Coronavirus: What’s important and what is not?

Places of worship have broadcast services to audiences who often for the first time are picking them up online.

Families are connecting the generations “virtually” while missing each other’s physical presence. The Queen, now a lady in her nineties and especially vulnerable, has addressed the nation to lift morale and encourage adherence to the ongoing advice.

Some health priorities have become more important than others. Certain NHS services have been temporarily suspended from some hospital sites to manage demand and reduce risk. Senior executives and politicians making decisions now, know they will be held to account and required to revisit them in a more transparent way when this emergency passes. Introduced in this way in the current climate surely the changes will not be allowed to become permanent, as neither the public nor professionals in a democracy should accept this without wider discussion? Those senior executives, now in the twilight of their careers, and politicians currently at the helm who are making urgent decisions for the greater good, will not want these or this process to be the legacy overshadowing any positives the public’s memory may have of their working lives.

Some medicines are critically important and some are less so.

1. Warfarin. This drug is used to thin the blood in patients who have had, or are at risk of having a clot. If you are on this drug it needs monitoring regularly to keep the level safe. Be guided by your practice on the frequency and location of testing. Remember that other medicines can affect warfarin including some like paracetamol that can be bought without your doctor being aware. If you are on other tablets to thin the blood they too should continue uninterrupted.

2. Immunosuppressant medication. If you have had a transplant or are having drugs to suppress your immune system for certain conditions including, rheumatoid arthritis, inflammatory bowel conditions and some skin conditions, you need to self-isolate but still ensure you are getting any necessary blood monitoring done. Patients on these drugs to prevent rejection of a donated organ need to continue on their medication as stopping this would result in organ failure and rejection.

3. Treatment after cardiac stenting. The regime prescribed must be taken consistently without interruption and for the length of time advised to avoid the stent blocking and causing sudden death.

4. Anti-epileptic medication. These drugs work by raising the threshold at which a fit will occur. Any of us could fit if certain circumstances are met. Alcohol, dehydration, fever, flashing lights, fatigue, stress and some drugs can make a fit more likely. For someone on epileptic medication it is important that they continue on their correct dose and avoid the factors above that may increase the chances of a seizure. Don’t run out of medication at this time.

5. Diabetic medication. A diabetic on insulin is more vulnerable if their medication supply is interrupted than someone who is on oral medication or diet to control blood sugars. If exercising less, eat less.

6. Blood pressure medication. Blood pressure control is important in reducing the likelihood of long-term damage to artery walls. If you are on a low dose of one drug to optimize your level, an interruption in supply would be less likely to affect you than it would a person who requires a combination of a number of drugs at maximum dosage. Certain drugs may be better stopped if you are getting dehydrated. There is no concern about drug supply but do allow enough notice for your prescription to be prepared. Tablets to lower cholesterol are less critical if missed for a number of weeks even.

7. Prednisolone. This is a steroid and is used in numerous conditions as it effectively reduces inflammation in many tissues. It has the effect of dampening down the immune system however and impairs the body’s response to infection, including the coronavirus. If you are on steroids for a long time don’t stop them abruptly without talking to your GP. If you are on them you need to consider yourself to be at greater risk and strictly isolate.

8. Vitamin B12 injections. Patients on this usually require it no more than every three months (12 weeks). It is not critical that this interval is rigidly applied although it should not lapse by more than a month. This injection takes only a few seconds to do and I have done it through an open car window to save a patient coming into the building. I’m sure most GPs will facilitate this in your own surgery still.

9. Hormone injections. Many men are on injectable hormone type treatment for prostate cancer and this should continue. It does not need to done “to the day” when due but most surgeries can facilitate this within a week of the scheduled date. As GPs are seeing less patients face to face, most GPs can do this for you if the nursing service is not accessible in your practice.

10. Hormone replacement therapies. Women on HRT will not come to harm without this although menopausal symptoms may develop a number or days after stopping. Men likewise who are on testosterone therapies may not miss the treatment for a number of days after stopping and will not come to harm. Thyroid medication for an underactive thyroid is required to keep the body’s metabolic rate at the right level. Missing a few days tablets won’t have a significant effect although it should be started at the usual dose rather than extra tablets taken to make up for the missed doses.

11. Inhalers. If you need regular inhalers to manage asthma, continue on your normal regime. Do not request inhalers “just in case” you need them. If you have not needed them in the last year it is unlikely you will need them now and it may not be prescribed at your request.

12. Medication for mental wellbeing. At times of increased anxiety in the community due to financial uncertainties and health concerns it is better if the supply of these medications and dosage taken is kept the same. Treatment for addictions should continue uninterrupted and named workers can generally be at the end of a phone for their regular patients. Although missing a few days of an antidepressant medication is unlikely to precipitate any symptoms it is unwise to miss medication used to control the symptoms of schizophrenia. Talking therapies can sometimes be accessible remotely. It is not appropriate for the rest of us to look for medication for minor sleep disruption or apprehensions which, although an understandable reaction at the minute, can be dealt with better by drawing on our inner strength, our faith or by empathetic conversations with others. “A burden shared is a burden halved.” Alcohol use at this time to help address symptoms with will have negative consequences both in interfering dangerously with medicines but also by lowering mood, increasing anxiety, precipitating aggression and unleashing violence in some users.

13. Ibuprofen. At the time of writing this article we have been advised that although there is no strong evidence that patients with coronavirus have suffered harm by taking ibuprofen, it is better to use paracetamol for fever if coronavirus infection is being considered as a possible diagnosis. (Ibuprofen is one of a group of drugs known as anti-inflammatories.) Clearly if you have an ache or sprain and would usually take ibuprofen or another anti-inflammatory with benefit, it is ok to do so still.

