In this weekly round-up, Richard Lehman looks at a personal selection of articles of relevance to clinicians dealing with covid-19
Florence Nightingale disliked hospitals. They created bad conditions for the sick: “Apprehension, uncertainty, waiting, expectation, fear of surprise, do a patient more harm than any exertion. Remember he is face to face with his enemy all the time.” She regarded hospitals as “an intermediate form of life”, a poor substitute for home nursing. After her work at Scutari hospital, she had a chronic illness, possibly brucellosis, and stayed at home for 40 years, mostly spent designing better hospitals. Her self-isolation wasn’t like ours: she was fed with a constant supply of viceroys, flowers, geese, architects, statisticians, fresh cheese, generals and Prime Ministers. When Nightingale did a thing, she did it thoroughly, and social distancing was no exception. PM Gladstone once turned up on urgent business, but was turned away because he did not have an appointment. She regularly refused to see members of the royal family as they would waste her time. How good it would be to have her thoughts about the new hospitals that bear her name. Over the door of each should be written: “For the sick it is important to have the best” FN.
If you knew how unreasonably sick people suffer from reasonable causes of distress, you would take more pains about all these things. FN
Between the asymptomatic cases and those in intensive care, there are hundreds of thousands suffering with covid-19. They have a constant painful cough, which prevents sleep. They cannot breathe properly and are intensely anxious. They lie totally exhausted, with myalgia and fever. Many are cut off from human comfort. You rarely read about these things in the academic literature which spills out by the ton every day. There is some NICE guidance giving generalised advice: but is there a forum of GP tips for covid-19 symptom relief that has escaped my notice?
End-of-life care at home
Let whoever is in charge keep this simple question in her head (not, how can I always do this right thing myself, but) how can I provide for this right thing to be always done? FN
How can we arrange for the right thing to be always done for people with covid-19 dying at home? A retired GP schoolfriend, Lyn Jenkins, posed this question two weeks ago and I have been unable to think of much else since. It could happen to me. Worse, it could happen to my wife. But that is not the point: it is happening, and will happen over the next few weeks, to many thousands of people. And the first part of the Nightingale quotation points to a gap: “Let whoever is in charge…” – could she or he please step forward?
When people with severe covid-19 decline to go to hospital, or are refused ICU on “robust” ethical grounds, what promise of care and comfort is to be made to them, and who will deliver it? I fear that instead of the central ethical overseer that Emanuel and others suggest for the USA there will be a variety of people deciding on the rules of admission to hospitals in different localities in the UK, and a variety of overstretched primary care services to pick up the pieces. Everyone will be distressed and exhausted. Palliative care physicians are producing excellent guidance. They and GPs are producing excellent consultation aids. Many localities are rushing to set up home services. But who is there to provide for these right things to be always done?
I could pretend to be referring to Un ballo in Maschera (1859) by Guiseppe Verdi, but I am actually referring to the official “wisdom” that has prevailed in England about wearing masks during the covid-19 pandemic. Official advice opined a while ago that they were unhelpful in reducing spread, and that people who bought them would be depriving front-line NHS staff of these scarce appurtenances. But when someone close to me went for immunotherapy at a cancer unit last week, nobody was wearing a mask. She even brought some with her to share around, but when told it “wasn’t policy yet” she felt it would be impolite to wear one herself. So, wearing a covering over your mouth to prevent you spraying viruses on other extremely high risk people wasn’t policy (though it is now), and as a public health measure it’s supposed to lack proof. A rapid review by some of the mighty ones of EBM confirms that there is no RCT evidence: and long may there be none. It would be an absurd question to try and answer with an RCT.
Perhaps in retaliation for these reviews, the GMC has restored my licence to practise medicine. Even before that, I spent a lot of my would-be sleeping time thinking of how GPs could function during an epidemic of serious respiratory disease, when they can’t even examine the patient. Most of the pneumonia is likely to be viral, either due to SARS-CoV-2 or a combination, mostly with influenza viruses, present in about a fifth of patients. But what about bacteria? Ordinary or atypical bacterial pneumonia will still occur sporadically, independent of covid-19, and it seems incredible that bacteria won’t take advantage of lungs congested with covid-19: yet it is very hard to find anything in the literature about bacterial co-infection. Meanwhile, from a safe distance, NICE advises the avoidance of antibiotics except in “severe” pneumonia or if the patient is at special risk. The usual arguments about antibiotic stewardship appear. But it’s a poor steward who keeps the armoury locked when the enemy stands ringed around the moat.
