Blogfinger

Severe cases of Covid-19 are treated with ventilators in China.

By Paul Goldfinger, MD.   Editor@Blogfinger.net

When it comes to medical care, what terrifies me the most is being placed on a ventilator, and I have personally  been through some risky business in the past.  At times I have been intubated (tube down your throat to keep you breathing.)

That is fairly routine for general anesthesia, under the watchful eye of an anesthesiologist, but it is almost always temporary, and the patient’s memory is usually only of a sore throat afterwards. So, in many situations, the ventilator is used until some reversible factor, for example sustained effects of anesthesia, is resolved.

But if you are critically ill in an ICU and require a temporary breathing machine  (ventilator) for a longer period of time, then you cannot remain conscious because it is intolerable. So they induce a sustained coma.

Years ago I can remember seeing patients’ hands being tied down for that, and then we would use IV sedatives to keep them unconscious.  Usually the ventilator would not be needed for a long time because given the opportunity, we would fix the problem, and normal respiration could resume, so we would extubate the patient, support breathing with oxygen, and allow him to wake up.   Thank goodness for the induced coma of recent years.

But the Coronavirus is a horrible organism that can damage and even destroy a victim’s lungs causing dependency on the ventilator usually for 7-10 days or less or longer. The lucky ones will show some improvement over time allowing removal from the machine.  But others develop complications, especially in high risk groups, and they may die before the ventilator could be implemented or while it is being used.

Or they may be stuck on the machine with no way out. Then the decision of taking someone off the ventilator is discussed.

The mortality rate for those on ventilators is 50-80% based on some recent observations.  The patients most at risk of dying are the elderly and those with underlying medical issues including heart failure, prior heart attacks, reduced immune responses as with chemotherapy, diabetes, hypertension, and chronic lung disease.

And then, for some, even if they are removed from the machine, there may be lingering severe complications and long term rehab or admission to nursing facilities.

An internist from Georgetown University Medical School, Dr. Kathryn Dreger, posted a “no holds barred” piece in the New York Times today.   It is painful to read, but  it is important to do so because you never know  when that miserable situation might land in your lap.

Here is the link below:

Editor’s note.  Paul Goldfinger, MD

So, is it a death sentence?  Well, there are individual situations, but suffice it to say that if a doctor recommends this approach, make sure you understand what the chances are that your loved one will benefit.

Of all who have symptoms of COVID-19, only 10% need hospitalization, and a minority would need the  ICU and a ventilator.  Some will “come off” within 7-10 days, but many will not. The exact numbers are not yet available.

For those who can be removed from the machine, some don’t do well afterwards. Being in that coma often has long-lasting consequences if the person survives.

From the National Post in Canada comes this statement:  “But as the number of Canadians made critically ill by the virus ticks up, some patients or their families are actually foregoing entirely the often-harrowing treatment afforded by ICUs and breathing machines.

“A number of elderly patients have died in long-term care homes rather than submit to intensive therapy that might have only made their passing more painful and uncomfortable.”

From Barnes Hospital in St. Louis:   “Most coronavirus patients who end up on ventilators go on to die, according to several small studies from the U.S., China and Europe. The mortality in that group at Barnes is 50-80%.”

“It’s very concerning to see how many patients who require ventilation do not make it out of the hospital,” says Dr.Tiffany Osborne, a critical care specialist at Washington University in St. Louis who has been caring for coronavirus patients at Barnes-Jewish Hospital.”

At Cornell Medical Center in NYC  it is reported that the “vast majority in their ICU come off the ventilators.”  But coming off the machine doesn’t necessarily equate with survival.

And from Maimonides Hospital in Brooklyn, as reported by the NY Post, an Emergency Medicine doctor is saying that the ventilators being used for CUVID-19 patients are being set with excessively high pressures which may be contributing to lung damage. Blogfinger has  no verification of that claim.

And some of the patients who continue to live can’t be taken off the mechanical breathing machines.

What should families do?

One approach is to invoke a  preexisting legal advanced directive that says,  “No machines to keep me alive.”  Or “Do not resuscitate if my heart stops,” but that might require interpretation by the next of kin after discussion with physicians.

A compromise would be to tell your next of kin to refuse or halt ventilators if the condition is or has become hopeless to a high degree. Perhaps a person could write a letter to that effect.

We have heard a great deal about how important it is to build and distribute ventilators all over the US and even the world. But understand that ventilator support is not a cure.