Now ye're talking - to a consultant in the HSE [ANSWERS thread]

I'm going to use this post to link to webpages/sites which I believe could be useful for those with medical questions/specific risk factors. I am willing to give some general opinions and repeat information which appears factual and has been published by reputable sources but specialist bodies and your own GPs and Specialists are definitely the place to go for individualised advice which will always be more useful to you as individuals than any general broad advice online. I am NOT offering anyone specific, individualised medical advice and wish to be clear on that. If you want that phone your GP or Specialist.

1. WHO myth busting page... VERY useful at this time. Some of the advice and rumours online are just so dangerous.

2. WHO Coronavirus page. Lots of useful, detailed, evidence based advice there.

3. HSE's Coronavirus page.

4. Royal College of Obs & Gobs UK advice re: Pregnancy & Coronavirus.

5. UK Asthma Society Coronavirus Advice

6. Irish Asthma Society Coronavirus Advice




Errata:
1. Phylogenetics of SARS-CoV2

2. COVID-19 Infected/Recovered etc Updates

3. A really good site for getting a breakdown by country, by date and multiple useful categories. Very succinct and easy to comprehend.

I'll add to this as

another post

celt262 wrote: »

What medicine should be taken if symptoms start to develop?

Thanks for the question. Honestly that would depend on what your underlying conditions are, the severity of symptoms you exhibit and your likely progression as well as what allergies you have so it is impossible to give a one size fits all answer here.

With that said the best advice is that IF you start having symptoms you should contact your GP and be assessed by them ( almost certainly over the phone ) and follow their advice. At this point in the pandemic in Ireland most people who think they have COVID-19 don’t, they have other more common viral or bacterial infections or even just psychosomatic issues. So long as you aren’t allergic I think you can’t go wrong with some paracetamol, rest and ensuring you are hydrated though.

As re: NSAIDs the best thing I can do is link to the HSE's advice. Might this change as we know more? Certainly but this is the advice as it stands at the moment. You'll have to make up your mind whose advice to follow. I have no reason, at this time, to doubt the HSE's advice on this issue.

dartboardio wrote: »

Hi,
Do you find yourself turning away lots of patients who don't have any real symptoms of the virus and are just taking up waiting rooms out of worry?
Are all your staff/colleagues full of panic/worry ? Is this the busiest you have ever been?

Thanks for the questions. I’ve certainly heard of a lot of people thinking that because they have a cough or whatever that they might have COVID-19 and I’ve heard a lot of frustration from people who want to be tested but don’t meet the criteria for testing.

It should be noted that Ireland had very few testing kits although that number is ramping up massively and will continue to ramp up. As availability increases the criteria for testing will be widened until we reach a point where we can test everyone we should be testing.

A lot of GPs are really struggling with the numbers of people phoning them seeking advice and testing and that isn’t helping. Thankfully most of those people have the sense not to come in in person and:
A) Clog up waiting rooms and
Risk spreading it to others if they do have COVID-19

I don’t think patients are being turned away but there are a lot of worried well who would do best to just self-isolate, phone their GP and then follow the GP’s advice. On a population level you don’t need to do anything amazing, just follow governmental advice and your doctors’ advices.

My medical colleagues and I ( Consultants and NCHDs) are worried but not really about ourselves so much, although we do know that if this gets really bad then we ourselves and our friends and colleagues stand to have higher rates of infection and mortality per capita (age adjusted) than the rest of the population. This was seen in both swine flu and SARS and I expect it will be seen with SARS-CoV2/COVID-19 also. What I see and hear much more than that is a grim determination to do our duties and pay whatever price needs to be paid. I’ve been saying for a while now that we need to gear up as though Ireland is about to fight a medium-sized war, with all of the sacrifice and difficulty and loss that that entails. I’m starting to hear colleagues use the same language … I heard it said a few times today.

This is going to be a war, there are going to be losses but I think the vast majority of doctors are determined not to let Ireland down, no matter the cost. Sure we REALLY don’t want to die ourselves but we’ll do our bit, roll the die and know it’ll happen to some of us.
I, personally, am more worried about my parents than I am about myself and I think anyone with parents feels the same way. You have to remember we’re just like you in terms of families and being more concerned about those we love than we are about ourselves right now.
I’m not a spring chicken anymore and I have two underlying health conditions which increase my risk of dying if I catch COVID-19. I estimate I have a 15 to 20% chance of dying if I catch it but I’m going in because that is what is needed to try and save as many people as possible. I don’t think my place is directly on a COVID-19 ward because I’ll absolutely catch it for sure then and I won’t do anyone any good becoming another patient and using up resources which could be used to treat others but I have a role to play and I’ll play it. I think everyone else feels the same.

My nursing colleagues have the same attitudes really. I know nurses who have been doing non-front line duties for years and who have worried wives, husbands and children and have simply accepted that they’re going to be deployed wherever they can do most good. They know the risk this puts them at --- nurses also die at higher rates per capita ( age adjusted ) during pandemics --- but they’re not going to let you, the public, our patients down. Some, with health issues etc, will be deployed in places where they are less likely to catch it so that they can contribute care as opposed to consuming it but everyone’s grimly determined to do their absolute best.

As for allied health professionals… Well, the secretaries and admin staff are still showing up, doing their best as are the OTs, Physios, Dieticians, Radiographers etc… And let’s not forget the security staff, porters, kitchen staff and cleaning staff. A few weeks from now it will be a definite act of courage for a kitchen staff or cleaning staff to come into work because they’ll be exposing themselves to high risks of infection with COVID-19. Some will falter but I expect the vast majority to continue showing up and doing their bit. We need them ALL to do their bits because doctors and nurses on their own can’t make a hospital or GPs surgery run. It is a team effort.

I do think that some the allied health professionals who haven’t done nursing or medical duties on wards don’t quite “get” just how serious this is yet. I’ve definitely had push-back from some line managers about instructions I’ve given my team because I wasn’t following HSE protocol etc but this isn’t because they’re bad people or managers it is just because it is a big ask to go from peacetime HSE footing where there’s a protocol for everything and a change in work practices is a big deal to a mindset of, this is war and in war we do WHATEVER is necessary. When the whistle sounds, we all charge, we won’t all make it but we all charge. That is one hell of a mindset change and it takes time to make it… but even today people who hadn’t made the adjustment yesterday were contacting me to let me know they’d made the adjustment and were now of the “do whatever it takes mindset”.

A lot of (insert expletive of your choice here) ;-) is spoken about the HSE and, to be fair, some of it is even justified but, right now, while I’m a bit scared for myself and my family and I’m sad that some people I’ve known and worked with aren’t going to survive this it really makes me proud of Ireland and the HSE and socialised healthcare in general to see people knuckle down and prepare to go to war and fight this. We aren’t all coming back but we won’t let you down. We will, to quote the Marvel Universe, make the Big Play.

One thing I would just say on a slightly self-serving note is that when this is all over and a year or two from now doctor and nurses etc are advocating for funding and better working conditions please do remember who ran towards the fire at this time while everyone else was avoiding it as much as possible. Support us as much as we will support you in the months to come.

I’m sure this applies to the Army and Fire Brigade and Gardai and many others as well. I just don’t have as much contact with them so can’t address their attitudes directly.


Is this the busiest we’ve ever been?

No, a lot of the people who used to clog A&E with stuff that they should never have come in with seem to be staying at home. I don’t know if this is out of civic duty or fear of catching COVID-19 but myself and a lot of colleagues are ticking over doing the day jobs but aren’t as swamped as we usually are with the worried well etc.

We’re all still busy though as we’re preparing for what is to come.

CtevenSrowder wrote: »

How long do you think the lockdowns will be required to last?

I don't think anyone knows precisely but any lockdown will need to last long enough to significantly impact on the chain of infection. To do that you MUST exceed at least one incubation period. Anything less than that is utterly useless. So that gives us a lower bound of 14 days. The more multiples of one incubation period you lock down for and the more completely the lockdown and social isolation is observed the better.

So, 8 weeks is better than 6 which is better than 4 which is better than 2.

I assume that what the government will do, and I have no behind the scenes insight into this and if I did I wouldn't be answering this question, is lock down for 2 to 4 weeks initially ( 1 to 2 incubation periods ) and then re-assess the situation. Then they'll decide whether they need another 2 to 4 weeks at the same intensity or whether we can ease it up a gradually.

How can you help at this time? Observe social isolation, handwashing, social distancing etc. The more strictly the public observes these measures the quicker the less transmission we will have, the fewer people will get sick and die and the quicker the lockdown will be over.

It is very true that while healthcare workers can save many of those who get sick it is you, the public, who can beat this. If you all go out and stand next to eachother in queues, don't wah your hands etc etc then the healthcare system WILL be overwhelmed and we will be traumatised as a nation like we were with the famine. If you follow all the advice about social isolation, distancing and handwashing and stay in as much as possible then this will hurt but we'll get through it fairly ok.

