SECOND OPINION : Critical questions in times of Covid

BY SANJAY NAGRAL

In 1952, a Danish anaesthesiologist, Bjorn Ibsen, got involved in a polio outbreak, where a large number of patients had respiratory paralysis. Ibsen used positive pressure ventilation by putting a tube into the trachea. He enlisted 200 medical students to sit next to patients and manually push oxygen and air into their lungs. The mortality declined significantly. These patients were kept together in special areas, which helped chart their progress. And the idea of adedicated area where critical patients receive focused attention was born. A year later, Ibsen set up what became the world’s first ‘ICU’ in anurse classroom in a municipal hospital in Copenhagen. An idea was born.

In its current form, an ICU is a special department in a hospital that provides close monitoring and treatment for severe illnesses. It is typically staffed by trained personnel who specialise in caring for critical patients. ICUs are also different from the other wards by a higher staff-topatient ratio and access to advanced resources and equipment.

The modern ICU is also characterised by intense drama and action. Beeps and alarms continuously going off, nurses scurrying to administer injections, patients receiving CPR. In Hindi movies, a patient in the ICU is always on oxygen and as the camera zooms in on the monitor where the graph is slowing down, the background music reaching a crescendo amidst gasps.

But an effective ICU is not about monitors, ventilators and high drama. It’s a place where specialised doctors, nurses, respiratory techs, physiotherapists, nutritionists, pharmacologists and counsellors join forces to help acritically-ill patient. Where evidence-based protocols are applied. Where triaging based on science and ethics is used to prioritise who needs to be inside and who should be transferred out. Where those with terminal illnesses are offered end-of-life care, including withdrawal of treatment. It’s also a place that respects sleep, quiet, pain, privacy and dignity.

Mumbai has hundreds of ICUs of different shapes and sizes. In nursing homes, it’s a small area, often a bedroom of a flat, where patients are hooked onto monitors and managed more by good intention. In large private hospitals, ICUs are central to their ability to deliver care as well as a major part of the revenue stream. They also help other services like cardiac surgery, transplantation and neurology to progress. Intensive care is now a speciality in postgraduate training. The creation of the identity of an ‘intensivist’ owning the ICU space has been key to its development. They are undoubtedly saving lives of critically-ill patients, which seemed impossible a few years ago.

But monetised care always comes with excesses. ICUs are places where astronomical bills seem to destroy entire families. Where the culture leads to compulsive testing and indiscriminate use of costly antibiotics. And where conflict of interest can lead to futile, costly care being continued indefinitely.

What about ICUs in public hospitals? It has largely been a story of individual initiative and good intention but poor vision. The policy in public hospitals to discourage doctors and nurses from specialising in critical care has not helped. Nurses have been reduced to mainly clerical work. These orphaned ICUs lack recognition, identity and incentives – two factors which encourage staff to put in the extra effort, needed in an ICU.

As Mumbai embarks on a pathbreaking experiment of amassive expansion of ICU facilities to deal with Covid, one needs to realise that it’s not just about monitors, ventilators, wonder drugs, good intention and even funds. It will need sensible triaging, effective protocols, good nurse to patient ratio and giving charge to trained doctors and nurses independent of pre-existing hierarchy. These are challenging areas difficult to fix quickly but the earlier we recognise their importance the faster we will move from optics to effective action. Time is running out.

► The writer is a surgeon who, when not wielding a scalpel, wields a pen