With hospitals under siege, U.S. to build hundreds of temporary coronavirus wards

With hospitals under siege, U.S. to build hundreds of temporary coronavirus wards
By Susan Heavey and Nick Brown

WASHINGTON/NEW YORK (Reuters) – The United States aims to build hundreds of temporary hospitals to ease pressure on medical centers struggling to keep up with a surge of coronavirus patients, officials said on Tuesday, a day after the number of U.S. deaths hit a new daily high.

The U.S. Army Corps of Engineers, which converted a New York convention center into a 1,000-bed hospital in the space of a week, is searching for hotels, dormitories, convention centers and large open space to build as many as 341 temporary hospitals, the chief of corps said on Tuesday.

“The scope is immense,” Lieutenant General Todd Semonite of the corps told the ABC News “Good Morning America” program. “We’re looking right now at around 341 different facilities across all of the United States.”

The U.S. caseload rose by more than 20,000 confirmed cases on Monday, overwhelming hospitals that are running out of doctors, nurses, medical equipment and protective gear.

A record 575 people died, pushing the death toll past 3,000 on Monday, more than the number killed in the attacks of Sept. 11, 2001, as the caseload rose to more than 163,000, according to a Reuters tally of official statistics.

U.S. officials estimate the death toll could reach 100,000 to 200,000.

The corps, the engineering arm of the U.S. Army, joined with New York state officials to convert New York’s Jacob Javits Convention Center into a facility to treat non-coronavirus patients. The conversion will relieve the pressure on hospitals treating patients with COVID-19, the respiratory ailment caused by the novel coronavirus.

In addition, construction of a 68-bed field hospital began on Sunday in Manhattan’s Central Park. Provided by the Mount Sinai Health System and non-profit organization Samaritan’s Purse, the makeshift facility is expected to begin accepting patients on Tuesday, Mayor Bill de Blasio said.

The converted convention center is blocks away from the Hudson River pier where the U.S. Navy hospital ship Comfort docked on Monday. The floating hospital will take up to 1,000 non-coronavirus patients starting on Tuesday. Another temporary New York hospital is planned for the USTA Billie Jean King National Tennis Center where the U.S. Open is played.

In Los Angeles, the USNS Mercy, similar to the Comfort, is already treating patients. Authorities in New Orleans, Los Angeles and Chicago were setting up field hospitals and convention centers in their cities.

EMOTIONAL TOLL

In the New York City suburbs, nurses are bracing for a surge of patients. The medical surgery unit at New York-Presbyterian Hospital’s Hudson Valley branch has 17 coronavirus patients, more than half its capacity, said nurse Emily Muzyka, 25.

Muzyka, who is training nurses on loan from other units, said she was trying to stay calm, but broke down when a relatively healthy, 44-year-old COVID-19 patient declined quickly and required ventilation.

“I had a meltdown and cried to my boyfriend,” she said.

No-visitor policies mean very ill patients may die alone, adding to the emotional toll.

“I’ve held patients’ hands through their final breaths in the past,” Muzyka said. “It’s a lonely death.”

In a tribute to first responders, New York’s landmark Empire State Building on Tuesday night illuminated the top of its tower in red with a pulsating light on its antenna that simulated an emergency siren. The building’s website said this was an homage to the “heroic COVID-19 emergency workers.”

The temporary hospitals aim to free all of New York City’s 20,000 hospital beds for coronavirus patients, de Blasio said.

New York is still short on doctors and nurses, and de Blasio asked the U.S. military for help.

“We are going to need a lot more military presence. We’re going to need a lot more help from the federal government, including medical personnel from the military, very, very quickly,” de Blasio told NBC’s “Today” show.

U.S. health officials are urging Americans to follow stay-at-home orders until the end of April to contain the spread of the virus, which originated in China and has infected about three-quarters of a million people around the world.

The U.S. government’s top infectious disease expert said on Tuesday there was some evidence that social distancing efforts to slow the spread of coronavirus were having an impact, even though the situation remained very dangerous.

“We’re starting to see glimmers that that is actually having some dampening effect,” Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, told CNN in an interview. “But that does not take away from the seriousness … We clearly are seeing cases going up.”

At least 30 of the 50 states have ordered people to stay home, leading economists to predict severe economic contraction.

U.S. House of Representatives Speaker Nancy Pelosi, a Democrat, said lawmakers needed to take up another coronavirus economic relief bill, but Senate Majority Leader Mitch McConnell, a Republican, said Congress should “wait and see” whether another bill was needed.

(Reporting by Susan Heavey, Doina Chiacu, Nick Brown and Barbara Goldberg; Writing by Daniel Trotta; Editing by Frank McGurty and Howard Goller)

One ventilator, two patients: New York hospitals shift to crisis mode

By Jonathan Allen and Nick Brown

NEW YORK (Reuters) – At least one New York hospital has begun putting two patients on a single ventilator machine, an experimental crisis-mode protocol some doctors worry is too risky but others deemed necessary as the coronavirus outbreak strains medical resources.

The coronavirus causes a respiratory illness called COVID-19 that in severe cases can ravage the lungs. It has killed at least 281 people over a few weeks in New York City, which is struggling with one of the largest caseloads in the world at nearly 22,000 confirmed cases.

A tool of last resort that involves threading a tube down a patient’s windpipe, a mechanical ventilator can sustain a person who can no longer breathe unaided. The city only has a few thousand and is trying to find tens of thousands more.

Dr. Craig Smith, surgeon-in-chief at New York-Presbyterian/Columbia University Medical Center in Manhattan, wrote in a newsletter to staff that anesthesiology and intensive care teams had worked “day and night” to get the split-ventilation experiment going.

By Wednesday, he wrote, there were “two patients being carefully managed on one ventilator.”

New York Governor Andrew Cuomo, who says his staff is struggling to find enough machines on the market, has touted the adaptation as a potential life-saver. “It’s not ideal,” he told reporters, “but we believe it’s workable.”

The U.S. Food & Drug Administration, which regulates medical device manufacturers, gave emergency authorization on Tuesday allowing ventilators to be modified using a splitter tube to serve multiple COVID-19 patients, though manufacturers still must share safety information with regulators.

Some medical associations oppose the unproven method.

