May 17, 2020

The Intensivist shortage: Is there a way around it?

Telemedicine
Physicians
USA
Hospitals
Gal Salomon, CEO of CLEW. 
6 min
In the ICU, the numbers just don't add up. There is a significant shortage of intensive care specialists, and despite efforts by hospitals to recruit mo...

In the ICU, the numbers just don't add up. There is a significant shortage of intensive care specialists, and despite efforts by hospitals to recruit more intensivists, there are not enough to provide quality care to intensive care unit patients. And according to one study, “the shortage of full-time intensivists is most likely 5-10 times more pronounced” than it is generally considered to be - because “the bulk of CCM board certificates are allocated to part-time physicians.” While a part-time intensivist is better than none, it is far from an ideal situation.

To cope with the lack of intensivists, hospitals have tried numerous solutions – but a UK study indicates that anything less than having an ideal number of intensivists on staff in ICUs (the study says that number is 7.5) is detrimental to patients' well-being. But perhaps technology could help bridge the gap in the ICU. Big data, machine-learning systems that can parse a patient's history could provide insights to intensivists that will indicate which patients need the most attention.

It's one solution for a shortage that will get worse before it gets better, according to the AMA. In a brief to the U.S. Supreme Court against a travel ban to and from eight countries (since upheld by the Court), the AMA says that the US cannot afford to keep out any qualified physicians who wish to immigrate here.

“Over the next several decades, the percentage of older Americans will increase, with patients needing care for a variety of chronic health conditions such as heart disease, cancer, emphysema, stroke, diabetes, and Alzheimer’s disease,” the brief states.

“The risk of a pandemic is also growing, given that infectious diseases can spread around the globe in a matter of days due to increased urbanisation and international travel. These conditions pose a threat to America’s health security—the nation’s preparedness and resilience in the face of incidents with health consequences.” Clearly, all those conditions could land a patient in the ICU.

The reasons for the shortage are well-known in the medical community. Suffice to say that a 2016 study indicates that as many as nearly half of the 10,000 critical care physicians in the US, along with a third (25% - 33%) of the 500,000 critical care nurses, “are reporting severe burnout” - far more than in other specialties. Among physicians specialising in paediatric critical care, that number was over 71%.

In fact, burnout among intensivists are among the same reasons doctors choose “easier” specialties – complicated cases, intensive work schedules, overarching responsibility, and the difficult atmosphere of working in ICUs, where patients are often deathly ill. If doctors are leaving because of these reasons, it's no wonder that getting new ones to fill the shortage is proving challenging.

How should hospitals cope with this situation? Various solutions have been proposed, among them  accelerated training programmes for physicians from other specialties as intensive care specialists; substituting nurse practitioners for physicians, to assist when intensivists are unavailable; and the increased use of telemedicine in ICUs to enable patients to more easily be “seen” by an intensivist when one is not available in the unit itself, in the case of an off-hours emergency, etc.

While incentives for training could arguably bring more doctors to take on the mantle of intensive care as a specialty, professional physicians arguably have many options they can choose from – which can be complicated, so relying on incentives to solve the problem is probably not a good move.

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The latter two solutions are certainly helpful – but all would agree that having actual intensivists providing the ideal coverage for ICU patients would be the best solution. Anything less means that patients aren't getting the best possible care. If an intensivist is available only part of the time and/or has to offload responsibilities to colleagues or technology, it means the patient is not getting the continuity of care that is important to their recovery.

Given that at this time it appears that getting sufficient intensivist coverage in ICUs is impossible, the question is what the best way is to utilise what time/skills we do have with available intensivist manpower. How do we make the most of what we have? One way is with big data, which can effectively supplement the knowledge and experience of an intensivist.

One of the tasks of an intensivist is to gauge what a patient needs in terms of treatment. One reason a patient is in the ICU is because they are quite ill – and unstable – and will likely need quick intervention at some point. ICU patients are generally connected to a slew of machines, which collect data about their condition in real time. Those data reflect what is happening right now. But the data could also be a predictor of what is likely to happen to the patient in a few hours, or the next day. A fever, a drop in blood pressure, or even more prosaic symptoms – changes in heart rate, breathing rate, etc. - often presage a significant change in the condition of the patient.

Often, an experienced intensive care specialist will be able to look at those results and realise that “something” is happening – but even the best intensivist cannot monitor a patient 24/7. But a machine learning-based big data analytics system could do that, using its analysis to understand what that “something” is, or could turn into.

By examining the current situation of a patient, the system could check those symptoms against those of profiles of patients suffering from the same conditions – gathered from thousands of previous cases. The indicators would provide useful data about what could be expected in the patient's case, based on that profile.

If the current situation indicates that the current symptoms are moving in a direction that will soon produce a deterioration in the situation of the patient, staff can quickly move to alleviate the problem, if it can be treated.

The system checks thousands of data points each second, monitoring them as they fluctuate – far more than any human physician could. Thanks to its machine-learning component, the system also gets smarter as it processes more patients. Thus, it hones its “skills” by analysing the condition of a patient at any specific time, and comparing it to their condition later on. As it gathers more data, the system becomes better at making predictions.

