Ruminations of an idle surgeon

  • A bird in hand: most bat coronaviruses cannot infect humans, so the important question is how did 

Sars-CoV-2 evolve into a significant human pathogen

    A bird in hand: most bat coronaviruses cannot infect humans, so the important question is how did Sars-CoV-2 evolve into a significant human pathogen

  • Joseph Froncioni, MD is an orthopaedic surgeon

    Joseph Froncioni, MD is an orthopaedic surgeon


On March 16, 2020, all elective surgery was stopped at King Edward VII Memorial Hospital. We would not get our first confirmed cases of Covid-19 until March 18, but the higher-ups at the hospital knew we needed to prepare for the worst while hoping for the best.

That week, work was begun to make changes to our operating rooms and recovery room in order to maximise our capacity to treat critically ill patients. Areas were partitioned, ventilation adjusted and staff retrained. As a result KEMH, which is normally able to accommodate nine patients on ICU ventilators, added 13 ICU/ventilation beds in the recovery room, increasing its capacity to 21.

In addition, plans were put into place so that the operating rooms could quickly be converted to accommodate a further eight critically ill patients for a grand total of 30 ICU beds if the Covid-19 storm were to hit.

We were ready!

So with no possibility of performing elective surgery, added to the unexpected silver lining that road trauma decreased dramatically with the lockdown and curfew, what’s a surgeon to do with all the spare time?

My wife may be the right one to answer this question because for the first time in our 35 years of marriage, she found herself stuck with me all day nearly every day!

Patients are reluctant to come to the office during a health crisis such as Covid-19, as their various aches and pains take a back seat to the threat of contracting the virus. I started doing “telemedicine” as many of my colleagues did, but this took up only a fraction of my time.

It soon became obvious that I was still in my wife’s hair and I had to find a way to keep busy — or else!

As the true magnitude of the Covid-19 pandemic became evident, so did its historical significance. I began to realise that we were witnessing a once-in-a-lifetime, perhaps once-in-a-century event; I could not let history slip by unnoticed.

I began scanning the internet for stories related to Covid-19. I created a document I called Covid-19 Timeline&Archive and started populating it with entries from mainstream media, scientific and medical journals, as well as news-aggregator websites. The timeline is now nearly 180 pages long and contains more than 1,500 entries. I’ve got Covid-19 information coming out of the wazoo!

I recently did a FaceTime Live presentation for Patients 1st Bermuda and perhaps this may be an appropriate forum to address some of the more interesting topics that resulted from the comments and questions. In no particular order, people were interested in the following:

The Virus

The virus that causes Covid-19 is a coronavirus — looks like a beer cap under the microscope — called Sars-CoV-2 and is related to Sars-CoV-1, the virus that was responsible for Sars, which gave us a scare in 2003.

Viruses are only a fraction of the size of bacteria and are not even considered living things because they are unable to reproduce on their own.

You would think they should be no match for us. Humans are made up of 37 trillion cells, 100 billion in the brain alone. The human genome (DNA) or genetic blueprint is made up of three billion letters (base pairs); we’ve walked on the moon, we’ve split the atom and we’re planning a trip to Mars!

Sars-CoV-2 on the other hand is a tiny capsule of lipid and protein that is very sensitive to desiccation (drying out), heat and detergents. Its genetic blueprint (RNA) is only one millionth the size of that of humans. And yet … and yet, this little critter has got us on our knees!

Origins

Where did this virus come from and how did we get stuck with it? The exact origin of Sars-CoV-2 is a hotly disputed topic around the world and is the cause of powerful geopolitical fault lines that are very likely to have long-lasting consequences for the planet. There are a couple of possibilities, each one with its supporters and detractors. In simplified terms, possible origins are as follows:

Bats — these pointy-eared flying balls of fur are a natural reservoir of coronaviruses. The viruses and the bat have adapted to each other and carry on with no ill consequences. Also of note is that most bat coronaviruses cannot infect humans, so the important question is how did Sars-CoV-2 evolve into a significant human pathogen?

At this point I have to introduce the word “zoonosis”, the process whereby a disease caused by a virus, bacteria, fungus or parasite passes from an animal or insect to a human; this is one of the ways Sars-CoV-2 may have infected us.

Bat poop or “guano” makes great fertiliser and so wherever farmers live near bat populations — in parts of China, for example — there is the opportunity for close interaction between bats and humans; farmers enter bat caves to scoop up guano for their fields and risk coming into contact with bat blood or body fluids.

In addition, some cultures hunt, butcher and sell bats in wildlife or “wet” markets for human consumption. We think the virus may have first infected a human in this fashion, but we know it would have taken many generations of virus reproduction and adaptation within its new host for it to develop the characteristics necessary to cause illness.

Alternatively, the virus could have come to us via an intermediate species such as a palm civet, snake or pangolin undergoing adaptations before infecting humans. Some virus geneticists have used phylogenetic analysis of large numbers of Sars-CoV-2 genomes to suggest that the zoonotic event might have occurred sometime in October 2019.

Lab escape — The Wuhan Institute of Virology is China’s first biosafety level 4 virology laboratory. A short distance from the now-infamous Wuhan Huanan wet market where some believe the zoonotic event may have occurred, this lab is known to have carried out extensive work with bat coronaviruses and in fact is considered the world’s epicentre of bat coronavirus research. The head researcher is Shi Zhengli, the Chinese virologist nicknamed “Batwoman” in the popular press.

There is a rising tide of chatter, much of it propagated by Donald Trump and his administration, who are using it as a cudgel in their spat with China, suggesting that the virus may have been modified in the WIV, using human cell cultures, and that there might have occurred an accidental lab escape of the virus into the Wuhan population that led to the pandemic.

China denies this. An independent and impartial investigation would be required to give us the truth in this matter, but given the present climate of distrust and lack of co-operation between the major players, this is unlikely to be a simple matter to resolve.

Joseph Froncioni, MD is an orthopaedic surgeon

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Published Jun 20, 2020 at 8:00 am (Updated Jun 20, 2020 at 7:51 am)

Ruminations of an idle surgeon

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