Things a rural doctor has in his iPhone during Alberta’s COVID-19 pandemic

Doctors were early adopters of Palm Pilots. My in-laws gave me one as a graduation president from medical school more than twenty years ago.

The ability to carry large texts around in your pocket was revolutionary–it saved many medical students from carrying the telegraphic handbooks with which my lab coats were always too stuffed. (Hard on the shoulders! Plus they tend to spill everything out of your stupid little short medical student coat, which makes you look even dumber than you actually feel, which is saying something.)

We’ve come a long way since then. Like most people, I now carry a supercomputer everywhere in my pocket. Sometimes I use it to watch funny videos.

But, I also use it as an “auxiliary brain” for medicine. It’s particularly useful for stuff that I will rarely use, but if I need it, I need it right now.

One of those things wasn’t in my iPhone until the COVID-19 pandemic. But it is now.

It’s an article that appeared in the Canadian Medical Association Journal. It begins like this: “All physicians should be prepared to manage dyspnea, especially during the coronavirus pandemic.”

What’s dyspnea?

It’s feeling short of breath–of being starved for oxygen, like you’re smothering or drowning. It is a terrible way to die. Even with all the oxygen we can blow at you, it isn’t enough. Each breath is torture.

Usually, my patients with dyspnea get quickly transferred to Lethbridge for an ICU. I might intubate them (sedate them and put a tube into their breathing passage) to help.

Right now, that’s what my patients with COVID get. (All of them that I have had to transfer to Lethbridge thus far have been unvaccinated.)

If the health care system becomes overwhelmed, and if we have to triage care (as described here), then that won’t happen. I even wonder if I might be sent patients from Lethbridge for whom there is no space in the ICU. The Lethbridge docs might decide that I can at least “palliate,” and so unclog their hospital slightly.

They help me so often with my patients, it would be nice in a way to return the favour.

What’s palliate?

To “palliate” means to treat symptoms for comfort until the patient dies. It is “keeping you comfortable.”

We can treat dyspnea.

We’ll give you things like morphine or fentanyl, and maybe drugs like Valium or Ativan if needed. Don’t worry, I don’t even need to look up the doses in my iPhone.

If things get bad enough, we’d put you into a medical coma. Not to save you–it won’t–but to spare you suffering. You’ll be unconscious as you drown to death.

Medical coma doses–those I would have to look up. But I’ve got my supercomputer to help. Won’t take long.

We won’t let you suffer. Your family might suffer–it’s hard to watch someone die of dyspnea. But, if you’re dying of COVID and the health care system is in the kind of crisis where a rural family doc is your top care provider, your family probably won’t be allowed at the bedside anyway. So they won’t have to hear you suffer, except as you say good-bye via Facetime before we sedate you.

I’m not trying to be dramatic. I hope it doesn’t come to this.

But this is the outcome we in health care have feared all along, and what we’ve tried so hard to prevent. And right now it is hard to see how this won’t happen to someone in Alberta in the next few weeks, maybe many someones.

Last thoughts

If it does come to this, the last thing you see will probably be the nurses’ and my gowned and masked faces (plus goggles or face shield and sweaty gloves). We drilled how to get in and out of all the gear safely at the beginning of the pandemic, since we knew we’d have to look after people while being vulnerable ourselves.

A nurse’s gloved hand will probably hold yours as we administer the meds. You won’t have to ask, and I won’t have to order it–it’s just what they do.

When I’ve done my part and moved on to the next patient, the nurses will watch you closely to make sure you don’t come out of sedation and suffer some more. I won’t have to order that either.

But, after you’re asleep and comfortable, we’ll probably think of all the people who told us COVID was a hoax, that vaccines don’t work, and masking was too inconvenient.

I might even think about all the people who’ve screamed at my clinic staff or the nurses I work with when asked screening questions. I hope not. Such people don’t bear thinking about.

We’ll be wearing masks. And yeah, they aren’t as comfortable as we’d like.

But we’ll be far more uncomfortable about everything else that’s going on. So we probably won’t notice the masks much.

You, at least, will be comfortable. We promise.

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Most important 6 minutes you can see today on COVID-19

There was a recent interview on CBC with Dr. James Talbott.

He was the Chief Medical Officer of Health for the Government of Alberta from 2012 to 2015.

He is currently Co-chair of the Edmonton Zone’s Strategic COVID-19 Pandemic Committee.

