If you are an HCP battling to manage MS remotely under the COVID-19 lockdown, or you have any specific problems that you need help with, please don’t hesitate to register for tomorrow’s Q&A session. The feedback we have been getting about these webinars has been amazing.
CoI: multiple
#MSCOVID19: musings from the frontline
Are we in danger of dropping the ball?
I am enjoying doing general medicine again but the majority of the patients under my care on an acute medical ward have social problems. Social problems that either got them into the hospital in the first place and/or social problems that are now preventing them from being discharged.
My brief sojourn into general medicine highlights why the social determinants of health are by far the largest determinants of health-related outcomes at a population level. Interestingly, social determinants of health, or the health gap that Michael Marmot refers to, is also playing out in the COVID-19 patients. Social deprivation not only increases your chances of getting COVID-19 but the economic fall-out of the lockdown will be felt by the poorest more than those of us who are better off.
If you have a social conscience I would urge you to read the report ‘From pandemics to poverty Hotspots of vulnerability in times of crisis’, by Vidya Diwakar from the ODI.
Another thing that strikes me is the unnecessary complications several of our non-COVID-19 patients are experiencing because of delays in their treatment. I have one patient who was meant to be treated with cyclophosphamide in mid-March for a so-called CNS vasculitis (inflammation of the blood vessels of the walls of the brain) who has recently been admitted in crisis. Several delays have occurred because of the COVID-19 epidemic. The consequences of this delay are potentially catastrophic for this patient. COVID-19 is not a reason to delay urgent medical treatments. I suspect the same thing is happening to people with MS, with potentially catastrophic consequences.
If you have highly active MS and you need aggressive control of your disease you probably need it sooner rather than later. Time is brain whether or not there is a COVID-19 pandemic. The risks of COVID-19 to individual patients who are immunosuppressed can be managed with self-isolation and shielding. In addition, I am not convinced outside of possibly acute treatment with HSCT or alemtuzumab that our immunosuppressive therapies carry much of a risk to pwMS. In fact, the more real-life data I see the more I am reassured that pwMS on licensed immunomodulatory and immunosuppressive MS therapies seem to be weathering the storm of COVID-19 rather better than expected.
The problem we have is that MS services have been halted or are been run by a skeleton staff with no capacity to treat MS actively and aggressively. I think we have been complicit in the government’s shutdown of routine services that provide important time-dependent treatment and care for patients with chronic conditions such as MS.
It is looking increasingly likely that we have over-resourced the management of COVID-19 patients at the expense of patients with other diseases. I predict that when the dust settles there will be many more deaths as a consequence of reconfiguring the NHS to deal with COVID-19 than there will be from severe COVID-19 itself. I am told that the London paramedics have seen a six-fold increase in calls for deaths at home during the lock-down compared to average. The question I ask is how many of these deaths could have been prevented if it wasn’t for the COVID-19 epidemic? Few people will die from MS, but how many pwMS will end up being more disabled because of COVID-19?
It is interesting how COVID-19 lock-down exit strategies are now dominating the news cycle. China who is relaxing its lockdown has just reported a flare-up of new cases, which is what happened in Singapore. This is the problem that now faces the UK and other countries.
We have quarantined a large number of vulnerable people including pwMS for several weeks and we now want to relax the lockdown with the risk of more infections and the potential exposure of high-risk people to the virus. Without widespread testing, contact tracing and repeated local lockdowns, relaxing the rules on social distancing is a risky exit strategy. I assume allowing the gradual spread of the virus through the general healthy population, whilst shielding the vulnerable is the covert or not so covert plan of the UK government. Eventually, this strategy will lead to sufficient herd immunity to allow the vulnerable back into society. The problem with this strategy is that it will be leaky and there will be an excess number of deaths. This shows you why governments are so edgy when asked what strategy they are pursuing. I am not sure that most have decided yet, which is why they are keeping both options open at present. What we really need is some certainty or an effective antiviral agent or a vaccine that works. The only way we are going to deliver on these is to invest in science and trust that as always scientist will innovate and get ourselves out of the mess we now find ourselves in.
I am interested to hear from you whether or not you feel the treatment of your MS is being compromised and whether or not you consider yourself vulnerable and, finally, what strategy you would like the government to adopt.
