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Intensive care units likely to be main battlegrounds in the war against H1N1
By Helen Branswell Medical Reporter (CP) ? 1 day ago
TORONTO ? Intensive care specialists who fought to save desperately sick swine flu patients this spring and summer have a warning for hospitals that haven't yet dealt with an influx of these difficult-to-treat patients.
Prepare. Now. Experts predict ICUs are likely to be the main battlefield in the war against a pandemic virus which so far doesn't appear to have much of a middle ground.
The vast majority of people suffer through a typical bout of flu. But of those who become sick enough to be hospitalized, a significant portion - maybe as high as 15 per cent, the World Health Organization says - end up in ICUs for weeks, hovering between life and death.
"I've never seen this," says Dr. Paul Hebert, editor of the Canadian Medical Association Journal and an intensive care physician in Ottawa who has treated several of these patients.
"As an ICU doctor, it's very, very, very rare I can't deliver enough oxygen to someone to keep him alive. They die of other things, right? They die because their organs fail."
"In this case, we can barely oxygenate them."
The worst-hit hospitals talk of having been on the brink of not being able to cope. They describe nearly running out of specialized equipment and the skilled staff needed to monitor these highly unstable patients in their high-tech hospital beds.
Public health officials need to look for ways to keep novel H1N1 patients from getting this sick and help hospitals access enough key drugs, equipment and even staff to cope with an expected surge of cases in the fall and winter, says Dr. Anand Kumar, an intensive care physician who has treated dozens of these patients in Winnipeg.
Kumar was so concerned about what he saw in the city's ICUs earlier this year that he has been agitating, in medical and political circles, for stepped up pandemic preparations for the country's hospitals.
"I want the public health people to understand: If we breach ICU capacity, a lot of people are going to die," he cautions.
"What I've been telling everybody is: 'You've got to think about the ICU because the ICU, for these kinds of events, is your choke point."'
Kumar's warnings appear to have been heard. The Public Health Agency of Canada has convened a meeting this Wednesday and Thursday in Winnipeg designed to bring together critical care and public health experts to brainstorm on how to prepare for the next wave of illness.
The scientific director of the agency's National Microbiology Laboratory says one of the goals of the meeting is to try to figure out what leads to severe disease, in the hopes some such cases can be averted. But it's also about alerting intensive care specialists who haven't yet dealt with these types of cases about what to expect. What works. What doesn't. What problems might arise.
"My understanding from talking to the ICU docs across the country, but mainly in Winnipeg, is that there are some particular challenges with managing the people who have severe pneumonitis (inflammation of the lungs)," says Dr. Frank Plummer. "Understanding that and exchanging that information between intensive care doctors is important."
"It's not just about more ventilators, although that probably will be part of it. But I think it's about the actual techniques and technologies that were required to keep these people going. They needed really advanced respiratory support from my understanding."
That's not all they need. Kumar notes these patients require high doses of sedating medications for long periods of time, so they don't struggle and actually fight against the ventilators being used to keep them alive.
During Winnipeg's outbreak the hospitals treating severely ill swine flu patients went through a year's supply of the sedating drugs in just two months, Kumar says.
"For some reason - and we don't know why yet - these patients are incredibly agitated and require incredibly high doses of sedation," he says, adding he's asked federal officials to alert manufacturers so they can step up production.
Winnipeg treated about 50 confirmed swine flu cases and another 15 who looked just like them but didn't test positive for the virus.
Kumar thinks the recommended test - a swab inserted deep into the nose - isn't reliable in severely ill patients. He thinks other specimens, from lower down in the respiratory tract, should be searched for viruses.
He's warned his ICU peers that patients who look like swine flu cases probably are swine flu cases and should be treated as such. "Look, guys, the test may say that it's negative, but think about it."
At a recent meeting of the U.S. Institute of Medicine exploring the question of what equipment health-care workers need to protect them during the pandemic, an intensive care specialist from Salt Lake City, Utah, warned two-thirds of his hospital's 60 or so ICU patients with swine flu developed acute respiratory distress syndrome or ARDS, a condition that is very difficult to treat.
