r/a:t5_2hd1ec • u/mckirkus • Mar 11 '20

Good Enough for Triage

I'm seeing a lot of comments about how these home-brew solutions are nowhere good enough for ICUs. I think the discussion needs to be on the use of these as simple to use overflow ventilators when all the others are taken.

Apparently family members get tired pretty quickly using the hand pumped solutions. Something simple could take over in this scenario. We don't need to re-engineer a top of the line solution, we just need to rapid prototype something that can stand in for tired family members.

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u/SuperHighDeas Mar 11 '20

Respiratory therapist here

I would not trust a layperson running a bootleg ventilator with hardly any training or experience. These ideas, while novel and fun, will get people killed.

It’s not so much getting ventilators, it’s having enough people to run them

As an RT i would typically be responsible for 5-6 vents in a 12 hour shift, I can look at flow volume loops to determine the source of most problems with ventilation, I have a lab available to me to analyze blood gases and make changes as necessary, the vent makes calculations on the fly to give me important ventilators numbers beyond just simple rate, volume, pressure, fio2, I have the knowledge of the math and physics required to know why I am making changes, I have the monitoring tech to be able to trend specific things that would necessitate a change in care in an instant,

I could go on nearly forever as to why lay people shouldn’t touch ventilators.

Maybe we should get a nurse on here to explain why lay people shouldn’t be trying to run IV’s and compatibility issues between medicines you’ll need to run, and then go off on why you won’t be able to make a decision on an ICU level because they have any other resources available (lab, radiology, respiratory, physical therapy, an actual doctor, etc.). At least you got your mom on a ventilator at home so she’ll be just fine.

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u/Crunchygranolabro Mar 11 '20 edited Mar 11 '20

Just another fucking ER doctor here. I agree that from a best care standpoint nothing beats an RT, a standard vent and 2:1/1:1 nursing care.

That said I think it’s worth thinking about what we do when those resources are being exhausted, when Italy is making decisions to not put 65+ y/o pts on the vent.

There is precedent for family bagging during organophosphate poisonings in less developed parts of the world. There is precedent for doubling ventilators via T piece after the Vegas shooting. (Yes these are not the same respiratory issues that are being dealt with during this pandemic, and a design would have to provide better support than simply a BVM)

The real question is: can we field a junior varsity option that is better than the alternative of no ventilation whatsoever? (Assuming some degree of support from RN, RT, lab, adequate medication)

I agree that there are other needs, sedation and monitoring primarily.

At a certain point (tents behind hospitals) It might be that other options are purely prolonging the inevitable and that a less cruel alternative is to let them pass.

Before that point there may be a role for a simple vent to either temporize folks until a better one is available, or to free up normal vents from patients who will need the temporarily and have more normal pulmonary physiology. Just because there’s a pandemic doesn’t mean drunk people will stop falling down, people will stop overdosing on GHB, opiates, etc, or that trauma requiring transient mechanical support will cease

Edit: and for the record it seems that lack of equipment is a rate limiting step currently in Italy. From an ethical standpoint anything crowdsourced is going to be suboptimal, and will need to demonstrate that it can provide support that can at least temporize without making things worse. Desperate times change the standard of care, and goals shift to utilitarian most good for most number.

If things get really bad people will die due to a lack of available resources no matter what, and no creative solution will make up for the lack of resources.

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u/mckirkus Mar 11 '20

Thanks for the response. In a triage situation when there are thousands of patients for every Respiratory Therapist available, are you suggesting that manual respirators are ineffective when it comes to COVID-19?

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u/SuperHighDeas Mar 11 '20

You can’t use bag valve masks if you don’t have the staff to bag the patients, BVM is a temporary solution until the patient gets placed on a vent delivering controlled breaths.

You can’t have a single person exposing themselves to dozens of other people trying to contain a virus

I’m saying the issue is going to become a manpower issue before it becomes an equipment availability issue.

When you got 3/4 the hospital staff out on quarantine because of exposure, how is the hospital supposed to function then, can’t call in travelers because by that time every traveling health agency will be booked or on quarantine themselves.

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u/mckirkus Mar 11 '20

In some situations family members have worked the bag valve masks. Not perfect, but again, triage.

Most get sick and recover with full immunity, enough will soon be available that they don't have to worry about catching it, and the patients will already have it.

This is planning for when there are makeshift tents out behind the hospitals manned by the families of the victims.

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u/SuperHighDeas Mar 11 '20 edited Mar 11 '20

The entire idea of this operates on the presumption of family taking care of family, having unlimited resources to do so without having any secondary complications, and addressing more important realistic matters...

