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).