His past jobs include:

  • Director, Prov Lab of Public Health for N. AB, Chair;
  • National Foodborne, Waterborne & Enteric Disease Committee;
  • Medical Officer of Health for Edmonton, Alberta Health Services
  • Chief Medical Officer of Health for Nunavut;
  • Founding member SIREVA and ARTSSN surveillance networks.

Given that he works for a University and his committee is a medical one–not a government one–he is free from political pressure.

If you’d like to see the “triage” document he refers to, here it is.

I have been asked if the triage means that those who are unvaccinated would go “to the back of the line.” Decisions are not made based on foolish decisions by the patient. Decisions are based on who has the best chance of survival and quality of life. Being unvaccinated lowers the risk of survival despite intensive care, so that would be factored into the decision.

There is more detail here, and a FAQ here.

The fact that I am reviewing it and that it is being circulated among physicians tells you where we are at.

Get vaccinated. Wear masks. Be smart.

You’re not just “choosing for yourself.” You’re choosing for all of us.

Those holding back are also choosing for me to potentially make choices I should never have to make.

How did things get so bad?

How did Alberta’s COVID situation become so bad?

Easily — by utterly ignoring what we know about this virus, wishful thinking for political reasons, and cherry-picking what they would believe.

In June, the province did what no other jurisdiction in the western world had done–they declared the pandemic “over” and told us we could just treat it as “endemic” (i.e., a disease that is always present at low but not dangerous levels in the population–colds are “endemic,” for example).

Why did they do this?

Jason Kenney seemed determined to have the Calgary Stampede go on, and to remove the unpopular public health restrictions. (If you think the fact that his plan allowed for everything to go back to “normal” on the precise dates needed for the Stampede to happen just by happy coincidence, I have beach front property in Calgary to sell you).

But didn’t they do modelling?

Yes. Sort of. Not really. Let me explain.

Models are mathematical simulations about possible outcomes in diseases. They obviously have limitations, but they can be useful tools.

A model is only as good as its assumptions. To make a model, you’re trying to simplify reality. So, you try to focus on the things that matter, and ignore the things that don’t. All models will ignore something.

Doctors have been demanding that the province release the models and data they used ever since the announcement. The province dragged its feet on this. (If that doesn’t make you suspicious, I will add a beautiful condo on the beach-front property I’ve already sold you).

They finally released the model. We can now look at what assumptions were made. This is from a Twitter feed that highlights some assumptions made by the model:

What are the problems?

When you make a model, you should not assume things that you know to be false.

Here’s some assumptions, and why they are clearly false.

  • Assumes “homogeneity” of vaccines — this means that it assumes that all areas of the province that interact have the same rate of vaccination. But we know this is false. Edmonton, for example, has about 85%. County of Warner, where I live, still has less than 50% of the population. FALSE, and known to be false from the beginning.
  • Case detection stays the same — government announced that they would stop contact tracing and testing in the same way. FALSE, and known to be false.
  • Assumes infected patients will not infect anyone else — this assumes that everyone who tests positive will self-isolate, and thus not infect people further. C’mon, this is idiotic. If you aren’t testing, people may not know if they are infectious. The province cancelled the requirement to quarantine even if you KNEW you were positive. FALSE, and government took active steps to MAKE it more likely to be false
  • Assumed no waning in protection from vaccinations — we’re still in early days, and this may not be a a reasonable assumption in all cases. Not necessarily false, but a dangerous assumption when combined with the other issues.

Finally, the model did not include the possibility of major gatherings without public health measures. What kind of gatherings? Oh, you know, things like 1st of July celebrations and the Calgary Stampede (which was 500,000 people this year).

Alberta used the UK as a model for how things would “improve” if they opened. Why the UK? Well, because they were the only country in western Europe which had the results that Kenney’s government wanted. It was an out-lier. (And it now isn’t doing very well again.)

So, they cherry-picked the one example from Europe that supported what they wanted to do, ignored all the others, and then patted themselves on the back for a job well-done. (As another modelling group–cited below–noted, “Alberta has not seen this trend, and neither has the United States.” So, the North American experience was not the same, and there were good reasons for this–levels of testing–that made it foolish to act as if the UK would apply to Alberta. And, this was known immediately, not after-the-fact.)

So, big surprise, given that almost all of these assumptions were clearly false, the model didn’t work so great.

Didn’t anyone realize this was a a problem?

Of course they did. Most medical groups in the country were screaming about it (here’s the Alberta Medical Association; here’s the Alberta Pediatrics section). We had other people doing models without these crazy assumptions, and they did not encourage happy warm thoughts.

