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Comment by oefrha | Hacker News Reader

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.

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> 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.

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Given how medicine works, the chances of actually seeing this in action are low. But....it's an options.

I now don't remember where I saw this, nor can I find it... but I swear I had seen something in the past week or two comparing how much retraining different medical professions needed to quickly get useful for staffing ventilator technology, and veterinarians came out on top; so like, people are (unless I dreamth this?!) looking into reusing people.

Veterinarians make sense. The ones that do surgery already know how to run vents on animals. Humans are a form of animal, after all.

That's a better idea, also, veterinarians tend to be much more all-round.

You didn't dream it, it was in Forbes.

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.

The question in a lot of ways is how many exponential doublings do we have to have before this situation switches in peoples' minds from a peace-time inconvenience to essentially real war.

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 question in a lot of ways is how many exponential doublings do we have to have before this situation switches in peoples' minds from a peace-time inconvenience to essentially real war."

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.

That’s not true. Once you start getting into the tens of millions of deaths worldwide, that’s going to include a lot of young people and medical staff and people who will die of other treatable diseases or injuries because half of the doctors in the country are sick or otherwise occupied.

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.

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.

The death rate is in no ways comparable to the seasonal flu. It's quite higher:

https://ourworldindata.org/coronavirus#case-fatality-rate-of...

Indeed,

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).

Your point still isn't clear or accurate. The worldwide CFR is over 4%. In Italy, it's currently at over 11%. The flu is nowhere near that level of risk. It's normally around 0.1% depending on demographic. Are you saying that the seasonal flu in Italy normally kills 11% of those who become infected? If that's the case, the facts don't bear that out.

But the CFR is mostly just a function of how many people get tested, no? And Italy seems to only be testing at hospitalization.

And how does Italy test the flu? In the US, there's minimal flu testing and most of the metrics are based around surveys.

I'm not disagreeing with you. However, at this point, some of the flu estimates are actually inferred/modeled by the CDC.

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.

The switch to war footing is already happening in the places hardest hit, for others it may be days or weeks away.

The question in a lot of ways is how many exponential doublings do we have to have before this situation switches in peoples' minds from a peace-time inconvenience to essentially real war.

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!

An empty school, at that.

I wonder if that decision was optimal for the circumstances, and if not, what actions we could take as a society to improve upon it?

I don’t think there’s going to be a mindset change in the population. The absolute worst estimates are between 0.5 and 1 percent of the population dying.

> Thr absolute worst estimates are between 0.5 and 1 percent of the population dying.

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:

https://news.ycombinator.com/item?id=22723647

1% of the world's population is almost 800m people. That's >10x the death-toll of WW2 (which took 6 years to achieve).

76 million.

Damn! That's what I get for posting while tired.

The problem is that X includes a nonzero risk to human life/limb that is the responsibility of the person doing X. If you are in charge of a hospital and just let Y people die because there's not enough qualified doctors to run ventilators then you can easily wash your hands of it as though it's not your fault. If you let less-qualified people run ventilators and Y/10 die from human error but you prevent 8Y/10 people from dying then all the families of the Y/10 that died from error are going to hold you responsible even though you minimized the number of overall deaths.

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.

> Given how medicine works, the chances of actually seeing this in action are low.

This has already been happening in Lombardy according to an account I read about two weeks ago.

Sorry, I should have been more specific.

Given how American medicine works, I see challenges with this approach.

> I don't think we really need to create more skilled medical professionals,

USA has 5 million medical professionals, almost as much medics per capita as Cuba.

Because it is a very, very unhealthy country in normal times.

Nah, we don't have all those doctors for the sick. We have doctors for every type of plastic surgery you can imagine, doctors for aging, doctors for athletic training, doctors that specialize in hips, others in just ankles, also shoulders only, others that only do laser eye surgery, others that only do teeth, some just for gums, some only do tooth implants. And on and on.

There is a shortage of doctors that actually treat sick people.

You just asked a person qualified to give you their professional opinion and then you turned around and more or less completely undercut that professional opinion.

