Covid-19 and purity spirals

[DreadPirateLuna]

Covid-19 is a very serious illness which threatens our most vulnerable and risks overwhelming the NHS. We should all do what we can to flatten the curve and save lives. People whose behaviour risks lives (e.g. urban residents traveling out to holiday homes in rural communities) should face criticism and sanctions.

However, I can't help feeling that some of the outrage at some behaviours is less about reducing the spread and more about getting caught in a "purity spiral".

Take all the outrage about people in parks. Fresh air and sunshine is good for physical and mental health, it improves the immune system which is particularly important during an epidemic! Many urban residents have no other source of open space except the local park. The ability to get outside can be lifesaving for victims of DV. Risks of contracting disease are very low if you keep your distance from others outside your household.

Yet I've seen photos of walkers and family groups in parks, keeping far away from others, but accused of selfishness and killing the elderly and disrespecting the NHS. Parks in London have been closed, meaning more congestion of other areas and residents confined to homes, which is damaging for reasons outlined above.

And it's usually (though not exclusively) women and esp mothers who get blamed. Those selfish Karens and their broods.

A more sensible solution would be to allow restricted access to the parks. Maybe allow only locals in nearby flats without gardens. But it seems we're not doing sensible these days.

www.washingtonpost.com/business/what-you-need-to-know-about-the-coronavirus-pandemic/2020/04/09/ecea0d2e-7a90-11ea-a311-adb1344719a9_story.html

Recent research (reported in a few places) suggesting the r0 might be a lot higher than originally thought, possibly 2-3 times the previous base estimate

this is the original report, not gone through it all yet

Thanks JusthadAThought, I knew I'd seen commentary about this!

My son was off work in February - for a number of weeks, with a high temperature and difficulty in breathing - as a number of others i his workplace had been too. He was diagnosed as having some kind of unspecified virus. I suspect now that many people had contracted coronavirus before it became a widely acknowledged issue.

If the case, it also suggests that my whole family have also been exposed, since he lives at home with us, and none of us has really suffered anything other than the usual, annual cold like symptoms - and maybe a few headaches.

Sounds to me like the test to see whether or not you've already had the virus will be the most significant and useful, going forward - in terms of resuming some degree of normal life.

That ‘Canadian specialist’ is no more of a specialist than exists in every hospital in the UK - every hospital will have a head of critical care. He also does not understand the NHS if he is comparing treatment in the UK with the USA which is hugely more interventionist. As for shutting down the economy to produce ventilators - hardly, very few companies can do this and their usual products are not being sold at the moment. Nor is he in the correct specialism to comment upon lockdown - as it says, he is a critical care specialist not an epidemiologist or a communicable disease specialist.

Once they have a reliable one then it would useful to get random sample testing done to try and get a better understanding of the true level of infection in the population - probably giving everyone in the sample both antigen and antibody tests

That is how Dr Thomas Voshaar, a lung specialist who runs a clinic in the town of Heinsberg in North Rhine-Westphalia sees it. In an interview with the Frankfurter Allegmeine, he speaks of how he has treated 29 patients without suffering a single death so far.

It says in the article though that he treats the patients “occasionally” after CT scanning them. Does that mean that most of the time they are well enough to need no intervention at all?

If those 29 patients had the option of “occasional” treatment then they probably didn’t really need breathing support as a baseline. Is his clinic a general hospital or an intensive care? If the former they not even be admitted in a busy U.K. hospital at the moment.

It’s hard to know the relevance of this without knowing what his equivalent specialty is in the U.K. If he’s a respiratory physician he’d be working on a medical ward, not in ICU and the cohort would be different. If he’s a physician rather than an intensive care specialist he’s just describing what the usual treatment course will be for many people.

I found the paper I was thinking of. The current “best practice” guidelines for critically ill patients (not ones well enough to need nothing at all as in the German clinic) are for early intubation.

Close monitoring for worsening of respiratory status and early intubation if worsening occurs is recommended (best practice statement).

jamanetwork.com/journals/jama/fullarticle/2763879

I've heard an American ITU consultant talking about ventilation and his opinion was that many hospitals weren't ventilating correctly. They were trying to keep oxygen saturation up to near normal levels but doing so required ventilator pressures to be very high. His view was that drs should accept sats being lower than normal (obviously not too low) but that meant that pressures in the lungs could be kept lower, reducing permanent damage to the lungs. In his view, that's why patients were better off with earlier standard oxygen therapy or CPAP because ventilation was actually, in many cases, damaging lungs and causing death.

