The U.S. tried to build a new fleet of ventilators
nytimes.com
nytimes.com
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.
This is not general purpose training - but very bounded / specific notes.
That's got to be better than exhausting more vital personnel.
I have not been able to find any larger case reports. Though on Tucker Carlson a few nights ago, a doctor on the front lines in NYC was interviewed and gave a similar report: If you reach the point of intubation and ventilation, the chances of survival is quite low.
A lot of these stats now coming out are going to be harder and harder to interpret going forward, regardless of the true numbers, as the media twists things around for their own political purposes. If ventilators turn out to be not the difference between life and death, even according to the raw stats, the media who wants to use lack of ventilators to blame one political party or another for the incompetency, isn't likely to tell the truth anyway.
Medical professionals learn how to do their entire job in a similar time frame. Ventilator operation is surely a small part of that. I'd be astonished if it would take someone more than a week or two to learn the basic mechanics of how to use a ventilator. None of the theory or nuances, but a course that says "hook it up like this, do X, Y and Z and come get me if this or that happens".
Regarding whether doctors would want undertrained help - that's immaterial. If current healthcare workers have the capacity to handle the pending wave of sick people, then that's great and we shouldn't get in their way. If they have another, better solution, then let's do that. If the alternative to having minimally trained people operate ventilators is letting people die without any intervention - I'd want to see some explanation or evidence as to why letting people die is better.
To my exceptionally limited understanding - and I would love to be corrected if I'm wrong - operating a ventilator correctly is not a matter of standing in front of a machine and watching a few numbers for problematic readings. That can be done by machines and computers. What requires training is everything else around it, which requires an understanding of medical protocols, anatomy, the ability to respond usefully to emergencies without being in the way, and so on.
Which is to say that this is not something that highly specialized and narrow technicians can be usefully trained for in a very short time at this particular moment.
That's not to say your idea is bad! It's definitely good and worth exploring in the future. There will be time to explore how to have smarter tools that can be used with a less general skillset can be developed. There will also be time to explore how to develop specialized and narrow curricula for such things - itself not a trivial task.
This thread isn’t about automating medical professionals responsibilities one task at a time, or attempting to step on their egos. I’m as proud of their title, their coat, and their debt as they are.
If a pandemic respiratory virus is not the time to “consider exploring” this idea, when is? When people are left to die in their homes because the ambulances stop taking calls...?
We are, of course, just shooting out ideas of grandeur. A reactive strategy will be maintained, people will die, and everyone will throw their hands up in the sky and say “nothing else could have been done. March simply was not the time to think about COVID-specific medical operation efficiencies. There will, however, be a time to explore...”
Please accept my deepest apologies if I have in any way seemed to imply that the current reactive strategy is an ideal long-term solution. I do not in any way think this.
Don't hesitate to ask if there's anything else I can clarify for you - I frequently fail to express myself as well as I'd like.
This will happen soon or not at all. The AMA and its equivalents worldwide have a very consistent attitude to anyone, anywhere being allowed to do anything a doctor can do. It should not be allowed. Psychologists should not be allowed prescribe; nurse practitioners should not be allowed practice independently under any circumstances, etc.
Indeed, doctors did more harm than good until the early 1900s at the earliest, and we can only be sure that they were on net leading to lower rather than higher mortality with the introduction of antibiotics.
Younger doctors without 4 years onsite experience are still probably extremely capable and I’m sure you’re right, they can learn how to do a subset of their eventual job very short amount of time and do it well if given the chance.
It sounds like there is some fundamental idealogical opposition to this.
I have a friend who is going through her residency now, she has to deal with a lot of very unhealthy psychological and physical treatment (ridiculously long hours) to get through it. Sounds more like a hazing than a professional introduction.
Now in war, you have to throw bodies at a problem, and if the bodies end up 6 ft under, that's war. But generally bad pilots only kill themselves, they don't kill patient after patient through malpractice.
It's quite interesting to hear the opinion of someone who has both education and hands on experience directly in the field, and then compare that opinion to the opinions of those who have neither.
Getting nurses, doctors from other specialties, or even medical students through an intensive training is one thing, and I suspect it's actually a good idea. These are people who have (or, in the case of students, are at least likely to have) the knowledge required not just to learn how to operate a piece of machinery, but also to understand when they're in over their heads, when to ask for help, and to understand the magnitude of what they're doing.
But IMHO -- also based on my experience in other potentially dangerous fields -- putting people with zero medical education except for a thirty-day training in charge of observing people in a life-or-death situation is a really bad idea. Under-educated, even if well-trained assistance has a very high potential of making things worse, not better -- worse than doing nothing at all, that is.
