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  • Ventilator Math

    Posted by Dan from Madison on March 27th, 2020 (All posts by )

    So Andrew Cuomo says that they need up to 40,000 ventilators in New York City.

    But “the number of ventilators we need is so astronomical,” Cuomo warned, pegging the “apex number” of ventilators that could be required in New York at 40,000.

    So, I like math and I enjoy trying to suss out these types of problems. I’m assuming that a normal “joe” can’t just wake up and intubate someone, and that probably your run of the mill nurse who checks your blood pressure can’t either. I found this list of physicians in New York State as of 2019:

    Psychiatry 6,759
    Surgery 4,293
    Anesthesiologists 4,262
    Emergency medicine 4,560
    Radiology 3,999
    Cardiology 3,149
    Oncology (cancer) 2,213
    Endocrinology, diabetes, & metabolism 902
    All other specialities 18,771
    Total specialty 48,908

    My guess is that at least half (more?) of these doctors probably aren’t able to intubate someone. So…I’m wondering (paging Dr. K), looking at these numbers of doctors that are up and running with their practice in the state of New York that are qualified, how would they even be able to use 40k ventilators? Maybe I am missing some legislation that would allow doctors from other states to practice in New York State right away. Perhaps it is easier than I think to intubate a patient and Joe Radiologist can do it. Anyone?

     

    39 Responses to “Ventilator Math”

    1. TMLutas Says:

      Intubation generally takes no more than a minute to do the actual tube insertion which is the hardest part. The apex number would be worst-case disease burden, all happening at once with zero ventilator sharing. New York is not going to need 40k ventilators.

    2. Dan from Madison Says:

      Ah thanks TM. And it isn’t like people can’t recover – and then that ventilator is free again once sterilized.

    3. george m weinberg Says:

      I watched a series of 4 videos instructing how to operate a ventialator starting with this one
      https://www.youtube.com/watch?v=gk_Qf-JAL84

      worth a look if you have time on your hands. It is not super simple.

    4. Dan from Madison Says:

      Outstanding thanks George. Definitely a lot of training involved.

    5. Brian Says:

      Couple of things to note:
      1. They’ve been saying for weeks now that NY needs to massively increase the # of beds. Like be 2x. And to increase the ICU beds by a much larger factor than that. I have no idea what it takes to say you have a bed ready, or to make it count as ICU worthy. If they have plenty of ventilators but not enough beds, or whatever else they need, what good are they?
      2. It’s been reported widely, for 2 months now, that coronavirus patients who need assisted breathing typically need it for 2-3 weeks, which is apparently much longer than the average ICU patient needs such treatment, like literally by 10x.
      3. This page was shared here weeks ago, when what appeared to be a post-flu-season coronavirus related increase in ER visits was just starting, and has just kept rising: a816-health.nyc.gov/hdi/epiquery/visualizations?PageType=ps&PopulationSource=Syndromic . NYC is definitely an anomalous situation, very dense, very reliant on public transportation, and governed by idiot ideologues who refused social distancing measures for way too long, and even now aren’t really enforcing them in any serious way. So I think models still say that they’re low on an exponential growth curve.
      4. I have zero idea what number they will need. Cuomo is a grandstanding idiot, though he’s been not too bad the last couple weeks. DiBlasio is completely worthless. It’d be better to surge 40k ventilators there and “only” need 25k than to need 25k and only have 10k, no?
      5. Every country seriously impacted has seen scarily high numbers of doctors and nurses infected. Presumably the intubation process has an extremely high risk to them, compared to everything else they’re trying to do.

    6. MCS Says:

      I saw a picture of the Dyson vent. It looked impressive. It will be interesting to see if they can actually produce 15,000 as quickly as promised and how they work.

      I’m pretty sure that it would take months if not years to get it approved in normal times. A major asset of the companies that do this are the people and expertise to navigate the regulatory structure.

      Hope it works.

    7. Anonymous Says:

      All the anesthesiologists and almost all the ER docs could intubate. Half the surgeons would say they could. About a quarter really could. ENT could probably manage in a pinch. A few family docs in rural areas. So….

      Lets say 15K doctors could do this. But add in a lot of nurse anesthetists and I bet you could find 20 to 25K more or less capable folks to intubate.

      Now, running the meds, the vents, all the tubes, the needed nutritional supplementation, infection control of bodily secretions, anti DVT measures……

      It’s about more than the ventilators.

      TW (retired) MD

    8. Mike K Says:

      Intubating someone is not the easiest thing to do. Most doctors, unless they have ICU experience or anesthesia training are unable to do it.