On Thursday, the Society of Critical Care Medicine, the American Association for Respiratory Care and four other practitioner groups issued a joint statement saying the practice “should not be attempted because it cannot be done safely with current equipment.”

It is difficult enough to fine-tune a ventilator to keep alive even one patient with acute respiratory distress syndrome (ARDS), the statement said; sharing it across multiple patients would worsen outcomes for all. They proposed doctors instead choose the one patient per ventilator deemed most likely to survive.

At Columbia, Smith noted that they could not split a ventilator across just any two COVID-19 patients, but were only pairing patients with sufficiently similar respiratory needs.

Across Manhattan, Mount Sinai Hospital told staff in an email that officials were “working to figure out” whether they could split ventilators. The hospital has ordered the necessary adapters, a nurse there said in an interview on condition of anonymity because she was not authorized to speak to reporters.

Experts at Columbia pointed to a 2006 study where researchers, using lung simulators, concluded that a single ventilator could sustain four adults in an emergency scenario.

One author of that study, Dr. Greg Neyman, cautioned against the application in COVID-19 cases in part because the lungs themselves are infected. If one patient’s lungs were deteriorating faster, he said, it could cause imbalances in the closed system. One patient could starve for oxygen while the other patient’s lungs would get increased pressure.

“Unless they were very very closely monitored, such a set up may end up doing more harm than good,” Neyman wrote in an email to Reuters.

(Reporting by Jonathan Allen and Nick Brown; Editing by David Gregorio)

A daughter learns in voicemails that coronavirus has killed her mother

By Tim Reid

(Reuters) – Debbie de los Angeles woke up on March 3 to two voicemails from nurses at the Seattle-area care home that housed her 85-year-old mother, Twilla Morin.

In the first one, left at 4:15 a.m., a nurse asked a troubling question – whether the “do not resuscitate” instructions for her mother’s end-of-life care were still in force.

“We anticipate that she, too, has coronavirus, and she’s running a fever of 104,” the woman on the recording said. “We do not anticipate her fighting, so we just want to make sure that your goal of care would be just to keep her here and comfortable.”

The nursing home in Kirkland, Washington was dealing with the beginnings of an outbreak that has since been linked to more than 30 deaths. De los Angeles had not yet fully grasped the grave threat; she comforted herself with the thought that her mother had made it through flu outbreaks at the center before.

Then she took in the next voicemail, left three hours after the first by a different nurse.

“Hi Debbie, my name is Chelsey … I need to talk to you about your Mom if you could give us a call. Her condition is declining, so if you can call us soon as possible that would be great. Thanks. Bye.”

De los Angeles called the home immediately. Her mom was comfortable, she was told. She did not change the “do not resuscitate” instruction. She wanted to visit, but held off: She is 65, and her husband Bob is 67; both have underlying medical conditions that pose serious risks if they contract coronavirus. She thought they had more time to find the best way to comfort her mother in what might be her final hours.

At 3 a.m. the next morning, Wednesday, March 4, de los Angeles woke up and reached for her phone. Life Care Center had called – leaving another voice message just a few minutes earlier, at 2:39 a.m.

“I know it’s early in the morning but Twilla did pass away at 2:10 because of the unique situation,” the nurse said. “The remains will be picked up from the coroner’s office. They’ve got your contact.”

The “unique situation” has of course become tragically common worldwide, as thousands of families have been separated from their loved ones in the last days before they died in isolation, often after deteriorating quickly. The three voicemails – eerily routine and matter-of-fact – would be de los Angeles’ final connection to her mother. She had gone from knowing relatively little about the threat of COVID-19 to becoming a bereaved daughter in the span of one day.

The hurried voicemails with such sensitive information were one sign of the chaos inside the facility at the time, as nurses worked feverishly to contain the outbreak while residents died from a virus that was just hitting the United States. One of the nurses who called de los Angeles, Chelsey Earnest, had been director of nursing at another Life Care facility and volunteered to come to Kirkland to care for patients through the outbreak. She never expected the disease would cause dozens of deaths and the mass infection of patients and staff.

Earnest worked the night shift, when patients with the disease seemed to struggle the most, and many, like Morin, succumbed to the disease. Infected patients developed a redness in and around their eyes. The center’s phones rang constantly as worried families called for updates. About a third of the center’s 180 staff members started showing symptoms of the disease; the rest started a triage operation.

“There were no protocols,” said Life Care spokesman Tim Killian, as nurses found themselves thrust into a situation more dire than any faced by an elderly care facility “in the history of this country.”

The center’s nurses, he said, would not normally leave such sensitive information about dying relatives in voicemails, but they had little time to do anything else – and did not want anyone to hear about a loved one’s condition in the news before the center could inform them. Outside the home, journalists and family members gathered for the latest scraps of information on the home’s fight against the virus. Many relatives, barred from going inside for safety reasons, stood outside the windows of their loved ones’ rooms, looking at them through the glass as they conversed over the phone.

Leaving the emergency voicemails, Killian said, made “the best of a difficult situation.”

From the outside, the messages appear abrupt and impersonal, but may well have been the best or only way to properly notify families in such a crisis, said Ruth Faden, professor of biomedical ethics at John Hopkins University’s Berman Institute of Bioethics. While medical professionals should normally aim to impart such urgent information in person, the circumstances – an overwhelmed staff, dealing with dozens of dying patients – likely made that impossible, she said.

“The way to find out is difficult, always,” Faden said. “What people remember is how much the nurse cared about the person.”

When de Los Angeles heard of her mother’s death in one of those voicemails, she immediately called one of the nurses back, looking for any bits of information about her mother’s final hours. The nurse sounded upset.

“She told me my Mom was one of her favorite people there; she was going to miss seeing my Mom going up and down the hallway in her wheelchair,” de los Angeles said.

They had given her mother morphine and Ativan to keep her calm and comfortable, the nurse told her.

“My Mom was asleep, and then she just went to sleep permanently,” de los Angeles said.

De los Angeles, an only child, aches over not having spoken to her mother before she died. Morin had been a bookkeeper for several companies. De los Angeles fondly remembers doing household chores with her mother on Saturday mornings, then going to the local mall or to Woolworth’s for lunch.

