Dr Dan Goyal Profile picture
Mar 8 22 tweets 12 min read
Pandemic Mistakes
Part 3 of 10

One of the worst pandemic mistakes, IMO:

In the UK in April 2020, a nationwide directive to ration oxygen was issued.

Rationing oxygen, in the UK!

🧵

#PandemicMistakes
A bit of background:

1. For the vast majority of Covid patients, the lower part of the lungs are unaffected. Most symptoms come from the infection in the upper airways, but don't affect our ability to absorb oxygen.

2. Severe Covid is defined as the requirement for oxygen...
...this means the lower lungs are affected.

[Picture shows Severe Covid. Unique pattern in the very lower parts of the lungs. The red = inflamed. Blue = normal. Where it is red, the ability to transfer oxygen into the blood is reduced]
If enough lung is inflamed, then our blood oxygen levels will start to decrease. This is called hypoxia (low blood oxygen).
Hypoxia leads to tissue damage, increases the risk of clotting, and worsens inflammation.
If hypoxia worsens further and is not corrected, then death or disability occurs due usually to heart and/or brain damage.

Normal (healthy) oxygen levels are between 96 to 98%.
We normally administer oxygen if oxygen levels fall below 95%.

brit-thoracic.org.uk/quality-improv…
On April 9th 2020, NHS England issued a directive to reduce oxygen targets nationwide.

Overnight we went from admitting all hypoxic patients to admitting only the more severely hypoxic patients.

madeinheene.hee.nhs.uk/Portals/0/Clin…
A couple of points about the directive:

1. It was nationwide.
2. It applied to all conditions, not just Covid.
3. It was issued NOT due to oxygen shortages but due to concerns the oxygen pipes would not be able to handle the increased flow of oxygen in some hospitals.
At the time, London was the epicentre of Covid. Indeed, elsewhere in the country the demands were considerably lower. There was to my knowledge no threat of oxygen supply problems except for a few hospitals in London. But the directive was national! And many trusts followed it.
It became a new normal across much of the country (including devolved nations) to only admit Covid patients if oxygen levels were 91% or lower. Not 94% as usual, but 91%.
Many ambulance services also changed their 'conveyance' protocols to this new target.
Part of the issue was the wording of the directive.
Note the first part.

The reason for the rationing was concerns about the possible supply/demand issue...
Fine. There isn't enough oxygen so we will need to ration it and until we get more!

But the directive tries to justify the decision as in someway harm-neutral....stating trials suggest 'hyperoxia' (higher than normal) oxygen levels are bad for you and lower levels are safe.
The evidence referenced is the IOTA study of 2018. This study had nothing to do with Covid or pneumonia. The study looked at true hyperoxia, where supernormal levels of oxygen were trialled to 'treat' stroke, heart attack, etc. not hypoxia.

frontiersin.org/articles/10.33…
NHSE trying to detract from the compromise in care caused by oxygen rationing by suggesting there will be no harm resulting is, IMV, disingenuous and risky.
It has the whiff of 'spin' so typical of our current government...bad news delivered with half truths to lessen the blow.
Rationing oxygen is a sign of failed pandemic controls or pandemic preparedness. Many countries have 'had' to ration oxygen, such as Italy, Brazil and India as they were running out. Other countries did ration oxygen - US, Belgium, Spain - but seemingly not due to supply issues.
The consequences are grave.
There is the issue of sub-optimal/delayed care.
Bigger issue is sending patients home who have clearly progressed to lower lung involvement. They receive no oxygen, often no monitoring, and no supportive treatments such as blood thinners.
So why did the UK, where oxygen was not in short supply, consider it necessary to ration oxygen?

Was the directive motivated by an attempt to reduce hospital admissions?

Where is the evidence of safety for this sudden change in standards?
Did people come to harm due to this rationing of care?

How many suffered long-term disability due to this policy?

And would quicker action by the UK Gov - flattening the curve earlier - have prevented the concern about oxygen altogether?

Q's for the Covid Inquiry!
Thankfully, many NHS Trusts have reverted back to our normal British Thoracic Society guidelines for oxygen targets of 94-98%, commencing once oxygen falls below 95%.
But some still believe lower oxygen targets are safe. This, the risk of 'positive spin' in healthcare and science
The Bottom Line:

The biggest error was implementing a policy rationing oxygen NATIONALLY.

The second mistake was not to REVERSE it once the wave had passed.