Some things have not changed.

Attendance at emergency departments have dropped dramatically which has been welcomed as other demands on staff and resources have increased.

Concern has however been expressed that some patients who have significant symptoms are delaying presenting with serious problems. Pathways of care for what could be serious conditions are still being staffed and urgent appointments for possible cancers are being arranged. Please don’t hold back on these if you have symptoms that need followed up on.

“999” still needs to be called for suspected stroke or heart attacks. Our paramedic crews continue to honour their commitment to respond to calls even though they are being exposed to increased risk themselves. Please continue to show our gratitude to the men and women of this service by only using them when necessary. In many ways they typify our frontline workers in the NHS and other services who by their commitment have made our lives possible and safe. They and others on our roads continue all year round and in all conditions to keep people and goods moving and are still doing so despite the current difficulties.

Unexplained weight loss. Still needs to be investigated.

Chest pain on exertion. May need prompt medication or referral.

Coughing up blood. X-rays and other investigations can be started by your GP.

New pigmented areas on the skin or other changes that persist need sorted in a timely way in case they are malignant.

Blood in faeces or urine needs checked out. Any abnormal blood loss or bruising in fact needs to be satisfactorily explained.

Breast lumps need investigated as do unexplained new swellings or lumps in any part of the body.

Self-help can be safer help.

1. Wax in ears. Ear syringing to remove wax is not essential at the present time nor are prescribed products to soften wax. By placing a few drops of clean Olive oil in a waxy ear you will be able gradually soften the wax. The drops will be most effective if placed at night when you can lie with the ear up and allow gravity to let it penetrate better. You will need to do this for a week or more.

The water from a shower may help irrigate out the wax when soft enough. If you have a perforated ear drum or a vent in place don’t put any oil or water in your ear. Keep it dry.

2. Foot care. Diabetics need to avoid trauma to the feet at all times but especially at the minute. Don’t wear tight footwear but do protect your feet from even minor impact within the house by keeping robust slippers or comfortable shoes on.

3. Minor burns. Put the area burned under clean running water as soon as possible to cool it and reduce damage. A silver based cream is widely prescribed for placing on minor burns which can then be covered with either a clean plastic bag or lightly wrapped in cling film. The anti-septic cream stops the plastic sticking to the wound and acts as a physical barrier to infection. Clean Vaseline/petroleum jelly is a reasonable initial measure to apply to stop the plastic sticking.

4. Home blood pressure monitoring. Many patients have bought wrist blood pressure monitors to keep an eye on their own level. If you are using these make sure you are sitting rested and relaxed for ½ an hour before taking a reading. If you get an unexpected reading try it out on someone else in your household who is known to have no blood pressure issues. Make sure you are using it on the correct arm and correctly placed!

5. Knee and hip pain awaiting surgery. Whilst joint replacement may not be life saving it can restore pain-free mobility and be life-changing. When you are waiting for surgery use a stick and take measures to get your weight down. It will reduce pain and make recovery quicker when surgery is eventually done.

6. Health screening. Many of the screening programmes have been suspended and those eligible are not getting the opportunities normally afforded to targeted groups. It is right that these have been stopped at this time but it does not mean that we should not be on the lookout ourselves for warning signs.

Breast lumps, skin changes, bowel changes and abnormal bleeding from anywhere will still be getting seen and given priority. Still contact your GP surgery if you have concerns. Hospital doctors are doing all they can to keep urgent treatments and investigations running despite the pressures they are under.

7. Smoking. Death rates from coronavirus have been higher in men and it has been hypothesised that as in China more men than women smoke, this may explain the difference in mortality rates between the genders. It would seem now would be a good time to quit.

8. Stress symptoms. We all have a lot on our mind at the minute. Every aspect of life has become uncertain. Health, wealth, family, future, lifestyles, work and future expenses are all unknowns. There are a few things that we know that can make things worse but many that can make us manage better.

Alcohol, whilst it can give temporary escape for some on occasions, is recognized to have a depressant effect on mood and often is a negative influence in domestic violence and aggression. Be careful of the destructive impact it can have on you and your family at this time. We know that sharing our concerns in conversations with others is therapeutic and reduces anxiety and sleep problems. Phone a friend, share each other’s burdens, find humour in adversity and look beyond the present.

I had a patient in her late 70s tell me that she is taking all necessary precautions. She went on so say that she was “laundering money”. I had known her to be a very honest and upright woman and was quite shocked at this confession. When I asked her who she was doing it for she assured me it was her own money and that she was not involved in organised crime!

The “Samaritans”, “Rural Support” and “Lifeline” are at the end of a phone. Those of us fortunate to live and work in the countryside may have space and a degree of freedom but we can also feel isolated and out of the loop at times with churches, markets and other social and family contacts reduced.

We live in a great country here with many great people. I have seen patients offer their services, retired senior teachers doing pharmacy deliveries, a local shop keeper made a sign for my health centre, a car mechanic is on stand-by for us, health care students are working for nothing and many others are doing simple acts of kindness. I’m proud to be part of this community and privileged to be doing what I can. I’m sure you are too.

Thank you for doing your bit and continuing to:

a) Isolate

b) Social distance

c) Hand wash

d) Catch coughs

“There will be challenges ahead for all of us to work through but I know we have it in us to make a better future out of our murky political past and our gloomy present with its economic and health uncertainties.”