CtevenSrowder wrote: »

Why is it presumed that warm weather will reduce the number of cases?

Well, that's because a lot of respiratory viruses have a seasonal component and people are assuming that SARS-CoV2 will also. This seems to be a reasonable assumption but we don't know if it is correct. We could be surprised.

I think most people are using the Spanish Flu model where it hit in three waves, early 1918, October to December 1918 and then again in Spring 1919 before being pretty much burnt out by the end of 1919. Is that the right model to use? Well, it seems reasonable but we don't know for sure.

sgthighway wrote: »

What is your speciality?

A reasonable question but not one I will not answer for the following reasons:
1. when I posted here initially a few weeks ago I got abuse for posting. People online can be horrendous to eachother and I don't care to expose myself and my family to that abuse online or in the real world. If my identity became known I fear that could happen.

2. The HSE can be very vindictive and were I to identify myself I don't trust them not to go after me if I survive this.

I'm being careful not to present myself as an HSE representative. I'm just a doctor answering questions using my experience and knowledge to provide the best quality answers I can at this time of national emergency. I'm trying to be responsible in my answers and be open about the fact that I don't know everything and thus can't answer every question. Plus I'm fallible and make mistakes.

With that said when a Consultant came out a few years ago to talk about the trolley crisis the HSE went after him by querying whether or not he broke patient confidentiality in doing so. he clearly didn't but they just wanted to punish him and warn the rest of us to shut up. We're pulling together now but I'm very aware that if I survive the HSE management will likely return to their previous form and seek to punish doctors who say things they dislike - even if those things are true.

If I said what specialty I work in I would hugely narrow down the field for them to search to find me. I'm already concerned enough about Boards knowing my identity and technical means being used but:
a) I think this is my ethical obligation as a doctor and my moral obligation as a human
b) I think there's about a 15-20% chance I won't be alive in 6 months to be gone after and I'd hate to die thinking I hadn't done what I felt was right and
c) If I'm lucky enough to survive and they do decide to come after me then I'll just have to emigrate to Australia or Canada and get paid a lot more money for doing the same job. There are worse fates ;-)

So, I hope people will respect me desire to remain anonymous so as to avoid reprisals.

History Queen wrote: »

Have ye received any further guidance regarding coronavirus and pregnancy? Specifically the case in the UK where the newborn tested positive for the virus, has that changed anything regarding the treatment/guidance for dealing with pregnancy?

Thanks for the question. I think that the number of pregnant women who have been confirmed to have been infected is so low that it is difficult to draw any definitive conclusions. With that said I have been directing patients and staff ( there are lots of pregnant nurses and doctors who are worried about this on a personal level ) who are concerned about this to the Royal College of Obstetricians and Gynaecologists website which has a really good page on this:

https://www.rcog.org.uk/en/guidelines-research-services/guidelines/coronavirus-pregnancy/covid-19-virus-infection-and-pregnancy/

I think that explains it really well. I think the bottom line is that we must all assume pregnant women are more prone to infection and therefore they and their families need to be really strict about social isolation and distancing and hand washing measures.

coastwatch wrote: »

No question yet, but just to say a sincere Thank You to all HSE staff, frontline and support for the huge effort that has gone into the preparations for the spread of this virus, and for the ongoing effort that will be required to deal with it over the coming months.

Thanks. There has been a real sense of people beginning to understand the severity of this since the Taoiseach's statement last Thursday - which almost seems like weeks ago at this stage. Before Thursday some of patients and family members were complaining about delays in being seen or not being seen in person etc but today they seemed to understand that this was an emergency situation and previous norms no longer applied. Sure, not all of them but most of them ;-).

This is really helpful because over coming months a lot of assumptions about what the HSE should and shouldn't be doing are going to be thrown out the window. As a country but particularly in the HSE we're at war and we'll do our best for you but you need to understand that what you consider urgent and severe and what we consider urgent and severe is going to be very different over the next few months to a year. We're not trying to be unsympathetic but we're at war and we have a much better idea of what will keep most people alive at this instant. You'd better believe that's what we're going to focus on --- while doing our best to provide a service to everyone in the country who isn't infected with COVID-19.

For example: People will still get pregnant, get cancer, get asthma attacks, get heart attacks, develop depression, anxiety, OCD, have car crashes, fall and break bones etc. We are going to be dealing with ALL of the above PLUS COVID-19 and no-one suddenly found clones of us to flesh out the service. All we have to make up the numbers are redeployment of staff from non-essential services, retirees called back to the colours and early-graduation medical students and nursing students. With that said we will work harder than we've ever worked before (and we weren't slackers previously no matter what you might have heard or read) and will , inevitably, die in some numbers over the coming months but what we WON'T do is let you down. That simply isn't an option. We WILL be there for as many of you as possible for as long as you need us and as long as we can still stand.

I'm sorry if that comes across as wishy washy or emotional but, you know, I'm really inspired by my colleagues in the health service right now. Anyways, massive emotional outburst over for now ;-). My team would be surprised to think I wrote the above, this is another reason I can't be identified. I've got a reputation as a bit of a tough SOB to maintain and if I'm ever linked to this post my street cred with the cool kids will be totally shot ;-)

What you can do to help us is pretty simple but really powerful. You need to socially isolate, socially distance, hand wash and convince any of your friends and family who still think this is overblown that no, this is war and if they are selfish and think of themselves first and foremost they are going to condemn a lot of good people to death over the coming weeks and months.

little bess wrote: »

The Uk are asking over 70’s to self isolate, would you recommend the same thing to that age group here?

Yes, absolutely. My parents are in that age group and they've been self-isolating for almost two weeks now on my advice. They told me they went out to the pharmacy for medicines and I almost lost it with them... but they'd have been upset if I said that so I bit my tongue... They should have let me go to the pharmacy instead and take that risk instead of them.

So, I would advise anyone over 70 to really strictly self-isolate and have food and medicines delivered to them. Show them how to use kindle and netflix and let them spend the time reading, doing netflix and chill and skyping with everyone in the family. I've spoken with my family on the phone more in the last two weeks than I did all last year.

little bess wrote: »

I’ve heard diabetes, hypertension, copd are all extra risk factors, should these people take more care with social distancing?
Many Thanks

Yes, absolutely. It is unclear precisely how much these increase the risk of mortality but it is clear that they increase it. Most figures I've seen say each of these factors increases the risk of mortality by roughly 5% and having more than 1 of these risk factors would likely increase your risk of mortality more then 10% ( risk factors don't cause risk to go up additively they compound ).

Gloomtastic! wrote: »

What’s the difference between a bad dose of the flu and Covid-19?

Wow!!! I'm going to rephrase this question slightly so we are comparing apples to apples. What's the difference between a bad dose of the fly and a bad dose of COVID-19... Well the difference for people over 70 is the difference between having a 1 in a thousand chance of dying and a roughly 10% chance of dying. Those are rough figures but the general gist is that if you are over 70 you are 100 times more likely to die if infected with COVID-19 than the flu.

That SHOULD terrify anyone who has a loved one in that age group and why we all need to encourage them to socially isolate, get their messages, medicines etc and practice social isolation, social distancing and hand washing ourselves.

And lastly two pictures showing fatality rate by age and risk factor in China. It isn't the most up to date but I think they make the point graphically and eloquently.

dharma200 wrote: »

All my Chinese students families have been wearing masks at home at all times. They take the masks off for bed. The children ( my students) do not wear masks. They have emphatically told me over and over again to wear a mask, at all times. That this is the success against the virus. I have been seeing my parents with masks on now for five weeks. At home.
I am wondering why the advice here is not to wear masks. is it that it is a false sense of security?
My chinese families do not understand why everyone here in the west is not being told to wear a mask.
Thanks,

Great question. To be honest I think masks for the public are worse than useless for one simple reason: People don't know how to put the masks on properly, fit them properly and take them off properly and therefore they are useless for most people.

Also, it is FAR safer to stay at home socially isolated than be out and about wearing a mask so I think the government has hit on one simple message and are focusing on that - socially isolate/distance and handwash. I think they are probably right to do so.

Almost every picture I've seen online of people wearing masks shows them not being worn properly and being useless.


Even with this simple message they are having to fight idiots who just make up lies and rumours which will kill people. If they went for more nuanced messaging it would be difficult to get a consistent message through to people.


With that said it is different for healthcare workers and people who know how to use the masks and MUST be out and about. E.g. I plan to wear masks on my way into work and home starting Wednesday. But I know how to put them on, fit them and take them off so they'll be effective for me, hopefully.


In the picture below from the BBC this mask isn't being worn properly and thus provides almost no protection. All this woman is doing is preventing a healthcare worker from using this mask properly and being protected at work.

And that's me done for the evening/morning. I wanted to answer the first two pages. I'm going to bed now, catch you all later today. I hope you found some useful information here and you got an insight into how Consultants' minds work. We're... different.

Fann Linn wrote: »

What happens after you've self isolated for the 14 days after testing positive?
Have you built up an immuninty?
Could you catch it again?