CoI: multiple
#MSCOVID19 – DMT update (2)
This week saw several bits of information appear that has led me to change my position on several DMTs in terms of their risk for pwMS during the COVID-19 pandemic.
Firstly, the verbal update by Maria Pia-Sormani on the Italian cohort of patients with MS who had COVID-19. These figures were given during the iWiMS weekly COVID-19 &MS webinar. There are now 380 cases of pwMS and COVID-19 reported in the Italian register with only 5 deaths. The mortality rates are well below that of the general population and suggest that pwMS are not at increased risk of severe COVID-19. This is good news. This data also supports the hypothesis that mild-to-moderate immunosuppression may be good and in fact, reduce the chances of pwMS getting severe COVID-19. This is not surprising as severe COVID-19 is almost certainly immune-mediated disorder. The five patients that died (see table below) tended to be older, have more advanced disease and comorbidities.
It is now clear that SARS-CoV-2 is neurotropic with the second, but first published, case of meningoencephalitis with virus detectable in the spinal fluid. This now increases the risk of natalizumab for pwMS. You don’t want to be on natalizumab if SARS-CoV-2 disseminates to the CNS. It is very important that if you are on natalizumab and get COVID-19 that you look-out for CNS symptoms. The fact that most MS centres have shifted their patients onto EID (extended interval dosing) will reduce this risk but it remains concerning. For more information on how EID reduces this risk please see my explanation on MS-Selfie.
At a personal level I have now 6 patients with MS on various DMTs who have all come through having had COVID-19 without any problems. I have asked them to register themselves on the MS register study and I will be reporting them next week.
I would urge you to watch the weekly iWiMS webinar which will keep the MS community up-to-date with what is happening in relation to COVID-19 and MS.
I therefore updated my table and have added a ranking to reflect the changing advice. Please note I have downgraded the risk associated with anti-CD20 therapies based on the emerging evidence as well. More on this later.
Moriguchi et al. A First Case of Meningitis/Encephalitis Associated With SARS-Coronavirus-2. Int J Infect Dis 2020 Apr 3 PMID: 32251791
Novel coronavirus (SARS-Coronavirus-2:SARS-CoV-2) which emerged in Wuhan, China, has spread to multiple countries rapidly. We report the first case of meningitis associated with SARS-CoV-2 who was brought in by ambulance due to a convulsion accompanied by unconsciousness. He had never been to any foreign countries. He felt generalized fatigue and fever (day 1). He saw doctors nearby twice (day2 and 5) and was prescribed Laninamivir and antipyretic agents, His family visited his home and found that he was unconsciousness and lying on the floor in his vomit. He was immediately transported to this hospital by ambulance (day 9). Under emergency transport, he had transient generalized seizures that lasted about a minute. He had obvious neck stiffness. The specific SARS-CoV-2 RNA was not detected in the nasopharyngeal swab but was detected in a CSF. Anti- HSV 1 and varicella-zoster IgM antibodies were not detected in serum samples. A brain MRI showed hyperintensity along the wall of right lateral ventricle and hyperintense signal changes in the right mesial temporal lobe and hippocampus, suggesting the possibility of SARS-CoV-2 meningitis. This case warns the physicians of patients who have CNS symptoms.
CoI: multiple
#MSCOVID19: assessing and managing relapses remotely
Can we assess MS relapses remotely?
Yes, I think we can. Most neurological assessments are based on history and examination. You definitely can take a history of new-onset neurological symptoms by telephone, or preferably using video consultation. I am currently using accuRx the most widely adopted NHS platform for remote consultations. It is remarkably easy to use and satisfaction levels are very high for both clinicians and patients. In addition, you can also do a brief or truncated neurological examination using a video link. I am beginning to ask some of my patients to complete a battery of online assessments (webEDSS, 9PHPT, T25W) and PROMS (MSIS-29) to document the impact of the relapse on their physical functioning.
Once you have documented a relapse the question arises should you treat the relapse with steroids?
At the moment I am trying to avoid steroids for relapses. Why? In general, the benefits of steroids in the treatment of relapses are quite small. They essentially speed-up the recovery by about 2 weeks. At 6-months the level of recovery from a relapse, as assessed by EDSS, is the same whether or not you have steroids. When you tell patients this they often agree not to be treated, particularly when you mention the potential side effects of high-dose steroids, i.e. avascular necrosis of the hip, steroid psychosis, diabetes, hypertension, insomnia and infections.
