MOSCOW -- As the COVID-19 epidemic continues to sweep Russia, doctors say they are increasingly forced to make daunting choices regarding the use of limited resources, or are concerned about the looming prospect of having to do so.
"We will use everything we have," said intensive-care doctor Nikolai Osadchy of Hospital No. 4 in Perm, some 1,400 kilometers east of Moscow, which has not yet begun accepting COVID-19 patients.
"We have 18 respirators for 18 intensive-care beds, although only three of them are modern ones suitable for COVID-19 patients.... We have two or three free beds in the intensive-care ward at the moment. If all of a sudden.... I guess we could open up our operating theaters, but that is also a finite resource. We have nine operating rooms and nine ventilators. And that is it."
RFE/RL spoke with 20 intensive-care doctors from across the country about the ongoing crisis, as the number of coronavirus infections in Russia exceeded 317,000, according to official figures that many suspect are significantly understated. As of May 21, Russia had registered 3,099 COVID-19 fatalities.
All of the doctors interviewed by RFE/RL said they had heard of cases, even before the pandemic, in which scarce medical resources had to be allocated, leaving some critically ill patients without the care they required. None of them, however, spoke in specific terms even under condition of anonymity because of the serious potential legal ramifications of such matters.
Some were quoted on condition they be cited using first-name pseudonyms. Hospital doctors who do not work in intensive care generally told RFE/RL they had never heard of such cases -- a possible indication that intensive-care doctors take great pains to not even discuss such issues with close colleagues.
Anastasia Vasilyeva, a physician who heads the nongovernmental medical professional organization Doctors' Alliance, says she does know of instances during Russia's COVID-19 battle when doctors "were forced to make choices in favor of the patient who has the best chance of surviving."
"Such a choice is definitely against the law, but what is a doctor to do?" she told RFE/RL. "This is an emergency situation that has pushed aside all mundane legal norms. Doctors are forced to take risks and a sort of natural selection is taking place. There is nothing to be done about that, as horrible as it sounds. It is such a difficult matter that it is hard for me to even discuss it."
Like many countries coping with a mass of COVID-19 cases, Russia faces shortages of crucial ventilators that are needed to help patients breathe when their lungs fill with fluids and their blood-oxygen saturation falls. Many of the respirators in Russian hospitals are old, dating even from the Soviet period, and inadequate for treating COVID-19 patients.
Russia's situation was made more acute earlier this month when the government suspended the use of Aventa-M ventilators after they were linked to fatal hospital fires in Moscow and St. Petersburg. There are more than 1,000 such ventilators in Russian hospitals and just this month nearly 200 of them were rushed to hospitals in Moscow and St. Petersburg.
The government's official position is that Russia has all the equipment it needs to cope with the emergency. However, during a meeting with President Vladimir Putin on April 8, St. Petersburg Governor Aleksandr Beglov complained his city faced a shortage of 1,680 ventilators. The press services of the Health Ministry and the Moscow Health Department declined to respond to questions for this story.
"Yesterday we had a male patient whose CT scan showed 75 percent of his lungs affected by COVID-19," one intensive-care doctor from a Moscow hospital told RFE/RL. "He was stable and walking under his own power, feeding himself, conversing. He was 45 years old and for four or five days he had had a fever around 40 degrees Celsius. But in the evening, his blood-oxygen saturation fell sharply and he developed cyanosis. But our intensive-care unit was full. The head doctor and I were the only ones there."
"We gave him prednisolone and ran him to intensive care," the doctor continued. "It was full. There was an elderly man who'd suffered a heart attack. He had a broken rib and other issues. In short, he was hardly moving and hadn't opened his eyes for 10 days. It was a very serious case, plus he had COVID-19. We had to take him off the ventilator and hook up the young man in order to save him."
"Sometimes serious cases are transferred to the wards in order to free up intensive care for young patients who suddenly take a turn for the worse," the doctor said. In this particular case, the doctor said, the 45-year-old patient died, while the elderly man was stabilized.
RFE/RL has not been able to independently verify the doctor's account.
'A No-Win Situation'
Shortages of critical equipment, particularly ventilators, have been a common issue for Russian doctors for years -- one that has been exacerbated, not created, by the coronavirus emergency.
