Weekly Update from the Bellingen Covid-19 Clinic: Dr Trevor Cheney

By November 17, 2020 In Focus 5 Comments
Dr Trevor Cheney gives his weekly report from the Bellingen Shire Covid-19 Clinic

Dear Bellingen Shire

17 November 2020

Today brought to you by the letter R

Refrain Repetition Replay.

Round. The world moves Relentlessly forward in modern western thought, but so many indigenous cultures talk of life in circles. At least that is what I have Read and heard – having not grown up with enough indigenous heritage. Nevertheless, sometimes a circular concept of time is a little comforting, because our linear obsessions make life feel like it is barrelling on to inevitabilities way too fast after a year like 2020. A circular concept of time brings with it a notion of getting back to Restart, or giving back to the start, and therefore to the next turn of the circle. Now that is even more attractive as we are most beautiful when we are giving.   The greatest Reward is found therein. This seems to be a common theme in most world religions and philosophies. But this is getting a bit mystical and I’m supposed to be keeping on a scientific topic.

“Refrain” on the one hand -from an old English root- can mean to hold back, control one’s impulse. Kind of the opposite of Reporting about the Recalcitrant Regal Resident of the Republic across the Rolling waves who Rambles, Redolent with Revolutionary Rhetoric.

Or it means a Repeated concept, phrase, chorus, a bit like the DNA strip (called a telomere) that secures the ends of our chromosomes, but which, as it wears away, is the most accurate biomarker for biological aging that we have yet.

A Refrain or Repetition in music is engaging and important, in poetry is useful but fraught. In prose it is delicately dangerous – the literary equivalent of eating puffer fish in Japan, or the berries of a Gympie Gympie (giant stinging tree). Now, if you are new to our subtropical area and don’t know what a giant stinging tree is, please go the Dorrigo Rainforest Centre and the beautiful, easy walks to learn ASAP how to recognise it. Bumping into one here (or in other Aussie subtropical and tropical rainforests of northern NSW, southern QLD, and tropical Far North Qld) is a horrible way to find out. I grew up with pioneering/invasion tales from the Border Ranges behind the Gold Coast of fellas felling trees en masse, and occasionally being swiped by the leaves of a giant stinger – to die in screaming agony. When we worked in the rainforest of FNQ decades ago, some considered it very tough to eat the little berries of the Gympie Gympie – the only part of the younger trees that does not sting. This Risks anaphylaxis and Rapid airway obstruction, or maybe just three months of pain in the mouth and lips. Anyway, pretty stupid – don’t try it. Respect stingers. By the way, the berries are tasteless and have no significant nutrition. Yeah, I was pretty stupid too once.

Repetition is vital in marketing. It’s an essential building block of learning. It is irreplaceable in skills development. Even mental Repetitions. I recall studies of surgeons gaining skills in operations by mentally Rehearsing every step of an operation, greatly accelerating their skills even before touching a patient.

So, once again – the point of this segue? Adelaide’s outbreak. Over and over we need to Repeat that this is not over. Outbreaks will keep Recurring. As we mentally Rehearse our strategies, should it occur in our own community, home, family, then we will be better prepared to quickly pivot, control, and limit the spread of this virus.

But just as importantly, by Reminding ourselves not to be blasé, I hope we may better mentally survive such an event, as well as the future 6 to 24 months still to go before this global event settles. Even now, Professor Pat McGorry (living national treasure in psychiatry) is warning in an article in the Australian Medical Journal of the parallel pandemic of mental health deterioration and suicide. Understanding and empowerment are vital in Resilient mental health.

Another Repetition is about the promise of vaccines and the Risk of early announcements. It needs to be said again and again, it takes a long time to ensure new medicines and vaccines are not dangerous, do what they say they do, but most importantly achieve what we need – that is less people dying, and arresting disease transmission. Each of these is a quite different endpoint. Even today the WHO is cautiously enthusiastic but Reminding us that there is still a way to go. We must not leap before the testing is done, on enough people, in all risk categories, for long enough for late complications to arise, or to prove test subjects were protected against the infection.

Dr Norman Swan and his Radio guest pointed out that there is a Risk that some of the candidate vaccines so far are only tested in young to middle aged people, fit, without blood pressure or heart problems, thereby excluding the very people most at Risk of the disease. If so, it obliges the Regulatory authorities to only licence that product to be used in that part of the population tested. This would exclude pregnant women, children, old people, those with heart conditions from getting access to a successful vaccine!

