Wednesday 29 April 2020

Intubation, nope

Intubation is an invasive procedure to keep the lungs going in and out and to try to force some oxygen across the membrane of the alveolae and into the blood. One 2008 study at the Deaconess Hospital in Boston found that intubation was a rare procedure in their Emergency Department: 163 cases from 50,000 ED cases in a calendar year. I guess they are reluctant to try because the failure rate is high: 30% of non-trauma patients died anyway as did 16% of trauma [car-crashes I'm guessing for many of them: 5/6 of the traumatic dead had a brain bleed] cases. The non-trauma cases were about 10 years older than the others, and that may also be relevant to their lower survival rate. In Wuhan, "The most recent report showed that, among the 22 ICU patients who were intubated, 19 (86%) of them died" [source]. Another early report [cited here] had an even higher intubation=futile rate.

Intubation is hard to do well at the best of times. It is a taxing technique to learn because only one pair of eyes can see what's happening at a time. Consultant anaesthetists are great at doing it but can get impatient as junior doctors poke about in the pink mush at the back of the mouth trying to find the vocal chords [pic R]. These are are a whiter shade of pink, because there's a lot of connective tissue in their structure, and they are the gateway to successful intubation. One problem is that there are two tubes - trachea & oesophagus - going away into the dark and nobody is helped by inflating the stomach. It's hard enough if there is no great hurry, but if it's an emergency, the intubatee is very sick and needing help now, then successful intubation can involve a brutal assault on the mucous membrane - not for nothing called soft tissue. Damage is likely to precipitate inflammation which will involve heat, pain, swelling and redness. Cripes, if you're sick already, that sort of thing will finish you off.

Your resilience to all these assaults is inversely proportional to your age. I'm 65 and I know this already. I cannot, with impunity yomp up the hill and run down again without feeling it in my bones either at the time (jaysus, man, stop doing that a knee or ankle will holler) or the following morning. All those finely tuned physiological systems just get less good at their jobs; less responsive to change. Pat the Salt my aged father-in-law was pushing a mower up and down his lawn until he was 85 but he's much less determined in his perambulations 10 years later.

Intubations are significantly associated with Ventilator-associated pneumonia (VAP) where a wide variety of microbes [Streptococcus pneumoniae, Haemophilus influenzae and methicillin sensitive Staphylococcus aureus (MSSA);  methicillin resistant Staphylococcus aureus (MRSA), Pseudomonas aeruginosa, Escherichia coli, Klebsiella pneumoniae, and Acinetobacter baumannii] exploit the damage and impaired immune system to give you "fever and purulent tracheal secretions" eeeuw! There are a variety of solutions to minimise these nosocomial infections.

If you catch a dose of Covid-19 and you get sick, you'll find your self bundled off to hospital where all sorts of active interventions are possible. Once you get to hospital, all bets are off w.r.t. your agency and that of your nearest and dearest. Corona virus is so infectious that the hospital staff won't want anxious untrained ignorant relatives getting in the way. If you're sick enough to indicate a session in ICU, then you won't be well enough to object or argue the point about whether to get extra oxygen for your failing respiratory system by mask or by endotracheal tube. If the ICU is "overwhelmed" and serviced by frazzled sleep-deprived shorthanded uncaped heroes I doubt if they'll be phoning the rellies to ask their opinion on the options.

Apparently <shock> some hospitals in Italy were having to make decisions about who would get the ventilator because there weren't enough to go round. Heck, there weren't even enough beds in the ICU. I'm not going to make the ethical call -- and for sure YMMV -- because they don't pay me the big bucks for the realpolitik of health-care provision. But I'm telling my grown-up children to add endotracheal intubation to the list of interventions which I want them to refuse on my behalf.
There are worse things than dying.

1 comment:

  1. No intubation for me either please! Gack gack, could only skim this one.