Corona Diary Part 3: Wednesday April 1st to Friday April 10th

Wednesday April 1^st

Lindsay’s birthday today.  Bright and sunny again.  Nati has thought to have a patisserie delivery from Mark Bennett.  What a good idea.  Long Facetime with various family members and my Aunt, aged >90 rings from Cambridge with good wishes.

To take up where the Stop Press finished last time.  Lindsay’s cousin lives in Lancaster, Pennsylvania, USA.  He’s in touch with birthday good wishes.  He tells us that we might be pleased to know that liquor stores are closed, but gun shops are regarded as ‘essential businesses’ and they remain open.  Confirmation comes from family members returning to Canada, driving through West Virginia, who find it difficult to find a food store open, but find plenty of outlets for guns and ammo doing a roaring trade.  Presumably one has to defend one’s stash of toilet rolls somehow.  Scary footage is seen on the UK news of US paramilitary militias, training in secret, in case there is a ‘breakdown in law and order.’

The film club watched ‘Made in Dagenham’ last night (released 2010).  It tells the story of the 1968 women machinists’ strike at the Ford factory.  Hard to comprehend that at that time Ford UK employed 55,000 men on the Dagenham site, and only 187 women.  An excellent film.  Sally Hawkins is superb as the machinist plucked from the factory floor to represent the women.  The late Bob Hoskins is also very good as the Trades Union representative.  I loved his exchange with the trades union bosses:

Union Boss:  As a union we have to remember who comes first.  The Communist Party.  And Marx himself said “Men write their own history.”  That’s “men”, Albert.

Albert (Bob Hoskins):  But didn’t he also say “Progress can be measured by the social position of the female sex.”?  Or was that a different Marx?  That was Groucho, was it?

Thursday April 2^nd

A rather grey day.  The mother of a friend of ours died last week.  At 0930 she will be cremated with no-one in attendance.  Lindsay walks down to Bournemouth gardens at 0920 to think about her.

Substantial increase in UK cases and deaths yesterday – deaths jumped by 563 to 2352 and total cases reached 29,474.

And now, something of a confession:

In nursing homes up and down the country, hundreds, no thousands of elderly people sit, gently nodding in easy chairs.  Some of these are mentally alert, interested in day to day affairs, reading, interacting with relatives.  Many of them are empty shells, no longer interested in anything, propped in front of televisions which hawk the usual daytime trash, and awaiting the next meal of slop and the subsequent assistance with toileting.  Unlike our treatment of animals, we have no known ethical way to allow these poor folk to exit the world with dignity.  I’m sure many of us have heard the confused screams of pain from some of these poor people as they are turned in bed, or helped off commodes, the muscle and fat which once insulated them from bony discomfort having long since disappeared.  When we first heard the news from China about coronavirus, it seemed clear that only the oldest and most fragile victims were dying.  Did you – for a moment – have that Machiavellian thought that for once a natural illness, one of the ‘thousand natural shocks that flesh is heir to’ might not be doing a disservice to many of these husks of humankind?  I know that I did.  But as time has gone on, it has become clear that despite the statistical data predicting a higher death rate in the elderly, the Covid-19, or SARS CoV-2 to give it the new correct title, does not discriminate particularly in whom it kills.  Yesterday we heard of a 16 year old girl in the UK who died, and this morning it’s reported that a 3 month old baby in the US has died.

To digress into science.  Death in Covid-19 is due to respiratory failure secondary to massive macrophage infiltration (macrophages are cells which mobilise in the immune response, produce active compounds to cause inflammation, and ingest foreign material) into the lung alveoli (small air spaces).  This is apparently driven by a cytokine – Interleukin 6.  It’s interesting that oestrogen is a natural inhibitor of IL-6, which may explain the much lower rate of severe illness in women.  Antibodies to IL-6 have been produced in an attempt to treat many inflammatory conditions, but it is unclear whether they may play a role in Covid-19 therapy.  It is of course a truism that we have never found a cure for the common cold, and many common colds are caused by coronaviruses.  Perhaps a by-product of the pandemic will be a treatment for the common cold.

