one of those words that tends to frighten people.
It automatically conjures images of that newly widowed single father in every disaster movie. Heroically carrying his injured child across the wasteland. Only for a cruel solider to pin a black tag to the child and leave them to die.
In reality triage is just a normal part of everyday medical practice. It's about making sure that the patient recieves the right sort of care.
So if you go into a hospital's Emergency Department with stab wounds to your chest you're going to the front of the queue for treatment. If you've got a small broken bone in your hand you go to the back of the queue. If your head and the rest of your body arrive in two seperate vehicles you don't go into the queue at all.
The medical profession is one of the oldest in the World. Tracing its roots back some 2,300 years to Hippocrates in Ancient Greece.
Over that time the medical profession has developed a deeply engrained culture of excellence. Everybody is constantly striving to not only give their patients the best possible care but also to make better care possible.
In the UK it takes 6-7 to years for someone to qualify as a Doctor. However after qualifying they are then expected to complete the equivalent of a fresh new university module each year in order to remain qualified. That is on top of actually doing their day job.
This constant pursuit of excellence coupled with the precautionary principle means often medical professionals provide their patients with too much treatment. Which, under normal circumstances, is no great problem.
This is something which is particularly true in Britain's NHS.
Treatment under the NHS is free at the point of use.
Not having to worry about how to pay for it means British people feel they can bother medical professionals with just any old nonsense. With the NHS being seen as public property those medical professionals are then under pressure to provide care for what are, frankly, timewasters.
Seriously. The NHS' motto could well be;
"There's Nothing Wrong With You, Go Home!"
A couple of years ago a relative of mine was admitted to an NHS hospital with an Acute Respiratory Syndrome (ARS). Although one caused by an obscure fungus rather than 2019nCoV.
This was the same NHS hospital which went on to treat the Skripals and the other Novichok patients. I gather Russian President Putin has been having fun. Visiting COVID-19 patients, dressed in full Nuclear, Biological, Chemical (NBC) protective gear.
Amid this culture of seeming mass panic I don't really want to get into the specifics of the symptoms of either ARS or SARS.
They say a little knowledge can be a dangerous thing. I don't want to contribute to people wrongly diagnosing themselves, panicking and turning up at hospital demanding treatment.
One of the main indicators in both ARS and SARS though is blood, oxygen saturation (Sats). The amount of oxygen in your blood. You need a special machine to measure this so you won't be able to do it at home.
Normal blood oxygen saturation varies. Even on your altitude above sea level. It is though normally in the range of 95%-100%. If it falls below 95% you enter a condition known as Respiratory Distress. If it falls below 80% you enter a condition known as Respiratory Failure.
One way to think about this is using the Traffic Light triage system. So;
95%-100% is GREEN. Perfectly normal, no need for concern.
80%-95% is YELLLOW. Exert caution, however no action required.
Below 80% is RED. Serious problem, urgent action required.
At their worst my relative's condition could be described as; LIME. That is to say generally green, with a hint of citrus.
The hospital's response was to put them on a Ventilator Bed in an Intensive Care Unit (ICU). Although they never actually used the ventilator.
This was totally pointless. There was no need for my relative to be in an ICU.
However the thinking was that their condition could detoriate, for some unknown reason. So it was safer to put them in the Ventilator Bed that was available. Just in case.
Obviously in a situation where demand is outstripping supply that is the sort of practice which needs to stop.
Rather than thinking about providing the best care to a small number of people we need to start thinking in terms of what's the minimum we can get away with for a large number of people.
The data indicates that potentially as many as 90% of patients who become infected with 2019nCoV will experience either mild symptoms or no symptoms at all. They will not go on to develop SARS-CoV-2.
That means that they will not require any medical attention at all. They will, what is known as; "Self-Resolve."
The remaining 10% will go through a progression of symptoms.
From what are classed as; "Severe" through to "Critical." Some will also die. However the vast majority will not progress beyond the "Severe" catergory. Of those who progress to the "Critical" category more than half of them will not go onto die.
How a person's condition is classed as either "Mild," "Severe" or "Critical" depends on a number of factors. However for simplicity I will concentrate on just one - blood, oxygen saturation (Sats).
As the person's condition progresses the treatment they recieve will also progress. In the hope of stablising them and halting that progression.
The first available treatment is incredibly simple. Oxygen Therapy.
The air that we breathe is actually a mixture of, primarily, Oxygen and Nitrogen. So if a person's Sats start to drop you simply hook them up to a supply of pure oxygen. Meaning that there is a little bit more oxygen in every breath they take.
If the person's Sats continue to drop the next available treatment is to hook them up to a supply of slightly pressurised oxygen. That oxygen then takes priority over the non-pressurised nitrogen, oxygen mix of air in each breath. Increasing the amount of oxygen in each breath.
If the person's Sats continue to drop the next step is Positive Pressure Ventilation. Essentially putting them on a ventilator.
People may be more familiar with venitilators than they realise.
The US medical industry has largely invented a condition called; "Sleep Apnea." This is treated by selling the patient a Continuous Postive Airway Pressure (CPAP) machine to sleep in.
A CPAP machine is technically a ventilator, pumping pressurised air into the lungs. However the pressure provided by a CPAP machine is so low that it doesn't need to perform the other role of a traditional ventilator. A latent cycle allowing the air to be expelled from the lungs.
Sleep Apnea patients are typically so ridiculously healthy their lungs can expel the air on their own. Even against the pressure provided by the CPAP machine.
What a medical professional can do though is hook a CPAP machine up to a pure oxygen supply. Providing something of a halfway house between pressurised oxygen therapy and full venitilation.
If you already own a CPAP machine please do not attempt to hook it up to an oxygen supply yourself. It is highly likely that you will only succeed in blowing yourself and your house to bits.
If a person's Sats continue to drop then they will have to be put on a traditional Positive Pressure Ventilator. A machine which pushes pressurised air into their lungs via a facemask.
If that doesn't work then the final option is Invasive Ventilation. This is where the person is put on a Positive Pressure Ventilator. However instead of a facemask a plastic tube is shoved down their airway. Delivering the air directly into their lungs.
At the risk of a tangent I should mention Italy. Despite having a population around 6 million smaller than China's Hubei Province they have experienced far more COVID-19 deaths. Currently in excess of 10,000.
The main reason for that seems to be that Italian Doctors don't follow this universally accepted treatment route for any form of SARS.
When Positive Pressure Ventilation has failed to stablise a person's condition Italian Doctors do not move onto Invasive Ventilaton. Instead they put a plastic hood over the person's head and fill it with slightly pressurised oxygen. Reverting to pressurised oxygen therapy.
Funnily enough reducing the treatment for the most seriously ill patients has increased the number of deaths.
I don't mention this to attack Italian Doctors. Or to inspire others to do the same. Those Doctors are simply following the treatment protocol they have been told works and trained to use.
When the situation has calmed down a bit though serious questions do need to be asked. About why they were told that treatment protocol would work.
In the meantime Italian Doctors really need to start using the universally recognised treatment protocol of invasive ventilation.
Despite the name people with COVID-19 in the "Severe" category aren't actually in a particularly serious condition.
One thing that has started to emerge recently are social media videos of COVID-19 patients. In which they tearfully plead with people to stay home and save lives!
These seem to have caused a fair bit of amusement at the World Health Organisation (WHO).
From those videos one thing is obvious. If you know what you are looking at. Those people are not in anything even closely resembling a life-threatening condition.
Yes, they're slightly short of breath. However that is having no impact of their wider health other than being slightly uncomfortable.
This is really the first thing anybody is taught on a First Aid course;
Ignore the people who are crying out in pain. They are clearly conscious and clearly breathing. You need to focus on the people who have suddenly gone quiet.
To be categorised as a "Severe" patient you only need to be suffering from Respiratory Distress. Meaning your Sats will be in the YELLOW range I mentioned above. Between 80% and 95%.
If demand is far outstripping supply we need to start asking whether even these "Severe" patients actually need to be in hospital.
Instead they really only need to be in a place where their condition can be closely monitored by medical professionals.
Again this is not a revolutionary idea. It is a normal part of everyday medical practice.
Most British hospitals already have such a place. Known as a Clinical Decision Unit (CDU) it is a small area within an Emergency Department.
If someone comes into an Emergency Department complaining of chest pains it is possible that they are having a heart attack. However, particularly if it is an NHS Emergency Department, it is far more likely that they simply have indigestion.
The way you solve this mystery is by hooking them up to an EKG machine for about an hour. The CDU is where they will sit and wait for that hour.
The advantage of treating COVID-19 patients in CDU's rather than hospitals is that they can be quickly and massively scaled up. All you really need is an indoor space and simple monitoring machines.
You don't even strictly speaking need beds. Although particularly with Respiratory Distress calm, relaxed patients are stable patients.
You can actually improve a persons breathing just by changing the angle of their chest and airway using an adjustable bed. It doesn't have a huge effect. It does though make patients feel better. Particularly if they can adjust the angle themselves, as it suits them.
Frontline medical professionals do many complex things. Some of which require years of training.
However checking a person's vital signs every 15 minutes or so is not one of them. It is simply a matter of recognising the shape of a number on a machine and then writing it down.
It is something you could probably train a chimp to do. Although I gather that these days they prefer to be referred to as; "Health Care Assistants."
So you don't actually need a large number of medical professionals to staff these COVID-19 CDU's or; "Fever Clinics."
Somebody like a Red Cross or St John's Ambulance volunteer First Aider should already be sufficently trained. Any other volunteer should be able to be trained up in about a day.
You will though need some medical professionals. Writing down a series of numbers is very easy. Making a decision based on those seemingly random numbers is the tricky bit.
When you would move a person from a Fever Clinic to a Hospital is exactly the sort of question you need an actual, proper Doctor to answer.
However I would assume it would have something to do with the speed at which they can be moved from the Fever Clinic to the Hospital. Speed being Distance/Time.
I first floated this idea on the Internet back on March 18th (18/3/20). There I used the example of London's NHS St Thomas' Hospital. This sits directly across the road from several, now empty, hotels which would be ideal for Fever Clinics.
In that close proximity I would be happy to keep patients in the Fever Clinic upto the point they actually go into Respiratory Failue - the RED mentioned above.
Even a Paramedic could perform Invasive Venilation and then just wheel them across the road. They often have to transport patients in that condition much further.
Since I floated the idea the British Military have been building a so-called Field Hospital at the Excel Centre in East London. Which I suspect they desperately wanted to name; "NHS Canary." After all it is down by the Wharf, where they used to bring in the coal.
Despite all the publicity I've been struggling to find the sort of detailed information I need. I believe though that the plan is for the "NHS Nightigale" facility to be made up of 4,000 beds.
Of those 3,500 are intended to be, what are being called; "Critical Care Beds." I suspect though that in reality they are going to be Observation Beds. This is the NHS after all. Everybody needs to be made to feel special.
The remaining 500 beds are intended to be ICU beds. In short Ventilator Beds.
The NHS Nightigale is only about 1km (0.6 miles) in length. Meaning the furthest Observation Bed is only around 1000 yards from the Venitilator Beds. Significantly less than the distance between the Emergency Department and the ICU in a typical hospital.
In that situation I would be happy to leave people in the Observation Beds right up until the moment they need to be put on a ventilator.
I would assume the decision when to move a person from a Fever Clinic to a hospital would also depend on the type of care you can provide in the Fever Clinic.
I am really not qualified to be making that sort of clinical decision for one COVID-19 patient. Let alone all of them.
So this absolutely should not be viewed as me giving medical advice.
It should be viewed as me trying to ask constructive questions. Of people who are qualified to give medical advice.
There shouldn't though be any great problem in providing Oxygen Therapy in a Fever Clinic.
At its most basic oxygen therapy is just putting a tube under the patient's nose and attaching the other end to an oxygen supply. All you do then is wait and watch as the patient breathes, hopefully, normally.
Likewise it shouldn't be too much of a challenge to provide pressurised oxygen therapy and even CPAP oxygen therapy within a Fever Clinic. As long as you can safely provide the equipment needed.
So under the right conditions I would be prepared to keep patients in Fever Clinics and out of hospital. Right up to the point when they require a Ventilator Bed.
I think what is key is setting up the Fever Clinics as close as possible to a hospital. While keeping it seperate from the hospital.
At around 16:20 on 1/4/20 (UK date) there is more to follow.
Edited at around 19:55 on 2/4/20 (UK date) to copy & paste;
What type of care you can provide in any location obviously depends on what type of care you have available.
In developed nations such as the US and Britain providing all types of Oxygen Therapy shouldn't be an issue.
They have large numbers of industrial oxygen plants along with stable electricity grids needed to power them. So oxygen is really the one thing that's never going to run out.
There may be a few logistical bottlenecks. Where the supply exists but just isn't making it to where it is needed. As I mentioned in my previous post these can be easily overcome. Through coordination between customers, suppliers and government.
This is one of the things that annoys me about people comparing this to a war.
In a war the enemy quickly identifies what is essential to you. Industrial oxygen plants etc. Then starts trying really hard to blow them up.
Dealing with a large amount of casualties, even biological ones, is just one tiny, little bit of a war.
I am though concerned about less developed nations which lack that oxygen production infrastructure. Even the two largest economies in Africa - Nigeria and South Africa - are notorious for their erratic electricty grids.
Governments in nations such as those need to be particularly aware of exactly what and where their oxygen production capacity is.
They need to work very closely with production plants to ensure that they are able to continue operating. Such as by bringing electrical generators onsite. Along with the fuel needed to power those generators.
If they are importing oxygen from neighbouring countries they need to make sure that supply chain runs as smoothly as possible.
This certainly isn't the time when you want oxygen tankers or trucks carrying bottled oxygen to be held up at customs. It might be worth looking at organising such shipments into convoys with police/military escorts.
Plans also need to be drawn up to make sure oxygen is only being used on patients who will benefit from it the most. At the time they will benefit most from it.
I think normally oxygen would be given as soon as someone enters that YELLOW range. They would then typically move onto pressurised oxygen when their Sats are around 85%. Moving onto ventilator when they enter the RED range. Below 80%.
If demand is outstripping supply it might be that people can only be put on oxygen when their Sats drop to around 85%. Then pressurised oxygen when they drop to around 80%. Only moving to ventilator when they reach 75%.
