I find it strange that all we hear about these days is the shortage of ventilators (okay, PPE too), as if it’s the only bottleneck. The reality is ventilators are useless without intensivists to operate them, and you need anesthesiologists and probably other skilled personnel too.
I learned through a personal connection who was actually on the ground in Hubei (but not Wuhan) caring for serious but non-ICU patients that doctors and nurses in their ward outnumbered patients, and they were at capacity. The staff-to-patient ratio should be higher in the ICU. With an overwhelming number of patients you simply can’t care for them, whether you have the machines or not.
It’s relatively easy to ramp up production of machines. It’s much harder to ramp up production of medical professionals.
> It’s much harder to ramp up production of medical professionals.
I have a mixed opinion on this. In particular, I don't think we really need to create more skilled medical professionals, we just need to change the way they work.
Most of doctors have exposure to the basics of intubating and ventilation through medical school. Those without direct critical care experience would likely be absolutely terrible at it. However, they all still have the baseline knowledge. They're able to assess patients, read charts, and report on vitals.
I just asked my wife (a psychiatry resident) if she could intubate/ventilate a patient. Here response was, "If I were the last person alive, I could intubate. You wouldn't want me to do it, but I could do it. I don't know how to run a vent, but I'm sure I could figure it out if I consulted with a doctor/therapist that does". I think most non-critical care doctors would express the same opinion.
What I'm getting at is we have a large amount of doctors that can act as multipliers for intensivists, hospitalist, ER docs, and pulmonologists. They are able to do much of the time consuming work while relying on specialists to guide overall care plan and intervene the on most challenging cases.
----
Given how medicine works, the chances of actually seeing this in action are low. But....it's an options.
If you repeat the same task 20 times a day you rapidly become an expert at it. If all the patients have exactly the same condition I would assume that the staff would quickly upskill to treat that condition.
I’m not a medical professional so hopefully someone more knowledgeable and confirm or counter.
From what I’m reading the treatment of COVID19 seems to require a pretty narrow set of practices. Mostly around monitoring, administering of medication, ventilation / oxygen and general bedside care. If this is true can we not cross train adjacent areas like EMT, army medics etc fairly quickly to provide care? They don’t even need to perform diagnostics.
Is there any evidence that access to medical professionals is a bottleneck? Even after all elective surgeries and routine doctor visits have been postponed? All the stories I've been seeing from other Western countries that have already reached peak capacity say that ventilators, not medical professionals are the real bottleneck.
> It’s much harder to ramp up production of medical professionals.
and the fact that we think about "ramping up production" of "medical personel" leads the way to terrible industry-like education systems which emphasize cost-efficiency rather than quality education.
I think about this whenever I think about how many expert frontline healthcare workers we’re going to lose in the coming months, especially considering the state of PPE in the USA. It may not show up immediately in economic metrics, but we will be losing untold man years of training and expertise.
Another shortage is lack of ambulances to take you to the ventilators as demonstrated in NYC already as more and more drivers and personnel are already sick and not allowed to work
Once you are on a ventilator for covid19 you tend to monopolize it for 2+ weeks, hence the endless need for more machines
This conversation begins when the number of residencies increases. And that will not change until congress approves more funding for residencies. Until then, there will be no change.
If only there were a nation, so far unaffected by the virus, with a large number of skilled medical professionals willing to travel to other countries and help. I'm sure if such a place existed, the US would be negotiating right now to get a supply of such medical professionals. And certainly wouldn't be sabotaging that country's ability to aid other countries /s.
Saying it is easy to ramp up machinery implies that it actually is... while your point that human capital is more valuable than tools is correct, ask yourself why a sophisticated pump costs 10k$ and requires a medically trained person to operate it.
There is a lot of money to be made by keeping these barriers in place, through legal, technical means and by limiting people’s access to “experts” that know what to do with them.
I've been wondering if there is any way to improve this as well. Say we get the new ventilators but now we're short on people. You can't overnight train nurses, but can you get people just enough training for this specific task? Is there any inefficiencies in the process of dealing with these patients that can be improved? Can some of these tasks be delegated to less experienced people who can be trained quickly, while the processes that need in depth knowledge and experience can still be performed by the qualified health care workers?
Right, so it's a mistake to make ventilators, masks, PPE, all pointless in your opinion. Give up now we should.