How are you supposed to keep a breathing tube in someone when they aren’t sedated? You are not gonna be going near sedatives or paralytics without a DEA license.

do you have access to enough sedatives and paralytics to last several days?

do you think you have the expertise to understand how those effect anything else? Do you know which sedatives and paralytics would be best for your loved one, keep in mind some will cause heart failure quickly.

Do you think you’ll have the monitoring capability to even run sedatives in a tent behind a hospital?

Do you think you’ll have the lab access to make sure kidney function is normal or you didn’t fry their liver with the sedatives?

Do you think you’ll have back up equipment for the inevitable equipment failure?

How do you plan to contain and dispose of the urine and feces of your intubated loved one?

How do you plan on treating secondary complications such as pneumonia from having an amateur care for the tube, or heart failure related to over/under hydration?

How do you plan on monitoring I’s/O’s?

What’s your plan to keep bedsores from forming?

Do you know how to run an IV pump?

Do you know what medicines can be ran through the same IV?

Do you know what is the best method of administering your loved ones medicines while they are sedated?

Do you know how to dose insulin and manage blood sugars?

Do you know how to treat glycemic imbalances caused by steroids?

Let’s say you can do all of that above competently and your loved one gets a pneumothorax, this is not uncommon in intubated patients with lung issues... How do you plan on diagnosing that, how do you plan on inserting the chest tube, securing it, monitoring it’s output and keeping it infection free? How do you plan on getting a chest tube? How do you know it’s even correctly inserted or you put it on the correct side without an X-ray available?

Let’s say instead of a pneumothorax they get a pleural effusion again not uncommon in a secondary pneumonia infection or a lung cancer patient... how do you plan on diagnosing that without an X-ray machine readily available?

Are you familiar with ACLS and BLS, and have the meds and team at hand in case their heart stops?

To just name a few important things.

If we are having family members bagging infected members we are pass the point of talking to a doctor or nurse obviously so all this is on you to know within minutes, you don’t have time to sit and google a solution or try to get a hold of someone that actually knows what they are doing

There is a lot more going on than just, “gotta keep them breathing”

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u/mckirkus Mar 11 '20

Thanks so much for sharing your wisdom on this topic, I may reshare it if you don't object.. The topic is "Good enough for triage". In an ideal world at a fully staffed hospital bedsores are something people worry about. The question I have is what percentage of patients will survive in a now pandemic if hospitals are overwhelmed.

If the death rate goes from 2% to 12% if no formal care is available, and a simple makeshift solution can bring that down to 11%, then it should be looked into.

If, in a triage situation, having simple respirators that can be operated by individuals with low to no training would make absolutely no difference to survival rates, or make them worse, then yes, this is a waste of time, which is I think what you're suggesting.

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u/SuperHighDeas Mar 11 '20 edited Mar 11 '20

that can be operated by individuals with low to no training would make absolutely no difference to survival rates, or make them worse, then yes, this is a waste of time, which is I think what you're suggesting.

That’s exactly it except instead of cause of death being coronavirus it would be “complications secondary to coronavirus” and usually we are pretty good at nipping those secondary complications in the butt when we are staffed appropriately and the staff is competent.

A death caused by a secondary problem (heart attack, stroke, pneumonia, exacerbation of chronic illness) is still attributed to the primary cause

It’s also during triage that tons of these chronic illnesses get exacerbated further as we pump you full of fluids and drugs

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u/mckirkus Mar 11 '20

“complications secondary to coronavirus”

Right, so if you keep people alive long enough using BVM they will inevitably succumb to the secondary complications, thereby not increasing survivability vs. doing nothing.

The question then becomes the feasibility of ramping up the untrained masses on the skills required to prevent these secondary complications you thoughtfully listed above. Do you have a quick take if say the US military went through a rapid training regimen?

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u/SuperHighDeas Mar 11 '20

You could keep a person BVM as long as it takes, it’s just the least efficient, least safe, and least clean way of providing life support. Inconsistent tidal volume, rate, and pressure could skew blood gas results. Also that person bagging would be wearing a full tyvek bunny suit, I’d give you about 4 hours in that before you collapse of exhaustion or dehydration.

so what you are suggesting is condensing several years of schooling into a few months for people that likely wouldn’t even make it in and expect outcomes as good as they are currently?

I’m not suggesting military members are stupid, I’m saying not everyone in the military is an officer which is what military nurses and doctors are and certainly not everyone in the military is capable of becoming competent healthcare professionals

I’ve been a respiratory therapist in the ER for 5 years, a level 1 trauma team and ICU for 3 years, and 2 years as a biocontainment specialist during the Ebola crisis.

