Friday, March 27, 2020

What Is A Ventilator and Do We Have Enough?

What's a ventilator and do we have enough of them to fight coronavirus? The ongoing coronavirus pandemic has drawn attention to a vital piece of lifesaving medical equipment: a ventilator. You might not immediately know what it is — but you would have seen them. In hospitals, online or in television medical dramas.

So what exactly is it, and why are they needed right now more than ever? The ventilator is effectively a breathing machine, or the most common component of a "life support" machine. It's connected to a tube that goes into the mouth, past the vocal chords and down into the windpipe.

Professor of Respiratory Medicine at the University of Sydney, Greg King, said it helped a patient by doing either all of their breathing or some of it. "If breathing fails, the patients obviously dies. So you can think of ventilation as very much a life-support system," he said.

It is mainly used for the very serious cases of COVID-19. Anaesthetist Dr Simon Macklin from the Australian Medical Association (SA) said in those cases, patients were weakened to the stage where they have difficulty getting enough oxygen into their lungs and enough carbon dioxide out. "When that happens patients often have to work extremely hard to try to maintain adequate oxygen levels," Dr Macklin said.

"Often patients become so fatigued by this process they're unable to do it on their own." They are then given drugs and placed into an artificial coma, before being connected to a ventilator through the tube we mentioned earlier. The ventilator then does the breathing for the patient.

In hospitals, there are two types of ventilators that are used. The ones we're talking about at the moment for patients with coronavirus are Intensive Care Unit ventilators. They're attached to ICU beds, and are considered the "gold standard" of ventilators.

The other ventilators are used in operating theatres for major surgery. They're like one of the original models of the iPhone. Still good — but with fewer features. Dr Macklin said the intensive care ventilators are specifically designed to cope with "very sick patients with very sick lungs" while the operating theatre ventilators aren't as sophisticated.

President of the Australian Society of Anaesthetists, Dr Suzi Nou, said in critical cases, ICU ventilators were used because there were a wide range of settings you could plug into the machine to minimise risk to the patient.

"When I've had sick patients in the operating theatre, you can have trouble ventilating them for whatever reason, the patient and the machine are not getting along so well, and then you transfer them into ICU and you put them on a nice ICU ventilator, and it becomes a lot easier."

Do we have enough ICU ventilators? At this stage — yes. But the concern is that we will not have enough as the coronavirus outbreak escalates. "It's the crystal ball question." Dr Nou said. Currently, there are about 2,000 ventilators attached to beds in ICU units around Australia. The government is looking to double those to 4,000.

Going off global figures, about 5 per cent of coronavirus cases will become critically unwell and will need ICU care. So based on the way the virus is tracking, doctors are concerned many more than 4,000 people will need to be hospitalised during the pandemic, and require ICU ventilators to help breathing.

But when we talk about shortages, we're not just talking about the machines. Ventilators are run by anaesthetic, intensive care and emergency doctors, while the day-to-day, minute-to-minute management of the ventilator is overseen by specifically trained intensive care nurses. And there are fears that there are not enough critical care staff to use the extra machines when they come into play.

Australian government  is  currently in talks with car manufacturer Ford about the potential to make machines, while Finance Minister Mathias Corman this week told the Senate that "the states also have processes to convert existing equipment into ventilators."

A draft letter by one of southeast Michigan’s major hospital systems was leaked online Thursday revealing the hospital’s policy to prioritize care for “patients who have the best chance of getting better” in the event of a shortage due to the coronavirus pandemic.

The letter was drafted by officials at the Henry Ford Health System and is addressed to “our patients, families and community.” It outlines the criteria for which patients will be eligible for care if the hospital reaches capacity and is forced to ration limited resources. “Patients who have the best chance of getting better are our first priority. Patients will be evaluated for the best plan of care and dying patients will be provided comfort care.”

The letter explains the policy in the event of a shortage of ICU beds and ventilators: “If you (or a family member) becomes ill and your medical doctor believes that you need extra care in an Intensive Care Unit (ICU) or Mechanical Ventilation (breathing machine) you will be assessed for eligibility based only on your specific condition.” Some of the conditions that may make a person ineligible are listed as “severe heart, lung, kidney or liver failure; Terminal cancers; Severe trauma or burns.”

A statement issued Thursday night by Dr. Adnan Munkarah, executive vice president and chief clinical officer of Henry Ford Health System, confirmed the authenticity of the draft letter, but stressed that it reflects a “worst case scenario.”

