On July 15–16th, ~30 respiratory therapists will meet in Phoenix to train as trainers for SNS ventilator equipment. I will be one of several instructors for this session. This process will repeat at intervals until all 200 USPHS MRC therapists are certified to use this equipment and train others. A work in progress, we will also be emphasising use under altered standards, austere conditions and scarce resources. Our scenarios must impart a realistic enough experience for the providers grasp as there will be little chance of a live fire exercise. The 30 will be available for hurricane season and I am assured of deployment if medical teams are required. Realtime work on the ground will enhance our training. We have recruited 50 (so far) of the best Rts in the country, mostly with critical care/transport/neonatal-pediatric experience. I will continue to post on this thread as more develops. This is HHS working with AARC. We must continue to but the best of what we have with the best of what they have. I’m not sure how high up this blessing at HHS goes. Parker, the Acting Sec for OPHEP for sure, but maybe this has Leavitts wand on it too. I’m sure there are those that still believe our medical response will fold in a blink. We’ll see.
itsa me
This is public/private partnership at work and we’ll be paying attention. rrteacher, keep posting and let us know how this goes.
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rrteacher or anyone else who might know the answers.
These may seem like silly questions, but I heard so many reports than if panflu did hit, I started wondering:
How expensive are they? In other words, how big of a deal would it be to encourage hospitals in your local area to buy more.
For the public hospitals, is there any way to get them to tell the public or media just how many they have?
I assume from post above operating them requires special training, is this for legal or technical reasons? Would an ordinary nurse fresh out school know how to use one?
Can anyone buy one? I mean could a group of concerned citizen hold a fundraiser and raise money and donate to local medical centers? Can a non HCW be trained and certified in using one, kinda of like with those cardiac arrest machines you see on plans and some office buildings ?
How expensive are they?
I will leave cost questions to rrteacher or others who have more accurate figures. I can tell you about the resources it takes to manage a very sick person on a vent. At least one person who can manage the vent, pref a trained RT, but in a pinch a properly trained person otherwise. To manage fluid balence, hemodynamic drips, antibiotics, SEDATION ISSUES( most most people on vents need to be sedated or they will “fight” the vent and pull tubes out) assist unskilled personal with moving, Ect one trained RN for each three vents.
Now I just know that the RNs here are gonna say” three vents, Kelly you are outta your mind” If you have enough semiskilled support you can do it, I have. Not willingly, but I have. I am not optmistic about finding enough Skilled RNs to do this. I know rrteacher thinks it can and will be done, but looking at ICUs now and many operating in crisis mode, I am not optmistic. Kelly
Thanks Np1. Not being knowledgable in this area, I had thought it would be kinda of like an IV. Nurse puts it in place, alarm goes off if something is going wrong. From your response, I see it is much more.
Also, coming from someone who is not very knowledgable about the medical industry. I have recently learned that hospitals have different levels assigned to them and that this level basically determines what level of treatment/trauma cases they can handle. Are all levels able and equiped to handle respirators. I know many of you have medical backgrounds, so thanks in advance for taking time to answer questions that probably seem very obvious to you.
anon_in_ga,
This has to do with the trauma levels assigned to emergency rooms and infectious diseases requiring negative pressure rooms. In pandemic conditions all hospitals will be completely swamped and trauma levels will not apply.
My federally-funded clinic has started discussing panflu plans. Apparently I was the first one to show concern, but my colleagues are taking it up now also. Our tiny hospital has one ventilator, and we have one respiratory therapist (there are three who trade shifts, one is always on duty); also only one RN on duty. Ventilator management is complicated, and I never felt comfortable doing it alone as a resident. They are used in ICU settings, and our hospital does not have an ICU. If you have 500 sick people, who get the ONE vent?