Despite this, some patients still prefer to be treated. This raises the question of IV (intravenous) versus oral. There have been several studies showing that there is no difference between high-dose IV or oral steroids in terms of relapse outcome. Therefore, in the current COVID-19 environment, when we are trying to avoid patients having to travel and come to the hospital, oral steroids are the prefered route. The steroids can be dispensed via your general practitioner or through our pharmacy with courier delivery if you live locally (within London or in the home counties).
Before starting steroids it is good to get some basic things done to try and de-risk the adverse events. This includes a recent blood pressure; we don’t want to prescribe high-dose steroids to someone with uncontrolled hypertension. Nowadays most people have access to some form of home BP measurement device.
If you have a history of recurrent urinary tract infections it is always advisable to have a urine dipstick done to make sure you don’t have an asymptomatic infection. Five days of steroids are sufficient to blunt your innate immune response, which has the potential to allow a bacterial urinary tract infection to become a systemic infection and to cause septicaemia. I learned a hard lesson early my MS career when I agreed for a patient to have his relapse treated by his GP without considering a UTI. The patient was admitted to ITU on day 4 of his course of oral steroids in septic shock and nearly died. A lesson to take UTIs seriously.
It is also important to make sure the relapse is not a pseudo-relapse, which are often triggered by a UTIs in patients with more advanced MS.
Not all patients have urine dipsticks at home, which is why you may have to attend your local GP practice or come to the hospital to get this done. Another solution is to purchase urine dipsticks online and do the test yourself. The latter is an example of taking control and self-managing your MS or UTI.
Please be aware in the context of a UTI the dipsticks assess two main things; (1) urine nitrite levels and (2) the presence of esterase and enzyme that is produced by white blood cells or leukocytes. Please be aware that about a third of UTIs are caused by bacteria that don’t produce nitrate reductase, the enzyme that converts nitrates to nitrite, so your urine, even if you have a UTI, maybe negative for nitrites, however, it should be positive for white cell esterase if you have a significant infection.
In summary, to diagnose a probable UTI you need white cells and possibly nitrites to be positive on the dipstick. Other abnormalities that can be found with UTIs are a raised protein and red blood cells, which are also detected on most commercial dipsticks. However, positive protein and red blood cells in the absence of the white cells and nitrites are not indicative of a UTI and can be caused by other pathologies.
If you have doubt about interpreting the dipstick you can always take a photograph of it and send it to your MS nurse, GP or neurologist for interpretation. If you have a UTI it is advisable to get your urine cultured in a laboratory and to start a course of antibiotics. The antibiotics can be changed if the culture grows a bacteria that is resistant to the antibiotic you are on. To get a culture done you need to drop-off fresh urine to your GP that needs to be sent to the laboratory within two hours. Please note you will have to collect a prescription for antibiotics from your GP. I personally like you to start your antibiotics for at least 24 hours before starting steroids.
If you are overweight or obese and have a family history of diabetes it is also worthwhile getting your blood glucose checked. We don’t want to give high-dose steroids to someone who has uncontrolled diabetes. Blood glucose is checked using a finger prick test that can be done by your GP or anyone who has a glucose home testing kit.
Will high-dose oral steroid put you at risk of COVID-19 or severe COVID-19?
I don’t know the answer to this question. However, significant immunosuppression is only considered to occur with a prolonged course of steroids, i.e. longer than 3 weeks at a dose of greater than 20mg of prednisone per day or equivalent. Therefore the level of immunosuppression with a short 5-day course of high-dose 500mg/day of methylprednisolone is relatively low. Although this is medical dogma there is good scientific evidence that high-dose steroids blunt innate immune responses, i.e. neutrophil and monocyte/macrophage responses to infection, which is why short-term steroids can cause UTIs to become systemic. The blunting of the innate immune response may be important in the early stages of COVID-19. Because of this, I am telling my patients who opt for steroid treatment to self-isolate for a period of 14 days after completing the 5-day course. The logic of this is simple; with a lack of evidence, it is better to be safe than sorry.
In addition to 500mg/day of methylprednisolone for 5-days, I also prescribe lansoprazole 30mg daily for 14 days to protect you from steroid-induced gastritis. I am aware that not all neurologists prescribe gastric protection with high-dose steroids. Steroid-induced gastritis is not an uncommon problem and the last thing you need is an upper GI bleed that needs hospitalisation.