Running a ventilator as in pushing the right buttons is something you can learn to do just by reading the manual. I can obviously operate every medical device I've worked on. I've obviously had more than 30 days of exposure to them. And nonetheless, I think the chances of getting someone killed by operating them are extremely high. I am also 100% convinced that they are much higher than the chances of someone who's had some medical education doing the same thing, even if they've never seen that machine and have never read the manual. What doctors and nurses do with the things I've built is way above my level of understanding.
I can't speak for medical students but I can guarantee that, if you let 30 final-year engineering students walk around a power plant without constant supervision, one of them will get themselves killed by the end of the day. And that's after three years of education. 30 days shouldn't even get you past the lobby.
I'm reading that hospitals may be overwhelmed. I understand that to mean there will be more people requiring intensive care than capacity to give intensive care. If the choice is between the hospital sending people who need ventilators off to die and sending them to someone with thirty days of training and good intentions... Well, my intuition is that you'd have better outcomes with the latter.
The point is not "can we do this without killing people." Nope. More people will die with amateur ventilator-operators than professionals. What I'm suggesting is that more people will die without amateur ventilator-operators in the event hospitals are overwhelmed.
If we think hospitals are going to be overwhelmed in thirty days then the time to start training amateur ventilator-operators is now.
Given that we likely have more spare doctor cycles now than we will in the future, we should utilize them now. We can also do things like hire doctors from countries not as badly stressed to come teach the classes.
And of course there are many levels to addressing bottlenecks. For example, operators wouldn’t have to be amateurs at first, they could be any of the non-essential medical professionals who are not able operate business as usual due to the virus. Could a podiatrist or urologist operate a ventilator given enough training?
In general we are brainstorming proactive measures. I think, at least in the US, we continue to have a reactive as opposed to a proactive strategy because of our decentralized government structure as well as the delicate balance between effective mitigation and maintaining social order. While we should be leveraging the current shelter in place strategy to build as much healthcare infrastructure as possible (both physical and technical, as per the thread) to handle slowly returning society to normal operations, we probably are not moving fast enough. In several weeks, as the unemployment and anxiety builds, so too will unrest. And I guess then it will really be a test of a nation’s people.
It takes an inordinate amount of time just to teach people what they can and can't touch and when and how, how to wash their hands properly, how to put on and take off their masks/gloves, and where to stand so as not to be in the way of people. All this in the context of a pretty contagious disease. I am pretty sure that, within 20 days, most of the volunteers would be infected themselves, and end up putting even more strain on the system.
I've been in an OR as part of my job, and I'd definitely think twice before enrolling in a program like this one (and definitely not just for my own safety, although yeah, that would be a big factor, too).
https://www.vettimes.co.uk/news/veterinary-sector-primed-to-...
But my SO runs, (COO), a system of hospitals. Including some teaching hospitals. And part of their plan definitely includes sequestering final year med students and all residents at their respective homes. Apparently the idea is that as hospital staff go down, this pool of residents and med students can be drawn on.
I know she stays up nights worried sick that residents might go to a party, or invite their boyfriend over, or engage in some other risky behavior instead of stay home alone and safeguard their health. So I get the idea that they really don't have a backup to that plan. I suspect med students and residents are a pretty critical part of the plan for surge operations across the nation.
Just pointing that out because I think hospital administrators and medical directors are starting to plan on doing things they wouldn't normally do. Like pressing 4th year med students into service, or taking 68 year old women off of ventilators if a 33 year old woman presents with a need for it. It's not so much a question of what doctors want to do, as it is a question of doing what has to be done to get through this with the maximum number of recoveries.
The person was asking a question, not proposing a plan of only training people for thirty days.
This thread is a like a giant version of that telephone game that we used to play in school, except in that game you didn't have the advantage of reading the exact words that the person said, as we can in this thread.
Of course, it flies in the face of a common sense view that someone careful, able to follow orders, just hold things or press button etc would provide some use in a world where the doctors are fundamentally limited.
It seems like a world where the medical industry has piled goldstandard-or-nothing upon goldstandard-or-nothing approaches, to the point yeah, doctors really don't know how to produce useful people without those fricken' eight years or twelve years. Well friend, you should start thinking "outside the box" about how to make other people useful or many, many people will dies.
FYI: The US produces field medic with 16 week training period after basic training. That might who you want attending to you but things are going to be resembling a war zone really soon.
And, yeah, maybe I know little of what exactly ICU processes are but it seems indeed implausible that there are no intermediate levels of skills that are the slightest bit helpful, just about physical task can aided by a "third hand" etc.
Doctors would still be responsible for reviewing the care protocol and making decisions on treatment, but one doctor could oversee many respiratory therapists, each caring for many patients.
HN denizens apparently seem to disagree, and believe that if you can learn some JavaScript framework in 30 days you can do anything in 30 days, but the world doesn’t work like that.