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.

> Just like you don't want a front-ender doing back-end or systems

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?

There are exactly 6 known instances of talk down landings that I'm aware of. All concerned general aviation and in one of them the person had prior flight experience. Several of those ended in a crash. A general aviation plane is in no way comparable to a large airliner, and no instance of such a landing has ever been recorded, nor has it been attempted.

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.

Life is not a movie, some stuff is just hard ...

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"....

> 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.

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.

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.

> This language of addressing each posters as if they personally had this intention is pretty bizarre.

Oh, so it's just posturing. Forgive me then for taking you serious.

From what I have read the Italians have repurposed all kinds of doctors to be able to treat Covid patients as best they can with all available equipment. So I don't think it's too far out to say that in New York and other places you will see doctors stepping up and learning on the job in order to treat this disease. You will also see doctors coming into New York from other places to help.

Yes, and for doctors that may make more or less sense. But that's very far from the ideal situation: that we had managed to keep things under control when we could and that right now we stay home as much as possible to reduce the load on the system. But since people aren't even doing that (see this gem of a thread: https://news.ycombinator.com/item?id=22724268 ) I fail to see why we should at the same time break things even further.

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.

> Let's first all stay the fuck home

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? ;)

> The only thing I hear is "this won't work" "but what can we do?" "don't you understand that this won't work"....

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.

The flawed decision making was right at the start, when this thing could have been bottled up, and then after that at just about every junction where decisions were postponed. Now it's too late and everybody and their brother will start telling the ICU personnel how to clean up our messes?

It could be, I'm not overly familiar with those details, and therefore hold no opinion. Only when I sense I have a fairly decent understanding of a situation do I form any opinions on it (or more accurately, this is how I try to approach things!). And often even not then, as I have awareness of and profound respect for the ~multidimensional complexity of reality, where many of the variables and associations involved are completely invisible from an individual human perspective.

Regardless, is this somehow related to my comment above?

no instance of such a landing has ever been recorded, nor has it been attempted

It has in a simulator.

Doctors that don't know how to properly operate a vent are currently a problem in the US. Not blaming them, as there doesn't seem to be any real alternative.

Here's an /r/medicine discussion of it.

https://www.reddit.com/r/medicine/comments/fr0x3m/how_do_you...

I don't think you can pick a single /r/medicine thread as evidence of a widespread problem. My wife and every other doctor to ever practice medicine can give you anecdotal examples of other doctors mismanaging patients.

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.

I think some European countries have tried to deploy Dermatoloists and Gynecologists, etc s into ER in the present scenario after a training course.

Some medical students also could be utilised, if there is acute shortage, perhaps.

Do you have any idea how long it took your wife to learn to achieve the level of skill she is at? Let's say this was WW3, and we somehow lost 75% of these specialized personnel, what would be a ballpark estimate to get a reasonably intelligent person with no medical experience up to a "functional" level?

There's a lot to this question.

> 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.

Sorry, I probably should have been more clear, I was referring to teaching someone only the skills necessary to operate a ventilator, in a supporting role to a properly trained medical professional, who would handle the more complex situations.

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 an ophthalmologist/comedian on Twitter @dglaucomflecken with an entertaining, somewhat tongue in cheek feed with similar sentiments (https://twitter.com/DGlaucomflecken/status/12389545581407723...)

Priceless, and just what the ICU backseat driver crowd needs to see.

Thank you. That made my wife's morning.

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.

The subject matter is probably a bit more complex than “repeating the same task 20 times a day” even if it’s the same condition fundamentally.

Typical for tech oriented people to look at it this way. Patients with the same condition are still meatware and each has the capacity to develop their own variation on a large number of themes all of which require adaptations in treatment regime and sometimes very rapid intervention lest you lose a patient.

Your assumption doesn't hold.

I assume OP is referring to conditions during a pandemic. There have been numerous reports out of Italy about how they are operating under a wartime triage system - presumably under these conditions the response is more focused on repetition of the same process rather than unique personalised care.