The actual very interesting issue right now with ventilators is that there's companies in the US that make them and they say no one is ordering them. They cost around $25,000 each. Hospitals and states are sitting around waiting for the federal government to buy them and gift them to them, and whining that everything is the government's fault when that doesn't happen.
Documentation will be one of the biggest bottle necks. You can not do anything in the system without documenting every single item you used or action you have taken. It takes huge amounts of time. These doctors could increase the patients they see I would guess 10 fold if they didn’t have to document every detail. But it would be hard to bill without the details and for some things documentation is critical and important. In a triage situation however a lot of stuff could be ignored completely and focus solely on critical elements like lab values not that you used 12 pieces of cotton so bill that.
I always criticized the idea that “radical technology could exist but the competition buys it up” as a naive conspiracy theory.
It’s pretty remarkable that the government paid for this but somehow the international medical corporation can swoop in, buy the competitor who is threatening their margins, and void the contract.
Another line of inquiry to pursue would be why it took the government five years from canceling the Covidien contract to ordering ventilators from Philips.
We believe many things to be true, that are not true. And not only do we believe them, we passionately defend them!
I don't think many of us would recommend writing software on top of such uncertainty, yet we seem to think it's possible to do so with a society and economic system. Then we're surprised when it blows up in our faces every decade or so.
The surprised Pikachu meme seems fitting.
EDIT: To those who disagree, I'm rather curious to know the specifics of why you disagree. Do you actually believe that humanity, and each individual in it, has evolved to the point of something resembling omniscience? Perhaps we don't know everything, but that the subset of everything that we do "know", is absolutely perfect, not the slightest imperfection, however small?
Have our various societies and financial systems evolved to the point of near perfection?
And if it isn't that, then is it something else I'm off on? Just trying to get a better understanding of what the situation is here.
Does anyone know the survival probability of a covid-19 patient once he requires the assistance of a ventilator? I have heard people mention it is fairly low but haven’t seen any figure on that.
what is so complicated about ventilators? Serious question as I don’t know enough about this. I see a lot of DIY posts that are probably not 100% the same thing but are they even close?
This opens up a bigger question too, is there such a thing as a path for open source medical devices to be built and certified and deployed? Is there a company that supports something like this? I follow Scott hanselman, a Microsoft employee who’s diabetic, and there is a big movement within that community to build open source artificial pancrea, using insulin pumps and software and such. Is there a play like that for ventilators? And other critical medical devices?
My wife is a doctor (I am not). I've been following COVID closely and discussing with her/peers. I'm not an expert (but feel I have an above average understanding, thanks to my wife)
> I see a lot of DIY posts that are probably not 100% the same thing but are they even close?
I have yet to see (though I haven't looked extensively) a DIY ventilator that has the fine tune control many doctors are suggesting are required for COVID patients.
My understanding is most of the DIY vents are comparable to emergency or transport vents. They'll keep a patient breathing for minutes/hours until they can be transferred to a proper ventilator. After a short period of time, you really need to transfer a patient to a proper ventilator to continue to support life.
Two big challenges with COVID patients in particular:
* They require ventilation for DAYS or even weeks. Over durations of that long, you really need precise control over a vent. A tech analogy is using floating point numbers for finance. Over a small number of transactions, a floating point number may be sufficient. Over time, though, the inaccuracies of floating point numbers will become apparent.
* Many COVID patients needing ventilation also have Acute Respiratory Distress Syndrome (ARDS). The simple explanation is their lungs are functioning so poorly that you can't simply stuff oxygen into them and hope it works. You need to be extremely particular with how you control breathing.
* Bonus, related to point two, many doctors are reporting using pretty crazy ventilation settings as a baseline. They're basically overclocking a CPU/GPU by default then hoping they can keep overclocking as CPU/GPU load increases (not fully accurate, but it's an analogy).
Partly this is a problem with jargon. When healthcare professionals talk about "beds" or "ventilators" they mean "the bed and all the staff needed for the patient in that bed", or "the ventilator and all the staff needed to put a patient on, and take a patient off, the ventilator".
And another simplified cheat sheet for people who use machines in one setting which are now being used in other settings, but it has replies from doctors asking questions that give some hints at the complexity: https://twitter.com/aroradrn/status/1244134454001635329?s=20
Then you have all the "human factors" stuff caused by machines having different layouts.