This is somewhere where I would very much defer to actual, proper Doctors.
A few years ago I myself suffered ARS. The result to exposure to Chlorine Gas. I did not seek medical attention.
The reason is that I knew exactly what was causing my ARS. Along with how my condition would progress.
Molecules of Chlorine were irritating my lung tissue. My body though was breaking down those Chlorine molecules. As soon as enough of them had be broken down my lung tissue would stop being irritated and the ARS would end.
Even then though there was a very clear set of criteria at which I would seek medical attention. It is free after all.
When my relative suffered ARS though my advice was to seek medical attention immediately. That's because we initially had no idea what was causing their ARS. Let alone how it would progress.
Likewise I have no idea how SARS-CoV-2 progresses.
Obviously the intention of treating SARS-CoV-2 is to stablise the patient and stop their illness from progressing.
You don't put them on oxygen to fill the time until they're sick enough to require a ventilator. You put them on oxygen so they do not get sick enough to require a ventilator.
It may be that the sooner you start a person on oxygen therapy the sooner they stablise.
In that case you want to do the opposite of what I've just suggested. Starting oxygen when people are still in the GREEN range. Then moving the sickest patients off oxygen and onto ventilators sooner.
Before moving a person onto a ventilator there is always the question of whether you should.
This isn't a question about rationing or supposed; "Death Panels." It is a question of whether it is in fact the best way to care for that particular person.
I find myself frequently talking about the death of my paternal grandmother. That was a full on Crime Against Humanity.
We've not totally ruled out this being her vengeance on the NHS. If you'd met her you'd understand.
What I talk about much less is the death of my maternal grandmother. She just got old and died.
Although I don't have the notes to hand she developed some form of Cardiovascular Disease. Eventually leading to Multiple Organ Failure.
So one Friday night she was admitted to an ICU. Where a quivering Junior Doctor laid out all the treatment options. Ventilation, invasive ventilator, kidney dialysis etc.
Now my maternal grandmother had a long career as a medical professional. A clinical pharmacist. In a hospital where she met her husband, a Doctor.
So she gathered her children and grandchildren. Many of whom are also medical professionals.
After careful consideration she decided not to go on a ventilator. Dying a few days later. We were really only frustrated that it was the weekend so we couldn't arrange for her to be discharged to die at home.
My grandmother didn't make that decision because she was depressed or suicidal. She just understood.
This wasn't a question of her going on a ventilator and getting better. This was a question of her going on a ventilator and then dying on a ventilator.
I don't think the death of any loved one can be described as; "Enjoyable." However dying on a ventilator is a particularly unpleasent way to go.
You have this tube rammed down your throat. That not only feels incredibly uncomfortable it prevents you from talking to your loved ones. It also forces you to lie flat in bed, starring at the ceiling. So you can't even give your loved ones a final hug or kiss goodbye.
Often the discomfort from this ventilaton tube is so great Doctors are forced to put you in an induced coma. As far as your mind is concerned the world ends the moment that sedation starts. No matter how long the ventilator may keep you breathing.
In recent years there seems to have been a growing public understanding of just how uncaring this type of medical intervention can be. Leading to the rise in Do Not Recusitate orders and so-called Living Wills.
If a person has been put on a ventilator there is then also a question of how long they should remain on a ventilator. Even with absolutely no chance of recovery ventilators can keep people technically alive for a very long time.
In an earlier post I mentioned the case of Jahi McMatch. Which I followed at the time. To all intents and purposes she died in December 2013. However a ventilator kept her vital organs functioning until June 2018. Almost a full five years later.
Some of you may remember that in December 2019 there was an anti-Semitic attack in Monsey, New York State, US. A knifeman attacked a group of Jews gathered to celebrate Hannukah. Just as 2019nCoV was coming into being.
During the attack Rabbi Josef Neumann suffered serious brain injuries. To all intents and purposes killing him. However he was also put on a ventilator.
With rather spectacular timing that ventilator was no longer able to keep Rabbi Neumann's other vital organs functioning on March 29th (29/3/20). Three months after the attack and just as 2019nCoV was really starting to hit New York State.
Like I've said I do not know how SARS-CoV-2 progresses. I do know that it will progress differently in each individual patient.
So I am not happy about putting a firm, one-size-fits-all figure on how long a person should stay on a ventilator.
Some data though suggests that most patients will recover 9-14 days after the first onset of symptoms. That data however does not detail the type of care they recieved.
Even so if someone has been on a ventilator for around that length of time. Without signs of improvement. It's time to start thinking about whether they should continue on that ventilator. Whether there is someone else waiting for that ventilator or not.
The youngest person I've heard of to die from SARS-CoV-2 was just 12 years old. While the oldest person I've heard to recover was 112 years old.
So deciding whether ventilation is an appropriate treatment for an individual is not as simple as looking at just their age.
It is a difficult decision that can only be made by weighing a number of different factors.
It is in making this type of decision that Doctors really rely on their training. And really earn their pay.
Amongst the key factors to be considered are what are known as; "Comorbidities". The risk factors I mentioned in my F.E.A.R.S (16/3/20) post. Cardiovascular Disease, Chronic Lung Disease etc.
People with these risk factors are known to be less likely to survive SARS-CoV-2.
So if you had a 78 year old SARS-CoV-2 patient with Cardiovascular Disease and Chronic Lung Disease I would find it hard to justify putting them on a ventilator. Regardless of whether that ventilator is needed by somebody else.
Likewise I would find it difficult to justify putting a 25 year old SARS-CoV-2 patient with Lung Cancer on a ventilator. If it meant denying that ventilator to an otherwise healthy 75 year old SARS-CoV-2 patient.
Aside from specific risk factors you also have to consider other life limiting conditions the patient may have. Things which will shorten their life or significantly reduce their quality of life. Even if they were to make a full recovery from SARS-CoV-2.
A good example of such a condition is Cystic Fibrosis. This is a condition people are born with in which cysts cause scarring (fibrosis) in the lungs. In the US the average life expectancy for someone with Cystic Fibrosis is just 37 years.
So again I would find it very difficult to justify putting a 30 year old Cystic Fibrosis patient on a ventilator for SARS-CoV-2. If it meant denying that ventilator to an otherwise healthy 60 year old SARS-CoV-2 patient.
In the UK, as in much of the developed world, Doctors can't actually make decisions whether to put someone on or to take them off a ventilator. They can only act on the informed consent of either the patient or their next-of-kin.
People who often have absolutely no idea what they are talking about. At absolutely the worst moment of their lives.
In the other ear they often have a Care Home. Demanding the tube goes down the throat. So the funnel can stay in the bank account.
If a signficant disagreement arises all Doctors can do is apply to the Court of Protection (COP). That Court then takes guardianship over the patient. Effectively becoming their next-of-kin.
I think it would be an extremely bad idea to scrap that patient protection entirely. After all I've seen what some Doctors are like behind their masks.
In a time of severe crisis though that process might need to be streamlined. So the Court can make decisions in a day or two rather than a week or more.
That would involve putting clerical staff from the Court into the hospitals where these decisions are needed. In order to assist both the medical staff and the next-of-kin in correctly submitting their applications and evidence in shortened timeframe.
Politicans can further ease the burden by simply being honest with the public.
Many politicans seem to be approching COVID-19 as if humans are otherwise immortal.
Constantly repeating the mantra; "Every Death is a Tragedy."
If you have watched someone die on a ventilator you would know that not all deaths are a tragedy. Some deaths are a blessing.
A physical, emotional and spiritual blessing.
They mark the end of the pain.
The pain that has continued to wrack the body. Long after the person you once loved has gone.
20:20 on 2/4/20 (UK date).
In that post I looked at COVID-19. The virus that causes it (2019nCoV) and the illness it causes (SARS-CoV-2).
That reveals that COVID-19 is not a serious illness.
Even the worst case scenario envisioned by the British Government shows COVID-19 to be around 85% less deadly than Influenza is during a typical year.
Instead the threat posed by COVID-19 is that so many people will become mildly unwell at the same time society is no longer able to function properly.
As I covered in my previous post the first challenge is to build extra capacity within the healthcare system.
Once you have built capacity as much as possible you need to start using that capacity as efficently as possible.
Triage.
This one of those words that tends to frighten people.
It automatically conjures images of that newly widowed single father in every disaster movie. Heroically carrying his injured child across the wasteland. Only for a cruel solider to pin a black tag to the child and leave them to die.
In reality triage is just a normal part of everyday medical practice. It's about making sure that the patient recieves the right sort of care.
So if you go into a hospital's Emergency Department with stab wounds to your chest you're going to the front of the queue for treatment. If you've got a small broken bone in your hand you go to the back of the queue. If your head and the rest of your body arrive in two seperate vehicles you don't go into the queue at all.
The medical profession is one of the oldest in the World. Tracing its roots back some 2,300 years to Hippocrates in Ancient Greece.
Over that time the medical profession has developed a deeply engrained culture of excellence. Everybody is constantly striving to not only give their patients the best possible care but also to make better care possible.
In the UK it takes 6-7 to years for someone to qualify as a Doctor. However after qualifying they are then expected to complete the equivalent of a fresh new university module each year in order to remain qualified. That is on top of actually doing their day job.
This constant pursuit of excellence coupled with the precautionary principle means often medical professionals provide their patients with too much treatment. Which, under normal circumstances, is no great problem.
This is something which is particularly true in Britain's NHS.
Treatment under the NHS is free at the point of use.
Not having to worry about how to pay for it means British people feel they can bother medical professionals with just any old nonsense. With the NHS being seen as public property those medical professionals are then under pressure to provide care for what are, frankly, timewasters.
Seriously. The NHS' motto could well be;
"There's Nothing Wrong With You, Go Home!"
A couple of years ago a relative of mine was admitted to an NHS hospital with an Acute Respiratory Syndrome (ARS). Although one caused by an obscure fungus rather than 2019nCoV.
This was the same NHS hospital which went on to treat the Skripals and the other Novichok patients. I gather Russian President Putin has been having fun. Visiting COVID-19 patients, dressed in full Nuclear, Biological, Chemical (NBC) protective gear.
Amid this culture of seeming mass panic I don't really want to get into the specifics of the symptoms of either ARS or SARS.
They say a little knowledge can be a dangerous thing. I don't want to contribute to people wrongly diagnosing themselves, panicking and turning up at hospital demanding treatment.
One of the main indicators in both ARS and SARS though is blood, oxygen saturation (Sats). The amount of oxygen in your blood. You need a special machine to measure this so you won't be able to do it at home.
Normal blood oxygen saturation varies. Even on your altitude above sea level. It is though normally in the range of 95%-100%. If it falls below 95% you enter a condition known as Respiratory Distress. If it falls below 80% you enter a condition known as Respiratory Failure.
One way to think about this is using the Traffic Light triage system. So;
95%-100% is GREEN. Perfectly normal, no need for concern.
80%-95% is YELLLOW. Exert caution, however no action required.
Below 80% is RED. Serious problem, urgent action required.
At their worst my relative's condition could be described as; LIME. That is to say generally green, with a hint of citrus.
The hospital's response was to put them on a Ventilator Bed in an Intensive Care Unit (ICU). Although they never actually used the ventilator.
This was totally pointless. There was no need for my relative to be in an ICU.
However the thinking was that their condition could detoriate, for some unknown reason. So it was safer to put them in the Ventilator Bed that was available. Just in case.
Obviously in a situation where demand is outstripping supply that is the sort of practice which needs to stop.
Rather than thinking about providing the best care to a small number of people we need to start thinking in terms of what's the minimum we can get away with for a large number of people.
The data indicates that potentially as many as 90% of patients who become infected with 2019nCoV will experience either mild symptoms or no symptoms at all. They will not go on to develop SARS-CoV-2.
That means that they will not require any medical attention at all. They will, what is known as; "Self-Resolve."
The remaining 10% will go through a progression of symptoms.
From what are classed as; "Severe" through to "Critical." Some will also die. However the vast majority will not progress beyond the "Severe" catergory. Of those who progress to the "Critical" category more than half of them will not go onto die.
How a person's condition is classed as either "Mild," "Severe" or "Critical" depends on a number of factors. However for simplicity I will concentrate on just one - blood, oxygen saturation (Sats).
As the person's condition progresses the treatment they recieve will also progress. In the hope of stablising them and halting that progression.
The first available treatment is incredibly simple. Oxygen Therapy.
The air that we breathe is actually a mixture of, primarily, Oxygen and Nitrogen. So if a person's Sats start to drop you simply hook them up to a supply of pure oxygen. Meaning that there is a little bit more oxygen in every breath they take.
If the person's Sats continue to drop the next available treatment is to hook them up to a supply of slightly pressurised oxygen. That oxygen then takes priority over the non-pressurised nitrogen, oxygen mix of air in each breath. Increasing the amount of oxygen in each breath.
If the person's Sats continue to drop the next step is Positive Pressure Ventilation. Essentially putting them on a ventilator.
People may be more familiar with venitilators than they realise.
The US medical industry has largely invented a condition called; "Sleep Apnea." This is treated by selling the patient a Continuous Postive Airway Pressure (CPAP) machine to sleep in.
A CPAP machine is technically a ventilator, pumping pressurised air into the lungs. However the pressure provided by a CPAP machine is so low that it doesn't need to perform the other role of a traditional ventilator. A latent cycle allowing the air to be expelled from the lungs.
Sleep Apnea patients are typically so ridiculously healthy their lungs can expel the air on their own. Even against the pressure provided by the CPAP machine.
What a medical professional can do though is hook a CPAP machine up to a pure oxygen supply. Providing something of a halfway house between pressurised oxygen therapy and full venitilation.
If you already own a CPAP machine please do not attempt to hook it up to an oxygen supply yourself. It is highly likely that you will only succeed in blowing yourself and your house to bits.
If a person's Sats continue to drop then they will have to be put on a traditional Positive Pressure Ventilator. A machine which pushes pressurised air into their lungs via a facemask.
If that doesn't work then the final option is Invasive Ventilation. This is where the person is put on a Positive Pressure Ventilator. However instead of a facemask a plastic tube is shoved down their airway. Delivering the air directly into their lungs.
At the risk of a tangent I should mention Italy. Despite having a population around 6 million smaller than China's Hubei Province they have experienced far more COVID-19 deaths. Currently in excess of 10,000.
