Steering on ICU capacity
The aim of the lockdown was to stay within the ICU capacity and that was a success. The IC staff have had to work their way around three times and are still doing so. It was reported on the radio that they even work 200% shifts - that may have been proverbial, but it gives an impression. And they are not alone. We all stand behind them in solidarity: other patients are pushed back, departments are cleared, companies go under, unemployment rises, billions evaporate so that the ICU can do its work. They work very hard and it must be all the more frustrating to see that so many of their patients do not make it.
Vanuit de zorgverlenend perpectief is dit niet meer dan logisch. Immers de IC is -naast andere dingen- ook een laatste redmiddel als verder niets helpt en een patiënt heeft het gevoel dat hij niet meer kan ademen. Ook als hij dat wel kan maar zijn longen halen geen zuurstof meer uit de lucht, is een arts het aan zijn taak en zijn stand verplicht om bij elke patiënt het onderste uit de kan te halen.
Zelfs in bijna uitzichtloze situaties moet een arts kunnen volhouden, tot kansloze behandelingen in de IC aan toe. Dat is bewonderenswaardig en tegelijkertijd zou je artsen tegen zichzelf moeten beschermen. Ze zouden ongetwijfeld meer kunnen betekenen voor meer patiënten.
For a few weeks now, we have been seeing more or less what that overcrowded ICU has meant so far. Thanks to the ICU, the mortality rate from corona has been reduced by one-tenth of a percent: 0.1%. That means: 1 in 1000 corona-infected people has been saved by the ICU. The RIVM does not have exact figures - we are used to that by now - but according to them it is something like 1.4% instead of 1.5% mortality among corona patients, around and near. Or 1.1% instead of 1.2%. So that is an effect. Can we also look at how that effect relates to the efforts? It's almost sacrilege, but I'll take the risk anyway.
The success rate of ICU treatment in numbers
The mortality rate of corona patients in the ICU is sometimes estimated at 20%. Unfortunately, for corona patients, this fluctuates between 65%-70%. So the survival rate is about 1 in 3.
In Italy, the results were even worse. There they also admitted patients with no chance than in the Netherlands. The horror images we have seen could have been prevented if an age limit (and/or later: a BMI limit) had been used. If Italy had used stricter guidelines, promising patients who have now died in the corridor would still have had a chance. In Italy it was more of a glorified hospice. They didn't have the capacity for that.
The Netherlands, April 22
[28-4: numbers are higher, key point still valid]
In de afgelopen 6 weken zijn er 2680 IC-patiënten opgenomen [28-4: 2773]. Daarvan lagen er op 22 april nog 965 op de IC [28-4: 788]. Van de overige 1715 ex-IC-patiënten [28-4: 1985] zijn er 572 [28-4: 625] levend* van de IC afgekomen (inderdaad: 33%). De gegevens komen van de Stichting Nederlandse Intensive Care Evaluatie. Hoeveel van deze patiënten later alsnog overlijdt is niet bekend.
The blue line indicates that fewer people leave the hospital alive than come out of the ICU alive. But the delay also plays a role here and we also do not know how long ICU patients stay in hospital on average. So because of (again) the incompleteness of the data, we leave this out of consideration.
Source (dated 22 April):National Intensive Care Evaluation
There are about 550,000 people infected with the virus.(source dated April 16:Sanquin Hotels)Hence, the 572 ICU patients rescued represent 0.1% of mortality among infected people. The assumption is that the ICU survivors would not have made it without ICU, so that, for example, (home) treatment with medication and oxygen would not have helped.
I will leave aside the possibility that the ventilator has worsened the condition of many patients. There are indications of that, but that is all there is to it at the moment.
Conclusion
As a non-physician and non-economist, I would like to hear that the treatment contributes to public health and is affordable in accordance with the current standards or perhaps 2x the current standards. My main reason for writing this piece is that considerations such as these seem to be ignored.
This relativization may read like a direct attack on everything that has to do with IC. This is emphatically not the intention. What is intended: the policy focus on the ICU and what is thrown into the fight for it requires an ongoing evaluation of our targets, our performance and the ROI in terms of public health and well-being. I have not yet seen any trace of an evaluation.
Money is not just 'money'. It also stands for culture and care.
Dan ook nog even een financiële overdenking: de miljarden die nu worden geïnvesteerd zullen later vooral ten koste gaan van de collectieve voorzieningen zoals cultuur en gezondheidszorg. Gezondheidszorg is daarvan misschien wel de belangrijkste (zeg ik als muziekmaker).Tekorten in de zorgbudgetten zullen ten koste gaan van de volksgezondheid. Ik heb zelf niet de expertise om te berekenen hoe elk miljard minder zich vertaalt in ziekte en sterfte. 'Poverty kills', dat wijzen de cijfers wel uit, maar meer weet ik niet. Het scenario waarin de gezondheidszorg zelf aan de beademing moet is echter niet zo moeilijk voor te stellen.
So I would like to see the discussion about when are we going to make tough decisions, now or in the future when the money runs out? At the moment we still have options, but then, after the crisis, we are faced with a fait accompli that may cost many more lives than we have saved. Then we have 'We regret afterwards what we have now failed to do', to quote Rutte.
*Living in the ICU: A minority of survivors are back on their feet after a few months. The majority are not in good shape with permanent lung damage and/or psychological trauma. No one is surprised by a two-year rehabilitation. Not all ex-ICU patients can then resume their former lives.