      The fatal case in Tucson that I linked yesterday, which was mishandled several ways, may have been a failure to intubate successfully.

      Her husband drove her to Tucson Medical Center.

      By the time she arrived, Anderson’s family says, her airway was so constricted she couldn’t be intubated and there was a lot of pressure in her abdomen.

      Despite efforts by the staff to resuscitate her, Anderson died within an hour of her arrival.

      I wonder. I can remember a woman with a rupturing aneurysm that we could not intubate in the OR and we had to do an emergency trach on.

      I have intubated a few patients that another doc, either an ER doc or even an anesthetist, could not intubate.

    9. Dan from Madison Says:

      Would I be correct in assuming that anyone on a ventilator must be sedated in some fashion?

    10. Mike K Says:

      Pretty much a person on a ventilator for any time would need sedation. I don’t know how long most of these require.

      I still have seen no discussion of the role of remdesivir in these cases.

      This report, dated March, has no more information.

      Bilateral lung involvement with ground-glass opacity was the most common finding from computed tomography images of the chest. The one case of SARS-CoV-2 pneumonia in the USA is responding well to remdesivir, which is now undergoing a clinical trial in China. Currently, controlling infection to prevent the spread of SARS-CoV-2 is the primary intervention being used. However, public health authorities should keep monitoring the situation closely, as the more we can learn about this novel virus and its associated outbreak, the better we can respond.

      That was the top reference.

    11. Alfred Sauve Says:

      A lot of states are fast tracking, or waving requirements for licensing out-of-state doctors and nurses.

      Also, you “list” of physicians may be optimistic. I wonder how many are in active practice. My experience, a while back I admit, with Florida’s licensing board was they didn’t remove professionals from the list for 10 years after their last renewal.

    12. Mike K Says:

      My experience, a while back I admit, with Florida’s licensing board was they didn’t remove professionals from the list for 10 years after their last renewal.

      California now has a provision that , if you promise not to work for money, you can renew for $12. I did so and have my new license card. No limitations that I can see.

      I hear they did this so doctors could work in free clinics.

    13. Gavin Longmuir Says:

      Back when I was a volunteer EMT, part of basic training was how to intubate a patient with a Combitube — a double lumen airway which is pushed down the patient’s throat. The expectation was that we would have to do this with no time to waste beside a freeway, in the dark, while it was raining, on an unconscious traffic accident victim with a life-threatening airway problem. Patient had to be unconscious — otherwise we would have had a fight on our hands.

      If patients require to be intubated for weeks, that sounds more like a tracheostomy — a surgical procedure. Emergency tracheostomies can be performed in the field by trained paramedics.

      The intubation process is unlikely to be the controlling factor.

    14. Dan from Madison Says:

      Gavin – if it was thought that someone would be intubated for weeks, wouldn’t it be “easier” to put them into an induced coma?

    15. Brian Says:

      It does sound like they usually have to be heavily sedated for that extended time period:
      twitter.com/bobambrogi/status/1242907503614189572
      https://www.nytimes.com/article/ventilator-coronavirus.html
      https://www.theguardian.com/world/2020/mar/27/how-ventilators-work-and-why-they-are-so-important-in-saving-people-with-coronavirus

      (I think this is a big part of the triage in places like Italy–you can’t afford to have an elderly person on a ventilator for a week and then die, when you have younger patients flooding in who you can be pretty confident will survive as long as they get a ventilator themselves.)

    16. chuck Says:

      Intubation isn’t that hard. EMT-P’s used to do it, until fun things like Esophogeal Obdurator Airway and all those other idiot proof shove-in-mouth-inflate things came along.

    17. Mark Matis Says:

      Remember that these are New Yorkers that you’re talking about, and the only ones who count live in the Big Craphole. For them, it don’t really matter WHICH orifice you shove that tube into!!!

    18. SWRichmond Says:

      This is New York commies doing what they do best (well, it’s the only thing they are good at): whine loudly and demand everyone else help them, give them what they want, and sacrifice for them, because New York! (TM).

    19. Dan from Madison Says:

      SW – while I agree with the thrust of your argument, I am not ready (yet) to put it in those harsh terms. I hope they do the right thing for the rest of us in flyover after their infections die down.

    20. Mike K Says:

      Intubation isn’t that hard. EMT-P’s used to do it, until fun things like Esophogeal Obdurator Airway and all those other idiot proof shove-in-mouth-inflate things came along.

      Intubation isn’t hard until it is. I have personally pulled out EOAs that were put down the trachea. Killed his ass, don’t you know.