This is not universal in the US. You can do Bac + Med School in six years even there[1]. That’s the standard route outside the US’ former colonies and those countries with colonial cringe. Medical school in the UK and Ireland varies from five to six years with undergraduate entry. Graduate entry is four years like in the US, but pre-med doesn’t exist; you can start med school with a degree in dance[2]. Even in the US you can do med school in three years[3]
[1] https://www.forbes.com/sites/noodleeducation/2018/06/18/3-bs...
[2] https://www.ul.ie/gems/programmes/bmbs-programme
[3] https://med.nyu.edu/education/md-degree/accelerated-three-ye...
But when you're dealing with a pandemic, you can do without. Do you really think that your typical doctor spent all that much time in med school or residency learning how to operate a particular kind of machinery? If we have the ventilators, we'll be able to find people to operate them.
No, it's because medicine has a very low fault tolerance, and requires a large body of technical knowledge to even understand what needs to happen for your patient.
Having a team of incompetent clinicians perform complicated medical procedures "good" as a layperson still results in disproportionate people dying, that would have survived under a competent practitioner.
Bringing us back to the topic of this thread, a potential lack of competent practitioners if the pandemic worsens, and what the best solution to address this would be, such as a COVID-specific ventilator training.
The army knows how to train people to basic competency very fast, and they know a thing or two about drafting volunteers ;)
Not everyone need be coming in completely untrained. And job shadowing is the obvious thing most people are over looking. Nobody is going to dump a bucket of scrubs with 30-days classroom training all over the ER floor. Groups of trainees would be shadowing trained professionals 15 hours a day.
Those are a lot simpler and safer than a mechanical ventilator, which requires intubation or a tracheostomy, which you might say is highly invasive of the respiratory abstraction layer, and can cause correspondingly subtle and messy failures.
Your idea is to take a bunch of people who are not experts in ventilating, who have minimal experience with ICU vents, and give them a training course on ICU and anaesthetic vents and hope that they remember the difference and can work out the different panels, while exhausted, while in full PPE.
This is happening, but it's scary.
Your wider point - can we reskill a huge amount of the existing workforce to do a different job - is a good point, but that's already happening. Lots of people are doing jobs that they were not trained to do and they're doing those jobs with minimal re-training. This may help some patients, and it may cause harm to others.
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.
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.
Once you are on a ventilator for covid19 you tend to monopolize it for 2+ weeks, hence the endless need for more machines
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.
The US did a disaster prep simulation for virulent flu, that involved a shortage of ventilator scenarios. They took people with something approximating medical backgrounds, including nurses, other kinds of docs and vetinarians, and gave them training in how to use a ventilator. After two days they were given a test and the vets had the best score.
Right now, the death rate still isn't higher than a flu epidemic but just the number of known infections promises a lot worse and the potential doublings after that are terrifying.
It seems like there's an endless dialogue of:
A: How would you accomplish X? B: I wouldn't, X is not what I do.
But we need to give the final answer: A: I didn't ask whether you can do X. I'm telling you, "do X or many people die, you are all we have at this point. Think outside the box".
The millions of people who would die in a worst-case scenario are mainly demographics that society is already used to neglecting: the elderly, the terminally ill, those with lifelong chronic illnesses where any infection could be a killer, etc.
Therefore, I would expect this to continue to be considered more of a peacetime inconvenience than a real war. A frequent response to this is, "But they could overwhelm the healthcare system so you or me couldn't be treated for our needs!" Well, if the bulk of the population is left inconvenienced and unemployed for too long, I can imagine some ugly scenarios where the population demands, broadly speaking, that those demographics simply be triaged out of treatment so that they don't overwhelm the healthcare system for everyone else. This is said to be already happening in Italy to a degree.
People imagining such triaging seem to think that a willingness to be appalling brutal means such brutality could be achieved with limited costs.
Italy's situation is far from the worst-case scenario. It's death rate is not that much higher than a seasonal flu, it's just the death-process that is far more messy.
Which is to say, let the infection rate get high enough and you'll have hospitals crowded with the young and healthy even if carry the old directly to the morgue.
Moreover, authorities shouting "all clear" in the midst of this dreck isn't going just summon a phalanx of consumers ready to go to restaurants, death chance or not.
In short, just because you're evil doesn't mean you aren't stupid too.
https://ourworldindata.org/coronavirus#case-fatality-rate-of...
If you read my parent post in context, I hope it's clear that I mean currently in Italy, people are not dying at a rate higher than the seasonal flu BUT this has a big potential change if the infection rate were to shoot up (we know this is prevented by extreme quarantine measures, enforced by the army).
The flu is a well-enough study disease that they're able to, relatively accurately, model population statistics based on a sub-set of tested patients.
Indeed. I was organizing some people to make face shields and was looking for a big room. When I talked to the city about using a school gym, one of the criteria was that everyone needed to have background checks. Because it would be in a school!