“With a pandemic of this nature, health systems must be prepared for a worst case scenario,” Munkarah said. “Gathering the collective wisdom from across our industry, we carefully crafted our policy to provide critical guidance to healthcare workers for making difficult patient care decisions during an unprecedented emergency.”

He added, “These guidelines are deeply patient focused, intended to be honoring to patients and families. We shared our policy with our colleagues across Michigan to help others develop similar, compassionate approaches. It is our hope we never have to apply them and we will always do everything we can to care for our patients, utilizing every resource we have to make that happen.”

The draft letter was leaked online Thursday when Nicholas Bagley, a University of Michigan law professor, tweeted out an image of the letter on what appeared to be official hospital letterhead. The full contents of the letter was printed by the Detroit Free Press (emphasis in original):

To our patients, families and community:

Please know that we care deeply about you and your family’s health and are doing our best to protect and serve you and our community. We currently have a public health emergency that is making our supply of some medical resources hard to find. Because of shortages, we will need to be careful with resources. Patients who have the best chance of getting better are our first priority. Patients will be evaluated for the best plan of care and dying patients will be provided comfort care.

What this means for you and your family:

1. Alert staff during triage of any current medical conditions or if you have a Do Not Resuscitate (DNR)/Do Not Attempt Resuscitation (DNAR) or other important medical information.

2. If you (or a family member) becomes ill and your medical doctor believes that you need extra care in an Intensive Care Unit (ICU) or Mechanical Ventilation (breathing machine) you will be assessed for eligibility based only on your specific condition.

3. Some patients will be extremely sick and very unlikely to survive their illness even with critical treatment. Treating these patients would take away resources for patients who might survive.

If you're dying of diseases other than Chinese CoronaVirus
Michigan hospitals will gladly let you die, w/o a ventilator .
4. Patients who are not eligible for ICU or ventilator care will receive treatment for pain control and comfort measures. Some conditions that are likely to may [sic] make you not eligible include:

severe heart, lung, kidney or liver failure
Terminal cancers
Severe trauma or burns

5. Patients who have ventilator or ICU care withdrawn will receive pain control and comfort measures.

6. Patients who are treated with a ventilator or ICU care may have these treatments stopped if they do not improve over time. If they do not improve this means that the patient has a poor chance of surviving the illness — even if the care was continued. This decision will be based on medical condition and likelihood of getting better. It will not be based on other reasons such as race, gender, health insurance status, ability to pay for care, sexual orientation, employment status or immigration status. All patients are evaluated for survival using the same measures.

7. If the treatment team has determined that you or your family members does not meet criteria to receive critical care or that ICU treatments will be stopped, talk to your doctor. Your doctor can ask for a review by a team of medical experts (a Clinical Review Committee evaluation.)

Michigan has become an emerging hot spot for the coronavirus pandemic in the United States. The state’s top health official, Dr. Joneigh Khaldun, said hospitals in southeast Michigan are “at or near capacity.”

New York Governor Andrew Cuomo acknowledged Friday the state did have a stockpile of unused ventilators, despite his complaints the federal government was not sending enough. Cuomo responded to a comment from President Donald Trump on Twitter that there were thousands of ventilators in New York not being used.

“Yes, they’re in a stockpile because that’s where they are supposed to be, because we don’t need them yet,” Cuomo said. “We need them for the apex, the apex isn’t here, so we’re gathering them in a stockpile.”

Cuomo’s comments demonstrate there is not an immediate shortage in ventilators in the city, despite alarming reports. “We don’t need them today, because we’re not at capacity today, that’s why they’re not deployed because they’re not needed,” Cuomo said.

The governor has repeatedly complained that the federal government is not sending enough ventilators to New York. On Tuesday, Pence said that the federal government had sent 2,000 ventilators to New York and an additional 2,000 more on Wednesday.

But on Friday, Cuomo explained expert projections showed he would need up to 140,000 beds and 40,000 ventilators. “I don’t operate here on opinion, I operate on facts and on data and on numbers and on projections,” he said.

In an interview on Fox News on Thursday night, Trump appeared skeptical that New York would need 40,000 ventilators. “I have a feeling that a lot of the numbers that are being said in some areas are just bigger than they’re going to be,” he said.

The topic of ventilators appeared to be on the president’s mind for most of Friday, as cable news repeatedly focused on a “shortage” and suggested that the president do more by invoking the Defense Production Act.

The Democrat governor is hoarding 2,000 unused ventilators for his extended family and relatives.