I actually wrote this blog back on the 7th April 2020 when the Covid-19 pandemic was just starting to hot up but didn’t get around to publishing it as there were other more pressing “All-Things-Covid” to blog about. However, as we come to the end of the year, I thought I’d reflect and have another look at this blog to see if my fears materialised or not…. I’ve kept the original text and added “December 2020 notes” after as to what I think now.
It has been remarked on a number of occasions recently that I seem too calm in regards to Covid-19; but the person making the remarks usually goes on to suggest that this has helped them keep calm, so I’m taking this as a compliment!
I think the reasons that I am “Covid-calm” are:
Having realised that I am genuinely not panicking about Covid-19 I thought about what is going on that does worry me... because I do worry about things… they just might not be the most obvious and pressing issues that are on other people’s minds right now.
So here are my 3 main worries… brace yourselves, this could get scary?!
Let me explain these further…
1. Antibiotic resistance
Over the past weeks I have seen a rapid escalation in the amount of antibiotics being given to patients. The vast majority of patients being seen in both primary and secondary care at the moment have a fever… it is after all one of the main symptoms of Covid-19.
Now to many people, Doctors included, fever = infection. And it often does but in this case the majority of fever = VIRAL infection, and antibiotics make no difference to these.
All that is going to happen to the majority of patients given antibiotics for Covid-19 is that they are going to change their normal flora to something abnormal including bacteria resistant to the antibiotics they have been given. If they are given lots of different antibiotics then they are going to end up with bacteria resistant to lots of different antibiotics, and this is a problem.
Let’s imagine a patient admitted to hospital with mild symptoms of Covid-19 who then gets worse and ends up on ITU. If the “answer” every time they worsen is to give broader-spectrum antibiotics (which is likely to be quite a common response when HCW are starting to worry) they could go through antibiotics as follows:
I think the reasons that I am “Covid-calm” are:
- I am learning as much as I can about Covid-19 so that I have the most up-to-date information to help me make decisions – this stops me being afraid of the unknown
- I am not having to put on and take off PPE everyday whilst directly looking after patients – I can take a step back and look at the bigger picture
- There are other things about Covid-19 I am more worried about…
Having realised that I am genuinely not panicking about Covid-19 I thought about what is going on that does worry me... because I do worry about things… they just might not be the most obvious and pressing issues that are on other people’s minds right now.
So here are my 3 main worries… brace yourselves, this could get scary?!
- Over use of antibiotics during the Covid-19 is going to cause increased antibiotic resistance after the pandemic
- The cancellations, postponements and delays in other aspects of medicine are going to cause a massive hidden peak in demand for the NHS
- Healthcare workers (HCW) are at further risk of mental health problems and burnout as a result of Covid-19 (as are many people who aren’t HCW as well!)
Let me explain these further…
1. Antibiotic resistance
Over the past weeks I have seen a rapid escalation in the amount of antibiotics being given to patients. The vast majority of patients being seen in both primary and secondary care at the moment have a fever… it is after all one of the main symptoms of Covid-19.
Now to many people, Doctors included, fever = infection. And it often does but in this case the majority of fever = VIRAL infection, and antibiotics make no difference to these.
All that is going to happen to the majority of patients given antibiotics for Covid-19 is that they are going to change their normal flora to something abnormal including bacteria resistant to the antibiotics they have been given. If they are given lots of different antibiotics then they are going to end up with bacteria resistant to lots of different antibiotics, and this is a problem.
Let’s imagine a patient admitted to hospital with mild symptoms of Covid-19 who then gets worse and ends up on ITU. If the “answer” every time they worsen is to give broader-spectrum antibiotics (which is likely to be quite a common response when HCW are starting to worry) they could go through antibiotics as follows:
Click for larger image
So the patient has already had SIX different antibiotics... and where do you go from here?!