The separation continued even after her mother’s death. De los Angeles telephoned the crematorium where her mother had been taken, as Morin had arranged years earlier, to ask if she could view the body.

“Absolutely not,” the woman told her, out of concern de los Angeles could be infected.

Morin had been tested for coronavirus shortly after she died, on March 4. The results confirmed her coronavirus infection a week later. Soon afterwards, she was cremated.

“We picked up her ashes on Saturday,” she said. “I never saw or spoke to mom. It’s put off the closure.”

It’s also put off the funeral. De los Angeles had planned the ceremony for April 4 – the birthday of her father, who died ten years ago. Her ashes would be placed next to his. But the service will have to wait because Washington’s governor, Jay Inslee, has banned gatherings of 10 people or more.

In the meantime, de los Angeles has worked to make sure her mother’s death certificate records her as a causality of the pandemic. The doctor who signed it did not have confirmed test results showing a COVID-19 infection at the time of her death, de los Angeles said, and listed the cause as “a viral illness, coronary artery disease and a respiratory disorder.” But the doctor has since moved to include coronavirus as a cause, at de los Angeles’ request.

As she waits for the funeral, de los Angeles has put the urn holding her mother’s ashes behind some flowers on the mantle in her living room. She says she can’t bear to look at it.

(Reporting by Tim Reid; Editing by Brian Thevenot)

Virus fight at risk as world’s medical glove capital struggles with lockdown

By Liz Lee and Krishna N. Das

KUALA LUMPUR (Reuters) – Disposable rubber gloves are indispensable in the global fight against the new coronavirus, yet a month’s lockdown in stricken Malaysia where three of every five gloves are made has upended the supply chain and threatens to hamstring hospitals worldwide.

The world’s biggest maker of medical gloves by volume, Top Glove Corp Bhd, has the capacity to make 200 million gloves a day, but a supplier shutdown has left it with only two weeks’ worth of boxes to ship them in, its founder told Reuters.

“We can’t get our gloves to hospitals without cartons,” Executive Chairman Lim Wee Chai said in an interview. “Hospitals need our gloves. We can’t just supply 50% of their requirement.”

The virus, which emerged in China at the end of last year, has left Malaysia with the highest number of infections in Southeast Asia at nearly 1,800 cases, with 17 deaths. To halt transmission, the government has ordered people to stay home from March 18 to April 14.

Glove makers and others eligible for exemption can operate half-staffed provided they meet strict safety conditions. Still, the Malaysian Rubber Glove Manufacturers Association (MARGMA) said it was lobbying “almost every hour” to return the industry to full strength to minimize risk to the global fight.

“We’re shut down,” said Evonna Lim, managing director at packaging supplier Etheos Imprint Technology. “We fall under an exempted category but still need approval.”

Dr Celine Gounder, an infectious diseases specialist at the New York University School of Medicine, said she was using up to six times as many gloves as normal each day due to the number of patients with COVID-19, the illness caused by the virus.

“If we get to the point where there is a shortage of gloves, that’s going to be a huge problem because then we cannot draw blood safely, we cannot do many medical procedures safely.”

GLOBAL CALL

With glove supplies dwindling, the U.S. Food and Drug Administration on its website this month said some gloves could be used beyond their designated shelf life. On Tuesday, the United States lifted a ban on imports from Malaysian glove maker WRP Asia Pacific who it had previously accused of using forced labor.

Britain’s Department of Health & Social Care has urged Malaysian authorities to prioritize the production and shipment of gloves that are of “utmost criticality for fighting COVID-19,” showed a letter dated March 20 to glove maker Supermax Corp and shared with Reuters.

MARGMA is considering rationing due to the “extremely high demand,” its president Denis Low told Reuters. “You can produce as many gloves as you can but then there’s nothing to pack them into.”

Under normal circumstances, Top Glove can meet less than 40% of its own packaging needs. For the remainder, it said just 23% of suppliers have gained approval to operate at half strength.

“We are lobbying almost every hour, we are putting in a lot of letters to the ministry,” said Low. “We are lobbying hard for the chemical suppliers and we want to ensure that the printers are also being given approval and any other supporting services, even transportation.”

In a statement, MARGMA said that as they were having to rely on half of their staff to work overtime during the lockdown, costs would rise by up to 30% and that buyers had agreed to bear that.

Malaysia’s Ministry of International Trade and Industry on Tuesday said it had received masses of applications to operate through the lockdown, and that it was seeking cooperation from industries to give way to those producing essential goods.

AUTOMATION

Developed economies are home to only a fifth of the world’s population yet account for nearly 70% medical glove demand due to stringent medical standards. At 150, U.S. glove consumption per-capita is 20 times that of China, latest MARGMA data showed.

MARGMA expects demand to jump 16% to 345 billion gloves this year, with Malaysia’s market share rising two percentage points to 65%. Thailand usually follows at about 18% and China at 9%.

Top Glove said orders have doubled since February and it sees sales rising by a fifth in the next six months. Its stock, with a market value of about $3.5 billion, has risen by a third this year versus a fall of 16% in the wider market.

The company, with customers in 195 economies, registered the highest net money inflow last week among listed Malaysian firms, along with peer Hartalega Holdings Bhd, showed MIDF Research data. Other glove makers include Kossan Rubber Industries Bhd and Careplus Group Bhd.

“We are fortunate enough to be in essential goods,” said Lim. “These few months and at least the next six months will be an all-time high in terms of sales volume, revenue and profit.”

With more than 80% of its 44 factories worldwide automated, Top Glove itself is less impacted by the lockdown than its more labor-intensive domestic suppliers. Packaging woes aside, however, ramping up production could turn under-supply into over-supply when the coronavirus outbreak finally subsides.

“This outbreak will create awareness and make humankind healthier,” said Lim. “People will pay more attention, they will invest more, they will buy more so demand will be more.”

(Reporting by Liz Lee and Krishna N. Das; Additional reporting by Ebrahim Harris and Daveena Kaur; Editing by Christopher Cushing)

U.S. FDA approves first rapid coronavirus test with 45 minutes detection time

By Kanishka Singh

(Reuters) – The U.S. Food and Drug Administration has approved the first rapid coronavirus diagnostic test, with a detection time of about 45 minutes, as the United States struggles to meet the demand for coronavirus testing.