If you have diabetes and/or hypertension it is important to monitor your blood sugars levels and blood pressure whilst you are on steroids in case your medications need to be adjusted.
The one side effect that worries me the most is steroid-induced hypomania, psychosis and depression. I have a handful of patients in my career that have had to be sectioned because of psychosis. It is important to be mindful of the mood-altering effects of steroids and if necessary seek help. I always warn partners or family members of the possibility of hypomania, psychosis and depression and that it is better to address these as soon as possible if they occur. The good news is that steroid-induced psychosis tends to respond to treatment relatively quickly.
Another side effect that is common is steroid-induced insomnia. If you have a history of this please ask for a short course of sedatives to help you sleep. The sedatives are only needed for 4 to 5 days and shouldn’t be taken for longer than this.
As you can see assessing and treating relapses remotely is possible, but on balance we should try and avoid using steroids.
If you any queries I will happy to ask them. I will also post this information to MS-Selfie, my COVID-19 and MS microsite.
COVID-19 & MS update from Australian neurologists
I received this email, which may be of value to you all.
| Latest COVID-19 information for people with MS
UPDATE FROM MS NEUROLOGISTS – 08/04/20 Dear MS Stakeholder, We hope you are keeping safe and well since our last communication. In our last COVID-19 update to you on 27/03/20 we shared a statement prepared by an independent group of Australian and New Zealand neurologists. MS Research Australia continues to work closely with these experts and would like to share an update to the advice for people with MS provided at the end of March. The statement is outlined below, with the key updates to the previous information highlighted in red for your convenience. BACKGROUND Since December 2019 following cases emerging in and around Wuhan, China most regions of the world have now experienced cases of a novel respiratory illness (COVID-19) caused by a new coronavirus which has been identified as SARS-CoV-2. The mortality of this infection amongst cases displaying symptoms and confirmed to have the virus is in the order of 1-7%. National and International measures to reduce the risk of transmission of the virus have been implemented in most jurisdictions. It is likely that these measures will slow the rate of transmission, but at this point it is unclear if further spread can be prevented and it is unclear how long the present outbreak will last. At present there is no known effective treatment for COVID-19 and there is no vaccine. Older persons and those with pre-existing medical conditions (respiratory disease, heart disease, diabetes, cancer) have a higher risk of complications from COVID-19 infection. Men may also be at a slightly increased risk. At this stage, there is no evidence that being immunosuppressed increases a person’s risk of being infected with COVID-19 or developing complications, but there is a theoretical risk of both. In Australia, we are still in a containment phase where it is hoped that the measures being implemented will limit the number of people infected and the present risk of being infected with COVID-19 remains low. The latest data indicate that the number of new cases is declining. This suggests that the present transmission prevention efforts may be working. This is result of two main factors. The first is that the population of Australia has largely followed the recommendations of social distancing and personal protection. The second is the outstanding work undertaken by our Public Health team who have successful traced the source of 80-90% of cases and implemented testing, quarantine and self-isolation as necessary. This has been an amazing achievement and goes largely unnoticed. However, we need to remain vigilant as the situation may still change. We will continue to monitor this and change our advice accordingly. HOW CAN I PROTECT MYSELF FROM GETTING COVID-19? In order to minimise the risk of being infected by COVID-19, you should follow the standard precautions advised by the Australian Government. This is the best source of advice on how to keep yourself safe and will be updated daily. WHAT IF I DEVELOP SYMPTOMS OF COVID-19 INFECTION OR HAVE A CONFIRMED DIAGNOSIS OF COVID-19 INFECTION? If you develop symptoms of COVID-19 infection or have a confirmed diagnosis of COVID-19 infection you should:
WHO SHOULD I CONTACT IF I HAVE SYMPTOMS OF COVID-19 INFECTION? If you are concerned that you are developing symptoms of COVID-19 you can:
SHOULD I COME TO MY OUTPATIENT CLINIC, INFUSION, BLOOD TEST OR MRI APPOINTMENT? If you have visited a high-risk area, have symptoms of COVID-19 infection or have had close contact with someone who has been diagnosed with COVID-19 please do not attend your outpatient, infusion, blood test or MRI appointment. Please contact your specialist clinic, MRI department, infusion centre or MS Nurse to advise of your need to cancel the appointment and make alternative arrangements. Most neurology clinics have now moved to telephone or telehealth consultations. It is important to remember that MRI scans and blood test form an important part of the monitoring of your disease activity and potential side effects of medication. In some instances, there may be adverse consequences of delaying or cancelling these investigations. Please contact your neurologist before making any changes to your planned investigations. MRI departments in hospitals and private radiology practices have implemented measures to limit the risk of infection. Some private pathology services offer a home collection service. Please contact your pathology service for details. This may require the approval of your neurologist. SHOULD I TRAVEL OVERSEAS? Current travel advice is available on the Australian Smart Traveller website, but essentially all travel has now been banned. SHOULD I HAVE THE FLU AND PNEUMONIA VACCINATIONS? It is recommended that all persons with MS and related disorders have the flu vaccination when it becomes available in April. The Pneumococcal vaccination is also recommended. WHAT IF I AM A HEALTHCARE WORKER? At present we have no evidence of an increased risk of COVID-19 infection or its complications in people with MS or related conditions, even in those on treatment. However, as indicated below there are potential, theoretical risks with some medications and it would be sensible for healthcare workers on any of these therapies to avoid work environments that would bring them into direct contact with people either known to be or likely to be infected with COVID-19. If you require any documentation to this effect, please contact your neurologist who will be happy to assist. WHAT SHOULD I DO ABOUT MY MEDICATION? If you are on a regular medication for MS or a related condition, then it is recommended that you should continue to take this medication because of the very real risk of relapse when medication is ceased. With regards to specific therapies:
Signatories Simon Broadley Michael Barnett Todd Hardy FOR THE LATEST UPDATES VISIT THE COVID-19 INFORMATION FOR PEOPLE WITH MS HUB ON OUR PARTNER ORGANISATION MS AUSTRALIA’S WEBSITE
MS Research Australia |
Does immunosuppression protect you from severe COVID-19?
The hypothesis that immunosuppression may protect you from severe COVID-19 is gaining traction. New data released on the 4th April 2020 from the UK’s Intensive Care National Audit & Research Centre suggests it may. When comparing 2249 patients admitted to ITU in the UK with severe COVID-19 the proportion of immunocompromised patients was 3.7x lower than the proportion of immunocompromised patients admitted to ITU with viral pneumonia (the comparator) between 2017 and 2019 (2.3% vs. 8.5%). This was a highly significant difference (p<0.00001).
This clearly justifies the current research strategy being tested across the planet to see if immunosuppressive therapies may improve disease outcome in patients with COVID-19.
Does this mean we can now assume that immunosuppression protects against severe COVID-19 and COVID-19-related ARDS (adult respiratory distress syndrome)? Not yet. The UK’s ITU cohort of severe COVID-19 is biased in that those patients who are deemed too frail and/or disabled may never get to ITU, which may include a disproportionate number of immunosuppressed patients. Whereas this specific bias is unlikely to apply to ITU admissions between 2017 and 2019 (viral pneumonia cohort) when there was no such pressure on resources.
Despite this caveat, this is an important tidbit of information that will allow pwMS on immunosuppression to sleep a bit easier. I sincerely hope the wider MS community will reconsider their advice about not giving MS DMTs that are if anything mildly immunosuppressive to patients with active MS. By not treating our patients we may unintentionally be increasing their chances of developing severe COVID-19. Could our guidelines be another example of the law of unintended consequences? Let’s hope the real-world data that is being collected at present will answer this question.
CoI: multiple
#MSCOVID19: who has the power and chutzpah?
If you have MS and think you are vulnerable to severe COVId-19 have you asked the obvious question? How long do I shield or self-isolate for?
The impact of Boris Johnson’s admission to ITU with severe COVID-19 on the collective mind of the UK will be substantial. I suspect pwMS who think they are vulnerable will now go into shielding mode in an attempt to never get exposed to SARS-CoV-2. Is this a feasible long-term strategy?
Yes, trying to never get infected with SARS-CoV-2 and waiting for a vaccine is one feasible option if this was in-line with the governments COVID-19 strategy. However, at the moment the government strategy is not clear. Without aggressive testing, case and contact finding and local quarantine programmes we have to assume their current strategy is still trying to flatten-the-curve and extending-the-tail of the epidemic until herd immunity does the job and the COVID-19 epidemic fizzles out. This strategy will take many many months to run its course during which vulnerable people will need to remain shielded. Shielding has social and mental-health consequences that most of us have yet to appreciate.
