May 2022
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Critical care at the time of Covid
Critical care has received much importance with the Covid pandemic. Government and NGOs were trying to improve the critical care capacity to couteract the COVID pandemic.

Critical care had its begining during another epidemic caused by Polio virus in 1952.

Many patients who had respiratory paralysis were given assistance to breathe with a machine called iron lung from which the modern ventilators evolved.

Earlier days, doctors specilazed in the branch of anaesthesia were managing the patients who required some sort of ventilator assistance. Later on the department of critical care estabilished itself into a separate speciality, caring for the critically ill patients.

Doctors, nurses and other healthcare workers need special training to be eligible to work in ICUs. Critical care doctors are generally called Intensivists. In India , doctors need a three year training after MD to become qualified Intensivists. They are trained in monitoring the function of each organ and also in using life support equipment like ventilators, dialysis machine and so on . They are also trained in resuscitation of patients.
Here I am presenting some of the concerns one may have when their dear or near ones are cared in intensive care units.

1. What is the difference between various ICUs like cardiology ICU,neuro ICU, multidisciplinary ICU etc?
ICUs can be generally organ specific like cardiology, neurology etc which are managed by the respective speciality doctors or a multidisciplinary unit which are usually managed by an Intensivist.

When a patient is in ICU with a single organ problem they are admitted in the concerned ICU. But when they have multiple organ involvement ,they need care in a multidisciplinary unit. In such cases, the patient is admitted in MDICU under an Intensivist who coordinates the care along with other speciality inputs if required.

2 What are the facilities in a MDICU?
It depends on the level of care provided by the unit. In a tertiary care center all facilities for resuscitating a patient will be available. Monitors which can provide accurate minute to minute data of a patient's vital organ functions,pacemakers, ventilators, machines which can provide renal replcement therapy, methods to regulate temperature of a patient etc will also be available. Also the unit will be manned with staff who can manage critically ill patients; experinced nurses,paramedics are important.

3 Who are the staff available in a multidisciplinary unit?
The unit will be headed by an Intensivist. The team includes doctors nurses, nursing assistants, nutritionist, respiratory therapist, clinical pharmacist ,counsellors, infection control nurses etc. Inaddition the services of other specialities are taken as and when required.

4 Why is critical care incurring heavy bills to patients?
Unlike a general ward , the square feet /patient in ICU is more in a ward that can admit 18 to 20 pt ,if its an ICU only 10 patients can be admiited.The monitors ,ventilators are costly equipment and hence their usage charges are also high. Many of medicines used are high end antibiotics and drugs to mainatin organ function will add to the the cost. Lot of gloves aprons,disposable pads are required by each patient and all this together makes the cost of care comparatively high in MDICU.

2. Why is there visitor restriction in ICU?
ICU is a place where lot of activities happen round the clock. Presence of more people inside can hinder the work . Also,many patients are immuno compromised, which put them at risk of infection.
Also patient's privacy is also important. These are the reasons why there is a visitor restriction in ICUs.
But now a days so as to improve the satisfaction of patients and relatives
extended visiting hours are given in many hospitals.

3. Can a patient deny a treatment like ventilator or other special care if he/she is in ICU?

The right to make a decision to avail a treatment is with the patient. A doctor can advise a patient on the benefits and risks of treatment. Based on this the patient can take an informed consent. Patient also has the right to take a second opinion if he desires so. He can ask for a medical report for trhe same.

4. Is there any harm occuring to patients when they are in ICU
No. They are taken care of very well. A doctor is in charge of about 10 patients. As per standards each ventilated patient will have one nurse . Also for the general well being of a patient light is adjusted for each patient so as to resemble normal day and night variations. Also their mental well being also is taken care of. They can listen to music or TV if their health permits.

5. What were the facilities done when there was a COVID pandemic?
During covid surge we have increased the capacity of beds . More wards were converted into ICU's . Doctors from other departments were given training in ICU care and they were posted in the ICU under the supervision of ICU doctors. The same thing was done for nurses and other staff also.
Oxygen cylinders were procured to meet extra requirements. Inorder to preserve oxygen , stringent measures were taken to reduce .wastage

6. What are the chances of a patient to recover from COVID if admitted in ICU?
It depends on many factors. Only about 10 -15% of COVID patients require ICU admission.
Of those requiring ICU admission almost 60% will improve, but if their disease worsens and needs ventialtion then the chances of recovery may be approximately 30%.

7. What other treatment can be offered in COVID?

If a patient with COVID pnuemonia worsens inspite of a maximum support on ventilator, ECMO can be used . It is available only in few centers currently. ECMO has a success rate of 40 to 50% in COVID which is very significant considering the fact that they have high mortality without ECMO.

Critical care units have saved many lives during COVID pandemic and it is essential that we prepare ourselves for any forthcoming challenge by equipping our ICU units and also training adequate manpower.

Dr Deepak .V MD,EDIC
Deputy Director-Clinical Services & Co-ordinator Critical Care

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