There is a narrow range of pressure where you're not damaging the alveoli from underpressure, but not bursting the lungs from overpressure. You need a mechanical scalpel, not a butcher's knife.
They're really not very complicated; the requirements can be written out in a few pages. I'd say they're a bit more complicated than your fridge, but a lot less complicated than a car. Generally the primary barrier to entry for manufacturing medical devices is not their complexity but the onerous requirements of certification by the FDA. On the whole that's a good thing, since it means that properly certified medical devices are rarely built by fly-by-night organizations that disappear once they have your money.
In the meantime COVID19CZ created an open source version - https://news.ycombinator.com/item?id=22724130, crowdfunded the first batch of 100 ventilators, and they start producing them in the first week of April
They acknowledge the New York Times at the end of the article. Perhaps they licensed the content. I don't think that anybody aside from legal staff at the New York Times can determine if anybody was fully ripped off. If you have concerns about copyright and want to do something about it, you could report the issue. I assume that the New York Times is fully capable of hunting down violations without any help.
The site is much nicer than the New York Times. I'd prefer that the New York Times be banned, both for the paywall and for severe political bias.
I’ve always said that governments should use our tax money to design and validate key health and infrastructure components and only outsource manufacturing and only to local businesses. Governments are so utterly broken and inefficient that they can’t do it.
However even if they produced a design now we have supply chain problems globally.
Edit: I seem to have stirred up capitalist defence here. To clarify: The government runs healthcare here in the UK. They have a responsibility for making sure there is supply of equipment available for us. This isn't some car pooling company that says "there's no cars available until next Wed", this is healthcare. And as for production, the government should have agreements in place with manufacturers to switch to infrastructure build out.
We've screwed up flood defences, energy, healthcare so far. Lets stop now.
> Governments are so utterly broken and inefficient that they can’t do it.
Mostly when your entire platform is that governments are broken so you do your utmost to make them broken to prove your point. All governments have issues, but there are many that aren't "broken" like the US, and more and more so the UK.
"Companies submitted bids for the Project Aura job. The research agency ... chose Newport Medical Instruments, a small outfit in Costa Mesa, Calif"
This is the problem. Instead of allowing several companies to compete for a large order of new ventilators, the $ were given to one company to be spend on design not on the product.
No, that is specifically not the problem. The problem is that the company had demonstrated a working design and was near production... but then the wheels of finance (by way of publicly traded company) stepped in with a profit-only motive.
If three companies were all competing, there's absolutely no guarantee that each of those three would not have been bought in the same way. No large company would have gone for such a contract unless it had no other way to make money; there wasn't enough profit incentive.
[+] [-] oefrha|6 years ago|reply
I learned through a personal connection who was actually on the ground in Hubei (but not Wuhan) caring for serious but non-ICU patients that doctors and nurses in their ward outnumbered patients, and they were at capacity. The staff-to-patient ratio should be higher in the ICU. With an overwhelming number of patients you simply can’t care for them, whether you have the machines or not.
It’s relatively easy to ramp up production of machines. It’s much harder to ramp up production of medical professionals.
[+] [-] SkyPuncher|6 years ago|reply
I have a mixed opinion on this. In particular, I don't think we really need to create more skilled medical professionals, we just need to change the way they work.
Most of doctors have exposure to the basics of intubating and ventilation through medical school. Those without direct critical care experience would likely be absolutely terrible at it. However, they all still have the baseline knowledge. They're able to assess patients, read charts, and report on vitals.
I just asked my wife (a psychiatry resident) if she could intubate/ventilate a patient. Here response was, "If I were the last person alive, I could intubate. You wouldn't want me to do it, but I could do it. I don't know how to run a vent, but I'm sure I could figure it out if I consulted with a doctor/therapist that does". I think most non-critical care doctors would express the same opinion.
What I'm getting at is we have a large amount of doctors that can act as multipliers for intensivists, hospitalist, ER docs, and pulmonologists. They are able to do much of the time consuming work while relying on specialists to guide overall care plan and intervene the on most challenging cases.
----
Given how medicine works, the chances of actually seeing this in action are low. But....it's an options.
[+] [-] cm2187|6 years ago|reply
[+] [-] romanows|6 years ago|reply
[+] [-] yibg|6 years ago|reply
From what I’m reading the treatment of COVID19 seems to require a pretty narrow set of practices. Mostly around monitoring, administering of medication, ventilation / oxygen and general bedside care. If this is true can we not cross train adjacent areas like EMT, army medics etc fairly quickly to provide care? They don’t even need to perform diagnostics.
