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.