Now, this was just his opinion, he wasn't presenting research just sharing his experience so far but it's food for thought. Also interesting when you view it alongside German data which seems to show they have a much lower case fatality rate than we do and they have much better treatment in the early stages than we do with home oxygen treatment and daily visits by health care staff so that admission to hospital can be done as soon as it is needed.

I'm hearing so many reports now of patients calling 111 and even 999 three or four times and being refused help because oxygen saturation isnt in the 80s, which is shockingly low. In one case that I heard, a nurse called four times and was seen by paramedics once. All told him he had to stay at home. He died at home. Another, a local man phoned four times. He went into hospital once, got sent home. Went back the next day and died.

None of the "admitted as a precaution, admitted to ITU as a precaution" that a certain politician seems to have benefited from.

Once they have a reliable one then it would useful to get random sample testing done to try and get a better understanding of the true level of infection in the population - probably giving everyone in the sample both antigen and antibody tests

They've done this. 800 random samples being tested for antibodies at Porton Down

I very much doubt the NHS is over ventilating. Remember of course that we have less ventilators than the big private hospitals in America (and are less likely to sue for them not throwing every treatment at the patient) so I expect the threshold to ventilate someone here will be higher.

I don’t understand how patients phoning 111 are being refused help ” being refused help because oxygen saturation isnt in the 80s” How do they know?

Because paramedics are coming out, testing sats and then refusing to take them in, with sats in the low 90s and because 111 are refusing even to send an ambulance unless the patient is cyanotic ( which means sats in the 80s usually, or lower) or until they can't speak.

As for over ventilation, I'm not sure what you mean. Do you mean we aren't ventilating too many people? Maybe we aren't, but maybe the ones that we are are much sicker when they are eventually ventilated and had they received earlier oxygen therapy they wouldn't have needed a ventilator.

My comment about the American doctor is about the settings of the ventilator. That the drs are making mistakes and in doing so are irreparably damaging the lungs and meaning that the gaseous exchange function cannot happen. If what he believes is true, then that has massive implications for the treatment of this. That lower pressure ventilation, even if that means oxygen sats aren't in the high 90s for a time, is preferable.

This is such a new disease and drs are feeling their way through. I just hope that lots of good quality research is happening, and that results are available and shared quickly so that best practice guidelines are published as soon as possible.

The guidelines for critical care medics from that JAMA consensus paper wasn’t just created by Americans either (in spite of being published by JAMA).

It was authored by 36 experts from 12 countries and supported by the European Society of Intensive Care Medicine and the Society of Critical Care Medicine, with the latter a group of critical care specialists from many countries.

If what he believes is true, then that has massive implications for the treatment of this

Then he needs to raise it with his peers, bang out a quick observational study and be transparent about his outcomes. Not look for his 15 minutes of fame with Joe Public.

nolongersurprised

Those guidelines are very interesting and do indeed back up the American Dr that I quoted in regards ventilator pressures.

Interestingly they also highly recommended oxygen therapy when sats are 90% or lower which is clearly not happening in the UK

Then he needs to raise it with his peers, bang out a quick observational study and be transparent about his outcomes. Not look for his 15 minutes of fame with Joe Public.

As above, the study concurs with his findings so not sure why you are being quite so aggressive really.

As above, the study concurs with his findings so not sure why you are being quite so aggressive really.

The study says that higher PEEP is required though. It’s not clear from your post whether he was talking about PEEP or tidal volume, just referring to “pressures” isn’t helpful.

There does seem to be some very contradictory info coming out re vent use which is really unhelpful for the public as it will reduce their trust in receiving the right healthcare.

I hadn't seen that re Porton Down - I thought they were still trying to evaluate the antibody tests. I'd hope they're doing both tests though given it's likely to take several weeks to show antibodies (and for at least some of that you'd still be testing positive)

His view was to keep tidal volume as low and then to increase PEEP ( with certain parameters) but he ran through many different adjustments depending on results. His view was that many drs were increasing tidal volume in an attempt to improve oxygenation but this was actually causing damage to the lungs and that it was better to accept a lower oxygen level.