Everyone is right so far. The lungs/ventilator do not function in a vacuum, (word play, yes?). As NP1 alludes to, just putting a healthy person on a ventilator changes electrolytes, fluid balance, blood pressure, hormones and not to mention the inability to speak, the ease of getting a bacterial infection from further impairing lung defenses, (the vent and ET tube do this all by themselves) and the FEAR. It is a very complicated process. And if you perfectly balance all of those, there are complications like VILI, (ventilator induced lung injury) adding to the cytokine storm damage, collapse of the lung, pulmonary embolism, and the list is long. People rarely die as a direct result of the ARDS damage as long as the oxygen level stays, at least, marginal. They die of the complications of treatment most often. That is a simplified understatement, but the picture is there. This is the up side on a good day in a well equipped ICU with a good MD/RN/RT on top of things. The downside is obvious. I have heard that humanity is at its best when things are at their worst. Over the years, I have become a little cynical. HMOs, Fat CEOs, make money, pay me more, give me a better parking space, ad nauseum. When I was young I thought I could change the world, I would do great things, I would help people, I would heal people. Somewhere I, and maybe we, lost some of that. It’s a non realistic idealism, but everyone I know has at least a little somewhere. All the vents and HCWs we manage to throw into this war will require something we don’t have a lot of right now. A sense of purpose. It will be who we are and what we do that determines how successful we are.
Thank you all for your answers, from someone not from a medical background it has been very educational.
I guess the only questions that I still have is there anyway to find out how many respirators your local hospital has? And how much do they cost? We participate in 2 local fundraisers each year for our local public hospital. If we purchased new ones, would the county owned hospital have the funds to train the staff to use them? How much additional training would a hcw need to know how to operate one properly?
Thanks again for taking time to answer questions for someone who has zero knowledge of how the medical industry works.
I think questioning the nurse:ventilator ratio is a very short-sighted issue. As the infection rate peaks, and the volume of patients skyrockets, and number of med tech plumments, this might all be academic. There will be terminal patients to be sedated; anyone else will be sent home for their family to administer home care. Grim, but realistic
Townplanner. Yes, two ends of the spectrum. Perfect World vs Worse Nightmare. However, our plan is to train every RT in the country, not only ventilator operation, but how to do more with less. Under the alter states, austere conditions, scarce resource scenarios of MC and PF5.1. Beyond that, training EMPersonnel, (who already have a big leg up) and all medic/medical capable of monitoring and providing basic care. In the Polio Epidemic of 1959, medical students worked around the clock in shifts providing manual ventilation to victims. It was the Polio Epidemic that thrust critical care and mechanical ventilation into the current age of “automatic” technology. Tier Morch, an anaesthesiologist, developed one of the first modern ventilators. His son was a victim. The first electro-mechanical devices were clumsy and not precision instruments. The distrust of the technology forced us to improve reliability and accuracy. Today, the technology exists for much more technological autonomy in providing ventilation, but FDA and others are reluctant to trust computers with human life. We may again, be propelled into an unsure and unproven science to save lives. Out of the cube thinking begins with what can we do with what we have. Not liking the answers, we begin a “what if” course out of the necessity to save lives. Not make cheaper or easier or even safer. It will be time for another leap.
I’m glad to hear about progress, rrteacher. But I Googled sns ventilator. One costs $30,000. There can’t possibly be enough during a pandemic. Is there any other solution? Would oxygen be helpful even without a vent? Adding a humidifier? Tilting the bed with head down to drain the lungs?
If any of the home remedies are helpful, laymen should be taught. There isn’t the equipment for a pandemic anyway, not to mention the skilled people to monitor the patients. I never dreamed it was so complex.
Incorrect-The list price for the Eagle 745 (main battle vent used by the military and 1/2 of the SNS inventory) is $8945. I’m pretty sure we can get them cheaper than list. We are operating on the premise of saving more, not all. That is a harsh reality, but one more victim is one more family without a loss. I have proposed some vents in the $3000 range that would work as well, but require more skill. We are looking at ALL the possibilities.
Ok, I agree that less experianced RNs could manage a vent patient, with support . Perhaps a “charge” RN could oversee the others..But….. Where are you going to find more monitors, beds, space for these new ICU patients? As it is, I have spent many hours trying to find an ICU bed in the Valley for my rural patients?The available beds are full now. When the BF hits, things won`t stop. People will still have MIs,CVAs, accidents, etc. True, elective surgeries will stop, but most of these patients don`t need ICU care.An elective CABG, triple A repair are a few that come to mind. And, what happens if the power goes out for days? Most hospital gens don`t have an unlimited amount of fuel available.Everyone gets a turn at bagging? Been there did that, for 8 hours one blizzard, when the gen at the rural hospital I was at went down. Twas not fun.1/2 hour was the limit, then your hands go into spasms. Even had the janitor bagging. Doing that for a large number of patients at a time….Blows my mind. When TSHTF, I think that , as bad as it sounds, we are going to need to do aggressive Triaging, and some folks are going to have to be sent home, probably to die. It honestly makes no sense to tie up scarce medical personal to care for someone who is ,in all probabilty going to die anyway.
ok, this is a question about how HCW handle the stress of patients dying, should be moved over to the stress thread but I’ll ask it here and we can move there. What advice can you give us non medical people in dealing with death?