[+] [-] lern_too_spel|6 years ago|reply
[+] [-] naringas|6 years ago|reply
and the fact that we think about "ramping up production" of "medical personel" leads the way to terrible industry-like education systems which emphasize cost-efficiency rather than quality education.
[+] [-] faitswulff|6 years ago|reply
[+] [-] ck2|6 years ago|reply
Once you are on a ventilator for covid19 you tend to monopolize it for 2+ weeks, hence the endless need for more machines
[+] [-] unknown|6 years ago|reply
[deleted]
[+] [-] ohbleek|6 years ago|reply
[+] [-] joe_the_user|6 years ago|reply
https://en.wikipedia.org/wiki/Healthcare_in_Cuba
[+] [-] relativitypro|6 years ago|reply
There is a lot of money to be made by keeping these barriers in place, through legal, technical means and by limiting people’s access to “experts” that know what to do with them.
[+] [-] noelsusman|6 years ago|reply
[+] [-] baybal2|6 years ago|reply
Get guard reservists and order them to squeeze the airbag by hand if 5 million American health professionals are not up to task
[+] [-] VectorLock|6 years ago|reply
[+] [-] droithomme|6 years ago|reply
The actual very interesting issue right now with ventilators is that there's companies in the US that make them and they say no one is ordering them. They cost around $25,000 each. Hospitals and states are sitting around waiting for the federal government to buy them and gift them to them, and whining that everything is the government's fault when that doesn't happen.
[+] [-] 14|6 years ago|reply
[+] [-] appleshore|6 years ago|reply
It’s pretty remarkable that the government paid for this but somehow the international medical corporation can swoop in, buy the competitor who is threatening their margins, and void the contract.
[+] [-] mhb|6 years ago|reply
[+] [-] AlexCoventry|6 years ago|reply
[+] [-] blunte|6 years ago|reply
Perfectly normal and common in the US low-regulation economic system.
> and void the contract
Most likely the government officials with the ability to allow this cancelation were bribed, or rather lobbied, to allow it.
[+] [-] mistermann|6 years ago|reply
I don't think many of us would recommend writing software on top of such uncertainty, yet we seem to think it's possible to do so with a society and economic system. Then we're surprised when it blows up in our faces every decade or so.
The surprised Pikachu meme seems fitting.
EDIT: To those who disagree, I'm rather curious to know the specifics of why you disagree. Do you actually believe that humanity, and each individual in it, has evolved to the point of something resembling omniscience? Perhaps we don't know everything, but that the subset of everything that we do "know", is absolutely perfect, not the slightest imperfection, however small?
Have our various societies and financial systems evolved to the point of near perfection?
And if it isn't that, then is it something else I'm off on? Just trying to get a better understanding of what the situation is here.
[+] [-] ajb|6 years ago|reply
https://jamanetwork.com/journals/JAMA/articlepdf/403323/jama...
(or course, it didn't need to be sterile because unlike modern positive pressure ventilators, the air it pumped didn't go inside the patient).
[+] [-] pacetherace|6 years ago|reply
[+] [-] cm2187|6 years ago|reply
[+] [-] rasz|6 years ago|reply
Two hospitals, not a single patient survived ventilation/ecmo to date (last week).
[+] [-] lucretian|6 years ago|reply
in on study, 24/26 of pts with non-invasive mech ventilation and 31/32 of pts with invasive ventilation died.
https://www.thelancet.com/journals/lancet/article/PIIS0140-6...
note that the study demographics were skewed to the more vulnerable cohorts (avg age = 56, range = 46-67, 62% male, 48% with a comorbidity).
[+] [-] lukevp|6 years ago|reply
This opens up a bigger question too, is there such a thing as a path for open source medical devices to be built and certified and deployed? Is there a company that supports something like this? I follow Scott hanselman, a Microsoft employee who’s diabetic, and there is a big movement within that community to build open source artificial pancrea, using insulin pumps and software and such. Is there a play like that for ventilators? And other critical medical devices?
[+] [-] SkyPuncher|6 years ago|reply
> I see a lot of DIY posts that are probably not 100% the same thing but are they even close?
