The Scarce Resource Dilemna

indigo girl · Sep 29, 2009

Critical care doctors want escalated pandemic planning

http://www.cmaj.ca/cgi/content/full/181/5/253

"It's exceedingly likely that come the late summer, early fall, there is going to be much more H1N1-A and the absolute number of patients are going to be a lot higher. It may very well exceed our capacity and our plan to care for them," says Dr. Rob Fowler, a critical care physician at Sunnybrook Hospital in Toronto, Ontario. "Our response needs to be escalated substantially more than we're doing right now."
Fowler, a member of the Canadian Critical Care Trials Group, is gathering case descriptions of critically ill patients in ICUs across the country. His report will describe the patients' clinical presentation, treatment challenges and outcomes. About half the patients whose data Fowler and colleague Dr. Anand Kumar have collected were treated in Manitoba. Quebec, Ontario and Alberta have seen the next largest concentrations of critically ill patients. In addition, Fowler has access to data from Mexico's critical care group. The picture emerging from Mexico is of an influenza that largely affects people aged 10-55, with a core group of patients typically in their 40s who have developed acute lung injuries and hypoxic respiratory failure.
"We're seeing a very similar thing, and in a subset of patients, severe lung injury requiring extraordinary support in intensive care, with means to oxygenate that a lot of the world doesn't have, and is in limited supply in Canada," Fowler says.
These patients have required aggressive and unconventional means of oxygenation, often staying on ventilators for weeks at a time, says Kumar, who describes many of the Winnipeg patients he treated as "the most difficult patients in terms of ventilator management that I've ever seen in my 20 years of practice."
"To a great extent, among adults, this is an ICU disease," Kumar notes. Many of those who were admitted needed high-frequency oscillatory ventilation-a jet-like ventilation that oscillates oxygen into patients at the rate of 300 times a minute or more. This therapy also requires nitrous oxide and airway pressure relief, as well as other advanced ventilation techniques, he adds. About half a dozen Canadian patients also had to be placed on heart-lung bypass machines to give them extra-corporeal membrane oxygenation or likely would have died.
Most hospitals in Canada do not have oscillating ventilators, and there are only a few centres that can do heart-lung bypass. That has left critical care physicians concerned about the country's readiness if a second pandemic (H1N1) 2009 wave hits in the fall.
"I don't think that everybody realizes that the pandemic stores, the emergency store of ventilators that a lot of people are depending upon in case of emergency, simply aren't advanced enough to take care of these patients," says Kumar.
Ventilators made more than 15 years ago and those routinely used in emergency rooms aren't advanced enough for this type of therapy, he adds. However, older ventilators may be useful for the less severely injured.
In a written response to CMAJ questions, the Public Health Agency of Canada (PHAC) confirmed that of the additional 370 ventilators it is trying to purchase as part of its National Emergency Stockpile System, none are oscillating ventilators. PHAC does not have a stockpile of heart-lung bypass machines.
Nurses and respiratory technologists will be as critical if Canadian hospitals see even 3.5 times more cases of pandemic (H1N1) 2009 patients with lung injuries in a second wave-and that is a conservative estimate, says Dr. Allison McGeer, director of infection control at Toronto's Mount Sinai Hospital. Like Kumar and Fowler, she is concerned that ICUs may become the choke point in the health care system come fall.
Unlike ICUs in the United States, which routinely keep some beds empty and ventilators free, Canadian units normally run at 90%-95% full --sometimes more, with patients waiting in emergency before being admitted. "It's very efficient from a systems point of view, but it means we have no surge capacity in our ICUs in Canada," says McGeer. Even so, "I am less worried about the ventilator supplies than I am about the staff resources to care for them," she adds.
Hospitals should also be stockpiling sedatives, paralytics and antibiotics, because the ventilated patients with pandemic (H1N1) 2009 often require "massive" sedation.
Administrators should also be making plans to designate staff to make tough triage choices, Kumar says. "The idea of, how you triage 2 young people to a single ventilator-that's a very difficult issue."
Fowler is also worried that Canadian hospitals will have to limit resources to people who are very sick because of inadequate capacity. "That's a position we haven't found ourselves in throughout the history of medicare in Canada."
With each province and region developing its own pandemic plan, the Canadian Critical Care Society is concerned that "from a national perspective, there's no coordinated effort to help with resource utilization and sharing that sort of resource planning," says Dr. John Granton, a Toronto ICU physician and the Society's president.
Pandemic planning has largely been devoted to securing a vaccine and rolling out immunization, but federal oversight is needed to ensure provincial licensing requirements are waived and malpractice insurance is extended so that, if necessary, health care professionals and medical equipment can be shared between jurisdictions, Granton says.