In the news this morning – a plane load of supplies including protective equipment arrives from Russia into the USA this morning.  What a coup for Putin.  US physicians lament the same issues as the UK again; not enough PPE; not enough ventilators; not enough testing.  The UK government, rightly it would seem today, is being criticised for not getting up to speed with testing.  This has been a major Achilles heel of the UK’s preparedness, or indeed lack of preparedness, or organisational skills in this crisis.  News has emerged of a pandemic review some three years ago called Exercise Cygnus which we failed dramatically, and which was hushed up.  The exercise took place in 2016 and the final report in 2017 was apparently too apocalyptic for the Government and NHS England to contemplate, so its findings were never published.  In this modelling, the same issues were identified as we are seeing now.  The virus example in Cygnus was an influenza virus – considered to be H2N2 – with the same complications – illness occurring in frontline staff, inadequate beds, inadequate ventilation facilities, inadequate mortuary storage.  It’s thought by some that the previous dire predictions for Swine Flu in 2009 came to naught, and therefore it was assumed that Cygnus was an overreaction to something we could deal with.  The truth will undoubtedly come out eventually.

In the meantime Sweden continues to be the most relaxed country in the world as regards social distancing.  Only in the last few days has gatherings of over 50 persons been banned.  There is opposition to this policy among some scientists.  A Swedish sociologist however points out that Swedes are used to social distancing – it’s their normal behaviour.  In addition, the country has the largest proportion of single people living alone in the world.  Rarely do they make physical contact when greeting one another, unlike many Southern European countries.  There are signs however that all this may change as the death rate increases.

April 1^st has come and gone, with some good April Fool’s stories.  A friend posts a picture of a huge gathering – the strapline is ‘March to Stop the Spread.’  The same friend posts spoof pictures of the General Medical Council registration certificates for various retired doctors whom we know.  Great laugh!  Only a few hours later does one of them bother to check and finds that it is actually true.  Without asking the GMC has just restored him to the register…

Friday April 3^rd

The film club watched the free transmission last night of the National Theatre’s production of ‘One Man, Two Guv’nors’, their reworking of the Carlo Goldoni play ‘The Servant of Two Masters’, a farce written in Italian in 1745.  Although it is nearly 10 years since we saw it, it is very very funny, with a substantial amount of clever slapstick humour.

Later in the day, an e mail arrives for me from the GMC.  In the second wave of restorations to the register I am now reinstated as a consultant cardiologist and physician.  Whether they will need me remains to be seen.  Late evening walk on Talbot Heath, which is fairly quiet, fortunately.

Saturday April 4^th

Another sunny day.  For our exercise today Lindsay and I take to the smallest roads we can find to do about 16 miles of cycling.  There is not much else to report.  Cases and deaths continue to accumulate – 4,313 confirmed in-hospital cases of Covid-19 have died, an increase of 708 on the Friday figure.  These should be taken in context with the total number of confirmed cases being put at 41,903.  This suggests that the in-hospital mortality is around 10%.  Not quite Ebola severity (15 to 90%; average 50%) but bad enough.  Ebola is in the news too.  In the 2014 outbreak, a successful vaccine was developed and some experimental drug treatments were at least partially successful.  Naturally, with the cessation of the outbreak, the firms working on these projects mothballed them because of the lack of any likelihood of commercial return.  Now they are back in development and trial.

There is good news this weekend of the turnaround in production of ventilators and CPAP machines.  Many engineering companies are helping to produce these in double quick time.  Even Burberry have turned their resources from fashion clothing to making hospital gowns.  Lindsay hopes that they will at least have a little of the tell-tale check pattern on the garments.  Less good news is that Premier League Footballers seem reluctant to take much of a pay cut.  99% of the population finds this hard to swallow – after all they aren’t even playing any football!

