What is needed is not “playing intensive care” – Ask Osamu Nishida, President of the Japanese Society of Intensive Care Medicine Vol.2 | m3.com

Ventilators are not “white goods”

――When you explained to the people involved, you emphasized that it was “intensive care” and that “intensive care play” was not good.

Manage by connecting a ventilator, monitor, drip, etc. Dialysis is performed when urine stops coming out. To the layman, it looks like they are in “intensive care”. However, unless treatment is provided by specialists based on a correct understanding of pathophysiology, it is nothing more than a “intensive care play” and may even worsen the condition of the disease.

Indeed, like white goods, a ventilator can default to a certain number of ventilations when switched on. If you weigh about 50kg, you can set it to 400mL once and 12 to 15 times per minute. Patients with healthy lungs can still cope. However, in patients with, for example, ARDS, a condition sometimes referred to as “baby lung”, with very little remaining lung volume, normal ventilation can cause the lungs to rupture.

Taking the new coronavirus infection as an example, if it becomes severe, it is necessary to “rest the lungs” in order to restore the slightly remaining lung function. How much ECMO should “rest the lungs” requires comprehensive judgment and fine-tuning while watching various monitors as the condition changes from moment to moment. Only intensive care specialists with Anyone who has had any experience with intensive care knows how difficult it is, but someone who thinks “I can just push a button and turn the ventilator on” won’t understand.

During the first wave of the new coronavirus, about 90% of patients on respirators (non-ECMO) died in New York, USA. On the other hand, in the case of Japan, about 80% are still alive. It’s the difference between “intensive care” and “intensive care play”. It is true that if you put on a ventilator in the ICU, you can live for a while, but if you don’t manage it properly, it will only prolong your life.

(Provided by Mr. Nishida)

A yacht club in college, living that experience

Q: As a result of appealing the importance of intensive care, the government and others realized the addition of an “intensive care department.”

Not necessarily.

Even if the “wind” was blowing against us, it was by no means a “favorable wind.” But no matter what direction the wind blows, it can be done.But if there’s no wind, things don’t move

――Even if there is a headwind, it is better than no wind.

When I was in college, I was a yacht racer. There is a yacht event called “Triangle Course,” which involves going around a triangular course consisting of windward, leeward, and side marks. The yacht can go upwind at an angle of 45 degrees when well maneuvered. Start downwind and change the direction of the sails as the wind changes direction. This is a race where you compete to see how fast you can go around the course while making subtle adjustments and reading the tide.

That’s why I thought that as long as the wind was blowing, I would be able to manage even if the wind was headwind. I also thought, “If I stay still, I will be blown away. The situation will be worse than now.”

“Turn around” when explaining to related parties

――What kind of “headwinds” did you encounter during the corona crisis?

Even when I tried to explain to Diet members, there was little interest in the system for providing intensive care medical care. At present, there is no distinction between “intensive care” and “emergency care” in the government, or even in the medical world.

The government thought that there would be a shortage of ventilators due to a pandemic, and did not consult with us. , There is also an episode that the order stopped at the last minute after explaining to the government. There are already 40,000 ventilators in Japan, and with only 17,000 beds in ICU and HCU, there is almost no shortage of ventilators. will run out. I think that “mochi is a mochi shop” and should be consulted, but there was a current situation where we were not seen as a mochi shop.

(Provided by Mr. Nishida)

I also went to the bureaucrats of the Ministry of Health, Labor and Welfare who were introduced to me by a member of the Diet regarding my request regarding the intensive care department, but since the matter involved multiple departments, I made an appointment with a key person in a “passing around” situation. Even if I took it, it continued to be canceled due to reasons such as the Diet response.

As I mentioned earlier, there was a misunderstanding within the Ministry of Health, Labor and Welfare that we wanted to become an “advertising medical department.” We don’t even publish the number of ICU beds when we look at how the intensive care delivery system is distributed as a matter of national policy, not advertiseable. I don’t even know the number of the most important bearers. I’m just asking for improvement as a national crisis management.

“Signature activity” that Mr. Shinya Yamanaka also agreed

――Even in the face of such a “headwind,” you didn’t give up.

