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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 a

by oefrha 7y ago

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.

romanows 7y ago
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?
- cycrutchfield 7y ago
  About 4 years of medical school, and around 4 more years of residency training.
  - onetimemanytime 7y ago
    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...
    - rajandatta 7y ago
      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.
    - verytrivial 7y ago
      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.
      - onetimemanytime 7y ago
        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 ;)
        hiram112 7y ago
        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.
        barry-cotter 7y ago
        Most people who get put on a ventilator die under the best of circumstances.
  - ALittleLight 7y ago
    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".
    - cycrutchfield 7y ago
      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?
      - choeger 7y ago
        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.
        cycrutchfield 7y ago
        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.
        choeger 7y ago
        Forget about an ICU as we know it. Think about a field hospital near the beaches on D-Day.
      - ALittleLight 7y ago
        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.
  - URSpider94 7y ago
    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.
    - cycrutchfield 7y ago
      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.
      - URSpider94 7y ago
        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.
  - barry-cotter 7y ago
    > 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-bsmd-programs-only-6-years/ https://www.forbes.com/sites/noodleeducation/2018/06/18/3-bs... [2] https://www.ul.ie/gems/programmes/bmbs-programme https://www.ul.ie/gems/programmes/bmbs-programme [3] https://med.nyu.edu/education/md-degree/accelerated-three-year-md https://med.nyu.edu/education/md-degree/accelerated-three-ye...
- deleted 7y ago
  [deleted]
- marcoperaza 7y ago
  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.
  - omar_a1 7y ago
    > 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.
    - marnett 7y ago
      > [...] 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.
      - omar_a1 7y ago
        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.
        mistermann 7y ago
        I believe there is a third possible outcome that you overlooked.
- Rapzid 7y ago
  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.
VectorLock 7y ago
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?
noelsusman 7y ago
You answered your own question in the last sentence.
- tmpz22 7y ago
  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.
  - AlexCoventry 7y ago
    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.
  - DanBC 7y ago
    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 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.
faitswulff 7y ago
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.
naringas 7y ago
> 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.
- ryanmccullagh 7y ago
  Maybe we need a Doctor bootcamp?
droithomme 7y ago
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.
ck2 7y ago
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
ohbleek 7y ago
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.
- epmaybe 7y ago
  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.
- hiram112 7y ago
  Is it Congress making this decision, or the lobbyists for the AMA?
  - casefields 7y ago
    They don't want to let their prestigious profession become what it essentially is—a body mechanic.
lern_too_spel 7y ago
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.
SkyPuncher 7y ago
> 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. ---- Given how medicine works, the chances of actually seeing this in action are low. But....it's an options.
- saurik 7y ago
  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.
  - SkyPuncher 7y ago
    Veterinarians make sense. The ones that do surgery already know how to run vents on animals. Humans are a form of animal, after all.
    - jacquesm 7y ago
      That's a better idea, also, veterinarians tend to be much more all-round.
14 7y ago
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.
relativitypro 7y ago
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.
- cycrutchfield 7y ago
  Yes, the only thing stopping us from 3D printing ventilators and hooking them up to patients are those evil “barriers” we call regulations.
joe_the_user 7y ago
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 https://en.wikipedia.org/wiki/Healthcare_in_Cuba
- chinathrow 7y ago
  Cuba is already supporting Italy at this time. https://www.youtube.com/watch?v=n-93Uhrpam4 https://www.youtube.com/watch?v=n-93Uhrpam4
- AlexCoventry 7y ago
  Where can I read more about those sabotage attempts?
  - joe_the_user 7y ago
    "US pressures countries to reject Cuban aid during coronavirus pandemic" https://morningstaronline.co.uk/article/w/us-pressures-countries-reject-cuban-aid-during-coronavirus-pandemic https://morningstaronline.co.uk/article/w/us-pressures-count...
    - AlexCoventry 7y ago
      Thanks.
baybal2 7y ago
> 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
yibg 7y ago
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.
- jacquesm 7y ago
  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=medium https://pbs.twimg.com/media/EUNYuOuU4AApgBX?format=jpg&name=... Still want to gamble on that 'narrow set of practices'?
  - yibg 7y ago
    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.
    - jacquesm 7y ago
      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.
deleted 7y ago
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cm2187 7y ago
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.
- read_if_gay_ 7y ago
  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.
- jacquesm 7y ago
  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.
  - knz 7y ago
    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.
    - jacquesm 7y ago
      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.
  - strken 7y ago
    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?

