[tc]

Got it. Thanks. I had a sneaking suspicion he was missing a big part of the jigsaw, so thanks to both of you for setting that straight. I find numbers confusing half the time (or 25% if you prefer).

[petejh]

Rant wasn’t aimed at aimed you TC btw. Just had loads of debates in the past couple of weeks with a friend who thinks this is overblown 

[tc]

Rant wasn’t aimed at aimed you TC btw. Just had loads of debates in the past couple of weeks with a friend who thinks this is overblown

Oh, good. That means I don't have to tell you to go fuck yourself, I can just wish you a Happy Easter instead 😁

[petejh]

Has anyone else twigged that Boris Johnson came back from the dead on Easter Sunday?

Genius plan by Cummings.

[webbo]

You can contribute to his get well present.
https://www.crowdfunder.co.uk/getwellboris

[tomtom]

Has anyone else twigged that Boris Johnson came back from the dead on Easter Sunday?

Genius plan by Cummings.

Can't be Cummings - otherwise it would have been a three point resurrection.

[Nigel]

Saying "the right PPE was in the post" would not cut it.

I asked this question elsewhere and got a bad reaction (Twitter of course). What's the latest with this? I'm still finding it baffling that the current PPE situation isn't just a clear breach. 

It seems that at least from the coverage on Radio 4 and the Guardian that PPE is now starting to make the odd headline, so I probably don't need to fill you in. One interesting thing I noted from an interview with the CEO of the NHS trusts on Radio 4 Today was that when this interview was "repackaged" into the soundbite headline for the regular "and now the main headlines again" later in the broadcast, the snippet they chose to use was that the NHS was a) short of gowns, b) China has been sending us boxes of masks mislabelled as gowns. Having heard the whole interview it seemed a very weird headline to take from it. The implication seemed to me to be that somehow our shortage of PPE was partly China's fault. As I raised earlier, if you want a resilient response to a pandemic you need to have a domestic stockpile as an initial buffer, plus a pre-planned process for quickly producing this stuff domestically to keep up supply. Buying stuff from abroad is not ideal for the very obvious reason that the demand is global. I note that this point about limited global supply has also been made by cabinet ministers in their briefings. I have yet to hear a journalist ask the obvious question of why we don't have this capacity in this country. Also no mention of the "PPE piracy" practiced by the USA in particular and mentioned by others earlier in the thread. My cynical view would be that it doesn't fit with the narrative of "free markets = always good". Maybe after this PPE manufacturers will get the same helping hand from government as say oil companies, or arms manufacturers.

If you want some extra food for thought, consider that *as far as I can glean from the internet* (happy to be corrected!) South Korea, population 50 million, has no known deaths of healthcare workers from Covid-19. Yes they took a different approach overall, but they were largely able to do that because their government had a plan - they arranged with test providers to produce kits in January, and fast-tracked the approvals. We have the health sec ringing round labs issuing pleas in mid-April to help dig him out of his over-promising on tests. From UK gov in January there seemed to be more interest in getting Big Ben to make a noise.

In terms of PPE, and again caveated *by the fact I read it on the internet* (i.e. could be wrong!), China had approximately 1500 healthcare workers test positive for Covid-19 in Wuhan. At one point they traced 41% of all new cases to transmission within hospitals. Subsequently there was an influx of 40,000+ extra healthcare workers to Wuhan, all given proper PPE and training from the lessons learned. None of these were recorded as testing positive for Covid-19  . That is the difference PPE can make and still a couple of months later we have NHS workers contracting Covid and dying. "Protect the NHS" indeed...

[Nigel]

Also forget to mention, current UK guidance is that certain PPE is only required for healthcare workers doing "aerosol generating procedures". The wording seems weird - surely coughing (one of the main symptoms of Covid) is "aerosol generating"? However it is not a "procedure" in the medical sense. Rather just something people do. It looks unclear to my untrained eye.

[Nigel]

It seems that at least from the coverage on Radio 4 and the Guardian that PPE is now starting to make the odd headline, so I probably don't need to fill you in.