So why does Pfizer announce its vaccine before the testing is fully completed, or peer reviewed? Look at the stock price. Pharmaceutical companies (and IT companies for the last 30 years) have been very adept at announcing a product well before it is on the table. It sucks all the oxygen in the debate and focusses all eyes on the company. An early announcement flattens competitors and starts to lock in contracts. They then hope like hell it works. It worked for Boeing with their Jumbo Jet, according to a recent SBS documentary. It helped make certain software companies strong with “Vapour ware”. I was exposed to vapourware announcement marketing as a Resident doctor in Fremantle Hospital on a committee to get in a computer system. The best system was always announced well before it existed and was always just around the corner. Such a premature announcement may have some political Role in the US as well at this extraordinary time, but we dare not go there..

Humans have always been vulnerable to what Philip Adams (veteran Radio broadcaster, film maker, advertising executive) called a “Pathology of Hope”. Its what keeps gamblers sacrificing their children for an impossible chance. It makes casinos Rich. It’s the bread and butter of marketing, making us buy lots of stuff we don’t need and didn’t even know we wanted. But in the glow of it one loses sight of what matters, what is Real now.

Nevertheless, the news is hopeful, for next year. And our health services will get there – next year. So, this game is the long game. So long as we all don’t take our collective eye off the ball, with precautions, CovidSafe behaviour, jumping on to testing Real quick – like they did in Shepparton (to that community’s great credit), and hopefully like they will be doing with 17 new cases in Adelaide now. Just shows, ya can’t get cocky with this one.

A curious debate that has arisen in medical Reports is – who to vaccinate first. Should we get a vaccine to all old, or defined medically at-risk people, or front-line health workers? A contrary view is to vaccinate everyone 20-39 years old first because although fewer get sick in that cohort, they are the more likely mobile super spreaders with less interest in, or more financial Risk from, trying to isolate.

On the upside, as we have previously discussed, the chances of effective treatments are increasing and possibly will be available way before the widespread vaccines. The WHO reports that several good treatment trials are due to Report in December with completed Results. Mostly because, by happy chance, most of the successful trial teams have been achieving much better survival Rates with medications that already exist. Ironically, some Reports I have seen have Relegated the newer, very expensive drugs to marginal additional benefit, while some older medicines and even nutrients are being Reported by teams in the US as giving big leaps in survival Rates.   There is a particularly active team at the East Virginia Medical School treating a lot of patients (with caution) but successfully drawing on all the evidence from all trials so far.   In Australia there is a strong, cautious national consensus on treating patients with any new therapy only in the context of a Registered formal trial. A bit slower, but we have a much smaller case load to study. Once again, we will learn from others’ success, but more importantly from any of their failures.

It may be improving treatment skills that supports an interesting Report in today’s Sydney Morning Herald. The US is Reporting a Rolling average of about 145 000 cases per day and a horrible, but smaller tally of 1000 deaths per day. Less than 1 percent. This may be because they are Rapidly learning better ways of treatment. Or better timing of treatment -we discussed months ago that some medications such as steroids are dangerous at one phase of the disease but very effective at the middle stage for someone who deteriorates Rapidly. The EVMS are reporting they are succeeding in diverting deteriorating patients from Ventilators. Indeed, just across the border Mexico is at >1million cases and about 100 000 have succumbed. So far – that is a mortality of about 10%, possible Reflecting less access to treatments. Or it may be that the latest surge of cases in US is demonstrating the Result of policy decisions of a month ago and the gatherings around the election. The mortality curve may still trail the case Rate by a couple of weeks.

A nicer alternative is that maybe the virus is Really mutating and getting less severe. Nice thought. Lots of debate to go yet on that one. Certainly, it is mutating, and there are now multiple strains being picked up. Again, there is an interesting and very Readable article in today’s (16/11/20) SMH website.

Another Replay: on “Background Briefing” on Radio National last week, experts again pointed out that the most vulnerable/ poor/ least educated cop the worst of a pandemic. But if that does not move you then the counterfoil is that by neglecting that portion of society you create a reservoir of disease of all kinds. And disease does not really respect your artificial suburb boundaries. Our society succeeds on how we look after the vulnerable.

I am delighted to see that the Victorian government, and some others, have announced that they will put part of their stimulus spending into building affordable housing, at last. Australia used to be Really good at that. A triple win –Recovering/creating construction jobs, a positive step for those thrown off the mainstream wagon, a chance to Reduce homelessness with its misery, disease and violence that Reside therein. Experts have been banging on about this for a long time. I just hope those houses are intelligently designed.

Remember Christmas functions need a COVID-19 safe plan. If you’re having it at a venue, they will have already worked through a plan to be open. You can look up on NSW govt “What you can do under the rules”.  For Employers there are OH&S Responsibility implications for such functions.

Please also Remember this is one perspective. I invite you to Retain your Ready Rapport with your own Reliable GP to Revisit any of the above Remonstrations.

Dr Trevor Cheney

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