Not every patient needs a ventilator, life support machine

A patient in the intensive care unit for the coronavirus disease.

When the World Health Organisation declared Covid-19 a pandemic in mid-March 2020, intensive care units in Kenya started witnessing an influx of severely ill patients. Even though the virus was taking a toll on countries like China and Italy, there was still minimal knowledge about how the virus affected patients and the threat it posed to medics.

In the ensuing months, doctors got a better grasp of Covid-19 and an improved sense of intervention to use and how to conquer their fears of contracting coronavirus.

Wangari Siika, a critical care Specialist at Aga Khan University Hospital in Nairobi, recalls that “Covid came when there was very little evidence to support any interventions we had. We found ourselves in a very unusual place where lives were at stake and we had no firm evidence to stand on in terms of what to do and how to provide care.”

Prof Siika was, however, not scared when she was asked to handle the first Covid-19 patient in the ICU. Unlike before, local doctors did not have to wait for direction from Western experts during a medical emergency.

“The first time I entered a room of a patient who was confirmed to have Covid-19, I was not afraid, but I remember being highly aware that colleagues around the world in such situations have lost their lives and I didn’t take that lightly. I am glad I took that step. I was able to support my younger colleagues who were willing but anxious. I reassured them to put attention to how they put on their PPEs and take it off as it guarantees safety,” says Siika.

Unscathed

She never got sick, and has since tested negative for Covid-19, saying it is because of observing simple measures and religiously wearing masks, and avoiding gatherings.

The number of patients admitted to the ICU in Kenya has not been static. When the pandemic started the numbers were low, but rose steadily, then went low before peaking again during the second wave.

Covid-19 wreaks havoc on the lungs, leaving severely ill patients struggling to breathe. The spectrum of this has not changed, but the approach to treating critical patients has changed.

In critical care, oxygen is one of the important interventions for severely ill patients. But medics have since found out that not every patient is supposed to be put under a ventilator or a life support machine.

Siika recalls: “In the beginning, we were quick to intubate, largely for not having adequate information, and being anxious for waiting too long, and potentially losing a patient, and fears about our safety.”

Now the doctors are using non-invasive ventilation, a machine that helps in breathing, but a patient does not need a breathing tube. They now use machines that provide high flows of oxygen without traditionally ventilating someone. With this therapy, patients can get oxygen through the nose without a breathing tube.

Non-invasive therapy is preferred, as ventilators came with risks of infection and lung complications to patients, besides exposing healthcare workers to infected respiratory droplets.

The first surge of severely ill Covid-19 patients challenged many doctors, as there were no drugs against the virus. Even now, Siika says, “We are still looking for that magic bullet. There is still nothing that can be called a cure yet for Covid-19.”

“A lot of research is still going on in the country and across the world. We have been able to identify that at the end of the day it’s all about providing good basic healthcare and good attention to critical care,” she adds.

Proning

The act of proning (placing patients in respiratory distress on their stomach in intensive care) has also helped handle Covid-19 patients.

“When patients lie on their bellies, as long as they can tolerate, it continues to be of help and it’s encouraged,” explains Siika, who adds that in terms of medication, steroids to reduce inflammation in the lungs and dexamethasone, which helps in minimising the severity of the virus, remain the best routes.

But it is also worth noting that there are therapies that work for some patients and not for others, according to the medic. “Therefore the only way, as far as this virus is concerned, continues to be prevention and not cure,” Siika adds.

Having been a doctor for 24 years, Siika says losing patients is an occupational hazard that did not change during the pandemic. “Losing a patient is something you are prepared to handle from medical school, but it doesn’t make it easy. What we are told is you have to pick yourself up and move for the sake of the next patient.”