Active surveillance and contact tracing are what is being done in China, Korea and Singapore. The downside of the latter is that it takes hard work. Already in Singapore, we have seen a second flare, i.e. the peak appeared to come and gone, but once social distancing regulations were being lifted the epidemic flared-up again.
I think there is some disagreement between public health officials, epidemiologists and politicians which is the best approach to take. It would help if we had better data on how many of the population had already been infected with the virus, but we don’t. Current estimates on the proportion of the population who may have already been infected vary wildly. A major blow is a laboratory study from Oxford showing that the point-of-care finger-prick antibody tests to see if you have had SARS-CoV-2 don’t work very well. This means we will have to resort to the doing standard laboratory tests for antibodies on whole blood samples. This doesn’t matter; it is better to get reliable data that will allow the modellers to work-out what is best for the UK to quell this epidemic and to allow us to get back to business, which for me is treating pwMS and studying MS.
I reviewed a patient with MS in my telemedicine clinic yesterday. He has classified himself as being vulnerable, which I don’t agree with, and has put himself into shielding. He is quite disabled and hence has stopped his carers coming into his house. He is now having to battle with doing his own domestic chores, cooking his own food and doing his own on-line shopping without help. This is complicated by the fact that he is often incontinent, which creates an extra burden on personal hygiene. He has a dog that needs walking, which he is battling to do in his small back garden. His is clearly under a lot of stress. I am not convinced his position is tenable for much longer. He is just one example of how the COVID-19 epidemic is affecting individuals with MS.
This is why we need to start planning an exit strategy for pwMS. When do we start derisking patients, i.e. taking them off the vulnerable list and managing them face-2-face, encouraging them to reconnect with their families and friends, and eventually the wider community? Do we wait for herd immunity? Do we wait for a vaccine? Do we wait for a reliable antibody test and derisk/reintegrate those that are antibody positive? Do we tell our low-risk patients that it is okay to get COVID-19 because once you have had the infection you are then immune to reinfection? Or do we wait for the government to say now is the time to get back to normal? When do we start redosing alemtuzumab and other DMTs and restart our HSCT programme? When do we restart our clinical trials? Many questions and no answers.
If I was in charge of government policy I would hedge my bets and implement both strategies, i.e. (1) case and contact finding with quarantine and (2) flattening-the-peak and extending the tail of the epidemic until we have herd immunity. Once the seroprevalence data comes in; i.e. what proportion of the population has been infected asymptomatically and have early data from vaccine trials we can then definitively commit to one of the two paths based on data.
At the moment I am very frustrated; we are fighting a tactical war without a longterm strategy in place. Sadly, with Boris Johnson in ITU will there be anybody in government, with the power and chutzpah, to make a strategic decision?
#MSCOVID19: update on the outcome of cases with MS & COVID-19
We keep getting asked about if there is any data on whether or not people with MS are more likely to get COVID-19 if they do get are they more likely to get the severe disease and die from the infection?
Last week I logged into a very useful webinar organised by the iWiMS. They have now put the webinar online for you to watch.
The Italian registry reported 143 patients with MS and COVID-19 with five deaths. As you can from the table below the five patients who died from COVID-19 had more advanced or progressive MS and were all over the age of 50. Only two were on DMTs; one on rituximab and the other on dimethyl fumarate. Importantly the observation that to date only a 143 patients with MS had developed COVID-19 suggests that pwMS are not at increased risk of COVID-19. Please be aware that these figures may be biased in terms of reporting. On the webinar the Spanish, French, Australians, Germans and Americans discussed their cases as well.
The messages I took away from the webinar were reassuring and in line with my expectations. People with MS don’t seem to more susceptible to COVID-19 than the general population, nor are they more likely to get severe COVID-19 and die from complications than the general population. Similar to the general population age is an important risk factor when it comes to COVID-19 mortality in pwMS.
CoI: multiple
Live or let die – #MSCOVID19 decision-making
Although the following story is fiction a variation of it is playing out in many hospitals across the world right now.
Can you help Dubs make a decision? COVID-19 is pushing us to places we don’t want to go, but we have to prepare for the inevitable.
