
The U.S. tried to build a new fleet of ventilators - onetimemanytime
https://www.nytimes.com/2020/03/29/business/coronavirus-us-ventilator-shortage.html
======
oefrha
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.

~~~
SkyPuncher
> 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.

~~~
joe_the_user
The question in a lot of ways is how many exponential doublings do we have to
have before this situation switches in peoples' minds from a peace-time
inconvenience to essentially real war.

Right now, the death rate still isn't higher than a flu epidemic but just the
number of known infections promises a lot worse and the potential doublings
after that are terrifying.

It seems like there's an endless dialogue of:

A: How would you accomplish X? B: I wouldn't, X is not what I do.

But we need to give the final answer: A: I didn't ask whether you can do X.
I'm telling you, "do X or many people die, you are all we have at this point.
Think outside the box".

~~~
Mediterraneo10
"The question in a lot of ways is how many exponential doublings do we have to
have before this situation switches in peoples' minds from a peace-time
inconvenience to essentially real war."

The millions of people who would die in a worst-case scenario are mainly
demographics that society is already used to neglecting: the elderly, the
terminally ill, those with lifelong chronic illnesses where any infection
could be a killer, etc.

Therefore, I would expect this to continue to be considered more of a
peacetime inconvenience than a real war. A frequent response to this is, "But
they could overwhelm the healthcare system so you or me couldn't be treated
for our needs!" Well, if the bulk of the population is left inconvenienced and
unemployed for too long, I can imagine some ugly scenarios where the
population demands, broadly speaking, that those demographics simply be
triaged out of treatment so that they don't overwhelm the healthcare system
for everyone else. This is said to be already happening in Italy to a degree.

~~~
joe_the_user
_Well, if the bulk of the population is left inconvenienced and unemployed for
too long, I can imagine some ugly scenarios where the population demands,
broadly speaking, that those demographics simply be triaged out of treatment
so that they don 't overwhelm the healthcare system for everyone else._

People imagining such triaging seem to think that a willingness to be
appalling brutal means such brutality could be achieved with limited costs.

Italy's situation is far from the worst-case scenario. It's death rate is not
that much higher than a seasonal flu, it's just the death-process that is far
more messy.

Which is to say, let the infection rate get high enough and you'll have
hospitals crowded with the young and healthy even if carry the old directly to
the morgue.

Moreover, authorities shouting "all clear" in the midst of this dreck isn't
going just summon a phalanx of consumers ready to go to restaurants, death
chance or not.

In short, just because you're evil doesn't mean you aren't stupid too.

~~~
greedo
The death rate is in no ways comparable to the seasonal flu. It's quite
higher:

[https://ourworldindata.org/coronavirus#case-fatality-rate-
of...](https://ourworldindata.org/coronavirus#case-fatality-rate-of-
covid-19-compared-to-other-diseases)

~~~
joe_the_user
Indeed,

If you read my parent post in context, I hope it's clear that I mean currently
in Italy, people are not dying at a rate higher than the seasonal flu BUT
_this has a big potential change_ if the infection rate were to shoot up (we
know this is prevented by extreme quarantine measures, enforced by the army).

~~~
greedo
Your point still isn't clear or accurate. The worldwide CFR is over 4%. In
Italy, it's currently at over 11%. The flu is nowhere near that level of risk.
It's normally around 0.1% depending on demographic. Are you saying that the
seasonal flu in Italy normally kills 11% of those who become infected? If
that's the case, the facts don't bear that out.

~~~
zwily
But the CFR is mostly just a function of how many people get tested, no? And
Italy seems to only be testing at hospitalization.

~~~
greedo
And how does Italy test the flu? In the US, there's minimal flu testing and
most of the metrics are based around surveys.

~~~
SkyPuncher
I'm not disagreeing with you. However, at this point, some of the flu
estimates are actually inferred/modeled by the CDC.

The flu is a well-enough study disease that they're able to, relatively
accurately, model population statistics based on a sub-set of tested patients.