I have yet to see (though I haven't looked extensively) a DIY ventilator that has the fine tune control many doctors are suggesting are required for COVID patients.
My understanding is most of the DIY vents are comparable to emergency or transport vents. They'll keep a patient breathing for minutes/hours until they can be transferred to a proper ventilator. After a short period of time, you really need to transfer a patient to a proper ventilator to continue to support life.
Two big challenges with COVID patients in particular:
* They require ventilation for DAYS or even weeks. Over durations of that long, you really need precise control over a vent. A tech analogy is using floating point numbers for finance. Over a small number of transactions, a floating point number may be sufficient. Over time, though, the inaccuracies of floating point numbers will become apparent.
* Many COVID patients needing ventilation also have Acute Respiratory Distress Syndrome (ARDS). The simple explanation is their lungs are functioning so poorly that you can't simply stuff oxygen into them and hope it works. You need to be extremely particular with how you control breathing.
* Bonus, related to point two, many doctors are reporting using pretty crazy ventilation settings as a baseline. They're basically overclocking a CPU/GPU by default then hoping they can keep overclocking as CPU/GPU load increases (not fully accurate, but it's an analogy).
[+] [-] gregoriol|6 years ago|reply
[+] [-] DanBC|6 years ago|reply
Ventilators turn out the be pretty complicated.
Here's a useful thread: https://twitter.com/aroradrn/status/1243091107149418496
And another simplified cheat sheet for people who use machines in one setting which are now being used in other settings, but it has replies from doctors asking questions that give some hints at the complexity: https://twitter.com/aroradrn/status/1244134454001635329?s=20
Then you have all the "human factors" stuff caused by machines having different layouts.
[+] [-] toomuchtodo|6 years ago|reply
[+] [-] unknown|6 years ago|reply
[deleted]
[+] [-] db48x|6 years ago|reply
[+] [-] neonate|6 years ago|reply
[+] [-] ciceryadam|6 years ago|reply
[+] [-] Jemm|6 years ago|reply
[+] [-] dang|6 years ago|reply
[+] [-] wiseleo|6 years ago|reply
[+] [-] burfog|6 years ago|reply
The site is much nicer than the New York Times. I'd prefer that the New York Times be banned, both for the paywall and for severe political bias.
[+] [-] relativitypro|6 years ago|reply
Once you allow incumbents to rewrite the rules, they will do so to entrench and enrich themselves.
“Too big to fail” “Too big to jail” “Lower interest rates to fix covid-19”
[+] [-] robomartin|6 years ago|reply
I am starting to hate publishers who produce COVID-19 articles and post them behind a paywall or registration form.
[+] [-] Erwin|6 years ago|reply
If the newspapers get more people to pay for their stories, they will have to fire the journalist hard at work on the Corona stories.
[+] [-] robomartin|6 years ago|reply
My comment has NOTHING to do with business during normal times. Paywalls or subscription forms are OK for that stuff. No problem.
I simply don't think it good citizenship to write COVID-19 articles and lock them behind paywalls or modal subscription forms.
[+] [-] m0xte|6 years ago|reply
However even if they produced a design now we have supply chain problems globally.
Edit: I seem to have stirred up capitalist defence here. To clarify: The government runs healthcare here in the UK. They have a responsibility for making sure there is supply of equipment available for us. This isn't some car pooling company that says "there's no cars available until next Wed", this is healthcare. And as for production, the government should have agreements in place with manufacturers to switch to infrastructure build out.
We've screwed up flood defences, energy, healthcare so far. Lets stop now.
[+] [-] Dobbs|6 years ago|reply
Mostly when your entire platform is that governments are broken so you do your utmost to make them broken to prove your point. All governments have issues, but there are many that aren't "broken" like the US, and more and more so the UK.
[+] [-] ck2|6 years ago|reply
https://simulation.health.ufl.edu/technology-development/ope...
as people commented yesterday, there are also other projects but that one from University of Florida doesn't need 3D printing
[+] [-] agrenader|6 years ago|reply
This is the problem. Instead of allowing several companies to compete for a large order of new ventilators, the $ were given to one company to be spend on design not on the product.
[+] [-] blunte|6 years ago|reply
If three companies were all competing, there's absolutely no guarantee that each of those three would not have been bought in the same way. No large company would have gone for such a contract unless it had no other way to make money; there wasn't enough profit incentive.