A sobering note arrives today.  My consultant at Royal Bournemouth Hospital writes to tell me that I am at high risk if I should acquire Covid-19 (presumably due to my IgM paraprotein) and I should practise social isolation.  I still hope that I should be able to contribute medically, even if only by teleconferencing.  Another pseudo-Machiavellian thought intrudes.  Since I am 72, and have by and large had a very rich and enjoyable life, shouldn’t it be me and others like me who become the cannon fodder on the front line?  A more practical response comes from another part of the brain (!) – at age 72, if you become ill you are far more likely to need ventilation and a prolonged hospital stay and will put extra strain on the NHS and your colleagues.  A further thought – what if they triage me to ‘no escalation of therapy.’?!

Enough for Saturday night.  Apart from more fatuous and frankly insulting remarks from Donald Trump.  He has stopped the company 3M from making masks and protective equipment for Canada and for South America.  He has also diverted 200,000 masks intended for Germany, and has threatened to invoke the Defense Production Act, first used during the Korean War, which is intended to force companies to work for the US Government.  I’ve mentioned Trump at length before.  Every day seems to bring some new action which inspires incredulity.  Interestingly though, a photograph of a Chinese hospital worker wearing a mask clearly stamped with 3M leads to the discovery that up until now, much of the 3M protective equipment has been made in China.  I wonder if President Trump will repatriate that and MAGA (Make America Great Again).  Or should that be ‘Make America Grate Again’?

Sunday April 5th

Sunday is of course now hard to distinguish from the other days of the week.  Our main exercise today is taken in the late evening – a walk around all 18 holes of Parkstone Golf Club.  Total distance 3.9 miles; time 1hr 11min (quite pleased with that).  Lindsay is disbelieving; ‘But when I’ve seen your Strava after a round of golf it’s 6 or 7 miles.’  Hmm, er, there’s a reason for that…

We are back in time for the Queen’s speech to the nation at 8pm.  This happens extremely rarely, and is widely seen as inspirational.  It’s sad (personal view) that the press are aware of what she is going to say days beforehand and we have already been told much of the content of her speech, thus diluting its impact.

In other stories, there is extraordinary coverage and footage of some completely moronic individuals who have attacked and set on fire a 5G telephony mast.  Apparently there has been some bizarre rumour circulating on Facebook or Twitter that these are somehow responsible for Coronavirus.  Amanda Holden, a TV person known for her beauty rather than her brain has given some credence to this by retweeting a petition against 5G masts.  She hurriedly withdraws it.  More importantly, Boris Johnson, the Prime Minister, has clearly not recovered from Covid-19, is still pyrexial after 10 days, and is admitted to hospital.  Somewhat worrying.

The film club decided to revert to box sets this evening and watch the first episode of ‘The Crown’.  Good stuff.  George VI is shown smoking at every opportunity.  Two interesting facts not mentioned in the episode:  George first acquired the cigarette habit as a naval cadet at Dartmouth and clearly suffered from stomach ulcers even in his teens.  Most of the Royal family prior to the present generation died from the effects of smoking.  Contrast the lifelines of two sisters – Elizabeth (non-smoker) and Margaret (heavy smoker).  Secondly, a famous part of medical folklore took place in a room in Buckingham Palace (specially converted into an operating theatre), where the surgeon, Sir Clement Price Thomas, having performed a pneumonectomy, turned to his assistant and said; ‘Sew up the chest.’  ‘But Sir, it is the King.’ came the reply.  Whereupon ‘Clem’ turned to him and said; ‘I haven’t closed a chest for the last 25 years and I’m not going to start practising on the King.’

Monday April 6^th

Apart from Mr Johnson’s admission to hospital, the main news today concerns the Scottish Chief Medical Officer, Dr Catherine Calderwood, who has resigned from her post after being found twice to have disobeyed her own injunctions to ‘Stay Home’.  She visited her second home two weekends in a row, and was spoken to by the police about her unnecessary travel.  She is 51 and her bio states that she is a gynaecologist.  This leads me to muse on how it is doctors manage to get into such influential posts, when most of us are content to try to be the best doctors in our field.  In some instances, it is flagrant disregard of the posts they were appointed to – spending time on committees and vital meetings in the hierarchy of medicine.  Or doing distinguished research and then absenting oneself from the lab to talk about the results all around the world.  One wag once asked whether the collective noun for academics should be ‘an Absence of Professors.’

There has been some rain in the night but it remains rather a lovely day.

