The Evening Hill Diaries: Corona Diary Part 4: Saturday April 11th to Wednesday April 15th

Easter Saturday, April 11^th

If only we could have February’s weather back again – at least for a short while. It remains beautiful. Extraordinary how Parkinson’s Law of Social Distancing operates – the day seems to vanish before us and before we know it the time has marched around to 5.30pm and it is time for our walk. We might be getting fitter; in what seems like no time at all we cover four and a half miles. By the time we reach the beach it is fortunately quiet. One of our lovely cardiac nurses from Royal Bournemouth CIU jogs past and we exchange a few (socially distanced) words. Good to see that the team is looking well and seemingly standing up to the present crisis. There are still a few idiots around who obviously don’t think it matters if their dog runs right up to you, especially as they have one of those pelota-like ball hurlers with a dog saliva covered ball in evidence.

We walk back up Alum Chine, and do something I have intended to for years, but never have – visited the site of Skerryvore, the tiny miniature garden in Westbourne on the site of Robert Louis Stevenson’s house, where he lived from 1885-1887. It was while he was here that he wrote Kidnapped and The Strange Case of Dr Jekyll and Mister Hyde. The house was destroyed during a German bombing raid in 1940, and all that remains this evening is a rather overgrown plot (opened as a garden by Bournemouth Council in 1957) with some nodding white harebells, while a woman of middle European appearance talks animatedly into a mobile phone and a bored looking little girl scratches a stick in the dirt. In another part of the garden a middle aged jogger with a 1960s hippy hair-do and a headband does some stretching exercises. And so to home. Another episode of The Crown, and at last, Queen Elizabeth is crowned. The Duke and Duchess of Windsor watch on a tiny TV screen while throwing a party in Paris. Alex Jennings, who looks uncannily like the Duke, has some marvellous lines. The acting is generally excellent.

The previous evening, we did indeed return to ‘Jane Eyre’ and this production left me with the feeling that it was three hours of my life I would never get back. ‘Reader, read the book.’ (Sorry, wrong author).

Sunday, Easter Day, April 12^th

‘What is this Life, if, full of care

We have no time to stand and stare?’

Except that we are not supposed to ‘stand and stare’, but to carry on walking.

But as a child, growing up, at least in part, in Wales, W.H.Davies was dinned into us as a Folk Super Hero, an itinerant who celebrated the beauties of nature. We had to learn that poem by heart in school in Fishguard. Friends post pictures of bluebell woods (they do live in the country and claim that they are on the regular walking route). It induces a faint sense of envy however.

I did return to Burma ‘44 and am now more than half-way through it. It is certainly a superb historical document, though still somewhat dry. I am just about to read about the ‘Battle of the Admin Box’, an action which I had never heard of until a few weeks ago, but in which a friend’s father was involved. He has mentioned that his father’s experiences in this theatre resulted in nightmares to the end of his life. Nowadays we knowingly refer to this as ‘Post Traumatic Stress Disorder’, PTSD, but it remains the same wherever you are. PTSD will undoubtedly be a significant problem among healthcare personnel after the coronavirus outbreak is over. With regard to Burma, I do wish that the book we are reading is the superb ‘Quartered Safe Out Here’, by George MacDonald Fraser, author of the Flashman novels. I read this soon after it came out in 1993. It’s immensely readable, much like Spike Milligan’s wartime series of autobiography, and tells of Fraser’s experiences as a 19-year-old private in the Border Regiment in Burma 1944-45. The title is of course ironic, and a reference to the 1890 poem ‘Gunga Din’ by Rudyard Kipling, which in this post-colonial era we are really not allowed to mention, let alone read.

Our exercise today was a bicycle ride. During this we passed the superb statue outside the RNLI depicting the lifeboatman saving a seaman. On to Poole Quay, where the superyacht ‘Here Comes the Sun’ is currently moored and mothballed. This 83m yacht is truly extraordinary. The given name of the owner would suggest that he is Russian, but presumably not resident on the yacht! More yachts for mothballing are expected later.