Dr Claire Dubois or Dubs as her friends preferred to call her was exhausted. She had been working for 14 hours with only short breaks to feed her caffeine addiction and to have a drink of water. Hunger was not a problem needed to worry about. She had just completed three death certifications in the palliative ward; cause of death ‘respiratory failure secondary COVID-19’.
Dubs had just been called to say an ITU bed had become available; fortunately, one patient had pulled through and was being stepped-down to the general ward. She was asked to go to ward 13e to do triage, that is she had to decide who was the most worthy patient to be stepped-up from the ‘COVID HOT’ ward to ITU. Two nights ago she had to perform this task twice. Dubs hated this part of her job. She had only been a consultant pulmonologist for just over two years and she had never had to make these kinds of life-and-death decisions before. To Dubs triage was a word that was meant to be used on the battlefield. Then again the prime minister had used the analogy of war to describe our fight against coronavirus; little did he know how appropriate the war analogy would become.
Sarah, the charge nurse on ward 13e, said there were three patients who had dropped their oxygen saturations in the last few hours and would almost certainly need a ventilator. Sarah had already checked for ITU beds availability in the other London COVID centres and none had a spare ventilator bed.
Patient 1: Louise was a 22-year old final year law student. She had been admitted to the hospital yesterday afternoon from a drug rehabilitation unit in Southeast London. She had been in her final year of University when her drug habit had escalated. She has started off using drugs recreationally on weekends, but over the last year, her drug habit had spiralled out of control. Her boyfriend had been the problem and had become her dealer and had gotten her hooked on oxycodone. Her parents had taken her out of University and booked her into a private drug rehabilitation centre ten weeks ago. She had been doing well. She was off all drugs, had broken up with her boyfriend and was just starting to complete some of her University assignments remotely. She was however still quite frail. Over the last two years, she had lost a lot of weight and had only weighed 43 kg when she was admitted to the rehabilitation unit. She had almost certainly picked up the coronavirus from someone in the rehab unit; she was the third inpatient to be diagnosed with COVID-19. She had become very short of breath yesterday and when she was admitted to the hospital her CT scan of the chest confirmed COVID pneumonia with greater than 50% white-out of her lungs. Louise had been coping with oxygen, but over the last 4 hours her oxygen saturations had dropped below 90% and her respiratory rate had increased to 36 breaths per minute. Without ventilation, Louise would not survive; even with ventilation, her chances of pulling through were maybe fifty-fifty.
Patient 2: Michael is a 46-year medically retired civil servant. Michael has secondary progressive multiple sclerosis and needs a walker or wheelchair to mobilise. In the last year, Michael had been admitted to hospital twice with severe urinary tract infections. During his last admission, he had had to have a suprapubic catheter inserted. Michael was not on any disease-modifying therapy but was on baclofen and clonazepam to control his spasticity and duloxetine for depression and chronic back pain. Michael had stopped working three years ago and had recently separated from his wife. Michael had a care package in place and carers came in twice a day to help him wash and get dressed in the morning and to help him in the evening. Michael could not cope with domestic chores and needed someone to come in once a week to clean his bungalow. Michael has two children a daughter of 17 studying for her A-levels and a 19-year old son studying engineering at the University of Bristol. Michael has a large friend group and would get out at least twice a week. He was an avid reader and spent a lot of time online as an active member of several Facebook groups. Michael had no idea where he picked up the virus but had been admitted to hospital two days ago by his GP who was concerned he was not coping at home. Michael had been doing very well but over the last 12 hours he had developed COVID-19 ARDS (acute respiratory distress syndrome) and his oxygen saturations had plummeted precipitously over the last two hours. It was clear that without assisted ventilation he would not survive the night.
Patient 3: Reverend Charles Ryan is 78 and semi-retired. Reverend Ryan is married to Josephine his partner of 52 years. They have three children and six grandchildren. Reverend Ryan is still an active member of his congregation and in semi-retirement has taken on a lot of charitable work. He is a governor of the local school, a trustee on a charity that supports church schools in Malawi and he teaches theology at the local college. He writes a weekly column on religious matters for the local newspaper. Reverend Ryan is still physically active walking their dog twice a day. Apart from well-controlled hypertension and mild osteoarthritis of the left hip he has no other medical problems. He almost certainly picked-up the virus from one of his congregation a week or so ago. Initially, he thought he had a common cold and on the advice of his GP was self-isolating. He had been improving but two days ago he became short of breath and had to be admitted to hospital urgently yesterday. He was diagnosed as having COVID-related pneumonia. Over the last 24 hours, his breathing had become more laboured and his blood oxygenation levels had plummeted despite oxygen therapy. It was clear that he was tiring rapidly and would need to be ventilated very soon if he was going to survive.
