ICUs in districts: Where are the experts?

More than two-thirds of all Covid-19 cases in Bangladesh were identified in June, indicating an escalation in transmission of the deadly novel coronavirus.

In these circumstances, treatment may seem the next plausible move to minimise the impact brought on by the pandemic.

Since 5 percent of Covid-19 patients suffer from life-threatening health conditions, the repeated pledges of the Director General of Health Services (DGHS) to set up intensive care units (ICUs) up to district-level hospitals might feel reassuring.

However, the DGHS has not yet determined what it means by intensive care, whom it will cater to and how the facilities will be made accessible. Experts say laying out all these details is a precondition for an expansion of intensive care facilities.

Against the backdrop of Covid-19, acute respiratory distress syndrome and ventilators have become buzzwords – the former means a condition in which patients feel their breathing tracks have choked up while the latter is a device used to help them breathe mechanically.

What is missing from the scene is that when life hangs in the balance, patients' vital organs – lungs, cardiovascular system and kidneys, for example – may fail. And intensive supervision by a team of specialised doctors, nurses and other staff are required to support the failing organs.

The ICUs are meant to provide that support rather than treating the disease.

Depending on the patients and the kind of care needed, ICUs have different names like Coronary Care Unit, Paediatric Intensive Care Unit and Neonatal Intensive Care Unit.

If all the differentiating lines are coalesced into only one facility – ICU – all patients, irrespective of age and health conditions, as those turn critical, become candidates for a bed in the facility.

Should patients with different complications compete for admission into the one or two-bed ICUs to be set up at the district hospitals?

If those are meant to cater only to Covid-19 patients, the standard of the care provided has to be based on the reality on the ground, said Prof Nezamuddin Ahmad, who worked as an intensive care specialist before moving to the palliative care department of Bangabandhu Sheikh Mujib Medical University (BSMMU) as its head.

He continued, "With the technological advancement in medical science, the concept of intensive care and its quality is always evolving, in which 'sky is the limit'.

"But when resources and manpower are in short supply, the authorities have to set the limit and contemplate how they will deploy them to benefit patients the most. If it is all about equipment, nothing will change with new ICUs in place."

Manpower shortage

Ideally, intensive or critical care specialists are the ones to lead the team of experts who work in coordination in treating patients at ICUs.

The country has 35 critical care medicine specialists. Of them, 30 are posted in Dhaka, with a majority of them hired by private hospitals, said Dr Debasish Kumar Saha, publication secretary of the Bangladesh Society for Critical Care Medicine.

Anaesthesiologists can fill the gap, as they have been entrusted with the job because of their knowledge of artificial ventilation. Their usual responsibility is to take care of patients' respiration before, during and after surgery.

About 2,500 anaesthesiologists are there, with half of them posted in Dhaka city alone, according to Dr Debabrata Banik, general secretary of the Bangladesh Society of Anaesthesiologists.

"Public hospitals already have an acute shortage of anesthesiologists. It is not possible to open ICUs with the existing manpower," he said, adding that if the government wants to do so, a good number of anesthesiologists must be recruited as part of the preparation.

At ICUs, the doctor to patient ratio and nurse to patient ratio are much higher than that in hospital wards because for each patient a tailor-made approach is deployed in terms of treatment management, diagnosis and medical interventions.

To illustrate this, the BSMMU can be an example. It has been preparing a 21-bed ICU for Covid-19 patients, and has listed 90 doctors who will be split in five teams to provide the services round the clock.

"Apart from them, doctors from other disciplines of the university will chip in, whenever necessary," said AKM Akhtaruzzaman, chairman of the intensive care medicine department at the BSMMU.

He suggested that the government should begin with setting up ICUs at 36 medical college hospitals because they have doctors of different specialisations.

All medical college hospitals across the country must adhere to the same standard of healthcare at ICUs so that patients from outside Dhaka do not have to rush to hospitals in the capital to get critical care.

"That will reduce cost, delay in treatment and the mortality rate," Akhtaruzzaman said.

To understand how challenging the job will be, The Business Standard talked to Dr Mohammad Bakir Hossain, director of Sher-e-Bangla Medical College (SBMC) Hospital in Barishal.

The hospital has an 18-bed ICU for Covid-19 patients and another 10-bed facility for non-Covid-19 patients. "There is no dedicated manpower. It is run by doctors and nurses from other departments. And some workers with no experience have been deployed to clean the ICUs."

A lack of manpower is the reason why some facilities remain unused even as the ICUs at the BSMMU or Dhaka Medical College Hospital are witness to long queues of patients.

Who should get an ICU bed?

To make the most of the healthcare system, the conditions to be met by patients should also be defined for admission into an ICU.

Otherwise, it always boils down to exercising one's power to lobby for a bed, and the practice often ends up losing both the patients – who got a bed and who did not, said several doctors working at ICUs in the capital, seeking anonymity.

Globally, doctors tend to weigh a patient's possibility of recovering against the risks if he gets the specialised care because the do-everything-possible attitude in many cases renders nothing but a painful "high technology death."

But patients should not be left to die when curative treatment does not hold any hope. The World Health Organisation advocates for the integration of palliative care with curative care to give relief to Covid-19 patients from pain and suffering.

ICUs need a referral system   

ICUs can function well when all other parts of the healthcare system work in sync with one another.

If it is at the peak of the pyramid of the system, the rest of the structure should play its due role with a referral system brought into effect. That again stresses the need for establishing a primary healthcare system at the bottom, on which the entire health system will stay firm.

In the absence of a referral system, patients move from one hospital to another and often get admission to an ICU when it is too late.

As coronavirus cases are feared to spike due to the failure of the preventive and control mechanism at the grassroots, the healthcare system will flounder. And 5 percent of the infected patients who need critical care may appear to be negligible statistics now, but will be rendered overwhelming with a surge in cases.