Dr. Tom Kirschen from King's College Hospital ICU, London - Life in a COVID World - Part 3

Dr. Tom Kirschen is my son-in-law's "best mate" working in a London ICU. This is his experience and a video message attached.

“As the number of cases began to climb in the UK, colleagues and I became ever more anxious. With the anticipation of things to come and an expectation of the worst, as portrayed in the media from Italy, we imagined corridors lined with patients waiting for critical care treatment, with others being denied treatment on account of their age or medical history. Thankfully, it has been more manageable than expected and we have consistently been able to meet demand.

As expected, we have certainly seen higher mortality rates than we’re accustomed to, which can be difficult to deal with and there is undoubtedly an emotional fatigue associated with this. The extent of this fatigue will largely be dictated by duration, however, and not the specific mortality of coronavirus. In fact, having predicted a 50% death rate among the intensive care cohort, many hospitals are achieving less than 30%, with this being the most critically ill group of affected people. Nonetheless, it is quite conceivable that there will remain critically ill patients with coronavirus for many months, or even a few years, to come.

For those patients requiring intensive care, it typically takes two to three weeks of supported ventilation, deep sedation and at times support of other organs, particularly the kidneys and cardiovascular system, before being well enough to move to a normal ward. This can also be delayed by extensive episodes of delirium which is not unusual following a period of sedation. Similarly, the physiological impact of being ventilated and sedated for that length of time – not even breathing for oneself – results in a profound loss of muscle mass, which can significantly affect progress in breathing independently, talking and mobilizing.

As for the future – anyone who offers a clear picture is speculating. We simply cannot reliably predict the trajectory this will take. Clinically, the patterns of pathophysiology are nothing short of bizarre, with patients showing great variation in their illness, quite unlike many of the typical illnesses seen in intensive care. For example, rather than seeing a steady decline in blood pressure over an hour say, it may fall quite suddenly, inducing an immediately life-threatening situation in a patient felt to be stable minutes earlier. Some patients exhibit interference with their pulmonary circulation making the balance of gases in the blood unstable. Blood clots in the deep veins and lungs are common, but not universal, and the incidence of renal failure remains high but largely unpredictable. So from a clinical perspective, there is no well-established pattern to follow and I feel the epidemiology of this is likely to be the same. As such, I can only imagine a gradual, ever-reviewed process is required with a hesitancy to return to normal life probably a safer option than haste.

            On a personal note, I have to admit I have no idea what lockdown ‘normal’ is for the majority of the nation. I still get up, go to work, albeit on an adjusted shift pattern, get into my scrubs and PPE and onto the unit. I don’t go to work feeling especially endangered, though without doubt we all know there is a risk and are are constantly vigilant of where the threat is coming from. I know I have coronavirus on me, and I’m meticulous about removing my PPE systematically, washing my hands and face before I head home from a shift. With this said, having it on me can’t hurt me, or my partner, I just need to prevent it from getting into us! Meanwhile, as always, my A&E nurse fiancé is much braver than I, barely giving the situation a second thought – perhaps thanks to some terrifying experiences in Sierra Leone responding to the Ebola crisis – but it keeps me both balanced and motivated.

As for now, I am feeling cautiously optimistic. The number of patients being discharged is increasing, while the in-flow of new patients is decreasing. There remains anxiety over the prospect of a post-lockdown resurgence, and the question of whether we see a further peak in the autumn as global travel is likely to be re-established and the weather cools. Nonetheless, I am confident the NHS will be better prepared and better experienced to respond, perhaps even alongside many of the usual services that we hope to see reinstated over the coming weeks and months. In the meantime, we need to encourage each other to continue with the special measures in place as, despite my cautious optimism, we are not out of the woods just yet. We will be though, and I look forward to joining you in celebration when the day comes. Stay safe.”

Video message from Dr Tom Kirschen

What the Numbers Really Mean: Life in a COVID World - Part 2

By the numbers and for the record...
3,170,000 - cases worldwide
1,028,065 - cases in the US
   224,708 - deaths worldwide
     59,443 - deaths in the US
            47 - days without other human contact
            42 - nights outside singing God Bless America at 7 pm

That's the reality and this is what's on my mind...

Today marks one million cases of COVID–19 and almost 60,000 deaths in the US, an increase of 900,000 cases and 55,000 deaths in less than a month.  

Most Americans watch the daily fluctuations up and – from time to time, albeit rarely – down as if they are a function of a ghastly viral algorithm. COVID-19 keeps moving on. It does not care that its victims were individual human beings, souls who have lived and shared life, touched others, quietly influenced generations. That memory is left for us, the living, who are destined to comfort those who have been afflicted or mourn for those who have been lost. We, who have survived and feel victimized as we remember the faces of those we love, living or forever gone. 

Not everyone, however, has been personally touched – yet. That makes it easier to let the abstract nature of numbers be the perceived truth of this pandemic. We cannot do that. Let me give life to the statistics…

One million cases represents the infection of every person living in the states of:

Alaska,

Delaware,

Montana,

North Dakota, 

South Dakota, 

Rhode Island, 

Vermont, and 

the District of Columbia.