And a big well done to all in emergency services and the HSE.

Well, if you test positive it isn't about waiting 14 days and then going out and about again. It is about waiting until you are symptom free, fully recovered + a few days. You will be advised about this by your GP or Consultant/treating medical team. That may be 14 days, it may be significantly longer.

Illnesses and human bodies don't run to schedules, when we have a lot of experience with them we can talk about the range within which most people fall but it is still early days with this virus and we are learning more about it all the time.

Fann Linn wrote: »

Have you built up an immuninty? Could you catch it again?

You'll have built up an immunity to the strain of COVID-19 you caught. There is some evidence there might be another strain out there already although that isn't confirmed yet. The two strains are tentatively labelled L and R

What we do know is that RNA - which is what this virus is made from - has a really poor error checker and so mutations are very common. When enough mutations happen a new strain can develop which is sufficiently different from previous strains that having been infected by other strains doesn't confer immunity.

This is what happens with the flu and cold etc so that catching it once doesn't make you immune to other strains the next year, or even the same year.

Most doctors expect that SARS-CoV2 will mutate sufficiently to create new strains eventually, if it hasn't already, and thus become seasonal. When will this happen? No-one knows for sure.

I'll link to a really nice website which helps people visualise the phylogenetics of this. If you press the play button on the image on the right you can see the genetic drift as we've tracked it over time.

https://nextstrain.org/ncov

Cork Boy 53 wrote: »

I am just curious as to whether you think a time may come when a virus or some type of infectious disease will appear that will have the potential to effectively wipe out all of humanity. I`m talking 12 Monkeys style here. Hopefully this one won`t be it! Anyway my thoughts and prayers are with you and your colleagues for the ordeal that lays ahead of you.

Wow!!! and my posts are accused of increasing anxiety ;-). I think that over the past two decades we've had Swine Flu, SARS, MERS and now SARS-CoV2. That's pretty much one pandemic or potential pandemic every 5 years.

Unless we change our relationship to the planet I see no reason that that pattern won't continue but if we continue to fund vaccine research and pandemic prevention planning beyond the current crisis I think we won't be wiped out by one.

With that said on a philosophical level I agree with Elon Musk that so long as humanity exists only on one planet that planet represents a critical vulnerability for the human race and so the sooner we get self-sufficient colonies on other planets the better. But that's more a philosophical point than the death knell of humanity in the next few months. Even the absolute worst case scenario for SARS-CoV2 won't wipe us out or reduce human civilisation to Mad Max levels .

Funnyonion79 wrote: »

My question is this...in two weeks time, after self isolating at home with my husband and children, is it safe for us to visit my parents/in-laws, who have also been self isolating at home, during this time? The only time any of us would've left the house is to go for a walk or go to the supermarket. The in-laws are mid 70s but in good health.

Well, I am not trying to dodge the answer here but I don't think there's a simple yes or no answer to that. Certainly after two weeks of self-isolation your risk of being infected without symptoms is low but it isn't zero. And going to the supermarket definitely creates a risk of infection.

My position with my family is that I'm dropping things at their door and picking things up from their door while the door remains closed. We wave at eachother through the window and talk on the phone or via skype. I think that's the safest way to proceed.

You can certainly go and visit them but that introduces a bit more risk and only you can balance that risk/benefit ratio for you and your family. Either way I wish you the best.

JustAThought wrote: »

Still wondering where the answers are, please - is there a link?

Q: While front line staff paid are being allowed home on paid sick leave inc to mind their children off school unpaid inexperienced volunteers are being emailed from the HSE asking them to go into hospitals to help with the virus. Something fundamentally wrong with this. Surely the time for paid HSE staff to pull their weight is when there is a crisis and they are needed and not be asking or relying on emailing randomers from a charity database to pick up their slack.

My family member called in sick on full HSE pay to mind her children - surely this type of abuse should be stopped.

I'm not an HR professional so cannot address this but I do know we've all received memos stating that the HSE is recording who steps up and who doesn't at this time. You don't have to be a genius to figure out what that means for people who are adjudged not to have made themselves available when they could have. With that said individual circumstances are often highly personal and I'd be slow to rush to judgement. There may be stuff going on you aren't aware of ( undisclosed medical conditions etc ).

So, my general policy at this time has to try to be kind and thoughtful and not jump to the assumption that people are shirking... but I'm sure those cases will be looked into afterward.


@Purgative,
Thanks. I'm glad to hear you found my answers of some value and hope those you shared them with find them helpful also.

irishgeo wrote: »

How long is the recovery period?

I think that depends very much on the severity.
1. It seems that most "mild" cases ( meaning not requiring hospitalisation ) should be fine within less than a fortnight... and may just need to self-isolate up to 14 days to make sure they're not shedding the virus even though recovered.

2. I've seen figures from China and Italy which say the 10% who require hospitalisation but not ventilation can take somewhere from a week to a month to be fit for discharge. The median reported by Wang was about ten days.

3. I've heard figures of about a month being quoted as the average for patients with severe illness requiring ventilation but I think that figure will change as we get more data from more recovered patients.

Seamai wrote: »

What is the protocol if a work colleague tests positive? Is the work place contacted? and if so by who? What happens after that?

I think that advice has changed a few times based on exingent factors and developing medical understanding over recent weeks so I'll answer with two general points:

1. The affected individual will be contact traced by the HSE as per their protocols.

2. If you haven't been contacted but are concerned you can phone your GP who can assess you and determine whether you meet testing criteria. Follow their advice as it will be individualised to you and thus be higher quality than any general advice you can get on the internet.

JoChervil wrote: »

It was a disease running around late December/early January. In reports from that time it was said that there was a 25% increase in hospital admissions of patients over 75.

So my question is: how HSE ruled out that it was not Covid-19? How many tests were made to prove it was something else like a different kind of flu (I mean percentage of cases checked for it)?

Not in Ireland it wasn't. The phylogenetics of SARS-CoV2 show it wasn't in Ireland at that time. This is an unhelpful assumption/internet rumour not supported by facts.

I'm sure the seasonal flu was around and quite a few people got sick and died from it, as they do every year. But it wasn't SARS-CoV2. Check out the link I've provided above to look at the genomic epidemiology yourself. The phylogenetics speak for themselves.

I hope you find this answer helpful and can put this unhelpful internet rumour to bed.

piplip87 wrote: »

Hi there,

Have you seen any day services cancelled ? My OH has MS and is on a monthly infusion. As far as I understand there is a massive increase in the risk of an attack if left for more than 5 weeks between treatments.

Have you seen or heard if any alternative arrangements for these treatments ?

I think that, whenever possible, essential services will continue to be provided. With that said if we have 20,000 cases a month the number of normal services we can decide are essential will be a LOT more than if we have 100,000 cases a month.

So, again, it comes down to social isolation, social distancing and handwashing. The best thing any member of the public who is worried about a relative with treatment which may be cancelled is work to reduce the spread. That gives the greatest chance that we will have the staff and space to continue these sorts of services.

Kerry25x wrote: »

How do you feel about the speculation happening that health care workers are at much higher risk of developing severe/critical illness if they come infected? Have you any advice for other front line hospital staff?

I am not familiar with this speculation. Healthcare workers on the front lines, doctors, nurses, cleaning staff etc get infected at higher rates than the rest of the population but I'm unaware of any increased mortality rate ( as opposed to absolute mortality ).

laserlad2010 wrote: »

If you're not a public health specialist you have no business providing official COVID-19 advice, even cloaked as personal advice, to the public. It's bad enough with the Whatsapp rumours, but talking about writing your own will at the same time as attempting to give advice in your capacity as a consultant is inapproriate. Regardless of whether it turns into a "war".
Even if you claim you're not representing the HSE people will still place weight on your words.

I've been explicitly clear that I'm posting in my personal capacity informed by my training and experience. It isn't my problem if you cannot read and say I'm "providing official COVID-19 advice".

As to the will. It is what I've done. It is a sensible precaution.

Balf wrote: »

Maybe we should ask him if threats like Covid 19 show the impracticality of organising access to medical knowledge through a tiny bunch of highly paid consultants. I think he'll know what we mean.

I actually don't know what you're getting at. I'm assuming it is some sort of class warfare dig at Consultants which makes the mistake of thinking that being able to google a thing and UNDERSTANDING IT enough to be able to make really difficult decisions are the same thing. They aren't but, you know, you do you.

What I will say is the two of you amply demonstrate:
a) that some people still don't understand what we're facing and
b) why I want to remain anonymous. You're the sort of people I don't want to run into in the real world.

With that said I wish you and yours the best of health into the future.

Agus wrote: »

Thanks for taking the time to do this, I think it really helps to have good information out there as much as possible.

1. How soon do you think the number of infected people in Ireland who need treatment will reach a level where the health service is finding it hard to treat them all?

This is a really great question actually. It gets at the heart of a lot of confusion out there about models and probabilities - and humans are really bad at understanding probability.

