Thread by @drgregkelly

I think much of the incoherence & backflips in #COVID19 response, esp in rich countries, came about b/c ppl don't understand who ICU teams are & what they do

I'm an intensive care specialist who did an MBA to try & understand this better myself, here goes at an explanation: 🧵⬇️

Firstly, it's TOTALLY MEANINGLESS to talk about death or mortality rates in a pandemic without talking about ICU teams

If you are in a rich country with a functioning health system there is ALWAYS an ICU team standing between you & a potentially avoidable premature death

We're NOT used to thinking like this b/c epidemiologists & ID normally think either about outbreaks of deadly diseases in places w/out ICU teams Ebola in Africa) OR non deadly diseases in other places where ICU is irrelevant - gonorrhoea is embarrassing, not life threatening

The other outbreaks we've had in the era of modern ICU teams (SARS, MERS, etc) have severely strained local systems but not overwhelmed them - hence ICU capacity didn't become a major issue

ICU as a field was developed because of another pandemic of avoidable premature death: polio

Kids dying b/c they couldn't breathe, realisation that if we helped them breathe they wouldn't die

So ICU is inextricably linked to pandemics, we just forgot

nature.com/articles/d4158…

As well as never thinking about how pandemics meet ICU capacity in the modern era few people understand what ICU teams actually does in a modern system

ICU is the CENTRE OF GRAVITY of high intensity, hospital health care

Primary care other centre of gravity, of community care

ICU is not one thing - like cancer care, or heart surgery, transplant, etc

Rather, ICU teams look after the sickest patients at their most vulnerable time FROM EVERY OTHER AREA

ALL high intensity health care DEPENDS ON ICU TO FUNCTION

B/c workload of ICU teams drawn from diverse areas the patients average out & DEMAND IS RELATIVELY STABLE

Liver transplant work is up, neurointerventional slightly down - etc

Capacity so finely tuned that ONE PATIENT can strain system

Which patients strain system? Those that stay long time. Big majority ICU patients come in & get better quickly.

E.g. 85% of our pts are in & out < 3 days. Remaining 15% take weeks or even months

Those 15% of our 'long stay' patients = 2/3 of our bed capacity

Why is this so relevant for #COVID19? If you make it to ICU with COVID, esp. if you end up on a ventilator YOU STAY A VERY LONG TIME

Melbourne data last year - median ICU LOS 16 days. UK data avg 30 days

So just 1 severe COVID pt = estimated 20 heart or major cancer surgeries

So those 50+ patients we have in NSW, many on ventilators, represent far more workload than an average 50 ICU patients. It's not just that it's 6% of our 875 beds, it represents FAR MORE OF OUR BED DAYS

Remember the finely tuned capacity? Yep, well those 50 don't come with reduction in anything else

The pandemic patients are always 'on top' of everything else. In fact, this year, it's on top of worse seasons of seasonal viruses, plus all the elective work we are catching up on

Can we just expand the ICU teams? My mate has a 3D printer & said he can make a ventilator

It took me 15 years to train & I can't really work any harder so that's not easy thing to do. ALL OF OUR STAFF are specialists - nurses, physios, pharmacists, social work, child life, etc

Sure we can surge ICU team capacity temporarily but it is NOT SUSTAINABLE

UK NHS already seeing effect with staff leaving rather than face another surge. Costs of sick leave, mental health, lack of training, no time to build systems. Robbing Peter to pay Paul

This is why western countries, despite repeated flirtations with #LiveWithCovid repeatedly find they can't

Because you can't die prematurely in rich country w/out meeting ICU team

& if ICU overwhelmed w #COVID19 (remember happens v easily) then we CAN'T DO ALL THE OTHER STUFF

This means we need #COVIDZero to AVOID THE ROLLERCOASTER that almost every country's graphs have

Then, in order to open safely need:
1. High vax rate (probably including kids once safe & approved vax available)
2. #COVIDisAirborne recognition & mitigation
3. Test Trace Isolate

Truth of this is demonstrated by the few countries w advanced health systems that had national experience w deadly epidemics in modern era (e.g Taiwan, Singapore w SARS)

They have NOT F#*CKED AROUND a la "live with covid"

Understand that #COVIDzero is the only coherent response

Great piece here from @EJBourke that explores these issues in beautiful and human detail

abc.net.au/radio/adelaide…