On Friday, I woke up to a tweet about ventilators.
How many ventilators are needed during this crisis?
According to data published by the Journal of the American Medical Association, 80% of Covid-19 cases are mild and can be managed from home. Twenty percent require hospital care and among these 5% require critical care.
Among the patients who were admitted in ICUs, more than half of them required ventilatory support initially non-invasive and then in invasive form.
Hospitals in the United States have roughly 160,000 ventilators. There are a further 12,700 in the National Strategic Stockpile.
According to rough estimates, there a total of 30,000 ventilators in India.
The numbers become alarming when you consider the fact that Covid-19 rapidly spread from one city to all of China in just 30 days.
Why a ventilator and how is it different from a face mask delivering oxygen?
Face masks deliver oxygen at a fixed rate set by the physician. The patient takes the effort to breathe in and out.
Ventilators are complex machines that pump air in and out. They can be invasive and non invasive.
The machines everyone is talking about are the invasive ones, which are computerised microprocessor-controlled machines. These are connected not by face masks but through tubing that is inserted into the throat (trachea). These are highly complex machines with a myriad of settings that take care of respiration even in brain-dead patients. They require intricate settings and constant monitoring.
How many personnel are required to run a single ventilator?
The ideal nursing:patient ratio in an ICU is 1:1. Ventilators are run in an Intensive Care Unit with constant monitoring of heart rate, rhythm, blood pressure, oxygen saturation, urine output and other parameters. Patients might also require additional support for other vital organs like dialysis for kidneys or heart pumps. They are usually managed by a multidisciplinary team of doctors that include emergency physician, ICU physician, anaesthesiologist and various specialty physicians, respiratory therapists, ICU technicians and critical care skilled nurses.
Ventilators also require constant oxygen supply, power supply (they do run on batteries for some time), tubings and filters.
What if we increase the production of ventilators and double the numbers available in hospitals right now?
It’s not a simple process. Ventilators require a lot of testing and approval because these are semi autonomous machines controlled by microchips. An intricate setting gone wrong can be a difference between life and death of a patient. They require many parts that are manufactured in various countries.
Even if we bypass the testing and approval, ventilators still require the additional skilled personnel mentioned before to run it. Making the existing ones operate more ventilators will result in burnout and inadequate individual attention increasing the likely mistakes.
If we build new hospitals like China or convert existing hospitals for exclusively treating Covid-19 patients, recruit additional personnel and import more ventilators, does it solve everything?
Unfortunately no, the numbers required are humbling. The population of Italy is roughly the population of Gujarat, which is only around 5% of the Indian population. We simply cannot let the virus rampage through the entire Indian population. The only solution is to stagger the infections. That is, not letting everyone get infected at the same time.
This will lessen the burden of hospitals letting them treat and discharge patients before admitting new patients. Instead of 100 patients getting admitted in a 20-bedded ICU hospital in a single day, 10 patients over 10 days will make a big difference. This is what flattening the curve means. We are not stopping the spread entirely, we are just allowing it to happen slowly so that the system doesn’t get overwhelmed.
What are the challenges faced by the frontline healthcare personnel in India?
Frontline healthcare personnel are the ones directly in contact with Covid-9 patients and suspects. They include the screening personnel, emergency physicians and nurses, ICU, ENT, pulmonology physicians and more. To be protected from exposure, they require Personal Protection Equipment, which includes masks, gloves and gowns. From the data reported, 15% of healthcare personnel infected with Covid-19 became critical, compared to 5% of the general population.
The various theories to explain this include repeated exposure by healthcare personnel to virus, being exposed to high viral load in ill patients and direct exposure during resuscitation. This makes them and their families and contacts vulnerable. This also makes our system weak because these are skilled personnel who are not easily replaceable. Even mild infections that require a isolation of 14 days will put a strain on the rest. The mass production of PPEs does not require a complex process or approval, but they just need the political will and funding.
Burnout from additional duties and prolonged working hours is another concern. A solution to this is to recruit more personnel temporarily, minimal deployment of staff in primary and secondary care centres and divert the rest of them to tertiary care centres which primary deal with Covid-19 cases.
The hospitals also need personnel to take care of other critically ill patients who are already occupying ICU beds and ventilators. Difficult decisions need to be made on whom to allocate ventilators, in what priority.
Is there hope?
Yes, China, despite the initial numbers, has managed to keep the new cases to single digits now. South Korea, Germany, Singapore and Taiwan are other examples of good success so far with extensive testing and strict enforcement of quarantine procedures.
There were many new developments this week. We have a potential vaccine under testing. Older drugs repurposed for Covid-19 find success in small trials and that look promising. This means more cure and lesser spread of the disease. Newer serological tests will decrease the testing time and would make it cheaper to test.
The Indian government has expanded the testing criteria allowing more people to be tested. More people testing positive and getting isolated early will help us contain the disease soon. It will also help in the rational use of PPEs by healthcare professionals. Some states have announced complete lockdown and hopefully more will follow suit. Hope we will tide this over sooner rather than later.
Dr Amith Viswanath’s Twitter handle is @avstmd.