The test’s developer, California-based molecular diagnostics company Cepheid, said on Saturday it had received an emergency use authorization from the FDA for the test, which will be used primarily in hospitals and emergency rooms. The company plans to begin shipping it to hospitals next week, it said.

The FDA confirmed its approval in a separate statement. It said the company intends to roll out the availability of its testing by March 30.

Under the current testing regime, samples must be sent to a centralized lab, where results can take days.

“With new tools like point-of-care diagnostics, we are moving into a new phase of testing, where tests will be much more easily accessible to Americans who need them,” U.S. Secretary of Health and Human Services Alex Azar said on Saturday.

The United States is not even close to meeting domestic demand for coronavirus testing. Many medical experts have predicted that delayed and chaotic testing will cost lives, potentially including those of doctors and nurses.

On Friday, Anthony Fauci, director of National Institute of Allergy and Infectious Diseases, was asked whether the United States can currently meet demand for tests.

“We are not there yet,” Fauci said.

The diagnostic test for the virus that causes COVID-19 has been designed to operate on any of Cepheid’s more than 23,000 automated GeneXpert Systems globally, the company said.

The systems do not require users to have special training to perform testing, and are capable of running around the clock, Cepheid President Warren Kocmond said in the statement.

The company did not give further details or say how much the test will cost.

The U.S. FDA has been pushing to expand screening capacity for the virus while the World Health Organization has called for “order and discipline” in the market for health equipment needed to fight the outbreak.

(Reporting by Kanishka Singh in Bengaluru; Editing by Sonya Hepinstall and Daniel Wallis)

Who gets the ventilator? British doctors contemplate harrowing coronavirus care choices

By Stephen Grey and Andrew MacAskill

LONDON (Reuters) – The coronavirus pandemic is forcing senior doctors in Britain’s National Health Service to contemplate the unthinkable: how to ration access to critical care beds and ventilators should resources fall short.

The country’s public health system, the NHS, is ill-equipped to cope with an outbreak that is unprecedented in modern times. Hospitals are now striving to at least quadruple the number of intensive care beds to meet an expected surge in serious virus cases, senior physicians told Reuters, but expressed dismay that preparations had not begun weeks earlier.

With serious shortages of ventilators, protective equipment and trained workers, the physicians said senior staff at hospitals were beginning to confront an excruciating debate on intensive care rationing, though Britain may be a long way from potentially having to make such decisions.

Rahuldeb Sarkar, a consultant physician in respiratory medicine and critical care in the English county of Kent, said local NHS trusts across the country were reviewing decision-making procedures drawn up, but never needed, during the 2009 H1N1 flu pandemic. They cover how to choose who, in the event of a shortage, would be put on a ventilator and for how long.

Decisions would always be based on an individual basis if it got to that point, taking into account the chance of survival, he said. But nevertheless, there would be difficult choices.

“It will be tough, and that’s why it’s important that you know, that two or more consultants will make the decisions.”

Sarkar said the choices extended not only to who was given access to a ventilator but how long to continue if there was no sign of recovery.

“In normal days, that patient would be given some more days to see which way it goes,” he added. But if the worst predictions about the spread of the virus proved correct, he suspected “it will happen quicker than before”.

Britain is by no means the only country that faces having its health system overwhelmed by COVID-19, but the data on critical care beds – a crucial bulwark against the disease – is concerning for UK authorities.

Italy, where the coronavirus has driven hospitals to the point of collapse in some areas and thousands have died, had about 12.5 critical care beds per 100,000 of its population before the outbreak.

That is above the European average of 11.5, while the figure in Germany is 29.2, according to a widely-quoted academic study https://link.springer.com/article/10.1007/s00134-012-2627-8 dating back to 2012 which doctors said was still valid. Britain has 6.6.

‘MANY TIMES MORE’ VENTILATORS

Estimates of the potential death toll in Britain range from a government estimate of around 20,000 to an upper end of over 250,000 predicted by researchers at Imperial College. As of March 19, 64,621 people had been tested, with 3,269 positive.

The NHS is preparing for the biggest challenge it has faced since it was founded after the ravages of World War Two, promising cradle-to-grave healthcare for all.

It was stretched long before COVID-19, struggling to adapt to the vast increase in healthcare demand in recent years. Some doctors complain that it is underfunded and poorly managed. About a tenth of its more than one million staff roles in the health service are vacant while almost nine out of 10 beds are occupied.

The department of health referred a request for comment to NHS England, which said it was crucial to reduce the coronavirus’s infection rate to ease peak pressure on the health system.

“Unmitigated, there is no health service in the world that would be able to cope if the virus let rip,” said NHS England head Simon Stevens. “In the meantime, what the NHS is doing, of course, is pulling out all the stops to make sure that we have as many staff, beds and other facilities available.”

So how many life-saving ventilators are needed?

Health Secretary Matt Hancock said on Sunday that hospitals had around 5,000 but that they needed “many times more than that”.

The physicians interviewed by Reuters said, if ventilators were secured, the aim was to increase intensive care beds from around 4200 to over 16,000, partly by using beds in other parts of hospitals.

Rob Harwood, a consultant anesthetist in Norfolk who has worked in the health service for almost four decades, said access to critical care could ultimately have to be determined by patient scoring systems for survivability. Systems developed for SARS, another coronavirus that broke out in 2003, could for example be refined, he added.

“Once you have exhausted your capacity and exhausted your ability to expand your capacity you probably have to make other decisions about admission into intensive care.”

But he emphasized that, for now, admission criteria would stay unaltered: “We are a country mile from that at the moment.”

‘BECOME CANNON FODDER’

While shortages of critical care equipment may be most alarming, the coronavirus has exposed how generally ill-equipped the health system is for a pandemic.

The British Medical Association said doctors have been asked to go to hardware stores and building sites to source protective masks.

Some doctors are worried about Public Health England’s (PHE) new advice last week which reduces the level of the protective equipment they need to wear.

Previously, staff on ward visits were told to wear full protective equipment, comprising high quality FFP3 face masks, visors, surgical gowns and two pairs of gloves. But the new advice recommends only a lower-quality standard paper surgical face mask, short gloves and a plastic apron.