What doctors and the state have are models which show what estimated numbers of infected will be based on various levels of social isolation, distancing and handwashing as well as curbs on flights, pubs etc.

In simple terms the outcomes of those models range from - "Oh that wouldn't be too bad" to "Oh S**t!!!". The more the public socially isolates whenever possible, socially distances whenever going outside is essential and hand washes the closer we'll get to the "Oh that wouldn't be too bad" level of outcome.

I've heard reporting on the radio that the government is estimating there could be 10,000 to 15,000 cases by the end of the month, two weeks from now. If we assume 10% may need ventilation that would be a requirement for 1,000 to 1,500 ventilators. We have about 250 although as explained previously we can repurpose more. That's pretty grim.

And, yeah, you guessed it the best thing you all can do is socially isolate, socially distance and handwash.

Agus wrote: »

2. I've seen reports that asthma may be a risk factor because Covid might exacerbate the asthma, but the actual Covid illness itself isn't necessarily more severe. In other words, the claim is that the main extra risk to people with asthma is that they will end up with both Covid illness & a severe exacerbation of the asthma, and therefore the additional risk for people with mild asthma is probably not much greater than people without asthma. Is this likely to be accurate or not?

I think that gets into an unnecessary level of detail of disease action which we just don't know yet. It appears that anyone with a chronic respiratory illness is at increased risk of mortality. It certainly seems reasonable to assume that someone with COAD is going to be at more risk than someone with mild asthma well-controlled with inhalers but I simply don't know that for certain at this stage and certainly don't know any figures I could quote which I'd consider reliable and solid.

I can provide you two links which could be useful:
1. UK Asthma Organisation advice page. This seems solid to me.

2. Irish Asthma Society's page. The UK one seems better to me honestly but I provide this for the Irish perspective.

In this situation the best thing to do is read those organisations' websites and if you have further questions/symptoms seek advice from your GP or treating Respiratory team.

Quick answer to something and then some links...

1. I think the best preventive measure is total social isolation but recognise that isn't possible for most. So, going for walks is a calculated risk.

Ideally if you're going for a walk it should be alone or only accompanied by whoever you are in social isolation with ( partner, children etc ), you should avoid other groups of people and do your best not to touch anything with your bare hands - e.g. door handles to apartment buildings, lift buttons, gates etc -- which others who might be infected might have touched.

Those steps should reduce the risk significantly. So, in summary, going for a walk when lots of people are around and having chats with them while touching door handles, lift buttons, gates, then popping in to the local shop to pick up a coffee all increase the risks.

Going out for a walk with your partner and/or kids when/where there aren't large groups out walking, having a walk, taking care not to touch things with your bare hands others may have touched and not stopping for chats - even if you stand 1 metre apart - all contribute to a walk being a low risk.

I happen to have a treadmill at home and so I've made the decision to only use that from now on but I recognise that isn't an option for most people.


In other news I've been contacted about Remdesivir and other potentially effective treatments and I think it would be worthwhile to curate a post with links to scientific journals about possible treatments. I am NOT endorsing any treatment or anything like that, just hoping to:
a) provide a little hope
b) provide links to actual research articles as opposed to whatsapp rumours and
c) provide a short summary ( a couple of paragraphs which are simplified and should be easily understood ) so as to "translate" from "medical" to English ;-)

Let me know if you think this linking to research is useful or not. If not I'll find better ways to spend my time.

1. New England Journal Of Medicine Case Report of US Male with COVID-19 successfully treated with Remdesivir.

Basically a patient who was in Wuhan and then returned to America tested positive for COVID-19 and was then admitted to hospital. They received supportive care (paracetamol, ibuprofen, saline) for the first 5 days of hospitalisation. On Day 5 their Oxygen Saturation fell below 90% ( anything below 92% is significant in a previously healthy person ) and they were started on supplementary oxygen ( the nasal prongs or oxygen mask you'll often have seen people on in hospital ) and antibiotics for query hospital acquired pneumonia.

On Day 6 their chest X-rays were showing worsening lung involvement and the doctors applied for "compassionate use" of a the drug Remdesivir ( a known antiviral which had been trialled in the treatment of Ebola in 2019 but didn't do well ) and started it on Day 7.

By Day 8 the patient was improving.

Conclusion: Remdesivir may have utility. More evidence needed. A single case study so hardly proof positive of a treatment for all. Still, a damn sight better than giving it to someone and them not recovering. We WILL find existing medications and/or new medications which work to kill the virus and then survival rates will improve markedly. It is just a matter of time. Buy us that time with social distancing, social isolation and handwashing.

RiseAbove4 wrote: »

I’ve been reading your posts with both interest and high anxiety. I believe all your facts and thank you for doing this.

Question:

I’m a 44 year old male with Cerebral Palsy. In addition I’ve early Osteopenia and I’ve picked up some kidney stones in the last couple of years. I’m also allergic to Penicillin which is used to fight off lots of bugs. .

My CP is mild compared to others. I can still walk and I try to exercise as much as possible.

Am I at any higher a risk than another 44 year old male?

I’ve been distancing myself from most people for about 10 days now and I’m going to focus on looking after my immunity with high dosage Vitamin C, Zinc and more.

Cheers again.

Thanks for the question... I haven't seen any clinical data on mortality rates of individuals with Cerebral Palsy with COVID-19 so I can't give you an evidence-based answer in that sense. With that said having discussed this with a couple of colleagues today our consensus was that we don't think someone with mild CP who is able to walk unaided and exercise should be at higher risk.

As to the penicillin allergy. I wouldn't worry about that, there are lots of other effective antibiotics still available to treat any bacterial pneumonia which might develop should you develop COVID-19.

With that said I would, as ever, urge social isolation, distancing and handwashing.

faceman wrote: »

As the Americans say to the veterans, “thank you for your service sir”

My question is probably more complex than I think but here goes

Viral loads and contagions. How does it work with this virus. We know that there are drugs for example that can suppress viral loads of HIV to levels that make it virtually not transmittable. What is it that makes this virus so contagious? Is it it’s ability to replicate itself? Or have I oversimplified it?

LOL! You were right that any answer to your question would be very complex and nuanced. At a basic level though different viruses have different levels of infectivity and we have just gotten quite unlucky that SARS-CoV2 combines quite high infectivity with a high R0 and quite a high rate of causing severe infections when it infects people. This basically gives it a high chance of overwhelming critical care resources. When this happens death rates could be reasonably expected to rise from roughly 2% ( when the system has enough critical care resources ) to 10% ( when the critical care resources are overwhelmed ). If you run the numbers from Italy you can see that their number of dead has been slowly but surely creeping up towards 10%.


@ Dummy_crusher
Thanks. I'll pass you over then.

Imreoir2 wrote: »

Is there a reason for the high mortality rate experianced in Italy to date as compared to other countries?

Discussing it with colleagues we think there are four main factors.
1. We don't yet have proven, effective treatments to beat the virus back in those who present with it.

2. Italy has a proportionally high number of aged individuals - who have higher mortalities.

3. They didn't react quickly and aggressively enough in terms of aggressively imposing social isolation on their citizens. They ratcheted it up gradually and by the time they got serious about it their numbers were destined to climb so high that their healthcare system got overwhelmed.

I think it is really encouraging that their numbers aren't breaching 500 dead a day yet. On a worst case scenario I had thought they could be breaching 1,000 dead a day by now so clearly their lockdowns have had some impact but they needed to take the Singapore approach ( mass testing, harsh, massive enforced social isolation) much earlier to prevent this death rate. They didn't and so they'll likely end up with somewhere between 8,000 to 10,000 dead by the end of the month - it could be a bit less if their lockdown from two weeks ago kicks in but I think that any [positive impact in Lombardy will be negated by rising cases and deaths in other regions of Italy where they didn't take it as seriously until much more recently.

4. The healthcare system in Lombardy has been overwhelmed and in that region it seems their death rate is at 10% already and has been for some time - this is the sign that their critical care systems have been overwhelmed.

I talked about mass casualty ethical triage previously and mentioned "black tagging" people as not suitable for any treatment. Channel 4 News is, in my opinion, providing the best news reports on this. They had a very interesting piece in which an Italian healthcare worker spoke about their active black tagging policy. This shows you how overwhelmed they are.

Channel 4 News Link: The relevant section begins about 3:20 but watch the whole thing. It is striking.

Also note that none of the civilians with face masks are actually wearing them properly. If you freeze frame at 4:40 you can see two people with face masks ( wife and daughter of a COVID-19 patient ) both of whom haven't fitted the masks properly. They think they're getting protection but I guarantee you they will both come down with COVID-19 Essentially all they've done is wasted those masks.

At 5:25 the kids of the man being taken to intensive care are allowed to touch his hand before he goes into ICU. He's lucky enough to get a bed but their awareness of infection control is very poor. To be fair, they're young and almost certainly will have caught it before this but it hurts to see the lack of infection control measures evidenced throughout this video by the public in Italy.