There are news reports right now on HN on how the real death rate on countries that are not falsifying reports might be up to 4 times the assumed rate.
The hypothesis is supported by the increase in total deaths compared with the baseline, and after subtracting deaths linked to covid19.
This being true, we might be looking into 2 to 4% of the population.
Link to the HN thread:
We have spent decades holding people systemically dis-incentivizing people from doing positive things in bad situations by assigning responsibility in this perverse "who was the last one to touch it" manner. Society has made its bed and now it gets to lay in it. Nobody is gonna be the one that bucks the trend and reduces and sort of real or perceived safety standard in order to increase volume of care until the situation becomes so obviously bad that not doing so is indefensible.
This has already been happening in Lombardy according to an account I read about two weeks ago.
Given how American medicine works, I see challenges with this approach.
USA has 5 million medical professionals, almost as much medics per capita as Cuba.
There is a shortage of doctors that actually treat sick people.
You need the experience and you need the detailed instruction. That's why there are certification programs around the operating of complex healthcare machinery. Just like you don't want a front-ender doing back-end or systems work you don't want your psychiatry residents to operate an ICU.
This is not the argument I'm making though. That implies the front dev has no oversight.
I'm making the argument that a frontend development can successfully complete features with the guidance/oversight of a backend dev. The results might not be ideal, but it can provide an acceptable outcome.
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> You need the experience and you need the detailed instruction. That's why there are certification programs around the operating of complex healthcare machinery.
These programs are focused on developing individuals who can robustly and independently manage this complex machinery.
Should we also discredit airline pilots because laypeople have landed planes in emergencies? Or discredit sports professionals because many can kick a ball?
Life is not a movie, some stuff is just hard and requires a long time of training before we'll let you go 'solo'. One mistake and someone ends up dead, there are no do-overs, there is no undo button.
The last thing ICU's need right now is on top of all the stress already going on there to be overrun by eager rookies that are trying to help.
The best we can do - and this is happening in some places - is to move up the training schedule and to graduate ICU nurses early. This is need for several reasons: to man the extra ICU capacity that is coming online and to take the place of those who have died or can't take it anymore due to psychological stress.
I think this sort of language is why a lot of non-professionals are sort-of balking. Life currently is like a movie. A zombie or some similar disaster movie, a situation where things are changing fast, where the normal plans are expected to fail.
...and requires a long time of training before we'll let you go 'solo'. One mistake and someone ends up dead, there are no do-overs, there is no undo button.
We are talking about a situation, coming up in X many days, when it won't be a matter of the authorities "letting" people try but a matter of the entire health system being overwhelmed. What are the other, workable plans you have for people dying in the parking lots of the emergency room? And yeah, this is a different world, one where we expect people to end up dead and we're asking how to decrease that are much as possible.
This horrible movie is the consensus of most projections. The question is not "could we deal with this? Can we play doctor, please!" but rather "how should we best deal with an ongoing disaster where we're assured, the doctors will be gone. Surely there's something one could beside 'die in place'?".
The last thing ICU's need right now is on top of all the stress already going on there to be overrun by eager rookies that are trying to help.
If the ICUs have a different, workable plan for when they are overrun with a massive number of patients, I'll be tremendously happy. The only thing I hear is "this won't work" "but what can we do?" "don't you understand that this won't work"....
No, because after a movie you get to go home, no matter how terrible it was. And in real life you don't get to go home. So you will have to trust in the people that have spent their lives preparing for stuff like this while we, the software smartasses were 'changing the world' with our SaaS toys.
Right now the best programmer is worth less than a mediocre ICU nurse, and that will remain so for a while. Afterwards we can all go back to pretending they don't matter but right now this is how it is.
> We are talking about a situation, coming up in X many days, when it won't be a matter of the authorities "letting" people try but a matter of the entire health system being overwhelmed.
That's a past station in some places.
> What are the other, workable plans you have for people dying in the parking lots of the emergency room?
I don't have any plans. They will die. Because we were too stupid to listen to those sounding the alarm when it mattered.
> And yeah, this is a different world, one where we expect people to end up dead and we're asking how to decrease that are much as possible.
We can decrease it as much as possible by stopping to move around so much. And yet, that seems to be too much to ask. Just now in another thread some religious guy claiming an exception just because the risk was low. I sincerely hope they'll all be fine, I also hope that if they are not that they'll trust their god rather than to hog precious ICU capacity needed by people who were careful and who did not seek this out on purpose.
> If the ICUs have a different, workable plan for when they are overrun with a massive number of patients, I'll be tremendously happy. The only thing I hear is "this won't work" "but what can we do?" "don't you understand that this won't work"....
The ICU staff is working double shifts and around the clock in plenty of places. They too get ill, plenty of them have already died. It's a bit late to stick your oar in now and make it your mission, I totally sympathize with the intentions but this isn't your fight other than to stay put, tell other people to stay put and accept that this story will not have a Hollywood ending for many people.