The third was to try and convince clinicians it wasn't a compromise in care.
At some point the reality of the situation needs to be owned. Yes, care was rationed. Yes, people suffered because of it. Apologies, remediation, and then LEARN.
Another variant looms. A further pandemic is almost certain. A proper Covid Inquiry could be life-saving!

RT pls

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More from @danielgoyal

Mar 9
The Week In Covid.

March 8th 2021

A weekly summary of what's happening with Covid.

#TheWeekInCovid
While some world leaders try their best to convince their citizens that "Covid is Over", Covid remains the biggest killer of all infectious diseases worldwide.

➡️ 500K more deaths since 2022.
➡️➡️ 52K deaths reported in the last week... Image
A more detailed analysis carried out in the US (@cynthiaccox and co @KFF) showed Covid was the second leading cause of death in the US, even before Omicron hit in Dec '21

...and the leading cause of death in the 45-54 age group!!!

So, no, not a disease of the elderly! Image
Read 24 tweets
Mar 4
Covid hospital admissions rising in the over 60s.

Some tips if you do get Covid.

Job 1: Do NOT delay seeking medical care if you are concerned or there are worrying signs.

BE prepared!
🧵
1/12
If you don't have them already, get:

1. A thermometer
2. A Pulse Oximeter*

*this is a small device you place over your finger and it measures how much oxygen is in your blood. It costs about £30 and can be shared and reused.
Secondly, find out if you are in a 'high risk group'. There are new treatments available including antibodies and antivirals that if taken within 5 days can make a HUGE difference.

More info here:
nhs.uk/conditions/cor…
Read 15 tweets
Mar 3
Pandemic Mistakes
Part 2

Did we try hard enough to “Find the Sick!”?

Symptom Profiles:

Why did the U.K. not include the other common symptoms of Covid for testing and case I.D.?

Does this expose the true motives of the UK’s approach?

🧵
By now we have all learned the symptoms of Covid, at least those symptoms that lead to a PCR test in the U.K.:

1. Fever
2. Cough - “new and persistent”
3. Loss of taste or smell

But most of us are also aware that Covid can present just like a cold or flu or gut symptoms or etc,
Even from the start of the pandemic the choice the U.K. made to narrow the symptoms down seemed very odd. Undoubtably many cases - perhaps the majority - would be missed. This would mean containing the viral spread via Test and Trace would be near impossible.

As time went by…
Read 17 tweets
Mar 1
Pandemic Mistakes
Part 1

Covid Inquiry is due. The PM will no doubt try and dodge.

I am going to post on one major pandemic mistake a few times a week until.

I will focus on mistakes relating to clinical care or impact on health systems

You can judge how This Gov done!

🧵
There are three basic tenets to an infectious disease outbreak:

1. Find the sick
2. Treat the sick
3. Stop others getting sick.

Looking at the first aspect, and specifically TRIAGE - finding the sick!

➡️ Why did we leave so many at home?
Triage.
Triage has different meanings. Both apply here. The first type of triage is to carry out a brief assessment and try and categorise how serious the problem may be. Often this leads to a triage disposition - how soon is a full assessment required and who should do it?
Read 27 tweets
Feb 28
The Covid Con!

How many governments have been conned into thinking Protections against Covid are no longer required?

🧵
When Covid first reared its head in East Asia, the surrounding countries went on high alert. Perhaps it was their experience with SARS1 and MERS that kicked them into action.

Or the initial reports suggesting a 10% mortality rate.
Testing ramped up quickly, alongside significant deployment of medical personnel and field hospitals to affected areas.

Contact and Trace - honed by previous experience - was exceptional. Quickly the test positivity rate fell.

It soon became clear that mortality was <3%.
Read 22 tweets
Feb 27
With so much happening just now, I thought I would try to provide a weekly update of Covid stuff you might find relevant.

#TheWeekInCovid

[Inspired by @RussInCheshire & his #TheWeekInTory]
First, Policy Changes:
Where to start? It has been a colossal week for policy changes. The race to declare Covid 'over' has kept the spin-masters busy!

Denmark was first.
The confidence of their assertion Covid was no longer a significant threat met the harsh reality this wk.
2/ Not to be outdone, the UK Gov, while saying Covid is the cause of the UK's healthcare crisis (not ten years of trying to privatise the NHS) and having double the healthcare burden of Covid than when 'Plan B' was implemented, declared it is time to end isolation for +ve cases.
Read 22 tweets

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