The main reason for that seems to be that Italian Doctors don't follow this universally accepted treatment route for any form of SARS.
When Positive Pressure Ventilation has failed to stablise a person's condition Italian Doctors do not move onto Invasive Ventilaton. Instead they put a plastic hood over the person's head and fill it with slightly pressurised oxygen. Reverting to pressurised oxygen therapy.
Funnily enough reducing the treatment for the most seriously ill patients has increased the number of deaths.
I don't mention this to attack Italian Doctors. Or to inspire others to do the same. Those Doctors are simply following the treatment protocol they have been told works and trained to use.
When the situation has calmed down a bit though serious questions do need to be asked. About why they were told that treatment protocol would work.
In the meantime Italian Doctors really need to start using the universally recognised treatment protocol of invasive ventilation.
Despite the name people with COVID-19 in the "Severe" category aren't actually in a particularly serious condition.
One thing that has started to emerge recently are social media videos of COVID-19 patients. In which they tearfully plead with people to stay home and save lives!
These seem to have caused a fair bit of amusement at the World Health Organisation (WHO).
From those videos one thing is obvious. If you know what you are looking at. Those people are not in anything even closely resembling a life-threatening condition.
Yes, they're slightly short of breath. However that is having no impact of their wider health other than being slightly uncomfortable.
This is really the first thing anybody is taught on a First Aid course;
Ignore the people who are crying out in pain. They are clearly conscious and clearly breathing. You need to focus on the people who have suddenly gone quiet.
To be categorised as a "Severe" patient you only need to be suffering from Respiratory Distress. Meaning your Sats will be in the YELLOW range I mentioned above. Between 80% and 95%.
If demand is far outstripping supply we need to start asking whether even these "Severe" patients actually need to be in hospital.
Instead they really only need to be in a place where their condition can be closely monitored by medical professionals.
Again this is not a revolutionary idea. It is a normal part of everyday medical practice.
Most British hospitals already have such a place. Known as a Clinical Decision Unit (CDU) it is a small area within an Emergency Department.
If someone comes into an Emergency Department complaining of chest pains it is possible that they are having a heart attack. However, particularly if it is an NHS Emergency Department, it is far more likely that they simply have indigestion.
The way you solve this mystery is by hooking them up to an EKG machine for about an hour. The CDU is where they will sit and wait for that hour.
The advantage of treating COVID-19 patients in CDU's rather than hospitals is that they can be quickly and massively scaled up. All you really need is an indoor space and simple monitoring machines.
You don't even strictly speaking need beds. Although particularly with Respiratory Distress calm, relaxed patients are stable patients.
You can actually improve a persons breathing just by changing the angle of their chest and airway using an adjustable bed. It doesn't have a huge effect. It does though make patients feel better. Particularly if they can adjust the angle themselves, as it suits them.
Frontline medical professionals do many complex things. Some of which require years of training.
However checking a person's vital signs every 15 minutes or so is not one of them. It is simply a matter of recognising the shape of a number on a machine and then writing it down.
It is something you could probably train a chimp to do. Although I gather that these days they prefer to be referred to as; "Health Care Assistants."
So you don't actually need a large number of medical professionals to staff these COVID-19 CDU's or; "Fever Clinics."
Somebody like a Red Cross or St John's Ambulance volunteer First Aider should already be sufficently trained. Any other volunteer should be able to be trained up in about a day.
You will though need some medical professionals. Writing down a series of numbers is very easy. Making a decision based on those seemingly random numbers is the tricky bit.
When you would move a person from a Fever Clinic to a Hospital is exactly the sort of question you need an actual, proper Doctor to answer.
However I would assume it would have something to do with the speed at which they can be moved from the Fever Clinic to the Hospital. Speed being Distance/Time.
I first floated this idea on the Internet back on March 18th (18/3/20). There I used the example of London's NHS St Thomas' Hospital. This sits directly across the road from several, now empty, hotels which would be ideal for Fever Clinics.
In that close proximity I would be happy to keep patients in the Fever Clinic upto the point they actually go into Respiratory Failue - the RED mentioned above.
Even a Paramedic could perform Invasive Venilation and then just wheel them across the road. They often have to transport patients in that condition much further.
Since I floated the idea the British Military have been building a so-called Field Hospital at the Excel Centre in East London. Which I suspect they desperately wanted to name; "NHS Canary." After all it is down by the Wharf, where they used to bring in the coal.
Despite all the publicity I've been struggling to find the sort of detailed information I need. I believe though that the plan is for the "NHS Nightigale" facility to be made up of 4,000 beds.
Of those 3,500 are intended to be, what are being called; "Critical Care Beds." I suspect though that in reality they are going to be Observation Beds. This is the NHS after all. Everybody needs to be made to feel special.
The remaining 500 beds are intended to be ICU beds. In short Ventilator Beds.
The NHS Nightigale is only about 1km (0.6 miles) in length. Meaning the furthest Observation Bed is only around 1000 yards from the Venitilator Beds. Significantly less than the distance between the Emergency Department and the ICU in a typical hospital.
In that situation I would be happy to leave people in the Observation Beds right up until the moment they need to be put on a ventilator.
I would assume the decision when to move a person from a Fever Clinic to a hospital would also depend on the type of care you can provide in the Fever Clinic.
I am really not qualified to be making that sort of clinical decision for one COVID-19 patient. Let alone all of them.
So this absolutely should not be viewed as me giving medical advice.
It should be viewed as me trying to ask constructive questions. Of people who are qualified to give medical advice.
There shouldn't though be any great problem in providing Oxygen Therapy in a Fever Clinic.
At its most basic oxygen therapy is just putting a tube under the patient's nose and attaching the other end to an oxygen supply. All you do then is wait and watch as the patient breathes, hopefully, normally.
Likewise it shouldn't be too much of a challenge to provide pressurised oxygen therapy and even CPAP oxygen therapy within a Fever Clinic. As long as you can safely provide the equipment needed.
So under the right conditions I would be prepared to keep patients in Fever Clinics and out of hospital. Right up to the point when they require a Ventilator Bed.
I think what is key is setting up the Fever Clinics as close as possible to a hospital. While keeping it seperate from the hospital.
At around 16:20 on 1/4/20 (UK date) there is more to follow.
Edited at around 19:55 on 2/4/20 (UK date) to copy & paste;
What type of care you can provide in any location obviously depends on what type of care you have available.
In developed nations such as the US and Britain providing all types of Oxygen Therapy shouldn't be an issue.
They have large numbers of industrial oxygen plants along with stable electricity grids needed to power them. So oxygen is really the one thing that's never going to run out.
There may be a few logistical bottlenecks. Where the supply exists but just isn't making it to where it is needed. As I mentioned in my previous post these can be easily overcome. Through coordination between customers, suppliers and government.
This is one of the things that annoys me about people comparing this to a war.
In a war the enemy quickly identifies what is essential to you. Industrial oxygen plants etc. Then starts trying really hard to blow them up.
Dealing with a large amount of casualties, even biological ones, is just one tiny, little bit of a war.
I am though concerned about less developed nations which lack that oxygen production infrastructure. Even the two largest economies in Africa - Nigeria and South Africa - are notorious for their erratic electricty grids.
Governments in nations such as those need to be particularly aware of exactly what and where their oxygen production capacity is.
They need to work very closely with production plants to ensure that they are able to continue operating. Such as by bringing electrical generators onsite. Along with the fuel needed to power those generators.
If they are importing oxygen from neighbouring countries they need to make sure that supply chain runs as smoothly as possible.
This certainly isn't the time when you want oxygen tankers or trucks carrying bottled oxygen to be held up at customs. It might be worth looking at organising such shipments into convoys with police/military escorts.
Plans also need to be drawn up to make sure oxygen is only being used on patients who will benefit from it the most. At the time they will benefit most from it.
I think normally oxygen would be given as soon as someone enters that YELLOW range. They would then typically move onto pressurised oxygen when their Sats are around 85%. Moving onto ventilator when they enter the RED range. Below 80%.
If demand is outstripping supply it might be that people can only be put on oxygen when their Sats drop to around 85%. Then pressurised oxygen when they drop to around 80%. Only moving to ventilator when they reach 75%.
This is somewhere where I would very much defer to actual, proper Doctors.
A few years ago I myself suffered ARS. The result to exposure to Chlorine Gas. I did not seek medical attention.
The reason is that I knew exactly what was causing my ARS. Along with how my condition would progress.
Molecules of Chlorine were irritating my lung tissue. My body though was breaking down those Chlorine molecules. As soon as enough of them had be broken down my lung tissue would stop being irritated and the ARS would end.
Even then though there was a very clear set of criteria at which I would seek medical attention. It is free after all.
When my relative suffered ARS though my advice was to seek medical attention immediately. That's because we initially had no idea what was causing their ARS. Let alone how it would progress.
Likewise I have no idea how SARS-CoV-2 progresses.
Obviously the intention of treating SARS-CoV-2 is to stablise the patient and stop their illness from progressing.
You don't put them on oxygen to fill the time until they're sick enough to require a ventilator. You put them on oxygen so they do not get sick enough to require a ventilator.
It may be that the sooner you start a person on oxygen therapy the sooner they stablise.
In that case you want to do the opposite of what I've just suggested. Starting oxygen when people are still in the GREEN range. Then moving the sickest patients off oxygen and onto ventilators sooner.
Before moving a person onto a ventilator there is always the question of whether you should.
This isn't a question about rationing or supposed; "Death Panels." It is a question of whether it is in fact the best way to care for that particular person.
I find myself frequently talking about the death of my paternal grandmother. That was a full on Crime Against Humanity.
We've not totally ruled out this being her vengeance on the NHS. If you'd met her you'd understand.
What I talk about much less is the death of my maternal grandmother. She just got old and died.
Although I don't have the notes to hand she developed some form of Cardiovascular Disease. Eventually leading to Multiple Organ Failure.
So one Friday night she was admitted to an ICU. Where a quivering Junior Doctor laid out all the treatment options. Ventilation, invasive ventilator, kidney dialysis etc.
Now my maternal grandmother had a long career as a medical professional. A clinical pharmacist. In a hospital where she met her husband, a Doctor.
So she gathered her children and grandchildren. Many of whom are also medical professionals.
After careful consideration she decided not to go on a ventilator. Dying a few days later. We were really only frustrated that it was the weekend so we couldn't arrange for her to be discharged to die at home.
My grandmother didn't make that decision because she was depressed or suicidal. She just understood.
This wasn't a question of her going on a ventilator and getting better. This was a question of her going on a ventilator and then dying on a ventilator.
I don't think the death of any loved one can be described as; "Enjoyable." However dying on a ventilator is a particularly unpleasent way to go.
You have this tube rammed down your throat. That not only feels incredibly uncomfortable it prevents you from talking to your loved ones. It also forces you to lie flat in bed, starring at the ceiling. So you can't even give your loved ones a final hug or kiss goodbye.
Often the discomfort from this ventilaton tube is so great Doctors are forced to put you in an induced coma. As far as your mind is concerned the world ends the moment that sedation starts. No matter how long the ventilator may keep you breathing.
In recent years there seems to have been a growing public understanding of just how uncaring this type of medical intervention can be. Leading to the rise in Do Not Recusitate orders and so-called Living Wills.
If a person has been put on a ventilator there is then also a question of how long they should remain on a ventilator. Even with absolutely no chance of recovery ventilators can keep people technically alive for a very long time.
In an earlier post I mentioned the case of Jahi McMatch. Which I followed at the time. To all intents and purposes she died in December 2013. However a ventilator kept her vital organs functioning until June 2018. Almost a full five years later.
Some of you may remember that in December 2019 there was an anti-Semitic attack in Monsey, New York State, US. A knifeman attacked a group of Jews gathered to celebrate Hannukah. Just as 2019nCoV was coming into being.
During the attack Rabbi Josef Neumann suffered serious brain injuries. To all intents and purposes killing him. However he was also put on a ventilator.
With rather spectacular timing that ventilator was no longer able to keep Rabbi Neumann's other vital organs functioning on March 29th (29/3/20). Three months after the attack and just as 2019nCoV was really starting to hit New York State.
Like I've said I do not know how SARS-CoV-2 progresses. I do know that it will progress differently in each individual patient.
So I am not happy about putting a firm, one-size-fits-all figure on how long a person should stay on a ventilator.
Some data though suggests that most patients will recover 9-14 days after the first onset of symptoms. That data however does not detail the type of care they recieved.
Even so if someone has been on a ventilator for around that length of time. Without signs of improvement. It's time to start thinking about whether they should continue on that ventilator. Whether there is someone else waiting for that ventilator or not.
The youngest person I've heard of to die from SARS-CoV-2 was just 12 years old. While the oldest person I've heard to recover was 112 years old.
So deciding whether ventilation is an appropriate treatment for an individual is not as simple as looking at just their age.
It is a difficult decision that can only be made by weighing a number of different factors.
It is in making this type of decision that Doctors really rely on their training. And really earn their pay.
Amongst the key factors to be considered are what are known as; "Comorbidities". The risk factors I mentioned in my F.E.A.R.S (16/3/20) post. Cardiovascular Disease, Chronic Lung Disease etc.
People with these risk factors are known to be less likely to survive SARS-CoV-2.
So if you had a 78 year old SARS-CoV-2 patient with Cardiovascular Disease and Chronic Lung Disease I would find it hard to justify putting them on a ventilator. Regardless of whether that ventilator is needed by somebody else.
Likewise I would find it difficult to justify putting a 25 year old SARS-CoV-2 patient with Lung Cancer on a ventilator. If it meant denying that ventilator to an otherwise healthy 75 year old SARS-CoV-2 patient.
Aside from specific risk factors you also have to consider other life limiting conditions the patient may have. Things which will shorten their life or significantly reduce their quality of life. Even if they were to make a full recovery from SARS-CoV-2.
A good example of such a condition is Cystic Fibrosis. This is a condition people are born with in which cysts cause scarring (fibrosis) in the lungs. In the US the average life expectancy for someone with Cystic Fibrosis is just 37 years.
So again I would find it very difficult to justify putting a 30 year old Cystic Fibrosis patient on a ventilator for SARS-CoV-2. If it meant denying that ventilator to an otherwise healthy 60 year old SARS-CoV-2 patient.