Students at the front
In many British medical schools, over half of the clinical students have volunteered for some kind of front-line hospital role in the care of covid-19 patients. For many, it will be an experience they remember for the rest of their lives. It was similar for some students in 1945, such as a group at St Thomas’s (as it was spelt in those days) in Godalming (as it was located in those days), who were due to be flown to Holland to treat victims of the Nazi starvation policy. In fact they ended up in Bergen-Belsen, watching hundreds of inmates die in the days and weeks after the liberation of the camp. Alex Paton kept a diary of this experience, but when I knew him as a friend 50 years later, he scorned the idea that it had scarred him for life. He was born energetic, life-loving, and resilient. Not all of us are so lucky, and I do wonder what support we should put in place for students who risk lasting trauma from their voluntary service.
In time of war, rumours fly. Don’t get too worried about them ventilators, mate, they’re going over to CPAP any day now. We’ll know more this week from Italy. No pal, it’s not Italy, it’s Spain and it won’t be through till next week. Someone (I think Bishal Gayawali) has named this covid-related phenomenon “hearsay-based medicine”, or HBM. There is another kind of HBM that deals in bold assertions such as “Health staff are particularly likely to die from covid-19 due to viral load”. Everybody nods solemnly, while their thoughts turn anxiously to personal snot exposure. But the Oxford covid-19 Evidence Service Team cannot find any support for this concept in relation to coronaviruses. “If readers are confused by the mass of contradictory information, so are we. What can be desumed by this post is that no one really knows what is going on…” Desumed. Oxford, how I love you.
Keep leukin for covid treatments
We know structure of the causative agent of covid-19 down to the last squiggle, but we don’t know why it invades many people without causing the least symptom, while it is so lethal for an unlucky few. In these it triggers an agonal cascade of inflammatory events involving interleukin 6, amongst other bad molecules. Now there happen to be lots of IL-6 experts sitting at home and lots of interleukin-6 blocking agents sitting expensively on pharmacy shelves. Time for the experts to write papers about IL-6 and covid, and time too for these drugs to leave the shelves in trials for people with life-threatening illness. There are already preliminary reports on agents like siltuximab or tocilizumab. We’ll keep leukin.
In the Yorkshire of my youth, ferrets were widely kept as part of the food chain. It’s not that ferret-based delicacies often appeared on the menu, rather that these lithe rodents were used to drive rabbits from their burrows into coal sacks, and thence to the ovens of the hungry classes. Two world wars (with food rationing) had led to much ferret-keeping, and to a special class of ferret jokes involving trousers. The importance of tying string round the trouser ankles was taught to many an ashen-faced son of the dales. But today ferrets pose a new peril: they can transmit SARS-coronavirus-2. Avoid stroking strange ferrets. And lads, always remember the string, if you ever want to become a father.
Covid-19 is teaching us that the sort of collaborations which normally require years of build-up and industry funding can be set up in days with the right amount of drive, common purpose and public funding. We’re learning to place the adjective “nimble” in places we would never previously have dreamt of: before the initials NIHR, for example. The suite of covid-19 interventional trials now being organised through it is a model for the world: RECOVERY, PRINCIPLE and REMAP-CAP. As these trials come online, they will teach us a lot about tipping points, when the evidence matures from a presumption of nil effect to a presumption of benefit or harm, and clinical practice needs to change accordingly. And all this will be supported by new models of real-time evidence synthesis such as covid-evidence. Will the slow model of academic-industrial knowledge production ever recover? I hope not.
Richard Lehman is professor of the Shared Understanding of Medicine at the University of Birmingham.
Competing interests: None declared
Articles from MedRxiv get special prominence in these reviews. MedRxiv is a completely free site for the rapid exchange of knowledge which was launched last year as a joint initiative by The BMJ, Cold Spring Harbor Laboratory and the Yale University Open Data Access project. All MedRxiv articles carry the caveat: This article is a preprint and has not been certified by peer review. It reports new medical research that has yet to be evaluated and so should not be used to guide clinical practice. This review is intended as a quick source of information in a readable form. While every effort has been made to be accurate, the opinions are those of the author and should not be relied on without reading the full articles cited in the context of current NHS guidance.