by oefrha 7y ago

romanows 7y ago

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?

cycrutchfield 7y ago
About 4 years of medical school, and around 4 more years of residency training.
- onetimemanytime 7y ago
  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...
  - rajandatta 7y ago
    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.
  - verytrivial 7y ago
    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.
    - onetimemanytime 7y ago
      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 ;)
      - hiram112 7y ago
        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.
      - barry-cotter 7y ago
        Most people who get put on a ventilator die under the best of circumstances.
- ALittleLight 7y ago
  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".
  - cycrutchfield 7y ago
    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?
    - choeger 7y ago
      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.
      - cycrutchfield 7y ago
        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.
        choeger 7y ago
        Forget about an ICU as we know it. Think about a field hospital near the beaches on D-Day.
    - ALittleLight 7y ago
      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.
- URSpider94 7y ago
  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.
  - cycrutchfield 7y ago
    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.
    - URSpider94 7y ago
      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.
- barry-cotter 7y ago
  > 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-bsmd-programs-only-6-years/ https://www.forbes.com/sites/noodleeducation/2018/06/18/3-bs... [2] https://www.ul.ie/gems/programmes/bmbs-programme https://www.ul.ie/gems/programmes/bmbs-programme [3] https://med.nyu.edu/education/md-degree/accelerated-three-year-md https://med.nyu.edu/education/md-degree/accelerated-three-ye...
deleted 7y ago
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marcoperaza 7y ago
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.
- omar_a1 7y ago
  > 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.
  - marnett 7y ago
    > [...] 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.
    - omar_a1 7y ago
      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.
      - mistermann 7y ago
        I believe there is a third possible outcome that you overlooked.
Rapzid 7y ago
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.

VectorLock 7y ago

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?

noelsusman 7y ago

You answered your own question in the last sentence.

tmpz22 7y ago
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.
- AlexCoventry 7y ago
  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.
- DanBC 7y ago
  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 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.

faitswulff 7y ago

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.

naringas 7y ago

> 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.

ryanmccullagh 7y ago
Maybe we need a Doctor bootcamp?

droithomme 7y ago

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.

ck2 7y ago

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

ohbleek 7y ago

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.

epmaybe 7y ago
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.
hiram112 7y ago
Is it Congress making this decision, or the lobbyists for the AMA?
- casefields 7y ago
  They don't want to let their prestigious profession become what it essentially is—a body mechanic.

lern_too_spel 7y ago

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.

SkyPuncher 7y ago

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

saurik 7y ago
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.
- SkyPuncher 7y ago
  Veterinarians make sense. The ones that do surgery already know how to run vents on animals. Humans are a form of animal, after all.
  - jacquesm 7y ago
    That's a better idea, also, veterinarians tend to be much more all-round.

14 7y ago

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.

relativitypro 7y ago

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.

cycrutchfield 7y ago
Yes, the only thing stopping us from 3D printing ventilators and hooking them up to patients are those evil “barriers” we call regulations.

joe_the_user 7y ago

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

chinathrow 7y ago
Cuba is already supporting Italy at this time. https://www.youtube.com/watch?v=n-93Uhrpam4 https://www.youtube.com/watch?v=n-93Uhrpam4
AlexCoventry 7y ago
Where can I read more about those sabotage attempts?
- joe_the_user 7y ago
  "US pressures countries to reject Cuban aid during coronavirus pandemic" https://morningstaronline.co.uk/article/w/us-pressures-countries-reject-cuban-aid-during-coronavirus-pandemic https://morningstaronline.co.uk/article/w/us-pressures-count...
  - AlexCoventry 7y ago
    Thanks.

baybal2 7y ago

> 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

yibg 7y ago

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.

jacquesm 7y ago
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=medium https://pbs.twimg.com/media/EUNYuOuU4AApgBX?format=jpg&name=... Still want to gamble on that 'narrow set of practices'?
- yibg 7y ago
  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.
  - jacquesm 7y ago
    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.

deleted 7y ago

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cm2187 7y ago

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.

read_if_gay_ 7y ago
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.
jacquesm 7y ago
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.
- knz 7y ago
  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.
  - jacquesm 7y ago
    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.
- strken 7y ago
  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?