In the UK, as in much of the developed world, Doctors can't actually make decisions whether to put someone on or to take them off a ventilator. They can only act on the informed consent of either the patient or their next-of-kin.
People who often have absolutely no idea what they are talking about. At absolutely the worst moment of their lives.
In the other ear they often have a Care Home. Demanding the tube goes down the throat. So the funnel can stay in the bank account.
If a signficant disagreement arises all Doctors can do is apply to the Court of Protection (COP). That Court then takes guardianship over the patient. Effectively becoming their next-of-kin.
I think it would be an extremely bad idea to scrap that patient protection entirely. After all I've seen what some Doctors are like behind their masks.
In a time of severe crisis though that process might need to be streamlined. So the Court can make decisions in a day or two rather than a week or more.
That would involve putting clerical staff from the Court into the hospitals where these decisions are needed. In order to assist both the medical staff and the next-of-kin in correctly submitting their applications and evidence in shortened timeframe.
Politicans can further ease the burden by simply being honest with the public.
Many politicans seem to be approching COVID-19 as if humans are otherwise immortal.
Constantly repeating the mantra; "Every Death is a Tragedy."
If you have watched someone die on a ventilator you would know that not all deaths are a tragedy. Some deaths are a blessing.
A physical, emotional and spiritual blessing.
They mark the end of the pain.
The pain that has continued to wrack the body. Long after the person you once loved has gone.
20:20 on 2/4/20 (UK date).
Thursday, 26 March 2020
The Pox On All Your Houses.
A continuation of; https://watchitdie.blogspot.com/2020/03/far-eastern-acute-respritory-syndrome.html
In that post I looked at COVID-19. The virus that causes it (2019nCoV) and the illness it causes (SARS-CoV-2).
I also looked at the people who have been infected with 2019nCoV. Whether they've gone onto develop SARS-CoV-2. Their risk factors. The treatment they've recieved and how successful that treatment has been.
This all reveals that COVID-19 is not a serious illness. Of those infected with 2019nCoV 81% will not contract SARS-CoV-2.
Amongst the remaining 19% who do. In the normal population, those outside high risk groups, the case mortality rate is just 0.1%. Even in the absolute highest risk groups the case mortality rate is still only 49%. Meaning that 51% of even the sickest people recover.
In talking about COVID-19 we all seem to have forgotten one basic truth; All people die.
In developed nations, with advanced healthcare systems, this is how they die. They get old. They become frail. They then succumb to infections which are mild or even completely irrelevant to the vast majority of the people.
So the threat posed by COVID-19 is not a threat to life. Instead the threat is that so many people become mildly unwell at the same time that society is no longer able to function normally.
In that previous post on the topic I said that its actually really easy to treat SARS-CoV-2. First with simple Oxygen. Then with an escalating scale of treatments up to things like invasive ventilation.
I say that it's easy. It becomes a lot harder when you don't have Oxygen cylinders or Ventilators. Or the frontline healthcare workers who know what those things are and how to use them.
So the first challenge in responding to COVID-19 is that of Capacity Building.
Increasing the capacity within the healthcare system. To treat the 19% of the population who are predicted to develop SARS-CoV-2.
The obvious answer would be to buy 19% more ventilators and train 19% more staff. However that takes time. Even to train a General Practice Nurse into a Intensive Care Nurse.
I would say that the time pressure to do that was overwhelming back in December 2019, when COVID-19 first came into existence. Here in late March 2020 that time has now run out.
However that is not to say that extra capacity cannot be found.
For reasons which will become obvious later in this post Britain is really not the example anybody should be following. I though live in Britain so am absolutely deluged with information about Britain's response.
One thing that makes Britain pretty unique is that it has a socialised healthcare system. The famous National Health Service (NHS).
This means that the majority of hospitals in Britain are owned and operated by the state. Something that not even Communist China can claim.
Lets say, for arguments sake, that the NHS has 5,000 Ventilator Beds. In logistical terms this is not just a bed. It is a unit made up of the staff and equipment required to provide invasive ventilation. The last resort treatment for SARS-CoV-2.
Although the majority of healthcare in Britain is provided by the NHS there are still private healthcare providers. Let's say those private hospitals have 2,500 Ventilator Beds.
Then there is the military. Getting killed and injured is quite a big part of going to war. Obviously in a war the British military can't just call the NHS for an ambulance. So they have their own healthcare system.
Let's say that the British military also has 2,500 Ventilator Beds.
What the government needs to do is take those Ventilator Beds from the military and private sector. Placing them under the control of the NHS.
In nations without an NHS they simply need to put all the Ventilator Beds under government control.
I appreciate that probably conjures images of troops with heavy machine guns storming into hospitals. However what I mean is a hospital phoning a government operations centre and telling them they require a Ventilator Bed.
In response that operations centre checks what Ventilator Beds are available and where. It then phones another hospital to tell them they are getting a patient.
That treatment is then paid for in the way treatment is normally paid for. If the patient has insurance then the insurance company pays. If not the care is paid for by the government programs for people without medical insurance. Medicare or Medicaid in the US.
Within healthcare systems there are also hidden things that can quickly become Ventilator Beds.
The obvious being equipment which has been replaced by a newer version and placed into storage. It's time to take that equipment out of storage, service it and put it back into use. Let's say there are 1,250 such potential Ventilator Beds.
Another important area is surgical suites. Operating theatres etc.
Before you undergo major surgery the Doctor will probably tell you that they are going to put you to sleep. That is a lie. What they are going to do is use a cocktail of drugs to slow your body to the point of death. They hold it there for the duration of the surgery.
To do this they require three machines. A gas and air machine to administer the drugs. A ventilator to keep you alive and a machine to monitor your vital signs.
In many modern hospitals these tasks are all done by a single, combined machine. However those machines can work simply as ventilators. Although when people are undergoing invasive ventilation they need to have their vital signs closely monitored and often need to placed under anesthetic.
Let's say there are 10,000 such surgical suites across in Britain. Across the NHS, the private sector and the military.
Obviously you need to keep some of those surgical suites open to perform emergency surgeries. COVID-19 is not going to stop people getting stabbed, getting into car accidents and experiencing complications during childbirth.
What you can quite easily do is cancel all non-essential, elective surgery. Surgeries where the patient's life is not in danger and their condition is not going to significantly worsen by delaying treatment.
One example I'm reasonably familiar with are hip replacements. These are very common elective surgeries. Many British hospitals have entire wings dedicated to doing just hip replacement surgery.
The hip joint is a ball and socket joint. There is a ball shaped bone on the top of your leg which fits into a cup shaped bone on your pelvis. The inside of the cup shaped bone is lined with cartilige. To stop the two bones rubbing together.
What often happens is that cartilige wears away. That causes the two bones to rub together limiting movement in the hip and causing pain.
Obviously your pain is not my pain. However I would be prepared to put up with even severe pain. In order to avoid being in a hospital in the middle of all this with a giant surgical wound in my side.
If the patient's condition does worsen then they become an emergency case. Meaning they are then treated in one of the emergency surgical suites.
Let's say Britain can close 75% of its surgical suites. Creating a further 7,500 Ventilator Beds.
The advantage of closing surgical suites over digging equipment out of storage is that they already employ the properly trained staff. A Surgical Nurse is already a qualified Intensive Care Nurse and then some.
The other important commodity is Oxygen.
Within most modern hospitals the oxygen supply is built into the building. Rather like how the electrical supply is built in. You get an oxygen plug socket in the wall.
Those oxygen sockets are supplied by large oxygen storage tanks. Those storage tanks are refilled by tanker trucks from an industrial oxygen plant. A facilty which has an Industrial Oxygen Concentrator.
An industrial oxygen concentrator is essentially a large air filter. Which removes everything except oxygen from the ambient air.
Obviously an industrial oxygen concentrator is a complicated to build. However once built they are relatively simple things to keep running. Compared to say a ventilator factory.
You only need a reliable electricity supply and a few spare parts. The main raw material constantly delivers itself to the site. Whether you want it to or not.
Hospitals regularly use a lot of oxygen. So will already have a good relationship with their oxygen suppliers. They need to work with those suppliers to meet an increased demand. Say going from one tanker truck delivery a week to two.
The government operations centre also needs to indentify and establish connections with all oxygen suppliers. To ensure that if one suddenly exceeds capacity, say by breaking down, demand can be met from elsewhere with the minimum disruption.
Oxygen is also supplied in bottles. Which are filled from the same industrial oxygen plants as the tanker trucks.
As I will move onto I envision oxygen therapy being given in places outside of modern hospitals. These places will need to be supplied with oxygen in bottle form.
So government and suppliers need to be prepared for a significant increase in demand for bottled oxygen. Along with the ability to prevent and overcome disruption to the supply chain.
Oxygen is also extremely flammable and extremely explosive. A bomb is actually just a chemical being oxygenised really, really quickly.
The people who make and work with oxygen everyday know this. However people who are not used to working with oxygen really need to be taught about specific fire safety. The Fire Service also needs to know exactly where they are and what they are doing.
Oxygen can also be supplied by Portable Oxygen Concentrators. A suitcase sized device that provides oxygen from the ambient air to an individual. However, as with ventilators, if you don't have these machines already it's really too late to start building them.
The British Prime Minister clearly has some World War Two fetish he needs to work through. However I don't see large numbers of ventilators suddenly rolling off the production lines.
So any extra ventilator capacity will come from existing capacity being re-purposed. This means that any extra machines will come with the staff needed to operate it. The complete Ventilator Bed unit.
Unfortunately frontline healthcare workers are particularly succeptible to all types of infections. Including 2019nCoV.
One way to think about it is like drinking alcohol. If you only have a small amount of alcohol in your body it has no effect. Within the EU the term; "Alcohol Free" actually means; "Only 0.5% alcohol."
However as you increase the amount of alcohol in your body the symptoms increase and become more obvious. Up to the point where you can actually go into Respiratory Failure and die.
It's the same with viruses like 2019nCoV. The difference is that the body immediately starts breaking down alcohol reducing the amount. Viruses start replicating within the body increasing the viral load.
Frontline healthcare workers are basically there are the bar doing shot after shot. Picking up more virus cells from each infected patient they treat.
This means their viral load can rise really rapidly. Much faster than through simple replication. Sometimes to the point where the immune system becomes outnumbered and cannot fight off the virus.
So you have to assume that all frontline healthcare workers are going to get infected with 2019nCoV. Meaning that 81% of them are going to be unavailable for about two weeks as they recover from mild illness.
That means you will need extra staff to cover those abscences. An effective way of doing this is recalling workers who have recently left the profession.
So a recently retired Doctor could take over the duties of a General Practioner. Allowing that GP to take over the hospital duties of an Emergency Department Doctor. Allowing that Emergency Department Doctor to go and work in an Intensive Care Unit.
It should also be easy to expand the workloads of existing staff.
Let's say it takes five staff members to make up a Ventilator Bed. However that does not mean that there are five people constantly standing by one bed.
Instead the same five staff will oversee five Ventilator Beds. That can be expanded to eight or even ten Ventilator Beds.
Faced with increased workloads it is also important that existing staff are protected. Both from illness and from burnout/exhaustion.
Let's assume that everyone has a shift pattern of five days on, two days. That can be changed to six days on, one day off.
However that one day off becomes mandatory. Nobody has the option of working overtime.
It may also be worth checking staff members temperatures at the begninning and end of their shifts.
Anyone who is showing a high temperature is sent home or kept away from patients. Until either signs of illness emerge or their temperature returns to normal. In order to prevent infected staff having their viral load increased by contact with infected patients.
Then there is the issue of Personal Protective Equipment (PPE).
Much of this is complete hokum. Particularly the wearing of paper facemasks.
The wearing of paper facemasks stems from a Japanese cultural practice. Japanese culture is extremely deferential. It is considered the height of rudeness to give someone else your germs. So if you are ill you are expected to wear a paper facemask.
The idea is not to protect the person who is wearing the mask. They are already ill. The objective is to be seen to be being respectful of everybody else.
It has absolutely no basis in science. It is as relevent as sipping warm water every fifteen minutes or rubbing Garlic on your forehead.
Also dressing up like Darth Vader really worries patients. At exactly the time healthcare professionals should be trying to reassure them.
So it is frankly alarming to listen to supposed healthcare professionals demand paper facemasks. It makes you wonder whether they're going to start trying to treat patients with healing crystals.
In terms of treating patients without SARS-CoV-2 normal infection control is more than sufficent. So the changing of gloves and aprons and the washing of hands with alcohol gel between each patient.
Things are different though when treating patients with SARS-CoV-2. Particularly ones requiring intensive care.
Many of these patients will be undergoing invasive ventilation. That involves sticking a plastic tube down their throat and into their lungs. Bypassing all of the body's natural protections against infection. Nose hairs for example.
Obviously the last thing you want to be doing with a patient already critically ill with a lung infection is start ramming more infectious material down into their lungs. So they need to be treated in as sterile environment as possible.
Those tubes need to be periodically cleaned of debris and moisture. They also need to be removed and sometimes replaced.
This can cause all the infected droplets in their respiratory tract to become aerosolized. Making it much easier for anyone around them to breath them in.
So when treating those patients staff need to wear surgical protective equipment. Sterile gown, gloves and haircovering. Along with a sterile respirator mask capable of stopping fine particulates. N95/FFP2 or higher.
Obviously you don't need to worry about alarming patients who are undergoing invasive ventilation. They're normally unconscious.
Once you have built capacity as much as possible you need to start using that capacity as efficently as possible.
At around 17:05 on 26/3/20 (UK date) looking at that will be my next task.
In that post I looked at COVID-19. The virus that causes it (2019nCoV) and the illness it causes (SARS-CoV-2).
I also looked at the people who have been infected with 2019nCoV. Whether they've gone onto develop SARS-CoV-2. Their risk factors. The treatment they've recieved and how successful that treatment has been.
This all reveals that COVID-19 is not a serious illness. Of those infected with 2019nCoV 81% will not contract SARS-CoV-2.
Amongst the remaining 19% who do. In the normal population, those outside high risk groups, the case mortality rate is just 0.1%. Even in the absolute highest risk groups the case mortality rate is still only 49%. Meaning that 51% of even the sickest people recover.
In talking about COVID-19 we all seem to have forgotten one basic truth; All people die.
In developed nations, with advanced healthcare systems, this is how they die. They get old. They become frail. They then succumb to infections which are mild or even completely irrelevant to the vast majority of the people.