More of The Crown this evening. Poor Princess Margaret and her romance with Group Captain Peter Townsend were the main subjects…

Easter Monday, April 13^th

A bright, mostly sunny day, but now with the promised very chill northerly wind. A jigsaw preoccupies me for far too long, but there is time for reading as well. Also time to look at the possibilities of therapy for SARS-CoV-2. Most experts think a vaccine is a very long way away. The NEJM (New England Journal of Medicine) publishes an article about the compassionate use of a new drug, remdesivir, in seriously ill patients with Covid pneumonitis. In an uncontrolled trial it appears to be beneficial. The drug is an RNA polymerase dependent adenosine nucleotide analogue. In other words it mimics one of the bases inserted into the nucleic acid chain of RNA, and seems to result in premature termination of the RNA synthesis in viral infected cells. It was first developed by Gilead Sciences in California as a likely agent for treatment of Ebola and Marburg virus infections. Reading the history of Gilead Sciences certainly gives one the impression of a Tech Company with an impressive list of meaningful contributors, including Nobel laureates. Production is limited, and the company have announced that it will now only be available for use in a controlled trial.

Also interesting over the weekend has been the finding that patients with Covid-19 pneumonitis tolerate much lower oxygen saturations than was thought safe previously. One intensivist likens it to measuring blood saturations in otherwise healthy people at altitude. We know that carbon dioxide is an extremely small and very diffusible molecule, and that in subjects without airways obstruction elimination of carbon dioxide is rarely a problem. So with Covid-19 patients, the CO₂ elimination appears to happen without any retention, and hypoxaemia is the main concern. As such it would seem that the key factor in treatment is increasing the supply of oxygen, and invasive ventilation should be the last resort. In 2007, when visiting the Nepal Himalaya, I met an American doctor who was walking with his children. He had been concerned about the susceptibility of children to altitude sickness and had brought his own personal saturation monitor. At about 3800m he recorded their saturations (and his own) at 83%. Normal is 98 to 99% at sea level. All were asymptomatic.

A colleague who I spoke to today told me that they have learned that the most important people to give the masks to are the patients! Seems self-evident but turns out to be important to reduce infectivity.

An incessant inbox of WhatsApp jokes, videos, and cartoons seems to be without end. Some are funny, but not all.

Another episode of The Crown. Winston Churchill’s stroke. Preceded by a little escapism – the film of Paddington – surprisingly good. Cuddly and comforting for the Covid season! The film club seems to have been temporarily disbanded, and Lindsay and I often pursue our own watching preferences. Lindsay has started in on the new Julian Fellowes series, ‘Belgravia’. Victoria Coren-Mitchell, writing in the Telegraph recommends ‘Gentleman Jack’ which she says is ‘Like Belgravia, but with more lesbian sex scenes.’

Tuesday April 14^th

Another sunny day, but chill. Same northerly cold wind. The main topic on the news this morning is Care Homes. The newshounds are keen to say they are ‘being airbrushed from the figures.’ An alert young man from the ONS (Office of National Statistics) is interviewed by Victoria Derbyshire, who is unused to having so much maths thrown at her first thing in the morning. We do not know for sure whether deaths in Care Homes are due to Covid-19; this is unsurprising. As some will know, when filling out a death certificate, there is a section 1a – Cause of Death. Then Section 1b – ‘Other disease or condition, if any, leading to 1a. There is a section 2 – Other significant conditions CONTRIBUTING TO THE DEATH but not related to the disease or condition causing it. According to Nick of ONS, 21% of care home deaths mentioned Covid-19, though he did not say whether this was in 1b or 2. In London this figure is nearer 50%. He stated that the observed versus expected death rate in Care Homes was around 50% higher than normal, in the week up to April 3^rd (there is a lag in reporting and validation of deaths in Care Homes).

So, the media are now in a feeding frenzy of conspiracy fever. ‘Many more people are dying from Coronavirus than the Government would have us believe’ is the general proposition. In fairness, neither the Chief Medical Officer, nor the Chief Scientific Officer have sought to gloss over these figures. Sir Patrick Vallance repeatedly points out in his briefings that deaths in hospital, validated, and in Covid-19 proven cases, is the statistic that the COBRA team is relying on to establish whether current social distancing measures are working. Reporters should be very wary in relying on death certification. Investigation after investigation has shown that the cause of death is inaccurate in up to 50% of cases; at least up until the present Coronavirus era. Let me give you an example – and I need to be careful here because of possible identification. A medical colleague was known to have bilateral carotid artery stenoses (narrowings). During his normal medical practice, a patient left his consulting room. He did not appear to call in the next patient. After a short while the receptionist went to his room to find him stone dead. His colleagues certified the death as due to ‘Stroke’. We know (from the Framingham study in Massachusetts) that the most frequent cause of death in subjects with bilateral carotid stenoses is myocardial infarction (heart attack), because ‘furring up’ in one vessel predicts furring up (atheroma) in other vessels. Death in this instance is commonly instantaneous – as in the case I have described. Any doctor or nurse who has had the misfortune to observe death in stroke will immediately recognise that what was described above is not the mode of exitus in such patients.

