WHY YOU SHOULD CONSIDER GETTING A DNI BRACELET
As countries clamor for ventilators, these complex machines have been assigned a kind of messianic status, but they also have a dark side. For a patient with COVID-19 (the disease caused by the novel coronavirus, SARS-CoV-19), placement on a ventilator is itself a dismal prognosticator. By that time, the patient is gravely ill and the prospects of coming off the ventilator are grim. For example, researchers in Wuhan have reported that out of 37 critically ill COVID-19 patients who were placed on mechanical ventilators, 30 (81%) had died within a month. New York state and city officials have documented a similar percentage.
Although ventilators are potential life savers, they are also agents of spread of the novel coronavirus. This is because during the procedure of intubation, a COVID-19 patient’s secretions are invariably aerosolized, directly exposing the physician to a high risk of contracting the virus. In Italy, many of the more than one hundred physician deaths due to COVID-19 have been linked to inadequate PPE (Personal Protective Equipment) during intubation, the very procedure designed to save a life. Without comprehensive PPE similar to the all-encompassing protective garb of the Ebola era, many of the world’s doctors have become sitting ducks for SARS-CoV-19 infection. Even if PPE is adequate during the procedure, removing (“doffing”) the shield, mask, robe and in some cases the PAPRs (powered air purifying respirators) can be a risky process as well.
Full PPE (Som Taste/Shutterstock)
Decades ago, I was an aggressive young intern at the USC Medical Center. There was no procedure I wouldn’t attempt to save a life. As I intubated a man in respiratory failure one night, a rich gob of sputum came up his windpipe and splattered me. What I couldn’t see, though, were the millions of “nanoparticles” that were undoubtedly released from this patient, who turned out to have tuberculosis. A similar phenomenon applies to the novel coronavirus. Not only does it threaten the life of the physician performing an intubation, the lingering virus-laden air droplets may indirectly expose innocent bystanders.
Physicians have a deep-seated urge to intubate patients in respiratory distress. The procedure has been logically extended to COVID-19 sufferers with pneumonia or the dreaded acute respiratory distress syndrome (ARDS)—a condition in which severe inflammation engulfs the lungs and impairs gaseous exchange. But are we correctly weighing the benefits versus the risks? Some doctors, and rightly so in my opinion, are moving away from ventilators as a treatment for COVID-19 because of the extraordinarily high mortality rate of coronavirus patients on ventilators. The reasons, at least in part, may be that much higher ventilator pressure settings are required in COVID-19 ARDS cases and may thereby cause pulmonary barotrauma, especially since these patients may be on a ventilator for prolonged periods before either death or survival.
How to intubate (Shutterstock/ellepigrafica)
The bottom line is, if I’m ever unfortunate enough to be rushed to an emergency room in COVID-19 respiratory failure, look for the bracelet on my left wrist that reads, Do Not Intubate (DNI). “Do not resuscitate (DNR)” is too vague and broad a term, and it might be misinterpreted as a rejection of simpler procedures like high-flow oxygen and antiarrythmic medications, which I would consider absolutely reasonable. So, my dear fellow physician: try everything you have in your medical armamentarium, but whatever you do, do not intubate me.