Thirty-nine COVID patients in Israel are currently connected to ECMO machines, which replace the function of the heart and lungs and are used in the most serious cases, where lives are in danger. People who are unaccustomed to visiting coronavirus wards may be surprised to learn that most of the people attached to these machines are not elderly and suffering from a plethora of background illnesses. In fact, 29 of the 39 are between the ages of 40 and 60. Thirty-three are unvaccinated, with only four patients fully vaccinated.
The ECMO system, spread out over 11 hospitals, contended with a more serious situation during the third wave of coronavirus, with the spread of the British variant. “There is no ECMO bed available anywhere in Israel,” Dr. Yigal Kassif, head of ECMO services at Sheba Medical Center, Tel Hashomer and the head of Israel’s ECMO society, said last January. At that point, doctors had to delay the hookup of two patients to ECMO machines due to a shortage in manpower that could look after them. This was the first time since the outbreak of the pandemic in which a patient needing lifesaving treatment did not receive it. According to Kassif and other hospital officials, Israel is again on the brink of such a situation.
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The ECMO machine replaces the heart and lungs when these are impaired for a variety of reasons, until they are functional again. The machine draws the blood of a patient through a tube inserted into a vein in the neck or groin. The blood is transferred to the ECMO machine, where it absorbs oxygen. The blood is then returned to the body, where oxygen is delivered to different tissues and their cells. This system can operate for several weeks.
Kassif says that the system in Israel is operating close to its upper limit. In addition to coronavirus patients there are 13 other patients now connected to ECMO machines, bringing the total to 52. Israel has 82 such machines, with one third of them serving as backup for the ones in use. Thus, hospitals have only a handful of machines that can serve new patients. “We hope and pray that patients continue to recover and that no new ones arrive,” says Kassif.
But now there is another variable that was absent in previous COVID waves. Most of the people attached to ECMO machines are young people who were not vaccinated. This is provoking criticism and anger among medical personnel. The ECMO teams’ WhatsApp group is inundated with reports of serious cases, requiring ECMO machines, that deteriorated into very grave ones. Some people in the group call these patients “COVID fools,” expressing the frustration of medical teams, exhausted after a year and a half of fighting the virus.
The group was set up after the epidemic broke out. It is an effective tool for mutual support among hospitals, required due to the need to quickly move patients and machines between hospitals. “There is a sense of collapse,” wrote one group member. “We’re quite close to the end,” wrote another. One message included a request to attach a 39-year-old man whose condition had deteriorated rapidly over three days. Another report was of a 40-year-old unvaccinated man who had arrived at a hospital, miraculously in stable condition.
Among those supported by ECMO at Shamir Medical Center Hospital (formerly Assaf Harofeh) is a 34-year-old unvaccinated pregnant woman whose condition deteriorated after an emergency Cesarean section. That hospital also has a 43-year-old unvaccinated woman with no background diseases attached to an ECMO. Assuta Hospital in Ashdod has a 29-year-old unvaccinated, obese man on such a machine. On an ECMO at Soroka Medical Center in Be’er Sheva is a 40-year-old unvaccinated woman whose condition deteriorated after she miscarried in the last trimester of her pregnancy.
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That center also has a 56-year-old woman who has been connected to an ECMO machine for two weeks. She is unvaccinated and has no underlying medical issues. Since the beginning of July, 72 people have been connected to ECMO machines. 21 of them were successfully taken off the machines, nine died and the rest are at different stages of COVID, still connected.
ECMO machines are a very limited resource that requires a large number of personnel, placing a heavy load on the system, often requiring the closing or restricting of the number of beds in other hospital units. Even though there is anger among medical staff because these machines are taken by unvaccinated young people, when they have to choose whom to connect, the consideration is often the age of the patient. One doctor said they don’t connect anyone over the age of 70. Some hospitals have a lower cutoff age.
“With a limited number of ECMO beds, there is no other choice,” says Kassif. “Furthermore, the results with older patients are very poor. In emergencies, only medical priorities are taken into account, we can’t discriminate against someone who isn’t vaccinated even when we feel great anger towards them, just like we treat a wounded terrorist, who we’re even more angry at. When I come to a site with multiple injuries I need to prioritize and devote resources to people who can be saved by immediate intervention.”
A position paper published by the Israel Medical Association’s Ethics Board in April 2020, which addressed the topic of intensive care ventilation during the coronavirus epidemic, noted that ECMO support requires more resources in comparison to regular intensive care, and when patient numbers are extraordinary, treatment should be reserved for cases likely to see relatively quick recovery. Dr. Tammy Karni, the board’s chairwoman, adds, “Medical treatment should be given where there is hope. The main and only consideration is the chance of successful treatment.”
ECMO and intensive care teams are witnessing something different than occurred in earlier waves. “If you want an effective campaign for vaccination, you should broadcast live from an ECMO unit,” says a doctor in one such unit. “There are some really hard cases. Lung tissue hardens and the lungs stop functioning. Respiration volumes drop to five cc, compared to 450-500 in a healthy person. Moreover, connecting to an ECMO machine causes bleeding, leading to grim sights. This is the hardest wave we’ve encountered and teams are almost at the end of their wits. The number of patients needing ECMO machines is rising faster than the rise in the number of seriously ill patients.”
The profile of seriously ill patients has changed. At the beginning of the current wave, most of these were older vaccinated people with background problems, whose vaccination efficacy had declined. They were seriously ill, but not acutely so. Now, 90 percent of the people on ECMO machines are young and unvaccinated, says Prof. Michael Halbertal, the director of Rambam Medical Center. “This wave is more prolonged and unstable. Mortality has increased from one in eight or nine patients in previous waves to one in five.”