In this weekly round-up, Richard Lehman looks at a personal selection of articles of relevance to clinicians dealing with covid-19
Do you belong to the precariat? If you’re reading this, then the answer is almost certainly no. Reviews in The BMJ have little reach among tower blocks on sink estates, refugee camps, prisons, and bedsits occupied by people once on the minimum wage and now living on nothing until their Universal Credit comes through. “Precarious” was a word invented in Shakespeare’s time to describe circumstances from which you prayed to escape (from Latin precare, to pray). Precarity is a term coined much more recently: it is used to describe the plight of people scraping by from one day to the next. These are also the people hit hardest by the consequences of covid-19. Old middle-class people like me should make a vow to San Precario (invented in Milan in 2003) that if they survive covid-19, they will remember their shielded days of relative precariousness*, and be generous to refugees and the homeless, and vote for politicians who believe in social justice.
*I will leave it to Jeff Aronson to decide whether “precariousness” and “precarity” are true synonyms.
While millions of people have acquired covid-19 over the last 5 months, and thousands are dying from it as I write, I’m finding it strangely difficult to locate good descriptions of its natural history. Systematic reviewers are familiar with the idea of “grey literature”—evidence that’s hidden away beyond the usual databases of medical journals. Covid-19 is producing a sort of “red literature” of patients and relatives recounting their own experiences, and health professionals doing the same with stray information about the sorts of patient trajectories they are seeing each hour and day. I hope someone is following social media and collating all this in real time. But what I’m not seeing is a systematic collation of physiological and biochemical data on the course of covid-19 in large groups of non-hospitalized patients, prospectively tracked: a virtual observatory of clinical findings from all parts of the world. Or even a single country.
Beware the tenth day of covid-19, when about a tenth of patients will take a sudden nose dive. Of course it isn’t quite as simple as that: add a bit of nuance to your decimal thinking. Whether on day 7,8,9 or 10 or a bit afterwards, they will get acutely ill and some may die at home or in transit or shortly after arrival in hospital. Once they reach a hospital bed, we have an abundance of data about them: not before. Hence the need for an inclusive covid-19 observatory. At the moment, we have to work back from that miscellany of ward data to work out why they got so ill so quickly at home. A wonderful new source has just appeared from Leora Horwitz and her team in New York City, describing the characteristics of 4103 hospital patients. But we still badly need lots of prospectively collected data from patients in the community, to understand the decimation* phenomenon which will send about a tenth of them to hospital.
*I will leave “decimation” to Jeff Aronson too.
The publicity of oxygen
Oxygen has had a lot of publicity over the last few days. I am not sure Margaret Thatcher would approve, but even the Daily Telegraph has devoted some space to this dangerous, but necessary, gas in severe covid-19. Readers of that newspaper will be incensed to find it measured in kilopascals and not in ounces per quart. Their article is a good deal easier to follow than the Italian paper which catalysed the debate among ICU doctors and respiratory physiologists. Some patients with severe covid can be sitting up and talking with O2 sats normally considered barely compatible with life: others show extreme respiratory distress once their sats drop much below 90%. Crude talk of two “phenotypes” will hopefully give way to more nuanced discussion as clever doctors observe the range of responses to disease and treatment: and I do wish the word “phenotype” would be locked back in the word-hoard of gene gnomes and not brought out to describe everything from baldness to egg sandwiches.
Nerds are natural self-isolators, traditionally depicted as living in basements and sporting thin appendages of facial hair (if male), or large glasses (either sex). In cartoons they always look cross, arguing at graphs on screens using bad language like meta-regression or fixed splines. The fact that nerds exist in a state of permanent disagreement is illustrated in the hundreds of contradictory modelling articles which continue to appear: they cannot even agree whether a given covid curve is flattening or rising. When they are finally released from their basements, they will no doubt hold a conference to permit assortative mating, and to see which of them was wrongest.
Emergency palliative care
Good thoughts, good words, and good deeds. These three principles of Zarathushtra apply to all parts of medicine, but especially to end-of-life care. In the terminal cascade of covid-19, all three may need to be applied quickly. Will this deteriorating patient make it to hospital? Is there time for a conversation about choices? How can I do that kindly? What can I do to relieve their distress here and now? Palliative physicians have mobilized as never before to meet these challenges: an article about emergency palliative care for covid at home has just appeared from Switzerland. In the UK, palliative care associations have produced several good communication aids, and Anna Sutherland has compiled a whole formulary of transmucosal drugs that can be used without a syringe driver. Unfortunately it does not include dexmedetomidine, an IV anxiolytic analgesic which does not produce respiratory depression and is well known to ICU doctors. A buccal form called Sileo is widely available, but unfortunately only for use in dogs who are scared of loud noises.
In some parts of England, and even more in Wales and Scotland, the NHS is regaining its original vision as a coordinated system for delivering the best care for everyone. In the covid-19 crisis, this means bringing together primary care, hospital care, and care for the dying. Now would be a good time for clinicians in these three domains to jot down all the barriers that have fallen and all the links that have been made, so that we can never return to the full horrors of the purchaser-provider divide. I also harbour a hope that it may hasten the day when palliative care is fully integrated into the NHS. For far too long its centres have had names like medieval monastic institutions and relied on middle class voluntarism.
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.