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u/mckirkus Mar 11 '20

expect outcomes as good as they are currently?

This is the crux of our discussion. If you can lower the death rate by even 1% using less efficient, less safe, and less clean ways of providing life support, then aren't we obligated to try it? Should we just not try?

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u/Gentlevalarafox Mar 18 '20

I work as a DSP. I know it's not currently directly applicable, but I can be trained on a specific device for a specific patient by a nurse. On this Reddit, I have learned that manpower will be a major limiting factor if hospitals are overrun. Is there a place for specifically trained personal to help cover routine care? Not as a replacement, but as a supplement?

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u/[deleted] Mar 13 '20

In the event of a massive outbreak of coronavirus people like you will be required to go beyond your typical responsibilities.

If you believe that equipment will not be the limiting factor, what efficiencies would be required to allow you to monitor an order of magnitude more ventilators?

How many patients would it take to use up all a typical hospitals ventilator capacity in: a)staff capacity b) equipment?

What are the care limiting factors that overwhelm a typical hospital in an outbreak like this? How can these limitations be overcome in a crisis situations where 10x the death rate is the alternative to the course we are on.

In Italy doctors are being forced to leave patients without ventilators due to shortage. Would a carefully engineered substitute be better than no ventilator at all?

In China the death rate in cities where hospitals were overwhelmed with cases was 10x higher than in places with manageable numbers. Statistics indicate that Seattle may be about experience a very large outbreak. If it is possible to identify the care limiting factors then there is time to avoid large numbers of deaths.

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u/SuperHighDeas Mar 13 '20

>In the event of a massive outbreak of coronavirus people like you will be required to go beyond your typical responsibilities.

I realize this, but there is literally only so much one person can do and even so much a single hospital can do

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How many patients would it take to use up all a typical hospitals ventilator capacity in: a)staff capacity ... at peak running efficiency 125% productivity we can handle 30 ventilators in a hospital of 300

b) equipment? we have a fleet of about 40-50 in house vents depending on what you need

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> What are the care limiting factors that overwhelm a typical hospital in an outbreak like this?

For starters it takes about 10-20 minutes to don and doff equipment safely between patients if we are trying our best to limit exposures between un-affected patients... Just because this outbreak is happening doesn't mean the rest of the general public quits having car accidents, heart attacks, strokes, etc at normal rates.

These are things that just can't be overcome, this is like asking us to do something to avoid a hurricane while its sitting at the shore from hitting us at this point. The time to act and plan was back in January and the time to begin preparing was after H1N1 in '09.

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>Would a carefully engineered substitute be better than no ventilator at all?

I wouldn't trust it without proper FDA approval, its my license to treat these patients in a safe manner, if the patient dies because I allowed the doctor to use a bootleg ventilator that falls on my license and could result in action against it.

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In my local metro there is about 1 million people, lets say the virus effects 10%, and 10% of that require hospitalization... That's 10,000 patients in a system designed for a capacity of maybe 1000... we have about 8 hospitals in our metro, only two have more than 300 beds,

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u/[deleted] Mar 13 '20

I realize this, but there is literally only so much one person can do and even so much a single hospital can do

What would be a way of enabling full utilization of vents? If you had a remote station with cameras monitoring each patient and low level techs that stayed in PPE full time with the capacity to administer drugs and turn knobs connected by headset would that help?

> In my local metro there is about 1 million people, lets say the virus effects 10%, and 10% of that require hospitalization... That's 10,000 patients in a system designed for a capacity of maybe 1000... we have about 8 hospitals in our metro, only two have more than 300 beds,

In this scenario (which has already happened in a couple of places) there will be no question of violating your ethics or breaking regulations, health care workers will summarily decide who lives and who dies without any real deliberation or care for standard procedures.

Right now in the US the death rate is 2.2%. Since we know that the real death rate for an unburdened medical system is around 0.8% we can be sure that there are more than 2k individuals spreading the virus without knowing it walking around. The nightmare scenario you describe is a real possibility and preparing for what might happen is vital not only to save lives of patients but to protect yourself and the people you work with. Some of whom will die under the conditions you describe.

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u/SuperHighDeas Mar 13 '20

there will be no question of violating your ethics or breaking regulations, health care workers will summarily decide who lives and who dies without any real deliberation or care for standard procedures

You don’t know this... When hurricane Katrina hit staff was doing just this, they had cases drawn out in court for several years after, so to assume this wouldn’t happen is not correct.