A digression: Professor Keith Simpson, forensic pathologist, used to lecture to us at UCH. He was a superb lecturer. Forensic pathology lectures were, of course, packed. His lectures and indeed some of his slides, could not be given now, even to medical students; political correctness being one reason. His lectures were often filled with spooky dramatic effects, where he would drop his voice to a low hushed tone. One such case involved a not particularly able country GP, who was widely recognised to be such. A female patient, in her fifties, was fit and apparently well, though known to have mild rheumatic valvular heart disease. She died suddenly. After some thought, the GP consulted a textbook to see if he could find a plausible cause of death, and wrote on the death certificate ‘Cause of Death – 1a Heart Failure, due to 1b Ball-valve thrombosis of mitral valve.’ As many will know, this event, where a significant sized clot forms in the left atrium behind a diseased mitral valve, is an incredibly rare cause of death, even in known rheumatic heart disease. At this point, Simpson dropped his voice: ‘After a few weeks, there was talk in the village. Her relatives had a business which was said to be in financial difficulties. The death was regarded by many as “too convenient.” Eventually, after various representations had been made to the police, permission was given to exhume the body to perform a post mortem examination. Most exhumations take place at night, to avoid upset, especially in a small community. “It was a cold wintry night. I wore my gum-boots. If you are going to be a forensic pathologist you must always invest in a good pair of gum-boots. Together we trooped down the little lane which led to the churchyard. Under a tent, we identified the plot and retrieved the coffin (here a slide of the lid of the coffin with the inscription on a brass plate). I returned to the local hospital mortuary, where I opened the chest and examined the heart. (Voice even lower). What do you think I found? (Slide). A ball-valve thrombus obstructing the mitral valve leading to almost instantaneous death from acute heart failure!” Great story. The recounting doesn’t do the tension or the theatrics of it justice. When one looks at Keith Simpson’s entry on Wikipedia, it seems surprising that he was never knighted. He must have offended someone…

I apologise for medical navel gazing – but a few of my readers have said they are interested in the scientific parts.

Total deaths in UK announced today (data from April 13) is 11,329, but daily new cases and daily new deaths have reduced in the last few days. We will need to be sure that this is not a reporting quirk caused by the Easter weekend.

Wednesday April 15^th

Another beautiful bright and sunny day. Priorities go like this:

1. Check the news
2. Make Lindsay a cup of tea and self a small glass of orange juice
3. Get up. Have a light breakfast. Make coffee in an Italian Moka pot.
4. Desperately try to find a better news programme than the BBC. You probably want some justification for that statement. How long have you got? (A long time, Ed.) Try CNN for a while which at least mentions other countries in the world for a time. Give up.
5. Finish a fiendish jigsaw. Probably not so bad as the one I bought when we visited the Pollock-Krasner house on Long Island a few years ago – Pollock’s ‘Convergence.’ This is next on the jigsaw list. Still, we should have time…
6. Guitar practice. In our moves within the last year my guitar footstool went missing. I have found that the combination of the hardback of Stephen Fry’s Heroes (477 pages), Earthly Powers by Anthony Burgess (649 pages), Shantaram (paperback by Gregory David Roberts, 933 pages) brings the foot support to the required height. I am working on the Bach 1^st Cello Suite Prelude – not bad, but then I learned it in my 20s; and have picked up again Sylvius Leopold Weiss’s Passacaglia; not so good. But beautiful. I suggest searching YouTube and listening to Julian Bream playing it. So fluent.
7. Virtual coffee morning with friends and neighbours.
8. Ring Care Home where my father-in-law spent the last three and a half years of his life to enquire how they are getting on. Of course we can’t visit them at the moment, but they do feel like family after all that time.