So the threat posed by COVID-19 is not a threat to life. Instead the threat is that so many people become mildly unwell at the same time that society is no longer able to function normally.
In that previous post on the topic I said that its actually really easy to treat SARS-CoV-2. First with simple Oxygen. Then with an escalating scale of treatments up to things like invasive ventilation.
I say that it's easy. It becomes a lot harder when you don't have Oxygen cylinders or Ventilators. Or the frontline healthcare workers who know what those things are and how to use them.
So the first challenge in responding to COVID-19 is that of Capacity Building.
Increasing the capacity within the healthcare system. To treat the 19% of the population who are predicted to develop SARS-CoV-2.
The obvious answer would be to buy 19% more ventilators and train 19% more staff. However that takes time. Even to train a General Practice Nurse into a Intensive Care Nurse.
I would say that the time pressure to do that was overwhelming back in December 2019, when COVID-19 first came into existence. Here in late March 2020 that time has now run out.
However that is not to say that extra capacity cannot be found.
For reasons which will become obvious later in this post Britain is really not the example anybody should be following. I though live in Britain so am absolutely deluged with information about Britain's response.
One thing that makes Britain pretty unique is that it has a socialised healthcare system. The famous National Health Service (NHS).
This means that the majority of hospitals in Britain are owned and operated by the state. Something that not even Communist China can claim.
Lets say, for arguments sake, that the NHS has 5,000 Ventilator Beds. In logistical terms this is not just a bed. It is a unit made up of the staff and equipment required to provide invasive ventilation. The last resort treatment for SARS-CoV-2.
Although the majority of healthcare in Britain is provided by the NHS there are still private healthcare providers. Let's say those private hospitals have 2,500 Ventilator Beds.
Then there is the military. Getting killed and injured is quite a big part of going to war. Obviously in a war the British military can't just call the NHS for an ambulance. So they have their own healthcare system.
Let's say that the British military also has 2,500 Ventilator Beds.
What the government needs to do is take those Ventilator Beds from the military and private sector. Placing them under the control of the NHS.
In nations without an NHS they simply need to put all the Ventilator Beds under government control.
I appreciate that probably conjures images of troops with heavy machine guns storming into hospitals. However what I mean is a hospital phoning a government operations centre and telling them they require a Ventilator Bed.
In response that operations centre checks what Ventilator Beds are available and where. It then phones another hospital to tell them they are getting a patient.
That treatment is then paid for in the way treatment is normally paid for. If the patient has insurance then the insurance company pays. If not the care is paid for by the government programs for people without medical insurance. Medicare or Medicaid in the US.
Within healthcare systems there are also hidden things that can quickly become Ventilator Beds.
The obvious being equipment which has been replaced by a newer version and placed into storage. It's time to take that equipment out of storage, service it and put it back into use. Let's say there are 1,250 such potential Ventilator Beds.
Another important area is surgical suites. Operating theatres etc.
Before you undergo major surgery the Doctor will probably tell you that they are going to put you to sleep. That is a lie. What they are going to do is use a cocktail of drugs to slow your body to the point of death. They hold it there for the duration of the surgery.
To do this they require three machines. A gas and air machine to administer the drugs. A ventilator to keep you alive and a machine to monitor your vital signs.
In many modern hospitals these tasks are all done by a single, combined machine. However those machines can work simply as ventilators. Although when people are undergoing invasive ventilation they need to have their vital signs closely monitored and often need to placed under anesthetic.
Let's say there are 10,000 such surgical suites across in Britain. Across the NHS, the private sector and the military.
Obviously you need to keep some of those surgical suites open to perform emergency surgeries. COVID-19 is not going to stop people getting stabbed, getting into car accidents and experiencing complications during childbirth.
What you can quite easily do is cancel all non-essential, elective surgery. Surgeries where the patient's life is not in danger and their condition is not going to significantly worsen by delaying treatment.
One example I'm reasonably familiar with are hip replacements. These are very common elective surgeries. Many British hospitals have entire wings dedicated to doing just hip replacement surgery.
The hip joint is a ball and socket joint. There is a ball shaped bone on the top of your leg which fits into a cup shaped bone on your pelvis. The inside of the cup shaped bone is lined with cartilige. To stop the two bones rubbing together.
What often happens is that cartilige wears away. That causes the two bones to rub together limiting movement in the hip and causing pain.
Obviously your pain is not my pain. However I would be prepared to put up with even severe pain. In order to avoid being in a hospital in the middle of all this with a giant surgical wound in my side.
If the patient's condition does worsen then they become an emergency case. Meaning they are then treated in one of the emergency surgical suites.
Let's say Britain can close 75% of its surgical suites. Creating a further 7,500 Ventilator Beds.
The advantage of closing surgical suites over digging equipment out of storage is that they already employ the properly trained staff. A Surgical Nurse is already a qualified Intensive Care Nurse and then some.
The other important commodity is Oxygen.
Within most modern hospitals the oxygen supply is built into the building. Rather like how the electrical supply is built in. You get an oxygen plug socket in the wall.
Those oxygen sockets are supplied by large oxygen storage tanks. Those storage tanks are refilled by tanker trucks from an industrial oxygen plant. A facilty which has an Industrial Oxygen Concentrator.
An industrial oxygen concentrator is essentially a large air filter. Which removes everything except oxygen from the ambient air.
Obviously an industrial oxygen concentrator is a complicated to build. However once built they are relatively simple things to keep running. Compared to say a ventilator factory.
You only need a reliable electricity supply and a few spare parts. The main raw material constantly delivers itself to the site. Whether you want it to or not.
Hospitals regularly use a lot of oxygen. So will already have a good relationship with their oxygen suppliers. They need to work with those suppliers to meet an increased demand. Say going from one tanker truck delivery a week to two.
The government operations centre also needs to indentify and establish connections with all oxygen suppliers. To ensure that if one suddenly exceeds capacity, say by breaking down, demand can be met from elsewhere with the minimum disruption.
Oxygen is also supplied in bottles. Which are filled from the same industrial oxygen plants as the tanker trucks.
As I will move onto I envision oxygen therapy being given in places outside of modern hospitals. These places will need to be supplied with oxygen in bottle form.
So government and suppliers need to be prepared for a significant increase in demand for bottled oxygen. Along with the ability to prevent and overcome disruption to the supply chain.
Oxygen is also extremely flammable and extremely explosive. A bomb is actually just a chemical being oxygenised really, really quickly.
The people who make and work with oxygen everyday know this. However people who are not used to working with oxygen really need to be taught about specific fire safety. The Fire Service also needs to know exactly where they are and what they are doing.
Oxygen can also be supplied by Portable Oxygen Concentrators. A suitcase sized device that provides oxygen from the ambient air to an individual. However, as with ventilators, if you don't have these machines already it's really too late to start building them.
The British Prime Minister clearly has some World War Two fetish he needs to work through. However I don't see large numbers of ventilators suddenly rolling off the production lines.
So any extra ventilator capacity will come from existing capacity being re-purposed. This means that any extra machines will come with the staff needed to operate it. The complete Ventilator Bed unit.
Unfortunately frontline healthcare workers are particularly succeptible to all types of infections. Including 2019nCoV.
One way to think about it is like drinking alcohol. If you only have a small amount of alcohol in your body it has no effect. Within the EU the term; "Alcohol Free" actually means; "Only 0.5% alcohol."
However as you increase the amount of alcohol in your body the symptoms increase and become more obvious. Up to the point where you can actually go into Respiratory Failure and die.
It's the same with viruses like 2019nCoV. The difference is that the body immediately starts breaking down alcohol reducing the amount. Viruses start replicating within the body increasing the viral load.
Frontline healthcare workers are basically there are the bar doing shot after shot. Picking up more virus cells from each infected patient they treat.
This means their viral load can rise really rapidly. Much faster than through simple replication. Sometimes to the point where the immune system becomes outnumbered and cannot fight off the virus.
So you have to assume that all frontline healthcare workers are going to get infected with 2019nCoV. Meaning that 81% of them are going to be unavailable for about two weeks as they recover from mild illness.
That means you will need extra staff to cover those abscences. An effective way of doing this is recalling workers who have recently left the profession.
So a recently retired Doctor could take over the duties of a General Practioner. Allowing that GP to take over the hospital duties of an Emergency Department Doctor. Allowing that Emergency Department Doctor to go and work in an Intensive Care Unit.
It should also be easy to expand the workloads of existing staff.
Let's say it takes five staff members to make up a Ventilator Bed. However that does not mean that there are five people constantly standing by one bed.
Instead the same five staff will oversee five Ventilator Beds. That can be expanded to eight or even ten Ventilator Beds.
Faced with increased workloads it is also important that existing staff are protected. Both from illness and from burnout/exhaustion.
Let's assume that everyone has a shift pattern of five days on, two days. That can be changed to six days on, one day off.
However that one day off becomes mandatory. Nobody has the option of working overtime.
It may also be worth checking staff members temperatures at the begninning and end of their shifts.
Anyone who is showing a high temperature is sent home or kept away from patients. Until either signs of illness emerge or their temperature returns to normal. In order to prevent infected staff having their viral load increased by contact with infected patients.
Then there is the issue of Personal Protective Equipment (PPE).
Much of this is complete hokum. Particularly the wearing of paper facemasks.
The wearing of paper facemasks stems from a Japanese cultural practice. Japanese culture is extremely deferential. It is considered the height of rudeness to give someone else your germs. So if you are ill you are expected to wear a paper facemask.
The idea is not to protect the person who is wearing the mask. They are already ill. The objective is to be seen to be being respectful of everybody else.
It has absolutely no basis in science. It is as relevent as sipping warm water every fifteen minutes or rubbing Garlic on your forehead.
Also dressing up like Darth Vader really worries patients. At exactly the time healthcare professionals should be trying to reassure them.
So it is frankly alarming to listen to supposed healthcare professionals demand paper facemasks. It makes you wonder whether they're going to start trying to treat patients with healing crystals.
In terms of treating patients without SARS-CoV-2 normal infection control is more than sufficent. So the changing of gloves and aprons and the washing of hands with alcohol gel between each patient.
Things are different though when treating patients with SARS-CoV-2. Particularly ones requiring intensive care.
Many of these patients will be undergoing invasive ventilation. That involves sticking a plastic tube down their throat and into their lungs. Bypassing all of the body's natural protections against infection. Nose hairs for example.
Obviously the last thing you want to be doing with a patient already critically ill with a lung infection is start ramming more infectious material down into their lungs. So they need to be treated in as sterile environment as possible.
Those tubes need to be periodically cleaned of debris and moisture. They also need to be removed and sometimes replaced.
This can cause all the infected droplets in their respiratory tract to become aerosolized. Making it much easier for anyone around them to breath them in.
So when treating those patients staff need to wear surgical protective equipment. Sterile gown, gloves and haircovering. Along with a sterile respirator mask capable of stopping fine particulates. N95/FFP2 or higher.
Obviously you don't need to worry about alarming patients who are undergoing invasive ventilation. They're normally unconscious.
Once you have built capacity as much as possible you need to start using that capacity as efficently as possible.
At around 17:05 on 26/3/20 (UK date) looking at that will be my next task.
So Who's Getting Nervous?
*Coughs*
Yep.
Last Sunday (15/3/20) I sat down to write my assessment of COVID-19. The virus (2019nCov), the way the body responds to it and the illness it can cause (SARS-CoV-2).
This significantly cut into my drinking time.
So on Monday (16/3/20) I was surprised to discover I had a significantly worse hangover than usual. I also wanted to know why it had suddenly become so warm. Although there had been a 100% (5C-10C) increase in ambient temperature.
This obviously didn't stop me finishing my assessment of COVID-19. Which can be read here; https://watchitdie.blogspot.com/2020/03/far-eastern-acute-respritory-syndrome.html
On Tuesday (17/3/20) I went to the supermarket. Where the situation can be described as; "Gone a bit Lagos."
So obviously I was tired when I came back. In fact I needed to stay up drinking to around 3AM. To recover psychologically.
I woke up late on Wednesday (18/3/20). Then rapidly took the decision to go back to bed. This is a routine I got into during the war. Day off Saturday, half-days on Sunday and Wednesday.
On Thursday (19/3/20) I decided this wasn't normal. It was a pretty aggressive immuno-response.
So the groggy, almost drunken feeling in your head. Which made it really difficult to absorb, let alone process complex information.
Along with significant fatigue. Not the; "I've overdone it at the gym" fatigue. The fatigue where you can almost feel all the energy being stripped out of your body at a cellular level.
What was striking about it was how unlike anything else I'd experienced before.
It was certainly much more severe that a Common Cold. In it's nature I would say that it was closer to Influenza. However noticably much less severe than the Flu.
How can I put this delicately?
When people have the Common Cold they often claim they have the Flu. This causes them to forget that the Flu is actually a real ass-kicker of an illness. Whatever this was it was more of a kick in the balls.
At no point have I developed a cough. Persistant or otherwise. However I have been experiencing a tightness in the lungs. Which makes it clear that this immuno-response is to something respiratory in nature.
I live with my father. Who fits into the 70-79 age group.
He also checks most of the "High Risk" boxes for COVID-19. In the sense he's never been formally diagnosed with either Cardiovascular or Chronic Respritory Disease. He has though smoked tobacco for about 60 years.
He is also expericencing an aggressive immuno-response and a persistant cough. However he is harder to assess.
The flippant comment would be that he's had a persistant cough since about 1997.
Back in January I developed what I termed; "The Winter Grot." A general bacterial infection which fell far below the Common Cold.
I shook it in something like two days. He though contracted it and was more ill with it for longer. He described is as a; "Fluey Cold." Although his main health condition is hypochondria. After that he picked up another infection. As far as I can tell there hasn't been a break between that and this.
Fortunately his current symptoms are not currently significant enough for it to occur to him that he might have COVID-19. A realisation that will induce in me a condition similar to a severe ear infection.
He's certainly not as ill as he was when he had Flu in January 2019. Compared to the Bronchitis scare on 2017/18 this barely registers.
This of course all higlights the massive failure in the British Government's COVID-19 testing policy. Neither of us are eligible for tests.
I suspect that over the last couple of days the British Government has recieved requests to confirm or deny whether my father and I actually have COVID-19. They're certainly going to be getting them now.
