Thread by @JamesLynchGTC

John Campbell @Johnincarlisle has stepped away from misinterpretting studies and turned his hand to NG163, the NICE Guideline for COVID (now replaced by NG191 on the MagicApp).

As usual, he's wrong.
Here's why:
🧵

He starts by focussing on 6.5 shown in full below alongside the bits he has typed up (no idea why he keeps doing this).
Specifically 6.5 is combined low dose opioids and benzodiazepines for people who are:
-end of life AND
-have mod/sev breathlessness AND
-are distressed.

"This is a well tried, trusted treatment we use for terminal agitation" he correctly states but then goes on to suggest it is only used in "conditions such as cancer...incurable conditions"
It isn't. Its an important part of palliative care regardless of primary illness.
Eg. 👇

"What NICE have done is take that and transpose it into the COVID situation...when most people can get better from it"
He seems to have forgotten that this is for patients who are "At the End of Life". Unsurprisingly most people who are at the end of life do not "get better".

"Giving these two together, that stops people breathing"
Well no.
Not in these doses.
It will as he says "depress respiration" but then it is being used to treat mod/sev BREATHLESSNESS with distress. So that's kind of the point.

"Given a lot of those people had Acute Respiratory Distress Syndrome..."
False.
ARDS is clearly defined using the Berlin definition.
It requires the presence of PEEP/CPAP.
The majority of these patient's were on respiratory wards/care homes and did not have ARDS.

"If you give these drugs...you dont need me to spell out the consequences of that".

But it isnt as simple as that.
Often treating breathlessness has no/little impact on gas exchange. Anecdotally it sometimes improves it.
sciencedirect.com/science/articl…
journals.sagepub.com/doi/abs/10.119…

We aren't entirely clear why.
Breathlessness may be driven by distress rather than purely hypoxia. The mechanics are complicated but we know in other settings, rapid shallow breathing doesn't lend itself to great gas exchange.

So Campbells presumption is no more than that.

"How many patients with COVID 19 were at the end of life?" he asks.
Whilst you can argue "self fulfilling prophecy" here we know there were some 45,000 deaths involving COVID by June '20 in England.
So certainly enough to warrant a plan of care that provides some symptom control.

"How do you know they are at the end of life?"
We know this isn't always easy and is often more intuitive than objective, but honestly. He's a nurse educator of decades. Surely he knows the basic signs and symptoms.
nice.org.uk/guidance/qs144…

And no, you don't need sophisticated, diagnostic testing facility to identify somebody at the end of life.

You do for ARDS though. Which John seems to be diagnosing lots of people with, incorrectly.

"The most concerning bit..." he goes on "Sedation and opioid use should not be witheld for fear of respiratory depression...its almost like saying respiratory depression is acceptable."
🤬
Its not only acceptable, its literally the aim of the guidance.
TO
REDUCE
BREATHLESSNESS.

The last few minutes he, as many have before him demonstrates a correlation between palliative care drug use in the community...and people needing palliative care in the community.
This is not evidence of anything except appropriate care.

Urgh.
He's already posted a further 20minute video on this.
Sorry, but more 🧵

He correctly points out NG163 was used (though regularly updated) until NG191 in Mar '21.
We start with correlation between community use of palliative care drugs and people needing palliative care again.
No surprise. No evidence of malfeasance.

He interestingly then points out that the guideline came in on 3rd April but tries to suggest the guidance could have been cause of all deaths thereafter.
Why deaths would suddenly plummet 2 weeks after introducing a guideline that he believes is killing people isnt explained.

He wants to take issue with the fact that existing care plans, advanced directives and DNRs should be taken into account when planning care. I have no idea why. They should always be taken into account when planning care for any illness.
That's the point of them.

He then makes the same point as here:

https://twitter.com/JamesLynchGTC/status/1625438348390146050?t=22Zt2hv2r08fgHWu6OqGXA&s=19

About struggling to identify dying patients in diseases that most recover from.
Most people recover from most illnesses. See flu, pneumonia, # hip.
But we should still spot those who are dying and respond appropriately

He then makes a point about antibiotics saving thousands of lives.
(As an aside this is quite suspicious of @jikkyleaks nonsense about azithromycin).
Antibiotics are for bacterial infections. They should be used when secondary bacterial infection is suspected.

NG191 clearly points this out. As did existing guidelines.
Most patients with COVID did not develop secondary bacterial infection.
link.springer.com/article/10.100…
They don't have meaningful evidence of efficacy outside this.
ncbi.nlm.nih.gov/pmc/articles/P…

"How many patients could have survived with antibiotics...and steroids"
1. As above antibiotics when indicated otherwise no evidence of impact on mortality.
2. There was no evidence of steroids in the first wave.

The next five minutes are literally a rehashing of the previous video. Almost word for word.
The exception is the acknowledgement that morphine and midazolam dont have UK marketing authorisation for breathlessness.
They dont.
We use lots of drugs outside of their MA effectively.

Next, the BNF warning. This is good. A reminder to Nurses and Doctors to be cautious and use low doses.
Note he shares the part that warns about "potentially fatal" side effects, not the part about warning patients so that they can seek attention themselves in the community.

And then 5 minutes showing more correlation between palliative care drugs (midazolam, levomepromazine and haloperidol) use in the community and people requiring palliative care in the community.
"There's real questions here for NICE" John states.
But Ive not heard him ask any.

"How many of these deaths were COVID?" He asks, particularly referencing the first and second wave.
Well, given the table he shares is deaths by death certification (neatly cropped off), we know at least one Doctor in each case felt they were.
They also corrwlated with cases.

"How many of these deaths were iatrogenic?" He asks before some marvellous acting but no actual evidence.
"We know this happened in Sweden" he falsely claims.

"Its fundamental you treat the underlying cause when you can and not simply suppress the symptoms"
...

He is correct, ofc.
But when you don't actually have any treatments (March through June '20) all you can do is treat the often distressing symptoms.

When "end of life" has been identified (which isn't easy, but far easier than he suggests) symptom control should be the priority.

He's keen to use his "44 years in healthcare" here.
"...something that goes against so many axioms"

Palliative care is well established. Symptom control in disease is well established.

That during his "44 years" John hasn't come across these axioms speaks volumes.
About him.

Continuing the acting (head down, lots of sighs, broken sentences) John claims that some of these deaths were caised by nurses and doctors "squirting drugs into people".

He is calmly and deliberately accusing former colleagues of murder.

But has provided NO evidence.

Finally, he quotes the foreward to NG163.
"...are expected to take this guidance fully into account."
Note where he stops.

"If you go against the guidance and something goes wrong..." he tails off.

You'll note the sentence after he stops adresses this exact point and rather contradicts him.

"EBM should be based on empirical evidence, expert opinion and patient preferences" he summises.
"It seems to me these last two have completely flown out the window..." with aggressive hand clapping.

But NICE guidance is based on:
1. Empirical evidence.
2. Where this is lacking, expert opinion.
And, as the paragraph says shortly after he ended it, should be taken into account alongside an individuals needs.

And after sincere condolences to anybody affected, thats it.
An accusation of mass murder purely based on John's speculation that we can't identify when somebody is dying and the correlation between use of palliative care drugs and people needing palliative care.