British Columbia has a modelling group for COVID-19. Unlike in Alberta, that modelling group is independent–they are scientists who do the modelling who don’t answer to the premier. It’s amazing how not fearing for your job can make you be more honest. (If you don’t believe this, I will throw in a Porsche for sale when you act now on my beach property offer.)

You can see their modelling work here. It is eerily accurate. They explained precisely why Alberta’s modelling was wrong, and why it would go wrong. And they were right.

They also used multiple models, and came up with the same answers. That tells you you’re on to something.

The BC group wrote:

It is important to remember, as noted above, that these figures are projections in a scenario with no change in policy or behaviours. The projected peak in hospital occupancy is several times higher than previous peaks, and those led to substantial changes in both individual behaviour and public health policy. We do not expect to observe these projected incidence or hospital volumes, because we think policy would change to protect hospital capacity, and individuals will change their behaviour in response to such high case numbers. What is clear from these analyses is that there are substantial evidence-based reasons to believe that greater utilization of non-pharmaceutical interventions – such as social distancing, masking and air filtration will be required to protect the Alberta health care system, and the health of Albertans, while vaccination coverage is expanded

Thus far, they are wrong in one thing–a substantial worsening has not resulted in the Alberta government deciding that “policy would change to protect hospital capacity.” Apparently even they can’t factor in Jason Kenney, Tyler Shandro’s, and the United Conservative Party’s utter stupidity.

Ah well. No model is perfect.

But, their advice is still valid: “greater utilization of …. social distancing, masking and air filtration will be required.”

Required, maybe. But whether it will be done remains to be seen.

So, how did government respond?

In a word? With mockery. Doctors and scientists (along with the media reporting their concerns) were accused of stirring up fear, and of refusing to admit the pandemic was over.

Here’s Premier Kenney:

And here’s Matt Wolf, who is paid $194,253 per year of taxpayer money to be Kenney’s “issue manager.” His job seems to be mainly mocking Kenney’s enemies on Twitter:

But, since they’ve seen the error of their ways, I’m sure Kenney, Wolf, Shandro, and the rest will admit their mistake, apologize to those they attacked, and take steps to correct their errors, right?

Right . . . . ?

Yes, I’m sure they will.

I’ll show you a video of them doing so as soon as you sign for the deal on that beachfront property I’m selling.

With luck, it comes with towel-boy Matt Wolf, and his salary will go to paying for a few more nurses’ shifts.

ICU status in Alberta – worse than you think

The condition of Alberta ICUs is dire. We are currently at around 140% — that is, we have 140 people for every 100 beds usually available. This has certainly never happened in my memory of the last 20 years.

Government makes this look better than it is by talking about “surge” capacity. These are supposedly “extra” ICU beds.

Here’s the graph

The blue line is number of patients who need ICU care. Red line is typical ICU numbers.

The extra “ICU surge” is in yellow. As of the evening of 13 September, we had 202 people (above the “record 186 COVID-19” line).

For those telling you that “this is no worse than the flu,” you can also see the grey line at the very bottom, which shows the worse flu season levels ever.

The “extra” beds

What you need to realize is that the “extra beds” aren’t quite the same as regular beds. Normally ICUs have one ICU nurse per patient. There are reports from health care workers of:

  • 4 patients being cared for by 1 ICU nurse, assisted by nurses “recruited” from other areas, such as administration and public health
  • patients being “doubled bunked” — two beds in one room looked after by 1 ICU nurse
  • And so forth.

Duh, just open more beds!

People and government talk rather casually about “expanding ICU beds” and “opening more beds.”

This is naive. Beds and equipment are important but they are not much use without staff. We need ICU nurses (and physicians). ICU nurses are retiring or transferring elsewhere due to burn-out and the government’s on-going disrespect. Anyone who wants to be working ICU nursing is already doing it. There is not some untapped pool of nurses waiting to do this job.

AHS is compelling nurses who have never worked in the ICU to work there. I’m sure they’ll do their best, and they deserve credit for “stepping up”–but they don’t deserve to be put in that situation, and from what I’ve seen I think those nurses would be the first to admit that the level of care isn’t going to be what it should be.

It ain’t over yet

Even if we could stop all infections right now from spreading, the next few weeks are locked in stone. They are already rolling, and we can’t change that. It will get worse before it gets better.

Many are warning about a health system failure. I’m afraid that is not an unlikely possibility.

Health care workers will continue to do their best. But the public needs to help us. And we can only do so much with limited resources. Eventually the need may be too great.

