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Coronavirus: thinking outside the box

2020-03-09 08:05:19

Something a mere virus has been able to do, as opposed to the prime minister, is drive Brexit almost completely from the national media. Not since the referendum, nearly four years ago, has coverage been so slight.

Not least of the reasons is that things are not shaping up too well in Italy. Incidence of Covid-19 has leapt 25 percent from 5,883 to 7,375 cases, with the death toll climbing 133 in one day to 366 a rate of 4.25 percent and rising.

Apart from anything else, that seems to be more than enough evidence to illustrate that we have something serious on our hands serious enough to warrant fast and effective action if we are to avoid the same fate, and worse.

Instead, we have an idiot prime minister pratting about in Bewdley visiting victims of the recent floods, something he should have done weeks ago, if it were to be done at all.

At another level, there are millions of people who desperately need training in hand washing. But, rather than dealing with matters below his pay grade, there is an urgent need for somebody to take charge on the political dimension of the strategic management of the response to this growing epidemic.

Short of the high level quarantine exercised by the Chinese government, which seems hardly possible even if it is being attempted (rather badly) by the Italians it seems that we also need some creative thinking if there is any chance of keeping the death rate down.

One crucial element, it has emerged, is the need for intensive care units (ICUs) to deal with the number of sufferers. Critical care experts in Italy have warned hospitals in Britain and across Europe to prepare for a surge in admissions of people with severe lung failure.

Already, Antonio Pesenti, head of the Lombardy regional crisis response unit, is warning that the health system in Lombardy is "a step away from collapse" as ICUs have come under growing strain from the new caseload.

"We're now being forced to set up intensive care treatment in corridors, in operating theatres, in recovery rooms. We've emptied entire hospital sections to make space for seriously sick people", he says. But it is less than a week since Lombardy's health minister said hospitals had the capacity to deal with patients.

This is redolent of Johnson's boasting - also less than a week ago - that the country "is very, very well prepared". It wasn't, and isn't. And, with many ICUs already at or near full capacity, if Covid-19 develops into a full-blown epidemic, the NHS could go into meltdown. People who could have been saved will die, as patients wait in corridors and ambulances and even die waiting for ambulances to arrive.

Needless to say, Public Health England is making reassuring noises about capacity being expanded, but one does not have to be an expert to appreciate needs will be difficult to meet. As many as ten percent of all those infected with coronavirus may need intensive care.

Of course, much will depend on the rate of increase in the case rate and that will depend on the broader community measures and the actions of individuals. But the probability is that heroic measures would be needed to meet the expected demand for ICUs and it is here that the creative thinking will be most needed.

Potentially, there are three main bottlenecks: the space required in secure facilities; the equipment and; the trained staff.

As to the space requirement, while building brand new hospitals in the style of Wuhan is probably not practical, there are buildings which could be pressed into service as single-purpose coronavirus hospitals.

Photographs from the 1918 Spanish flu epidemic show sports halls, leisure centres and even aircraft hangars being used, and there is no reason why we could not adopt the same strategy. This might be faster and easier than converting space in existing hospitals, where infection controls will be needed to protect existing patients and the staff caring for them.

Temporary buildings, however, will need equipping. Beds need not be much of a problem as basic institutional supplies can be accessed. The beds can be discarded once the crisis is over, so durability is not an issue.

The big problem is going to be providing the specialist equipment, of which ventilators are going to be the most expensive and difficult to source. And until coordinated inquiries are made of suppliers (and emergency stocks), it is not going to be possible to determine availability. Ventilators, though, may prove to be the limiting factor in any expansion programme, especially as there will be worldwide demand.

Assuming this problem can be overcome, the availability of trained staff then becomes the major hurdle. What must be recognised is that treating patients with communicable disease in ICUs is even more laborious and time consuming than normal processes.

Staff have to wear complex protective equipment, aseptic regimes must be intensified and concurrent disinfection will be needed. That alone will bring down the utilisation rate of ICUs and the actual number of staff would have to increase even if there were no additional ICUs.

To meet the demand, there is some talk of bringing back retired staff, which is not necessarily the best of options. This cohort will include some of the most vulnerable to severe infection, so patient contact might present an unacceptable risk.

There again, the problem is that ICU medicine is a highly-skilled speciality. Under normal circumstances, additional staff cannot be made available without prolonged training, and there simply isn't time.

According to The Times, Alison Pittard, dean of the Faculty of Intensive Care Medicine, says that hospitals will need to take a novel approach as the outbreak progresses. "My main concern for ICUs is capacity", she says. "We're simply not going to have enough beds. To manage the increase in numbers we are going to have to dramatically change the way we work".

Thinking, though, tends to be rather pedestrian and limited in scope. To meet the exceptional demand, we probably need to look outside the medical profession for answers. One place to go might be the flight deck of a US Navy aircraft carrier, where one will see "colour-coded" crews, with different colours for each of the key task groups.

This came about because the US Navy had to contend with a major expansion of the air fleet, using conscripts with low education attainment and only limited time in service. As it was not possible to train crews to high levels, the procedures were broken down to a number of tasks, and crews were trained only for their specialities. Fully-trained all-rounders were not needed.

As to recruiting the staff, a leaf can be taken from the wartime Henry Ford who was asked to build mass-production factories in order to increase the number of aircraft coming on-stream.

When it came to staffing these factories, Ford did not want skilled craftsmen. He preferred untrained housewives, coming freshly into to the labour market, who could be better fitted for fairly restricted, repetitive tasks.

By that token, ICU functions in temporary hospitals could be performed by raiding trainee doctors, nurses and even paramedics, with the care organised on a standardised, production-line (or carrier deck) basis.

All this may be so much pie in the sky as it stands, but what is becoming very clear is that the NHS, as presently structured and staffed, will not cope with a major epidemic.

Here, if the worst-case scenario comes to pass, the figures are staggering. In a nine-week period, we are looking to over 40 million people becoming infected, and over four million seriously ill people needing intensive care with the best part of half a million people dying, or more if the system breaks down.

On that basis, there is no room for business as usual in the NHS. The new chancellor is saying that the NHS will get whatever it needs to deal with coronavirus. But unless that money is made available right now, and put behind some heroic and innovative measures, he might as well not bother. It will be too late.

And here is where a prime minister worthy of the name might make the difference, as long as he is able to think outside the box. Belated visits to flood areas and more hand-washing photo-opportunities simply won't cut it. We need a strategic political manager. Instead, I rather fear, we have Johnson.