These patients weren't old, said Dr. Russell Miller, medical director of respiratory ICU at Intermountain Medical Center. In fact, the median age was about 30 years old.
One day the hospital nearly ran out of the dialysis machines needed to do the work of failing kidneys. And it came close to having a shortage of ICU nurses. Miller suggested hospitals preparing for the fall and winter need to think about how they will allocate resources and the difficult issue of triaging care.
Kumar agrees that hospitals need to plan for how they'll cope if ICUs become over-burdened with pandemic flu cases, something that nearly happened in Winnipeg.
"Had the situation persisted much longer, we would have been looking to shift ... (non-H1N1) patients to other cities, basically, in order to concentrate on dealing with our own guys. And we would have had to formally cancel surgery."
Other things hospitals and local and provincial authorities need to think about is whether legal arrangements are in place that would allow for the shifting of resources - people and specialized medical equipment - across provincial and territorial boundaries, Hebert said in a recent editorial in the Canadian Medical Association Journal.
If Saskatchewan needed more ventilators and Alberta had spares, could they be transferred? How could Alberta be assured it could get the ventilators back when it needed them?
Kumar says ICU specialists are experts at thinking outside the box - finding something else to try when standard approaches fail.
That's a skill they'll need with these patients, he suggests, noting some places used extra-corporeal membrane oxygenators or ECMOs - devices like the heart-and-lung bypass machines normally used in heart operations - to oxygenate the patients until their lungs could recover.
He says planners need to look at expanding their supplies of a range of medicines and disposable medical equipment. And they need to be preparing for the fact that while flu works its way through a community, ICU staff may end up sleeping in the hospitals.
No one knows what this new flu virus has in store for humans. But health-care professionals who've dealt with the sickest pandemic flu patients say it makes sense to prepare for tough times.
"I always say that the one thing I don't want to do is in a year look back and say 'I could have done this' or 'I should have done that' kind of thing," Kumar says. "I'd rather look back and say: 'Man, I really over-reacted."'
Intensive care units likely to be main battlegrounds in the war against H1N1
By Helen Branswell Medical Reporter (CP) ? 1 day ago
TORONTO ? Intensive care specialists who fought to save desperately sick swine flu patients this spring and summer have a warning for hospitals that haven't yet dealt with an influx of these difficult-to-treat patients.
Prepare. Now. Experts predict ICUs are likely to be the main battlefield in the war against a pandemic virus which so far doesn't appear to have much of a middle ground.
The vast majority of people suffer through a typical bout of flu. But of those who become sick enough to be hospitalized, a significant portion - maybe as high as 15 per cent, the World Health Organization says - end up in ICUs for weeks, hovering between life and death.
"I've never seen this," says Dr. Paul Hebert, editor of the Canadian Medical Association Journal and an intensive care physician in Ottawa who has treated several of these patients.
"As an ICU doctor, it's very, very, very rare I can't deliver enough oxygen to someone to keep him alive. They die of other things, right? They die because their organs fail."
"In this case, we can barely oxygenate them."
The worst-hit hospitals talk of having been on the brink of not being able to cope. They describe nearly running out of specialized equipment and the skilled staff needed to monitor these highly unstable patients in their high-tech hospital beds.
Public health officials need to look for ways to keep novel H1N1 patients from getting this sick and help hospitals access enough key drugs, equipment and even staff to cope with an expected surge of cases in the fall and winter, says Dr. Anand Kumar, an intensive care physician who has treated dozens of these patients in Winnipeg.
Kumar was so concerned about what he saw in the city's ICUs earlier this year that he has been agitating, in medical and political circles, for stepped up pandemic preparations for the country's hospitals.
"I want the public health people to understand: If we breach ICU capacity, a lot of people are going to die," he cautions.
"What I've been telling everybody is: 'You've got to think about the ICU because the ICU, for these kinds of events, is your choke point."'
Kumar's warnings appear to have been heard. The Public Health Agency of Canada has convened a meeting this Wednesday and Thursday in Winnipeg designed to bring together critical care and public health experts to brainstorm on how to prepare for the next wave of illness.
