Back Draught

Sunday 19th April 2020

COVID Figures for 18th April

UK Hospital Deaths 888 / Total 15,464

James Cook Hospital – Total deaths – 134

James Cook cases in Critical Care – 20 / 10 ventilated

The media is currently full of stories about PPE shortages. Whilst we have experienced shortages we have so far been able to acquire alternatives. We have run out of surgical gowns to use but these have been replaced with the white suits that we are currently wearing. However, these pose a problem for those of us using ventilated hood systems.

These systems feature a hood with an inbuilt visor that covers the whole head. The hood is connected via a hose to a ventilation unit that you wear around your waist. A high flow of virally-filtered air enters the hood and keeps contaminated air out. We are using them for the small number of people for whom a FFP3 face mask does not fit well enough to provide complete protection. They are also for stubborn people like me who refuse to shave their beards…

The problem with the white suits is that ideally the ventilation unit should be worn inside the suit to decrease the likelihood of viral contamination. The ventilation units are hard to clean thoroughly. However, the suits are relatively air-tight and so if you wear the ventilation unit inside it cannot entrain enough air and sucks air out of the suit – essentially vacuum-wrapping you. This can be quite flattering for the svelter indivual but causes problems. The ventilation unit senses the increased resistance to the inflow of air and, believing the filter to be blocked, alarms continually.

Ventilated Hood System worn externally (Picture courtesy of Drager)

The only way of fixing this is to cut a vent in the back of the suit low down below the ventilation unit. This is not as bad as it sounds as the standard theatre gown is far from airtight at the rear so there is no increased risk of infection. However, it means having your ‘buttock area’ open to the air. Your PPE now looks like it was designed by one of the Village People.

A more pressing issue is the news that there is a national shortage of neuromuscular blocking agents. These are the drugs that cause paralysis and allow the passage of the breathing tube through the mouth, down the trachea and into the lungs during intubation. They may also be used during your ICU stay if you have severe respiratory failure to relax your chest muscles and stop the patient’s own attempts at breathing that can be counter-productive.

We are using alternative drugs for now, but this is concerning. We have seen unprecedented shortages of some drugs in past year and it is not clear why. Some blame Brexit, others manufacturing problems and an increased global demand but no-one really seems to know why.

We are also running out of the fluid that we use for dialysis in the ICU. Without this fluid we are limited in the amount of treatment we can offer for kidney failure. Currently we can use a supply of different kidney machines from the Cardiothoracic ICU or traditional intermittent dialysis - the sort of dialysis that regular patients get at hospital or at home. However, a limited supply of something so critical to survival is unnerving.

Of course, the world is seeing an unprecedented demand for the provision of hospital care, particularly Intensive Care. This will lead to a huge increase in demand for drugs, fluids, oxygen and equipment. Shortages will surely follow. The only solution has to be an international one; we need a coordinated increase in manufacture and distribution of drugs and equipment to where it is needed. The last thing we need right now is a Trump-esque ‘every man for himself and screw the WHO’ approach.