PHE referred queries about doctors’ worries to the health department, which did not respond to requests for comment on the matter.

A senior NHS epidemiologist, who was not permitted to be named, told Reuters this advice was based on a sensible assessment of the biohazard risk of the virus. “It’s not Ebola,” the doctor said, pointing out the risk to medical staff without underlying medical conditions was low.

Matt Mayer, head of the local medical committee covering an area in south of England, said GPs had been sent face masks in boxes that said “best before 2016” and that have been relabeled with new stickers reading “2021”.

“If you are going to lead people into a hazardous situation then you need to give them the confidence that they have the kit to do a decent job and they are not just going to become cannon fodder,” said Harwood the anesthetist.

The department of health said that they had tested certain products to see if it is possible to extend their use.

“The products that pass these stringent tests are subject to relabelling with a new shelf-life as appropriate and can continue to be used,” a spokesman said.

RAPID GUIDELINES

Dr Alison Pittard, dean of the Faculty of Intensive Medicine and a consultant in Leeds, northern England, said there had been chronic underinvestment in critical care in Britain. But she said the country was not yet at the stage where it had to make calls about rationing patient resources.

She said, if rationing became necessary, medical ethics should still prevail and guidelines needed to be issued on a national level so that no patient was worse off based on where they lived. The NHS might need also need the advice of military leaders, she said, on how to effectively triage.

“If we got to a difficult position where we had to exhaust every bit of resource in the country then, yes, we may have to change the way we approach the decision-making.”

Stephen Powis, the National Medical Director of NHS England, said there were plans to issue new guidance to give doctors advice on how to make difficult decisions if there was a surge in coronavirus cases, like in Italy.

The National Institute for Health and Care Excellence (NICE) said on Friday it would shortly announce a “series of rapid guidelines” on the management of people with suspected and confirmed COVID-19, including in critical care.

The guidelines are not, however, expected to be prescriptive but to suggest leaving key decisions to individual doctors.

Pittard said patients with pre-existing conditions who already had life-threatening health difficulties should be having conversations with their family about how they wished to spend their last days, in the event of them being infected.

“If I get coronavirus now I’ve got a very high chance of dying of it,” she said, putting herself into the shoes of such a patient. “So do I want to die in hospital and when my relatives can’t come in to visit me because it’s too risky, or would I like to die at home?

“And if I do want to go into hospital, do I then want to go to intensive care where my chances of surviving are minimal?”

(Editing by Guy Faulconbridge and Pravin Char)

Special Report: Iran’s leader ordered crackdown on unrest – ‘Do whatever it takes to end it’

By Reuters staff

(Reuters) – After days of protests across Iran last month, Supreme Leader Ayatollah Ali Khamenei appeared impatient. Gathering his top security and government officials together, he issued an order: Do whatever it takes to stop them.

That order, confirmed by three sources close to the supreme leader’s inner circle and a fourth official, set in motion the bloodiest crackdown on protesters since the Islamic Revolution in 1979.

About 1,500 people were killed during less than two weeks of unrest that started on Nov. 15. The toll, provided to Reuters by three Iranian interior ministry officials, included at least 17 teenagers and about 400 women as well as some members of the security forces and police.

The toll of 1,500 is significantly higher than figures from international human rights groups and the United States. A Dec. 16 report by Amnesty International said the death toll was at least 304. The U.S. State Department, in a statement to Reuters, said it estimates that many hundreds of Iranians were killed, and has seen reports that number could be over 1,000.

The figures provided to Reuters, said two of the Iranian officials who provided them, are based on information gathered from security forces, morgues, hospitals and coroner’s offices.

The government spokesman’s office declined to comment on whether the orders came from Khamenei and on the Nov. 17 meeting. Iran’s mission to the United Nations did not respond to a request for comment for this story.

What began as scattered protests over a surprise increase in gasoline prices quickly spread into one of the biggest challenges to Iran’s clerical rulers since the 1979 Islamic Revolution.

By Nov. 17, the second day, the unrest had reached the capital Tehran, with people calling for an end to the Islamic Republic and the downfall of its leaders. Protesters burned pictures of Khamenei and called for the return of Reza Pahlavi, the exiled son of the toppled Shah of Iran, according to videos posted on social media and eye witnesses.

That evening at his official residence in a fortified compound in central Tehran, Khamenei met with senior officials, including security aides, President Hassan Rouhani and members of his cabinet.

At the meeting, described to Reuters by the three sources close to his inner circle, the 80-year-old leader, who has final say over all state matters in the country, raised his voice and expressed criticism of the handling of the unrest. He was also angered by the burning of his image and the destruction of a statue of the republic’s late founder, Ayatollah Ruhollah Khomeini.

“The Islamic Republic is in danger. Do whatever it takes to end it. You have my order,” the supreme leader told the group, one of the sources said.

Khamenei said he would hold the assembled officials responsible for the consequences of the protests if they didn’t immediately stop them. Those who attended the meeting agreed the protesters aimed to bring down the regime.

“The enemies wanted to topple the Islamic Republic and immediate reaction was needed,” one of the sources said.

The fourth official, who was briefed on the Nov. 17 meeting, added that Khamenei made clear the demonstrations required a forceful response.

“Our Imam,” said the official, referring to Khamenei, “only answers to God. He cares about people and the Revolution. He was very firm and said those rioters should be crushed.”

Tehran’s clerical rulers have blamed “thugs” linked to the regime’s opponents in exile and the country’s main foreign foes, namely the United States, Israel and Saudi Arabia, for stirring up unrest. Khamenei has described the unrest as the work of a “very dangerous conspiracy.”

A Dec. 3 report on Iran’s state television confirmed that security forces had fatally shot citizens, saying “some rioters were killed in clashes.” Iran has given no official death toll and has rejected figures as “speculative.”

“The aim of our enemies was to endanger the existence of the Islamic Republic by igniting riots in Iran,” said the commander-in-chief of the elite Revolutionary Guards Corps, Hossein Salami, last month, according to Iranian media.

The Revolutionary Guards declined to comment for this report.

Iran’s interior minister said on Nov. 27 more than 140 government sites had been set on fire along with hundreds of banks and dozens of petrol stations, while 50 bases used by security forces were also attacked, according to remarks reported by Iran’s state news agency IRNA. The minister said up to 200,000 people took part in the unrest nationwide.