The latest muck up: https://www.theguardian.com/world/2020/apr/13/uk-missed-three-chances-to-join-eu-scheme-to-bulk-buy-ppe

[TobyD]

Some interesting posts Nigel. Aerosol generating procedures refers to doing things like inserting tubes to airways, suctioning, and chest compressions in CPR among other things to my knowledge. But yes, potentially anyone can cough in your face, but that's only different to everyday life in that currently healthcare workers tend to be closer to other people than most at the moment. Services like mine have PPE but we don't need the full on surgical gowns and suits, three pairs of gloves at once etc that ICU have to deal with, I think the real issues are with distribution of that stuff. It's probably more of a problem in care homes in my experience in the last few days of having been to some. It's a significant government oversight, but the China stats I'd deeply mistrust, I wouldn't be surprised if they underreported deaths, and covered up all manner of information which might lead to criticism of their government or the re starting of their economy.

[Nigel]

That's partly my point about the wording Toby i.e. use of the word "procedures" after "aerosol generating" seems to imply that you must be involved in intubation, compression etc. to justify certain PPE per the guidelines. By extension it seems to exclude coughing as sufficient justification, despite this being a prominent symptom. Surely the hospital is somewhat different to normal life in that healthcare workers and patients are in constant fairly close proximity? The chances of transmission are clearly much higher than my normal life for instance (all day at home, quiet walk / cycle, shop once every 10 days ish). I freely admit I'm out of my area here, so will happily defer if its seen as ay OK by those in the know. From chats with medics I get the general feeling that they perceive the guidance as having been downgraded to suit the available PPE, rather than the way it should be done (PPE to suit the risk of hazard). I know you said you have had concerns / confusion over changing guidance?

On care homes I know very little. My only direct experience is that our family took our 94 year old Nana out of one in early March (it was a temporary measure anyway) as we were worried by the fact that although they had stopped family visits they were still taking in residents straight out of hospital. It seems to be filtering through now that there is a problem with Covid in care homes, including deaths which are not counted in government figures. Its always interesting to hear more of your reports from the coalface. Given I've nothing actually useful to say RE care homes, how about a bit of politics - wouldn't distribution of PPE to care homes be easier if we had a National Care Service already?

RE China stats, I wouldn't be surprised if they under-reported deaths either, for the simple reason that our government is clearly doing so too. Anyway the stats I gave (if true) weren't intended to, and don't really seem to show China in a good light initially, it shows them struggling - 1500 healthcare workers confirmed infected, high transmission rate in hospital, before they sorted out how to respond. I hold no candle for the Chinese government but I am wary of this emerging line that China somehow covered up the emergence of the "Chinese Virus" (Trump!). No doubt to some extent they did try at first, but as Bonjoy said earlier in the thread the widespread pictures out of China of Wuhan in lockdown, full hospitals, and workers in hazmat suits appeared back in late January and told a pretty obvious story. The truth of China's figures may well come out in time but does it matter? We have our own figures here and elsewhere in Europe to worry about now. Even if they did under-report then we still had a headstart on our response. Blaming China looks like deflection from our own deficiencies.

[Paul B]

Also forget to mention, current UK guidance is that certain PPE is only required for healthcare workers doing "aerosol generating procedures". The wording seems weird - surely coughing (one of the main symptoms of Covid) is "aerosol generating"? However it is not a "procedure" in the medical sense. Rather just something people do. It looks unclear to my untrained eye.

This is the bit I hadn't stumbled upon. Thanks.

[spidermonkey09]

Interestingly, my girlfriends Trust have decreed that CPR is not an aerosol generating procedure and have therefore instructed staff that full PPE is not required to carry it out. This seems to be at odds with the BMA position, along with common sense.

