Q: If I get severe COVID-19 will I be managed in a critical care unit?

Who will get admitted to intensive care with COVID-19?

In medicine, we often use case scenarios to illustrate an important learning point. My post last week in which I presented three potential cases needing ventilation during the COVID-19 crisis got criticised.

The main aim of asking you to make a decision about who gets to be ventilated or not is to make you think about what may or may not happen to you if you got severe COVID-19. The scenarios are also designed to give you an idea of the issues that need to be taken into account and the perspective of the clinicians making the decisions. Many learned societies are issuing guidance to clinicians to help them make these life-and-death decisions; this is an issue that is uppermost in the minds of all of us who are about to enter the front line NHS services dealing with the crisis.

I think there is consensus that the young woman (case 1 below) was the most deserving patient of the three to be admitted to ITU and ventilated. The post raises the important question that if ITU or critical care beds and ventilators become limited who gets them or more importantly who doesn’t get them.

As always clinical decisions have to be taken in context but recent NICE guidance states that critical care teams need to involved in discussions about admission to critical care for a patient where:

• the assessment suggests the person is less frail (for example, a clinical frailty score (CFS) score of less than 5), they are likely to benefit from critical care organ support and they want critical care treatment or
• the assessment suggests the person is more frail (for example, a CFS score of 5 or more), there is uncertainty regarding the likely benefit of critical care organ support, and the critical care advice is needed to help the decision about treatment.

In addition the impact of underlying pathologies, comorbidities and severity of acute illness on the likelihood of critical care treatment achieving the desired outcome need to be considered.

The implications of these guidelines (see below) for pwMS who are disabled and in the more advanced stages of MS cannot be over-emphasised. In other words, you don’t want to find yourself in a position where a critical care clinician is assessing your frailty to decide whether or not you can have an ITU bed and/or ventilator.

These issue highlight some of the reasons why it is important for people with more advanced MS self-isolate to lower the risk of SARS-CoV-2 infection and COVID-19.

Patient 1

Louise was a 22-year old final year law student. She had been admitted to the hospital yesterday afternoon from a drug rehabilitation unit in Southeast London. She had been in her final year of University when her drug habit had escalated. She has started off using drugs recreationally on weekends, but over the last year, her drug habit had spiralled out of control. Her boyfriend had been the problem and had become her dealer and had gotten her hooked on oxycodone. Her parents had taken her out of University and booked her into a private drug rehabilitation centre ten weeks ago. She had been doing well. She was off all drugs, had broken up with her boyfriend and was just starting to complete some of her University assignments remotely. She was however still quite frail. Over the last two years, she had lost a lot of weight and had only weighed 43 kg when she was admitted to the rehabilitation unit. She had almost certainly picked up the coronavirus from someone in the rehab unit; she was the third inpatient to be diagnosed with COVID-19. She had become very short of breath yesterday and when she was admitted to the hospital her CT scan of the chest confirmed COVID pneumonia with greater than 50% white-out of her lungs. Louise had been coping with oxygen, but over the last 4 hours her oxygen saturations had dropped below 90% and her respiratory rate had increased to 36 breaths per minute. Without ventilation, Louise would not survive; even with ventilation, her chances of pulling through were maybe fifty-fifty.

Patient 2

Michael is a 46-year medically retired civil servant. Michael has secondary progressive multiple sclerosis and needs a walker or wheelchair to mobilise. In the last year, Michael had been admitted to hospital twice with severe urinary tract infections. During his last admission, he had had to have a suprapubic catheter inserted. Michael was not on any disease-modifying therapy but was on baclofen and clonazepam to control his spasticity and duloxetine for depression and chronic back pain. Michael had stopped working three years ago and had recently separated from his wife. Michael had a care package in place and carers came in twice a day to help him wash and get dressed in the morning and to help him in the evening. Michael could not cope with domestic chores and needed someone to come in once a week to clean his bungalow. Michael has two children a daughter of 17 studying for her A-levels and a 19-year old son studying engineering at the University of Bristol. Michael has a large friend group and would get out at least twice a week. He was an avid reader and spent a lot of time online as an active member of several Facebook groups. Michael had no idea where he picked up the virus but had been admitted to hospital two days ago by his GP who was concerned he was not coping at home. Michael had been doing very well but over the last 12 hours he had developed COVID-19 ARDS (acute respiratory distress syndrome) and his oxygen saturations had plummeted precipitously over the last two hours. It was clear that without assisted ventilation he would not survive the night.

Patient 3

Reverend Charles Ryan is 78 and semi-retired. Reverend Ryan is married to Josephine his partner of 52 years. They have three children and six grandchildren. Reverend Ryan is still an active member of his congregation and in semi-retirement has taken on a lot of charitable work. He is a governor of the local school, a trustee on a charity that supports church schools in Malawi and he teaches theology at the local college. He writes a weekly column on religious matters for the local newspaper. Reverend Ryan is still physically active walking their dog twice a day. Apart from well-controlled hypertension and mild osteoarthritis of the left hip he has no other medical problems. He almost certainly picked-up the virus from one of his congregation a week or so ago. Initially, he thought he had a common cold and on the advice of his GP was self-isolating. He had been improving but two days ago he became short of breath and had to be admitted to hospital urgently yesterday. He was diagnosed as having COVID-related pneumonia. Over the last 24 hours, his breathing had become more laboured and his blood oxygenation levels had plummeted despite oxygen therapy. It was clear that he was tiring rapidly and would need to be ventilated very soon if he was going to survive.

Date & Disclaimer: 30-March-2020; please note this information will be time limited and will change as new data emerges.