Inside the hospital that saves swine flu sufferers' lives
As the number of people with the virus grows, Jeremy Laurance visits one of just five units in Britain that can treat the worst afflicted
Tuesday 21 December 2010
This is the machine on which your life could depend upon if you are struck down by swine flu. The treatment of last resort is delivered by a battery of pumps and monitors, festooned with tubes and wires, to patients with the severest illness, whose inflamed and congested lungs have ceased to function under assault from the virus.
The first thing that strikes the visitor to London's only Extra Corporeal Membrane Oxygenation (Ecmo) unit, in the intensive care ward at the Royal Brompton Hospital, is the youth of its patients. In the first bed a young pregnant woman, her cheeks aflame, lies sleeping. Two thick plastic tubes emerge from her chest at the base of her neck, one carrying bright scarlet blood, freshly oxygenated, back to her body, the other dull bluish blood on its way to the Ecmo machine.
She will lie like this, heavily sedated, for seven to 10 days while her lungs recover. Some patients take up to 40 days. She is receiving five drugs, including morphine for pain relief and Tamiflu to combat the H1N1 virus which has invaded her body. Her life, and that of her unborn child, hang in the balance.
Yet her chances of survival are good – 80 per cent of patients treated on this unit recovered last year. It will, however, be a long road back to health. Prolonged immobility in intensive care leaves the body weak.
There are only 15 Ecmo beds in the country and after the recent surge of severe swine flu cases – they almost doubled to 190 in intensive care last week – specialists fear they could be overwhelmed. Last year, a patient was flown to Sweden for treatment because of a shortage of Ecmo machines in the UK. Beds were later opened at two hospitals – Papworth in Huntingdonshire and the Royal Brompton in London, in addition to the permanent unit at Glenfield Hospital in Leicester. This year extra beds have been opened in four hospitals – Papworth and the Royal Brompton plus Newcastle upon Tyne NHS Trust and University Hospitals of South Manchester.
Three of the four patients with swine flu at the Royal Brompton are pregnant. They are four times more likely to be admitted to hospital with the virus, which targets the young. Of the 14 deaths from swine flu so far this winter, six have been under 18.
Nurses wearing masks, gloves and aprons check the monitors and adjust the flow of blood, normally set at around five litres a minute. Twice the normal number of nurses are required. The unit was activated two weeks ago in response to a surge of severe swine flu cases and has so far treated six patients, compared with 20 during the whole of last winter.
Simon Finney, a consultant in adult intensive care, said: "We have had a much more rapid influx this year. Is this a blip or is it going to grow? We don't know. You can't predict with flu. The one thing we do know is that the people who get sick seem not to have had the vaccination."
Patients are brought to the unit from across the South-east. Swine flu is a mild illness in most people. But in a few it strikes so severely they need ventilation. "An inflamed lung becomes leaky – the lungs fill with fluid. People become breathless and the oxygen levels in the blood fall. The normal level is 98 to 100 per cent, but we hear of people coming in with 60 to 70 per cent. It is incredible they are still alive," Dr Finney said.
Once admitted to intensive care, patients are sedated, a plastic tube is inserted down the windpipe and into the lungs and their breathing is taken over by a ventilator.
For the worst-affected, whose blood oxygen level fails to respond to ventilation, Ecmo is the only option. Blood is taken from a central artery in the neck, pumped through an "oxygenator" – where it is warmed, the carbon dioxide removed and oxygen added – and returned to the patient via a central vein. The lungs are rested and can recover while the patient is dosed with Tamiflu. "It is amazing – you can see the oxygen level climb back over 90 per cent in one minute. You can see a pinkness in the patient again," Dr Finney said.
The biggest risk is from brain haemorrhage. Diverting the circulation through a machine increases the risk of a fatal blood clot. To counteract this, patients are given the blood-thinning drug heparin, but this can cause a bleed anywhere, especially in the brain. Experience from Australia last year suggests the risk is 8 to 10 per cent. "That is a sizeable risk. That is why we have to judge when the situation is serious enough to justify switching to Ecmo," Dr Finney said.
Last year, 80 per cent of swine flu patients treated on Ecmo across the UK survived. The six patients treated so far this year at the Brompton are doing well.
Case study: 'I would be dead without this treatment'
Peter Skuse, 56
In October last year, Peter was flown from hospital in Northern Ireland to the Royal Brompton in London. He was dying from swine flu and the ECMO unit there was his only hope.
"My son had flu and I came home feeling miserable on the Wednesday. Over the next couple of days I took paracetamol and when I got worse my wife phoned the doctor who said continue taking the paracetamol," he said. "By the Sunday I was worse and my wife drove me to Belfast City Hospital where they put me in intensive care. I don't remember anything after that."
Two weeks later, on 10 November, he returned to Belfast City Hospital, having had the life-saving treatment provided by the ECMO unit at the Royal Brompton. But it took another month of recuperation to get fit again and be allowed home a week before Christmas.
"All the time I was in hospital I just thought about getting out in the hills. That's what I love to do. But when I came home I could do nothing for myself. I lost the power to walk and had to be taught to do it again," he said.
Today, he has recovered his fitness but lost his job as a kitchen salesman because of his illness. He is happy, nonetheless, to be able to enjoy the hills as he used to. "I am more than thankful for what they did. They saved my life," he said.
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