It’s all about the beds-and-vents

Media alarmed at lack of COVID-19 equipment, but not the nurses needed to run it

Physician Aaron Carroll’s March 2020 New York Times piece about what we need to help coronavirus patients has helpful elements. But it is also a striking example of what has become a mini-stereotype of nursing: the misconception that such mass casualty events require surge capacity in I.C.U. beds and ventilators, but that those items just manage themselves, or perhaps are managed by physicians. In fact, skilled nurses play the leading role in providing care for such critical patients.

March 12, 2020 – As awareness of Covid-19 has grown in the United States, the news media has rightly run many stories, relying on authoritative health figures, about the woeful lack of surge capacity in U.S. hospitals. And in most cases, this seems to come down to a lack of sufficient beds and the ventilators needed to address the respiratory symptoms the virus causes. But there is rarely any mention of the nurses who would in fact be the primary managers of that care and vital to any meaningful response to such a patient surge. Think we’re exaggerating? Consider the headlines for pediatrician Aaron Carroll’s piece in today’s New York Times: “Here’s the Biggest Thing to Worry About With Coronavirus: We don’t have enough ventilators and I.C.U. beds if there’s a significant surge of new cases. As with Italy, the health system could become overwhelmed.” In fairness, Carroll makes many good points about what can be done to address the impending crisis. But he never dispels the impression left by his core message that the lack of physical equipment is the biggest problem. Of course, physicians make appearances in the piece. Early on, Carroll refers to his authority as a “medical doctor who analyzes health issues for The Upshot.” He also says that in Italy, physicians are treating coronavirus no matter what their specialties are, and that they are having to ration care, “having to choose who will die.” Indeed, he laments that in Italy, “there’s not enough equipment” and “there aren’t enough physicians.” This wrongly suggests that only physicians are involved, or at least that they they are directing everything and they are the only health workers who matter. In fact, nurses play the central role in the care of patients who need intensive care for serious respiratory symptoms. Respiratory therapists also play important roles. The beds-and-vents formulation could be defended as using equipment as a handy shorthand for the system that surrounds it, including providers like nurses. But that insults the humans. And how many readers will understand it that way, when the obvious interpretation is that patients are lying in beds, hooked up to magic life-saving machines, while physicians provide all the skilled care that matters, just like on most Hollywood television shows? In addition, the beds-and-vents focus wrongly suggests that if we just solve the equipment shortage, all will be well–encouraging decision-makers and the public to ignore the equally desperate need for more nurses and other health workers. These press stories amount to stereotyping by absence: relentlessly ignoring nurses in areas where they are in fact critical reinforces the common impression that they are low-skilled and peripheral to serious care.

Physicians and equipment

Carroll starts by noting that as “a medical doctor who analyzes health issues for The Upshot,” he usually tries to reassure readers, but he can’t do that with the novel coronavirus, because the U.S. health system’s surge capacity is much weaker than is commonly believed. He stresses that if too many people get sick at the same time, the U.S. “has only 2.8 hospital beds per 1,000 people,” which is fewer than Italy and China, and “more important, there are only so many intensive care beds and ventilators.” He piles on the statistics about these precious inanimate objects:

It’s estimated that we have about 45,000 intensive care unit beds in the United States. In a moderate outbreak, about 200,000 Americans would need one. A recent report from the Center for Health Security at Johns Hopkins estimated that there were about 160,000 ventilators available for patient care. … A few years earlier, the same group modeled how many ventilators would be needed in unusual circumstances. In a pandemic akin to the flu pandemics in 1957 or 1968, about 65,000 people might need ventilation. … It’s very possible that many of the ventilators are being used right now for patients with other illnesses. They’re also not mobile, and local outbreaks will quickly surpass the numbers of ventilators and respiratory therapists. Moreover, if a pandemic more closely followed the model of the Spanish flu outbreak of 1918, we would need more than 740,000 ventilators.

Note the passing, isolated reference to respiratory therapists; impressive. Anyway, Carroll goes on to stress that in Italy, many patients have needed hospitalization at the same time, and this has been beyond the nation’s “capacity for care.” Two things matter: physicians and equipment.

It doesn’t matter what physicians’ specialties are — they’re treating coronavirus. As health care providers fall ill, Italy is having trouble replacing them. Elective procedures have been canceled. People who need care for other reasons are having trouble finding space. In an unthinkable fashion, physicians are having to ration care. They’re having to choose whom to treat, and whom to ignore. They’re having to choose who will die. Italy, especially Northern Italy, has a solid health care system. It might not be the best in the world, but it’s certainly not lacking in ability. It’s just not ready for the sudden influx of cases. There aren’t enough physicians. There’s not enough equipment.

Carroll argues that the U.S. is no better off. Most people here will likely be at least exposed to if not infected by the virus. But, he says, we can buy time with greatly expanded paid sick leave, testing for the virus, social distancing, good hygiene, and appropriate quarantine measures. Without quick action, Carroll warns, we may face “terrible consequences.”

We applaud Carroll’s effort to sound the alarm about the resource shortages the U.S. faces and the need to pursue the sensible measures he advocates. We understand that big picture well. But we have to point out the harmful messaging that we see here, and in countless other statements from influential health officials, physicians, and journalists, to the effect that if we just had a lot more equipment, and some more physicians, we would be in good shape. We would not. Skilled nurses are needed to take the lead in this surge, because it is nursing care that patients primarily need once they have a Covid-19 diagnosis and serious symptoms requiring intensive care. Nurses manage ventilator care; suction frequently to keep airways clear; keep patients sedated to facilitate ventilation; titrate IV medications to regulate blood and heart pressures and heart rate; turn patients (many of them quite heavy) frequently to prevent pressure sores; and collect blood and monitor lab results, to name just a few nursing activities. All of this is difficult and time-consuming, and requires great skill. Nurses coordinate and provide most of the skilled care to patients in I.C.U. beds; hospitals exist primarily to provide nursing. But when decision-makers are relentlessly told only the equipment matters, they will not direct sufficient resources to the skilled nursing staff required to manage that equipment—during the current crisis, or ever.

See the article “The New Health Care: Here’s the Biggest Thing to Worry About With Coronavirus: We don’t have enough ventilators and I.C.U. beds if there’s a significant surge of new cases. As with Italy, the health system could become overwhelmed,” by Aaron E. Carroll, posted on March 12, 2020 on the New York Times site.

Note on ventilator care: Although this is no substitute for adequate nursing care, please see this research paper and video on how to connect four patients to one ventilator, and also consider using CPAP to ventilate patients. We aren’t sure how these patients will get the nursing care they need, as we discuss above, but these may be promising workarounds to one aspect of the equipment shortage we are facing.