In life – and especially in the ICU – knowledge is power. ICUs, already strained as they attempt to provide care adequate for the patients that are in the unit, find themselves behind the eight ball. They need qualified staff, but cannot find them.

Equipped with a machine learning-based big data system, ICUs will be able to compensate for the lack of personnel, improve patient results and reduce the mortality rate. This system is actually especially suited for ICUs, where patients are by definition sicker and in greater need of full attention. With a machine learning-based big data analysis system, ICUs get the extra “eyes” they need to help their patients move out of the ICU – and, hopefully, well enough to get out of the hospital.

Credit: Gal Salomon, CEO at CLEW

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Jun 14, 2021

Long haul Covid, the brain and digital therapies

#longcovid
#digitaltherapy
#neuroplasticity
#covid19
4 min
Neuroplasticity expert Ashok Gupta tells us about the symptoms of long Covid, how it affects the brain, and digital therapies

It is estimated that around 10% of people who get Covid-19 develop long haul Covid, a debilitating condition that can last many months and cause breathlessness, exhaustion and pain. 

Research is underway to find out who is more likely to get it and how to treat it. Here neuroplasticity expert and owner of Harley Street Solutions in London Ashok Gupta tells us how the condition affects the brain. 

What is long Covid exactly? 

Long Covid is when patients who have experienced Covid-19 go on to have continuing symptoms for weeks and months afterwards. These symptoms can include breathlessness, exhaustion, brain fog, gastric issues, pain, and post-exertional malaise. It is estimated that around 10% of Covid-19 infections may result in developing long haul symptoms, and in the USA, this may be affecting over 3 million people.

How does it affect the brain?
Here at our clinic, we hypothesise that it is due to a malfunction in the unconscious brain, creating a conditioned response that keeps the body in a hyper-aroused state of defensiveness. At the core of this hypothesis is the idea that we are here because our nervous system and immune system have evolved to survive. We are survival machines!

When we encounter something such as Covid-19, the brain perceives it as life threatening, and rightly so. And in the era of the pandemic, with more stress, anxiety and social isolation, our immunity may be compromised, and therefore it may take longer for the immune system to fight off the virus and recover. 

If the brain makes the decision that this is potentially life threatening and we get to the stage where we’re overcoming the virus, a legacy is left in the brain; it keeps over-responding to anything that reminds us of the virus. Even if we’ve fought off the virus, the brain will react in a precautionary way to stimuli reminiscent of the virus. 

The brain may get stuck in that overprotective response, and keeps stimulating our nervous system and our immune system, just in case the virus may still be present.

What symptoms does this cause? 

These signals cause a cascade of symptoms including breathlessness, extreme fatigue, brain fog, loss of taste or smell, headaches, and many others. And these are caused by our own immunes system.

In the case of long-haul Covid, symptoms in the body get detected by a hypersensitive brain which thinks we’re still in danger. The brain then chronically stimulates the immune and nervous systems, and then we have a continuation of a chronic set of symptoms.

This isn’t unique to long-haul Covid. Many patients develop chronic fatigue syndrome, sometimes known as “ME”, for example, after the flu, a stomach bug, or respiratory illness. Covid-19 may be a severe trigger of a form of chronic fatigue syndrome or ME.

How does long-haul Covid affect mental health? 
Anxiety is a very common symptom in long haulers. It can be frightening to wonder about what may be happening in your body, and what the prognosis is going to be for one’s long term health. Reaching out for support for mental health is crucial for long-haulers.

How does neuroplasticity treatment work for long-haul COVID patients?
We have been working with patients for two decades with a brain retraining programme using neuroplasticity or “limbic retraining.” 

We believe that through neural rewiring, the brain can be “persuaded” that we are no longer in danger and to come back to homeostasis. But to be very clear, we are not saying it is psychological in any way, but we believe there are novel ways of accessing the unconscious brain. 

We recently worked successfully with a 56-year-old male with long-haul Covid, who prior to contracting Covid-19 in March of 2020 was running half-marathons and cycling, but afterwards he struggled to get off the sofa for months. Within 3 months he’s now back to 100% and  running half marathons again.

At our clinic, we train the patient to be able to recognise those subtle unconscious danger signals on the periphery of consciousness. This, coupled with supportive techniques and the natural hallmarks of good health such as sleep and diet help prepare the patient to respond to perceived threats that might trigger the response. 

The natural state of our brain is to default to protection. The brain prioritises survival and passing on our genes to the next generation, over any other impulse. It cares more about that than you feeling healthy and well. Protective responses are evolutionary, and are the right thing for the brain to do – it’s survival. 

What digital therapies or apps are proving effective at treating long-haul Covid? 
It seems that long haul patients are availing themselves of many online therapies and services, including meditation apps and wellness websites. We have an online neuroplasticity “brain retraining” video course called the “Gupta Program” which hosts 15 interactive videos and many audio exercises. This is proving very popular with long haul patients, and we are currently conducting a trial to test the effectiveness of this therapy. 

What is the danger of leaving long-haul Covid untreated?
The longer it goes untreated, we hypothesise that it may become more entrenched in the brain, and  become chronic in the longer term. Therefore we advise all patients to get help and advice as soon as possible.

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