Lasst update and review: June 11, 2020.
Hospital administration, bureaucrats, management and owners of private hospitals are those who bear responsibility for malpractice.
This article contains a critique of medical doctors. It is very important to keep in mind, however, that medical doctors should NEVER be made the ultimate scapegoats. Skills of medical practitioners should be continuously assessed by the entities that employ them. If there are incompetence and malpractice, hospital administration, bureaucrats, management and owners of private hospitals are those who bear responsibility.
Medical malpractice has been killing more COVID-19 patients than the virus itself.
An article entitled “Rethinking the early intubation paradigm of COVID-19: time to change gears” was published ahead of print by a group that includes many intensive care unit doctors (Rola et al., 2020 (1)).
The title of the article is misleading. Indeed, “Early intubation” was never a paradigm. It was always hardcore malpractice.
“We started with “intubate as fast as you can”.
An ICU doctor from Italy Marco Garrone, who is one of the study (1) authors, honestly admits during a video conference (3):
“We started with “intubate as fast as you can”.
Analysis: If there were Physiologically Literate solid thinkers among the ICU doctors, early intubation would not have happened. Also, the old standard of care would have prevented low oxygen saturation and would have eliminated even the pretext to the early use of mechanical ventilation.
A mysterious message from China told ICU doctors to intubate COVID-19 patients “as fast as you can”.
Rola et al., 2020 (1), wrote in their article:
“The initial message from the Chinese medical teams was to intubate early, somewhere around a 5-6 liter by nasal prong O2 requirement.”
There is no apparent reference to this statement in the article. How exactly this “message” from China was communicated to the authors of the article and to other ICU doctors who mention these mysterious instructions received from China?
Illiteracy in the article by Rola et al., 2020 (1): What does hypoxia mean?
Rola et al., 2020 (1), used the term “hypoxia” incorrectly in a sentence. The sloppy use of terminology is a demonstration of physiological illiteracy of all the eight authors of the article and of the possible reviewers.
A Test of Physiological Literacy:
Why the term “hypoxia” in the following sentence was used incorrectly? Give an extended answer.
Rola et al., 2020 (1):
In what has been termed the “happy hypoxic” of SARS-Cov-2, there appears to be an uncoupling of this relationship where the patient is in little or no distress, without tachycardia, yet with profound hypoxia with oxygen saturation often well below 80%.
If intensive care doctors had been practicing medicine intelligently, “mysterious instructions” from China to intubate early would not have confused them.
Pulmonologist Michael J. Tobin:
The most difficult cognitive challenge for intensivists is deciding whether (or not) patients can be managed without recourse to an endotracheal tube. This dilemma arises at the point of placing a patient on the ventilator, and it recurs at the point of deciding whether the ventilator can be discontinued.
Apparently, the cognitive challenge described above in the citation by Tobin is too hard for most of the intensive care doctors. If it were otherwise, “mysterious instructions” from China to intubate early would not have confused them.
Patients are unlikely to be well managed on mechanical ventilation even if fewer are intubated.
Michael J. Tobin: “The skills (required to install mechanical ventilation correctly) are not found in the quiver (among the available skills) of most intensivists.”
From another article on this website:
(Pulmonologist) Martin J. Tobin, MD, seems to be a rare individual to meet the description of a highly intelligent medical practitioner. He wrote two books on mechanical ventilation and intensive care published by McGraw-Hill, Inc, New York, and has more than 40 years of experience in “evaluating patients in outpatient clinics, hospital wards, and intensive care units (ICUs) while concurrently undertaking mechanistic physiologic research in patients and healthy subjects” (2).
Conclusions.
One of the actionable items of a COVID-19 response is to make sure that ICU doctors and pulmonologists DO KNOW that early mechanical ventilation does NOT work. It is also important that other complex techniques required for good management of mechanical ventilation are practiced correctly and intelligently. Highly intelligent doctors need to be identified and put at the head of intensive care units.
If you need help with the above as a doctor, as a hospital administrator, a health insurer or cost-sharing organization, and, of course, as a potential COVID-19 patient, do not hesitate to get in contact with us. As an immediate step, use the question of The Test of Physiological Literacy above to assess competence of a medical practitioner.
Related.
Selected references:
1. Philippe Rola 1 , Joshua Farkas 2 , Rory Spiegel 3 , Cameron Kyle-Sidell 4, Scott Weingart 5 , Laura Duggan 6 , Marco Garrone 7 , Adam Thomas 8. Rethinking the early intubation paradigm of COVID-19: time to change gears? Clin Exp Emerg Med. doi: https://doi.org/10.15441/ceem.20.043
Received: May 5, 2020. Revised: May 11, 2020. Accepted: May 11, 2020. Published online: June 10, 2020.
Authors’ affiliations:
1 Intensive Care Unit, Santa Cabrini Hospital, CIUSSS-CEMTL, Montreal, Canada
2 Department of Critical Care, University of Vermont, Burlington, VT, USA 3 Departments of Critical Care and Emergency Medicine, Washington Hospital Center, Georgetown University, Washington, DC, USA
4 Maimonides Medical Center, Brooklyn, NY, USA
5 Department of Emergency Medicine, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY, USA
6 Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, Canada
7 Emergency Department, Mauriziano Ospedale, Torino, Italy
8 Adult Critical Care, University of British Columbia, Vancouver, Canada
2. Tobin, 2019. Annals ATS Volume 15 Supplement 1, February 2018.
3. The video of the video conference in which many of the authors participated. A note: None of the speakers is likely to be competent. Anything the speakers say should be taken with extreme skepticism and scrutiny.
3 Comments