ABSTRACT
Introduction Our Critical Care Unit is a precious ressource in Malawi. Covid (C) could have lead to even more challenges on the withholding of ventilation. Often our non-physicians are involved in this decision. Not much is known about their opinions. Object To assess in a pilot study which hierarchical and social realities might influence the allocation of our ICU beds for our clinical officers (COs) and medical assistants (MAs). Methods Six patients in need of artificial respiration had to be evaluated in a questionnaire (Q).4 suffered from Covid (2 high ranking Ministry of Health [MoH] officials responsible for the countrywide response either against malaria or against Covid, the son of a business woman offering 100000 $ for ventilators to hospital and a tribal leader. 1 lady suffering from hemorrhagic shock after cesarean section and 1 from rabies. Non-physicians were asked to decide on the order of admission. The first patient to be admitted scores 1 point, the last 6 points. Lowest scoring is admitted first. The answers were compared with a Q our collaborators filled out previously (17 septic/nonseptic reasons for ICU). Moreover we tried in a series of confidental informal interviews to learn about life's reality on Covid ventilation. Results 19 Q were filled out correctly, so representing 90.5 % of our colleagues. 1st to admit was the mother after CS (1.1 points);2 nd: Patient with rabies (3 p.);All four dignitaries suffering from Covid scored worse: 3 rd: The donating business-woman (3.63 p.);4th: MOH collaborator for Covid (3.95 p.);5th: MoH collaborator for malaria (4.37 p.);6th: Traditional leader (4.95 p.). The same participants rated in the previous survey again CS 1 st, for admission, but rabies 2 nd last. Covid was then admitted as last and 3rd last. CS, but even rabies scored in comparison to 4 Covid cases even higher than in the first survey against 2 covid cases and several other non-covid related reasons for ICU admission. The patients with non-covid disease scored 2.05 points vs. the four dignitaries with a mean of 4.22 p. The business woman scored higher (3.63 p.) than the three potentially important members of government and civil society (mean 4.42 p.). We found in the previous survey that the dignitaries there (policeman, priest and businesswoman) scored uimpressively. The confidental background check discovered that at least four real life VIPs were admitted to hospital, and died there through Covid-without being ventilated. Conclusion Non-dignitaries with non-covid diseases scored higher than all dignitaries with Covid. MoH personal and traditional leaders are not seen as important in the fight against epidemics. An impressive implementation of a tough health policy was found.
ABSTRACT
Background Sepsis (S) is one of the most important reason to be admitted in ICU in Malawi. ICU is a precious ressource in developing countries. The Covid (C) pan-demic added pressure on us. In this country (<1 anaesthetist per 2.5 mio) ICUbeds are allocated with clinical officers (Cos) and medical assistants (Mas). Not much is known about the non-physicians ethical convictions. In Queens Hospital we tried to find a basis for decisions. Object To enhance our knowledge about the rel. weight of sepsis (S), C. and non-septic diseases for our 19 COs and MAs and to compare it with our future doctors, (34 fourth year medical students [MS]. Methods A questionnaire (Q) presents 17 existing patients in critical care was given to 19 Cos/Mas and 34 MS. All 17 were needed ventilation. Reasons: Covid (twice), sleeping sick-ness, haemorragic shock after cesarean section (CS), malaria, tetanus, Guillain-Barre-Syndrome, rabies, traumatic brain injury (TBI), measles, typhoid fever, Tb, bowel resection, PCP with HIV, bact. pneumonia, meningitis and polytrauma. Pat. were devided in 7 groups. Group 1: Patients suffering from S or very much prone to develop S. G. 2: Covid patients. G 3: Groups 1 plus 2 (Covid as S) G 4: S. after an infection. G 5 S. after a non-infect. disease. G 6: Pneumonia (main culprit for sepsis), G 7: Patients, not likely to develop S.The CO and MAs ranked