Difficult decisions and thorny issues lie ahead

I did not think when I was booked on this that a whole new compendium of “hot topics” was going be written by a virus.

Our new list includes testing, mask wearing, rationing of ventilators, protecting the NHS and other workers, payments to those unable to support themselves financially and the many topics unique to our current situation.

What is the difference between a bacteria and a virus?

A bacteria is more self-contained. It is a complete cell able to thrive if it has the right nutrition and temperature. It is like having a camper come into your house with a tent and all their gear. They put the tent in whatever room they prefer, cook for themselves using your food but their own equipment. They leave their rubbish and waste around the house when suits them. The waste may be harmless or it may damage the carpet, walls, drains and other essential fixtures or structures in the house and make you sick.

A virus is a fragment of genetic material that needs to break into and use the materials in a living cell to survive and replicate. It is more like a lodger who arrives with barely a loin cloth to their name! They come in and make themselves “at home” wherever suits them. They use all your stuff, expect you to cook for them, wash for them and in fact do all the things you do for yourself and family. Behind your back their identical twin arrives and takes over another room and does the same thing. If nothing intervenes another “identical twin” like a clone, appears and you lose the use of another room. Every room they use they trash.

Antibodies are created by our bodies to get rid of infecting agents. They are like the head of the house arriving and creating boundaries for the camper/lodger in preparation for eviction/disposal. Now that the head of the house knows what the camper/lodger looks like, the next time they appear and try to come in, they get rid of them. This is immunity.

A vaccine is like giving the head of the house advanced notice of what the camper/lodger looks like so they can stop them entering in the first place. The correct mask, hand washing, cough care, social distancing and isolation are akin to an electric fence keep the camper/lodger off your property in the first place.

So what is testing all about?

There are two types of testing.

a) A swab test taken from the mouth and nose of a person who is a suspected case is used to confirm that the patient has the coronavirus at the time of testing. At the start of the pandemic this test was only being used on patients admitted to a hospital ward (unless you are the heir to the throne or the prime minister!). It has since been used to identify NHS workers who are suspected of being infected.

b) The second test is aimed at checking whether the individual has been infected previously and may now have some protection or immunity from the coronavirus. Those of us who may have had the infection with minor symptoms can’t be sure without this test that the symptoms were not in fact just the common cold. That test at the time of writing this article is not yet available to health workers or the wider public. When it is available, it may be of reassurance that some protection has developed after their infection. They can still spread it from one surface to another by poor hand washing so still need to exercise care.

Mask wearing

It is difficult to get clear and consistent advice on mask wearing. We have seen the bizarre scenario where Donald Trump passes on the “voluntary” advice from his experts but finishes by saying he won’t be following the advice in the Oval Office. Some simple principles and common-sense may be of use.

1. Those who are working closely with infected patients are fitted with masks designed to filter out virus sized particles and they also should have full PPE (personal protective equipment).

2. Masks that are not air tight around the perimeter will not give full protection but may be of some value in stopping the wearer from sending out droplets from their mouth and nose towards others. In other words wearing a mask like this may give others some protection from you rather than giving protection to you. It is reason enough to wear one but remember touching the mask contaminates your hands and social distancing still needs to be done.

Access to hospital services

Coronavirus has brought to the fore concern that access to care may be restricted and that those who are elderly or disabled will be disadvantaged if it is rationed. In recent weeks one GP practice in Wales apologised for the way it communicated with vulnerable patients around this issue. Some of you as individuals or families may have had to discuss DNR directives (do not resuscitate). These are a voluntary directive designed to establish the hopes an individual might have about how they wish to be cared for in the event of an illness or event occurring which is likely to end their life even with attempts at resuscitation. Used wisely it reassures clinical staff present that they are acting in accordance with patients wishes. and allowing the patient to die peacefully without prolonging the dying process with medical interventions. It is not about not caring for the patient. It rather is about sensible symptom management and accepting that the patient is coming to an end of their natural life and should be allowed to go with dignity and respect rather than be treated like a technical challenge to be “managed” to the end.

We know that elderly patients who contract the coronavirus have a reduced chance of survival even with aggressive medical interventions. In many situations it may be more humane to accept that the dying process needs to be managed with respect and care rather than attempting futile aggressive medical treatments in vain. It is for this reason that some residents in nursing homes have continued to be nursed in that facility rather than be subjected to a transfer to hospital when it is not likely to help.

End of life care in the nursing home is not only nursing care it includes full medical care to control symptoms as would be used in a hospital setting. The care can be more personalised and attentive in the nursing home. It has the advantage of being done by nurses familiar to the patient and family with no need to be moved from ward to ward. This is not a new concept peculiar to the current situation but what may be new is the concern that if enough ventilators are not available for all who would benefit from them, some sort of priority ranking will be used to make choices.

To avoid this scenario we need to reduce the number of people catching the virus by following the guidance on social isolation, social distancing, hand washing and cough management. We also need to increase the access to appropriate medical equipment and expertise.

I believe that my colleagues will strive to do what is the right thing for each patient they encounter just as we rely on you to continue to do the right thing in your sphere of activity.

“Faith, hope and love, and the greatest is love”

We can get beyond the present difficulties. Many in our community have a strong sense of calling and desire to work sacrificially for the common good both in health care and in providing for our daily needs.

Thank you for doing your bit and continuing to do so.