      My son is a paramedic and knows about intubation by EMTs.

    21. Nathan Says:

      Here is my problem with the 40k estimate. There have been 28000 deaths so far worldwide from this. My understanding is that one out of two patients on a respirator will die. That means that over the entire course of this epidemic we have had 56000 people on respirators, and half died. That is a worldwide figure.

      Why does New York alone need 40000 ventilators?

    22. Mike K Says:

      If patients require to be intubated for weeks, that sounds more like a tracheostomy — a surgical procedure. Emergency tracheostomies can be performed in the field by trained paramedics.

      Yes, normally you would do a trach after 3 days or so. Light sedation after that is usually enough if the patient is even awake. ET tubes are very uncomfortable.

      In the field paramedics would probably use a percutaneous cricothyrotomy cannula, which does not require an incision and dissection. Lots of dentists have one in the office.

      A cricothyrotomy is (almost exclusively) used as a rescue technique to oxygenate your patient. It is therefore the last step in a ‘cannot-intubate-cannot-ventilate’ (CICV) scenario. You have to know by heart the place of a cricothyrotomy within difficult airway management guidelines!

      A cricothyrotomy is indicated when other methods of oxygenation following failed attempts at bag-mask ventilation and intubation have also been unsuccessful. By definition therefore the patient in whom you attempt a cricothyrotomy should have a (failed) LMA in place. In other words, if there is no LMA placed in the patient by the time you attempt a cricothyrotomy, you have not followed the CICV algorhithm!

    23. Brian Says:

      Nathan: no, the numbers have always shown that IF you get ICU treatment, your survival odds are well above 90%.

    24. Gavin Longmuir Says:

      Maybe slightly off topic, but well worth looking at. It turns out that Europe does produce data on “All Causes” mortality — and what does real data show, or rather Not Show?
      https://www.euromomo.eu/
      “Some wonder why no increased mortality is observed in the reported mortality figures for the COVID-19 affected countries.”

      At least so far, despite all the breathless reporting in the news media about Covid-19 deaths, Europeans are not seeing an increase in total deaths — as would be expected in a true pandemic. What the data says is that people who were already knocking on Heaven’s Door are dying with the virus in their systems and their deaths are being classified as Covid-19 instead of pneumonia, heart disease, cancer, etc.

      We are treating this disease all wrong. Instead of focusing our limited resources on protecting the relatively small number of At Risk people, our politicians & bureaucrats have shut down major pieces of the economy, causing substantial & growing economic harm to much larger numbers of healthy people.

    25. Anonymous Says:

      ” It’d be better to surge 40k ventilators there and “only” need 25k than to need 25k and only have 10k, no?”

      Not if they come from someone else’s needs. Apparently NY can’t even keep track of the 4000 sent to them. Saw an interview of a doctor in NYC who has been on the frontlines (Carlson last evening) and his experience is that very few of those who get to the ventilator stage recover.

      In a war zone, a bed is a bed. Temp conversion of emptied hotels can be made to work. Convention centers, etc. Surging doctors and other health care folks from low incidence places to hot spots along with protection equipment and other medical supplies can work. Just don’t tell the governor of Michigan that she can’t get exactly what she wants, right now. Allocation of shortages and boosting supplies, including non-certified and make shift options included, is a Federal role in such a situation. The governor of NY has no clue what is needed (ventilators, or anything else), but he does know that his whining in his bomber jacket will make every media lead story.

      Congress needs to consider some temporary legislation to reduce the legal liabilities of organizations and individuals who are operating in good faith outside the normal regulatory schemes and hoops.

      Death6

    26. Nathan Says:

      Brian: I’m not sure of your source for the “above 90%” number. The below link shows the death rate in critically ill patients to be 49% or higher. That is a study of 72,000 patients.

      The link also cites:
      The authors of the smaller study also found that 30 (81%) of 37 patients requiring mechanical ventilation had died by 28 days.

      That is a small sample size, but with that caveat in mind, those numbers would put an even smaller upper bound on the need for ventilators.

      http://www.cidrap.umn.edu/news-perspective/2020/02/study-72000-covid-19-patients-finds-23-death-rate

    27. MCS Says:

      My layman’s understanding is that intubation is a box that gets checked off in med school, and depending on specialty, maybe never performed again or several times a day.

      I hope all of us will be around to see how this eventually plays out. Until then, your guess is, literally, as good as mine. There are some conclusions that can be made now and it will be important for next time that they aren’t forgotten when this is over.