No, it's the fact that you need unique personalized care that makes it complex.

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.

It's not a choice between a doctor and a layman, though. It's a choice between a volunteer who's only trained in the very basics and watched a couple of intubations, and nobody at all.

How much training does someone need before they become a clear net positive for the patient?

I rather had in mind a nurse who would step up but still know when to call the doctor when things look unusual.

A couple of years should do it. A volunteer would not just be a 'net negative' but would leave a lot of dead people. Why is it so hard to see that the people that operate this stuff are not just button pushers but specialists that have been schooled over years to take care of people?

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'.

Again, it's clear that a volunteer is far worse than a trained professional. At what amount of training does a volunteer become better than nothing?

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.

I wonder how long it would take to teach someone to be more help than harm? After 30 intensive days of training, what would candidates lack?

About 4 years of medical school, and around 4 more years of residency training.

Most Covid patients die on respirators anyway, can a nurse do 90% of the job ("good enough") and ask a doc if the rest is needed? The other option is worse and I doubt USA can afford to have docs sitting for decades waiting for another Covid like scenario. Remember these ventilators will be produced and go in storage to wait...

I would think you could augment with other personnel - interns, students, volunteers - who are trained and who's only job is to watch the ventilator and monitor a patient. They do not try and treat a patient but call for help if the patient's condition takes a downturn or equipment shows a problem they have not been trained to address.

This is not general purpose training - but very bounded / specific notes.

That's got to be better than exhausting more vital personnel.

The numbers from Wuhan were something like 30% fatalities for those moved to ventilation. That doesn't detract from your point but does support why the path "make a ton of ventilators" is being persued.

Technically I should provide a citation and searched, but couldn't find it. I'm almost certain that I've read that wayyy more than 50% (prob 70% die) once placed on ventilator. Maybe because those ending there are already with one foot+ on the grave. The ventilator can save,say 30%, and also make us feel good "we did all we could," after all, we will all reach that point one day ;)

There is a small study / report released with 32 patients in Wuhan who were put on ventilators. 31 died.

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.

Most people who get put on a ventilator die under the best of circumstances.

Really? They spend 8 years learning how to operate a ventilator?

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".

Ask any doc if they want 4th year medical students to help in the ICU with COVID-19 patients and they will say “No, they would most likely be a hindrance rather than help”. If a 4th year medical student can’t help, then why do you suppose somebody with zero training would?

Look how radiologists work nowadays. They don't see their patients face to face. Everything except the decision making has been handed to someone else so they can be most efficient. That's the model a huge COVID19 ICU could work like.

Still, it’s an ICU, not an outpatient clinic. I think you are a bit over-optimistic about just how much care can be delegated.

Forget about an ICU as we know it. Think about a field hospital near the beaches on D-Day.

I'm not saying "zero training". I'm suggesting the minimum training necessary to run a ventilator. That way doctors or nurses could simply hand off care to ventilator-operators who could contact the doctor or nurses if things got out of control. This wouldn't be as high quality care as people would usually get, but hopefully it would be better than nothing.

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.

Respiratory therapists exist

I believe the point is that the minimum amount of training required to be of greater help than hindrance (i.e., net benefit) in an ICU and running ventilators is sufficiently high that it's not a small thing to spin up a cohort.

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.

> 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...”

I'm trying to suggest, as gently as possible, that a time when our medical system is verging on being flooded may not be the best of all possible moments imaginable to add a significant resource-consumer in the form of an experimental mass training program. I am attempting to encourage more systemic thinking and greater consideration of context. I understand that some may disagree with some or all of these arguments.

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.

> 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 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.

Pretty reasonable if you ask me. History is littered with quacks and snake oil salesmen. There is a reason why becoming a physician is such an arduous and selective process.

> History is littered with quacks and snake oil salesmen.

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.

You’re comment reminds me of the reluctant success of sending teenagers on bomber raids in in WWII over Germany. As opposed to relying on only experienced airmen, which there went enough of.

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.