This language of addressing each posters as if they personally had this intention is pretty bizarre. It's very much the language of "proper authorities are taking care of that." I don't personally have any intention of jumping but I'm part of a community and part of a situation where the proper authorities aren't taking care things.
Oh, so it's just posturing. Forgive me then for taking you serious.
Let's first all stay the fuck home, then ensure good personal hygiene and if and when infected self isolate as much as possible and leave the rest to the HCWs who are risking their lives in the most literal way possible.
All this well intentioned backseat driving isn't going to move the needle, not even a little bit.
This is a good point. Preventative medicine is the best medicine. That's true in general, but is especially true during this type of crisis.
We should also be more strict about isolation measures and lockdown, both individually and as a matter of policy and enforcement. That would keep our hospitals from flooding, to a much greater degree than an army of respiration therapists and ventilators would.
> All this well intentioned backseat driving isn't going to move the needle, not even a little bit.
But how else shall we spend our weekends locked indoors without pointless arguments on the internet? ;)
I find it doubly frustrating because the majority of these are asserted as fact, typically based on flawed reasoning, when what they really are, are estimations/predictions.
If this lack of concern (if not outright disdain) for correctness becomes too prevalent within a society, I worry that it may affect the quality of our decision making.
Regardless, is this somehow related to my comment above?
It has in a simulator.
Here's an /r/medicine discussion of it.
https://www.reddit.com/r/medicine/comments/fr0x3m/how_do_you...
Another thing to consider is this is a rapidly changing/progressing disease and there are no standards. The opinion of a recently graduated fellow has different biases than an experienced attending. They can both be correct while disagreeing on the specifics.
Some medical students also could be utilised, if there is acute shortage, perhaps.
> what would be a ballpark estimate to get a reasonably intelligent person with no medical experience up to a "functional" level?
It really depends and I'm speaking out of my comfort zone here.
Becoming a doctor takes a really long time because it includes a LOT of background and general medicine knowledge. Doctors know a lot about medicine outside their speciality.
Med school is 4 years (2 years of bookwork focus and 2 years of clinical focus) and builds on undergrad significantly. Residency is 3+ years. I'd say the majority of people with STEM backgrounds could have function acceptably as a general doctor with 2 to 5 years of postgrad training. Surgeons are built much more on experience so that's very hard to fast track.
In my opinion, the real measure is the ability to handle edge cases/unusual cases. Specialized/limited scope workers, especially those with the direct support of an experienced individual, could pick up tasks much, much more easily as long as an expert is there to take over the challenging cases.
I'm willing to consider that it isn't possible, but if that is the case, I'd be keen to know the particulars of why. If there happened to be a documentary on respirators that covered some of the complexity involved, I would be on my couch watching 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.
https://morningstaronline.co.uk/article/w/us-pressures-count...
Get guard reservists and order them to squeeze the airbag by hand if 5 million American health professionals are not up to task
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.
https://pbs.twimg.com/media/EUNYuOuU4AApgBX?format=jpg&name=...
Still want to gamble on that 'narrow set of practices'?
Your assumption doesn't hold.
Triage is just to deal with limited resources, essentially it divides the applicants into 'walking', 'dead' and 'care', and the fewer resources you have the more people will get sorted into the 'dead' category even if they still have a pulse when you see them. The 'care' category will still get unique personalized care otherwise you might as well sort them into the 'dead' category on the spot.
How much training does someone need before they become a clear net positive for the patient?
The ICU staff would not even allow the doctors to mess with their setup because it is critical and it is their responsibility until some either dies or is discharged from the ICU and allowed to move back to a normal ward.
Think 'airline pilot' not 'assembly line worker'.
If I had to choose between an uncontrolled emergency landing, and an emergency landing done by a volunteer who did two days of training, I'd choose the volunteer every time. I understand that the volunteer does not have the training to fly or land safely and that becoming an airline pilot takes a lot of training, but that doesn't matter if there's no pilot available.
If 20% of patients die with trained ICU staff, 90% die with no ICU staff, and 70% die with a trained volunteer, and you have no more ICU staff, then the volunteer is a net positive and the volunteer has left a lot of dead people. The question is not whether the volunteer is even anywhere close to a trained professional in effectiveness, it's whether the volunteer is better than sticking a red or black tag on someone's bed and leaving them to die.
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.
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.
If a company has a contract with the government, then the government should have (specified already in the contract, perhaps) the right to prevent the sale of the company (with some specific exceptions).
The primary problem here is that in theory, the government works for the people; but also in theory, the (publicly traded) corporations work for the shareholders.
But yes, even without regulation, the government should have made more effort to enforce the contract. Perhaps the key government people with the power to do so were influenced somehow... But even if the contract had been upheld, there's certainly no guarantee that the new big company would have put their best effort into meeting the original goals of the contract (especially if it was against their "best" (profit) interest).