[Offwidth]

Hindsight is a wonderful thing but I still see our UK lockdown response timing as inevitable, if partly because of the experts we chose to inform government. The behavioral science was OK but the models were not accurate enough for planning and we had too little input from medical experts who had fought virus outbreaks and who would have been pushing for harder faster action. It was clearly a shock to most of Europe when the virus took off so fast in Italy and after that to the UK government when it became apparent, as UK deaths took off, that we might not be 4 weeks behind Italy as their models said. The government quickly dropped herd immunity as an aim and accelerated its response very quickly after this hard data contradicted the models (even though they continued defending the 4 weeks gap publicly). It would have been brave for anyone, let alone Boris, to call the social mobility controls even a week earlier on the information the government team of experts provided.  I'm confident the balance of pandemic response medical expert  input compared to expert modelling input will never be as poor again.

The really bad UK government actions started when they buried the report of the 2016 pandemic response test, leaving us with infrastructure issues, too little capacity to respond with PPE stocks and to set up testing, and then in 2020 doing nothing about these areas when it was apparent this could become a serious international pandemic. Having an NHS hamstrung by austerity and a Public Heath and care system severely damaged by austerity didn't help.

[Nigel]

Interestingly, my girlfriends Trust have decreed that CPR is not an aerosol generating procedure and have therefore instructed staff that full PPE is not required to carry it out. This seems to be at odds with the BMA position, along with common sense.

Seems to tally with the sort of thing I'd heard i.e. guidance made to fit available PPE, rather than PPE provided appropriate to task. In a similar vein, reports now of face-fit testing now being abandoned in some hospitals: https://www.theguardian.com/world/2020/apr/14/nhs-hospitals-accused-of-risking-staff-lives-by-abandoning-ppe-fit-tests-coronavirus

Pretty much defeats the point of having an FFP3 mask.

[mrjonathanr]

The government quickly dropped herd immunity as an aim

Sure about this?

[TobyD]

Interestingly, my girlfriends Trust have decreed that CPR is not an aerosol generating procedure and have therefore instructed staff that full PPE is not required to carry it out. This seems to be at odds with the BMA position, along with common sense.

That's not what my trust are saying either. If I were her I'd be raising that officially with managers.

[TobyD]

That's partly my point about the wording Toby i.e. use of the word "procedures" after "aerosol generating" seems to imply that you must be involved in intubation, compression etc. to justify certain PPE per the guidelines. By extension it seems to exclude coughing as sufficient justification, despite this being a prominent symptom. Surely the hospital is somewhat different to normal life in that healthcare workers and patients are in constant fairly close proximity? The chances of transmission are clearly much higher than my normal life for instance (all day at home, quiet walk / cycle, shop once every 10 days ish). I freely admit I'm out of my area here, so will happily defer if its seen as ay OK by those in the know. From chats with medics I get the general feeling that they perceive the guidance as having been downgraded to suit the available PPE, rather than the way it should be done (PPE to suit the risk of hazard). I know you said you have had concerns / confusion over changing guidance?

On care homes I know very little. My only direct experience is that our family took our 94 year old Nana out of one in early March (it was a temporary measure anyway) as we were worried by the fact that although they had stopped family visits they were still taking in residents straight out of hospital. It seems to be filtering through now that there is a problem with Covid in care homes, including deaths which are not counted in government figures. Its always interesting to hear more of your reports from the coalface. Given I've nothing actually useful to say RE care homes, how about a bit of politics - wouldn't distribution of PPE to care homes be easier if we had a National Care Service already?

RE China stats, I wouldn't be surprised if they under-reported deaths either, for the simple reason that our government is clearly doing so too. Anyway the stats I gave (if true) weren't intended to, and don't really seem to show China in a good light initially, it shows them struggling - 1500 healthcare workers confirmed infected, high transmission rate in hospital, before they sorted out how to respond. I hold no candle for the Chinese government but I am wary of this emerging line that China somehow covered up the emergence of the "Chinese Virus" (Trump!). No doubt to some extent they did try at first, but as Bonjoy said earlier in the thread the widespread pictures out of China of Wuhan in lockdown, full hospitals, and workers in hazmat suits appeared back in late January and told a pretty obvious story. The truth of China's figures may well come out in time but does it matter? We have our own figures here and elsewhere in Europe to worry about now. Even if they did under-report then we still had a headstart on our response. Blaming China looks like deflection from our own deficiencies.