KimT-Fall apart after the pandemic is over. Cactus-Only the sickest will get monitoring beds. Ventilators will be set up in hospital rooms, hallways, tent-hospitals, anywhere you can lie a patient down. Power will come from generators, battery-backed systems/UPSs and pneumatic ventilators don’t require a power supply
KimT: What I have found is that “love” is the greatest power in the world. If you truly love your family, you will do remarkable things in a crisis, even one of a longterm duration such as an 18 month pandemic. And if one of your family dies, you will persevere for the others.
Conversely, if all of them die, you will likely be dead yourself. That is the way it crumbles.
rrteacher,
Could a nebulizer be used to “charge” an expanding bag (think of a balloon), and a trip valve(working on pressure or time) release the bag? If so, we could adapt thousands of those of semi-automatic operation in short order, and nebulizers are abundant as most parents with kids with asthma know. It still has the power issue, but it makes thousands of units available on short notice with limited funds. I know it sounds very MacGyver, but give it some thought.
rr-
Sounds like you’re slated for a tight schedule even prior to PF51. Will you have time to communicate with us here or do we need to arrange a point person to take a message from you now and then and relay it?
Have you communicated with any of the other selected instructors yet? Are most of them as senior and as current as you on the equipment and techniques? What do they think about all of this?
Are you going to be using stock materials from old training or will you have a new syllabus directly related to H5N1? Will you have an opportunity to refine the materials?
TRay,
Man, you are full of field-expedient ideas!
The nebulizer is a concern for many due to the high possibility of infection spread via aerosol. Now retrofitting the unit to expel air rather than aerosol is another thing altogether? Could it handle the back pressure? Does the output nozzle adjust for air only? Your idea, if made functional, would require a skilled operator.
NS1 I will be lap-top hot the entire trip and will post as I go.
Three others, one would be considered the worlds foremost expert on the ventilators in question and has been investigating/authoring material on MC care for some time. Another is a aero-transport therapist at Mayo Clinics and the third is a very technically seasoned, crusty old fart. Mass casualty is the main focus and PF5.1 is part of that. I will be adding the nuances of infection control, pathophysiologic considerations and specific treatment modalities.
We have a conference call this Tuesday among us to brainstorm and generate a set of objectives, course outline and learning packet. We’ll have less than 30 days.
30 days to generate materials, have them printed and delivered?
Will there still be a Dallas stop?
Of the other 3, how many consider this an exercise on H5N1 versus standard disaster MC? Will you get them to agree to lean toward tighter infection control, JIC?
Will there be any time given to field-expedient methods in the face of resource scarcity, or will you focus on streamlining currently-practiced and known methods?
In the long run, I am advocating that this show play everywhere. Over 40,000 RTs need to be competent, so Dallas is very likely. I will also advocate the course extend beyond RT to “others”.
I’m the FluFanatic, but all agree with the “all hazzards” approach. I will hammer H5N1 and have backing from friends, like “Deep Trachea”.
The “alpha group” are the HHS/OPHEP therapists. We fully expect and have had some training in field/transport medicine and some of us are ADLS providers. We will introduce those concepts to newbys. Also, HHS wants the training complete before the first big blow (CatX) so we can get some boots on the ground time in
rrteacher- re” SNS ventilator equipment”
SNS?
Congrats- this is an issue I know has concerned you for a long time and you have put alot of work and time into creating this training.
Np1-you’re right re the issues of vent/RN’s-and which RN’s? the percentage of nurses who have experience with caring for these most critical patients is relatively small I’d guess compared to the total number of RN’s-that said, improvise-adapt-overcome has been our unspoken motto…I have alot of issues re: alloting resources to vent patients over, say preventive/ambulatory care when TSHTF, but the predictable progression to ARDS opens up a door to the need for expanded vent care…..
Thanks Grace
Hi Grace! I believe SNS = Strategic National Stockpile.