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.
Generalized, we might state this as: the perception of high accuracy in our beliefs is illusory. Not only does this occur at the individual level, but also at the group level (see: religion, Trump supporters, etc)
I then compared that to the manner in which different people exhibit "unexpected" differences in insistence in accuracy/quality across different domains, demonstrating that the inner workings of this behavior can be counter-intuitive at times.
In light of this ongoing global pandemic, I am curious whether this "illusion of truth" phenomenon that psychologists suggest occurs within human consciousness may possibly have been a contributing factor to some of the perceived shortcomings involved in our response.
For example, as I understand it, Donald Trump seemed to believe that this pandemic was not terribly important, and the result of this was that the response from the United States government was slower than it could have been.
Similarly, prior administrations, I'm not sure going how far back, were also aware of the possibility and consequences of the outbreak of a global pandemic. It would have been possible at that time to make a significant permanent investment in nationwide infrastructure for stockpiling critical supplies, but for specific reasons not known to any of us, it seems like very few countries went forward with such an initiative. Not only in the United States, but many other countries.
Generally, I think it's fair to say that historic decisions related to pandemic response were less than optimal. Assuming this is true, it seems reasonable to speculate that a misunderstanding of risk was a contributing factor to the imperfect responses.
If we take a hypothetical example of two different countries, one with a brash, super confident leader, and the other with a much more restrained, cautious leader, one who is naturally distrustful of casual optimism and a culture of "don't worry about it", might these two leaders have had different perceptions of risk, and as a result made different decisions and taken different approaches, both during and in the years before an actual outbreak occurred?
I believe this is possible, and also that the magnitude of the difference may be significant, depending on the circumstances
And if that scenario is possible, might this phenomenon also occur in other domains, and if so, what might the plausible range of possible consequential variances look like?
Take the Iraq war as an example. Might it be possible that errors in perception of risk were a contributing factor in the decision to go forward with the war? Using a similar example to the one above, might a leader or society that insisted on a higher standard of certainty and trustworthiness of evidence have made a different choice on whether to proceed with a war? And if so, might this have had an effect on the amount of money spent as well as the number of casualties? I suspect that if the Iraq war did not take place, both cost and casualties would be significantly lower than they were under the scenario that actually did play out.
So what? Well...if we made better decisions, might we realize better outcomes? This seems both plausible and potentially significant to me.
If one assumes this is true, a question arises in my mind: should we perhaps consider collectively exerting additional effort towards the goal of making better decisions, and what are some of the things we could do in an effort to achieve that?
To be clear, I'm not suggesting we do such a thing at this particular point in time, and I'm certainly not insisting we do it. It's mostly just an idea I've had knocking around in my head for a while.
I found some of my father's school books from ~ 1960: that close after the war, it included lots of war-like information like how to use protective gear (not top NBC one, but how to improvise if needed), how to carry a stretcher, first aid, etc. Now people forgot about war, this is no longer in the school teachings and people lack self-preservation skills. If a country leader tells them to self-isolate, they will laugh and ignore until it gets serious and in hindsight they blame politicians. When you have no pandemic for 100 years you don't care about ventilators and ventilator contracts, you care about unemployment, taxes, football and the last iPhone models.
History is always forgotten because regular Joe and Jane don't read history and Einstein has a single vote.
I mostly agree, but I would replace "populist leaders" with something like "the rich and powerful". If you think back to before Trump's election, can you remember anyone complaining about the system being rigged in favor of the rich and powerful?
> With "one man, one vote" the lower 51% less educated and intelligent part of the voters will elect the politicians that play their tune, even if the other 49% that are more qualified will vote otherways.
I agree a lot with this also. Where you and I likely differ quite substantially is in the designation of who belongs in the groups "less educated and intelligent part of the voters" or "more qualified". I consider concepts like intelligence and qualification to be highly dimensional, where most people seem to see it as uni-dimensional (here I must speculate, because ideas like this seem to be a rather sensitive subject for many people).
> In a way, it is the dictatorship of the stupid (no intention to offend someone, just math and basic psychology).
I would absolutely love to see the math behind this, are you referring to a specific paper of some kind?
> If a country leader tells them to self-isolate, they will laugh and ignore until it gets serious and in hindsight they blame politicians.
This seems true enough, there have been all sorts of people on TV laughing it up on the beach with full knowledge that a global pandemic was underway. It would be nice if we could find a way to put some additional sense into these people's minds.
> When you have no pandemic for 100 years you don't care about ventilators and ventilator contracts, you care about unemployment, taxes, football and the last iPhone models.
110% agree here - it's true, and it is a very big deal, imho.
> History is always forgotten because regular Joe and Jane don't read history and Einstein has a single vote.
Yup. The interesting thing about that though, is that hardly anyone reads history. Take HN for example, I'd be surprised if even 10% of the people here would remotely qualify as "students of history", yet I suspect the percentage of people who consider themselves qualified to deploy phrases like "History is always forgotten..." would be up around the 90% range. Obviously I'm not referring to you here since I mostly agree with everything you've said, but I suspect I'm at least in the ballpark.
I don't have a specific paper in mind for the math, but the knowledge from college with a major in statistics (and demography). It does not make me an expert, just a bit more qualified than most people.
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).
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).
Since you seem to be knowledgeable, if ventilating isn't a big-impact intervention, what's the point of flattening the curve? Is there some other intervention that hospital is doing that actually makes a more meaningful difference that can't be done at home?
Or is it maybe just psychological?
that study may be overly pessimistic. elsewhere, i think i saw 50/50 survival rates for ventilated patients but i don't have a source at hand.
Two hospitals, not a single patient survived ventilation/ecmo to date (last week).
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?
People can survive at high altitudes, which will see pressure of 70% sea level (or less, especially when considering mountain climbing). Additionally, when SCUBA diving, something like 30 feet of depth = 1 atmosphere.
I feel like I'm missing something here. Any ideas?
The pressure that must be narrowly controlled in a ventilator application is the relative pressure: the difference between the absolute pressure outside the lung (in the room) and the absolute pressure inside the lung. This relative pressure is what does all the work --- mechanically opening airways and alveoli --- and could cause all the injury.
I know a bit about scuba diving, and you absolutely are not supposed to go diving if you have a lung injury.
I would speculate that if you put a person with serious covid on a mountain top or 30 meters under the ocean it would kill them pretty quickly..
That's because the pressure outside their body is the same as inside.
With a ventilator, the pressure going in is higher than atmospheric pressure. That can cause damage.
Increasing pressure with depth does increase work of breathing due to higher gas viscosity. Beyond a certain depth, divers can no longer ventilate enough to take in O2 and remove CO2. This problem can be mitigated to an extent by breathing lower density gasses such as helium. Occasionally hospitals even have patients with severely impaired lung function breathe heliox just to get better gas flow.
In theory it's possible to use a 2nd-stage scuba regulator as an improvised mechanical ventilator by partially blocking the exhaust valve with your hand and pressing the purge button. In practice it's unlikely to work, but if I was trying to rescue someone who had stopped breathing in the water and had no way to get them back to shore or a boat quickly then I might try it as a last-ditch effort.
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.
This is going to be a huge issue with the onslaught of different manufacturers.
I liken it somewhat similar to helping troubleshoot router/switch issues... yes at a high level they're all the same but, at the same time, each one has it quirks and peculiarities and even use slightly different nomenclature that make it a non-trivial exercise.
> 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).
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.
True, they were nice enough to link to the originals, but for some reason the vast majority of blogspam sites do that. Only the very bottomest of the barrel do not. I assume there's a reason for this other than invariable last-minute scruples, but who knows? Maybe an HN user knows that business and can explain.
The paywall question is a separate one, and decided here as follows: if there's a workaround, it's ok; if there's not a workaround, we bury the submission. Users usually post workarounds in the threads. The result is that more or less everyone can read more or less every submission that makes HN's front page, just with varying degrees of annoyance. I think that's the right tradeoff. The annoyance is real, but HN would be worse without links to these publications. Paywalls suck (https://hn.algolia.com/?dateRange=all&page=0&prefix=true&que...), but this is the best we can do until the publication industry sorts itself out the way music eventually did.
All publications are biased. We're not going to ban the NYT.
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”
I am starting to hate publishers who produce COVID-19 articles and post them behind a paywall or registration form.
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.
Click-through-rates are not going to increase because people signed-up for a free account with an email address. Greater revenue comes from greater traffic. Simple as that. If every time I see an interesting link from the NY Times and try to read it I am hit with a modal subscription request, well, very soon I just stop clicking NY Times links.
The other side of that is paid subscription to these newspapers-turned-web-news outlets. My guess is this is a bad (or let's just say, non sustainable) approach. If these outlets had to survive on paid web subscriptions they would likely shrink severely or evaporate. There's a reason for which television can still garner massive audiences. Imagine if every single TV channel demanded a subscription or registration.
Imagine if every media outlet and publisher took advantage of the crisis and required registration for access to information.
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.
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.
It wouldn't necessarily have been trivial for another company to pick the design up and produce it, but it would have been possible.
The big company that bought the small one would simply have claimed that the design was their intellectual property and nobody else could build it.
If I had a government slush fund to develop a low cost ventilator, I would try to structure the payments in the contract to be based on milestones with concrete deliverables. Not a tenuous agreement to buy a bunch of ventilators at below market price (it's implied in the article that the sales to the stockpile wouldn't justify the project for the company).