When one considers how rapidly this Covid-19 has spread around the world, I spare a thought for somebody whom I never met, but was nonetheless hugely influential in medicine (unlike some lady gynaecologists in Scotland).  This was Professor Brian Maegraith, Tropical Medicine Specialist, and for many years head of the medical school in Liverpool.  He it was who first drew attention to what he called the ‘Great Vector of Tropical Disease’ – his first lecture slide after this announcement was a picture of a B747 aircraft.  Now the long haul jet is the vector of the most serious illness to affect us in the modern age.  Not only can the carrier of a disease be on the other side of the world in less than a day, but as Maegraith pointed out, it can bring the non-human vectors of disease too.  For some years, there was puzzlement at the number of deaths from malaria which occurred in Paris – in people who had never been abroad.  Then it was realised that all of these deaths occurred within a few miles of Orly airport.  The anopheles mosquito, dispersed from the aeroplane, travelled a short distance before biting its nearest victim.  Nowadays, relevant flights ask you to cover your eyes before they spray insecticide after the doors are closed.  But there is no magic insecticide to kill the infections that humans carry within themselves, such as SARS Cov-2, to give the Corona virus its proper name.   Professor Maegraith wrote a seminal paper, published in the Lancet in 1963, entitled ‘Unde Venis.’  The translation from the Latin is ‘Where have you come from?’  This not only illustrates the nub of tropical medical diagnostics in two words, it also shows us that Prof Maegraith was a highly educated man who had read the Satires of Juvenal in the original Latin.

And this evening, after the second episode of the Crown, news comes that Boris Johnson has been admitted to St Thomas’ ITU.

Total UK deaths from Covid-19 - 5,373, increase from previous day 439.  This is the third day in a row that the number of deaths has been lower than the previous day (but just a quirk – see below).

Tuesday April 7^th

I saw a death notice in the paper yesterday of somebody I only met a few times, who had died aged 81.  He was the son of a man who had once been my father’s boss in the Admiralty in Bath.  I am sure he had no recollection of me whatsoever, but being 9 years older than me, when I first met him at the age of 5 or 6 and he was about 14, he seemed impossibly special, with a wonderful collection of grown up children’s toys – Meccano, model aeroplanes, etc.  Following these meetings, we were posted to Malta, and I never saw him again.

Sir James Mackenzie, who has good claim to be dignified with the label of ‘First Ever Cardiologist’, used to study the obituary column of The Times, as a way of obtaining follow up on his patients.  He it was who first recognised the grim significance of the ‘pulsus alternans’ as a bad prognostic sign in patients with heart failure.  In one of his textbooks, the appendix is a huge collection of case vignettes.  After identifying the gloomy outlook in one patient whom he observed to have this sign, he wrote baldly, ‘Soon after this I saw from The Times that he had died.’

Another beautiful day.  Our exercise today is a bike ride, exploring little known cycle trails within the purlieus of Bournemouth.

The evening is allocated to another episode of ‘The Crown’.  Part of the episode was related to the attempts of Lord Louis Mountbatten to change the name of the Royal House from Windsor to Mountbatten.  The argument ran that only the male scion of the King would necessarily be a Windsor, and the Queen should take her new husband’s name.  Such machinations were typical of Mountbatten, who on the face of it was a decorated war hero, but in truth was a philandering and manipulative individual who relied on his intelligence, drive, and his undoubted charisma to wheedle his way into the corridors of power.  A recent biography of him has some enjoyable quotes: ‘Edwina and I spent all our married lives getting into other people’s beds’ he said at one point.  An indication of the deviousness of his character is given in Field Marshal Sir Gerald Templer’s remark to him, ‘Dickie, you’re so crooked.  If you swallowed a nail you’d shit a corkscrew.’  Not mentioned in the Crown (because not entirely relevant) is his status as a war hero, in which he brought the damaged destroyer, HMS Kelly, back to safety after being torpedoed off the Dutch coast.  Subsequently the ship was sunk during the Battle of Crete.  Despite suggestions that Mountbatten needlessly gave away the position of his vessel, his reputation, like Teflon, was unsullied and indeed enhanced.