This is going to drive up the incidence of some truly scary bacteria such as:
There is really only one way to avoid this situation and that is to be willing to question every antibiotic decision we make and resist the temptation to give antibiotics to patients with Covid-19 “just in case”.
I get it, this is considerably easier to say than to do. Many of the traditional “markers” for bacterial infections are raised in severe Covid-19 and so are unreliable as guides as to who to treat. SARS Cov2 causes raised neutrophils, C reactive protein and procalcitonin in severe cases, all of which are traditional indicators for bacterial infection.
The National Institute for Health and Care Excellence (NICE) suggest the following to help differentiate bacterial from viral pneumonia:
In the hospital in which I work, I am also suggesting a “watch and wait” strategy for many patients. There is rarely a need to rush in with antibiotics for most patients with Covid-19. WATCH how they do with good supportive care such as oxygen and fluids; WAIT and see if they develop purulent sputum or have unilateral signs. There is usually time to make a decision, but if you rush in you can find yourself at the top of the slippery slope of antibiotic escalation and soon find your patient being the one sliding downhill!
Another aspect of antibiotic resistance I have noticed is a trend towards higher mortality from Covid-19 in countries who already have a high incidence of antibiotic resistance. The data is crude and has lots of potential biases and flaws (not least problems with Covid-19 testing and reporting of deaths) but in general European countries with high rates of antibiotic resistance (as taken from European Centre for Disease Prevention and Control website) have a higher mortality rate than those with low levels of resistance. There are lots of reasons why this may be the case but it could be that when healthcare related infections do occur in these countries they are harder to treat due to resistance.
So I am worried that after the dust settles on Covid-19 we may find that we have created ourselves an on-going problem of antibiotic resistance which will mean future infections are increasingly difficult to manage and will result in excess deaths as a result.
Note: December 2020 – this is exactly what is happening across the World, many countries are now realising that the failure to control unnecessary antibiotic prescribing in Covid-19 has driven antibiotic resistance up at unprecedented rates. It is probably too late to do anything about this now; we’re stuck with the problem we’ve created.
2. The hidden peak of work
In order to free up capacity to deal with Covid-19 the NHS has postponed, delayed or cancelled a lot of “normal” work. Many procedures and operations have been cancelled, cancer treatments have been delayed and attempts are being made to keep patients at home rather than bring them into hospital.
All of this means that at some stage in the near future the NHS is going to have to catch up again. The work hasn’t gone away, it has just been moved to later in the year.
If you thought waiting times were bad before Covid-19 just wait and see what they are going to be like afterwards!
As the UK comes out of the Covid-19 restrictions and everyone starts to return to their normal lives the NHS is going to face another surge in demand which will create a hidden peak of excess workload.
I worry at the resilience of the NHS and HCWs to cope with this late surge having come through the extraordinary demands of dealing with Covid-19 in Spring. I worry that this might break the NHS!
Note: December 2020 – the media has been full of patients who are not getting the appropriate treatment for their pre-existing clinical conditions e.g. cancer treatments, outpatient appointments, immunosuppressive treatments etc. Many of these delays and postponements have resulted in patients presenting late with more serious complications from their underlying diseases. I find this a very difficult situation to deal with; failing to treat one high mortality disease e.g. cancer, because of “a fear of” a usually low mortality disease e.g. Covid-19 in <70 year olds. It seems we’ve got our priorities wrong.
3. Mental health of HCWs
Okay, I’m no Psychiatrist and I don’t pretend to be an expert on this area but as someone who has suffered with stress at work and been burned out before I am worried about the effects of Covid-19 on not only my own mental health but also that of my friends and colleagues in the NHS.
How many times have we heard Doctors and Nurses around the World refer to dealing with Covid-19 as being in “a war”? Okay it’s not war; but for the people dealing with it there are periods of high levels of stress followed by inadequate periods of recovery, difficult life and death decisions to make and a serious perceived risk to their own health and safety, as well as potentially survivor guilt when the young patient in the bed in front of them dies. I can see how they may perceive this as a war situation.
