Ventilators are using up all the creative oxygen

Where do we go to manufacture nurses?

The anxiety over the number of ventilators is a waste. Mostly, it is generating fear and, more tragically, it is misdirecting priorities. The energy and brainpower can be better used. No matter how patriotic, well-intended or coerced, no company can manufacture care capacity.

Dr. Fauci did us an excellent service by giving us the phrase “flatten the curve.” Explicitly, he wanted us to prevent the healthcare system from getting “overwhelmed.” Yet, ventilators don’t get overwhelmed. Beds don’t either. What gets overwhelmed? People. We need to flatten the curve because there is a finite capacity to provide critical care. Ventilators aren’t enough.

The intensive care unit is a serious place. The last resort for respiratory distress is mechanical ventilation. Machines can breathe for you only temporarily because the risk of further complications climbs by the day — complications that are as serious as the conditions that landed you on a ventilator in the first place.

Ventilation is more involved than most can imagine. Breathing is instinctual, and we naturally fight a machine trying to do it. (imagine trying to exhale while the device is pushing air into your lungs). Doctors start by paralyzing you with drugs so they do not have to fight your reflexes. They place tubes for air and food leaving you sedated days. Your vocal cords are now useless and you are mostly asleep. Unable to move, talk or stay awake connected to a machine that cannot stop working even for a minute.

Attentive monitoring is mandatory. A team of highly skilled professionals is needed now: more than one MD, pharmacists, respiratory therapists, critical care nursing team, among others. To save your life, you must be attentively monitored because you are sick enough to be in the ICU, and the risk of serious complications is climbing by the day.

Human dexterity and cognitive load is a real factor. Humans cannot work like ventilators. Performance can deteriorate over time, especially when dealing with such a constant load. How many hours per day do you want your nurse to work?

Everyone is multi-tasking. Everyone on the care team typically has many patients. That means by definition they are dynamically prioritizing tasks, and they are constantly interrupted. It is easy to see this at the bedside: doctors rounding, techs doing treatments, locating missing meds/supplies, questions from the family, calls from the emergency department or surgery et al. Busy with bursts of panic, followed by heroism.

There is a worrisome drug shortage. Long before we heard of COVID-19, hospital pharmacists and the physicians have been struggling with alternatives when the preferred drugs are not available. These alternatives are, by definition, less than ideal. The alternative options can be contraindicated, they can extend the stay and add risk for the patient. Depending on the situation, changes to the hospital formulary and supply chain need to happen. (read: not timely or easily made available). They don’t teach just-in-time inventory systems in medical school.

If they were exhausted just five months ago, how do you think they are feeling now?

It’s up to the people to ramp up the care capacity. We don’t need a 10% improvement. We need a 10X improvement. I believe strongly that this can only happen when people mobilize organically. We cannot wait for the government to lead it. We can do it. A mobilized population can turn the most cynical and bureaucratic.

These unprecedented times are also an opportunity to do unexpected things. Even the most optimistic forecast of when things will get back to normal is months and months away. I believe the government offers only marginal improvement. Faster than a vaccine, we could have an entire army of people ready to provide care capacity. No one knows what can happen when millions of people mix creative thinking with logistics and take action. It can hasten our time in seclusion and buttress our future with unexpected innovation.

References

Klompas, Michael, Richard Branson, Eric C. Eichenwald, Linda R. Greene, Michael D. Howell, Grace Lee, Shelley S. Magill, Lisa L. Maragakis, Gregory P. Priebe, Kathleen Speck, Deborah S. Yokoe, and Sean M. Berenholtz. “Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals: 2014 Update.” Infection Control and Hospital Epidemiology 35, no. 8 (2014): 915–36. Accessed April 1, 2020. doi:10.1086/677144.

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