Nigel, two points, yes risk to healthcare workers is much, much higher than everyday life. For anyone else taking reasonable precautions, shopping is probably the greatest risk. Mine, and anyone else obliged to work with the public, is by far going to work. We pretty much have to suck that up. An ffp mask is overkill for most of what I do, and it'd be too hard to fit and dispose of it in the community. It's hard enough using the basic stuff properly. The way most punters use masks makes them probably worse than doing nothing by touching them, reusing them etc.

Re China I don't think it's mutually exclusive to roundly criticize their government and our own. China did behave appallingly, on this Trump is right, but he is horribly wrong to blame WHO as well. That's just to suit his own domestic agenda. Our government also didn't prepare well enough or react quickly enough. But they didn't try to cover the entire thing up, allowing it to escalate and become a global problem. If China had gone full lockdown immediately the world might and I emphasize might not be where we are.

[Nigel]

An ffp mask is overkill for most of what I do, and it'd be too hard to fit and dispose of it in the community. It's hard enough using the basic stuff properly. The way most punters use masks makes them probably worse than doing nothing by touching them, reusing them etc.

I'm sure you're right about your job Toby, I'm not at all presuming to say what you should or should not be doing (I don't know). Neither am I saying everyone should be wearing masks in normal life. Just that all health and social care workers should have the appropriate kit, and enough it. And know how to use it. Govt is definitely starting to catch up on guidance front at least...

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/878750/T2_poster_Recommended_PPE_for_primary__outpatient__community_and_social_care_by_setting.pdf  - your role probably comes under this doc?
https://www.gov.uk/government/publications/covid-19-personal-protective-equipment-use-for-non-aerosol-generating-procedures - instructions for use

Mine, and anyone else obliged to work with the public, is by far going to work. We pretty much have to suck that up.

You should only have to suck up actually going to work. You *shouldn't* have to suck up doing it without proper protection. It sounds like you are happy with your arrangements, which is great, and reassuring. This has not been the case for other people though - 51 health and social care workers now dead - https://twitter.com/NursingNotesUK/status/1250338676665540608?s=20

Re China I don't think it's mutually exclusive to roundly criticize their government and our own. China did behave appallingly, on this Trump is right, but he is horribly wrong to blame WHO as well. That's just to suit his own domestic agenda. Our government also didn't prepare well enough or react quickly enough. But they didn't try to cover the entire thing up, allowing it to escalate and become a global problem. If China had gone full lockdown immediately the world might and I emphasize might not be where we are.

I totally agree that we can criticise both China and our govt. As long as its rational and we apply the same standards, or we risk becoming Trumpian ourselves. Its all very well to say that if China had fully locked down then this might not have become pandemic, and probably true. But rationally, they had some unexplained cases of pneumonia in mid-December. WHO there 31st Dec. They had their first death and clinically confirmed it as a novel virus in early January, by which time they had already shut the wet market. 23rd Jan they shut down Wuhan city, next day other cities in the province. With the benefit of hindsight there are obvious gaps there during which the lockdown could have been brought forward, I agree. Equally with the benefit of hindsight all world governments should have been calling on China to lockdown earlier and harder, which I don't think they were? Certainly my recall of a lot of the media coverage at the time was that it was critical of China's approach to human rights and personal liberty. Trump definitely got a hammering for stopping flights from China - as you say turns out he was right.

So from what we know at present; from unexplained cases of pneumonia to starting lockdown took about 6 weeks in China. Compare that to the UK response, noting that we already knew exactly what was coming - first case in late Jan (from abroad), transmission in UK confirmed end of Feb, lockdown sort of starts 12th March with Boris saying maybe don't go to the pub, 20th March pubs shut. Did we ban international travel? How many cases has the UK exported to other countries? Are we not contributing to the pandemic also, despite already knowing about its existence before the our first case?