them for ICU admission. First to be admitted got 1 point, the last 17 points. Lowest scoring one admitted first. Results 53 Q were filled out, representing 66.6 % of the colleagues. CO &Ma: Group1: 8.58 points, G2: 11.55 p, G3: 9.24 p, G4: 9.6 p, G5: 6.44 p, G6: 10.04 p, G7: 8.13 p Med. stud.: Group1: 9.77 points, G2: 7.47 p, G3: 9.26 p, G4: 10 p, G5: 6.59 p, G6: 9.48 p, G7: 8.71 p. Overall: Group 1: 9.34 points, G2: 8.93 p, G3: 9.25 p, G4: 9.88 p, G5: 6.54 p, G6: 9.68 p, G7: 8.50 p.The most important admission for CO/MAs were: 1. CS (2.16 points), 2. TBI (4.68 p.), 3. Malaria (7.05 p.). The least important: Last: Covid (12.37 p.), 2nd last: Rabies, (12.1 p.);Second Covid pa tient shared 3rd last with a PCP patient who was HIV+ (10.74 p.). For our MS: 1. Polytrauma (4.56 points), 2. TBI (5.0 p.). 3. Malaria (10.26 p.). Least:Rabies (13.85 p.), 2nd last: Bact. Pneumonia (13.21 p.), 3rd last: Covid (12.59 p.). verall 1st admission is TBI, 2. CS, 3. Malaria. Least important: Rabies. Gender did only play a minor role as criterion for ICU admin.MS. admitted male patients 1 place earlier, COs and MAs it made no diff. Conclusion S. after non-infect. is more important than S. to infections or C. This is the difference between MS and our non-academics. Mothers and TBI scoredhigher than infect. &plain S.
ABSTRACT
Introduction Even before COVID-19 our country Malawi was suffering from endemic, epidemic, or pandemic diseases (.,E").Queens" in Blantyre is the largest referral center for emergencies in Malawi and ICU beds are precious ressources. We never have enough for all emergencies. With the second wave we tried to find the medical and ethical basis on which our current and future collaborators would admit patients from the emergency department to our ICU. Objective To evaluate how important COVID-19 is for the decision to admit patients suffering from respiratory insufficiency in the light of real life epidemics in Malawi. Methods Malawians involved in emergency care and ICU were asked to fill out a questionnaire (Q) with a short description of 17 emergency patients. Three groups of participants. Candidates for the spec. exam (MMEDs), medical assistants in a 2 years course for anaesthesia, (TACOs), together called .,Clinicians" and medical students (MBBS). The five existing anaesth. specialists were excluded, due to their decisive involvement in health politics concerning COVID-19. All emergency patients suffered from respiratory insufficiency due to different reasons, had a SaO2 of 78 % and were in need of artificial respiration. Here we consider 10 patients with endemics (sleeping sickness, malaria, tetanus, rabies), epidemics (measles, typhoid fever) or pandemics (COVID-19, Tb, HIV). Collaborators decided on the order they admit to ICU. First to admit scored 1 point, the last 10 p. The lowest scoring patient was admitted first. Results 59 of 61 Q were filled out completely (96.7 %). 2 Q were dismissed due to poor marking. Des-pite difficulties through COVID-19 we reached 78 % of our collaborators in Blantyre. Neither gender represented a criterium for ICU-admission (score female: 10, male 10) nor age (score > 30: 9, < 30: 9, = 30: 9). Between the .,E" the participating choosed for the first three admissions (scores 1,2,3): MMED: Malaria/Typh-oid fever/Measles, MBBS: Malaria/COVID-19/Tetanus, TACO: Tetanus + Malaria/Sleeping sickness, All Clinicians: Malaria/Tetanus/Sleeping sickness. The last three admissions were (scores 8,9,10): MMED: HIV/Rabies/TB, MBBS: HIV/Typhoid fever/Rabies, TACO: Tb/HIV/Rabies. The Clinicians: HIV/Tb/Rabies. The overall lowest scoring .,E" were: Malaria, Tetanus, Sleeping sickness and COVID-19 (each 3). The last in the overall ranking (scores 8, 9, 10) were HIV/Typhoid fever/Rabies. Endemic diseases scored overall 4.25 points, epidemics 7.5 and pandemics 5.75. The two patients suffering from COVID-19 were admitted through the MMEDs with a score of 6 and 7, through MBBS with 2 and 5, through TACOs with 4 and 5 and through Clinicians with 4 and 5. Conclusion COVID-19 is less dominant in critical care than in Europe. Endemics are more important than pandemics.