Ringside Reflections on Health Care
In the mid-1990s, I was in-charge of the Surgical ICU of KEM Hospital. A six-bed unit, it had four old-fashioned ventilators. There were constant fights for using them and often we had to deny ventilation to those who needed them. Most patients ventilated beyond a few days would die.
One particular day, when we were on rounds, a young man with a head injury was brought in desperately needing a ventilator. I realised, one had been sent for repair two days prior and the three functional ones were occupied. I called the company only to be told that they were waiting for a part to arrive. We then went to ICUs of all the other departments in the hospital, requesting to borrow one. All of them refused, saying they didn’t take ‘surgical’ patients. Our patience was running thin and I was losing my cool. I called up the Dean and almost shouted at her pleading for intervention. She responded, called the respiratory unit and ordered them to lend a ventilator.
After this drama had concluded, we were sipping tea in the shop across the hospital. We had a resident working with us from Rajasthan who hesitatingly asked, “Why were you so upset”? I asked him incredulously, “What do you mean?” “Well, in the large government hospital I trained back home there was only one ventilator which often didn’t work”. “So how did you ventilate patients?” I asked. “We didn’t,” he replied, adding, “We put in a breathing tube and connected it to a breathing bag which was pumped by the relatives for a few hours.” I asked, my surprise mounting, “After that?” To which he replied, “They all died within hours”. I guess he was trying to assuage me by providing the larger context. But it disturbed me more. It has been two decades since this incident but it’s indelibly printed in my mind. Have things changed? Yes and no.
The search for a mechanical device to support the failing ability to breathe is very old. However, it was only in the late 19th century that machines based on physiological principles were developed. Initially, ventilation was delivered using sub-atmospheric pressure delivered around the body to replace the work done by respiratory muscles. In 1864, Alfred Jones invented one of the first such body-enclosing devices. The first ‘iron lung’ to be widely used was developed in Boston by Drinker and Shaw in 1929 and used to treat children with polio. The modern ventilators in current use work on the principle of positive pressure. A mixture of oxygen and air is pushed rhythmically into the lung under pressure to inflate them. The current models are sophisticated machines that can control various aspects of breathing. It is now fairly common in modern ICUs for patients to be ventilated for days or even weeks and recover. There is another key reason why ventilation has become safer and more effective.
There are significant collateral issues when a patient is on a ventilator. Often these are the killers. These include preventing blockage of the breathing tube, preventing infection (called ventilator-associated pneumonia), maintaining nutrition and tackling problems related to prolonged immobilisation. For example, turning the patient from side to side periodically is key to reducing lung infection and bed sores. This means that besides doctors, the contribution of specialist nurses, physiotherapists, respiratory techs, dieticians, ward boys and ayah bais is immense, which is often overlooked. And it is exactly this team effort that large private hospital ICUs have been able to implement in India albeit for a huge cost. And this is where the public system has lagged. There is more to it than just the availability of ventilators when Covid peaks. Covid causes damage through a process called ARDS (acute respiratory distress syndrome) in which the lungs become wet and stiff. Ventilating these patients is very different from those whose lungs are normal and are unable to breathe for other reasons. It will need an ecosystem trained to ventilating patients for long with focus on these collateral issues.
We have two options. The first is to carry on with business as usual. In other words, those who can afford to access the advanced private sector ICUs will be treated there. First come first served. Many will get prolonged ventilation and a proportion will recover. The large majority will try to access public sector facilities which will be overwhelmed and will have limited capacity to nurse and sustain ventilation for long periods. Thus, a social triage based on ability to pay will come into play.
The other option will demand a bold leap of collective thinking; which is to quickly procure or produce ventilators to the extent possible, get them into a common pool, preferably in Covid-dedicated hospitals so that expertise in advanced ventilatory management can be shared. Also, decide a triaging system based on maximum benefit and not the ability to pay. This may mean a subset of elderly with pre-existing diseases or those with irreversible organ failure may have to forego ventilation or have the ventilator switched off. If this sounds utopian and heartless, it is. However, this is subtly practised in ICUs even today. I fervently hope all this is not needed. But if indeed we want to make a plan based on justice this is how it could be.
As I was finalising this piece, I got a panic call from an acquaintance from a wealthy family. “I heard about the likely shortage of ventilators. Worried about my family. Is there a way I can pre-book a ventilator for them? I can pay whatever amount as advance”. I was stunned. I hung up.
(Sanjay Nagral is a surgeon, who when not wielding a scalpel wields a pen)