A National Coordinator for Dr Rosenthals, International Nosocomial InfectionControl Consortium (INICC), Dr Yatin Mehta, Chairman, Institute of Critical Care& Anesthesiology, Medanta, The Medicity, talks to Ekta Srivastava, about variousaspects of Critical Care in India

How the modern day hospitalsare serving critical care topatients? What do you think ofnursing homes which say theyhave all the facilities?
Critical Care is something where lot of revenue is involved; it is a very expensive settlement. If the patient is sick then there is lot of devices and experts being used in the care of patients. Now these small nursing homes they called themselves specialise in Critical Care with the set-up of few beds and ventilator and they think they are in business. Thats where things go wrong because they know that they could not handle the serious patients well and other than making them better they sometime end up giving them infections and making them sicker. And then they try to move them in tertiary care orbetter intensive care for better facilities by the time the patients conditions become more deteriorated. So the problem in India is that we dont have quality care. There is no certification unless you really have a Journal of Clinical Investigation (JCI) or National Accreditation Board for Hospitals and Healthcare (NABH) accreditation which many of these set-ups dont have. I think Medical Council should get tougher plus we need to improve the facilities through education and improve the level of doctors.

Most of the equipmentsused are imported and veryexpensive. Whats your intake?
Yes most of the hardwares are imported. Some companies have tried manufacturing but the quality has been not so good and thats a pity because so much of money is being spent on the equipment itself which is as equal to the cost of it. In order to improve the quality China is one who is doing it reasonably successfully, so if they can do it then what is the reason that we cannot do it .We are just stuck in pharmaceutical industries; we need to move in hardwares also like monitory equipments, ventilators. We should start it but dont expect much at the base

What are the challenges, thathospital are facing in deliveringcritical care in India?
One of the major challenge that tertiarycare hospitals like us faces is thatpatients come very late, and when theyreach us they already been loaded withall antibiotic, have multi drug resistantorganism, they are already very sickwith multi-organ dysfunctions. Secondproblem is the cost, Intensive Care is very expensive because antibiotics and anti fungus are very costly. The average cost of the tertiary care hospital is around `40,000 to `50,000 per day. Now how the people will afford it unless the insurance goes up, like a middle class family cannot afford that, they sell their homes and property, thats all they are doing that. Obviously the private hospitals are not running the charity, even if you try to help them by reducing your professional fees but the cost of the stuff which is being used in the patients and salaries of the staff have to come out. We have one to one nursing in our ICUs; centralised AC; the filters to reduce the infections all that cost. I think government or semi government or private agencies should work towards this otherwise it will be very difficult to bear the cost.

How the community and districthospitals can take advantage ofoffering critical care?
They should resuscitate the patientsmay be incubate the patients ifnecessary then shift them either toprivate tertiary care hospital or togovernment university hospitals withbetter facilities. They should have mobilevans to shift the patients safely with thelatest equipments and experts .

What are the latest technologies and devices available in critical care?
There are more sophisticated and efficient ventilators which can pump oxygen up to the rate of 200 per minute in patients with adult Acute Respiratory Distress Syndrome (ARDS), while we breathe at the rate of 12-15 per minute. Then there is an Extracorporeal Membrane Oxygenation (ECMO), which is not used too much in India but it is increasing. Now we have ECMO conferences in which you do function of the heart and lung outside. This has been shown to improve the mortality. Dialysis technique has been improved now you can continue the dialysis even if the patients blood pressure is low. Then the patients whose brain has been affected because his heart is stopped, we cool these patients to improve the survival of the brain to reduce the oxygen consumption of the heart. Then transfusion indecision has been improved, to treat the infections newer antibiotics are available , then there are many therapies like Early Goal Directed Therapy (EGDT), if patient comes with severe infection within six hours you start there group read therapy their survival is much better ,which is also improving in India.

What are the critical care facilities you have in your hospital?
Well, we have everything whatever is possible in any good set-up in the world with more than 200 beds making it largest in Asia excluding China. We have top end monitors, ventilators, one to one nursing, and our infections rates are quite low comparable to the best centre in the world. We have rooms with the positive pressure with which all the bacteria can go out and for infective patients we have negative pressure rooms to allow air to flow into the isolation room but not escape from the room, where the bacteria doesnt infect other people. We are very good at air transporting the sick patients. We can transfer patients on ventilators with intra aortic balloon pump from all over India and neighboring countries. We have highly advanced air rescue in the country to bring the patients in our own ICUs where we can take better care of them. We have the Bed side CT machines, which means now you dont have to move the patients from one place to another with heavy life support systems, now we need to move the machine because it becomes so compact and this is the only set-up in India which have Bed-sided CT scan machines.

What is your opinion aboutCritical care in India?
Critical Care is a vastly and rapidlygrowing specialty. So, I will say thatthe future is bright. We just need to doethical practices; trained the doctorsand practice good medicine, and theneveryone will be happy including thepatients.

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