“SMELL OF GUNFIRE AND SMOKE”

For decades, Islamic Iran has tried to expand its influence across the Middle East, from Syria to Iraq and Lebanon, by investing Tehran’s political and economic capital and backing militias. But now it faces pressure at home and abroad.

In recent months, from the streets of Baghdad to Beirut, protesters have been voicing anger at Tehran, burning its flag and chanting anti-Iranian regime slogans. At home, the daily struggle to make ends meet has worsened since the United States reimposed sanctions after withdrawing last year from the nuclear deal that Iran negotiated with world powers in 2015.

The protests erupted after a Nov. 15 announcement on state media that gas prices would rise by as much as 200% and the revenue would be used to help needy families.

Within hours, hundreds of people poured into the streets in places including the northeastern city of Mashhad, the southeastern province of Kerman and the southwestern province of Khuzestan bordering Iraq, according to state media. That night, a resident of the city Ahvaz in Khuzestan described the scene by telephone to Reuters.

“Riot police are out in force and blocking main streets,” the source said. “I heard shooting.” Videos later emerged on social media and state television showing footage of clashes in Ahvaz and elsewhere between citizens and security forces.

The protests reached more than 100 cities and towns and turned political. Young and working-class demonstrators demanded clerical leaders step down. In many cities, a similar chant rang out: “They live like kings, people get poorer,” according to videos on social media and witnesses.

By Nov. 18 in Tehran, riot police appeared to be randomly shooting at protesters in the street “with the smell of gunfire and smoke everywhere,” said a female Tehran resident reached by telephone. People were falling down and shouting, she added, while others sought refuge in houses and shops.

The mother of a 16-year-old boy described holding his body, drenched in blood, after he was shot during protests in a western Iranian town on Nov. 19. Speaking on condition of anonymity, she described the scene in a telephone interview.

“I heard people saying: ‘He is shot, he is shot,’” said the mother. “I ran toward the crowd and saw my son, but half of his head was shot off.” She said she urged her son, whose first name was Amirhossein, not to join the protests, but he didn’t listen.

Iranian authorities deployed lethal force at a far quicker pace from the start than in other protests in recent years, according to activists and details revealed by authorities. In 2009, when millions protested against the disputed re-election of hardline President Mahmoud Ahmadinejad, an estimated 72 people were killed. And when Iran faced waves of protests over economic hardships in 2017 and 2018, the death toll was about 20 people, officials said.

Khamenei, who has ruled Iran for three decades, turned to his elite forces to put down the recent unrest — the Revolutionary Guards and its affiliated Basij religious militia.

A senior member of the Revolutionary Guards in western Kermanshah province said the provincial governor handed down instructions at a late-night emergency meeting at his office on Nov. 18.

“We had orders from top officials in Tehran to end the protests, the Guards member said, recounting the governor’s talk. “No more mercy. They are aiming to topple the Islamic Republic. But we will eradicate them.” The governor’s office declined to comment.

As security forces fanned out across the country, security advisors briefed Khamenei on the scale of the unrest, according to the three sources familiar with the talks at his compound.

The interior minister presented the number of casualties and arrests. The intelligence minister and head of the Revolutionary Guards focused on the role of opposition groups. When asked about the interior and intelligence minister’s role in the meeting, the government spokesman’s office declined to comment.

Khamenei, the three sources said, was especially concerned with anger in small working-class towns, whose lower-income voters have been a pillar of support for the Islamic Republic. Their votes will count in February parliamentary elections, a litmus test of the clerical rulers’ popularity since U.S. President Donald Trump exited Iran’s nuclear deal — a step that has led to an 80% collapse in Iran’s oil exports since last year.

Squeezed by sanctions, Khamenei has few resources to tackle high inflation and unemployment. According to official figures, the unemployment rate is around 12.5% overall. But it is about double that for Iran’s millions of young people, who accuse the establishment of economic mismanagement and corruption. Khamenei and other officials have called on the judiciary to step up its fight against corruption.

“BLOOD ON THE STREETS”

Officials in four provinces said the message was clear — failure to stamp out the unrest would encourage people to protest in the future.

A local official in Karaj, a working-class city near the capital, said there were orders to use whatever force was necessary to end the protests immediately. “Orders came from Tehran,” he said, speaking on condition of anonymity. “Push them back to their homes, even by shooting them.” Local government officials declined to comment.

Residents of Karaj said they came under fire from rooftops as Revolutionary Guards and police on motorcycles brandished machine guns. “There was blood everywhere. Blood on the streets,” said one resident by telephone. Reuters could not independently verify that account.

In Mahshahr county, in the strategically important Khuzestan province in southwest Iran, Revolutionary Guards in armored vehicles and tanks sought to contain the demonstrations. State TV said security forces opened fire on “rioters” hiding in the marshes. Rights groups said they believe Mahshahr had one of the highest protest death tolls in Iran, based on what they heard from locals.

“The next day when we went there, the area was full of bodies of protesters, mainly young people. The Guards did not let us take the bodies,” the local official said, estimating that “dozens” were killed.

The U.S. State Department has said it has received videos of the Revolutionary Guards opening fire without warning on protesters in Mahshahr. And that when protesters fled to nearby marshlands, the Guards pursued them and surrounded them with machine guns mounted on trucks, spraying the protesters with bullets and killing at least 100 Iranians.

Iran’s authorities dispute the U.S. account. Iranian officials have said security forces in Mahshahr confronted “rioters” who they described as a security threat to petrochemical complexes and to a key energy route that, if blocked, would have created a crisis in the country.

A security official told Reuters that the reports about Mahshahr are “exaggerated and not true” and that security forces were defending “people and the country’s energy facilities in the city from sabotage by enemies and rioters.”

In Isfahan, an ancient city of two million people in central Iran, the government’s vow to help low-income families with money raised from higher gas prices failed to reassure people like Behzad Ebrahimi. He said his 21-year-old nephew, Arshad Ebrahimi, was fatally shot during the crackdown.

