by Hal Newman<\/p>\n
I\u2019ve been looking at \tmedical surge as a series of ever-larger waves crashing ashore in that they \tcontinue picking up more and more debris and carrying that further inland \tuntil finally they begin to ebb.<\/p>\n
All the surge plans I\u2019ve \tseen are based on the notion that the emergency healthcare system will need \tto handle more and more patients until finally the peak flow is reached.<\/p>\n
There is a fair bit of \t\u2018resurrection medicine\u2019 built into these plans \u2013 the need to reach into \tdeath\u2019s door and pull the victims back into the land of the living.<\/p>\n
Shouldn’t we be looking at \tcreating critical care field triage levels that would prevent the surge \twaves from carrying patients requiring resurrection-medicine from reaching \tthe ERs? Isn’t it about time we took a hard look at plans that would include \tfield-based palliative care units?<\/p>\n
Any idea on the total \tnumber of mechanical ventilators and respiratory techs there are in any \tgiven major jurisdiction in the United States or Canada? Anyone have a \tbreakdown on that number per hospital \u2013 just the major centers?<\/p>\n
So now that we’re seeing a strong run on tickets for a \tpossible Kick Your Ass tour for A\/H1N1 in the fall, does anyone \thave any idea what we can anticipate in terms of both clinical attack and \tabsentee rates when it comes to the respiratory techs themselves? Has anyone \tgot any ideas about who to train and how to train them in Ventilation for \tthe Uninitiated?<\/p>\n
Does anyone have numbers for pediatric vents and resp \ttechs at pediatric centers? It seems that the vast majority of \thospitalizations in a more virulent return of H1N1 would be among children \tbelow the age of 15. Unless I’ve missed something, we just do not have the \tcollective pediatric resources to provide care on that scale.<\/p>\n
The estimates I’ve heard sure \tdon’t give me any peace of mind – and the fact that the actual numbers seem \tto be so closely guarded also gives me pause. Certainly don’t get the vibe \tthere are overwhelming numbers of either ventilators or the human beings \trequired to make them effective lifesaving tools.<\/p>\n
As my friend Roy says, “It has been nearly five years \tsince the discussion of vent shortages in the United States began with SARS \tas the stimulus. So, in five years the US has apparently done little to \tincrease the number of ventilators available for pandemic flu surge and \ttrain a much-enhanced healthcare cadre to manage ventilator systems in \tcompromised patients.”<\/p>\n
The problem is, as Roy so aptly quips, “Vents are not \tparticularly sexy or worthy of discussion in a healthcare system barely able \tto manage a bad season of colds and flu.”<\/p>\n
My educated guess would be that roughly 85 percent of \tthe available mechanical ventilators in Montreal hospitals are currently in \tuse. Combine that with an average ER occupancy rate in the 90-something \tpercent range and we’re not talking surge – we’re talking about a damned \tnear bankruptcy of the emergency healthcare system.<\/p>\n
Roy’s educated guess is that the same percentage of \tcurrent daily use holds true for the 100,000 or so ventilators available \tacross the United States at any given moment.<\/p>\n
“Disaster preparedness typically \tincludes plans that address the need for surge capacity to manage \tmass-casualty events. A major concern of disaster preparedness in \trespiratory therapy focuses on responding to a sudden increase in the volume \tof patients who require mechanical ventilation.” – Mechanical ventilation in \tmass casualty scenarios. Augmenting staff: project XTREME, Hanley ME, Bogdan \tGM. 1: Respir Care. 2008 Feb;53(2):176-88; discussion 189<\/p>\n
While I recognize the wonderful \twork done by major trauma centers that kick themselves into overdrive to \tdeal with 20-30 seriously injured patients from a single incident, I believe \tit’s time to take a real-world look at what happens when there are 100 or \t200 or 300 or maybe 1,000 people who are sick or injured?<\/p>\n
Or when there are tens of thousands of people concerned \tabout their children who are presenting with the signs and symptoms of \tpandemic flu.<\/p>\n
And perhaps it’s not a one-time \tevent.<\/p>\n
I live in Montreal where the EMS \tsystem runs on a Basic Life Support platform and where firefighter-first \tresponders have been limited to a SSU [sticky side down] approach when it \tcomes to providing care for patients prior to an ambulance crew’s arrival.<\/p>\n
The idea that somehow the \tcombined Fire\/EMS system would be able to successfully triage, then \ttransport more than 100 critically ill patients from a single incident \twithout completely outstripping available resources is pretty well pure \tscience fiction.<\/p>\n
The EMS system is constantly \tshort of ambulances and crews. There are a finite number of firefighter \tfirst responders. And that’s when the going is relatively good. Throw in an \ticy night and a few multi-patient car crashes and maybe simultaneous \tmulti-alarm fires [definitely not unheard of in a major metropolitan area].<\/p>\n
And we don’t need to be talking \tpandemics or terrorism. We could be talking about an ethyl-methyl-bad-stuff \tincident at one of the multiple chemical facilities that are smack dab in \tthe middle of a heavily populated center. All that’s required to tip the \tbalance between feasible and outright chaos is a higher percentage of \tcritically ill patients.<\/p>\n
If the walking wounded aren’t – \tthen we’ve got a serious problem on our hands. It’s not as if we’re going to \ttell the populace to get a pick-up truck and an air mattress and take their \tneighbors to the ER on their own. One major incident doesn’t come with \tpermission to suspend operations for the rest of the population. Just \tstanding with Serge and talking with Roy watching the waves crash on Tundra Beach.<\/p>\n
Be well. Practice big medicine.<\/p>\n","protected":false},"excerpt":{"rendered":"
by Hal Newman I\u2019ve been looking at medical surge as a series of ever-larger waves crashing ashore in that they continue picking up more and more debris and carrying that further inland until finally they begin to ebb. All the surge plans I\u2019ve seen are based on the notion that the emergency healthcare system will […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":[],"categories":[5],"tags":[29,6,27,7,30,28],"_links":{"self":[{"href":"http:\/\/bigmedicine.ca\/wordpress\/wp-json\/wp\/v2\/posts\/55"}],"collection":[{"href":"http:\/\/bigmedicine.ca\/wordpress\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"http:\/\/bigmedicine.ca\/wordpress\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"http:\/\/bigmedicine.ca\/wordpress\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"http:\/\/bigmedicine.ca\/wordpress\/wp-json\/wp\/v2\/comments?post=55"}],"version-history":[{"count":2,"href":"http:\/\/bigmedicine.ca\/wordpress\/wp-json\/wp\/v2\/posts\/55\/revisions"}],"predecessor-version":[{"id":149,"href":"http:\/\/bigmedicine.ca\/wordpress\/wp-json\/wp\/v2\/posts\/55\/revisions\/149"}],"wp:attachment":[{"href":"http:\/\/bigmedicine.ca\/wordpress\/wp-json\/wp\/v2\/media?parent=55"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"http:\/\/bigmedicine.ca\/wordpress\/wp-json\/wp\/v2\/categories?post=55"},{"taxonomy":"post_tag","embeddable":true,"href":"http:\/\/bigmedicine.ca\/wordpress\/wp-json\/wp\/v2\/tags?post=55"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}