Sixty thousand deaths equals the extinction of every person living in these state capitals:

Cheyenne, Wyoming

Charleston, West Virginia

Harrisburg, Pennsylvania

Olympia, Washington

Jefferson City, Missouri

Annapolis, Maryland

Juneau, Alaska

Dover, Delaware

Helena, Montana

Carson City, Nevada

Concord, New Hampshire

Bismarck, North Dakota

Pierre, South Dakota

Montpelier, Vermont

Augusta, Maine

Frankfort, Kentucky

Understanding these numbers as people is how we connect to the heartbreak that awaits our nation’s future. Take a deep breath. We all have more strength than we realize. Find it.

Into the Night - Life in a COVID World - Part 1

By the numbers and for the record...
2,500,000 - cases worldwide
   809,000 - cases in the US
   171,810 - deaths worldwide
     44,881 - deaths in the US
           41 - days without other human contact
           36 - nights outside singing God Bless America at 7 pm

That's the reality and this is what's on my mind...

       Six months ago, we rescued a Cavalier King Charles Spaniel bearing a distinctly Disneyesque name. Caveys, however, are so anciently British that they are the only dog permitted full access to Parliament, a law which remains to this day. As a result, my devoutly Anglophile wife, resolved to find a moniker reflecting both that heritage and the epitome of contemporary UK-ness. Thus, the pup became Dame Maggie Smith or Maggie to her nearest and dearest. Given COVID-19, that means us - alone. 

       At 11:00 pm, Maggie and I go out. Same pattern every night: lightweight coat,  iPhone and flashlight in left pocket, green doggy bags and house keys in right pocket, and - of late - a surgical face mask.  Over the last six weeks I have noticed a change. The increased quiet was to be expected.  But everything seems darker. Houses are unlit. Cars rarely drive up our street and few travel on the main boulevard outside our neighborhood. Fewer still pass on the nearby 405. And the air seems dense, as if the lack of light has become a physical barrier slowing all movement.

       When I first noted this, I defaulted to what was left of my rabbinic brain and remembered my "favorite" Egyptian plague -  number nine, darkness - not that I actually enjoyed any of them. Rather,  what I appreciated were the literary commentaries of the medieval rabbis answering a Johnny Carson-like question - How dark was it?  One of these Sages explained that the darkness doubled and redoubled upon itself. Another compared it to being inside of a mine.  The great traveler Ibn Ezra, said he had actually seen it happen many times while on the Atlantic Ocean, obviously referring to fog banks he had experienced.  Beyond just the description of the plague, these rabbinic riffs on the biblical story made the darkness substantial.  But according to the text, Jewish homes were still blessed with light meaning that although the distanced external reader of the story is generally immersed in the rushing narrative on the way to freedom, those "living" in the narrative display little emotional content. We do not know how the darkness made the enslaved Israelites feel.

        I know how the darkness makes me feel. When I walk with my dog, we do not dawdle. We share purpose. Maggie has to take care of her business. I have to take care of her outside so she can take care of us inside. It is not that we run, it is just that we have an intent to get done, move on, feel safe again.  Truth to tell, for the first time I feel discomforted and frightened.  I am hardly heroic, but my senses are definitely heightened over those 2250 steps. An overhead streetlamp that goes out makes me want to move faster, wishing that my beloved dog knew how to use a toilet.  Once a convoy of four police cruisers flew by with quiet intensity, their blue and red lights spinning wildly, making me think I heard the world whisper, “danger ahead” and I pulled back into the darkness rather than leaning forward wondering where they were going. Worse still, a bike rider who recently glided silently along our path startled me so much that I admit there is now a box cutter in my right pocket. I have no idea what I would do with it, but it seems to be important if not comforting. When I let my guard down, I realize that it is not the ninth plague of darkness that I actually think about as we walk, but the 10th – the passing through of the Angel of Death.

        Searching broadly through my rabbinic memory, I find myself unaware of disturbing  descriptions or explanations of that fatal last evening in Egypt in spite of the glosses that movies serve up to us, the visual images of that night gifted by deMille and DreamWorks. So it is that I wonder what kind of pain exists within those dark windows of houses I pass. How much sadness focuses their conversations? Do they carry their smart phones around with them anxiously awaiting phone calls? While I am willing to be entirely wrong about these reflections, it is fair to say that my usual optimistic self has already passed over cynicism, in and out of pessimism, landing squarely on realism when I ask myself these questions. 

They are not theoretical. 

Within a 2-mile radius of our home are the neighborhoods of Inglewood, Culver City, Westchester and Playa Vista. According to the last LA Times report of COVID-19 cases, in our little area, 251 individuals have been stricken.  Extrapolating the statewide number of cases and deaths that means that there have been nine deaths nearby. On my nightly walk, it is that truth that I feel.

  And I carry my own truth as well, for night after night, when I plunge into the darkness thinking about that terrible last plague and hoping I walk under a symbolic portal like those doors in Egypt painted with blood to ward off the Angel of Death, I remember that I am the firstborn son of a firstborn son of a firstborn son.