“Initially they refused to give us the body and wanted us to bury him with others killed in the protests,” Ebrahimi said. “Eventually we buried him ourselves, but under the heavy presence of security forces.” Rights activists confirmed the events. Reuters was unable to get comment from the government or the local governor on the specifics of the account.

(Editing by Michael Georgy, Cassell Bryan-Low and Jason Szep)

Change in New York State law to usher in ‘tidal wave’ of child sex abuse lawsuits

New York Governor Andrew Cuomo speaks during a news conference in New York, U.S., September 14, 2018. REUTERS/Shannon Stapleton

By Tom Hals

(Reuters) – Thousands of child sexual abuse lawsuits are expected to flow into New York State courts in the coming weeks exposing decades-old misconduct at schools, hospitals, churches and youth clubs, according to lawyers for victims.

On Aug. 14, the Child Victims Act takes effect, giving people one year to sue over allegations of sexual abuse, regardless of when they said it occurred.

Under the law signed by Governor Andrew Cuomo in February, New York has gone from one of the toughest states to bring a case because of its strict statute of limitations to one of the easiest, potentially unleashing decades of unresolved claims.

“It’s going to be a tidal wave of litigation,” said lawyer Mitchell Garabedian, best known for representing victims of child abuse by Roman Catholic priests in the Archdiocese of Boston.

Cases will cut across society, illustrating the systemic nature of the abuse, victims’ lawyers said, although they expect many of the lawsuits to be against Catholic organizations and the Boy Scouts of America.

Both the scouts and the church said they were cooperative with people making allegations of abuse against their organizations.

“We believe victims, we support them, we pay for counseling by a provider of their choice, and we encourage them to come forward,” the Boy Scouts of America said in a statement.

New York State Catholic Conference spokesman Dennis Poust said that Catholic leaders dropped opposition to the new law once it was broadened to include public institutions.

“All survivors deserve to be heard,” Poust said.

The Child Victims Act arrives as victims have been empowered by the #MeToo movement and a steady stream of scandals, exposing a range of abusers from public figures to the team doctor of USA Gymnastics.

Lawyers for victims said they were teaming up to maximize resources and reconnecting with old clients whose cases were barred by the statute of limitations.

Jeff Anderson, who specializes in clergy sex abuse cases, said his law firm has dedicated almost 100 people to New York cases.

‘COME FORWARD’

After several states made it easier to sue, TV ads soliciting child sex abuse lawsuits spiked to more than 1,700 in both March and April, up from just 46 in January, according to X Ante, a consulting firm that tracks lawyer ad spending.

“If you were abused in a scouting program you are not alone,” said an ad by San Diego, California-based AVA Law Group, which X Ante said was one of the most frequently broadcast. “Come forward. New laws may allow you a path to significant financial compensation.”

However, victims and advocates often say the money is secondary, and many sue to expose perpetrators, hold organizations accountable and to further the healing process.

Some organizations, including the Boy Scouts of America, are acknowledging abuse, apologizing and reporting the accused to law enforcement authorities.

Others have offered compensation. The Archdiocese of New York has paid $65 million to 325 people since 2017. Only one person rejected an offer, according to the archdiocese.

Those who accept an offer give up their right to sue. Some victim advocates said compensation programs kept stories of abuse secret.

“I think the potential is huge for all kinds of things coming to the surface like we’re seeing with Epstein,” said victims’ attorney James Marsh, referring to the criminal sex trafficking charges against the once politically connected American financier Jeffrey Epstein. He pleaded not guilty and is jailed pending trial.

Victims’ lawyers said insurance policies will provide a significant amount of money. The Archdiocese of New York and the Boy Scouts of America have already become embroiled in disputes over insurance coverage.

The Travelers Cos have said they are planning to bolster reserves related to laws reviving old abuse claims.

Coordinating scores of lawsuits against an organization could also be difficult, although few New York cases are expected to go to trial.

Many lawyers said they expect organizations to file for bankruptcy, which would stop the litigation and create one forum where all the claims can be settled at once.

“Bankruptcy is the way to go,” said lawyer Tim Kosnoff, who specializes in cases against the Boy Scouts. “Most clients come out of it pretty satisfied.”

(Reporting by Tom Hals in Wilmington, Delaware; Editing by Noeleen Walder and Grant McCool)

Venezuela healthcare collapse: Four children die in same hospital this month

Relatives carry a coffin containing the body of Erick Altuve, a 11-year-old boy who died from respiratory problems while in care for stomach cancer at the public Jose Manuel de los Rios hospital, at Petare neighborhood in Caracas, Venezuela, May 30, 2019. REUTERS/Ivan Alvarado

By Vivian Sequera

CARACAS (Reuters) – Under a wooden arch decorated with white balloons in a small house in Caracas’ largest slum, the body of 11-year-old Erick Altuve lay in a small coffin covered in cuddly toys and cartoon drawings, one of four children who have died this month in Venezuela’s main pediatric hospital.

Altuve died on May 26 from respiratory problems while being treated for stomach cancer at the Jose Manuel de los Rios public hospital, a concrete tower ringed by a white security fence in the center of Caracas.

For the past six months, Altuve had not received his medication, his mother, Jennifer Guerrero, said, because of widespread shortages of drugs and medical equipment that have devastated Venezuela’s health system.

“My son really wanted to live,” said Guerrero, a 30-year-old housewife, during a protest over the deaths of the four children by their relatives and nurses outside the hospital.

Children have paid an especially heavy price from the collapse in Venezuela’s healthcare system as the economy has shrunk by over a half during six years of recession.

The most recent figures from Venezuela’s Health Ministry show that infant mortality, covering children age 1 and below, rose 30% to 11,466 cases in 2016 from the year before. There is no official data on children’s’ deaths from cancer.

More broadly, the mortality rate for children under 5 years has risen by 40% since 2000, the humanitarian group Save the Children said in its 2019 report.

Altuve’s death in particular has generated a wave of anger and grief across Venezuela, with outraged newspaper headlines, calls from the opposition for an investigation and an outcry from medical nongovernmental organizations.

Altuve and the three other children who died were part of a group of 30 kids at the hospital, better known as JM, waiting to go to Italy to receive bone marrow transplants under a 2010 agreement financed by the Venezuelan government that was intended to cover the cost of transportation and the operation.