(hat tip flutrackers/mixin)

RuRnurse? · Sep 29, 2009

"Administrators should also be making plans to designate staff to make tough triage choices, Kumar says. "The idea of, how you triage 2 young people to a single ventilator — that’s a very difficult issue."

This is going to be the biggest issue in the event of a real problem. There AREN'T enough supplies to go around, and there won't be. Triage would become necessary, and that isn't something that most people can do effectively. That theoretical situation, the two young people, is a call that someone would have to make, but anyone who might be put in that situation MUST think about it beforehand-Can I do it?

Unfortunately, most people who may end up there aren't able to do it for real. It takes a practical and somewhat cold mindset, what training do most HCW's have for this? A military person perhaps, but again, not everyone can, even a trained soldier...it all sounds fine on paper, but real-world? A different story.

I'm sure many facilities have assigned someone for this task, but whether or not they will be able to actually perform under the pressure of reality is another story. You have 2 young people and 1 ventilator-you can only save one. So, who is it? Quick now...times-a-wasting...both are young, and families crying and begging you to save their kid, you have to pull the trigger here...AND, most importantly, you have to be able to make that choice, and drive on, because there will soon be another choice to make, and you can't do it if you end up collapsing into a tearful pile in the back room afterwards...

There is a short story that anyone likely to be put into this situation should read. It's called "The Cold Equations", by Tom Godwin. It's a sci-fi story, but the whole idea is that there are situations that just are what they are, and require an impossible choice to be made, and made NOW. The situation doesn't care about the feelings of those involved, it is a simple mathematical problem with 2 possible outcomes, a "cold equation"...pick one, and remember, the clock is ticking. Would YOU be able to do it?

Zookeeper3 · Oct 2, 2009

Last flu season we had run 28 of 30 regular ICU beds with all vents. This doesn't count the neuro ICU and CVICU that took overflow as well. OUr hospital was out of vents and Bipap machines and had to go several counties away to rent more equipment.

My point is that before this "pandemic" we were maxed out last flu season. This season we are short staffed as usual going in... I sure hope there is a plan in place because if we repeat last season or pass it with acuity everyone will be in a mess.

We curently only have 4 reverse isolation ICU rooms for 41 beds, they're all in use for H1N1 now... it's going to be messy.

indigo girl · Oct 2, 2009

Last flu season we had run 28 of 30 regular ICU beds with all vents. This doesn't count the neuro ICU and CVICU that took overflow as well. OUr hospital was out of vents and Bipap machines and had to go several counties away to rent more equipment.
My point is that before this "pandemic" we were maxed out last flu season. This season we are short staffed as usual going in... I sure hope there is a plan in place because if we repeat last season or pass it with acuity everyone will be in a mess.
We curently only have 4 reverse isolation ICU rooms for 41 beds, they're all in use for H1N1 now... it's going to be messy.

Zookeeper, could you tell us what area you are located in? We know that come places are more impacted than others. Right now Texas, is an area of intense activity.

Does your hospital have ECMO capacity? Mine does, and it was only supposed to be used for transplant patients though now it is beginning to take on H1N1 cases.

