Meanwhile, actual ventilator manufacturers are not getting many orders:
https://www.washingtonpost.com/health/2020/03/18/ventilator-...
https://www.washingtonpost.com/health/2020/03/18/ventilator-...
They are not raising prices, but they're also not selling to new customers, as they're afraid intermediate buyers are taking advantage and raising prices on their end.
They also said they have about 2-3 months of runway until their supplies dry up, since parts from China aren't coming in. They did however get supplies ordered in December, because they anticipated the crisis.
China reported the new novel strain of the coronavirus to the WHO on December 31. [1] If correct, then this means they were monitoring the news, and reacted immediately, and on the very same day of the fresh report.
Our own president and task force kept on downplaying it for so long and giving us the wrong information. Even CDC was downplaying for a long time.
It also sounds like many patients don't need a full hospital ventilator. A CPAP machine could do. Those are already made in bulk for sleep apnea patients.
The fed has 13000 and the military an extra 2000. It currently seems more hamstrung by bureaucracy or lack of information. Hospitals have to request their state governments which have to then request them from the federal government. Only one state has requested them so far.
"“We have received, so far, only, I think, one request for just several ventilators,” he said. In contrast to Fauci’s disclosure that the stockpile contains nearly 13,000, Azar said the number was not disclosed for national security reasons."
This double request structure is stupid.
By the time we see a shortage is late, way too late. Lungs need oxygen and cannot wait for purchase orders and negotiations. You'll need MILLIONS of them, and doctors that know how to use them, like yesterday.
Some numbers for a conservative estimate where only low-risk people are infected: https://news.ycombinator.com/item?id=22590692
There's basically one entity in this country with the ability to actually make this happen, and the people trying to point out that it isn't doing anything useful are fighting downvotes here just to be dark enough to read.
The biggest effect GMs announcement seems to have had is convincing people that a car company that builds to PSI tolerances can build anything to the kind of tolerance needed to safely ventilate patients. I think this is a PR move and GM and Tesla will study the problem enough internally to determine they have no idea what they’re doing. Worst case we get ventilators from Tesla with the same manufacturing defects and quality issues which their cars have had. I personally would not feel safe on a Tesla or GM ventilator built without FDA oversight.
IYHO, would that be more or less time that manufacturing fully new units?
I'm just saying that the person that needs to get off their ass and move on these ideas isn't Mary Barra but Donald Trump (and McConnell and Pelosi of course).
Ironically the way to make this stuff cheaper would be a three-fold attack.
* Make MORE things that use the same parts, so that making the raw materials is commodity.
* Reduce waste in use (if sterilizing the filters for reuse / etc is possible, etc).
Part 3: Look for alternatives that are feasible.
A hot-zone (book) style line supplied breathing air positive pressure suit that can be scrubbed clean on the outside, OR a similar glove-box (negative draw?, scrubbed inside?) style phone-booth like I think I saw on TV from South Korea (IIRC) would be much better replacements.
Reportedly the Hungarian government learned about this operation & are likely to do something similar in the next days.
Also in parallel, Czech Airlines aircraft have been pretty much drafted and sent to China for more stuff - like more tests, respirators and personal protective equipment. And one of the huge Ukrainian AN-124s has been chartered and is already on way for ~100 tons of medical supplies in one go, with more likely to follow.
Basically any classical goods transfer methods are far too slow for this and time is of essence.
FWIW: Gall bladder operation in NL all in: 1500 euros, non-subsidized and paid for out of pocket because I wasn't paying into the local healthcare system when it happened. Same procedure in the USA: $24000!
https://www.lendingpoint.com/blog/gallbladder-surgery-costs-...
https://sccm.org/Blog/March-2020/United-States-Resource-Avai...
https://en.wikipedia.org/wiki/List_of_countries_by_hospital_...
It also fails the sniff test: The US has less total hospital beds than almost every other industrial nation, but at the same time the most ICU beds?
I disagree, I'd say it's the opposite.
A commercial system can value surge capacity for peaks just like an online retailer does; the capacity to handle extra load means extra profit.
Whereas in a public health systems like the UK NHS everything is geared towards routine operational targets such as A&E waiting times. There is no budgetary or promotional reward for having reserve capacity.
Incidentally the NHS has just identified an unintended reserve: a pool of nurses who have been sitting in nadministrative middle-management roles for years. They are being retrained and redeployed now, but it illustrates the lack of efficiency in the system. A private provider would not have 'wasted' nursing staff in those positions.
the retraining nurses is somewhat of a point in the opposite direction -- the NHS has an easy pool to pull in because of the inefficiency. if all of the nurses were being used efficiently to begin with, there would not be an easy group to bring in.
scaling the number of doctors and nurses available takes a bit more time than hiring a bunch of people to put items in boxes
Sure it can, but that's obviously not the reality and spinning up extra servers is not the same as adding extra physical rooms and beds. This analogy doesn't make any sense.
>ncidentally the NHS has just identified an unintended reserve: a pool of nurses who have been sitting in nadministrative middle-management roles for years. They are being retrained and redeployed now, but it illustrates the lack of efficiency in the system. A private provider would not have 'wasted' nursing staff in those positions.
You're right. A private company would just fire the nurses instead.
Want to build a hospital in many states? Better be able to convince the licensing agency there is need for the beds. Want to build a hospital and accept Medicare? Better meet all the structural requirements they put in place.
Open the March update pdf here and look at the "excess" column on page 4:
https://www2.illinois.gov/sites/hfsrb/InventoriesData/Monthl...
The state has big impact on the capacity of the medical system.
So $24000 is like the asking price, you can come back and say "yeah well, i'll write you a check right now for $2500 otherwise you're sol.". Once a provider realizes what the max they're going to get is then, magically, that becomes the price.
To anyone who doesn't know this, don't you dare pay out of pocket what the bill says. Never. What's on the bill is not based in reality at all.
I submit that rethinking needs to be started early rather than late so the discussion isn't dominated by euphemisms for some very dark path.
[1] As we know, social isolation is to spread out the pace of acute cases so as not to overwhelm hospitals. But it obviously slows the economy considerably. The alternative would be to not to isolate, keeping businesses wide open and allow the medical system to be overwhelmed with its accompanying higher mortality rate.
The latter seems to have been way more effective in containing the epidemic and less impactful on the economy.
So, there was third option which saves both people and economy, but it's probably politically unfeasible.
What you can easily compare are hospital beds for acute care - this is a much bigger pool than just icu.
You can also easily compare number of doctors per capita.
In both of these measures the US system lags behind places like Italy.
In the interest of avoiding possible hubris, I think it's worth noting that the numbers in the Statisica chart on ICU beds/100k persons (included in the oft cited link [1]) counts in its data for the USA all ICU beds, while the European numbers come from a study that explicitly exclude [2]:
"...private healthcare providers, neonatal and paediatric intensive care beds, coronary care, stroke and pure renal units"
The 34.7/100k number for the US does not exclude the above. According to [1] the US has:
"There are 68,558 adult beds (medical-surgical 46,795, cardiac 14,445, and other ICU 7318), 5137 pediatric ICU beds, and 22,901 neonatal ICU beds."
Attempting to match the criteria of both studies gives the USA about 46,795 beds. Assuming 320 MM people gives 14.5, not 34.7, per 100k. I haven't looked at the sources for other countries, but we can expect differences in methodologies of ICU bed counting.
I think this casual sort of comparison of national capabilities (like [3]) which lacks rigor is more dangerous than useful. I hope one will take a deeper dive if they're evaluating risks based on the numbers that have been posted.
[1] https://sccm.org/Blog/March-2020/United-States-Resource-Avai... [2] https://link.springer.com/article/10.1007%2Fs00134-012-2627-... [3] https://en.wikipedia.org/wiki/List_of_countries_by_hospital_...
are those businesses really going to want to fill all their space with Medicare patients? with fewer ventilators, I imagine they can decline care to more people?
If only billionaire Elon Musk knew someone who could pay.
1. https://observer.com/2019/10/elon-musk-british-diver-lawsuit...
https://sccm.org/Blog/March-2020/United-States-Resource-Avai...
Ancillary tasks may suffer from staff shortage, but if you need one, getting a ventilator and minimal care is a lot better than not getting a ventilator.
Longer guide: Read the manual for the specific ventilator and have fun adjusting air mixture, pump frequency, pressure, volume and other stuff. Choose one of several different models of mouthpiece, with or without tubes, depending on patient needs. Learn about different failure modes and associated alarms. Learn how to operate the pump manually in case of electronics failure. Learn how to properly clean the machine.
It isn't nothing, there are some things you can do wrong if you don't know what you are doing. But a trained medical professional should get up to speed with a crash course.
Some patients might need supplementary oxygen delivered through a canula, or through a mask, but that's nothing like the procedure used for a vent.
Can you elaborate? This ventilator documentation[0] says for invasive and noninvasive ventilation
[0] https://www.usa.philips.com/healthcare/product/HCNOCTN98/res...
Even using a syringe or blood draw on a patient is something one needs certification to do properly. That isn't bureaucratic nonsense. Having worked with syringes and sterile technique, there are so many ways you can give your patient an infection or otherwise cause them life-altering complications if you don't know what you're doing, even for the actually trivial techniques. Operating a ventilator incorrectly will result in death. Likely a grisly one, as incorrect pressure differentials and human lungs are not a good combination.
Now that doesn't mean we need to stick to these bureaucratic rules as they are for this situation, but the people on here advocating for trying complicated medical procedures while knowing fuck all about medicine (or even biology) really need to take a step back and take an inventory of what they don't know, and can realistically expect to accomplish with neither the technical knowledge nor manual dexterity of a trained clinician. A YouTube video and a technical manual aren't going to cut it, folks.
[1] Sigh... I know, I know. American lawyers and legal system.
I'm not saying the alternative is do nothing. But playing doctor because you think that you're reasonably qualified to administer a ventilator, then we're going to end up with, say 30% mortality rates from patients whose lungs were sucked through a ventilator tube because you guessed the wrong pressure. Or, more realistically, a terrible infection because you decided soap and water in the bathroom sink would be sufficient to clean the apparatus.
And then what do you suppose will happen after 30% of these amateur medical procedures go South? Are you going to throw in the towel, try something even more reckless, or decide that you need to get an actual doctor involved to clean up your mess? At which point, you've just added yet another case to the already overburdened medical system. And at a 30% failure rate, that would become a major burden.
There's a lot of room for action between doing nothing and acting foolishly (such as claiming a 30% mortality rate for botched medical procedures is a rational tradeoff). There are ways to help the situation here that don't involve magically becoming a nurse overnight.
The trick will be to find a minimal feature set design, that doesn't use a lot of specialist long lead time components, can be used by people who are less experienced, and is suitable for treating ARDS. That is a much harder problem than the basic one of getting some kind of ventilator mass produced on an emergency basis.
Modern CPAP machines can generate phenomenal pressures and can be adjusted with simple touch screens. They support automatic pressure reduction on exhalation, and Bluetooth/cloud access to the data in them for remote monitoring via mobile apps.
BTW it's not quite as simple as 'hospital ventilators are hard to use'. Firstly, modern ventilators are much easier because the manufacturers realised that high training costs were limiting their market, so they've got a lot easier to use. Secondly, the US did a previous disaster response training exercise where they trained a bunch of non-specialist medical staff like nurses and even vetinarians how to use the machines. After 2 days of training there was an exam: the vets did best.
You need: -Gas blending (relatively trivial) -A source of pressure (CPAP has this) -A way of modifying pressure up and down quickly and precisely enough to stimulate breathing (Don't think CPAP has this) -A way of measuring flow and pressure (Does CPAP have this with good time resolution? I doubt it as not required for CPAP) -A controller which uses the flow and pressure data to vary the system pressure (CPAP doesn't have the right software but presumably this is less time constrained than the others)
So I'm really not sure that you can do this with a modified CPAP machine.
BTW I'm not sure that you can print oxygen valves, maybe air valves or patient valves. High pressure inlet oxygen parts need to be oxygen compatible and many 3d printed materials may combust under those conditions.
I don't know how many active machines are pre-APAP/BiPAP/A-Flex (there are different names for it). A comment below says 90% but this seems very high to me.
I wonder if it's possible some doctors don't realise the machines have this feature or it's importance? When I first was prescribed CPAP the machine did not come with bi-level flex enabled, it made it very hard to tolerate. I pushed through it for months but when I "cracked" the doctor-only DRM (i.e. looked up the cheat code on Google) and enabled A-Flex it instantly became way easier to handle the machine and my AHI scores were super low; big success. Doctor was quite happy with my altered configuration. I was just surprised such a basic thing hadn't been explained to me.
I suspect a lot of CPAP machines support bi-flex but it either isn't activated or could be added via a software update. I don't think you need extra components.
Oxygen valves come from here: https://learningenglish.voanews.com/a/volunteers-produce-3d-...
-High PEEP (obviously any CPAP machine can do this)
-Low plateau pressure (probably possible, that's just software)
-Low tidal volume and high breathing rate. Breathing rate is just a cycling variable so should be software only issue. Managing low tidal volume will require the machines to have a flow sensor. Do you know if any of your machines do? If so, then this is likely fixable with only software.
My interpretation of that article is it must refer to the patient valve as those are one-time use (as they in contact with contaminated patient exhalations) rather than O2 inlet valves which are not disposable. Patients are breathing high-ish O2 but obviously not HP pure O2 so 3d printed is fine for that.
3D printing is useful for cases like that where due to logistics there is a temporary shortfall in local supply. I suspect that 3 months from now we are unlikely to be using those measures as global production and distribution of ventilator consumables ramp up.
There's an open source app called SleepyHead that can show you all the data in detail. It appears the maintainer burned out but the downloads are still available.
So it seems modern CPAP has all that's needed? Doctors can even monitor it remotely or via the cloud. It's intended to let clinics monitor patient progress without needing visits, so it's all pretty easy to use.
https://www.usa.philips.com/healthcare/product/HCNOCTN447/dr...
It's advertised as "CPAP & Bi-Level therapy".
To be clear, I'm talking about the ones that implement bi-level pressure. The difference is (as far as I know) primarily a matter of software; perhaps older machines can be upgraded if pricing/selling upgrades is taken out of the equation?
I've had my machines for I think a couple of years now and they were all bi-level from the start. I'm not sure when that started becoming standard or where you got that 10% figure from, you may well be right. But there are 300,000+ sleep apnea patients being treated in the UK alone. If even only 10% of them use modern machines (seems low given how much better bi-level makes it), that's still 30,000 portable ventilators available to be requisitioned at short notice. Sleep apnea patients don't have a critical need for them.
This still prevents future prices from increasing, which is good thing.