The opposition has blamed their deaths on President Nicolas Maduro, whose socialist administration has presided over the collapse of the once-wealthy nation’s economy and severe reductions in health-care spending.

Maduro’s government, however, says U.S.-imposed sanctions were responsible for the children’s deaths, by freezing funds allocated to buy medicine and send the children to Italy for treatment under the 2010 agreement.

Maduro’s critics noted that his government in 2013 cut the allocation of foreign currency to the health sector by one-fifth.

According to hospital and pharmacy representatives, the supply of medicine and medical equipment has steadily declined since the cuts to dollar funding in 2013, while the U.S. government began to impose sanctions in August 2017.

Virginia Segovia, president of the Foundation to Help Children with Cancer (Fundanica) in Carabobo state west of Caracas, said that in its first 22 years, the charity registered 98 child deaths from the disease in that region.

“In the past two years, we already have 105 dead children … and that is due to the lack of supplies and equipment in hospitals, the extreme emergency we have due to lack of medicines and chemotherapy,” she said.

Venezuela’s Information Ministry, which handles news media inquiries, and the health ministry did not respond to requests for comment.

‘SENTENCED TO DEATH’

Altuve was taken to the JM hospital on Dec. 25, 2018, due to a sharp pain in his stomach, his mother said. The hospital cleared him to go home after a few days but he returned on Jan. 14, 2019 and never left, according to his mother.

“He was saying that he was going to get better and the cancer wouldn’t take him,” his mother said.

On Friday, dozens of mourners carried his coffin through the narrow streets of Caracas’ eastern Petare slum from his grandparents’ house where the wake was held to a cemetery outside the city.

Children from his school clustered around to say goodbye as speakers played Vallenato, accordion-based music from Colombia’s Caribbean coast. “Erick, one more angel in heaven,” read a note on the coffin.

Venezuelan Foreign Minister Jorge Arreaza said on Monday that state-run oil firm PDVSA had signed a cooperation agreement in 2010 with Italy’s bone marrow transplant association. State-funded Venezuelan television network Telesur reported on Tuesday that the agreement had funded treatment and transplants for almost 900 patients since then.

Arreaza said on Twitter that U.S. sanctions had frozen 1.6 billion euros ($1.78 billion) of government funds held at Portugal’s Novo Banco, including 5 million euros ($5.57 million) allocated for fund bone marrow transplants for 24 Venezuelan patients.

Novo Banco and the Italian transplant association did not respond to requests for comment.

There are 52,800 new cases of cancer among adults each year in Venezuela, which has a population of 30 million people, according to Juan Saavedra, director of Venezuela’s anti-cancer society. In 2017, 26,510 people died from cancer, 15% more than the year before, Saavedra said.

“When you are born in Venezuela, you are already sentenced to death,” said Mauricio Navas, whose six-year-old daughter Mariana is being treated for leukemia at the JM hospital.

(Additional reporting by Tibisay Romero; Writing by Angus Berwick; Editing by Daniel Flynn and Jeffrey Benkoe)

Doctors go underground as Syrian government attacks rebel northwest

A general view of the Syrian town of Atimah, Idlib province, seen in this picture taken from Reyhanli, Hatay province, Turkey October 10, 2017. REUTERS/Osman Orsal

By Amina Ismail

BEIRUT (Reuters) – In part of northern Syria’s last rebel enclave, doctors have pulled back into cave shelters to treat the wounded and protect their patients from a government offensive that has hit health centers and hospitals.

The assault began in late April with air strikes, barrel bombs and shelling against the southern flank of the enclave, centered on Idlib province and nominally under the protection of a Russian-Turkish ceasefire agreed more than eight months ago. Limited ground advances have additionally taken place this week.

“The makeshift hospitals are very primitive,” Osama al-Shami, a 36-year-old doctor, told Reuters from the area. “We can barely save lives with the equipment we have and many of the injured die because of the lack of resources and equipment.”

The insurgents, dominated by the jihadist Tahrir al-Sham, describe the offensive as an invasion while the government accuses the rebels of violating the deal.

President Bashar al-Assad has sworn to take back every inch of Syria and the enclave including Idlib is the last big bastion of the rebellion that flared against him 2011.

The United Nations said last year that half of the region’s 3 million inhabitants had fled their homes, and the bombing has now caused a new wave of displacement.

More than 150,000 had left since April 29, The U.N. said on Tuesday, with bombs falling on over 50 villages, destroying at least 10 schools and hitting at least 12 health centers.

Under the bombs, medics are turning back to tactics used at other times in the eight-year war, moving patients into shelters under buildings or hacked into the ground. Some are opening up their houses as temporary health centers, said one surgeon.

But they are getting overwhelmed and Shami said several wounded children had died in his arms.

“One of them was a nine-year-old child who had a head and a chest injury and was severely bleeding. We tried to resuscitate him but he died within 15 minutes. There are no blood banks nearby or an equipped operating theater,” he said.

FRENCH, BRITISH CONCERNS

A war monitor, the Syrian Observatory for Human Rights, said that, in the latest escalation of fighting and bombardments, 188 people including 85 civilians had been killed since April 30.

France’s President Emmanuel Macron said on Tuesday he had “grave concerns” over the escalation of violence in Syria including the strikes on hospitals.

British Foreign Secretary Jeremy Hunt called the offensive a “flagrant violation of the ceasefire agreement”.

Backed by Russian air power and Iran-backed militias, Assad has retaken most of Syria.

U.S.-backed Kurdish forces hold the country’s northeast quarter, while control of the northwest is divided between jihadist groups and rebel factions supported by Turkey.

The current government offensive is focused on the southern flank of the rebel enclave.

On Wednesday, the Syrian army advanced into the town of Kafr Nabouda, rebels and a military media unit run by Assad’s ally Hezbollah reported.

The Observatory said fighters of Tahrir al-Sham – an incarnation of the former al-Qaeda affiliate the Nusra Front – launched a suicide attack against the army, detonating a bomb in an armored vehicle.

Rebels said heavy fighting continued at the town – close to where Shami is running his makeshift clinic – while the Hezbollah media unit said the army had gained complete control of it.

(Reporting By Amina Ismail, writing by Angus McDowall; editing by John Stonestreet)