I didn't realise that I was presenting a clinical paper and assumed talking about tidal volumes and PEEP in s non clinical setting probably would not mean much to many people.

He was also talking about titrating it to arterial blood gases too and so the ventilator settings were very dependent on those readings.

I hadn't seen that re Porton Down - I thought they were still trying to evaluate the antibody tests. I'd hope they're doing both tests though given it's likely to take several weeks to show antibodies (and for at least some of that you'd still be testing positive)

They already have a lab antibody test because they've tested in a town in Germany and another in Italy. I think the test they are trying to develop is a bedside antibody test. That's the one causing problems.

I don't know the full details of the Porton Down study other than its 800 random samples to determine the prevalence in the community.

He was also talking about titrating it to arterial blood gases too and so the ventilator settings were very dependent on those readings.

This is standard practice, everywhere. It’s what ICUs do. Sounds like he wanted his 15 minutes of fame.

This is standard practice, everywhere. It’s what ICUs do. Sounds like he wanted his 15 minutes of fame.

Oh I give up. Yes, I know. I was making the point that he wasn't just saying "tidal volume low, PEEP high". He was giving parameters and adjustments that he recommends based on specific values. I am trying to summarise what he said, not giving an in depth report. But, whatever.

This is sobering reading for anyone advocating a rush out of lockdown

m.huffingtonpost.co.uk/entry/coronavirus-nightingale-hospital-ventilator-covid_uk_5e9061b3c5b6319d8db64376?guccounter=1&guce_referrer=aHR0cHM6Ly93d3cudGhlZ3VhcmRpYW4uY29tL3VrLW5ld3MvbGl2ZS8yMDIwL2Fwci8xMy9jb3JvbmF2aXJ1cy11ay1saXZlLW5ld3MtcHJhaXNlLW5ocy1udXJzZXMtcHJpbWUtbWluaXN0ZXItYm9yaXMtam9obnNvbi1sYXRlc3QtdXBkYXRlcw&guce_referrer_sig=AQAAANRFAaoDO-ZvKglrFVCpywRh3rvNChBvg_kkMnYHHdym6VY2u-almp_EFyag2kvlDftw9SpivnY6KDCZKc-DYsn2sGNXgB_W7bvESpLcxARDzDzbIWWKh230b3PyVNhbnp6CdgkUGnseM_4wcC8Ex4gDzyFi0f60E0KZf0FqMUm7

It's certainly very much needed; the level of discrepancy in the possible cases is a huge problem.

The r0 could be significantly higher than first thought - which in turn means the current r0 is probably higher than estimated since it was basically a scaled down version of the original, but also that the number infected (currently or historically) is probably much higher.

The proportion of people who are totally asymptomatic is being reported within a massive range (I've seen 15-70% I think!)

The proportion with minor symptoms which are being missed - either not even suspected as covid but as a cold/hayfever etc, or which are suspected but not tested (everyone I know who has likely had it is in this category!)

The deaths which are being missed (community/care homes)

All of this means the death rates and intervention rates could be out by a very significant amount - in the UK the reported death rate could be anything from accurate (unlikely) to about 50x too high (we can hope).

In a way it would be a good thing if it transpired many more have had it than thought.

Recent research (reported in a few places) suggesting the r0 might be a lot higher than originally thought, possibly 2-3 times the previous base estimate

Which is both good and bad, presumably? It means that there’s probably higher baseline immunity in places with community spread (good) but containment is much less likely, if possible, once it’s taken hold.

Going by the German study though only 15% of the population in a hard hit town have had it. Bearing in mind 60 - 70% is needed for herd immunity I don't think infection rate is high amongst the population.

If only 15% have had it in an area that was badly hit then it stands to reason in a less affected area the rate will be much lower.

In the UK for example, maybe we'll see rates of 15% in London but under 10% in other parts of the country. Chris Whitty estimated single digits in the press conference the other day didn't he?

I don't see these figures as reassuring at all because it seems like there will still be huge numbers of people vulnerable not catching it when lockdown is lifted, so how will they avoid overwhelming the NHS again and again?