To be fair when I started enforcing this in my clinic a couple of weeks ago long before the HSE was mandating it co-workers thought I was hysterical too. They've come around.

Remember, every time you don't socially distance or hand wash properly you, personally, are making this scenario from Italy more likely to happen in Ireland.

The One Doctor wrote: »

No questions, just thank you for your forthrightness, bravery and determination. If we ever meet, I will buy you a beer. Several beers.

LOL! In all seriousness there's only two things I'd accept as thanks:
1. People passing this info/thread on to others so they could become informed and change their behaviours and

2. If you really want to give thanks I treated a lot of survivors of rape in A&E when I was a junior doctor. It left an indelible impression on me as a young male and so ever since I've supported the Rape Crisis Centre. Maybe drop them a donation in the name of Pseudonym121 ;-).
a) It'll help a very worthwhile organisation and
b) It just tickles my funny bone to think of how confused they'll be about any donations coming in with that nickname attached ;-)

Drumpot wrote: »

https://journals.lww.com/ajg/Documents/COVID_Digestive_Symptoms_AJG_Preproof.pdf

————————————————-
Conclusion: We found that digestive symptoms are common in patients with COVID-19. Moreover, these patients have a longer time from onset to admission and their prognosis is worse than patients without digestive symptoms. Clinicians should recognize that digestive symptoms, such as diarrhea, may be a presenting feature of COVID-19, and that the index of suspicion may need to be raised earlier in at-risk patients presenting with digestive symptoms rather than waiting for respiratory symptoms to emerge. However, further large sample studies are needed to confirm these findings.

—————————————————-

There are some reports that Gastro problems (like diarrhoea) can be an advance warning and in a small study of Hubei patients, just under 50% had this as their primary symptom. Have you heard anything regarding this or is there any sign that this has been a symptom from what you have seen thus far?

Thanks for answering all these questions, it really helps...

Fortunately we have a fox what used to be Professor of Cunning at Oxford Univesity but has moved on and is working for the UN at the High Commission Of International Cunning Planning working on this. ;-)

Yeah, gastro problems definitely seem to be more common than with the common flu. I know there is talk about this as a marker of potential severity of illness down the road but I don't consider that proven definitively by research yet. It is an evolving situation so that answer could chance a month from now.

Either way though you're just better off focusing on social isolation, distancing and hand washing.

Standman wrote: »

I'm a bit confused about the advice regarding hygiene/social distancing - HSE website says masks are unlikely to be effective for healthy people and seems to advise against gloves, but you reckon it's irresponsible to go to a supermarket without gloves and masks? Also, if we're worried about touching surfaces in a supermarket then what about the things we buy and take home? Should we be disinfecting packaging? Thanks.

Well the answer is nuanced:
1. Masks tend to be useless for the public because they don't know how to use them properly and so don't get much if any protection from them. Social isolation, distancing and hand washing are much easier for the public to actually do properly.

2. I think that if given the option one shouldn't go to the supermarket at all. One should just have food delivered. I haven't set foot in a supermarket for about a month now. I've moved to only home delivery.

3. If, however, you are determined to go to the supermarket in person then, yes, I'd suggest taking all the precautions you can... with that said there's no point wearing a face mask unless you've watched videos outlining how to properly put them on, fit them and take them off ( I provided several links for this in this thread ). Otherwise you're just wasting resources that healthcare workers could use.

As for the things you take home... That's a really good question. I use the following procedure and even then I think it isn't perfect but it is about as good as I'm going to get without professional equipment.

1. When a food delivery comes in I have an area set aside for the delivery to be dropped to. I now assume that the hallway it passed through and the room it is dropped into are infected. I wear a mask and gloves during the delivery process.

2. I don't go into the hallway or room it was dropped into for 3 hours without wearing a mask... Ideally I just don't go there at all. This is to let droplets settle.

3. I now retrieve the frozen goods, wipe them down with disinfectant wipes and place them in the freezer.

4. Non-frozen goods are wiped down or placed in a UV light steriliser ( for baby bottles ) as that has a decent chance of breaking down viruses etc and is a quick and easy thing to do with ready meals, keys, swipe cards etc which can be contaminated when out and about. I don't think is a perfect solution at all but in a home environment it is a a cheap enough intervention ( disinfectant wipes are cheap, gloves are cheap and the mask I wear is an N99/FFP3 reusable half face mask - the UV sterilisers can be bought on Amazon for 40 Euro to 100 Euro depending on size etc ).

5. Other jars, bags of pasta, rice etc are wiped down with a disinfectant wipe and then popped into the UV steriliser for about ten minutes at a time. Sure it might take me 6 hours to process a delivery but 3 hours of that is just leaving it sit in a closed room and then the next three hours is processing the delivery for storage and mopping the floor with bleach and cleaning other exposed surfaces.

It isn't perfect by any means but:
a) it only cost me the cost of the UV steriliser and
b) I only get a delivery every fortnight
c) I can have the radio and TV on during the process so am not missing out on any news etc. I don't make phonecalls during the time as being distracted is how mistakes happen.

Is it overly cautious? Well, it certainly is on the extreme end of preparations but, then again, I figure I have between 15 to 20% mortality if I catch this and if I survive I can expect to live maybe another 30 years so spending a few hours cleaning once a fortnight and looking like a weird survivalist prepper to the deliveryman is a price I'm prepared to pay. ;-). Additionally I have a responsibility to my patients and colleagues to stay as well as long as possible in order to continue providing care. Even if I were to die from this dying 6 months from now vs dying a month from now is 5 months of useful work supporting patients and staff. That's well worth it.

Obviously once a vaccine rolls around, even an experimental one, I'll take it and be delighted to abandon all of these precautions.


If there is interest in the routines and habits I'm trying to instill in myself to minimise the chance of bringing this into the home I would be happy to outline them in a post. Let me know.... you can't rely on yourself remembering these things willy nilly. You really need to think it out and have either a mental or written checklist. That's how we do things in surgery and when dealing with infectious or immunocompromised patients. We're learned that checklists work.

Skygord wrote: »

My wife finished chemotherapy 6 months ago, and had a splenectomy 3.5 years ago.

We understand she is in an at risk group.

Are there any extra precautions that we should follow - over and above the guidelines for self-isolation?

No, I would just stress that you need to really practice self-isolation... not self-isolation with the occasional chat across the fence or when I run into someone on a walk. Self-isolation means staying at home for the duration with only essential trips out ( for food or medicine but even there if your pharmacy will deliver then have them deliver). I'm picking up some medication tomorrow and I'll be wearing the latest Spring Armageddon look - gloves and facemask - when I go. With that said I am trained in how to properly use the gloves and facemask ( privately purchased, not from HSE stores ) which is why I say I don't think a facemask makes much difference for most people - as they don't get any benefit because they put them on, fit them and take them off incorrectly.

Drumpot wrote: »

My sister smokes but had leukemia when she was a child. ( not had problems or check ups in decades). She works in a hospital up north and when I asked her if she had spoken to a doctor about her risk factor she said she didn’t see it being a problem. She’s also refusing to buy these personalized masks they are offering. Would a person who has , I think, fully recovered from this illness theoretically not be anymore at risk then the average person? I appreciate you cannot give medical advice here, I am just wondering how insistent I should be with my sister that she should talk to a doctor regarding her risk profile, especially while she’s working in a hospital....

Yeah I can't really give individualised advice because I don't know the full situation but my compromise is that I can talk about the generalities which seem to apply and then suggest what I think would be a reasonable course of action.

I would imagine that a fully treated and in remission cancer from many years ago for which she isn't still taking any chemo shouldn't put her in a high risk category because, essentially, she had an illness, treated it and now doesn't have it any longer. With that said a lot would depend on individual factors - some jobs in the health service are lowish risk, some are very high risk and I'd expect 100% infection rates in some roles.

I think it would be smart for her to talk to a doctor regarding her risk profile given the fact she works in a hospital. With that said I'd expect they'll say that a resolved cancer with no ongoing treatment doesn't put her in a higher risk group. So, I expect it'd be good news.

Fluorescence wrote: »

Thank you for taking the time to answer the questions, and for continuing to work despite being at considerable risk. This really is a war.

I work in the veterinary sector. Many of our clinics and hospitals have ventilators. In the UK, the AHT is compiling a list of veterinary ventilators and liasing with officials to coordinate their potential donation/use in the hospitals in the weeks to come. I don't know if the Irish bodies are aware that these facilities may be available to draw upon?
It's not a standard piece of kit in every hospital but there are many around, which may be worth investigating.

Aside from ventilators, is there anything veterinary staff in particular can do to assist in the coming crisis?

Well, I think you can do two main things:
1. Contact your representative body and ensure they are in contact with the government about these ventilators. It does seem to me that the HSE has been pretty good about scouring the country for ventilators and it seems to me we have roughly doubled the number of usable ventilators ( from private hospitals, converting ORs and buying more ). That's going to have a huge impact on keeping people alive. We still need more though so I think ANY ventilator going would be welcome. Funnily enough we make a large portion of the world's ICU type ventilators in Ireland so that'll be helpful.