Through nothing more than its own stupidity the British Government is no more able to answer that question than the people asking. In fact, due to it's rampant Oppositional Defiant Disorder the British Government is probably less able than the people asking.
Also if we do have COVID-19 neither of our extremely mild illnesses will be included in the official data. Given my father's age and risk factors his case is very much clinically relevant.
Excluding cases such as these will cause the official data to massively overestimate the severity of COVID-19.
This is just astonishingly bad science. The British Government seems to be actively trying to exclude all evidence which disproves its rather madcap theory.
For example I can quite easily produce a statistical study which proves COVID-19 kills 100% of the people it infects. I simply need to exclude all cases except for the inital 44.
Obviously I also have no way of knowing whether I have COVID-19 or not.
However I hope that I do. It means I am now immune to it and this coming year to 18 months of anxiety is just something for you Muggles now.
Plus it's a pretty good excuse for not doing more to help. Field testing the bugger.
Mainly though;
If this is COVID-19 then I have genuinely had worse hangovers.
Since announcing this on March 22nd (22/3/20) I've been going through the motions of obeying the remaining six days of quarantine.
Not because I consider the British Government's advice to be even remotely credible. I suspect though that a lot of people around me do believe it.
I just know from experience.
When the British Government's delusions collide with reality.
I tend to bear the brunt of that conflict.
11:55 on 26/3/20 (UK date).
Yep.
Last Sunday (15/3/20) I sat down to write my assessment of COVID-19. The virus (2019nCov), the way the body responds to it and the illness it can cause (SARS-CoV-2).
This significantly cut into my drinking time.
So on Monday (16/3/20) I was surprised to discover I had a significantly worse hangover than usual. I also wanted to know why it had suddenly become so warm. Although there had been a 100% (5C-10C) increase in ambient temperature.
This obviously didn't stop me finishing my assessment of COVID-19. Which can be read here; https://watchitdie.blogspot.com/2020/03/far-eastern-acute-respritory-syndrome.html
On Tuesday (17/3/20) I went to the supermarket. Where the situation can be described as; "Gone a bit Lagos."
So obviously I was tired when I came back. In fact I needed to stay up drinking to around 3AM. To recover psychologically.
I woke up late on Wednesday (18/3/20). Then rapidly took the decision to go back to bed. This is a routine I got into during the war. Day off Saturday, half-days on Sunday and Wednesday.
On Thursday (19/3/20) I decided this wasn't normal. It was a pretty aggressive immuno-response.
So the groggy, almost drunken feeling in your head. Which made it really difficult to absorb, let alone process complex information.
Along with significant fatigue. Not the; "I've overdone it at the gym" fatigue. The fatigue where you can almost feel all the energy being stripped out of your body at a cellular level.
What was striking about it was how unlike anything else I'd experienced before.
It was certainly much more severe that a Common Cold. In it's nature I would say that it was closer to Influenza. However noticably much less severe than the Flu.
How can I put this delicately?
When people have the Common Cold they often claim they have the Flu. This causes them to forget that the Flu is actually a real ass-kicker of an illness. Whatever this was it was more of a kick in the balls.
At no point have I developed a cough. Persistant or otherwise. However I have been experiencing a tightness in the lungs. Which makes it clear that this immuno-response is to something respiratory in nature.
I live with my father. Who fits into the 70-79 age group.
He also checks most of the "High Risk" boxes for COVID-19. In the sense he's never been formally diagnosed with either Cardiovascular or Chronic Respritory Disease. He has though smoked tobacco for about 60 years.
He is also expericencing an aggressive immuno-response and a persistant cough. However he is harder to assess.
The flippant comment would be that he's had a persistant cough since about 1997.
Back in January I developed what I termed; "The Winter Grot." A general bacterial infection which fell far below the Common Cold.
I shook it in something like two days. He though contracted it and was more ill with it for longer. He described is as a; "Fluey Cold." Although his main health condition is hypochondria. After that he picked up another infection. As far as I can tell there hasn't been a break between that and this.
Fortunately his current symptoms are not currently significant enough for it to occur to him that he might have COVID-19. A realisation that will induce in me a condition similar to a severe ear infection.
He's certainly not as ill as he was when he had Flu in January 2019. Compared to the Bronchitis scare on 2017/18 this barely registers.
This of course all higlights the massive failure in the British Government's COVID-19 testing policy. Neither of us are eligible for tests.
I suspect that over the last couple of days the British Government has recieved requests to confirm or deny whether my father and I actually have COVID-19. They're certainly going to be getting them now.
Through nothing more than its own stupidity the British Government is no more able to answer that question than the people asking. In fact, due to it's rampant Oppositional Defiant Disorder the British Government is probably less able than the people asking.
Also if we do have COVID-19 neither of our extremely mild illnesses will be included in the official data. Given my father's age and risk factors his case is very much clinically relevant.
Excluding cases such as these will cause the official data to massively overestimate the severity of COVID-19.
This is just astonishingly bad science. The British Government seems to be actively trying to exclude all evidence which disproves its rather madcap theory.
For example I can quite easily produce a statistical study which proves COVID-19 kills 100% of the people it infects. I simply need to exclude all cases except for the inital 44.
Obviously I also have no way of knowing whether I have COVID-19 or not.
However I hope that I do. It means I am now immune to it and this coming year to 18 months of anxiety is just something for you Muggles now.
Plus it's a pretty good excuse for not doing more to help. Field testing the bugger.
Mainly though;
If this is COVID-19 then I have genuinely had worse hangovers.
Since announcing this on March 22nd (22/3/20) I've been going through the motions of obeying the remaining six days of quarantine.
Not because I consider the British Government's advice to be even remotely credible. I suspect though that a lot of people around me do believe it.
I just know from experience.
When the British Government's delusions collide with reality.
I tend to bear the brunt of that conflict.
11:55 on 26/3/20 (UK date).
Monday, 16 March 2020
Far Eastern Acute Respritory Syndrome (F.E.A.R.S).
That is the name I have given to this current Coronavirus.
Primarily because it will make people on TV sound like they've got a stutter. At a time they're trying to be all serious.
One thing is for sure though. We have got to stop referring to it as; "Coronavirus." That is an almost entirely redundant name.
Coronavirus is not a single virus but a sub-group of viruses. Rather like how humans are a sub-group of mammals.
The name comes from the way that all viruses in the family appear under an electron-scanning microscope. This produces a two dimensional image of the viruses nucleus surrounded by a Laurel, Crown or Corona of protein spikes in a circle.
The Coronavirus family is actually one of the largest group of viruses in the World. It contains an almost infinite number of individual viruses.
Many Coronaviruses have absolutely no effect on humans whatsoever. At any given point there is a good chance that you are infected with a couple of Coronaviruses. However you have absolutely no idea because they have absolutely no effect on you.
One of the most widely known Coronaviruses is the Common Cold. People often ask why modern science still hasn't been able to cure the Common Cold.
The reason is that each year the Common Cold is caused by a new or "novel" Coronavirus. Rather than catching the same illness year after year people are actually catching a whole new illness each year.
In fact the Common Cold is often caused by a cocktail of several novel Coronaviruses all infecting the body at the same time. Normally with a couple of bacterial infections thrown in for good measure.
The Virus.
The specific Coronavirus people are concerned with at the moment is; "2019nCoV." That is to say the Novel (n) Coronavirus (CoV) which was discovered in 2019 (2019).
2019nCoV lives in and is spread by minute water droplets carried in people's breath and through the air. These are the things you can see when you breathe directly onto glass or a mirrored surface.
This means that the virus normally first enters the body through the respritory tract. Everything from your mouth down, through the throat, to the tiny aveloei, air sacks in your lungs.
Once inside the respritory tract the protein spikes on 2019nCoV start latching onto the cells. Effectively hijacking them to suck out the protein which provides the fuel 2019nCoV needs to reproduce. This stops those cells from working properly and doing the job they are supposed to.
At the same time the immune system reacts. Essentially going to war with 2019nCoV, dispatching antibodies to kill the virus cells.
The symptoms you typically associate with being ill - fever, muscle fatigue, that groggy feeling etc - are often actually caused by the immune system. At the celluar level this immune response causes healthy cells to become inflammed. Reducing their ability to function properly.
This battle between healthy cells, 2019nCoV and antibodies produces lots of casualties. Cells of all types which die and are shed.
That sounds dramatic. However the human body is one long, continuous process of cells dying, shedding and being replaced by new ones.
The Half-Time Show of the 2020 Super Bowl saw us all talk extensively about menstruation. This is the monthly process of the cells lining the uterus dying, shedding and being replaced with new ones.
Household dust is made up of a surprisingly large amount of human skin. Skin cells are constantly dying, shedding off the body into our carpets and being replaced by new ones.
During a viral infection though this process happens much faster and in greater numbers. Meaning that the dead cells pile up faster than they can be cleared away. This produces the sputum or phlegm that you're all familiar with from being ill.
That build up of dead cells obviously takes up space within the lungs. Space which then cannot be used for the lungs normal function.
The Illness.
Those three factors combine to reduce the lungs ability to do their main job. Drawing Oxygen into the body and expelling Carbon Dioxide.
This can cause a number of knock-on effects elsewhere in the body.
Obviously the first area to be affected is the Respritory System itself.
With the lungs not drawing in enough Oxygen the body compensates. By taking more frequent breaths. With lung capacity reduced by inflammation and sputum build up breaths also often become shallower.
That forces the muscles, diaphragm, intercostal etc,which inflate and deflate the lungs to work much harder. The difference between walking at 6kmph or running at 16kmph. Like all muscles anywhere else in the body this can cause them to become fatigued and ultimately tear.
The second area to be almost immediately affected is the Cardiovascular System. The heart which pumps blood and all the tubes that carry blood around the body.
With less Oxygen entering the blood from the lungs the heart has to start moving more blood around the body. In order to maintain the same Oxygen level. This forces the heart to work much harder. Like all muscles anywhere else in the body this can cause the heart muscle to become fatigued and ultimately tear.
Tearing one of your hamstring muscles is painful. Tearing your heart muscle is normally pretty fatal.
The haemogloblin cells which carry Oxygen within the blood function almost exactly as tiny little ballons. They get blown up with Oxygen at the lungs. Travel inflated through the bloodstream and then deflate at another organ in the body.
Reducing the amount of Oxygen reduces the pressure these cells are inflated to. That changes the pressure throughout the circulatory system. Placing unusual demands on the pipes and valves. Increasing the chances that they will weaken and tear.
If one of the capillary tubes in your brain tears then you are having a haemorrhagic stroke. Like a tear in the heart muscles that almost instantly becomes a very serious problem. One which often results in death.
If the respritory and cardiovascular systems are not able to compensate for the reduced Oxygen intake then all the vital organs of the body stop getting the Oxygen they need to function. This means that they will be less able to do their job and ultimately could die.
I should point out though that most of the body's vital organs have far more capacity than they actually need. For example most people have two kidneys. You only really need about a quarter of one.
The human body is also extremely good at prioritising. So it will stop your fingernails from growing long before it shuts down your brain.
However once the function of vital organs starts to be reduced it starts causing another range of knock-on effects on the body.
For example the kidneys and liver primarily clean toxins out of the blood. As they become less able to do that the blood starts becoming clogged up with toxins. Increasing things like dehydration. Depriving cells already short on Oxygen of the fluid which is also vital to their function.
This all increases the risk of Sepsis.
Sepsis is somewhat like the immune system going into a mad panic. Rather than attacking viruses and toxins it just starts randomly attacking everything. Killing off healthy cells in vital organs, further weakening them.
It also often sees the immune system burn out and switch off. Leaving all the viruses and toxins to go about their business unchallenged.
Together these knock-on effects of infection of the respritory tract are known as; "Acute Respritory Syndrome (ARS)." Or; "Severe Acute Respritory System (SARS)." Depending on how severe the symptoms become.
The specific SARS caused by 2019nCoV is; "SARS-CoV-2." As in; Severe Acute Respritory Syndrome (SARS) caused by Coronavirus (CoV) - Variant 2 (2). Some of you may remember the 2002 outbreak of SARS-CoV-1. Which is known commonly as simply; "SARS."
Treatment.
The symptoms of SARS-CoV-2 obviously sound serious and frightening. However there is a vast range of very simple things which can be done to control and mitigate them while the body fights the infection. This is known as supportive treatment.
At the most simple the air which we typically breathe is not made up of 100% Oxygen. People can quite easily be provided with pure Oxygen. Normally through a little tube sitting just below the nostrils. This increases the amount of Oxygen in each breath. Reducing the amount of work the lungs need to do.
If that doesn't work it is quite easy to provide someone with Oxygen under pressure. Normally though a facemask. This forces pure Oxygen into the lungs. Further increasing the amount of Oxygen in each breath. Reducing the amount of work the lungs need to do.
If that doesn't work the patient can be hooked up to a ventilator. This forces air/Oxygen into the lungs and sucks Carbon Dioxide out. This takes much of the workload off the lungs and the muscles which inflate and deflate them.
If that doesn't work then the respritory system can be bypassed almost entirely. By inserting a tube down the throat and into the lungs. The other end of that tube is connected to a ventilator which forces Oxygen into the lungs and sucks Carbon Dioxide out.
If one of the tubes carrying blood bursts. Then a surgeon can go in and seal it back up again. Or insert another tube which bypasses the tear.
If the kidneys stop working. Then the patient can be hooked up to a dialysis machine which will clean the toxins from the blood.
If the immune system goes haywire and starts attacking everything. Then drugs can be administered to calm it down.
Some of you may remember the Jai McMath case from the US in 2013. Others can use search engines.
So-called "Lazarus" cases such as that show that it's no longer really a question of whether medical professionals can do all these things to keep people alive. It's really more of a question of whether ethically they should in cases where the patient has no chance of recovery.
That is how good the medical profession has become at this sort of thing. Since something like the 1918 Spanish Flu pandemic.
Testing.
The distinction between the virus (2019nCoV) and the illness (SARS-CoV-2) brings me onto the issue of testing. I know that particularly in the US this has become a very political issue of great concern to many people.
However in clinical terms, looking after patients, testing is almost completely irrelevant.
For example if you've tested positive for the virus bu't don't have any of the SARS symptoms. Then essentially you've won. This thing everyone's so worried about has attacked you and had absolutely no effect.
