On March 26, 2020 the L.A. Times ran a story about the lack of ventilators available to treat acute cases of the COVID-19 virus.
“It’s a choice most doctors never thought they would have to make: Who lives and who dies.
But in coming weeks, if COVID-19 continues to surge, such decisions will be inevitable.
The coronavirus will attack so many people’s lungs that thousands could show up at hospitals gasping for air and will need to be hooked up to machines that breathe for them. But there won’t be enough ventilators for everyone, forcing doctors to make impossible calls about which lives to save.” is what the article said.
It went on to decry that there will be doctors who will have to decide, based on lack of equipment, whether to “save” an 80 year old grandpa or a 20 year old both of whom are in sever respiratory distress.
There are a few problems with the L.A. Times story.
First off, up to this point, the vast majority of those who are severely stricken with COVID-19 are in the senior age range, (60 and above). The cohort of 20 year olds who exhibit any symptoms at all are, so far, infinitesimal. So, the Times article is setting up a “straw man” false choice.
Secondly, during his press briefing on Saturday, April 4, 2020, president Trump was asked about the shortage of ventilators complained about by New York governor Cuomo. His response was that perhaps the better question for examination is what can be done to prevent the need for the ventilators since no one would be comfortable with the answer. None of the media people asked the obvious follow up question, why would they not be comfortable?
Here is the terrible, horrible truth.
COVID-19 in older adults and seriously ill persons mostly kills by respiratory failure, progressing over a few hours or days from a sensation of breathlessness to a losing struggle to breathe. Only a minority of elderly persons who are put on ventilators survive to leave the hospital, and most have become more disabled from being very sick and mostly immobile. Older adults already living with eventually fatal illnesses and their families might make decisions to avoid all this and accept that a serious case of COVID-19 is likely the end of their lives.
Ventilators are no panacea for coronavirus patients. Research shows that most patients placed on the breathing machines still die, (upwards of 80%) — and ventilators themselves can cause fatal infections.
Patients end up on a ventilator when their lungs can no longer deliver enough oxygen to keep the body going. It’s an extreme measure. Patients are given sedation so that they go to sleep and then the doctors provide a paralytic that stops their breathing.
Next, they insert a long plastic tube through the trachea and vocal cords that allows a machine to deliver puffs of highly oxygenated air to the lungs. (This is done by cutting a hole in the neck called a tracheotomy).
The ventilator itself can do damage to the lung tissue based on how much pressure is required to help oxygen get processed by the lungs. Coronavirus patients often need dangerously high levels of both pressure and oxygen because their lungs have so much inflammation. Also, ventilators create a path for a wide range of infections to reach the lungs.
These are unpleasant facts but they must be faced.
Every one of us at high risk because of age or illness should be setting goals and making decisions about the desirability of hospitalization and ventilator support—yet no one is talking about making and using COVID-19 advance care plans.
Having the opportunity to make decisions ahead of becoming ill with COVID-19 is especially important for those who decide not to take the conventional pattern of going to the hospital and/or being put on a ventilator. These discussions are difficult.
We need to be having these discussions and decisions now.