Friday 16 June 2023

A finger on the scale

ICUs are only found in a minority of hospitals because they are heavy on equipment, energy and personnel. Economies of scale require this: an ICU with one active bed is inefficient and wasteful so the expertise should be consolidated into larger units spaced further apart. 

In 2020, Coronarama caught the Irish HSE with their pants down having one of the lowest rates of ICU beds per capita in Europe [R]. The end of the year saw a decision to increase ICU beds by 75% from 255 to 446. That will bring us into line with France and Czecho rather than lock-step with UK and Slovenia. Those number indicate that ICU beds is a political / policy decision rather than a GDP necessity. Having a low number of ICU beds is not necessarily a bad thing. It means that the finite resources of the health service is sliced differently: fewer dramatic interventions with oxygen, dialysis and intubation but maybe more boring old pelvic floor surgery, mental health services for youngsters and prophylactic lifestyle, diet and exercise education. 

It is almost certainly foolish to formulate ICU policy reactively during the biggest healthcare crisis for 100 years. It's very expensive if you have to mothball all that kit and re-allocate the trained staff when the pandemic ebbs away. Ireland has a poor record in allowing [local] political expediency over-rule utilitarian number crunching: closing of Roscommon A&E we're looking at you and your self-interested TDs.

Jim Down is an intensivist = ICU consultant at UCH in central London. Like many/most ICU mavens he trained as an anaesthetist. Those are the doctors who keep you alive while the surgeon hacks away on the other side of the table. Switching to ICU gives more autonomy and a wider experience - and maybe more I averted death. Surgeons do tend to suck all the I-am-god oxygen in the room. Dr Down has written a book! Life in the Balance: a doctor's stories of intensive care [2023] which is less anecdotal and more polemical than the title implies. After a few weeks waiting I got a copy from the Library. Having a page-turner is a welcome change of medium from all the ear-books.

It is clear from this book that Jim Down prefers to welcome sick people to his ICU - so long as there's a bed, he'll mobilise his team to give it a go. He does express surprise (and some misgiving) that he has that power to give it a go independent of the bean counters elsewhere in the hospital and the NHS. A medication costing £1,500 a day [like Brineura or Orkambi] would attract a lot of skeptical scrutiny from the accountants and the medics in charge would have to make a QALY argument for their patient. One problem is that having opened the bed, they are stuck with that patient until discharge - to step-down ward or the morgue. If a young father of three appears all banged up from a car crash an hour later then the bed is gone.

Making the metaphor literal at Mad magazine.

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