Dr Dubois has to make a decision on which of these three patients gets the one ITU bed. Who do you think deserves the bed? Who deserves the chance to survive?
Skilling-up for the eye of the #MSCOVID19 storm
I want to apologise to my students and colleagues for not delivering on certain teaching and academic tasks; I will get there. I have had to spend the last 48+ hours starting the process of reskilling and learning new skills for when I am redeployed onto the front-line of the NHS. Our hospital is being reconfigured as if we are preparing for war. There are red or hot floors that are for managing the COVID-19 positive patients and green floors for the COVID-19 negative patients. There are new systems being put in place to triage and manage patients depending on their predicted outcome. Several wards are being converted into ITUs or ventilator units. The Royal London Hospital is being transformed.
If you are a neurologist the following slides from Dr Ali Jawad, from the Royal College of Physicians (RCP), is a good starting point to learn about COVID-19.
In the last 48 hours, I have ploughed through a new Chinese textbook on how to diagnose and manage COVID-19 and I am reading as much as I can in relation to what needs to be done on the frontline. I am also having to reskill myself in relation to my general medical skills. I spent yesterday shadowing a college on the general medical wards at the Royal London Hospital. The experience was uplifting; I have always loved general medicine and my experience made me recall my days as a medical student and as a medical registrar. I am particularly grateful to Professor Tom Bothwell (see my obituary ‘Emulating your mentor‘) who taught and influenced me most in my early years as a medical trainee.
We are anticipating that neurologists will be redeployed to work in A&E (accident and emergency), the general medical ward or even in the new makeshift ITUs (intensive care units) that are being established in London. One thing I still don’t feel competent to do, which I used to be able to do when I was a general medical registrar 30+ years ago, are awake intubations and to manage patients on a ventilator. I recall it not being that complicated. I worked for four months on an eight-bed respiratory ICU and was responsible for managing the unit when on-call. I am sure I could relearn these skills if and when the need arises.
I am doing this post to make you aware of the seriousness of the storm or tsunami that is about to hit us and what is expected of all HCPs working in the NHS. This is underlined by the fact the NHS is constructing temporary morgues across the country and converting conference venues into mass hospitals.
The following is an excerpt of an email I was sent yesterday:
…. We have been asked to support the resourcing process for the new Nightingale Hospital based at the Excel in East London due to open this weekend. The resources we are seeking to identify are varied but include expertise in the following areas:
Staff:
Clinical care especially ICU and rehabilitation post-ICU
Educators for Teaching and training of clinical staff
I appreciate these are broad categories but the plan will be to train up around 1000 or more clinicians to run a unit for ventilated patients with around a week to move from where we are now to a functioning unit…..
These are just a few of the reasons why pwMS in the UK need to understand that the management of MS and many other chronic diseases are being put on the backburner. In these extraordinary times, you will also need to upskill yourselves in the self-management of MS; you may have to take responsibility for some of your own care.
I am so impressed with the professionalism and the ‘can-do’ attitude of my NHS colleagues. Prior to this crisis morale in the NHS seemed to be very low, but yesterday’s experience showed me what a remarkable organisation the NHS really is. The call to arms has given the NHS a new sense of purpose. The willingness of the people who work in the NHS to make a difference makes me very proud. I predict that we are going to get through this crisis better than we expect and hopefully this will convince our politicians and politicians the world over that healthcare has to socialised.
I will try to continue running my #MSCOVID19 microsite to give you advice at a distance. The idea behind the site is simple; to provide you with information on COVID-19 and MS and to collate all the answers to the questions you have in one place, which makes it easier for others to find. You are also welcome to ask me non-COVID-19 questions? As I am not meant to be giving personal opinions online I will anonymise the question and provide generic advice that can then be used by the wider MS community.
Please take care of yourselves and we will hopefully see each other in a few months time.
CoI: multiple