India needs ICUs, not just ventilators

Dr Harinder K Bali & Dr Priyanka Goyal

As India battles Covid-19, a number of serious fault lines have been exposed in our public health system. We seem to have done reasonably well in limiting the spread of the disease till now. This has been possible despite and not because of our public healthcare system.

The real challenge will arise when there is a progressive easing of the lockdown. In the absence of widespread testing, we have no idea about the extent of the spread of the disease in the community. Are we just seeing the tip of the iceberg? We also have started to believe that a majority of our citizens are immune to serious consequences of the disease. The widespread use of hydroxychloroquine to the national policy of uniform BCG vaccination have all been offered as possible explanations for this hypothesis.

Worldwide, there has been lot of talk about ventilators. This is because lungs are the predominant organs that are affected by this disease and ventilators are used to provide temporary support to patients who are unable to get enough oxygen for their body on their own. A feeling seems to have taken root that if we have enough ventilators, we can save more lives.

Ventilators are certainly one of the most essential components for management of these critically sick patients, but certainly not the only components. What we need are fully equipped and optimally managed intensive care units (ICUs). We need:

Manpower

a) Enough trained intensivists to manage these ICUs

b) Specially trained nurses to handle critically sick patients

c) Medical officers trained to evaluate patients and carry out instructions under the supervision of intensivists

d) Respiratory therapists/ physiotherapists

e) GDAs to assist medical officers and nurses

f) Biomedical engineers to regularly check the medical equipment, identify trouble shooting.

g) Sterilisation department

Equipment

a) Ventilators, obviously the most important part

b) All patients with critical diseases need to have monitors

c) Minimum of three to four infusion pumps would be required per patient

d) Portable dialysis machine

With a few exceptions (Kerala, Himachal Pradesh and J&K), most states have a completely dysfunctional public healthcare system. Most hospitals have no ICUs. There is no infrastructure, no qualified manpower and no equipment. Either there is no equipment or whatever is present is lying defunct for want of maintenance and qualified manpower.

It is ironic that even small nursing homes have 6-10 bed functional ICUs in the private sector. The present pandemic has completely exposed the inadequacies of our public healthcare system. It is a huge opportunity to get it back on track.

The government has already placed an order for around 50,000 ventilators. We also need to have all other equipment that is essential to run these ICUs. More important, we need to rapidly train manpower required to manage these units. If we start now, it will take nine months to a year to have these ICUs in an optimally functional state.

Till more trained intensivists become available, we should have aggressive short-term training for physicians and anaesthetists. We can also utilise the services of second and third-year DNB students to tide over the acute manpower shortage.

We must not lose this opportunity to reboot our dysfunctional public healthcare system. India needs more fully equipped and properly manned ICUs in each and every sub-district.

Dr Bali is a leading cardiologist and Dr Goyal a cardiac anaesthetist