It's not the age of the pilot or doctor, but the experience. In WW2, some pilots were considered combat capable after 150 hours of flight time, basically 6 months. They died. Eventually the flight programs ended up taking 1.5-2 years on average to crank out a new pilot. A pilot that also died quickly.

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.

I have been nursing for years and the battle of skills has never stopped. Only doctors can do A B or C. Then at some point the registered nurses start doing it and then eventually the licensed practical nurses get to do it. The shift in skill set is always happening and often fought from the top ie doctors fighting to keep the skill to theirselves. You are absolutely right there are plenty of people who could efficiently watch the ventilator patients and report back the important facts. And you are also right they don’t need to do a perfect job only better then just letting people die with no chance. That is what triage is all about. All hands on deck. It is just really hard to start giving extra direction and have new people on the ward when the shit is hitting the fan and that alone can fluster staff. But in a pinch we won’t have enough staff so other rolls need to be taken or people will die.

Thanks for adding your expertise to the discussion.

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.

I'm not an MD but I've had contact, on-and-off, with mission-critical equipment in the energy sector (according to my university I'm an EE but I was cleverly disguised) and then I've worked in the medical equipment industry for a few years. I would be very, very surprised if the parent comment(s) weren't correct. Training, no matter how intensive, is no substitute for education.

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 fully expect that a person who has only thirty days training will be worse than a professional and their relative incompetence will kill people. I don't understand how that is an argument against the plan to train volunteers though.

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.

I've sure you've already considered this, but wouldn't any kind of training program of the sort you describe risk diverting resources from current operations?

It's possible. That's something that would have to be weighed against how bad we expect shortages to be and how much we expect amateur ventilator-operators to help.

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.

There are clearly a lot of contrarians in this thread, perhaps that is because the premise of a flooded healthcare system is still too impossible for some to envision.

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.

I got your point, but I am not at all convinced that sending in people who have nothing but good intentions and 30 days of training, at a scale, and over a long period of time, will result in less harm (including among those with good intentions) than not bringing in extra personnel. Especially in ICU, which as far as I can tell is the RF engineering of medicine.

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).

Also vets could help out if necessary, as they are trained to use ventilators.

...and in the UK we've already seen calls to use the vents that vets have.

https://www.vettimes.co.uk/news/veterinary-sector-primed-to-...

This speaks volumes about the cronyist regulatory captured monopoly that the AMA has been able to install over the past hundred years.

I think it speaks more to the fact that medical school is mostly focused on book learning and residency is when doctors get most of their hands-on experience.

Doctors don't want someone with zero training "helping". That's for sure. The original idea of 30 days training is an end of the world worst case scenario. No one wants that right now. And someone with 30 days training is more of a hinderance than a help. Press more techs, nurses and PAs into service first.

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 original idea of 30 days training is an end of the world worst case scenario.

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.

Thanks for your comments in this thread. Some people seem to have an axe to grind concerning the hubris of software hackers and are pushing that debate rather than addressing the question.

It seems like you've outlined a situation that could well be true. The US indeed has a training process that only generates useful competence with a full 8-12 year apprenticeship of hazing and theory.

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.

Imagine thinking that the role of a medical professional in the ICU is to just sit around and “press buttons”.

In a huge medical emergency, when people essentially desperately pleading for a ramp-up of the effectiveness of medical personnel, it's kind of mind-boggling that the only answer you're giving is sneering at how little the layman knows (and yeah, that seems like a standard answer doctor in the US are going give).

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.

Several schools, after requests, are graduating students early, precisely because of covid. And I don't think normal times and these are the same. Having younger, less likely to be infected staff is not nothing. And the variety of tasks is a lot lower right now, than during more typical times.

I would be surprised if any of these students will be in the ICU. Most likely they will be assisting with more mild patients and freeing up experienced doctors to help with more severe patients.

That will change when they have 20 times as many patients and the alternative is to let people die alone in the hallways with no help at all.