Thanks for your information.

oramar · Oct 2, 2009

It is so strange that so many people think that the most serious problem with this pandemic is the H1N1 vaccine, whether to have it or not, if it has Thermisol. The most serious problem is actually a very real possiblity of shortages of supplies and equipment and health care workers.

WalkieTalkie, RN · Oct 2, 2009

I told people in my unit that we would start seeing a rash of H1N1 patients and that they needed to take the pandemic seriously. Most of them brushed the idea off... Well, needless to say, we have been hit hard the past couple of weeks.

I have seen several patients with flu-like illnesses (most are testing negative on rapid influenza tests). Often these patients are in their 40s and typically have one co-morbidity, like asthma or diabetes. They are coming into the hospital with "pneumonia" and being sent to the floors. They then deteriorate and go into ARDS. Some of them never do test positive for flu, but some of them are testing positive the second or third time around (usually from a BAL specimen). The ones testing negative for flu seem to have the streptococcal infections.

The high rate of false negative on the rapid influenza tests makes me think that the people I'm seeing with these "secondary" infections are really patients who had flu and now developed the infection.

We had a H1N1 related death this week, and we currently are using vents on 3 patients with confirmed or suspicious for flu. This doesn't include the other ICUs in my hospital... just my unit.

I am still dismayed at my co-workers' response to flu pateints with regards to PPE. I have been trying to educate them on using N95 masks when working with patients highly likely to be shedding the virus (i.e. ventilation, suctioning, etc). One co-worker even got into an argument with me last night about a comment I made on how I didn't feel safe with the surgical masks provided on our isolation cart. She said that "Oh our policy says to use surgical masks." I don't feel comfortable with this thought (mind you, our PPE recommendations for flu is based on articles from 2001).

We are ECMO capable, and I keep telling management and staff to expect an increase in ARDS and need for ECMO this year due to flu, but nobody is really taking me seriously. I am just so annoyed right now!

:banghead:

I am going to speak with some people to see if we can revise the policy and procedure for flu PPE.

indigo girl · Oct 4, 2009

Tamiflu for Kids

The govt just released more of this medication from the national stockpile.

With the liquid children’s version of the anti-influenza drug Tamiflu in short supply, pharmacists are making their own children’s version by mixing cherry syrup with the contents of the Tamiflu capsules.

More on this story at : http://www.nytimes.com/2009/10/04/health/04cherry.html?_r=2&hp

RedWeasel, RN · Oct 5, 2009

We have been told to wash with soap and water preferably (I do usually prefer that over hand sani anyway) over the hand sanitizer because the supplier is unable to keep up with the demand. Crazy right? How long have we known about this pandemic? You would think the govt may have alerted them to this fact! haha Guess we better get out to our drug stores now and stock up! I guess I will carry my own!

RuRnurse? · Oct 6, 2009

The hand sanitizers are alcohol based. In a pinch, one could simply use plain alcohol, which is not in short supply right now. Tough on the hands, yes, but serves the purpose if there is no water and soap available.

Hoozdo, ADN · Oct 7, 2009

I am still dismayed at my co-workers' response to flu pateints with regards to PPE. I have been trying to educate them on using N95 masks when working with patients highly likely to be shedding the virus (i.e. ventilation, suctioning, etc). One co-worker even got into an argument with me last night about a comment I made on how I didn't feel safe with the surgical masks provided on our isolation cart. She said that "Oh our policy says to use surgical masks." I don't feel comfortable with this thought (mind you, our PPE recommendations for flu is based on articles from 2001).

Face masks! N95 masks are recommended by the CDC. I am in a snit because one of the intensivists in my unit told me last night that "you should use one face mask the entire shift."

I replied, "not according to OSHA." I proceeded to use a new N95 everytime I went in the room. Actually, the CDC says an N95 is for one single use. Tonight I am bringing in the documentation. I will NOT be wearing one N95 mask for a 12 hour shift. :no: