How our health service is ready to wage war
Doctors are waiting with mounting apprehension for the first surge of coronavirus patients, writes Maeve Sheehan
THE scenes at Beaumont Hospital in Dublin last Friday were typical of hospitals all over the country. Consultant staff gathered in large numbers at the north Dublin hospital for a debriefing on the coronavirus. The expected surge of Covid-19 patients was days away.
In readiness, the hospital had identified 54 bays to ventilate critically ill patients who would need oxygen mechanically introduced to their lungs because of respiratory failure caused by the coronavirus. According to one consultant who was present at the meeting, no one was able to say how soon those 54 beds for severely ill patients would fill up.
The process of cancelling outpatients’ appointments and elective surgeries had begun. Staff were urged to continue to find more space for the expected influx. From tomorrow morning, medical teams will be doubling down on reviews of their patients. Those still in need of hospital care will be “decanted” to other facilities and others will be discharged. The meeting was told that the Health Service Executive (HSE) is in talks with private hospitals about taking in some public patients. Consultants were told to start wearing personal protective equipment (PPE) from this week, with tutorial videos circulated to all medical staff on how to remove them correctly without dispersing the virus.
“It was like we were entering a war zone,” said one person who was present at the meeting. “We don’t know what lies ahead. Everyone was putting their shoulder to the wheel.” In one way, a day to be proud of the medical profession, he said, but tempered by concerns for the seriously ill patients on their way, and that work might result in the virus being transmitted to their own families.
Now that schools have shut, shelves cleared by panic-buyers, holidays cancelled and staff urged to work from home, the focus has turned to the hospitals. If the public are the first line of defence in containing the virus, hospitals are the next battleground in the war on the coronavirus pandemic. The unknowns remain as great: how many will be infected; when will the surge start; are there enough critical care beds; are there enough ventilators to prevent deaths from respiratory failure; how far away are doctors from having to make harrowing decisions about prioritising those who have a chance over those who most likely won’t?
In 14 days, the number of cases in Ireland has jumped from one on February 29 to 90 on Friday. Italy — the new epicentre of the virus — went from its first two cases on January 30 to 15,113 confirmed cases and 1,016 deaths last Friday. In an alarming update that day, the European Centre for Disease Prevention and Control (ECDC) warned that Covid-19 was spreading so fast that “in a few weeks or even days, it is likely that similar situations to those seen in China and Italy might be seen in other EU/EEA countries or the UK. A rapid shift from a containment to a mitigation approach is required, as the rapid increase in cases, that is anticipated in the coming days to few weeks may not provide decision makers and hospitals enough time to realise, accept and adapt their response accordingly if not implemented ahead of time”.
According to Liam Glynn, a professor of general practice at University of Limerick, Ireland is exactly 14 days behind Italy. With social distancing the only way we know to stop the virus, he and others are urging more radical public health responses from the Government.
We do not have enough critical care beds to cater for the projected numbers of people who are expected to become seriously ill with the coronavirus. Irish hospitals have 255 critical care and intensive care unit beds — about 5.2 beds per 100,000 population; Britain has 7.2; and the European average is 11.5. Doctors in Italy are reporting that between nine to 11pc of patients there needed ventilation and predicted that Italy will need 4,000 more ICU beds over the next month.
Dr Tom Ryan, of the Irish Hospital Consultants’ Association and a consultant in intensive care, said: “About 4pc of people who get this end up in ICU. And it is different from being in an ordinary hospital ward. They will need a ventilator. And a nurse beside the ventilator. And all the monitors that go with the ventilator. Then will need the doctors familiar with running the ventilator. The ventilator is not a standalone item. It has to be plugged into compressed oxygen coming from the wall, and that’s part of the infrastructure of the hospital, it’s part of the plumbing. It’s not at every bedside.”
Exacerbating Ireland’s predicament is the international scramble for ventilators and other lifesaving equipment. The Financial Times reported yesterday that Germany has ordered an additional 10,000 ventilators and Italy’s only manufacturer of the product is quadrupling its supply. The HSE has already purchased 12 mobile ventilators, 60 intensive care ventilators and is sourcing more.
The problem, said Dr Tom Ryan, is no one really knows how big the surge will be.
Professor Sam McConkey, head of the department of international health and tropical medicine at the Royal College of Surgeons, has been to the fore in analysing the progress of the coronavirus since the outbreak started in China three months ago.
“When I look at even a good-case scenario , I am looking at something like 50,000 people in Ireland getting respiratory failure, meaning they need oxygen, meaning they need to be in hospital. Optimistically that could be spread over six to 12 months,” he said.
“If 50,000 people come in tomorrow with respiratory failure, we just are overwhelmed. If we can delay that over six or 12 months, then it’s possible.”
Prof McConkey said he did not want to talk about a worst-case scenario: “It’s overwhelming of the healthcare services and relative chaos. I hope we don’t get there. We need to take action to prevent this.”
Worst-case scenario also means that access to critical care could spell the difference between life and death.
“If you have more patients than resources, you can’t do a Solomon on it and divide the ventilator into two. You have to make choices. And those choices are based on ethical guidelines,” said Dr Catherine Motherway, a consultant intensivist and anaesthetist and members of the Intensive Care Society of Ireland. Such decisions are challenging but transparent.
“What you do is you prioritise people who actually will benefit — and we always do that anyway,” said Dr Motherway. “When you have difficulties with resources then you have to try and save the most lives, and you have to save the people who will survive using the least resources.
“We in no way, shape or form want this to happen, and we can as a community stop this from happening if we all pull together. It can only happen if we fail to control the surge, and the way we can control the surge is by washing our hands and social distancing.”
Medical teams have been working around the clock this weekend to prepare for what lies ahead. Their representative bodies are pushing for more staff, more personal protective equipment for staff, that it is of the right quality and to ensure that those who get sick are looked after.
The HSE is working to identify around 10,000 beds, in various locations, for Covid-19 cases, and is in talks with hotels, private hospitals, student accommodation and any other large-scale buildings that can be used for medical care.
Paul Reid, the head of the HSE, said it has received “significant offers” from the hotel sector while private medical providers have offered services at cost. The Lifeline ambulance service, owned by mortgage campaigner David Hall and his wife, has offered its 40 ambulances, seven rapid response vehicles and staff to the HSE on a cost basis.
Tomorrow morning, the Irish Defence Forces will step up for duty to support the HSE’s response to the coronavirus. More than 300 troops will be on hand at short notice to provide whatever assistance is necessary such as patient transfers within hospitals and contact tracing.
Dr Ryan fears the looming surge in the corona virus will expose the shortcomings in Ireland’s health system, but it has also served to highlight the spirit that underpins it.
As health professionals, they are cracking on, he said. “We are doing all the things we have to do, decanting patients, ordering more ventilators. We are trying to get our head around the scale of the problems we are going to face.
“We’ve cancelled all leave. We had a meeting of everyone involved, consultants, nurses — and we all decided that we are all in this together. We are going to ditch all the existing rules as to who works where. We are just going to crack on and get this sorted.”
The numbers could be “colossal”, according to Dr Motherway: “But it is up to the public not to let it get to that point.”
‘We are going to ditch all the existing rules as to who works where. We are just going to crack on and get this sorted’