------
appleshore
I always criticized the idea that “radical technology could exist but the
competition buys it up” as a naive conspiracy theory.

It’s pretty remarkable that the government paid for this but somehow the
international medical corporation can swoop in, buy the competitor who is
threatening their margins, and void the contract.

~~~
blunte
> somehow the international medical corporation can swoop in, buy the
> competitor who is threatening their margins

Perfectly normal and common in the US low-regulation economic system.

> and void the contract

Most likely the government officials with the ability to allow this
cancelation were bribed, or rather lobbied, to allow it.

~~~
AdrianB1
It does not look like a regulation problem, but a contract breach: the buyer
corporation should be held accountable to execute the contract as agreed, it
bought the company with everything - assets and obligations.

~~~
blunte
The government often makes decisions about companies buying other companies.

If a company has a contract with the government, then the government should
have (specified already in the contract, perhaps) the right to prevent the
sale of the company (with some specific exceptions).

The primary problem here is that in theory, the government works for the
people; but also in theory, the (publicly traded) corporations work for the
shareholders.

But yes, even without regulation, the government should have made more effort
to enforce the contract. Perhaps the key government people with the power to
do so were influenced somehow... But even if the contract had been upheld,
there's certainly no guarantee that the new big company would have put their
best effort into meeting the original goals of the contract (especially if it
was against their "best" (profit) interest).

------
ajb
The original "Iron lung" prototype was built by a tinsmith and used vacuum
cleaner parts:

[https://jamanetwork.com/journals/JAMA/articlepdf/403323/jama...](https://jamanetwork.com/journals/JAMA/articlepdf/403323/jama_255_11_030.pdf)

(or course, it didn't need to be sterile because unlike modern positive
pressure ventilators, the air it pumped didn't go inside the patient).

------
pacetherace
It’s ironic that Covidien was the name of the company that screwed up the
ventilator supply.

------
cm2187
Does anyone know the survival probability of a covid-19 patient once he
requires the assistance of a ventilator? I have heard people mention it is
fairly low but haven’t seen any figure on that.

~~~
lucretian
it's not good.

in on study, 24/26 of pts with non-invasive mech ventilation and 31/32 of pts
with invasive ventilation died.

[https://www.thelancet.com/journals/lancet/article/PIIS0140-6...](https://www.thelancet.com/journals/lancet/article/PIIS0140-6736\(20\)30566-3/fulltext)

note that the study demographics were skewed to the more vulnerable cohorts
(avg age = 56, range = 46-67, 62% male, 48% with a comorbidity).

~~~
alexandercrohde
Wow... I had no idea it was so low.

Since you seem to be knowledgeable, if ventilating isn't a big-impact
intervention, what's the point of flattening the curve? Is there some other
intervention that hospital is doing that actually makes a more meaningful
difference that can't be done at home?

Or is it maybe just psychological?

~~~
lucretian
i'm not sure. i'm not a doctor. at minimum, flattening the curve is buying
time for therapies and vaccines.

that study may be overly pessimistic. elsewhere, i think i saw 50/50 survival
rates for ventilated patients but i don't have a source at hand.

------
lukevp
what is so complicated about ventilators? Serious question as I don’t know
enough about this. I see a lot of DIY posts that are probably not 100% the
same thing but are they even close?

This opens up a bigger question too, is there such a thing as a path for open
source medical devices to be built and certified and deployed? Is there a
company that supports something like this? I follow Scott hanselman, a
Microsoft employee who’s diabetic, and there is a big movement within that
community to build open source artificial pancrea, using insulin pumps and
software and such. Is there a play like that for ventilators? And other
critical medical devices?

~~~
toomuchtodo
There is a narrow range of pressure where you're not damaging the alveoli from
underpressure, but not bursting the lungs from overpressure. You need a
mechanical scalpel, not a butcher's knife.

~~~
Nambia
Honest question: is the pressure range actually that narrow?

People can survive at high altitudes, which will see pressure of 70% sea level
(or less, especially when considering mountain climbing). Additionally, when
SCUBA diving, something like 30 feet of depth = 1 atmosphere.