For some reason, the BBC prefers to take the easy option of ‘Talking Heads’ where interviewees can give their perspective on how they have been ‘forgotten’, or ‘airbrushed from the statistics.’ Some of these cases are indeed very sad, and appropriate tribute must be paid to someone who reads a letter of love and farewell to someone dying alone in a Care Home, but for example, the Beeb spent about 10 seconds on President Trump’s decision to withhold funding from WHO (which is almost certainly partly a wish on his part to deflect blame from himself), and then reverted to the talking heads style of interviews. What we would really want is a few minutes of thoughtful and considered analysis of what WHO is, how much its budget is, how it spends its funds, and what its role in the current pandemic is – and whether it has fulfilled that role appropriately. Perhaps someone will think to investigate this in time…

I’ve reached the page in Burma ’44 which deals with my friend’s father’s part in the battle of the Admin Box. As the British 25^th Dragoons in three US-made tanks (superior anti-tank armour) advanced across open paddy, two were hit badly and freakishly, resulting in fire and death. My friend’s father helped to pull survivors out of the burning wrecks. Strange to think that had it been his tank which had been hit, we would not know the family at all – they would not exist. (Pages 240 and 241 if you are interested).

Another friend has sent some ‘funnies’ to look at, many of course unfunny, but surprisingly two of the most interesting and apposite quotes I’ve seen for some time*:

*But see below.

F Scott Fitzgerald, in a letter to a friend in 1920, while quarantined in the South of France during the ‘Spanish Influenza’ outbreak:

‘Dearest Rosemary,

It was a limpid dreary day, hung as in a basket from a single dull star. I thank you for your letter. Outside, I perceive what may be a collection of fallen leaves tussling against a trash can. It rings like jazz to my ears. The streets are that empty. It seems as though the bulk of the city has retreated to their quarters, rightfully so. At this time, it seems very poignant to avoid all public spaces. Even the bars, as I told Hemingway, but to that he punched me in the stomach, to which I asked if he had washed his hands. He hadn’t. He is much the denier, that one. Why, he considers the virus to be just influenza. I’m curious of his sources.

The officials have alerted us to ensure we have a month’s worth of necessities. Zelda and I have stocked up on red wine, whiskey, rum, vermouth, absinthe, white wine, sherry, gin and lord, if we need it, brandy.

Please pray for us.’

And:

Samuel Pepys’ Diary, London, 1664:

“On hearing ill rumour that Londoners may soon be urged into their lodgings by Her Majesty’s men, I looked upon the street to see a gaggle of striplings making fair merry, and no doubt spreading the plague well about. Not a care had these rogues for the health of their elders!”

EXCEPT THAT THIS IS NOT BY SAMUEL PEPYS! THERE IS AT LEAST ONE CLUE IN THE TEXT – CAN YOU SPOT IT?

It rings true though!

And, sadly, the Scott Fitzgerald is also fake, though the author, Nick Farriella, clearly stated this:

https://www.mcsweeneys.net/articles/this-side-of-paradise-a-letter-from-f-scott-fitzgerald-quarantined-in-the-south-of-france

I speak to a friend who runs a Care Home, which is part of a large national network. She says that they have no Covid-19 cases, that the ‘Network’ have been fantastic, but she doubts that without the clout of a big organisation they could have achieved the PPE needed for their staff. She feels very sorry for the staff of small privately run institutions. The Government and Local Authority response to them, for example, extended to one box of gloves. We agreed that the Government’s will and intention is not in doubt, but that the logistics are terrible. A number of their staff are self-isolating, and testing will be helpful to get them back to work in due course. Parenthetically, she states that she will be boycotting Tesco’s henceforth. Despite providing badges for all staff indicating they are care workers, Tesco has refused to honour these and therefore they cannot shop during the protected hour. Sainsbury’s and Waitrose have been sympathetic and have supported them.

And surprisingly, the morning has gone. Time for some family Facetime or Whatsapp time…

I note that the lengths of each section of this Corona Diary are relatively similar. This one is a little shorter than the others, so one final observation: a few weeks ago, I remember seeing one entry only of a Covid-19 related death in the Daily Telegraph Obituary column (the big one, not the death notices). Now it seems they come thick and fast. The latest and for many one of the saddest is that of Tim Brooke-Taylor, gentle humourist, who has been part of our lives for so many years. It was only in January of this year that Lindsay and I attended the recording here in Poole of the hugely funny radio show ‘I’m sorry I haven’t a clue,’ when Tim was on excellent form.

Let me leave you with some pictures taken on our (allowed) daily exercise walking down Bournemouth Gardens.