Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.

The question isn’t how many people in the United States will contract the coronavirus COVID-19. The key question is how many of these coronavirus cases will become extremely ill and wind up in an ICU. Authorities tell us two criteria define the threat of a virus: how quickly it can spread, and how severe or virulent the cases are.

How many of the infected patients will develop respiratory failure, and how many will require admission to an Intensive Care Unit (ICU) to be kept alive by a ventilator? To date there have been 90,000 coronavirus cases in the world and 3,000 have died, for a mortality rate of 3.33%. To date there have been 127 coronavirus cases in the United States and 9 have died, for a mortality rate of 7%. This statistic deserves an asterisk, because the denominator is likely too low. We don’t have data as to how many patients have contracted coronavirus, because testing has been limited to date.

We also have no information the numerator, the people who died. The Center for Disease Control (CDC) has released minimal information on the fatalities. For example, how many of the Kirkland, Washington deaths were elderly patients who were Do Not Resuscitate (DNR) status? That is, they were to be denied ICU treatment, ventilator support, and cardiopulmonary resuscitation (CPR) if they became seriously ill? How many of the deaths were vigorous adults who succumbed despite a full ICU effort to keep them alive?

What would the cause of these deaths be in a coronavirus-infected patient? The coronavirus is a respiratory virus which primarily infects respiratory tissues, much like the influenza virus does.  Symptoms could include sudden onset of fever, cough, headache, muscle pain, severe malaise (feeling unwell), sore throat, and a runny nose. With influenza illness may range from mild to severe and even death, but hospitalization and death occur mainly among high risk groups such as elderly patients or those with preexisting chronic illnesses.

A severe coronavirus infection would infect the lungs, and cause progressively increasing shortness of breath and dropping oxygen levels in a patient’s bloodstream. The medical treatment would be supportive, that is, a breathing tube would be placed in the patient’s windpipe (trachea) by an anesthesiologist, an ICU doctor, or an emergency room doctor, and the tube would be connected to a mechanical breathing machine, called a ventilator.

As of 2015, there were 94,837 ICU beds in the United States. Many or most of these beds are already filled by patients who need ICU support. If the new coronavirus were to become a pandemic which caused thousands or tens of thousands of cases of respiratory failure in the United States, each of these new coronavirus patients would require an ICU bed and a ventilator. This could quickly overrun our ICU capacity in America. 

That is the real scare of the coronavirus issue—the fear that our hospitals could not handle the volume of severe infections. Could temporary ICU beds be set up? Each bed would require a ventilator, a set of monitors, and around-the-clock nursing staffing. The supplies of each of these is finite. In addition, with an infectious disease such as coronavirus, each of these ICU beds would ideally be an isolation bed, which kept that patient quarantined from other patients and staff.

Can an anesthesia machine in an operating room be used as an ICU ventilator? Yes. Read more about that topic here. An operating room can be converted into an ICU room with the anesthesia machine ventilator keeping the patient alive.

In week one of the pandemic in California, I went grocery shopping at my local Safeway. The parking lot was full. When I arrived at the front door there were no shopping carts. Inside the store I saw hundreds of shoppers elbow to elbow in all the aisles. I asked an employee why the store was so busy, and she said, “This is nothing. You should have seen it yesterday—even busier!” “Why is it?” I asked. 

Her answer was two words: “The virus.”

She went on to say that customers were buying cleansing wipes, Advil, Tylenol, water, and food provisions that they could survive on for months. On my way out of the store, I saw my own primary care physician in the parking lot, and we discussed the shopping mayhem. He validated my views with the remarks, “It’s not if, but when, people will get infected. It’s just  too soon to know how many severe cases there will be.”

The Safeway customers buying Advil and Tylenol are worried. If you have a severe infection, Advil and Tylenol are not going to save you. What you would need is an intensive care bed with a ventilator, equipment to support your vital signs, and doctors and nurses to care for you 24 hours around the clock.

I hope and pray the overwhelming majority of coronavirus infections in the United States will be mild and self-limiting. A search for a vaccine and/or useful treatment drugs are underway. But because American medical systems need to be prepared, those in charge of health care administration are no doubt preparing contingency plans on how they can manage thousands of new patients in respiratory failure if needed. For more information on this topic see Stockpiling Ventilators for Influenza Pandemics.


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