There's of course a possibility that the government wrote the most aggressive contract they could find someone to work on. But I doubt that is what happened.
Why do you doubt that?
If the big company detests that idea, well, they don't get out of the original contract.
It probably could have been (that would depend on the details of the terms of the original contract), but it wasn't.
Exactly. Which means we should not be depending on governments to do it. This is exactly the sort of thing that private startup companies should be doing, without trying to involve the government's bloated and inefficient bureaucracy.
> even if they produced a design now we have supply chain problems globally
For this particular crisis, yes. But not for the next one, if we start now.
Ok, so how do we keep the government from being corrupted? Nobody has yet solved that problem, and people have been trying for centuries.
> Control for monetary expansion, and the US Government's portion of the economy has been steadily shrinking.
The money supply is not the same as the economy. Government spending as a percentage of GDP, which is the closest estimate we have to "the size of the economy", has been growing, not shrinking.
What? No it hasn't. It has kept pace with GDP since the end of WWII (prior to WWII it was much smaller), and the rate of GDP growth is higher than the rate of inflation. The size of government in the US has been growing continuously in real terms since before Eisenhower.
Well, of course. That's what we're talking about, right? Somebody has to do the long-term planning for emergencies like this one.
I understand that most of us thought it was the government's job to do this long-term planning so individual facilities wouldn't have to, but this article shows that the government failed at that job. Unless we have some reason to think the government wouldn't fail next time, it seems like the only alternative is for private entities to do it.
Private entities don't have to be subject to the market. Someone like Bill Gates or Elon Musk could set up a privately owned company, not publicly traded, that would not be subject to investors' demands for consistent quarterly growth. Matter of fact, maybe that's what Bill Gates should switch his attention to from malaria.
The fact is, a private individual, or a small group of them, can have a longer time horizon than the government does, and a longer time horizon is exactly what is needed for something like this.
What does this have to do with "government's bloated and inefficient bureaucracy"? The only government failure I see in this story is that they allowed the sale of the small company to the big one, or that they allowed the big company to get out of the contract.
If the government had done it in house they could have succeeded.
The problem here was the profit motive. Cheep ventilators endanger profits.
It is a side effect of free markets (I like free markets) that big firms get bigger, get more market power, kill off competition then price gouge. Health is a bad bad place to have free markets as the incentives are almost all wrong (exceptions: E.g. running clinics as a service for state run health systems turns out to work well here in Aotearoa - but even that is under pressure from consolidation)
Nationalise the whole ball of wax. Use waiting lists not wealth to ration access. FFS the richest country in the world is heading to a health catastrophe. What a bunch of idiots!
Ok, so how do we get the government to do it in house, and stick to it long enough so that the stockpile is there when the next disease crisis happens, which might not be for another 10 years? That's five Congressional elections and at least two changes of Presidential administration.
The civil servants work on what Congress and the President set as priorities. They cannot execute plans that span multiple Congresses and Presidential administrations unless every single Congress and Administration over that time period agrees to support the plan.
They built a horrifying arsenal.
I really do not see why they cannot build a health system. They have done so here.
Yes, because three successive Presidential administrations and six successive Congresses supported it.
More precisely, two successive administrations and about four successive Congresses supported it. The third administration began to back off, as did the fifth Congress; then the sixth Congress, along with the administration, stopped supporting it--and the moon missions stopped. Despite the fact that a large number of civil servants were making cogent arguments for why they should continue.
> They built a horrifying arsenal.
Yes, because every President and every Congress since 1945 has supported it.
Ok, so your plan for solving the ventilator issue is to change the entire system of government. Good luck with that.
Really not even for this particular crisis. We can build more of something on a short timescale, it just costs more then. You have to build facilities you know are only going to run for six months and then be decommissioned, so you have to amortize their construction cost over half a year instead of 30 years. You have to build them on the double, which means paying a lot of overtime and buying land and raw materials without taking a lot of time to negotiate on price or worry about efficiency. But we could do it.
And then the ventilators would cost ten times more than they ordinarily do and idiots would accuse anybody trying to do this of price gouging. But it could be done. (Unless the idiots pass a law against charging more than the regular price during an emergency.)
The fact that national or global human well-being suffered is irrelevant (so long as we accept that capitalism (as currently implemented) is the right way).
Now, there's a strong likelihood that the government officials with the power to prevent the sale of the company, or alternately the power to prevent the cancelation of the contract, were lobbied (and financially supported in various ways counter to the benefit of the people those officials represent). Otherwise, it's hard to imagine the government just casually agreeing to abandon a project that was already demonstrated to be near success (and the outcome of which was already demonstrated to be important).
Not to be a Communist when I say "not real capitalism", but it seems there's no pro capitalism political party in the US.
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.
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
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.
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.