2. Consider contacting the Ireland's Call website. If you know how to place lines etc then I could see there being a role for you and others doing minor clinical tasks which would normally be done by nurses etc which would allow them to be freed up for more crucial tasks.

It seems you understand this but it bears restating. Ireland is about to have a small to medium sized war, with all of the casualties that entails. Anyone who has skills in treating mammals will be useful because humans are just unusually hairless mammals with pretensions ;-). With that said I'm sure that if you aren't comfortable taking on a clinical role there will be a lot of roles in providing deliveries to the elderly during the cocooning phase etc.

Hobgoblin11 wrote: »

Is sex ok during this crisis or should we be avoiding that also?

When can we go back to this type of thing if it's not recommended?

Do you contact trace your partner?

Well I think having sex with someone you don't already live with is certainly increasing your risk. I'm not even sure this is a serious question but I'll answer it as though it is. I'm single and I certainly amn't going to be dating until either a vaccine is available or I've been infected and, hopefully, survive.

As to contact tracing... I assume that's a joke but if it isn't then I'd suggest that you can't know whether someone is infective or not no matter what level of contract tracing you plan to undertake. With that said people often put themselves in danger in pursuit of sex so I'm sure many people will continue behaving less than logically in this area going forward.

17-pdr wrote: »

I see that having high blood pressure is one of the risk factors. If you are on medication for it and your BP is now ok, is an underlying risk still there?

Yes but I would expect that well-controlled high blood pressure is less risky than poorly controlled high blood pressure. With that said even with well-controlled high blood pressure I would consider myself to be in a high risk group.

Arlessienne wrote: »

In your opinion, how high risk is someone (aged 40) with Inappropriate Sinus Tachycardia requiring 7.5mg bisoprolol daily and suffering fairly significant exercise intolerance? They are an ex medical scientist and looking to volunteer - is their risk of further burdening the health service if they get sick low enough to go ahead? It's impossible to get any response at the moment from gp or cardiologist. Obviously this would be just your theoretical opinion on this condition generally, without knowing full details.

Thanks for all you are doing both in the hospital and in spreading awareness here. Your posts are scary but I believe them to be realistic. Thanks for trying to get people to wake up to reality.

Thanks for the question. I don't wish to be difficult but there's no such thing as inappropriate Sinus Tachycardia. I think I know what whoever used that term meant though and I would think that this would qualify as Cardiovascular Disease and thus put them in a high risk category.

In terms of volunteering with the Ireland's Call initiative... There will be need for people taking on clinical roles and non-clinical roles. With the non-clinical roles some will be asked to present themselves to certain sites and others will be able to work from home.

So, even if in a high risk group and completely socially isolating at home I think there will be roles that this individually could do without increasing their risk of exposure one iota. If I were in your shoes I would encourage them to volunteer ( I think that's really helpful right now and everyone who can help out should ) but to do so in a role which could be done from home without them breaching their social isolation.

There are LOTS of young people in their 20s and 30s without any health conditions who should volunteer for patient-facing roles if at all possible. Some of us with health conditions need to put ourselves in the firing line because that's just where we need to be right now BUT I don't see any sense in this individual putting themselves in the firing line when there's an option to help out which won't increase their risk.

Obviously that's just a general answer but I hope you find it helpful.

lillycakes2 wrote: »

I am a nurse, I live with my mum who is over 70,self caring. I am not going near her, I am using just one room (my bedroom), with door closed, I am using my own toilet, my own cutlery and I just walk out front door when I go to work, she is not allowed to use this door , she uses the back door.i am not using any room in the house ,I am showering etc in work....
Does this sound ok to you ?.

Hi lilycakes2. Those all sound like sensible precautions alright. It seems there's a desire to have a post on how to prevent bringing infection into the home. I'll write an essay type answer up for that over the next couple of days but it definitely sounds to me like you're doing much more than most. There might be a few areas one could improve though through the purposeful establishment of a room to clean and change on entering or prior to leaving the house so that the rest of the house could basically be considered a "clean house". That's the approach I've taken -turning a spare bedroom into a changing area and taking off my clothes from work there and then cleaning my hands and showering on return from work. Once that's done I consider myself clean and then can just potter around the place with no concerns. When I'm going out I go into that room, assume everything in there is infected, change and then go out.

I'll write it up in fuller detail as I think there are a number of people living with elderly relatives who are concerned about this sort of issue and want to make reasonable changes ( which would have sounded utterly hysterical just a few weeks ago ) to make things as safe as possible.

supermouse wrote: »

Firstly, thank you for doing this AMA. Furthermore, thank you so very much for everything you have done to date and will no doubt continue to do well into the future to protect us all.

Why do you think we haven’t been put in lockdown yet? As we’ve all heard and seen, social distancing is working for some but so many are ignoring the rules. Mr Varadkar has access to the same data as you, is a medical doctor himself and is surrounded by some of the brightest minds we have in this country. Why are we delaying the inevitable do you think?

Stay safe. I truly mean that.

Thanks. This is part of my small contribution to this and I'll continue answering questions for the duration or until I'm no longer able.

I think that people, on average, are self-deluding and prefer to live with imaginary safety rather than real-world reality. It takes time for people's mentality to shift from their rose-tinted view of the world to the reality we now find ourselves living in. This is made worse by the fact that what scares me and others who understand viruses and epidemiology is NOT today's figures but where they'll be 1 month from now if we don't act now. People in general are very bad at visualising a future situation and acting now to prevent it. They look at today's situation and base their decisions on that --- you see this with climate change. People have really only started getting on board when current storms have undeniably become more frequent and severe --- even though we KNEW that would happen for at least two decades.

As to Leo being a medical doctor. LOL! If I remember correctly he went straight from internship into GP and from there into politics. I mean I was an intern and SHO at one stage too but God help us all if interns and SHOs are making these decisions. They're very much still learning. I see this with my own NCHDs whom I've been talking with about the epidemiology of this. They have a basic understanding but not enough to really get as scared of this as they should have been --- to be fair I think mine have been scared enough that they and their families took appropriate steps weeks ago because I sat them down and had some significant chats with them about how serious this was going to be and their responsibility to prepare in order to be of use to the health service and public going forward. I don't think too highly of Leo's insights into medicine - hell, I remember him as a GP trainee, I had occasion to interact with him professionally back then. He was fine but I wouldn't be listening to him on epidemiology right now. To be fair to him he hasn't made any claim that his medical background such as it was gives him any special insight right now. He has, as far as I've seen, stuck to the line that he's listening to the expert group. I am not a fan of him on a personal or elective representative level but I think he is managing this pretty well all things considered.

Anyways, the government has a public who just don't get it and moving them to where they need to be takes time. I think we are seeing that process in action. This reminds me a lot of how Singapore managed things with SARS back in the day. They tried gradually increasing restrictions etc too, realised it cost a lot more deaths and went straight to the full suite of measures this time. End result, they have this largely under control.

While I think we should have adopted the 2020 Singapore model from Day 1 I recognise that:
a) the resources and planning just weren't there and
b) the Irish people wouldn't have gone along with it... I think the public has had to go on a journey to understanding this was serious --- and even today there are really disheartening images of groups of people in town and shops etc.

Overall I think that going with the mass testing, contact tracing and delaying spread while building up ventilator and hospital bed capacity model is probably the best we could realistically do given the fact that Irish people just didn't have the SARS experience that Singapore had back in the day.

Whiplashy wrote: »

I live with my elderly parents and I myself am on weekly benepali injections. When the government recommends cocooning, would I need to follow that recommendation as well as my parents? We live in the country with no family nearby so would need to be thinking about trying to put arrangements in place if necessary.

I think that if they cocoon and you are out and about then there's a significant risk you'll bring SARS-CoV2 home. As I said above I'll post about the steps you could take to minimise the risk of bringing that into the home.

But the basic point is that if one person in a home is going out then they certainly have a risk of bringing it into the home and should take significant measures to reduce that risk.


Right now the real countries to look out for are, IMO:
1. Iran - but that's pointless because they are not being honest about their figures.

2. Italy - this is where we'll see lockdown in a Western European country work first. This should then enable the Irish government to sell these measures to Irish people.

3. UK - they're our closest neighbour, are taking a different approach and should exceed 100 deaths per day 5 to 6 days from now. I think that will be a psychological benchmark for them.

4. USA - I think they're going to have a horrendous outbreak of this. I think they're going to make Italy and the UK look like nothing. The Federal response has been terrible and only local state and even university-level actions have been in any way effective there. I think their number of undiagnosed individuals actively spreading it currently is huge and their healthcare system is NOT set up to provide the socialised care a pandemic needs so structurally unless the federal government steps in they're in terrible trouble.