If you believe the figures we have more confirmed cases of Covid-19 than China, and 4x as many deaths. The vast difference in population is well known. Yes we can be critical of China by all means, like I say I agree on that. But to effectively say that they should have sorted this out on behalf of the rest of the world looks a) unrealistic and b) applying standards which we clearly are not capable of achieving ourselves.

Looking at the current situation, going back in time to blame China does not solve the UK's immediate problems. That is the UK government's job which is why I prefer to be critical of them at present, particularly on planning.

PS to some extent China and the rest of Asia *did* "sort out" the previous pandemic scares earlier this century, and I am left wondering whether the western nations were indeed hoping this would happen again, instead of planning for the worst.

[spidermonkey09]

That's not what my trust are saying either. If I were her I'd be raising that officially with managers.

Its been raised, although not by her, and the BMA are involved, but the likelihood of them changing it seems slim to nil. Every Trust appears to have wildly different protocols in place where the sensible thing to do would be to follow the respiratory council advice across the board. It seems abundantly clear that the protocols are being dictated by the PPE supply and not the other way round, although that is anecdotal.

[Will Hunt]

That's not what my trust are saying either. If I were her I'd be raising that officially with managers.

Its been raised, although not by her, and the BMA are involved, but the likelihood of them changing it seems slim to nil. Every Trust appears to have wildly different protocols in place where the sensible thing to do would be to follow the respiratory council advice across the board. It seems abundantly clear that the protocols are being dictated by the PPE supply and not the other way round, although that is anecdotal.

Although that is a shocking state of affairs, it doesn't surprise me. You have quantity x of PPE. Your demand is >x. You cannot get more PPE. The only solutions are to reduce the demand for PPE either by rationing its use or not treating patients. Not the kind of call anyone wants to have to make.

[mrjonathanr]

The recommendations of PPE for different scenarios will be a consideration if there is a subsequent court case about its inadequacy, won’t they?

[Stabbsy]

That's not what my trust are saying either. If I were her I'd be raising that officially with managers.

Its been raised, although not by her, and the BMA are involved, but the likelihood of them changing it seems slim to nil. Every Trust appears to have wildly different protocols in place where the sensible thing to do would be to follow the respiratory council advice across the board. It seems abundantly clear that the protocols are being dictated by the PPE supply and not the other way round, although that is anecdotal.

Still anecdotal but similar story - my wife has been getting regular changes to PPE protocol from her trust, usually upping the amount required in each situation or requiring PPE usage in more situations than the previous update. It hasn't changed for a while now, but she was getting new guidance every few days. How much of that was driven by improving PPE availability and how much by the increased likelihood that patients will be infected is unclear. Initially they were only allowed to use PPE where the patient displayed Covid-19 symptoms. However, a number of patients at her surgery lied about symptoms at the triage stage in order to get to a GP appointment (as severe Covid-19 cases were being directed to hospital and mild cases were told to self isolate), so the doctor was unprotected when they announced they had symptoms.

[spidermonkey09]

That's not what my trust are saying either. If I were her I'd be raising that officially with managers.

Its been raised, although not by her, and the BMA are involved, but the likelihood of them changing it seems slim to nil. Every Trust appears to have wildly different protocols in place where the sensible thing to do would be to follow the respiratory council advice across the board. It seems abundantly clear that the protocols are being dictated by the PPE supply and not the other way round, although that is anecdotal.

Although that is a shocking state of affairs, it doesn't surprise me. You have quantity x of PPE. Your demand is >x. You cannot get more PPE. The only solutions are to reduce the demand for PPE either by rationing its use or not treating patients. Not the kind of call anyone wants to have to make.

Yep, clearly a bad decision tree! The argument seems to be that doing CPR on a covid patient is probably a waste of time anyway as they're extremely unlikely to survive an arrest, so little point exposing medical professionals to what is almost certainly an aerosol procedure. Disclaimer that I am notw a doctor and have likely misinterpreted everything I have been told!

[Duma]

Hancock said today old people returning to care homes will be tested first. Almost like they should have been doing that from the start and now the testing capacity is available