Covid-19: Intensive care and caring intensely

When we get through covid-19, and rest assured we will, these Intensive Care Unit (ICU) doctors, will march lockstep with others and argue for more beds, staff, and kit. We are not casting blame, but hospitals were full-to-the-brim well before covid-19. Minimal redundancy means decreased ability to surge. We need a grown-up chat about what we now understand to be our healthcare, especially given the likelihood of future viral waves. Let us garner support for that project by offering insights from the ICU covid-19 here-and-now. 

As we say when delivering unwanted prognoses, we hope to be wrong. Unfortunately, we suspect no single pill nor potion will swoop in and save the covid-day. Remdesevir (originally developed for Ebola) showed promise but attempts to obtain it via compassionate release are often soul-crushingly unsuccessful (“the patient is too sick”), just as they were for non-ICU colleagues (“patient not sick enough”). Alternatively, it’s a case of “cometh the virus, cometh the vaccine”, but again don’t hold your breath: not the best metaphor, we grant you. Over 70 vaccines are under development, with many targeting the virus’s spike protein: those crowns (coronas) from which it got its deceptively benign name. Before you throw up your mask in celebration, no vaccine is expected in 2020, even though the peddle has been pushed to the metal.

Unfortunately, viruses are as fascinating as they are awful. They are so sneaky that they highjack our cellular machinery to their nefarious ends. They are so submicroscopic that even bacteria wouldn’t see them if those bacteria magically developed the gift of sight. They are so minimalist—they contain nothing more than genetic material (the plasmid) plus a protective coat (a capsid) plus enzymes (proteases)—that microbiologists still debate whether they are “alive.” This all means it’s a tad difficult to make them “dead.” Just as Dawkins’ argued that lifeforms are the carriers of “selfish genes,” viruses are an even more effective means of getting around.

We have grown accustomed to “I want it now, safe and cheap.” But, even 2021 seems ambitious for a bespoke vaccine, given that the process usually takes a decade. It’s uncertain work, as illustrated by our zero-for-four result against the coronaviruses that cause the common cold. Next, we face the realisation that few companies make vaccines: all hail those that do. Presumably, we will also require an (im)modest 7 billion doses: herd immunity n’all. Which segues into another awkward issue. 

We suggest we use this pre-vaccine wait for a fulsome chat with influential anti-vaxxers. Measles was declared eliminated from the US in 2000 by the World Health Organization (WHO). Fast forward to 2019 and New York City declared a public health emergency because of 100s of measles cases resulting from 1000s of unvaccinated kids. Nowhere needs a covid-vaccine more than NYC, but one year later the president ceased funding the aforementioned WHO. It’s a substantial one-two punch. 

But there’s more, dear reader. Just as there is insufficient slack in healthcare, we have hardly funded our bioscientists to the max. We now expect studies on drugs and vaccines to be fast tracked and rigorous. However, these boffins are not borne overnight, and they require specialized labs. It is not enough to hope something works. Sorry, but currently, no antiviral, antiretroviral, antimalarial or antirheumatoid should be used until specialists have studied long and hard. Indiscriminate use has already caused deaths. In other words, yes, you do have something to lose.

Instead let’s pivot to what should make a difference right now, and what we can control. Doctors often preach from the pulpit of biochemisty, pharmacology and physiology, but we expect covid-19 to be managed as much by society’s humanity, kindness, and grace. If that sounds twee coming from biomedical physicians, we would argue ‘twas ever thus. While our medical industrial complex has a mighty part to play, 20 years of “ICUing” has shown us that our “life support” (machines and tubes) needs your ‘life support’ (the ability to look after yourself and others). So, how do we leverage our best during the worst of times?

Start by accepting that those scientists providing national recommendations are decent and sensible and open to change. As such they need your support. Next, understand that the scientific method is not perfect but it’s better than conspiracy theories and partisan rhetoric. Then let’s focus on caring “intensively” about each other. Fortunately, this also means you don’t need a medical or nursing degree to help. We simply need to decide to cope, much like Canadians do during cold winters, and Brits do during wet summers. 

Too many of us have been inwardly focused (how does this affect me) rather than outward (what do others need from me). You may have tried drinking from a fire hose (of information), but found it didn’t quench your thirst (for usable knowledge or peace of mind). You may have gone through those stages of grief (denial, anger, detachment, bargaining and acceptance) at break neck speed. Regardless it took one of us (PB) weeks to accept that covid-19 should not consume every waking moment.

If we are not careful then we will burnout sooner than this pandemic. I (PB) had to be reminded by my wife to enjoy sunsets and to get my recommended daily dose of joy. This non-medical maven reminded me that most of the world’s best brains—whether medical, political, or logistical—are leaning into this fight. I suggested that the same is true of the world’s best people: parents, teachers, and volunteers. We concluded that while none of us should be complacent, nor should we lean in so far that we collapse. 

Instead of chasing every rumour or tweet, we should find ways to connect. Seriously: do it now and do it properly. It isn’t morbid to let people know what matters to you. We have had “the chat” with family many times. Our weekly zoom catch-up with mates is now the highlight of our covid-week. While we never underestimate the power of community, we are very aware of the limits of Intensive Care. Doctors and nurses deliver excellent multidisciplinary supportive care but no machine can make you (or us) stronger than baseline, and our individual (previously hidden) genetic response will impact how we fare. We don’t like it any more than you, but life is too precious to candy-coat the truth. We will commit to building an ICU fit for the fight. Others will search for magic bullets and dispel magic beans. Regardless, let’s mobilize the very best antiviral yet known: the clever brain alongside the compassionate heart. 

Peter BrindleyDepartment of Critical Care Medicine, Department of Anesthesiology and Pain Medicine, and the Dosseter Ethics Centre, University of Alberta, Edmonton, Canada. Twitter: @docpgb

Matt Morgan, honorary senior research fellow at Cardiff University, consultant in intensive care medicine, research and development lead in critical care at University Hospital of Wales, and an editor of BMJ OnExamination. Twitter: @dr_mattmorgan

Competing interests: None declared