The longer government waits, either (a) the higher the cost in disability, illness, and death; or (b) the more severe measures we’ll have to take–e.g., I really don’t want to see the economy or schools shuttered again; or (c) both of the above.

Who cares? I’m young and won’t need an ICU even if I catch COVID

Let’s hope not. But if you’re in a car accident, and you need an ICU, you may be in dire trouble if the ICU beds are all full of COVID patients.

Wishful thinking is not–despite what Premier Jason Kenney seems to think–a good public health strategy.

What to do?

Call your MLA. Demand that provincial leadership act and that they hold daily briefings to keep the public informed and to allow the press to question them and hold them to account. (It’s no surprise that Kenney, Health Minister Tyler Shandro, and Medical Officer of Health Deena Hinshaw have been conspicuous in their absence in front of the press for the last 6 weeks.)

Get vaccinated. Mask and encourage the schools to require masking.

We know what works. But we need to be united in doing it.

Current state of health system in Alberta

The government of Alberta and Alberta Health Services are not being forthright with Albertans.

The current state of the health care system is very serious, verging on catastrophic.

This is a letter sent yesterday by the Edmonton Zone Medical Staff Association to the premier and company.

ICU is actually above levels of any previous point in the pandemic at this point.

Remember that anything we started doing now won’t be felt in the system for at least 3-4 weeks, since what is happening now will take time to work its way through the system.

What can you do?

  1. Vaccinate — Alberta has the lowest vaccine rate in Canada (neck and neck with Saskatchewan). Our local County of Warner has less than 50% of the population vaccinated. At present, all the COVID patients in the Lethbridge ICU are unvaccinated.
  2. Wear a mask.
  3. Urge school board to implement in-class masking in schools if not already in place. This is especially important for those under age 12 who can not yet be vaccinated.
  4. Contact your MLA and demand that they take action, and that they tell Albertans the truth.

This isn’t going to just affect people that aren’t vaccinated. “Elective” surgeries are cancelled. That doesn’t just mean “surgeries that would be nice to do.” It means “surgeries that if you don’t have right now, you’re not going to immediately die.”

This includes things like biopsies for cancer, cancer debulking surgeries, etc.

What does “failure” of the system mean? It means that at some point, people who need care to preserve life or limb won’t be able to get it at the level they should have it. We will have to start deciding who gets treated, and who doesn’t.

And if things get really desperate, you might have a family doctor running your intensive care . . . .

How effective a COVID-19 vaccine do we need?

In medicine, as in life, nothing is perfect.

This is true of vaccines. No vaccine is 100% effective. Yet, vaccines have produced massive declines in many serious illnesses, and succeeded in eradicating two such illnesses (smallpox in humans and rinderpest in cattle).

Herd immunity

Since COVID-19 has come along, everyone is talking about herd immunity. This is a straightforward idea. Let’s say I’ve never had smallpox. I’ve never been vaccinated against it. But, if you put me in a group of people who are immune to smallpox, I’ll never catch smallpox. Why? Because they can’t catch it to spread it to me.

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Hydroxychloroquine and why it doesn’t help COVID-19 in humans

New study may well explain why hydroxychloroquine doesn’t work in humans.

Unlike the tissue cultures, human lung cells don’t have the proper enzymes, so virus enters by different receptors that hydroxychloroquine can’t affect.

https://theconversation.com/why-hydroxychloroquine-and-chloroquine-dont-block-coronavirus-infection-of-human-lung-cells-143234

Remember, the 2005 study that everyone claims is a conspiracy was done in Vero E6 cells. These are green monkey KIDNEY cells, not lungs.

A slightly less wacky pro-hydroxychloroquine article

Newsweek published an article by a doctor who doesn’t (so far as I know) believe that reptilians run the US government and alien DNA is being used in scientific experiments.

He does, however, claim hydroxychloroquine helps COVID-19.

As far as we know, this is false. My brief note on this is here.

And his article is terrible. If you want a point by point analysis, see here. A quote:

The rest of Prof. Risch’s AJE article is a veritable Gish gallop of cherry-picked studies. Hilariously, he relies heavily on uncontrolled “studies” and case series from two grifters, Didier Raoult and Vladimir Zelenko….

I had a hard time believing that an actual professor of epidemiology at a school as reputable as Yale could write such drivel. The study he is referring to is Gautret et al., a study so awful, so full of flaws (and maybe even fraudulent), that it was quite properly dragged on science and medical Twitter for days and weeks afterward. That Prof. Risch would cite such an abomination of science tells you all you need to know about him.