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COVID-19: Keeping the baby in the bath

COVID-19: Keeping the baby in the bath (Part 1)

May you live in interesting times

English expression purported to be a translation of a Chinese curse

You see, one thing is, I can live with doubt, and uncertainty, and not knowing… I have approximate answers and possible beliefs and different degrees of certainty about different things. But I’m not absolutely sure of anything… It doesn’t frighten me

Richard Feynman 1981

Standardise until you need to improvise

Kevin Fong 2013

The COVID-19 pandemic has presented unprecedented public health and critical care challenges worldwide. In Australia and New Zealand, we have been fortunate that the quirks of geography combined with an effective public health response have so far greatly limited the pandemic’s impact here. Sadly, our friends around the world have not been so lucky. In some places, healthcare systems have been stretched to the limit, sometimes even beyond breaking point (Bong et al, 2020). Maintaining high quality patient care is nearly impossible when faced with supply shortages and limited access to continuous, attentive care from trained professionals. Healthcare workers are also being put in harm’s way due to a lack of basic supplies of personal protective equipment – an unacceptable situation that should never happen, but has (Nir, 2020). The challenges of the pandemic itself pose other burdens on the practice of critical care, perhaps most distressing is the limitation of patient visits, especially at the end of life (Burke, 2020). No one should die alone, no one should die without their loved ones. Thankfully, at the very least, healthcare workers are always there to hold their patients’ hands.

Given the enormity of these challenges, it seems trivial to focus on some of the controversies in critical care management that have arisen from the COVID-19 pandemic. However, as intensivists, we believe that small details matter and when added together they can make a difference. We will discuss “silent hypoxaemia” and the timing of intubation, whether COVID-19 is part of acute respiratory  distress syndrome (ARDS), lung compliance and mechanical ventilation, “to PEEP or not to PEEP”, and the role of novel therapies and innovations. There are other controversies too, such as the role of non-invasive ventilation (NIV) and high flow nasal cannulae, what defines an aerosol-generating procedure (AGP), the impact of isolation and personal protective equipment (PPE) requirements on every aspect of care from emergencies to rehabilitation and family interactions… We will leave those fights for another day.

We will argue that we need to focus on the basics, build on existing knowledge about the critical care management of respiratory illnesses, and that we need to appropriately test innovations and subject novel therapeutics to well designed clinical trials before administering them to patients. When faced with uncertainty and rapid change, we need to avoid throwing the baby out with the bathwater.

Let us begin with “Silent hypoxaemia” and COVID-19 intubation.

Further reading

Refer to the Coronavirus 2019 disease (COVID-19) page for a detailed overview of the disease from a critical care perspective.

COVID-19: Keeping the baby in the bath series

  1. COVID-19: Keeping the baby in the bath (Introduction)
  2. “Silent hypoxaemia” and COVID-19 intubation
  3. Is COVID-19 ARDS? What about lung compliance?
  4. COVID-19: “To PEEP, or not to PEEP”?
  5. MacGyverism and “hacking COVID-19”
  6. Novel drug therapies and COVID-19 clinical trials
  7. Overcoming uncertainty in the Age of COVID-19

References

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of three amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

Jack Iwashyna LITFL

Critical care physician and health services researcher bringing the tools of social science and outcomes research to improve the care of patients with critical illnesses. I practice as an intensivist at the University of Michigan’s and the Ann Arbor VA's Critical Care Medicine units, where we work to bring the latest science and the best of clinical practice to patients  | iwashyna-lab  | @iwashyna |

Intensivist in Wellington, New Zealand. Started out in ED, but now feels physically ill whenever he steps foot on the front line. Clinical researcher, kite-surfer  | @DogICUma |

One comment

  1. “May you live in interesting times” is a humorous way of expression, though it is not a Chinese curse, but was invented by Brits. 😉

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