Your biggest worry now is your government calling on you. To go out and start licking random strangers. In order to spread your antibodies far and wide.
Likewise if you are experiencing SARS symptoms but haven't tested positive for the virus that really doesn't matter. Rather than treating the virus medical professionals treat the SARS symptoms.
The way those SARS symptoms are treated are exactly the same regardless of what is causing them.
The way your treatment progresses will be based on the progression of the symptoms. Measured by a host of other tests. Primarily on lung function and the amount of Oxygen within the blood.
Where testing is vitally important is in research and surveillance. How the virus behaves in the human body and how it behaves in the population generally.
To give you an idea why this area is so important 2019nCoV initially had a 100% mortality rate. It killed everyone it infected.
In the sense that we only started looking for it because 44 people had died. We needed to explain why.
From those 44 the Chinese quickly identified the virus and developed a test for it. Although nucleic acid tests are pretty standard these days.
This allowed researchers to start collecting much more data about 2019nCoV. Giving a much broader and, thankfully reassuring, picture of what it is and what it does.
On February 17th (17/2/20) a study of that data was published. By lead author Yanping Zhang. Although it only looked at 44,672 laboratory confirmed cases this is the largest and really only clinical study into 2019nCoV which exists at the moment.
It showed that rather than dying 81% of those infected showed only mild symptoms. The groggy feeling, fatigue and slight cough that you're all familar with from being ill.
A further 14% of those infected experienced severe symptoms. Which I'll agree sounds severe. It's even got the word; "Severe" in there.
However what are considered severe symptoms in the study are not actually that severe.
A few years ago I accidentally made and exposed myself to Chlorine Gas. This caused me to experience laboured, shallow breathing. An erratic heartrate and, I assume, a drop in Oxygen levels in my blood.
It also caused coughing. A lot of coughing. To the point that the coughing caused hiccups. Trying to hiccup and cough at the same time is certainly an experience.
If those symptoms had been caused by 2019nCoV rather than Chlorine Gas, and my own stupidity, then I would be classed as severely ill.
However I really wasn't severely ill. I didn't require any medical treatment. It was just a matter of waiting a couple of days while my body neutralised the Chlorine.
Those particular symptoms do cause an interesting bio-feedback loop though.
When your brain panics it tells the lungs to start taking shallow, laboured breaths. When your lungs start taking shallow, laboured breaths for another reason it convinces your brain that it should be panicking. So it does and starts telling your lungs to start taking shallow, laboured breaths. Trapping you in a vicious cycle.
In my experience I've found it's important to remember that is just panic. Panic doesn't kill people. It just causes them to make bad decisions.
I suspect though that my plan to start forcibly drown-proofing the general population might be rejected by the ethics board.
Of the 44,672 patients in the Chinese study 4.7% epxerienced critical symptoms. These are very serious. Things like Respritory Failure, Sepsis and multiple Organ Failure.
However of the 2,087 patients who became critically ill only 49% died. The other 51% survived those serious symptoms.
Risk Factors.
There is an old saying in medicine that statistics mean nothing to the individual.
So despite the indications from the Chinese study it doesn't mean that for every 100 infected people 81 will have only mild symptoms and 3 will definitely die.
There are other risk factors which determine how 2019nCoV will affect you.
The main one these seems to be Age.
Rather like your car the longer you've had your body and the more you've used it the more likely it is the parts will wear out and break. So while the study shows infection peaking in the 40-49 age range mortality increases with age as infection rates fall away.
The study also shows Cardiovascular Disease to be a main risk factor.
Of the 875 patients with both 2019nCoV and Cardiovascular Disease 10.5% (92) died. I think we can also add to that group the 6% (161 of 2,683) of patients who died suffering from both 2019nCoV and Hypertension.
There are a host of things that can cause Hypertension (High Blood Pressure). Stress, a high salt diet, kidney disease. However Cardiovascular Disease is one of the main causes of Hypertension.
That Cardiovascular Disease and Hypertension are significant risk factors for SARS-CoV-2 is hardly surprising. It's well known that any form of SARS puts considerable extra pressure on the Cardiovascular system. If it is already weak to begin with it is going to be less able to withstand that extra pressure.
Likewise it's not surprising that Chronic Respritory Disease is also a major risk factor.
Of the 511 patients with both 2019nCoV and Chronic Respritory Disease 32 (6.3% died). We know SARS affects the respritory system. An already weakened respritory system is going to be less able to cope.
The picture with another major risk factor identified - Diabetes - is less clear. The health complications caused by Diabetes is a vast topic. However looming large amongst them is Cardiovascular Disease.
So I think it is reasonable to assume that of the 1,102 patients with both Diabetes and 2019nCoV were actually suffering from undiagnosed Cardiovascular Disease. Something which is probably true of the 80 (7.3%) who died.
Likewise the final major risk factor identified - Cancer - is another extremely broad topic. Possibly referring to almost every area of the human body.
Given that this is a respritory disease I think we can assume that someone suffering from Lung Cancer is at much greater risk. Compared to someone suffering from something such as Breast Cancer.
Also cancer treatment is extremely aggressive. It relies on using toxic chemicals or radiation to kill off the body's cells. The hope being that it kills the cancer cells before it kills all the other cells and the patient.
So I think it is reasonable to assume that someone who is undergoing treatment for Breast Cancer is at a higher risk. Compared to someone who is in remission from Breast Cancer.
If you have been diagnosed with any of those conditions then you will already be under the care of a Doctor. I strongly recommend you discuss it with your Doctor.
They will be far more knowledgeable about the specifics or your condition and significantly more qualified than I am.
Excluding age without those added risk factors the study shows the mortality rate for 2019nCoV infection dropping to just 0.9%.
There is also good reason to suspect that the Chinese study may paint a slightly more pessimistic picture than average.
Firstly China is a Communist country. However it does not have a socialised healthcare system. Instead relying on private health insurance. Although it has increased signficantly since the 2002 SARS-CoV-1 outbreak China is still very far away from having universal healthcare coverage.
Also where it is available China is still very much a developing country in terms of healthcare. With standards of care being significantly lower than in developed nations such as the US or Europe.
In the US or Europe a Doctor is just that. A person who holds a PhD in medical science. That means they've spent three years obtaining a Batchelor of Science degree. A further year obtaining a Master of Science degree. Then a further one to two years obtaining a PhD. All before undergoing clinical training.
In China Doctors often only hold the Batchelor's degree.
That is in the urban areas. In more rural areas China still uses what are known as; "Barefoot Doctors." Essentially people with little or no medical training who go around diagnosing and treating patients.
In China the designated First Aider at your workplace qualifies as a Doctor. They may even be over-qualified by Chinese standards.
Herd Immunity.
What other nations, particulary ones with signficant outbreaks, need to do now is widespread testing. In order to collect data and publish their own studies similar to the Chinese one. Allowing us to compare the results. Increasing our knowledge and understanding.
I think these future studies should pay particularly attention to people who are asymptomatic. That is to say who are infected with 2019nCoV but don't experience any symptoms. This is an important group that will be entirely missed if people with symptoms are the only ones being tested.
I have heard it said that as many as 35% of infected people are asymptomatic.
However I have no idea as to the source of that statistic. Let alone the validity of the methodology at which it was arrived.
So I am not prepared to recite that as though it is fact.
It is though something which is consistent with what we know about the behaviour of other Coronaviruses. Also from the speed with which 2019nCoV is spreading it is clear that there are infected people wandering about with no idea that they are infected. After all if you're not experiencing symptoms why would you assume you are infected?
I think particular attention should also be paid to whether the human body develops immunity to 2019nCoV. Along with how long that immunity last for.
What happens with most other viruses is that the body stores, almost, blueprints of the antibodies needed to defeat it. So the next time the virus enters the body the right antibodies are immediately produced and the virus is defeated before it can gain a foothold.
Typically those antibody blueprints are stored for life.
I have heard some ancedotale evidence from China that this might not be the case with 2019nCoV. There have been stories of people who have recovered from the virus becoming reinfected.
However there is strong reason to believe those reports are either inaccurate or not telling the complete story.
The second most important job the lungs perform is expelling waste from the body. When you burn fat and lose weight it actually leaves the body through the lungs.
So if some virus cells have travelled to other parts of a persons body it may take some time for them to exit through the lungs. Where they would be picked up in a throat swab test.
Also virus can lay dormant within the lungs for a very long time. Back in January 2019 I suffered Influenza. I swear it took until around November 2019 for all the crap to finally leave my lungs. If I'd undergone a throat swab then I probably would have tested positive for Flu.
Then of course there are some people who are just a bit odd. What is true of the entire rest of the human race is simply not true for them. For example there are actually an extremely tiny minority of people who are born with a natural immunity to the Human Immunodeficiency Virus (HIV). Obviously you do not develop immunity to a virus which destroys the immune system
If it is true that humans develop a lifelong immunity to 2019nCoV and that 35% of infected people do not experience symptoms it completely changes how we respond to the virus.
Right now what everybody is focused on is stopping people from getting infected. Or at least slowing down the rate at which people get infected.
If a large proportion of people experience no symptoms and then become immune we need to be doing the complete opposite. Actively trying to get as many people infected as quickly as possible.
If 87% of the population become immune after experiencing either no or just mild symptoms then what's known as herd immunity will quickly eradicate 2019nCoV. With only 13% of the population left to infect the virus quickly runs out of hosts and dies.
This is how vaccination programs work. People are infected with small amounts of an inert virus. Not enough to cause symptoms but enough for the immune system to draw up and store antibody blueprints.
Once enough people have been vaccinated there is nowhere for the virus to survive.
Even as recently as forty years ago Polio used to kill and maim hundreds of thousands of people each year. Now, thanks to herd immunity, it simply doesn't exist in the World anymore. With a handful of exceptions.
Obviously though you would want real, hard data that many people don't experience symptoms and that a lifelong immunity to 2019nCoV is created before adopting that new strategy.
If either part of that calculation are even slightly wrong the results could be utterly catastrophic.
Potentially you could be talking about 2019nCoV infecting and reinfecting people until absolutely everybody is dead.
That though would be highly unusual.
18:15 on 16/3/20 (UK date).
Primarily because it will make people on TV sound like they've got a stutter. At a time they're trying to be all serious.
One thing is for sure though. We have got to stop referring to it as; "Coronavirus." That is an almost entirely redundant name.
Coronavirus is not a single virus but a sub-group of viruses. Rather like how humans are a sub-group of mammals.
The name comes from the way that all viruses in the family appear under an electron-scanning microscope. This produces a two dimensional image of the viruses nucleus surrounded by a Laurel, Crown or Corona of protein spikes in a circle.
The Coronavirus family is actually one of the largest group of viruses in the World. It contains an almost infinite number of individual viruses.
Many Coronaviruses have absolutely no effect on humans whatsoever. At any given point there is a good chance that you are infected with a couple of Coronaviruses. However you have absolutely no idea because they have absolutely no effect on you.
One of the most widely known Coronaviruses is the Common Cold. People often ask why modern science still hasn't been able to cure the Common Cold.
The reason is that each year the Common Cold is caused by a new or "novel" Coronavirus. Rather than catching the same illness year after year people are actually catching a whole new illness each year.
In fact the Common Cold is often caused by a cocktail of several novel Coronaviruses all infecting the body at the same time. Normally with a couple of bacterial infections thrown in for good measure.
The Virus.
The specific Coronavirus people are concerned with at the moment is; "2019nCoV." That is to say the Novel (n) Coronavirus (CoV) which was discovered in 2019 (2019).
2019nCoV lives in and is spread by minute water droplets carried in people's breath and through the air. These are the things you can see when you breathe directly onto glass or a mirrored surface.
This means that the virus normally first enters the body through the respritory tract. Everything from your mouth down, through the throat, to the tiny aveloei, air sacks in your lungs.
Once inside the respritory tract the protein spikes on 2019nCoV start latching onto the cells. Effectively hijacking them to suck out the protein which provides the fuel 2019nCoV needs to reproduce. This stops those cells from working properly and doing the job they are supposed to.
At the same time the immune system reacts. Essentially going to war with 2019nCoV, dispatching antibodies to kill the virus cells.
The symptoms you typically associate with being ill - fever, muscle fatigue, that groggy feeling etc - are often actually caused by the immune system. At the celluar level this immune response causes healthy cells to become inflammed. Reducing their ability to function properly.
This battle between healthy cells, 2019nCoV and antibodies produces lots of casualties. Cells of all types which die and are shed.
That sounds dramatic. However the human body is one long, continuous process of cells dying, shedding and being replaced by new ones.
The Half-Time Show of the 2020 Super Bowl saw us all talk extensively about menstruation. This is the monthly process of the cells lining the uterus dying, shedding and being replaced with new ones.
Household dust is made up of a surprisingly large amount of human skin. Skin cells are constantly dying, shedding off the body into our carpets and being replaced by new ones.
During a viral infection though this process happens much faster and in greater numbers. Meaning that the dead cells pile up faster than they can be cleared away. This produces the sputum or phlegm that you're all familiar with from being ill.
That build up of dead cells obviously takes up space within the lungs. Space which then cannot be used for the lungs normal function.
The Illness.
Those three factors combine to reduce the lungs ability to do their main job. Drawing Oxygen into the body and expelling Carbon Dioxide.
This can cause a number of knock-on effects elsewhere in the body.
Obviously the first area to be affected is the Respritory System itself.
With the lungs not drawing in enough Oxygen the body compensates. By taking more frequent breaths. With lung capacity reduced by inflammation and sputum build up breaths also often become shallower.
That forces the muscles, diaphragm, intercostal etc,which inflate and deflate the lungs to work much harder. The difference between walking at 6kmph or running at 16kmph. Like all muscles anywhere else in the body this can cause them to become fatigued and ultimately tear.
The second area to be almost immediately affected is the Cardiovascular System. The heart which pumps blood and all the tubes that carry blood around the body.
With less Oxygen entering the blood from the lungs the heart has to start moving more blood around the body. In order to maintain the same Oxygen level. This forces the heart to work much harder. Like all muscles anywhere else in the body this can cause the heart muscle to become fatigued and ultimately tear.
Tearing one of your hamstring muscles is painful. Tearing your heart muscle is normally pretty fatal.
