06 December 2020

Treating COVID-19 patients in the ICU: A doctor's point of view

 A few days ago I posted this tweet:

In reply to that, I was contacted privately by “Dominique” (not their real name), a Twitter user whose profile says that they are an intensive care doctor in a country that has been quite badly affected by COVID-19. I have no reason to doubt that claim—indeed, it’s the entire basis of this post—but I haven’t attempted to formally verify it. I hope that regular readers of this blog will trust my judgment on this point; “false flag” theorists are invited to look away now.

Dominique’s initial contact was in response to my tweet, to discuss possible reasons why Germany’s numbers do not seem to be following the same pattern as other countries. But the conversation developed into a much wider-ranging discussion of the treatment of COVID-19 patients in the ICU. I found this fascinating, and thought it might be of interest (and perhaps even of professional use) to other people. So, with Dominique’s permission, I am converting this exchange of messages into a sort of interview, paraphrasing their responses a little and arranging them for context under “questions” that are intended to function as headings (they may not correspond to actual prompts that I gave during the exchange).

Dominique has read this post and approved it as a description of their thoughts. Everything here is written from Dominique’s point of view, unless it starts with “Nick:”.

Nick: Looking at my tweet, why do you think that Germany’s lag between cases and deaths seems to be so large?

One possible cause for the lag is that they wait for longer until withdrawing support. Waiting is somewhat futile in some cases, but we tend to wait longer if demand for ICU beds is not especially intense. That might not explain why the lag is so long, but it is a trend that we’ve noticed. But there might be other causes we don’t know about.

It could also be that German patients are more aggressively treated in general (the German system has plenty of resources), which could make it more likely that the elderly last longer, because they’re more likely to receive invasive organ support. On the other hand, maybe Germany has middle-aged patients attached to machines for a long time. We also wait longer in the younger patients, although it is futile in some cases.

Nick: I’ve also been wondering why Germany’s death rate is (or has been) so much lower than almost all its neighbours. This Wikipedia page suggests that Germany has 3-4 times more ICU beds than many comparable countries. Could that be a factor?

Germany did well from the beginning. I have the feeling that it has consistently shown the most robust response in Europe. They allocated resources according to the size of the problem. For example, they realized— which is not obvious to most physicians who don’t work in ICU—that proning patients [[i.e., lying them on their fronts in an induced coma]] clearly signals a likely stay of more than three weeks, which potentially leads to shortages of ICU beds. Apart from COVID cases, most people typically leave ICU much more quickly, one way or another

No other country reacted like this as quickly. Also, existing public health and hospital plans were typically designed for a bad flu epidemic, which requires different treatment patterns. The virus was quickly understood from an epidemiological point of view, but to design containment measures they needed to also understand the clinical aspects of the disease, which are what determine exactly what stresses it places on the healthcare system. It seems that Germany has understood this.

Nick: What are the conditions under which you stop treatment in the ICU?

There comes a point after which there will be no tissue function improvement, but we have to wait until the inflammation is over to determine that. It’s a bit like when Notre-Dame cathedral caught fire; they had to wait for it to stop burning to be able to evaluate whether what was left was enough to rebuild on. If what’s left in a patient is not enough to support life outside of the mechanical ventilation setup, one of us will mention this in the morning round and then we make a group assessment with several doctors involved; this might be “let’s wait a few more days”. Such decisions are not evaluated by a single person: there’s a stable group of physicians that receive the relevant information and coordinate such decisions for ICU patients. 

The process of actually switching off support after a provisional assessment to do so has been made can take a few days more, maybe even a week or two if we are waiting for other processes that might be ongoing (such as a bacterial sepsis or gut ischemia) to have an outcome, which gives us time to prepare the family for what might happen. In fact many deaths are “semi-programmed”, a result of withdrawal of treatment due to ethical reasons (for example, via Do Not Resuscitate notices); the ICU doctors don’t necessarily walk solemnly over to the machine and switch it off at a particular time. But today, for example, I have a withdrawal of invasive support in a (non-COVID) patient for whom the decision was made 36 hours ago, so I will be present for that one. They will be discharged from the ICU and put on palliative care.

End of life in ICU hasn’t been a particularly pressing issue in our region. Maybe in XXX (a region of the country with three times as many cases) they could give you some examples of ethical dilemmas with COVID. Fortunately we have been able to manage them like any other ARDS [[see below]].

Nick: People from Sweden have told me that (also before COVID) almost nobody in that country gets admitted to ICU, as it’s considered unethical. I suppose it’s a coincidence that it’s also cheaper for the system.

Maybe they offered only basic or intermediate care to the elderly. And the healthier among the elderly will generally survive for three weeks even if the final outcome is death.

It’s sensible to be parsimonious with ICU care. We should probably reinforce intermediate-level care instead, which is a lot less resource-intensive and probably equally effective for many COVID cases. As it is, we are often operating at the limits of ethicality. There are too many decisions to take in a day to get everything right.

