During coronavirus, doctors face difficult choices over ventilators

During coronavirus, doctors face difficult choices over ventilators
Written by Leon

It’s a choice most doctors never thought they would have to make: Who lives and who dies.

But in the coming weeks, if COVID-19 continues to grow, such decisions will be inevitable.

The corona virus will attack so many people’s lungs that thousands can show up in hospitals that suck in air and must be connected to machines that breathe for them. But there won’t be enough ventilators for everyone, forcing doctors to make impossible calls about which lives to save.

“You have an 80-year-old and a 20-year-old and you both need a valve and you only have one. What are you doing? “Said Dr. Christopher Colwell, the chief of emergency medicine at Zuckerberg San Francisco General Hospital and Trauma Center.

Across the United States, there may be as many as 31 patients needing ventilation for every available machine, according to an article published this week in the New England Journal of Medicine. The shortage can be just as serious in California.

Stately, there are approximately 9,500 ventilators, in total, which include new additions made by state leaders and others in anticipation of an increased number of COVID-19 patients. The federal government’s national inventory, which states can push for when their local deliveries become low, has an additional 16,000.

Gavin Newsom has not said how many fans he thinks California will eventually require, but studies in China showed that between 2% and 6% of people with COVID-19 needed to be on fans.

If half of Californians get sick of COVID-19 and 2% need ventilators, the state would need 390,000 during the outbreak. Even though these cases are spread over the next year, the state may still require 20,000 fans at a time.

“It can be disastrous,” said Dr. Robert Winters, a Los Angeles-based communicable disease physician.

The doctors have to resort to a war-like triage to decide who to put on the fans and who to turn away. In Italy, hospitals have been forced to deny potentially life-saving treatment for the elderly, fear of damage due to lack of machinery.

These are difficult decisions anywhere, but especially in America, where families often require extreme measures to keep people alive even if they are very ill, experts say. And they are not choices that medical workers, who have been training for years to save lives, want to make.

Colwell, the San Francisco physician, said he is already considering what to do in such a situation. The city’s hospital has about 750 fans and officials are trying to get others from spare parts, he said.

“How do I distribute them in a fair way that tries to honor the approach of the many to the benefits to the best?” So Colwell. “Does it mean life saved, saved life or quality of life?

“There is not a black and white answer,” he said.

In the New England Journal of Medicine article, a trio of Harvard Medical School experts called deciding who gets ventilators “the toughest triage.”

“Although rationing is not outstanding, the American public has never before been faced with the prospect of having to ration medical goods and services on this scale,” they wrote. “Of all the medical care that needs to be rationalized, the most problematic is mechanical ventilation.”

Ventilators provide oxygen to people who are not getting enough and who are physically pushing air in and out of their lungs. Infections can weaken patients and weaken the muscles so that they cannot contract and expand on their own.

The rationalization of such care has been the subject of ongoing discussions on the Sutter Health Network, where one of the weigh-ins said she thinks the best model is to have a panel of doctors, rather than individual doctors, decide who gets the care, said Dr. Janice Manjuck, a critical care specialist at a hospital in Oakland.

“A special doctor doesn’t have a bird’s-eye view of what’s out there,” she said, adding that as a doctor taking care of a patient, “you’re probably not the best at making that decision because you always advocate for the patient.”

Fans, she said, “can be the difference between life and death.”

With COVID-19 it is still unclear how often this is the case. A small study published in the medical journal, the Lancet found that of 37 patients in Wuhan who were ventilated, only seven survived.

Dr. Lewis Rubinson, a New Jersey intensivist who wrote a guide for physicians caring for critically ill patients with COVID-19 published by the Society for Critical Care Medicine, said that based on literature and information sharing in the intensivist community, half of the patients ventilated for COVID-19 survives, with the risk of survival to decline with age.

In recent weeks, he has had first-hand experience of ICU treatment of these patients in his position as chief physician at Morristown Medical Center. He said his advice on places that haven’t been hit as hard as the New York metro area is: “Don’t waste time. This is when you should be ready. “

New York, now the national epicenter for the outbreak, recently acquired 7,000 fans in addition to the roughly 4,000 already available in the state, according to Prime Minister Andrew Cuomo. But at least 30,000 more will be needed to deal with the ongoing outbreak, he said in a press conference Tuesday.

“What happens to New York will wind up events in California and the state of Washington and Illinois – it’s just a matter of time. We’ll only get there first,” he said.

Cuomo said doctors can try an experimental technique to put as many as four people on a single ventilator. Deficiencies in other states may eventually lead to similar measures born of desperation, experts say.

“You can’t let anyone die in the parking lot because you can’t ventilate them,” said Winters, the L.A. physician. “I’ve never seen two people on a ventilator in my entire life, but it beats the option of dying from respiratory failure.”

In extreme situations, lack of ventilators can also mean staff use a hand-held pump to push air in and out of the patient’s lungs, Dr. Wally Ghurabi, ER medical director at UCLA Medical Center in Santa Monica.

In Los Angeles County, there are 833 ventilators across the county’s 70 public and private hospitals, according to a survey by the county’s Emergency Services Agency conducted this week. The county administrative department that operates the four local public hospitals is working to get an additional 313, according to a statement.

If there are not enough ventilators, a hospital with extras can theoretically lend some to another facility that goes short, says Cathy Chidester, head of the county EMS agency. She said she believes L.A. the county will not be flooded at once, because of how widespread the region is.

“A hospital over here that doesn’t see the influx of patients. … They could move the fans if push was to fire, Chiedester said. “The beauty of L.A. County is that it is wide. It’s 4,000 square miles – it’s not like New York, it’s not like China. “

Other places that have already been hit hard by COVID-19 have offered horror stories that have made American suppliers on the outskirts. At a hospital in Lombardy, a heavily afflicted region in northern Italy, doctors reported patients in the hospital sleeping on floor mattresses. There, 70% of ICU beds are reserved for COVID-19 patients “with a reasonable chance of survival,” the doctors wrote in a recent paper.

“The situation here is bleak,” they wrote. “Elderly patients are resuscitated and die alone without appropriate palliative care, while the family is notified by phone, often by a well-meaning, exhausted and emotionally depleted physician without prior contact.”

Experts say these final decisions will be particularly tough for people to accept in America, where much more money is usually spent to keep very ill people alive than in the rest of the world.

California and especially L.A. County has some of the highest spending in the last six months of people’s lives, according to Dartmouth Atlas of Health Care, a Dartmouth University-led project that documents how medical resources are distributed in the United States.

“As it says in the United States, if your family member is convinced that you want everything done and you are 90 years old, wearing a diaper, severe dementia, you would put on a ventilator,” Dr. James Keany, ER physician at Providence Mission Hospital in Mission Viejo. “Most countries consider the malpractice what do you save the person for?”

Many Americans believe that life must be protected at all costs, he said, but “we may not have the luxury of this disease exploding.”

Dr. Arthur Jey, a doctor at the emergency room who works at a Sutter Medical hospital in downtown Sacramento, said there are discussions about how he can ration the care at his facility, but if there is a shortage, he also plans to ask patients if they want to be ventilated.

He said he has often been surprised by elderly patients who tell him they do not want any further medical measures.

“We think many people want to live no matter what, but over the years I have been surprised by so many people who have said, ‘No, I’m fine.'” He said. “There are people who would say, ‘You know what, save someone else. “

He said that the basic question that medical providers ask themselves in these tough situations is: “Do I think I can pull them through?”

If the answer is no, maybe the fan goes to someone else, he said.

“That’s scary.”

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