The haemogloblin cells which carry Oxygen within the blood function almost exactly as tiny little ballons. They get blown up with Oxygen at the lungs. Travel inflated through the bloodstream and then deflate at another organ in the body.
Reducing the amount of Oxygen reduces the pressure these cells are inflated to. That changes the pressure throughout the circulatory system. Placing unusual demands on the pipes and valves. Increasing the chances that they will weaken and tear.
If one of the capillary tubes in your brain tears then you are having a haemorrhagic stroke. Like a tear in the heart muscles that almost instantly becomes a very serious problem. One which often results in death.
If the respritory and cardiovascular systems are not able to compensate for the reduced Oxygen intake then all the vital organs of the body stop getting the Oxygen they need to function. This means that they will be less able to do their job and ultimately could die.
I should point out though that most of the body's vital organs have far more capacity than they actually need. For example most people have two kidneys. You only really need about a quarter of one.
The human body is also extremely good at prioritising. So it will stop your fingernails from growing long before it shuts down your brain.
However once the function of vital organs starts to be reduced it starts causing another range of knock-on effects on the body.
For example the kidneys and liver primarily clean toxins out of the blood. As they become less able to do that the blood starts becoming clogged up with toxins. Increasing things like dehydration. Depriving cells already short on Oxygen of the fluid which is also vital to their function.
This all increases the risk of Sepsis.
Sepsis is somewhat like the immune system going into a mad panic. Rather than attacking viruses and toxins it just starts randomly attacking everything. Killing off healthy cells in vital organs, further weakening them.
It also often sees the immune system burn out and switch off. Leaving all the viruses and toxins to go about their business unchallenged.
Together these knock-on effects of infection of the respritory tract are known as; "Acute Respritory Syndrome (ARS)." Or; "Severe Acute Respritory System (SARS)." Depending on how severe the symptoms become.
The specific SARS caused by 2019nCoV is; "SARS-CoV-2." As in; Severe Acute Respritory Syndrome (SARS) caused by Coronavirus (CoV) - Variant 2 (2). Some of you may remember the 2002 outbreak of SARS-CoV-1. Which is known commonly as simply; "SARS."
Treatment.
The symptoms of SARS-CoV-2 obviously sound serious and frightening. However there is a vast range of very simple things which can be done to control and mitigate them while the body fights the infection. This is known as supportive treatment.
At the most simple the air which we typically breathe is not made up of 100% Oxygen. People can quite easily be provided with pure Oxygen. Normally through a little tube sitting just below the nostrils. This increases the amount of Oxygen in each breath. Reducing the amount of work the lungs need to do.
If that doesn't work it is quite easy to provide someone with Oxygen under pressure. Normally though a facemask. This forces pure Oxygen into the lungs. Further increasing the amount of Oxygen in each breath. Reducing the amount of work the lungs need to do.
If that doesn't work the patient can be hooked up to a ventilator. This forces air/Oxygen into the lungs and sucks Carbon Dioxide out. This takes much of the workload off the lungs and the muscles which inflate and deflate them.
If that doesn't work then the respritory system can be bypassed almost entirely. By inserting a tube down the throat and into the lungs. The other end of that tube is connected to a ventilator which forces Oxygen into the lungs and sucks Carbon Dioxide out.
If one of the tubes carrying blood bursts. Then a surgeon can go in and seal it back up again. Or insert another tube which bypasses the tear.
If the kidneys stop working. Then the patient can be hooked up to a dialysis machine which will clean the toxins from the blood.
If the immune system goes haywire and starts attacking everything. Then drugs can be administered to calm it down.
Some of you may remember the Jai McMath case from the US in 2013. Others can use search engines.
So-called "Lazarus" cases such as that show that it's no longer really a question of whether medical professionals can do all these things to keep people alive. It's really more of a question of whether ethically they should in cases where the patient has no chance of recovery.
That is how good the medical profession has become at this sort of thing. Since something like the 1918 Spanish Flu pandemic.
Testing.
The distinction between the virus (2019nCoV) and the illness (SARS-CoV-2) brings me onto the issue of testing. I know that particularly in the US this has become a very political issue of great concern to many people.
However in clinical terms, looking after patients, testing is almost completely irrelevant.
For example if you've tested positive for the virus bu't don't have any of the SARS symptoms. Then essentially you've won. This thing everyone's so worried about has attacked you and had absolutely no effect.
Your biggest worry now is your government calling on you. To go out and start licking random strangers. In order to spread your antibodies far and wide.
Likewise if you are experiencing SARS symptoms but haven't tested positive for the virus that really doesn't matter. Rather than treating the virus medical professionals treat the SARS symptoms.
The way those SARS symptoms are treated are exactly the same regardless of what is causing them.
The way your treatment progresses will be based on the progression of the symptoms. Measured by a host of other tests. Primarily on lung function and the amount of Oxygen within the blood.
Where testing is vitally important is in research and surveillance. How the virus behaves in the human body and how it behaves in the population generally.
To give you an idea why this area is so important 2019nCoV initially had a 100% mortality rate. It killed everyone it infected.
In the sense that we only started looking for it because 44 people had died. We needed to explain why.
From those 44 the Chinese quickly identified the virus and developed a test for it. Although nucleic acid tests are pretty standard these days.
This allowed researchers to start collecting much more data about 2019nCoV. Giving a much broader and, thankfully reassuring, picture of what it is and what it does.
On February 17th (17/2/20) a study of that data was published. By lead author Yanping Zhang. Although it only looked at 44,672 laboratory confirmed cases this is the largest and really only clinical study into 2019nCoV which exists at the moment.
It showed that rather than dying 81% of those infected showed only mild symptoms. The groggy feeling, fatigue and slight cough that you're all familar with from being ill.
A further 14% of those infected experienced severe symptoms. Which I'll agree sounds severe. It's even got the word; "Severe" in there.
However what are considered severe symptoms in the study are not actually that severe.
A few years ago I accidentally made and exposed myself to Chlorine Gas. This caused me to experience laboured, shallow breathing. An erratic heartrate and, I assume, a drop in Oxygen levels in my blood.
It also caused coughing. A lot of coughing. To the point that the coughing caused hiccups. Trying to hiccup and cough at the same time is certainly an experience.
If those symptoms had been caused by 2019nCoV rather than Chlorine Gas, and my own stupidity, then I would be classed as severely ill.
However I really wasn't severely ill. I didn't require any medical treatment. It was just a matter of waiting a couple of days while my body neutralised the Chlorine.
Those particular symptoms do cause an interesting bio-feedback loop though.
When your brain panics it tells the lungs to start taking shallow, laboured breaths. When your lungs start taking shallow, laboured breaths for another reason it convinces your brain that it should be panicking. So it does and starts telling your lungs to start taking shallow, laboured breaths. Trapping you in a vicious cycle.
In my experience I've found it's important to remember that is just panic. Panic doesn't kill people. It just causes them to make bad decisions.
I suspect though that my plan to start forcibly drown-proofing the general population might be rejected by the ethics board.
Of the 44,672 patients in the Chinese study 4.7% epxerienced critical symptoms. These are very serious. Things like Respritory Failure, Sepsis and multiple Organ Failure.
However of the 2,087 patients who became critically ill only 49% died. The other 51% survived those serious symptoms.
Risk Factors.
There is an old saying in medicine that statistics mean nothing to the individual.
So despite the indications from the Chinese study it doesn't mean that for every 100 infected people 81 will have only mild symptoms and 3 will definitely die.
There are other risk factors which determine how 2019nCoV will affect you.
The main one these seems to be Age.
Rather like your car the longer you've had your body and the more you've used it the more likely it is the parts will wear out and break. So while the study shows infection peaking in the 40-49 age range mortality increases with age as infection rates fall away.
The study also shows Cardiovascular Disease to be a main risk factor.
Of the 875 patients with both 2019nCoV and Cardiovascular Disease 10.5% (92) died. I think we can also add to that group the 6% (161 of 2,683) of patients who died suffering from both 2019nCoV and Hypertension.
There are a host of things that can cause Hypertension (High Blood Pressure). Stress, a high salt diet, kidney disease. However Cardiovascular Disease is one of the main causes of Hypertension.
That Cardiovascular Disease and Hypertension are significant risk factors for SARS-CoV-2 is hardly surprising. It's well known that any form of SARS puts considerable extra pressure on the Cardiovascular system. If it is already weak to begin with it is going to be less able to withstand that extra pressure.
Likewise it's not surprising that Chronic Respritory Disease is also a major risk factor.
Of the 511 patients with both 2019nCoV and Chronic Respritory Disease 32 (6.3% died). We know SARS affects the respritory system. An already weakened respritory system is going to be less able to cope.
The picture with another major risk factor identified - Diabetes - is less clear. The health complications caused by Diabetes is a vast topic. However looming large amongst them is Cardiovascular Disease.
So I think it is reasonable to assume that of the 1,102 patients with both Diabetes and 2019nCoV were actually suffering from undiagnosed Cardiovascular Disease. Something which is probably true of the 80 (7.3%) who died.
Likewise the final major risk factor identified - Cancer - is another extremely broad topic. Possibly referring to almost every area of the human body.
Given that this is a respritory disease I think we can assume that someone suffering from Lung Cancer is at much greater risk. Compared to someone suffering from something such as Breast Cancer.
Also cancer treatment is extremely aggressive. It relies on using toxic chemicals or radiation to kill off the body's cells. The hope being that it kills the cancer cells before it kills all the other cells and the patient.
So I think it is reasonable to assume that someone who is undergoing treatment for Breast Cancer is at a higher risk. Compared to someone who is in remission from Breast Cancer.
If you have been diagnosed with any of those conditions then you will already be under the care of a Doctor. I strongly recommend you discuss it with your Doctor.
They will be far more knowledgeable about the specifics or your condition and significantly more qualified than I am.
Excluding age without those added risk factors the study shows the mortality rate for 2019nCoV infection dropping to just 0.9%.
There is also good reason to suspect that the Chinese study may paint a slightly more pessimistic picture than average.
Firstly China is a Communist country. However it does not have a socialised healthcare system. Instead relying on private health insurance. Although it has increased signficantly since the 2002 SARS-CoV-1 outbreak China is still very far away from having universal healthcare coverage.
Also where it is available China is still very much a developing country in terms of healthcare. With standards of care being significantly lower than in developed nations such as the US or Europe.
In the US or Europe a Doctor is just that. A person who holds a PhD in medical science. That means they've spent three years obtaining a Batchelor of Science degree. A further year obtaining a Master of Science degree. Then a further one to two years obtaining a PhD. All before undergoing clinical training.
In China Doctors often only hold the Batchelor's degree.
That is in the urban areas. In more rural areas China still uses what are known as; "Barefoot Doctors." Essentially people with little or no medical training who go around diagnosing and treating patients.
In China the designated First Aider at your workplace qualifies as a Doctor. They may even be over-qualified by Chinese standards.
Herd Immunity.
What other nations, particulary ones with signficant outbreaks, need to do now is widespread testing. In order to collect data and publish their own studies similar to the Chinese one. Allowing us to compare the results. Increasing our knowledge and understanding.
I think these future studies should pay particularly attention to people who are asymptomatic. That is to say who are infected with 2019nCoV but don't experience any symptoms. This is an important group that will be entirely missed if people with symptoms are the only ones being tested.
I have heard it said that as many as 35% of infected people are asymptomatic.
However I have no idea as to the source of that statistic. Let alone the validity of the methodology at which it was arrived.
So I am not prepared to recite that as though it is fact.
It is though something which is consistent with what we know about the behaviour of other Coronaviruses. Also from the speed with which 2019nCoV is spreading it is clear that there are infected people wandering about with no idea that they are infected. After all if you're not experiencing symptoms why would you assume you are infected?
I think particular attention should also be paid to whether the human body develops immunity to 2019nCoV. Along with how long that immunity last for.
What happens with most other viruses is that the body stores, almost, blueprints of the antibodies needed to defeat it. So the next time the virus enters the body the right antibodies are immediately produced and the virus is defeated before it can gain a foothold.
Typically those antibody blueprints are stored for life.
I have heard some ancedotale evidence from China that this might not be the case with 2019nCoV. There have been stories of people who have recovered from the virus becoming reinfected.
However there is strong reason to believe those reports are either inaccurate or not telling the complete story.
The second most important job the lungs perform is expelling waste from the body. When you burn fat and lose weight it actually leaves the body through the lungs.
So if some virus cells have travelled to other parts of a persons body it may take some time for them to exit through the lungs. Where they would be picked up in a throat swab test.
Also virus can lay dormant within the lungs for a very long time. Back in January 2019 I suffered Influenza. I swear it took until around November 2019 for all the crap to finally leave my lungs. If I'd undergone a throat swab then I probably would have tested positive for Flu.
Then of course there are some people who are just a bit odd. What is true of the entire rest of the human race is simply not true for them. For example there are actually an extremely tiny minority of people who are born with a natural immunity to the Human Immunodeficiency Virus (HIV). Obviously you do not develop immunity to a virus which destroys the immune system
If it is true that humans develop a lifelong immunity to 2019nCoV and that 35% of infected people do not experience symptoms it completely changes how we respond to the virus.
Right now what everybody is focused on is stopping people from getting infected. Or at least slowing down the rate at which people get infected.
If a large proportion of people experience no symptoms and then become immune we need to be doing the complete opposite. Actively trying to get as many people infected as quickly as possible.
If 87% of the population become immune after experiencing either no or just mild symptoms then what's known as herd immunity will quickly eradicate 2019nCoV. With only 13% of the population left to infect the virus quickly runs out of hosts and dies.
This is how vaccination programs work. People are infected with small amounts of an inert virus. Not enough to cause symptoms but enough for the immune system to draw up and store antibody blueprints.
Once enough people have been vaccinated there is nowhere for the virus to survive.
Even as recently as forty years ago Polio used to kill and maim hundreds of thousands of people each year. Now, thanks to herd immunity, it simply doesn't exist in the World anymore. With a handful of exceptions.
Obviously though you would want real, hard data that many people don't experience symptoms and that a lifelong immunity to 2019nCoV is created before adopting that new strategy.
If either part of that calculation are even slightly wrong the results could be utterly catastrophic.
Potentially you could be talking about 2019nCoV infecting and reinfecting people until absolutely everybody is dead.
That though would be highly unusual.
18:15 on 16/3/20 (UK date).
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