Something worth noting is that patients of all ages who die in the ICU share similarities in their disease progression. The older ones are somewhat more numerous, but otherwise their treatment, and the withdrawal of that treatment if it happens, is actually very similar to that of younger people. In fact we have very few patients over 75. So the idea that elderly people can somehow be blamed for taking up ICU capacity is rather unfair. An older person who gets infected is more likely to need the ICU than a younger one, but once they are there, they take up a similar amount of resources.

Another unusual thing with COVID ICU patients is that if they are going to improve, this often doesn’t happen until the third week. Before that their signs tend to oscillate randomly up and down. So we sometimes don’t know how the patient will do until the third week from the onset of severe symptoms, when acute inflammation declines noticeably.

Nick: Can you say something about the effects that all this has on your own mental wellbeing?

Part of the stress of COVID for healthcare workers, apart from the heavy workload, is the mental toll of not seeing what’s ahead in the mist any better than our patients can. It makes you feel like you are a passenger in the car, rather than the driver at the bedside. But once we recognised this pattern and came to accept it, it was easier mentally.

We were also lucky due to our region of the country having a relatively low level of the disease in the first wave. But because of the lockdown at that time, a lot of surgery was cancelled. So we spent part of that time doing planning and logistics, setting up decontamination routes, and customising our PPE. The sense of control that we got from that was good for dealing with our stress.

In the bad times we worked double shifts apart from the 24-hour ones, so there was one more of us on duty. It means we all worked more hours, but it took less of a mental toll, and it only lasted for a few weeks. Today we are over the worst of the second wave. We maintained a sense of control, and remained united like a small army, which really helped. It was also really great when people sent in gifts, especially PPE. I can’t imagine how hard it must have been in XXX.

Nick: What makes a case unrecoverable?

In this sense, COVID cases are easy to call. We sometimes have ethical cases in other pathologies for which we need to work with the support or advice of the medical ethics committee, but for COVID it’s quite clear-cut. After a month or so, there’s not going to be a major change in inflammation or further improvement to any tissue damage. So we test to see if the patient can live with that. The ones that can’t live quickly gasp and start to drown when you try to remove mechanical ventilation support. This relative uniformity in disease course, due to organ damage, can be seen from the fact that mortality waves lag weeks after the admission waves. Admission waves signal the onset of organ damage with loss of function.

There’s no way to escape permanent lung damage. Lungs will never heal in a way that recovers their previous function, and we don’t have the equivalent of a dialysis machine for them. People who manage to get out of ICU despite severe lung damage have a couple of likely outcomes, namely secondary right ventricular (heart) failure and tertiary liver dysfunction. It’s also unethical in any country to keep someone alive if that requires them to be sedated and connected to a machine. That’s worse than death. So the decision is straightforward.

Lung transplants are generally not an option. Only the best cases will be offered a transplant. Almost certainly nobody over 70, and probably not someone younger if they have other health issues. When a patients’ lungs (or heart, or kidneys...) fail, their relatives always ask “Maybe they can get a transplant?”, and we always give the same response: not unless they can survive without critical support. If they can’t make it to that stage, there’s no point. If a patient is not yet stable without invasive support then trying to transplant an organ is probably just a very nasty and expensive way to kill them. The patient would almost certainly experience multi-organ failure due to the extreme stress of transplant surgery, and we would have used a donor organ that could have saved another life. This is so obviously unethical that there are no dissenting opinions that we’re aware of. But I think transplant ethics might be worthy of some review. Transplant teams have been very stringent on some of these criteria, but probably for a good reason.

We only had an ethical issue in one patient when we tried to get her into transplant. We couldn’t, because she was too old, but we thought she deserved it. She made it out of ICU out of pure strength and effort. Maybe she could have had an opportunity, but now she will just have a couple of difficult years before her heart fails. Her kidneys and liver will follow. We hope that her case will be reviewed soon.

It’s a little like doing triage after a bad traffic accident. People with very extreme injuries are left to die if there are only limited resources available at the roadside and people with lesser injuries need those. That’s just how it is: Very severe patients are lower in the priority order sometimes.

But of course, our problems over a critical patient transplant seem trivial when the negligence of governments has caused thousands to die...

Nick: Can you say a bit more about ARDS (Acute Respiratory Distress Syndrome)?

ARDS is a symptom of many diseases, including COVID, but blood and plasma transfusions can cause ARDS as well, for example. Even giving people oxygen can cause a mild form of ARDS. The ARDS that we see in COVID and other SARS-type diseases has some specific features, but the lung management of all ARDS is more or less the same.

Of course we also have to treat the underlying condition that caused ARDS. For example, when we give corticoids to COVID patients, that’s aimed at treating the underlying infection. We don’t hope to improve ARDS directly with corticoids; several studies have reported that steroids are not consistently effective in ARDS. Corticoid treatment might prevent ARDS from getting worse, but we don’t know if it really improves the ARDS that has already been “programmed” by the course of COVID up to that point.

COVID ARDS is like a jail sentence, in that it requires the patient to go through the three week process described earlier. ARDS is much rarer in flu, and when it occurs it has much wider variation in the time spent in the ICU.