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News story #1: New York City auctioned off extra ventilators due to cost of maintenance. Yes, they did. Hundreds of them. Ventilators acquired by “Mini Mike” Bloomberg in 2006, in response to a new far-eastern flu strain. As part of that response, and in anticipation of an epidemic, New York City stockpiled ventilators and facemasks. Over the next ten years, their regular maintenance schedule pointed up the fact that the ventilators were aging (I expect parts became more difficult to obtain, and more expensive, as well), and they were subsequently auctioned off by the deBlasio administration.
This episode speaks to something I’ve always known to be true, which is that “stockpiling” critical medical machinery and electronics really isn’t a cost-effective and, over time, perhaps not even a clinically effective option. The equipment is cripplingly expensive, and the cost of having it on hand, lying around at a hospital, just-in-case, simply isn’t feasible. Stockpile it for too long, and you end up with a bunch of creaky old gear that may not work when it’s needed, and probably won’t interface or play nicely with the rest of the state-of-the-art equipment that’s in place when you do.
For better or worse, hospitals are nearly always running at full capacity with the equipment that they have, and cooperative inter-hospital-borrowing is a fact of life. Hospital stockpiles of expensive equipment with obsolescence and needy maintenance issues simply isn’t the norm. I’d even go so far as to say that with certain things “shortages” are more the norm, along with a fair amount of just-in-time inventory management. Hospital administration is trying to run a business, and, for better or worse again, has a balance sheet, and other factors, to consider.
Which does, if such stockpiles of medical equipment are desirable, leave them at the mercy of other entities, most likely agencies of government. Which have their own set of issues to consider, and perhaps don’t do stockpiles of expensive and sometimes proprietary or outdated electronic medical equipment all that well, either. I don’t know what the answer is, but I’m pretty sure, as with most other things, political grandstanding ain’t it.
News story #2: Some doctors moving away from ventilators for virus patients. Crimenutely. Maybe the only reason they’re doing this is just that they don’t have enough ventilators for the patients who need them. But wait! Didn’t Governor “The Sky is Falling” Cuomo just say that no-one who needed a ventilator didn’t have one, and that no-one who needed an ICU bed didn’t have one? Yes, he did just say that, amid revisions of numbers and data which indicate that the medical establishment, although stretched and in need of reinforcement, just may be up to the task, even in New York.
More likely, to quote from the article, it’s down to the fact that “doctors are still learning the best way to manage a virus that emerged only months ago. They are relying on anecdotal, real-time data amid a crush of patients and shortages of basic supplies.”
And as they do that, and as they adjust and learn, the hope is that care and outcomes will improve.
What doctors have noticed is that although the mortality rate among ventilator patients is always high, because it’s among the lastest of last resorts, the mortality rate among COVID-19 patients on ventilators is more than 80%. And
some health professionals have wondered whether ventilators might actually make matters worse in certain patients, perhaps by igniting or worsening a harmful immune system reaction.
“We know that mechanical ventilation is not benign,” said Dr. Eddy Fan, an expert on respiratory treatment at Toronto General Hospital. “One of the most important findings in the last few decades is that medical ventilation can worsen lung injury — so we have to be careful how we use it.”
The dangers can be eased by limiting the amount of pressure and the size of breaths delivered by the machine, Fan said.
Boy howdy. Takes me back to a time in almost 40 years ago when my fourteen-year-old stepson, who’d already “died” three times, was brought back to life again and spent weeks on a ventilator in Mercy Hospital in Pittsburgh with a traumatic head injury, numerous broken bones, collapsed lungs and just about every other hurt you can imagine. Although Michael was a big, strapping boy, he was put on a pediatric ventilator (less pressure, smaller breaths) for, as I understood it then, exactly the reason Dr. Fan describes above. Michael’s care was so innovative at the time that his team of doctors wrote it up and published it in a medical journal.
Once again, I don’t know the answer. But once again, I’m pretty sure that just about anything said by a politician, or even by a statistician whose numbers keep changing and who can’t really explain all that clearly why that is, isn’t it.
And I hope, daily, to see some evidence of humility, grace, and honesty on the part of those running this show, as they deal with what increasingly looks like a plethora of “unknown unknowns,” things they didn’t even know that they didn’t know, at the same time that they were acting with such certainty, and as if they knew absolutely everything. I think I occasionally see glimpses of such in “Deborah” but not in many others who occupy the various podia so excruciatingly for so many hours a day. (“Tony” looks as though he’s enjoying the situation and the attention a little too much, IMHO.) More than anything, I long for ideas, for open minds, and for leaders willing to roll up their sleeves and to find some other way of managing this mess besides simply declaring the country “closed” for an indefinite number of months, and then bribing us into submission with small amounts of our own money that ultimately won’t help very many people all that much when all is said and done.
Meanwhile, I’m becoming inclined to trust what amounts to crowd-sourced information that comes from physicians who are, in the words of the linked article, “relying on anecdotal, real-time data” rather than relying on charts and spreadsheets assembled and presented by talking heads in what increasingly appears to be a parallel universe. It may not be the best way to run textbook medical science and to do “controlled clinical trials,” but it may just be the best thing we have right now.
Who(m) do you trust?Published in