For some of the patients the code is dark gray: ‘Every day we choose who gets or doesn’t get a bed’

Jerry Braun, chairman of the Dutch Society for Thoracic Surgery and heart and lung surgeon at the LUMC: ‘These are strange conversations you are having now’.Image Raymond Rutting / de Volkskrant

Heart and lung surgeon Jerry Braun regularly happens these weeks that he walks into a patient’s room with his tail between his legs. Then he has to tell a patient for the fifth day in a row that the planned and hoped-for bypass operation is canceled again. Not a spot on the ic, covid has gobbled up the beds.

‘People understand it too’, says Braun, who works at the Leiden University Medical Center and chairman of the Dutch Society for Thoracic Surgery. Even at such a time, they still have enough altruism to think that someone else needs the bed more than they do. But they are weird conversations you have now. ‘

Since the beginning of the covid crisis, chest surgeons in the Netherlands, divided over fifteen specialized centers, have operated on 2,800 fewer patients than might be expected. For several weeks now, the surgeons have had to postpone about 100 operations a week.

This concerns operations that always require an IC bed afterwards: bypasses, but also aortic valve replacements. The urgency of such an operation differs per patient, but it always applies, says Braun: ‘The later you perform such an operation, the greater the chance of a less favorable effect. Some of the patients will die as a result of the delay. ‘

On the top

Hospital occupancy in the Netherlands must now be at the top, according to the RIVM. All models show: it will not be long before the vaccinations (now about 5.6 million injections) show their relieving effect. That is desperately needed, because the occupation increased again on Monday. 21 additional corona patients in intensive care (now 825), the same number in nursing wards (now 1,817).

Last weekend, says Peter van de Voort, IC doctor at the UMCG in Groningen and coordinator of the IC beds in the north of the Netherlands, ‘we had very tough days in the north. Almost all the beds were taken. ‘ Now the situation has eased somewhat again, and hospitals in other regions are full again. By moving patients, there is still room for all acute patients. But, says Van der Voort, ‘the number of IC admissions sometimes peaks to 60 to 70 per day. If we were to get that two days in a row, we would end up in a very difficult situation. We are that close to the border. ‘

That limit is Code Black: the moment when all IC beds are full and doctors have to make a choice as to which patients can and which cannot be admitted. There is also no room for patients who immediately need to use the IC.

The question is: now that so many operations have to be postponed (the Dutch Healthcare Authority calculated last week that more than half of the hospitals are also forced to cancel the care that must take place within six weeks), this cannot be called a form of code black. ?

Armand Girbes, head of the IC department at the Amsterdam UMC, says it has been ‘for months’. “We discriminate against non-covid patients compared to covid patients.” Where with a code black doctors have to actively make a choice between patients, this has now been done passively. In doing so, the covid patient is always given priority. ‘

‘The problems of a covid patient present themselves very clearly and they must be helped immediately. The non-covid patients are a bit further away from us, often out of sight, their disease is developing at a slower pace. But I have no doubt that what is happening now is at the expense of those patients. For them it is code dark gray. ‘

Skipper with standards

In fact, says thoracic surgeon Braun, ‘we already choose every day for whom a bed is available and for whom not. Operations that have to be done within six weeks are heading towards seven to eight weeks. In this way, we constantly compromise with the standards we have drawn up. ‘

And those are the people who are already in the hospital, says Braun. There is also a group of patients waiting at home who should be their turn within three months. ‘They will soon be in a really worse condition on the operating table. Their operations will be far less successful than intended. This situation leads to enormous health damage that will only become apparent in years to come. ‘

Figures from the United States show that the number of people who die related to bypass surgery has risen sharply, because a delay was necessary. This month, Dutch figures should be published on this, “but I wouldn’t be surprised if we see the same thing here,” says Braun.

Long-term effects

The problem with the code black discussion, says Peter Langenbach, chairman of the board of Maasstad Hospital in Rotterdam, is the focus on IC capacity. While elsewhere in hospital care the major problems are also piling up. He mentions the dozens of patients that the hospital treats remotely, but do not count in the daily figures. Or the people who don’t come to a doctor or hospital at all, and who are now walking around with undiagnosed conditions.

And on top of that: ‘If we continue to postpone operations on this scale, dozens of operations per hospital per week, at some point you will cross a border. Then you postpone care that cannot be postponed without long-term effects. You could also call that code black. ‘

The hospitals will also have to make up for all that delay, preferably as soon as possible. ‘The question is,’ says Langenbach ‘,’ whether doctors and nurses are already capable of this. ‘

Still, in his view, the situation is less worrisome now than it was a year ago. ‘We know more about the virus, much more about the treatment, the logistics are well organized, and 5.5 million vaccinations have been given. There will really come a time when the curve will bend. Last year we drove in a tunnel without light, now in a tunnel with light. ‘

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