"Our hospital has 12 intensive-care beds and three ventilators," said Natalya, who works at a hospital in a medium-sized central Russian city. "When it happens that all the machines are busy but some patient suddenly gets worse, we start using whatever we have -- we bring in breathing apparatuses from the operating rooms or use Faza ventilators that were created for field use by the military. They are very old, don't meet any contemporary standards, harm the lungs, and shouldn't be used in hospitals. Once I saw a patient intubated and connected to an Ambu bag [a hand-operated device for the temporary ventilation of the lungs].... I have several times witnessed examples of 'euthanasia,' but have never had to participate in one."
Russian doctors often use the term "euthanasia" as a sort of euphemism for making clinical determinations on the allocation of resources.
Larger hospitals face similar issues. Ivan, an intensive-care doctor at a large hospital in St. Petersburg, told RFE/RL that his ward was always full and virtually every patient required a ventilator. Some of them, he said, must be attached to "metal garbage," meaning hopelessly outdated equipment that is often from the Soviet era.
"Sometimes a doctor will call me and say, 'Take this old woman into intensive care -- she seems to be dying,'" he said. "And I go to the ward and find three dying old women and all three of them need to go to intensive care and be put on ventilation. But I simply don't have the machines. There is nothing to be done and three people are dying. It is a no-win situation. Later, the doctor won't even call me in such cases and the patients will just die in the wards. And that was even without a pandemic."
Hospital administrators, Ivan said, do their best not to attract attention to such cases. "In the case files, they write that the patient died in the ward from heart failure," he said. "If there is clear evidence of hypoxia, then there might be a note saying that the patient had been intubated and given CPR."
'Comrades In The Offices'
Front-line doctors often find themselves squeezed between the needs of patients and the demands of hospital administrators and, even, prosecutors. Armen Oganesyan, the head of anesthesiology and intensive care at a large Moscow clinic, wrote in a Facebook post that he later deleted that "the comrades in the offices are always waiting for doctors' mistakes."
Vasilyeva of the Doctors' Alliance agrees, saying that Federal Medical Insurance Foundation checks all case files marked with code U07 (indicating trauma of the lungs, including COVID-19), while the Federal Health Inspectorate (Roszdravnadzor) has requested the case files of all patients who die in hospitals.
"The Investigative Committee is also sitting and waiting," she added. "This is an enormous number of people who are checking to see if everyone was intubated and if there were intensive-care beds for everyone."
"If, God forbid, someone from outside the hospital starts looking around, the management of the hospital will begin blaming the doctors," St. Petersburg intensive-care physician Ivan said. "There will be a big investigation but the result is always the same -- the doctor who is responsible for the story getting out will, at the very least, be fired."
Viktor, an intensive-care physician in Moscow, agreed. "This has always been a problem," he said. "Even in medical school they tell us that case histories are written for prosecutors. Everyone writes it their own way -- 'progressive heart failure,' 'there wasn't time to hook up a ventilator,' or 'the patient died on the way to intensive care.'"
"Even after an earthquake or a mass illness, nobody will admit that someone didn't receive full care," Oganesyan told RFE/RL. "Such a situation will be viewed as a mistake by a specific on-duty doctor because any chief doctor will say: 'In the next room there was back-up equipment and he didn't use it. He could have called me and I would have organized everything.'"
'Optimized' To The Bone
The COVID-19 crisis is exposing the weaknesses of Russia's medical system, which has been the subject of "optimization" -- a government policy to improve care by streamlining the health-care sector -- for years now.
"On paper, we have everything," Oganesyan said. "Machines, medicine, disposable materials, the best doctors, and even 'psychologists who work with patients' families.' But I know how things really are, how doctors write on specialized forums that they don't have one thing or another. That there are four nurses working in an intensive-care unit with 30 beds. But is society ready to talk about this?"
"The tip of the iceberg here looks good," he concluded. "Some particular institute or some specialist is doing world-class operations. Modern cancer treatments have become available. But mass medical care has remained on its low, post-Soviet level. We have all seen photographs of hospitals where -- even after 20 years of [surplus state budgets brought about primarily by high global energy prices] -- the walls haven't been painted and the toilets haven't been replaced."
"No matter how many emergency situations we have had -- floods, terrorism, now this virus -- we haven't learned any lessons," he said. "The system wasn't properly designed or financed and it remains that way -- unprepared, false, working not for the patients but for reports [to higher-ups]. It is not acceptable to work in a deficit situation even during the good times because there will be no reserve for an emergency."