For the first time since the onset of the pandemic in Israel, seriously ill patients were unable to receive life-saving treatment due to hospital overload. No hospital space was found over the weekend for two patients that needed to be hooked up to a life-saving ECMO oxygenation machine which supports cardiac and pulmonary function.
For those who need it, survival chances are slim without such treatment.
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In recent days, the pressure on intensive care units has increased due to a spike in numbers of gravely ill patients. The patients, aged 65 and 66, were connected to a respirator at hospitals in the north of the country, but they require an ECMO machine, which for some seriously-ill patients is their only chance of surviving.
Dr. Yigal Kassif who heads the ECMO services at Sheba Hospital, and also heads the Israel ECMO Society (a professional union of the Medical Association), told Haaretz that a patient connected to such a machine has a 50 percent chance of surviving.
He added that a patient on a respirator, not necessarily a patient with COVID-19, who also needs an ECMO machine, has an 80-90 percent chance of dying without the ECMO machine.
He said that there are no statistics yet on COVID-19 patients in such circumstances. Kassif said the current wave is the most serious so far in terms of ECMO machine use for COVID-19 patients.
In the first wave, through May 19 patients were hooked up to these machines. During the second wave, from July to November, 96 patients used them, about 20 patients a month.
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Twenty more were hooked up in December. In the first six days of January, an additional eight patients required these machines.
This is the highest rate since the onset of the crisis, with 27 people hooked up to an ECMO at this time, 20 of whom are COVID-19 patients.
Dr. Yaron Bar-Lavie, head of intensive care at Rambam Hospital in Haif and head of the Israel Society of Critical Care Medicine said:
“There are currently 18 COVID-19 patients on respirators in Rambam, with three others on ECMO machines. We’re at the limit of the number of patients requiring these machines that we can take in. It’s much more extreme than in the earlier waves.”
“There is no vacant bed with an ECMO machine in the whole country,” said Kassif. An ECMO bed requires staff that are trained to provide the treatment, often the same staff needed to reat other seriously ill patients on respirators – there isn’t enough staff to treat everyone.
“There aren’t enough people to operate these machines, even though the number of machines is adequate, growing from 35 to 76 during the epidemic,” he said.
“In fact, beginning over the last weekend, for the first time in Israel we’ve needed to do triage regarding hooking patients up to ECMO machines,” says Kassif.
“If there’s an emergency, with a 30-year-old collapsing in intensive care, he’ll be attached to a machine and staff will be recruited to save him, but generally, we cannot operate additional ECMO beds at this point.”
Kassif said the heads of intensive care units at several hospitals, and Health Ministry officials were personally involved in seeking treatment for the patients for whom no ECMO was available, but were unable to find a solution.
“We spent hours with the ministry trying to find a place. The reason there is no space is the lack of nursing staff. There are beds and machines, but there is no space for these patients, since these machines are heavy users of staff power,” he said.
The standard for the number of nurses in intensive care units is one nurse for two patients. In case of patients on respirators, the ratio is one per patient, and even more so with ECMO machines. “These machines require more staff and a lot of extra care.
An operator of a heart-lung machine is needed in addition to a designated nurse. Each change in posture or washing a patient is much more complicated and requires the presence of a doctor, a nurse and a machine operator.
During the pandemic, because of the protection needed, two nurses are needed for each patient attached to an ECMO machine,” Kassif said.
Training medical staff to use the machines is not complicated but requires several days of time in addition to a few days of overlap with experienced staff. Kassif said that since the pandemic began there have been 24 courses held for more than 400 medical staff.
The problem is that in tandem with the rising need for ECMO machines there is a rise in the number of seriously ill patients in intensive care units, and there is no enough medical staff available.
Kassif said that 25 nurses from cardiac intensive care, general intensive care and pediatric intensive care units at Sheba were moved to the coronavirus intensive care unit where four patients are on ECMO machines.
Kassif collects information on the use of these machines across the country and he’s familiar with the situation in all intensive care units.
“In the last seven to 10 days these units have been swamped with people needing respirators, with some needing ECMO machines as well. At Soroka Hospital in Be’er Sheva, for example, there were three or four people on respirators last Tuesday.
“Now there are 14, with one on an ECMO machine. At Carmel Hospital, not a large hospital but with an active intensive care unit, there are 13 people on respirators, two of whom are attached to ECMO machines. This has been an explosion, just in the past week.”
Kassif said the stress is felt mainly in hospitals in outlying areas. Beilinson Hospital in Petah Tikva brought over a patient on ECMO from Nahariya.
“The hospitals in the north are overwhelmed, and a unit head there has to weigh whether to accept a patient on ECMO and thus cancel two intensive care beds,” Kassif said.