They'll show us the path out of this for us ( Italy ) and the worse (UK) and worst (USA) case scenarios we could have experienced if we didn't have the response the state has generated.

To their credit I keep hearing management tell us that "money is no object" right now and that if we need something which will improve outcomes then the money will be there. Obviously there's a lag time in ramping up production but at least the government in Ireland really is taking the attitude that it'll spend whatever it has to to save the most lives possible --- we just need you, the public, to do more social isolation. Right now you aren't doing your part and this will cost hundreds, possibly thousands, of lives in coming months.

Xertz wrote: »

A genuine question, and I know it might be impossible to answer, but do you foresee this going on for a few months or are we looking at a new normal well into 2021?

I've been on record since I first starting posting about this 3 or so weeks ago that we will still be talking about this in March 2021.

We will be talking about this until we get a vaccine and even then we'll still talk about it because by its nature I expect it will generate enough generations of infection to mutate into different strains. I expect ( but this isn't proven, just my expectation based on my understanding of how new strains develop ) that COVID will become a seasonal thing like the flu and generate COVID-21, 22, 23 etc and become just like seasonal flu except much, much deadlier to the elderly. It will probably drop worldwide life expectancy by a few months to a year over the next decade.

Arlessienne wrote: »

Thanks so much for your response. It was very helpful. I will pass on your advice about volunteering for a role with no or little contact and he will hopefully eventually get a specific response too from one of his doctors to be safe. (IST is the official diagnosis written in medical reports from a cardiologist specialising in electrophysiology and was deemed to be a type of SVT and possibly a form of dysautonomia or SA node malfunction.)

Best of luck and thanks to you and all your colleagues.

Hi, thanks for the reply. I can see i was unclear when I said there is no such thing as inappropriate sinus tachy. Sure it is a term that is used but it doesn't describe underlying pathology. It can be caused by anything from drinking too much caffeine to a serious life-threatening disorder of the electrophysiology of the heart. That's why I was saying there's no such thing --- although I can see that wasn't as precise as I should have been.

So, now you're saying that IST actually represented either the cardiac pathology of SVT or SA node dysfunction. Either SA node issues or SVT are cardiac issues. I think the best way to deal with this and play it safe and say - "Well, if I have a cardiac diagnosis then I'm going to assume that puts me at higher risk". Other doctors might differ.

I am unaware of any evidence which says SVT and A Fib are not associated with high mortality in COVID-19 so I'd prefer to play it safe and assume they are higher risk. If that evidence evolves or someone can post a link to such a paper I would obviously defer to it. Our knowledge base re: COVID-19 is continuously evolving.


Damn, I just deleted the answer I'd written to the next question. here goes again.
We simply don't know why some people incubate for 5 days or 14 days. We also don't know how long they are infective before they develop symptoms although most people now think it is at least 12 to 24 hours. For the test to be positive enough viral RNA needs to be on the swab to be amenable to PCR. But we don't know how long that takes and if that varies from the 5 day incubators to the 14 day incubators. We are still learning a lot about this virus.

up for anything wrote: »

Based on our figures today, 20th March, and the lack of proper social distancing going on, what do you think our best, medium and worst case scenarios are going to be regarding deaths?

Good questions albeit I think the answers may not be re-assuring. I've explained previously that in this sort of situation one method is to come up with 9 scenarios - Best, Middle and Worst and then divide each of these into Optimistic, Reasonable and Pessimistic.

I'm on record previously as stating that the best case scenarios I foresaw for Ireland over the next year were as follows:
Optimistic Best: 2,000 Dead.
Reasonable Best: 5,000 Dead.
Pessimistic Best: 10,000 Dead

Optimistic Middle: 20,000 Dead.
Reasonable Middle 50,000 Dead.

Given the steps we have taken I don't see us exceeding a reasonably middle case scenario anymore so I won't go into the worst case scenario numbers. I'm sure the government has even better estimates. These were my estimates created when I began researching this 3 to 4 weeks ago. I think they're still valid although we're now more likely to be in best case scenario territory than middle and worst case like we were 4 weeks ago.

The proviso for the above is that IF we got an experimental vaccine in good numbers by September 2020 then you could see those numbers fall by 80%. The reason is that if this follows the Spanish flu modality then we could expect a massive spike in deaths in Q4 ( I believe roughly 80% of all Irish deaths over 1918 and 1919 occurred in just 8 winter weeks in 1918). Is it guaranteed to follow this pattern? No, but I think that assuming it will isn't unreasonable. It could still be wrong though.

up for anything wrote: »

Are there going to be enough ventilators, do you reckon, for say the medium case scenario? I assume, probably wrongly, that as we are a manufacturer of them we may get first dibs on them.

No, no there won't be. The state has done amazing things to increase the numbers of ventilators, staff and beds but the public has NOT done its part in terms of social isolation and distancing and, as such, the public has condemned many more to death than were unavoidable. Well done guys.

Medtronic makes a large number of worldwide ventilators seemingly. They have boosted production and will boost it more. My understanding is that what they would have produced normally is already bought by other countries and it would be very foolish for the Irish state to requisition them - we'll need other countries soon enough and they'll remember if we screw them over and return the favour. I'm sure we've negotiated/strong-armed quite a good proportion of the increased production though - and this would be more tolerable to other countries.

up for anything wrote: »

Are patients who are within some hours of inevitable death actually in any sort of condition to say goodbye to family via phone or iPad like I've heard they've been doing in Italy?

If they're tubed and sedated then they're not. If they are more conscious then a remote goodbye may be possible so long as staff aren't overwhelmed.

LadyMayBelle wrote: »

Thank you so much for your advice and info, as well as your dedication. I'm glad you gave example of how you managed food delivery and wiping down items, as I worry about this as well as good intentioned people leaving items and bags of things at people's doors, esp elderly. I made clear in another thread that it's not about stopping kindness but a need to be mindful that more harm could be done than good? Once proper measures are in place then it's ok..ish.

Would love your broken down list you referred to..we would have been chuckled at for being preppers but took a lot of advice from your posts. Thank you.

Well, I actually enjoy watching those prepper shows for a laugh because I find their risk assessments and planning so one-sided and often missing huge issues which render the whole thing impractical. I've never gone in for that... but, like I said, when I figured out the stats behind this when I read into it 3 to 4 weeks ago I knew I had to prepare... and so I did and persuaded my family to also.

I'll write something up today/tomorrow re: dealing with food deliveries...

Funsterdelux wrote: »

Howdy doody Pseudy,

I was up on scaffold there starting to get the battens ready for slating the back of my cottage, the east wind is eating the face and hands off me. It got me thinking, with the measures of social distancing/isolation in place for months perhaps, other viruses such as the cold and flu would also find it hard to spread(i know we're going out of season). Would this have a positive or negative effect on our collective immune system? If a majority of us dont catch sars cov2 and other viruses, when/if things go back to normal would we be more at risk from getting a more severe cold/flu?

The question always sounds better in my head, anyway thanks again and good luck!

No worries. I don't think that the impact of social isolation on flu will have much impact on the flu season 2021.

trisha e wrote: »

If suspected cases have to wait days for a test and,as a result, test negative because theyre better what is the point in testing if not testing for antibodies at the same time?
Surely these tests should be allocated to people on the list with symptoms.
A work colleague of mine was sick for 2 weeks
GP booked a test on Monday and still waiting. Says he's feeling better now and wonders should he give his slot to someone else on the list. Thanks to you all.

I'd still go for the testing as enough RNA might remain to give a positive test and re-assure the individual that they are now immune to the current strain of SARS-CoV2.

I think the delays in testing and overly strict testing criteria will both change as more tests are available and more lab capacity is diverted to COVID-19 testing.

Yes, you're right that an antibody test would be very useful but, in the meantime, we use what we have because widespread testing and enforced isolation has been shown to be hugely beneficial in preventing spread.

fjortal wrote: »

Hello and thank you so much for answering questions during this time. My dad found out he needs a triple Bypass a week and a half ago. He is meeting with the surgeon on Monday. He is 75 and will be tested for Cov 19. My question is, in your opinion, could I visit him in relative safety before and after the operation while keeping 6ft between us, wearing gloves and mask? I am in good health, no symptoms whatsoever. I do have children. I am extremely close to my parents and other family members have visited, keeping their distance. I am torn between fear of passing something on and the negative mental health effects not seeing them is having. Many thanks Fjortal

I think that elective surgeries like that won't go ahead soon.... I'm unclear if you're saying he is due to be operated on on Monday - in which case it might still go ahead - OR if he is meeting with the surgeon to discuss surgery at a future date - in which case I would expect it to be postponed for the foreseeable future unless he would die without the surgery.

If it were me I wouldn't visit him. I'd use skype to videocall. I haven't seen my own parents except through a window or skype for about 3 weeks now. You have to balance the risks vs benefits yourself but heart surgery is a significant operation and putting him at extra risk seems madness to me - especially when we have skype. Sure it'll be a low level of extra risk but I just don't think it'd be worth it if it were my father.