Doctors don’t run ventilators. Respiratory therapists do. A respiratory therapy degree is a 2-year associates degree that includes basic training on physiology and biology. I’m betting that someone with an undergraduate degree in biology could learn the role in a few months of intensive training.

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.

It was a tongue-in-cheek comment. The point was that it takes more than a 30 day bootcamp to be more of an asset than a liability in a critical care environment.

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.

I think the push-back is that it's not black and white. If we end up in a situation where somehow we get 10x the number of ventilators and staffing becomes the limiting factor, you can bet that hospitals will get creative on how to operate them. You're right, pulling in people off the street is not the place to start (even 1337 Javascript coders). I would think you would start with trained physicians from other disciplines, PA's, NP's, RN's.

> About 4 years of medical school, and around 4 more years of residency training.

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...

Yes, people in this thread are letting the perfect be the enemy of the good. Everyone knows that doctors are overqualified for the vast majority of tasks they are responsible for. Normally, there's good reason for this, because you want a highly-trained eye to spot unusual and atypical cases.

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.

> Yes, people in this thread are letting the perfect be the enemy of the good

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.

> [...] 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.

Because the difference between letting someone die under inappropriately-applied ventilation versus just letting someone die is the occupation of a perfectly good ventilator. One that could be used to actually save someone. If you're in the business of killing patients, a gun would be more economical than a ventilator.

I believe there is a third possible outcome that you overlooked.

Heh, if it comes down to it we will see a lot of creative new processes that are apparently beyond the imaginations of many here.

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.

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.

So, just to reset your mental image of what a typical ventilator ICU setup looks like (don't click if you're squeamish):

https://pbs.twimg.com/media/EUNYuOuU4AApgBX?format=jpg&name=...

Still want to gamble on that 'narrow set of practices'?

Is that the typical setup for covid icu patients though? I imagine ventilators are used for all sorts of patients, some requiring much more involved care.

That's about as simple as it gets. This is a pediatric ICU ward, I just wanted a picture that shows you the essentials. It can get much more complex than that and not a whole lot simpler. Once you are intubated you are kept sedated (it's not exactly a pleasant experience) so you rely 100% on the world around you for your vitals and needs. Essentially you are in a controlled coma for the duration with all the difficulties that brings.

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.

Maybe we need a Doctor bootcamp?

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.

That's a weak argument, in my opinion. I've commented on this in the past, but there's nothing physically stopping hospitals and other institutions with their own funding from opening of more spots. You can definitely get ACGME accreditation without CMS funding for your program, institutions just need to be willing to find other funding.

Is it Congress making this decision, or the lobbyists for the AMA?

They don't want to let their prestigious profession become what it essentially is—a body mechanic.

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.

https://en.wikipedia.org/wiki/Healthcare_in_Cuba

Cuba is already supporting Italy at this time.

https://www.youtube.com/watch?v=n-93Uhrpam4

Where can I read more about those sabotage attempts?

"US pressures countries to reject Cuban aid during coronavirus pandemic"

https://morningstaronline.co.uk/article/w/us-pressures-count...

Thanks.

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.

Yes, the only thing stopping us from 3D printing ventilators and hooking them up to patients are those evil “barriers” we call regulations.

You answered your own question in the last sentence.

Is it though? Can't you train people on the basics of a single device as a sort of Tier-1 support with the ability to escalate to Tier-2 immediately? Governor Cuomo said in at least one briefing that they were considering training national guard troops to do exactly that.

The device he was referring to was a hand-driven bellows attached to a face mask, and he brought it up as a desperate, last-ditch scenario, ending his description of it with "No, thank you!" Though I think there's a good chance we'll end up there.

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.

People who are experts in using one class of ventilators (ICU) are already being trained in using a different class of ventilator (anaesthetics), and they're somewhat concerned about this because of the differences in the machines. https://twitter.com/aroradrn/status/1244134454001635329?s=20

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.

> The reality is ventilators are useless without intensivists to operate them,

Get guard reservists and order them to squeeze the airbag by hand if 5 million American health professionals are not up to task

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.

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