What is going to be the effect of this on the mental health of those dealing with Covid-19? How many are going to be adversely affected, burned out and leave the NHS? I don’t have answers to these questions, but I sincerely hope that someone high up is thinking about this and making plans of how to support everyone when we come out the other side because if not the consequences could be horrendous.
Note: December 2020 – I still have this concern and I see little being done to address it. Governments in the UK are talking about allowing hard won inflationary pay rises and possible bonus payments for frontline healthcare workers… but they’re missing the point. Few do these jobs for money… it is the “rest and support” that is lacking in the NHS, too few staff, doing too much with long term lack of recognition and respect. There needs to be a shift in attitude from cutting the NHS to the bone to investing in it as an organisation that thrives, not one that just survives and copes. Perhaps then we wouldn’t need to apply a sticking plaster of “here’s some money for supporting the mental health of healthcare workers”, we’d be that “world beating healthcare system”! Yes support for mental health is needed now but only because the system has already failed to set the culture of “well supported and over staffed” as the highest priority. It’s about long term reserve; there may be little NHS left after the dust settles (and while we’re at it frontline healthcare workers aren’t the only public sector workers that deserve recognition for their heroics in dealing with Covid-19!)
So those are my 3 main worries about Covid-19, not case and death rates, treatments or vaccine safety. It’s the resistance rates, hidden peak of workload and our own health as HCW that concerns me. On reflection these things worry me because I have no control over them what-so-ever… and a lack of control for me is as scary as the “unknown”.
This is going to drive up the incidence of some truly scary bacteria such as:
- Extended-Spectrum Beta-lactamase (ESBL) positive or carbapenem-resistant enterobacteriaceae (enterobacteriales)
- Multidrug-resistant Pseudomonas spp.
- Multidrug-resistant Acinetobacter spp. (MRA)
- Glycopeptide-resistant Enterococcus spp. (GRE)
- And possibly Glycopeptide-resistant Staphylococcus aureus (GRSA) – but this one is still thankfully very rare
There is really only one way to avoid this situation and that is to be willing to question every antibiotic decision we make and resist the temptation to give antibiotics to patients with Covid-19 “just in case”.
I get it, this is considerably easier to say than to do. Many of the traditional “markers” for bacterial infections are raised in severe Covid-19 and so are unreliable as guides as to who to treat. SARS Cov2 causes raised neutrophils, C reactive protein and procalcitonin in severe cases, all of which are traditional indicators for bacterial infection.
The National Institute for Health and Care Excellence (NICE) suggest the following to help differentiate bacterial from viral pneumonia:
- Deterioration within a few days of symptoms (most Covid-19 patients deteriorate after 7-10 days)
- Pleuritic chest pain (pain on deep inspiration)
- Purulent sputum
- Doesn’t fit the pattern of Covid-19 infection (hypoxia, bilateral chest signs, muscles aches)
In the hospital in which I work, I am also suggesting a “watch and wait” strategy for many patients. There is rarely a need to rush in with antibiotics for most patients with Covid-19. WATCH how they do with good supportive care such as oxygen and fluids; WAIT and see if they develop purulent sputum or have unilateral signs. There is usually time to make a decision, but if you rush in you can find yourself at the top of the slippery slope of antibiotic escalation and soon find your patient being the one sliding downhill!
Another aspect of antibiotic resistance I have noticed is a trend towards higher mortality from Covid-19 in countries who already have a high incidence of antibiotic resistance. The data is crude and has lots of potential biases and flaws (not least problems with Covid-19 testing and reporting of deaths) but in general European countries with high rates of antibiotic resistance (as taken from European Centre for Disease Prevention and Control website) have a higher mortality rate than those with low levels of resistance. There are lots of reasons why this may be the case but it could be that when healthcare related infections do occur in these countries they are harder to treat due to resistance.