I feel like I'm missing something here. Any ideas?

~~~
landryraccoon
Covid patients in the ICU probably don’t have healthy lungs. The people you’re
talking about at those pressure ranges are probably all young, healthy and
athletic.

I know a bit about scuba diving, and you absolutely are not supposed to go
diving if you have a lung injury.

I would speculate that if you put a person with serious covid on a mountain
top or 30 meters under the ocean it would kill them pretty quickly..

------
neonate
[https://archive.md/ZmW5l](https://archive.md/ZmW5l)

------
ciceryadam
In the meantime COVID19CZ created an open source version -
[https://news.ycombinator.com/item?id=22724130](https://news.ycombinator.com/item?id=22724130),
crowdfunded the first batch of 100 ventilators, and they start producing them
in the first week of April

------
Jemm
Covidien. If I had heard the company name in a sci-if film I’d have groaned.

------
dang
We changed the URL from [https://dnyuz.com/2020/03/29/the-u-s-tried-to-build-
a-new-fl...](https://dnyuz.com/2020/03/29/the-u-s-tried-to-build-a-new-fleet-
of-ventilators-the-mission-failed/) to that of the article that it fully
ripped off (and banned that site).

~~~
burfog
They acknowledge the New York Times at the end of the article. Perhaps they
licensed the content. I don't think that anybody aside from legal staff at the
New York Times can determine if anybody was fully ripped off. If you have
concerns about copyright and want to do something about it, you could report
the issue. I assume that the New York Times is fully capable of hunting down
violations without any help.

The site is much nicer than the New York Times. I'd prefer that the New York
Times be banned, both for the paywall and for severe political bias.

~~~
dang
Normally I use less emphatic language. However, I looked at the submission
history for the site. Of 11 articles posted to HN, every one was a copy.
They've copied from NYT, bgr.com, Polygon, FT, and Fast Company. That's a lot
of "licensing".

True, they were nice enough to link to the originals, but for some reason the
vast majority of blogspam sites do that. Only the very bottomest of the barrel
do not. I assume there's a reason for this other than invariable last-minute
scruples, but who knows? Maybe an HN user knows that business and can explain.

The paywall question is a separate one, and decided here as follows: if
there's a workaround, it's ok; if there's not a workaround, we bury the
submission. Users usually post workarounds in the threads. The result is that
more or less everyone can read more or less every submission that makes HN's
front page, just with varying degrees of annoyance. I think that's the right
tradeoff. The annoyance is real, but HN would be worse without links to these
publications. Paywalls suck
([https://hn.algolia.com/?dateRange=all&page=0&prefix=true&que...](https://hn.algolia.com/?dateRange=all&page=0&prefix=true&query=by%3Adang%20paywalls%20suck&sort=byDate&type=comment)),
but this is the best we can do until the publication industry sorts itself out
the way music eventually did.

All publications are biased. We're not going to ban the NYT.

~~~
lordgrenville
For the NYT, using a browser extension to disable js works like a charm.

------
relativitypro
This seems to be the cutting edge of capitalism, emboldened by legal force and
lobbying.

Once you allow incumbents to rewrite the rules, they will do so to entrench
and enrich themselves.

“Too big to fail” “Too big to jail” “Lower interest rates to fix covid-19”

------
robomartin
Lateral comment:

I am starting to hate publishers who produce COVID-19 articles and post them
behind a paywall or registration form.

~~~
Erwin
Media are suffering at least in this country. Not much interest in buying ads
these days.

If the newspapers get more people to pay for their stories, they will have to
fire the journalist hard at work on the Corona stories.

~~~
robomartin
Here's the fallacy with what you are saying:

Click-through-rates are not going to increase because people signed-up for a
free account with an email address. Greater revenue comes from greater
traffic. Simple as that. If every time I see an interesting link from the NY
Times and try to read it I am hit with a modal subscription request, well,
very soon I just stop clicking NY Times links.