      The first is that a doctor that’s competent to practice in Iowa is competent to practice in New York. If he isn’t, that’s a separate problem. Maybe he doesn’t get an invite to the annual golf tournament but it’s long past time that we stopped allowing the the medical societies to cut the country into their own little kingdoms. It should cut both ways; no more letting incompetents, drunks and pervs quietly become someone else’s problem. The same goes for nurses, and all the techs that make the healthcare system work. Then when we needed them, we could move them there without some special dispensation. It won’t end the rural health care problem but it will remove one obstacle.

      While we’re at it, do the same for barbers, hair dressers, funeral directors, etc.

      The supply chain needs to pay attention to the “expiration” of supplies. They should prioritize long storage life. I suspect that a lot of expiration intervals are driven by what the manufacturer can get away with. If not, it’s time to fix it. If suppliers started to lose business from short expiration they would change. This would allow a meaningful stockpile to be established without being ruinously expensive from having to replace it every year.

      The military puts all sorts of very sophisticated weapons in sealed containers and expects that they can be hauled anywhere and used anytime within 20 years. If we don’t have things like vents that will do the same, it’s time we did. This seems like the tenth time in the last eight years that we have been warned that we may die because there aren’t enough ventilators to go around.

      Hospitals and the supply chain in general need to revisit the choice between disposable and reusable. When we need it, the PPE in the trash isn’t doing anyone any good and getting more from China seems to be a problem. I have made the choice for disposable and know all the arguments. Having something I have to clean beats not having it at all.

    28. Brian Says:

      Gavin: Multiple times I have posted all-cause death info for Italy. Your ignoring it doesn’t make it go away. They are seeing massive increases over typical years–the coronavirus confirmed counts alone are like 1.5x, the total deaths are in some cases 6-8x. England seems to report numbers with a several week delay, Germany doesn’t seem to report national numbers very well (due to cultural memory about what government can do when it measures too much, etc.), I’m not super familiar with most others.

      Nathan: I believe the numbers in that paper are for the ~2% of patients who are “critical”, not the ~20% who need serious intensive care, which includes ventilators. Though even now resolved cases do look terrible–my understanding is that in Italy ~40% of CV cases have ended in death, if you compare deaths and “cured” as the only 2 final outcomes–because the recovery time is so long and the pandemic is ongoing, and so many places have been overwhelmed.

    29. Mike K Says:

      I’m sensing some confusion about terms. The optimal treatment right now, in my opinion and I am not involved beyond reading accounts, is that the onset of symptoms (cough, fever, chest pain) should lead to testing and hydroxychloroquione treatment until results of the test. That means PCR test not antibody testing, which is retrospective. If the PCR test is negative, treat as flu.

      If resolution of symptoms with HC, treat 7 days to 10 days until recovered, then antibody test to confirm.

      It sounds to me that such treatment will avoid progression to ICU except in very fragile patients. My wife has immunodeficiency and COPD from smoking in the past. She is very high risk. We have HC at home as she has taken it for rheumatoid arthritis for three years.

      For ICU cases, I would suggest remdesivir, which is supposed to be available outside the FDAs randomized trial.

      I just don’t think that many cases will get to ventilator care and those are probably 90% unsalvageable by then. That is assuming treatment with the drugs.

    30. Medic Says:

      The Real Question:
      So, lets just stipulate that the numbers are accurate (which they are not)and all of these vents are going to be needed. They may very well be needed as the number of infected goes up, it remains to be seen. What I want to know is when are we going to get serious about isolating entire cities/counties? NYC is most certainly a hot spot, probably MUCH hotter than the numbers currently reflect. Most if not all other major metropolitan cities are going to see much the same in the way of total numbers relative to their population. Seems to me the best way to get the rest of the country back to work is to isolate the hot spots- no one in, no one out, test everyone else, those positive stay on lock down. Everyone else- get your ass back to work. If we are going to allow people to leave these hot spots and come to places that currently have low, manageable numbers, then we are all f**ked. If we can’t get the majority of people back to work by May- I doubt the economy will come back to anything that even closely resembles where we were when this all started for years.

    31. Gavin Longmuir Says:

      Medic: “If we can’t get the majority of people back to work by May- I doubt the economy will come back to anything that even closely resembles where we were when this all started for years.”

      Exactly! In the real world, the choice is often not between Good & Bad, it is between Bad & Worse. Our Political Class is trying to make what they think is the Good choice — minimize the number of people who get sick from Covid-19. In reality, they have made the Worse choice — throwing people out of work, destroying savings, bankrupting companies. The deleterious effects of making that Worse choice are going to be with us for a long time.