You'll have far more negative mental health effects if you infect him with COVID-19 and he dies.

That'd be my attitude but you know yourself and your parents in a way I never could so you'll need to balance that yourself.

Potentially wrote: »

Firstly, thanks, no words could say it enough

Secondly: I am a single Mum with 12yo. Ex wants to continue contact, he has just collected her and has gone off for the day. He has been working as a salesman to pharmacies and has continued his normal socialising routines, with his new partner (nurse who home-cares for newborns) and others home recently from abroad....
I have been really careful to keep social isolation but is all that down the drain now?
My elderly parents and aunts rely on me; and if I get ill, there is no where for my child to go.
Please advise.

I can't tell you what to do in your situation but your ex's behaviour seems to be begging to be infected. If he continues having access to your child you should assume she will be infected also and from her you'll be infected.... and you could pass it on to whomever you have contact with.

I've heard many separated couples are fighting about this sort of thing when one partner isolates and the other doesn't. I think that is a tough situation to find oneself in.

Notsomindful wrote: »

Thanks for all you are doing.
My local testing centre is a drive through centre.
I have been referred for testing awaiting appointment.
Can I walk to test centre- as I dont have access to a car and dont want to risk spreading it to others unnecessarily like taxi drivers etc...

Yes, just be very careful to stay more than 2 metres from anyone if at all possible while on the way there. The risk of passing it to others outdoors if you pass by briskly and stay more than 2 meters away is low. Not zero, but low.

RobbingBandit wrote: »

Thanks for taking the time to do this.

I'm a diabetic I've just had my next couple of appointments postponed indefinitely I am currently dealing with several complications including foot and eye issues which require routine care and can turn nasty I am unable to contact anyone in the departments so far and really don't want to find myself going to a&e.

In short what is happening to patients with ongoing chronic issues in this current climate is my question.

I think we're doing our best to keep services going for our routine appointments but in a crisis like this routine care will inevitably suffer.

One of the unmentioned aspects of crises like this is that you only ever hear about the people who died from the crisis illness ( e.g. ebola, COVID-19 etc ). You don't hear about what epidemiologists call "excess mortality" which is those people who died in excess of the normal rate for that time of year.

So, let's say 100 people a day die in Ireland normally in April and this year we have 20 COVID-19 deaths per day in April but when we pull all the figures we find actually 130 people a day died in April. In that situation 30 additional people died every day due to the crisis, 20 from COVID-19, 10 from other illnesses who would normally have been saved but couldn't be because the health service was overwhelmed.

In Italy they are reporting an increase in death rates from cardiac problems and other issues even in patients who don't have COVID-19 because where it used to take 8 to 10 minutes to get an ambulance out to a heart attack it now takes hours - by which time many are dead.

So, that's grim.

In your case I'd try to make contact with the Public Health nurse or your GP if you can't reach your specialist. I'd also redouble whatever efforts you are making to manage your blood sugars etc as well as possible yourself.

So, in short we'll do our best but, yes, you won't get the quality of care you're used to and the more selfish A***oles go around not socially isolating and distancing and handwashing the more medical and mental health services will be overwhelmed, the more appointments will be cancelled, the more surgeries will be cancelled and the more people with ordinary health issues but not COVID-19 will die. Congratulations Irish public.

Airyfairy12 wrote: »

Hi I just have a question about coronavirus symptoms. Do they come on suddenly like in the case of a flu were you all of a sudden feel unwell or do they come on gradually, do you feel like youre coming down with something for a day or two before symptoms become obvious? Are swollen lymph nodes in the neck common with coronavirus like they are with cold and flu?

Thank you so much for taking the time to answer questions.

It is really quite variable. A lot of doctors have gotten it over the past week and many of them have described really rapid onset of symptoms. Some have literally sat down to dinner fine and been unable to finish the meal because they've become unwell.

Others report a gradual worsening of symptoms over days.

So, I think it varies a lot and there isn't a one size fits all presentation.

As to lymph nodes. I haven't heard much about swollen lymph nodes being a significant sign in COVID-19 presentations. With that said I think we're learning more all the time. Hell even today they're beginning to coalesce around anosmia etc as a significant symptom and that wasn't on anyone's radar in Europe a week ago. So, it is an evolving situation.

Ok, hope that was helpful, I think I'm caught up now.


Edited to clarify the answer for SVT/ A Fib and make it clear that the answer was based on "erring on the side of caution" in the absence of evidence of either issue not increasing the risk.

Bidd wrote: »

If you’ve had the vaccine for pneumonia would this protect you from pneumonia if you get Covid-19.

Not significantly no. Streptococcal Pneumonia is what this vaccine protects you from. Not all pneumonias are caused by streptococci and it isn't, to the best of my knowledge, a major contributor to the bilateral interstitial pneumonia people with COVID-19 often die from ( they die from other complications also of course ).

TLDR: No.

begbysback wrote: »

Given that deaths can be kept at a minimum by early diagnosis and treatment, are you guys lobbying for this, or just waiting at the doors of hospitals for critical cases?

Where are you getting this from? There aren't any validated treatments which are widely available beyond attempts to treat complications and/or support people with oxygen/ventilation until such time as oxygen and ventilators run out.

You assumption that there is a validated treatment which changes the course of illness if someone is diagnosed early isn't where medicine is at right now. The Chloroquinine and azithromycin combo is in a single small study which could have numerous confounding factors.

I think your assumption re: "early diagnosis and treatment" is incorrect, unfortunately, at this stage. Once we have a validated treatment then that could chance but we won't be in that position for weeks or possibly months and that's going to be too late for the people who will die in the initial peak in Ireland over the next 2 to 3 months.

Notsomindful wrote: »

Thanks for link.

That's reassuring for all of us who dont have access to a car/dont drive and dont want to risk.infecting others.in taxis/ high risk themselves...according to the hse, we" may be tested at home".

So we may not get tested at all.

Woohoo.

Absent a validated treatment the benefit of testing lies more in contact tracing and you knowing you must self-isolate. It doesn't benefit the individual hugely as there isn't a validated treatment which alters disease course and outcome yet.

So, just assume you're infected if you have those symptoms and stay at home.

It is dangerous to just make unwarranted assumptions about treatment evidence, availability and efficacy. We really aren't there yet. Everything will be thrown at this and weeks and months from now we will know what does and doesn't work but for the next several weeks to 2 months our best defence is the public socially isolating, distancing and hand washing.

Unfortunately you're doing a piss-poor job of it. I was delivering supplies to my parents today and there were large groups of people out and about chatting to eachother and not observing social isolation at all.

Sorry, I think I overlooked two questions somehow.

Beagslife wrote: »

Hi Pseudonym121,

Thanks for doing this. It's very informative and thought provoking. Stay well.

My questions is regarding suppressants (not sure if that is the right term) like cold and flu medications/remedies. I used to typically get a couple chest infections (with harsh chesty cough and perhaps sore throat and sometimes fever) a year. For the last few years I find that at the onset of symptoms if I take echinacea capsules regularly I can usually hold it at bay and after a few days I am back to normal. Where I have let it get deeper I would add astragalus to help clear it up. By the way, I'm not advocating the above in any way, shape or form as regards Covid-19.

Could the use of any of the above remedies by the general public cause problems by perhaps masking the Virus (reducing the symptoms and as a result people not looking for testing or being less cautious)? I think I read somewhere that some products had been banned in China for this reason. Possible fake news of course but perhaps you have better knowledge of this.

Would you have an opinion on this?

Sorry if it's not really relevant.

Anyway keep up the good fight and take care of yourself.

If in doubt I think you should ask your GP or respiratory specialist as that advice might vary depending on underlying medical issues. It has a quite a broad range of answers depending on underlying issues, sorry.

Fleetwoodmac wrote: »

Is there any truth in WHO giving directives regarding taking zithromax and chloroquine as prophilacs for covid?

Not that I've heard of. This appears to have been a very small study. Colleagues in the US have messaged me today with several messages from doctors using this combination to little effect... but Trump has run with it and so it is in the media.

It may end up being effective but I do not believe the evidence base is there to say that yet.

Happy4all wrote: »

Thanks for doing this and two questions if you don't mind:

1. My daughter works in a pharmacy and I fear for her health from additional exposure and then surely that impacts on the household's effort of social isolation, being made somewhat null and void. Should we be taken any additional measures?

2. The UK only reported 7 deaths today. A long way short of the daily 100+ prediction. Is this from lack of true testing numbers or signs that things are not as bad as feared?

Hmm... 7 Dead? I think it has been running quite a bit higher than that recently. Here's a good site which allows a breakdown of cases, mortality etc by country. Here's the UK page, scroll down for their daily number of deaths.

https://www.worldometers.info/coronavirus/country/uk/

They've had over 30 deaths a day for the last five days by my reckoning. Unfortunately I think it is only a matter of time ( just under a week probably ) until they have 100 deaths per day. It is very sad.