Why ventilators remain unused or locked up despite patients at rural hospitals needing them

Ventilators, which help patients breathe, are found in a hospital’s ICU and are traditionally operated by specialists in critical care medicine, called intensivists.

A patient on a ventilator | Representational image | Photo: Praveen Jain | ThePrint

New Delhi: The same story appears to be playing out across the rural pockets of Bihar, Uttar Pradesh, Punjab, and Himachal Pradesh, among other states: Critical Covid-19 patients, gasping for breath, are in need of ventilatory support but can’t get it. It’s not because hospitals don’t have ventilators. It’s because the ventilators, several of which have been supplied by the PM CARES fund, are locked away or lying unused for want of skilled staff. 

Ventilators, intricate machines that help patients breathe, are found in a hospital’s intensive care unit (ICU) and are traditionally operated by specialists in critical care medicine, called intensivists. Anaesthetists, pulmonologists, and physicians with additional training in critical care medicine are also qualified to operate ventilators and practise in ICUs. 

Data from the Indian Society of Critical Care Medicine (ISCCM), the largest body of critical care physicians, confirms that the number of qualified physicians in India is woefully inadequate for a country of over a billion people. 

“We have about 14,000 members, and this comprises most of the critical care professionals in the country. Of these, about 10,000 to 12,000 are fully qualified,” Dr Srinivas Samavedam, vice-president of the ISCCM, told ThePrint. 

Those in the field describe critical care medicine as a high-intensity job that requires one to think on their feet. Discussing the shortage, they say the high-stress nature of the job, which often involves irregular hours, puts off many people. 

Critical care was also only recently identified as a super-specialty by the medical education regulator, they add, noting that India doesn’t offer enough seats in the field vertical to address its demand. The lack of infrastructure in rural areas has been another impediment, they say.

The role of an intensivist

According to the American College of Physicians (ACP), a professional organisation representing doctors specialising in internal medicine, critical care is a specialty that “encompasses the diagnosis and treatment of a wide variety of clinical problems representing the extreme of human disease”. 

Intensivists who work in the ICU need to be “competent not only in a broad range of conditions common among critically ill patients but also with the technological procedures and devices used in intensive care settings”, says the ACP.

In the context of Covid-19, intensivists must know how to intubate patients for mechanical ventilation — when a tube is inserted into the throat to help air pass through. This has to be done carefully, and can cause excessive aerosol spray, putting the intensivist at risk of infection.

“In India, a bulk of critical care doctors are anaesthesiologists because they know how to use ventilators from their operating room experience. But ICU care requires more than just operating a ventilator, so many become critical care doctors after undergoing additional training,” said Sai P. Haranath, an intensivist and pulmonologist with Apollo Hospitals. 

As the patients they tend to are critically ill, Samavedam added, critical care physicians have to make snap decisions and work in a high-pressure environment.

“Every decision you make gives you a near instant result. You need to be available around the clock … don’t have fixed hours for work. Our exposure to illness is much higher. It’s a high-energy, adrenaline-filled speciality,” he added. “Because of the intensity of the work, fatigue also sets in. Lots of people are not very comfortable getting into this field because of these reasons.”

How to tackle shortage

A study from 2020 assessing India’s preparedness for Covid-19 estimated that the country had about 95,000 ICU beds and 48,000 ventilators. These numbers are likely to have gone up with hospitals setting up more beds and the PM CARES fund paying for 50,000 new ventilators. 

“In rural India, where approximately 80 per cent of the population live, ICU care is poor or absent at the district level, as is access to speciality care such as ventilation,” the study had noted. 

The availability of human resources has largely followed this pattern, with most critical care doctors being available in urban areas, say those in the field. 

The shortage is also partly due to the fact that the Medical Council of India — the erstwhile statutory body for overseeing medical education — recognised critical care as a super-specialty only in 2010. The National Board of Examinations, which is tasked with monitoring the standard of postgraduate medical education, had recognised it as a field a few years prior to this. 

“There are a very few doctors graduating with a specialisation in critical care medicine, and there isn’t adequate infrastructure in rural areas, which is what causes the urban-rural divide,” said Dr Deepak Govil, president of the ISCCM, adding that only a handful of doctors graduate with a specialisation in critical care year-on-year.

“There must be hardly 25 to 30 Doctorate of Medicine (DMs) seats, the National Board of Examinations must have around 200 seats for critical care all over India. With such small numbers, you can see why there would be a shortage,” Dr Govil added.

Dr Haranath, who conducts emergency ventilator training programmes, said although intensive care is a specialty, doctors can be trained to use a ventilator through telemedicine to compensate for the short-term shortage in specialist staff. 

“There is a rural-urban divide, with most critical care specialists being in urban areas. I’ve been doing remote intensive care, and even basic doctors can be trained over two weeks to use a ventilator when needed,” he told ThePrint. 

The ISCCM partnered with the Indian Medical Association last year to train 40,000 doctors in small centres on how to use a ventilator. 

It also offers courses on critical care medicine. Though these are not formally recognised by the Government of India, they are accepted by several private hospitals.

“In the short-term, telemedicine is the way to make up for the shortage in skilled staff. But in the long-term, what will help is popularising the speciality and giving accreditation to the courses we offer, so that the training is more widely accessed and recognised,” said Samavedam.