The other side of that is paid subscription to these newspapers-turned-web-
news outlets. My guess is this is a bad (or let's just say, non sustainable)
approach. If these outlets had to survive on paid web subscriptions they would
likely shrink severely or evaporate. There's a reason for which television can
still garner massive audiences. Imagine if every single TV channel demanded a
subscription or registration.

~~~
syspec
All nytimes articles related to covid19 are free, but you do have to sign in

~~~
robomartin
That’s my point, you should not have to sign in. Not to read articles about a
world-wide pandemic. Normal stuff, sure.

Imagine if every media outlet and publisher took advantage of the crisis and
required registration for access to information.

------
m0xte
I’ve always said that governments should use our tax money to design and
validate key health and infrastructure components and only outsource
manufacturing and only to local businesses. Governments are so utterly broken
and inefficient that they can’t do it.

However even if they produced a design now we have supply chain problems
globally.

Edit: I seem to have stirred up capitalist defence here. To clarify: The
government runs healthcare here in the UK. They have a responsibility for
making sure there is supply of equipment available for us. This isn't some car
pooling company that says "there's no cars available until next Wed", this is
healthcare. And as for production, the government should have agreements in
place with manufacturers to switch to infrastructure build out.

We've screwed up flood defences, energy, healthcare so far. Lets stop now.

~~~
pdonis
_> Governments are so utterly broken and inefficient that they can’t do it._

Exactly. Which means we should not be _depending_ on governments to do it.
This is exactly the sort of thing that _private_ startup companies should be
doing, without trying to involve the government's bloated and inefficient
bureaucracy.

 _> even if they produced a design now we have supply chain problems globally_

For this particular crisis, yes. But not for the next one, if we start now.

~~~
worik
I completely disagree.

If the government had done it in house they could have succeeded.

The problem here was the profit motive. Cheep ventilators endanger profits.

It is a side effect of free markets (I like free markets) that big firms get
bigger, get more market power, kill off competition then price gouge. Health
is a bad bad place to have free markets as the incentives are almost all wrong
(exceptions: E.g. running clinics as a service for state run health systems
turns out to work well here in Aotearoa - but even that is under pressure from
consolidation)

Nationalise the whole ball of wax. Use waiting lists not wealth to ration
access. FFS the richest country in the world is heading to a health
catastrophe. What a bunch of idiots!

~~~
pdonis
_> If the government had done it in house they could have succeeded._

Ok, so how do we get the government to do it in house, and stick to it long
enough so that the stockpile is there when the next disease crisis happens,
which might not be for another 10 years? That's five Congressional elections
and at least two changes of Presidential administration.

~~~
m0xte
Party politics is a separate shit show. It should be an elected council with
no single representation. That would allow smaller, manageable policy changes
rather than burn the entire universe every few years.

~~~
pdonis
_> Party politics is a separate shit show. It should be an elected council
with no single representation._

Ok, so your plan for solving the ventilator issue is to change the entire
system of government. Good luck with that.

------
ck2
Open-Source, Adruino-controlled, Proof of Concept Prototype

[https://simulation.health.ufl.edu/technology-
development/ope...](https://simulation.health.ufl.edu/technology-
development/open-source-ventilator-project/)

as people commented yesterday, there are also other projects but that one from
University of Florida doesn't need 3D printing

------
agrenader
"Companies submitted bids for the Project Aura job. The research agency ...
chose Newport Medical Instruments, a small outfit in Costa Mesa, Calif"

This is the problem. Instead of allowing several companies to compete for a
large order of new ventilators, the $ were given to one company to be spend on
design not on the product.

~~~
blunte
No, that is specifically not the problem. The problem is that the company had
demonstrated a working design and was near production... but then the wheels
of finance (by way of publicly traded company) stepped in with a profit-only
motive.

If three companies were all competing, there's absolutely no guarantee that
each of those three would not have been bought in the same way. No large
company would have gone for such a contract unless it had no other way to make
money; there wasn't enough profit incentive.

