25 July 2009

The best prepared country in the world

The Jobbing Doctor will tell you that swine 'flu is mild. He is sort of right. It was mild for Dr Grumble's two registrars who were back at work after a few days. But if you work in a hospital you may see one of the tiny number of patients in whom the disease turns out to be far from mild.

What happens, for example, if the dreaded 'flu virus invades your lungs? The answer is that your lungs won't work too well. But when you eventually get better from the 'flu your lungs should get better too. All your doctors need to do is keep you alive until you cure yourself of the 'flu. But keeping you alive if your lungs are riddled with 'flu virus is a challenge. Widely inflamed lungs cannot do their job. If they get really bad there could be only one option for you and that is to plug you into an ECMO machine that does the job of your lungs for you. Does it work? Probably. How do we know? We know from research done in the UK. Will you get this treatment in the UK? Probably not. Because in the UK we have only five ECMO beds for adults in the whole country. If you are very lucky you may be able to get treatment in another country.

Was the possible need for ECMO in a 'flu outbreak predictable? Dr Grumble thinks it was. Did the Department of Health plan for the 'flu? Yes. According to Alan Johnson, along with France, we are the best prepared country in the world. As is Australia by the way. How many ECMO beds do you think they have in Australia?

Of course ECMO doesn't come cheap. If you are not familiar with ECMO take a look at the video and then decide if you think it is worth it.

It is not easy to get funded to provide an ECMO service:

There is no funding stream for adults with respiratory failure at the time of writing (pdf).

There is money for 'flu planning ad nauseam, for unnecessary bottled water, for Connecting for Health, for Darzi clinics, for 'flu lines, for NHS Direct, for Walk-in Centres and for running an internal market. But ECMO funding is limited. Very limited. You could argue that to be right were it not for the very large sums of money wasted elsewhere on electoral bribes.

The Jobbing Doctor may be busy and Dr Grumble may want access to ECMO for his sickest patients but all most of us need is a good GP and not a window cleaner.


Witch Doctor said...

Lovely post!

It says it all!


DHS said...

41 ECMO beds in the system I work in (population roughly 7-8 million). Another 5 on order.


Thanks for the CESAR trial link; I was taught years ago that ECMO was primarily useful as a bridge to transplant because of the difficulty in weaning.

Dr Grumble said...

Thanks DHS. Quite a contrast with the UK!

The NHS is is well known to be a slow adopter of new technology (not that ECMO is that new).

I have used ECMO (many years ago) to treat conditions like severe chicken pox pneumonia. It has always seemed to me that in that context if you can keep the patient alive long enough the disease will cure itself.

Nevertheless the evidence of efficacy is not that strong: the CESAR trial can be criticised.

DHS said...

Do your transplant centres not use ECMO? The two hospitals that have ECMO - SV and PA - are the sole heart-lung transplant centre, and the major cystic fibrosis hospital, respectively. They use it for those horrendoma CF cases where transplant is the only cure, and if a 16yo comes in with CF respiratory failure, ECMO might keep them alive long enough for a biker to conk his noggin.

Dr Grumble said...

Do your transplant centres not use ECMO?


Probably but Dr G doesn't actually know. He has reason to believe that there is a bigger UK capability than the newspapers seem to think. What one of those documents Dr G linked to said was that adult ECMO was "not funded". At that particular hospital they do transplants so it could be that they do unfunded ECMO to keep alive youngsters in the hope a donor might suddenly become available.

Perhaps somebody else can answer that one for you, DHS.

rodgriff said...

It is not true to say that there is no funding stream for ECMO. The National Commissioning Group currrently funds ECMO for Adults at Leicester and for children at Great Ormond Street
Opinion in the past has been fairly skeptical but the CESAR trial is expected to report in the next few weeks and that will allow a more up to date assessment of ECMO's effectiveness and cost effectiveness so that further applications for funding can be assessed.
If the NCG were not funding Leicester they couldn't have done the CESAR.