Thread by @pmdfoster

NEW: SO. NHS is NOT just short of protective gear and ventilators, per fascinating leaked memo by senior doctor; also #COVID19
#Coronavirus is NOT a "one organ" (lung only) disease - my latest via @FT 1/thread

ft.com/content/e26524…

@FT First, the who/what etc

This is a 1,000-word memo from Prof Daniel Martin Intensive Care Lead for High Consequence Infectious Diseases at
Royal Free Hospital after a conference call with 80 other docs.

It is gripping for several reasons /2

It essentially reveals two things:

1) the shortages and pressures on the NHS, on staff and kit

2) how care is evolving and still under discussion by docs. It is not as simple as just 'deal with pneumonia'.

Take each in turn /3

First the shortages/staff

- nurse-patient rations (ordinarily one-to-one) are now 1-in-6 says Dr Martin

- and training is now 'on the job' has has 'fallen by the wayside' coz too much pressure /4

Also turns out that #Covid_19 is causing a lot of acute kidney disease (AKI), partly as a result of "over-zealous" use of diuretics (Frusemide) which, I understand from doc contacts, is part of a wider discussion on how much to hydrate Covid patients. Still an inexact science/5

This in turn is putting pressure on equipment, notably CVVHF machines, which I am told are a kind of dialysis/blood filtration machine used in intensive care. Also 'pumps' for treatments. This is causing doctors to shift treatment. /6

Dr Martin games out what happens if they "run out of machines" - saying he'll revert to "PD" or "peritoneal dialysis" (described to me as 'stick a load of fluid in your abdomen and then drain it out') which he says is "not great" - OR "sharing machines". /7

It really is all hands on decks - everyone is getting dragged in from 'med students' to dental hygienists; also clear that some "non-medical" workers are reluctant to go onto ICU. Dr Martin says is "unacceptable". His job to say that. I pass NO judgement. Not me on frontline. /8

On that note, more widely, none of this is about passing judgment. This is a wartime situation. Peacetime rules cannot apply. This is about docs fighting v hard to wrestle down a new enemy with less than perfect kit. Welcome to fight club. For real. /9

Which brings us to part 2 of this memo - the fact that #COVID19 is a moving target. It is NOT just a 'one organ' disease (fixing lungs/pneumonia)...it still sounds like a moveable feast out there. And recall this is a memo of 80 top docs sharing 'combat' experiences /10

So it turns out that ventilating patients too early, too aggressively as they head in ICU could be a mistake.

Also that taking patients off intubation too quickly may be a mistake.

We assume docs have all the answers; but they are learning as they go too. /11

There is also an intense debate about how hydrated patients should be under the heading "fluid balance" - which I understand from a doc is a big topic of conversation. Dr Martin reports that everyone reckoned we are "getting this wrong" /12

There is also an intense debate about how hydrated patients should be under the heading "fluid balance" - which I understand from a doc is a big topic of conversation.

Remarkably that Dr Martin report consensus that "we are getting this wrong". /12

All this is to note that - to quote Dr Martin in his sign-off - the docs know they need to "adapt *fast*" to learn about #Covid_19 #Coronavirus - and they are hard at it, trying to solve the puzzle.

And I love final words: "be kind to one another". All that. ENDS