      Something to think about: Volkswagen today is making cars in only one country — China! China’s ability to restart its industrial base quickly is going to put even more competitive pressure on US companies struggling to recover from the politicians’ Worse choice of an effective shutdown of large parts of the economy. We see the likes of Pelosi in Congress can’t stop stuffing pork into bills even in the middle of an existential emergency. There are very low hopes for our Political Class doing anything smart to help restart the economy.

    32. Mike K Says:

      I see glimmerings of a possible middle way, although it may not be attractive to the usual suspects.

      Trump might decide to restrict shutdowns to areas or states that are hot spots. Delaware and Florida are both quarantining New Yorkers fleeing the virus.

      Newsom in CA has shut the state down and LA now has a hospital ship to care for the usual ailments of the poor.

      The leftist Mayor of Tucson wants the governor to shut down the state but we have a mild version of the pandemic. Lots of older residents but it is easy for us to self isolate. We all are retired. We would have to figure out how to reopen restaurants, for example, but by Easter we should have most of the economy in “fly over” states back up and running. Let New York City, Chicago, Boston and LA deal with urban high density populations. The left is love with them anyway.

    33. Crna Says:

      Ok. Let’s get a few facts. -intubations. My experience 15 years of anesthesia 2-6 intubations a day.
      No they aren’t hard at this point. Until they are. Long term vent management. Isn’t easy if they develop ARDS. Standard vent settings won’t work. And high pressure settings require heavy sedation and paralysis. Reduced oxygen levels means multi system organ failure at some point. What am I seeing at my hospital —- not much just no elective cases. Seeing bad flu. But not being over run. The numbers are still less than the flu. Maybe I’m wrong.

    34. Mike K Says:

      Crna, any use of hydroxychloroquione or remdesivir in your hospital ?

      Any influence on progress to ARDS ? I am also told that elective surgery has stopped but COVID cases are not overwhelming, depending on location.

    35. Brian Says:

      “Trump might decide to restrict shutdowns to areas or states that are hot spots.”
      Not really up to Trump. He’s president, not dictator. Several states are already harassing people from other states (RI about NYers, FL about LAans, etc.). What’s going to have to happen is limiting domestic movement in ways that America has never had to do, so that “clear” areas can get back to normal, and they can stay that way.

      AK has announced no one may move from community to community. That’s going to happen everywhere, but how the logistics will actually work is beyond me. How do you prevent people from fleeing New York, New Orleans, etc.? These aren’t small walled cities we’re talking about.

      My guess is that after this is over, there will be a LOT of resentment towards big cities, because the infected people there are going to spread and prolong outbreaks.

      What will really turn things around is having real-time, accurate tests in mass quantities (i.e., hundreds of millions of them). Once we have that, we’ll be good.

    36. Mike K Says:

      My guess is that after this is over, there will be a LOT of resentment towards big cities, because the infected people there are going to spread and prolong outbreaks.

      I agree and the push to force everyone into mass transit and high density housing is probably dead until the next generation forgets the lessons.

      I don’t think Trump can order it but i suspect the briefings will include a conclusion that it is safe to open up areas with few cases and deaths.

      Testing will catch up and the death rate will drop. It is artificially high due to the testing screwup.

    37. MCS Says:

      If I was living in one of the cold zones, I might not appreciate a national announcement. I can’t imagine a group less inclined to follow an order to stay put and stay out than a New Yorker that feels he has no choice but to panic. I also can’t imagine how they would enforce it. Maybe Manhattan but there are thousands of ways out of the surrounding area.

    38. Crna Says:

      The South Koreans are using hydrochloroquine with good results. So I keep a 14 day supply for my self if I test positive and get symptomatic. Prophylactic im taking 50mg of zinc as a supplement. ARDS is always difficult to deal with it can happen with prolonged mechanical ventilation. Placing the pt prone using high pressures. Or alternative vent modes such as APRV can be helpful. Look at cdc guidelines for healthcare workers. Even if we test positive we can work as long as we wear a surgical mask. Only if we develop sysmptoms do we quarantine ourselves.

    39. Anonymous Says:

      Mike K Says:
      March 28th, 2020 at 9:05 am
      If patients require to be intubated for weeks, that sounds more like a tracheostomy — a surgical procedure. Emergency tracheostomies can be performed in the field by trained paramedics.

      Yes, normally you would do a trach after 3 days or so. Light sedation after that is usually enough if the patient is even awake. ET tubes are very uncomfortable.

      In the army medics just go straight to traching someone in the field.

      I assume from what I am reading on this thread it is because it is much easier than intubating someone.

      Is that a consideration if there are not enough doctors to intubate people?