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Who is the fan for? British doctors contemplate tough coronavirus care choices

LONDON (Reuters) – The coronavirus pandemic is forcing senior doctors at Britain’s National Health Service to consider the unthinkable: how to ration access to intensive care beds and ventilators when resources are scarce.

FILE PHOTO: A woman on Westminster Bridge wearing a face mask as the spread of coronavirus disease (COVID-19) continues, in London, Britain March 19, 2020. REUTERS / Hannah McKay / File Photo

The country’s public health system, the NHS, is ill-equipped to deal with an epidemic unprecedented in modern times. Hospitals are now striving to at least quadruple the number of intensive care beds to cope with an expected increase in severe virus cases, senior doctors told Reuters, but expressed dismay that preparations failed. not started weeks earlier.

With severe shortages of ventilators, protective gear and skilled workers, doctors said senior hospital officials were starting to face an excruciating debate over rationing intensive care, although Britain may be – to be far from having to make such decisions.

Rahuldeb Sarkar, a consulting physician in respiratory medicine and intensive care in the English county of Kent, said local NHS trusts across the country are reviewing the decision-making procedures developed, but never needed, during the H1N1 flu pandemic of 2009. They explain how to choose who, in the event of a shortage, would be put on a ventilator and for how long.

Decisions would still be made on an individual basis if it happened at this point, taking into account the odds of survival, he said. But nevertheless, there would be difficult choices.

“It will be difficult, and that is why it is important that you know that two or more consultants will be making the decisions.”

Sarkar said the choices extended not only to who had access to a ventilator, but how long to continue if there were no signs of recovery.

“Normally, this patient would have a few more days to see how it goes,” he added. But if the worst predictions about the spread of the virus turned out to be correct, he suspected that “it will happen faster than before”.

Britain is by no means the only country facing a health system overwhelmed by COVID-19, but data on intensive care beds – a crucial bulwark against the disease – is cause for concern for UK authorities .

Italy, where the coronavirus has pushed hospitals to the point of collapsing in some areas and thousands of people have died, had around 12.5 intensive care beds per 100,000 population before the outbreak.

That’s above the EU average of 11.5, while the figure in Germany is 29.2, according to a widely cited academic study. here dating from 2012 which, according to doctors, was still valid. Britain has 6.6.

“MUCH MORE” FANS

Estimates of the potential death toll in Britain range from a government estimate of around 20,000 to an upper limit of over 250,000 predicted by researchers at Imperial College. As of March 19, 64,621 people had been tested, including 3,269 positive.

The NHS is bracing for the biggest challenge it has faced since its inception after the ravages of World War II, promising cradle-to-grave health care for all.

It was stretched long before COVID-19, struggling to adjust to the vast increase in demand for health care in recent years. Some doctors complain that it is underfunded and poorly managed. About a tenth of the more than one million staff positions in the health service are vacant while almost nine out of 10 beds are occupied.

Prime Minister Boris Johnson was questioned at a press conference on Friday, after Reuters reported doctors’ concerns whether Britain could come to a point where NHS workers have to choose who to save because there were not enough fans. He urged people to follow public safety measures.

“The aim of this whole campaign is to make sure that we flatten the curve, as we have said several times over the past two weeks, but also that we raise the line of resilience and capacity of the NHS.” , did he declare.

“This means there is a massive effort underway right now to make sure we have enough ventilators and intensive care units to cope.”

So how many vital ventilators are needed?

Health Secretary Matt Hancock said on Sunday hospitals numbered around 5,000 but needed “a lot more than that”.

Doctors polled by Reuters said if ventilators were secured, the goal was to increase the number of intensive care beds from around 4,200 to more than 16,000, in part by using beds in other parts. hospitals.

Rob Harwood, a consultant anesthesiologist in Norfolk who has worked in healthcare for nearly four decades, said access to intensive care may ultimately be determined by systems for scoring patients for survival. The systems developed for SARS, another coronavirus that erupted in 2003, could for example be refined, he added.

“Once you’ve exhausted your capacity and exhausted your ability to expand your capacity, you probably have to make other decisions about admission to intensive care.”

But he stressed that, for now, the admission criteria would remain unchanged: “We’re a mile away from that at the moment.”

‘BECOME A CANNON FUR’

While shortages of critical care equipment can be most alarming, the coronavirus has revealed just how ill-equipped the healthcare system is generally for a pandemic.

The British Medical Association said doctors have been urged to visit hardware stores and job sites to obtain protective masks.

Some doctors are worried about new advice from Public Health England (PHE) last week, which reduces the level of protective gear they must wear.

Previously, visiting staff had to wear full protective gear, including high-quality FFP3 face masks, visors, surgical gowns and two pairs of gloves. But the new advice recommends only a standard, lower-grade paper surgical mask, short gloves, and a plastic apron.

PHE referred questions about the doctors’ concerns to the health department, which did not respond to requests for comment on the matter.

A senior NHS epidemiologist, who has not been cleared for appointment, told Reuters the advice was based on a sound bio-risk assessment of the virus. “It’s not Ebola,” the doctor said, stressing that the risk to medical staff without underlying medical conditions was low.

Matt Mayer, head of the local medical committee covering an area in southern England, said GPs had received face masks in boxes that said ‘best before 2016’ and which were relabelled with new stickers that said ‘2021 “.

“If you want to get people into a dangerous situation, you have to give them the assurance that they have the kit to do a decent job and that they are not just going to become cannon fodder,” Harwood said, the anesthesiologist.

The Health Ministry said it has tested some products to see if it is possible to expand their use.

“Products that pass these rigorous tests are re-labeled with a new shelf life where appropriate and may continue to be used,” said a spokesperson.

QUICK GUIDELINES

Dr Alison Pittard, dean of the School of Intensive Medicine and consultant in Leeds, in the north of England, said there had been chronic underinvestment in intensive care in Britain. But she said the country was not yet at the stage where it needed to make calls on rationing patient resources.

She said if rationing becomes necessary, medical ethics should always prevail and guidelines should be issued nationally so that no patient is worse off based on where they live. The NHS might also need advice from military leaders, she said, on how to triage effectively.

“If we find ourselves in a difficult position where we have to exhaust all the resources of the country, then yes, we may have to change the way we approach decision-making.”

Stephen Powis, the national medical director of NHS England, said there are plans to issue new guidelines to give doctors advice on how to make tough decisions in the event of an increase in coronavirus cases, as in Italy .

The National Institute for Health and Excellence in Care (NICE) announced on Friday that it will soon announce a “set of rapid guidelines” on the management of people with suspected and confirmed COVID-19, including in intensive care .

The guidelines are not meant to be prescriptive, however, but to suggest leaving key decisions to individual physicians.

Pittard said patients with pre-existing conditions who already had life-threatening health issues should have conversations with their families about how they want to spend their final days, in case they get infected.

“If I catch coronavirus now, I have a very high chance of dying from it,” she said, putting herself in the shoes of such a patient. “So do I want to die in the hospital and when my loved ones can’t come and visit me because it’s too risky, or would I like to die at home?”

“And if I want to go to the hospital, then do I want to go to intensive care where my chances of survival are minimal?” “

Editing by Guy Faulconbridge and Pravin Char

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