When giving explanations to the parties concerned, I tried to understand their positions and their accompanying thoughts in advance, rather than unilaterally insisting on my own views. When the Ministry of Health, Labor and Welfare and related parties requested information, we sometimes stayed up all night to collect and submit relevant information, and the entire academic society responded. “We respond politely and promptly. Everything starts from doing everything you are asked to do.” In order to be seen as a counterpart, I kept saying this and worked on it.

――When did you feel that the tide had turned?

In the end, it was the signature campaign that made the big difference. On July 28, 2021, we sent a signature request document to prefectural governors, ordinance-designated city mayors, related organizations, celebrities, etc. Some people, such as Professor Shinya Yamanaka, signed quickly.

However, other than that, only a small portion of them have received the support of governors and mayors of ordinance-designated cities nationwide. It seems that intensive care has a strong awareness of the “box” of the ICU, and the intensive care department is regarded as a department that specializes in the box, and it was difficult to gain an understanding. “It is a survey item of a statistical survey under the jurisdiction of the Ministry of Health, Labor and Welfare, and the prefecture is not in a position to express its opinion.” There was also an opinion that

Still, the signatures of 26 people who gathered were submitted to the Minister of Health, Labor and Welfare on October 5. Immediately after that, as a matter for the minister, the relevant departments began to consider adding the “intensive care department” to the “medical department name, etc.” of the “physician notification form”.

(Provided by Mr. Nishida, for presentation materials in July 2022, it is stated that “it will be incorporated from the next survey”).

Assuming that the discussion did not progress, I continued to approach the Japanese Medical Specialty Board. In the new specialist system that started in 2018, the purpose is to have him added as a subspecialty specialist recognized by the organization. If it is added to the “doctor’s notification form”, it will be easier to be recognized as a sub-spec, or if it is recognized as a sub-spec, it will be added to the “doctor’s notification form”. I assumed that if one moved, the other would move as well.

In September 2021, we submitted a request to the Japanese Board of Specialists for recognition of intensive care specialists as a subspecialty area (Click here for request form). At the 49th Annual Meeting of the Japanese Society of Intensive Care Medicine in March 2022, we plan a panel discussion on the theme of “Building a highly resilient medical care delivery system.” In addition to the Japan Medical Association, the Japan Hospital Association, and the Japanese Nursing Association, we also invited people from the Japan Medical Specialty Board to discuss the system for providing intensive care. Everyone agreed on the importance of maintaining intensive care delivery and the importance of intensive care specialists. In April 2022, it was certified as a subspecialty area by the board of directors of the Japan Medical Specialty Board, and was officially decided after the medical ethics council.

――I have heard that when you undergo surgery, you should look not only at the skill of the surgeon, but also at the level of intensive care.

That’s right. As a requirement for subspecialty medicine, the Japan Medical Specialty Board states, “Even if the public is not necessarily required to receive treatment at their own discretion, referral from a doctor in a basic area clinical department or other subspecialty clinical department etc. It is defined as an area where it is recommended to receive treatment in That’s exactly what intensive care is for. I was once told by the organization that I would never go to an intensive care unit. However, when undergoing major surgery and undergoing intensive care after the operation, whether a hospital has intensive care specialists or not is a matter of life and death, so it is clearly a public choice. will come in

Graduation from “I don’t know in intensive care”

――How do you think intensive care will change in the future with the addition of “intensive care department” to the “medical department name, etc.” of the “physician notification form”?

First of all, it is important to “get on the ring”, and I hope that the recognition will increase. I received a request for an interview from a TV documentary program, and I accepted the interview on the condition that I use the term “intensive care physician”. I was informed that it was decided at the directors’ meeting that I would broadcast as “emergency doctor”. The reason was, “Because it is easier for viewers to understand.”

Core hospitals all over Japan already have intensive care departments or intensive care departments with intensive care specialists on staff. We hope that the number will increase in the future.

Currently, there are only a handful of universities that have formal courses in intensive care, but I expect the number to increase in the future. We will also work on the creation of a textbook on “intensive care medicine” that conveys the fun of medicine.