The scientific director of the agency's National Microbiology Laboratory says one of the goals of the meeting is to try to figure out what leads to severe disease, in the hopes some such cases can be averted. But it's also about alerting intensive care specialists who haven't yet dealt with these types of cases about what to expect. What works. What doesn't. What problems might arise.
"My understanding from talking to the ICU docs across the country, but mainly in Winnipeg, is that there are some particular challenges with managing the people who have severe pneumonitis (inflammation of the lungs)," says Dr. Frank Plummer. "Understanding that and exchanging that information between intensive care doctors is important."
"It's not just about more ventilators, although that probably will be part of it. But I think it's about the actual techniques and technologies that were required to keep these people going. They needed really advanced respiratory support from my understanding."
That's not all they need. Kumar notes these patients require high doses of sedating medications for long periods of time, so they don't struggle and actually fight against the ventilators being used to keep them alive.
During Winnipeg's outbreak the hospitals treating severely ill swine flu patients went through a year's supply of the sedating drugs in just two months, Kumar says.
"For some reason - and we don't know why yet - these patients are incredibly agitated and require incredibly high doses of sedation," he says, adding he's asked federal officials to alert manufacturers so they can step up production.
Winnipeg treated about 50 confirmed swine flu cases and another 15 who looked just like them but didn't test positive for the virus.
Kumar thinks the recommended test - a swab inserted deep into the nose - isn't reliable in severely ill patients. He thinks other specimens, from lower down in the respiratory tract, should be searched for viruses.
He's warned his ICU peers that patients who look like swine flu cases probably are swine flu cases and should be treated as such. "Look, guys, the test may say that it's negative, but think about it."
At a recent meeting of the U.S. Institute of Medicine exploring the question of what equipment health-care workers need to protect them during the pandemic, an intensive care specialist from Salt Lake City, Utah, warned two-thirds of his hospital's 60 or so ICU patients with swine flu developed acute respiratory distress syndrome or ARDS, a condition that is very difficult to treat.
These patients weren't old, said Dr. Russell Miller, medical director of respiratory ICU at Intermountain Medical Center. In fact, the median age was about 30 years old.
One day the hospital nearly ran out of the dialysis machines needed to do the work of failing kidneys. And it came close to having a shortage of ICU nurses. Miller suggested hospitals preparing for the fall and winter need to think about how they will allocate resources and the difficult issue of triaging care.
Kumar agrees that hospitals need to plan for how they'll cope if ICUs become over-burdened with pandemic flu cases, something that nearly happened in Winnipeg.
"Had the situation persisted much longer, we would have been looking to shift ... (non-H1N1) patients to other cities, basically, in order to concentrate on dealing with our own guys. And we would have had to formally cancel surgery."
Other things hospitals and local and provincial authorities need to think about is whether legal arrangements are in place that would allow for the shifting of resources - people and specialized medical equipment - across provincial and territorial boundaries, Hebert said in a recent editorial in the Canadian Medical Association Journal.
If Saskatchewan needed more ventilators and Alberta had spares, could they be transferred? How could Alberta be assured it could get the ventilators back when it needed them?
Kumar says ICU specialists are experts at thinking outside the box - finding something else to try when standard approaches fail.
That's a skill they'll need with these patients, he suggests, noting some places used extra-corporeal membrane oxygenators or ECMOs - devices like the heart-and-lung bypass machines normally used in heart operations - to oxygenate the patients until their lungs could recover.
He says planners need to look at expanding their supplies of a range of medicines and disposable medical equipment. And they need to be preparing for the fact that while flu works its way through a community, ICU staff may end up sleeping in the hospitals.
No one knows what this new flu virus has in store for humans. But health-care professionals who've dealt with the sickest pandemic flu patients say it makes sense to prepare for tough times.
"I always say that the one thing I don't want to do is in a year look back and say 'I could have done this' or 'I should have done that' kind of thing," Kumar says. "I'd rather look back and say: 'Man, I really over-reacted."'