So I am worried that after the dust settles on Covid-19 we may find that we have created ourselves an on-going problem of antibiotic resistance which will mean future infections are increasingly difficult to manage and will result in excess deaths as a result.
Note: December 2020 – this is exactly what is happening across the World, many countries are now realising that the failure to control unnecessary antibiotic prescribing in Covid-19 has driven antibiotic resistance up at unprecedented rates. It is probably too late to do anything about this now; we’re stuck with the problem we’ve created.
2. The hidden peak of work
In order to free up capacity to deal with Covid-19 the NHS has postponed, delayed or cancelled a lot of “normal” work. Many procedures and operations have been cancelled, cancer treatments have been delayed and attempts are being made to keep patients at home rather than bring them into hospital.
All of this means that at some stage in the near future the NHS is going to have to catch up again. The work hasn’t gone away, it has just been moved to later in the year.
If you thought waiting times were bad before Covid-19 just wait and see what they are going to be like afterwards!
As the UK comes out of the Covid-19 restrictions and everyone starts to return to their normal lives the NHS is going to face another surge in demand which will create a hidden peak of excess workload.
I worry at the resilience of the NHS and HCWs to cope with this late surge having come through the extraordinary demands of dealing with Covid-19 in Spring. I worry that this might break the NHS!
Note: December 2020 – the media has been full of patients who are not getting the appropriate treatment for their pre-existing clinical conditions e.g. cancer treatments, outpatient appointments, immunosuppressive treatments etc. Many of these delays and postponements have resulted in patients presenting late with more serious complications from their underlying diseases. I find this a very difficult situation to deal with; failing to treat one high mortality disease e.g. cancer, because of “a fear of” a usually low mortality disease e.g. Covid-19 in <70 year olds. It seems we’ve got our priorities wrong.
3. Mental health of HCWs
Okay, I’m no Psychiatrist and I don’t pretend to be an expert on this area but as someone who has suffered with stress at work and been burned out before I am worried about the effects of Covid-19 on not only my own mental health but also that of my friends and colleagues in the NHS.
How many times have we heard Doctors and Nurses around the World refer to dealing with Covid-19 as being in “a war”? Okay it’s not war; but for the people dealing with it there are periods of high levels of stress followed by inadequate periods of recovery, difficult life and death decisions to make and a serious perceived risk to their own health and safety, as well as potentially survivor guilt when the young patient in the bed in front of them dies. I can see how they may perceive this as a war situation.
What is going to be the effect of this on the mental health of those dealing with Covid-19? How many are going to be adversely affected, burned out and leave the NHS? I don’t have answers to these questions, but I sincerely hope that someone high up is thinking about this and making plans of how to support everyone when we come out the other side because if not the consequences could be horrendous.
Note: December 2020 – I still have this concern and I see little being done to address it. Governments in the UK are talking about allowing hard won inflationary pay rises and possible bonus payments for frontline healthcare workers… but they’re missing the point. Few do these jobs for money… it is the “rest and support” that is lacking in the NHS, too few staff, doing too much with long term lack of recognition and respect. There needs to be a shift in attitude from cutting the NHS to the bone to investing in it as an organisation that thrives, not one that just survives and copes. Perhaps then we wouldn’t need to apply a sticking plaster of “here’s some money for supporting the mental health of healthcare workers”, we’d be that “world beating healthcare system”! Yes support for mental health is needed now but only because the system has already failed to set the culture of “well supported and over staffed” as the highest priority. It’s about long term reserve; there may be little NHS left after the dust settles (and while we’re at it frontline healthcare workers aren’t the only public sector workers that deserve recognition for their heroics in dealing with Covid-19!)
So those are my 3 main worries about Covid-19, not case and death rates, treatments or vaccine safety. It’s the resistance rates, hidden peak of workload and our own health as HCW that concerns me. On reflection these things worry me because I have no control over them what-so-ever… and a lack of control for me is as scary as the “unknown”.
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