Overcoming uncertainty in the Age of COVID-19

COVID-19: Keeping the baby in the bath (Part 7)

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

Clearly, we sympathise with physicist Richard Feynman’s point of view. However, we also acknowledge that maintaining equanimity about uncertainty and not knowing is challenging in the face of an existential threat. We need to act to try to save lives. However, as critical care physicians, this is what we do “day in and day out”, COVID-19 pandemic or no COVID-19 pandemic. 

We need to build on what we already know about patients with critical illness, acute respiratory distress syndrome (ARDS), and severe viral respiratory conditions. Not throw it away. It means we need to guard against radical COVID-19 exceptionalism, but keep our minds open to the specific characteristics and needs of this disease and new ideas for treating it. It means we need to enrol patients in trials and appropriately test innovations before implementing them into patient care. It means we need to rely on highly skilled health care workers to do what they do best, when they are provided with the resources to do so: take care of patients.

So, let us focus on what matters. Healthcare systems – especially public health and capacity for intensive care – needs appropriate funding and supply of basic equipment, including the personal protective equipment (PPE) that will protect the staff saving lives. It is time that the education and training of healthcare workers, and the capacity for design and human factors/ ergonomics (HFE) expertise, received due emphasis and funding. Cutting edge medications and advanced interventions are great, and we do need more high quality research, but nothing in critical care replaces the skill and availability of the people providing patient care, or the need for them to have the resources and environments that enable them to get on with the job. 

Meanwhile, as clinicians, we need to keep calm while we face uncertainty.  Let us not be afraid of not knowing. Use what we do know, standardise, and then optimise to the patient before us. Only improvise when we have to, when there is no alternative. Collect data, enrol patients in trials, and strive to learn more. Living in “interesting times” is both a curse and a blessing for us as healthcare workers: the curse of the pandemic is the inevitable death and suffering, and the blessing is that we can make a difference. In doing so, we must not throw the baby out with the bathwater.

Further reading

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 the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and 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 two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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 |

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