Wednesday April 8^th

Another perfect day.  After our cycle ride we have relaxed, though we will wait until later to walk on Talbot Heath, which is almost deserted toward sunset.  The PM remains in ITU, apparently only on oxygen, and not on assisted ventilation.  There are many more Covid-19 deaths, up by 938 in the last 24 hours.  A particular puzzle is the continuing low death rate in Germany, compared with other European countries.  A journalist during the daily briefing suggests that this is due to more and better testing in Germany.  The answer is, unfortunately, we don’t know.

Thursday April 9^th

A beautiful day, very little wind.  Sunbathing weather.  This is Maundy Thursday.  Very little to report.  Our only exercise is in the evening with a walk on Parkstone Golf Course again.  The National Theatre streams its production of Jane Eyre this evening.  Quite an oppressive story.  Good theatricality, but not a barrel of laughs (yes, I have read the book).  Despite the period clothing, it jars slightly when Mr Rochester falls off his horse and says ‘Fuck’ twice.  Given the general public state of depression we call a halt after the first half and will give it another go tomorrow.  The PM is now out of Intensive Care which is good news.  More deaths, inevitably.  I receive a phone call from Poole Hospital Occupational Health who express reservations about any role with patient contact.  Seems reasonable.  Weather forecast is even better for the weekend.  Video clip on the news this evening of police stopping two lads driving into the Lake District with a canoe on the roof of their car!  Haven’t they heard the news?

My musical education is coming on.  I now have time to listen to most of the ‘Composer of the Week’ series with Donald Macleod (no relation).  In a piece by Schubert he states that ‘Schubert here used the “Mannheim Skyrocket.”’  This is a rapidly ascending broken chord, often with a crescendo.  The Mannheim School (1740s to 1770s) influenced a number of composers including Mozart and Beethoven.  I’ve found the programme a very good way of going to sleep.  Donald Macleod has a gentle mellifluous voice, and after his introduction, the music can lull you off extremely well.  Particularly useful since we aren’t getting quite as much physical exercise as we used to.

Good Friday, April 10^th

Another beautiful day.  The police have a hard job of trying to reduce numbers in beauty spots today.  The Prime Minister is still at St Thomas’s Hospital, though now out of Intensive Care.  Objections from several friends at major medical centres when St Thomas’s is described on the BBC as ‘the best hospital in the country.’  A small digression about St Thomas’s: after my first summer in the USA, working in a research facility in Upstate New York, a fellow student who was studying at Downstate Medical Center in Brooklyn, came to do an elective in London.  After a week or two, he asked me, in all seriousness; ‘Andy, is it essential to have a double-barrelled name to get a job at Saint Thomas’s?’

Deaths yesterday in UK rose by 881 to total 7,978.  Johns Hopkins University in the USA estimates world death toll now exceeds 100,000.

Sorry about the gloomy statistics but this is a Corona diary.

As readers (if any) will realise, I am typing my diary and putting off my return to the Book Club’s chosen book of the month – Burma 44.  Somehow or other, although I have great admiration for ‘The Forgotten Army’, fighting the Japs in the jungle doesn’t seem to have much allure while we are fighting the present ‘Yellow Peril’ – a not inappropriate name given the source of the virus.  Truth to tell, I have been a little disappointed in our Book Club (though I realise that some of its members will read this).  It seemed a great idea – mostly, if not all, retired male medics; a counterblast to the innumerable women’s book clubs, and a way of being introduced to some books or authors whom one had not read.  But with a few exceptions, the books have either been what one might call ‘Boys’ Own Paper’ stories, or history books, and I’m told that the next book in the pipeline from the one person who has not selected so far is also a WW2 book, as was the one before Burma 44.  Did you know (I expect you did), that 93% of book clubs are women’s book clubs?  An article by Kristin Hunt quotes a character from a novel called ‘The Middlesteins’ who says, ‘What’s the point of having a book club if you don’t get to eat brownies and drink wine?’

So that’s the news on Good Friday, April 10^th.  And I am going to publish this and then go and read Burma 44; promise.