Had a meeting with all the necessary players today. The program will be property of the US Government and currently offered to the HHS RTs. It will be videotaped and packaged just the same and I would conclude that it will eventually be available for the masses. The major push for this program is hurricane season, but again, the “all hazards” approach applies to, well all hazards. Our foot is in the door for coming up with an introductory program. Our success or failure to do a good job of it will determine where we go from there. PF5.1 is another chapter. This is progress.
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Thanks MaMa, Will update soon. USGovt processes are sssssssssssssssssssssssssssssssllllllllllllllllllllllllllllllllllloo
I will quietly report that there is an official effort to provide EMS with updated, next level ventilator management skills. This is from my professional organization through the NAEMSP (National Association of EMS Physicians). Though no specific mention of pandemic planning is mentioned, it is the first handshake between ourselves and our cousins in the emergency medical field. This concept, fully extended, could increase pandemic capable ventilator care providers to around 250–300K individuals.
Sounds great! Good luck. These folks will someday save the lives of thousands. I wish that you had more resources because if this thing hits any time soon your 300K will be rapidly overwhelmed by sheer numbers needing these services.
Just wondering how come the screen here is not about 2x as large. Not so easy to read now.
Gary Near Death Valley – at 22:37 --- Caused by side scroll. PMWiki tends to throw up sometimes! Mods have been notified…tow truck and repair crew are on their way….
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Thanks BB, Mea Culpa for thw SS Sorry
“”This is progress.”
fron 02 July
rrteacher – at 19:17
I will quietly report that there is an official effort to provide EMS with updated, next level ventilator management skills. This is from my professional organization through the NAEMSP (National Association of EMS Physicians). Though no specific mention of pandemic planning is mentioned, it is the first handshake between ourselves and our cousins in the emergency medical field. This concept, fully extended, could increase pandemic capable ventilator care providers to around 250–300K individuals.
Off to Phoenix for training today. Have over 30mb of files to share with others like me. Most I found here and at CE. Thank you all for your support.
Carrying The Message.
Regards,
Richard
Back from a productive trip. Training was a drop in the bucket, but a hoop that needed clearing. With all the changes going on at OPHEP, we can only continue advocating our ideas and hope the FNGs are brighter than their predecessors. Did get an opportunity to meet many PHS officers in cammo and “ops” haircuts. Whoa!
Now we wait for a deployment opportunity. The overall capability we can bring to bear WTSHTF will be sharpened as we respond to local and regional incidents. You Know Who forbid a hurricane slam us somewhere, but we need a lot more practice and strength.
Now for some FEMA/DHS courses. That will make us smarter.
Regards,
Richard
I read an article in our local paper this past week that really impressed me. I have since tried to find the article - to no avail. This is a synopsis of what I read:
The local Red Cross has been giving courses to teenagers for the past three years on disaster training. I was (pleasantly) shocked. The article said they have focused on teens because they are the future and will be the next Red Cross volunteers. The courses have been so well received that they have had to increase the number trained.
The courses include basic CPR, disaster planning and how to assist during a crisis. The program is extensive (I believe 2–3 weeks long). These teens are sufficiently trained to be utilized in disasters and can help set up and staff shelters. Their training covers multiple disaster scenarios, including hurricane and bioterrorism.
I was pleased to see this. Some young, strong bodies with educated BRAINS, just might come in handy during a crisis.
“Some young, strong bodies with educated BRAINS, just might come in handy during a crisis.”
And, if this flu follows it`s earlier cousin (1918), more fodder for the pandemic. Good luck RTT. We all are going to need it. I`m still having a problem with vents in the halls. Where are you getting the necessary suction equipment for each patient? Are you encouraging hospitals to stock not only the vents but the circuits for changes( currently many places have the circuits changed Q 24 hours). Even if you go to 48–72 hours, that`s a lot of stock. And, when the oxygen runs out, what then?And, where are you getting the E tanks to run vents in the halls, anyways? Just a few worry points.
Sorry, rrteacher. Worked last night, and am going on just a few hours sleep. And suffer from fat finger( can`t type) syndrome.
:-)
yeah, cactus az…I thought of that too, in reference to panflu. But there are PLENTY of other disaster potentials that do not include cytokine storms, esp. hurricanes in our state.