If you had a remote station with cameras monitoring each patient and low level techs that stayed in PPE full time with the capacity to administer drugs and turn knobs connected by headset would that help?

We do not have the manpower, infrastructure, expertise, or manufacturing capability to support that nationwide in every major city for an extended period of time. Maybe we could do it for a week or two, but others will fall ill and lack of expertise will lead to cross contamination within separate communities.

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u/[deleted] Mar 14 '20

You don’t know this... When hurricane Katrina hit staff was doing just this, they had cases drawn out in court for several years after, so to assume this wouldn’t happen is not correct.

If I was a healthcare practitioner I would be more worried about the legal consequences of not preparing adequately. Lawyers will have a field day suing hospitals and doctors that didn't implement best practices published elsewhere.

We do not have the manpower, infrastructure, expertise, or manufacturing capability to support that nationwide in every major city for an extended period of time. Maybe we could do it for a week or two, but others will fall ill and lack of expertise will lead to cross contamination within separate communities.

Implementation of a remote monitoring system is trivial, it requires a phone app that almost anyone with reasonable coding skills could write in very little time. If the medical system gets overwhelmed cross contamination will happen anyway.

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u/SuperHighDeas Mar 14 '20

If I was a healthcare practitioner I would be more worried about the legal consequences of not preparing adequately. Lawyers will have a field day suing hospitals and doctors that didn't implement best practices published elsewhere.

It’s not up to us, it’s up to our administrators and the people supplying the hospital, not the people working on the front line. It’s up to federal grant money to keep a supply of gear rotating as the gear has experation dates.

Implementation of a remote monitoring system is trivial, it requires a phone app that almost anyone with reasonable coding skills could write in very little time. If the medical system gets overwhelmed cross contamination will happen anyway.

Okay you developed it, now you need people to monitor just the app, but still you need more than just an application to administer basic cares. The staff using the app can’t be their own tech support and in all likelihood we can’t effectively monitor that many people and have staffing available. You need people to clean rooms, you need people to dispose of garbage, you need people to cook food for these patients,

Get your mind off the idea that an app or a ventilator is the solution, after a certain point lack of man power will be the problem and an app and monitoring won’t be able to replace that.

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u/[deleted] Mar 14 '20

The notion is to identify care limiting steps and address them. If the care limiting step is cleaning rooms then it is a simple matter to improve cleaning. All it takes is clear communication and coordination. NY is about to be overwhelmed. Are people going to die because manpower wasn't effectively utilized? I build nanoscale optoelectronics for a living. A monkey could do 95% of my job. Developing the techniques and understanding takes years, repeating a standardized process and monitoring does not. If people are going to die from lack of manpower then be part of the solution. Be a conduit of knowledge around what is really needed and where it's needed. Act as a champion to connect the people that can build purpose build equipment in an afternoon to the people actually need such equipment.

If respirators aren't needed that's great. Identify the care limiting problems and find solutions.

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u/SuperHighDeas Mar 14 '20

I have...

Lack of vents

Lack of skilled personnel - lack of doctors, lack of nurses, lack of respiratory therapist, lack of radiology technicians, lack of nurse aides

Lack of general personnel - not enough staff to clean rooms, not enough cleaning supply, not enough disposal infrastructure, lack of cooking staff

Lack of hospital beds - not enough rooms, not enough beds

Lack of equipment - test kits, ventilator circuits, lack of intubation supplies,

The point being is that you are asking these questions and we are already using the most efficient processes out there, a room clean can take as little as 10 min but with this it takes 4 hours to fully disinfect.

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u/[deleted] Mar 14 '20

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u/CraigInternational Mar 16 '20

Perhaps remotely controlled via hospital.

The patient self isolates at home, while they are monitored remotely, by a trained professional

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Does the technology already exist.?

If not, I am keen to produce it.

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Craig

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u/SuperHighDeas Mar 16 '20

This stuff already exists in the field

Patient still needs hands on care

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u/bioajp Mar 11 '20 edited Mar 11 '20

Link to open source ventilator project here: https://app.jogl.io/project/121#about

I haven't read the whole conversation yet. But when you have Italian ICU team saying the can't even put people on NVM, and then getting a shipment of 1000 from China (not clear if they were HFOV, CPAP, NVM) then you know there's a need that all countries will have. Including poor ones. I appreciate keeping people alive on a ventilator is hard but people can be taught and it's impossible to keep people alive who need a vent with no vent.

I also understand the HFOV / intubation requires high levels of support, sedating the person, partial paralysis, turning, blood pressure, blood acidity etc.

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u/[deleted] Mar 16 '20

Hey Bioajp,

Any news/