As for the vent situation, I am happy to see others get training. But, at the risk of being pessimistic, there is no way in hades that we will have enough vents of any caliber to handle a panflu in the near future. Hell, probably in the FAR future either!
Have you read the info on the Medicare/Medicaid cuts? Hospitals are already almost at the breaking point. You know the first thing they will cut back on is personnel and then equipment. Anyone in healthcare knows that. Oh…and training…and benefits…anything else I left out? BTW, these cuts include nursing homes. Remember our discussion on those? Most are already minimally staffed. Imagine a reduction.
As for a few of your “worry points”…I have used portable suction devices that could be moved from patient to patient. Not ideal, but it would help. And the OR census should be drastically reduced in a panflu, so some of the suction equipment from there could be used.
As for circuit changes, I would anticipate that in a crisis, that changing filters more frequently could reduce the number of circuits utilized. Some of these poor panflu patients only lasted a few hours anyway. I can’t (yes I can) imagine this scenario. I am sure the secretions would be fulminant, with some massive hemorrhages as well.
I will bow to RTT’s expertise re: vents, but in my experience, it takes specific vents to operate without wall gas pressures. I have done volunteer work and had to hand ventilate pediatric patients for hours because of this. We rigged up a low pressure vent system, but it was less than ideal.
Thanks guys, I feel better already. We will use Viral capable HMEs on all patients, (I hope), as every RT/OR has these. HMEs of any variety will help reduce droplets and transmission as well as take care of the humidification issue. I only pray to You Know Who that we do not see a significant hemorrhagic component, as if we do, we are screwed. The SNS vents do not come with suction equipment but do have extra circuits. They are also electrically powered with decent battery back up. If we cant get power, we are screwed. Every OR may become an ICU bed and every positive pressure device, even the old Birds in the basement may get hauled out, but you are right about not having enough. We know that. I happen to have an old Laerdal Portable Suction that runs off Freon. EPA missed mine when they were confiscating them, but battery suctions will do and reusing catheters (same patient) after a rinse may be necessary. I cannot ascertain if the extensive systems failure seen in 1918 and so well described by Barry, is a result of severe untreated hypoxemia, (nobody got supplemental O2 in 1918) or a result of viral damage to tissues. DIC is very possible by hypoxic injury and if we intervene early, we may be able to obviate hemorrhagic problems. I am searching for someone smarter than me to splain it to me.
We had a Hanta virus patient in our ICU several weeeks back. Mid 40s, pretty good protoplasm. She had been sick for couple of days. When she started to slide there was nothing we could do to stop her. Massive third spacing, MOSF, all the pressors that we used worked for only a short time. Died within 24 hours of admission to ICU.
Our IC director said that she believes that this is what panflu could look like( clinically ), and she had been studing it since 1997. If this is even close to the truth then triaging to save the most salvageable will be very difficult. There is no way that we can have enough pressors, sedatives or antibiotics to save very many. Kelly
Oops, my handle is missing. Sorry. Kelly
Working in Montana, I saw a couple of cases myself. HPS, (Hantavirus Pulmonary Syndrome), presents much like pulmonary anthrax, creating massive hemorrhagic pulmonary effusions via the lymphatics. H5N1 as it will present as a human virus is still an unknown. She may be right. One merciful thing about HPS is, it is very fast. In developing an All Hazards approach, we are advocating an All Pathology thinking to our capability. Airway vs. Alveolar. Hemorrhage vs. Not, etc. We must think in terms of all pathology possibilities.
“They Might Be Giants”.
George C. Scott as Sherlock Holmes in movie of the same name.
RRT,
I have been assuming that the cytokine storm will start the patient on the slippery slope to DIC. And I don’t anticipate that all the O2 in the world will help once the cascade gets started. I am also assuming that an infected patient won’t have much of a chance unless they are identified EARLY, treated with antivirals, O2, IVs and any other support needed.
I also assume that some of the ORs will be used as critical care beds. Our anesthesia machines can be utilized as ventilators. There are multiple suction devices present in each room. But I suppose they could put more than one patient in each room and thus use them all. G.
And of course, all of the above is just my view of the world with a skeptical eye. This virus may not follow it’s current path. But you are right. One patient with a fulminant pulmonary edema/hemmorhage will use up a week’s worth of supplies in one day.
Triage is gonna be tough.
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