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GM’s CEO Offers to Make Ventilators in WWII-Style Mobilization (bloomberg.com)
831 points by avonmach on March 19, 2020 | hide | past | favorite | 548 comments

This is how to respond to big challenges. There are going to be a lot of comments about how we messed up, wasted time, etc., but they miss the point.

The WWII mobilization was a shitshow when it started. Kaiser Shipyards in Richmond, California turned out ships at an amazing rate [1] but it didn't begin that way. I remember hearing a story many years ago of what it was like when they first started. People were wandering around trying to figure out what to do, because nobody could read a blueprint. In the end some kid who had had a couple of years of college just sat down with older guys and they figured it out. (This was on NPR, sorry don't have the source.)

[1] https://en.wikipedia.org/wiki/Richmond_Shipyards

It already does a lot of inflexible manufacturing, often by outsourcing overseas, but I'd love to see part of the US military converted to a rapid-response, highly flexible, fully-domestic manufacturing system. LOTS of very flexible automation, so they could take a wide range of designs and raw materials and rapidly switch from making one thing to making another and the ability to hugely ramp up production on demand without having to retrain people or recertify facilities. The people involved would be trained to set up for a different product every couple of weeks or so.

The system could be kept almost constantly humming, making one thing, switching and certifying, making another, switching and certifying, keeping them pre-trained, tested, and certified. The military itself has an ongoing need to rapidly adapt to new situations, but things are needed domestically for planned infrastructure, sudden large-scale destruction from earthquake/fire/flood/tornado disasters, sudden economic changes (ex: some sort of trade cutoff), strategic domestication (ex: immediately end reliance on some import), round-robin top-off of local emergency prep supplies, individual citizen preparedness supplies, etc.

This is literally what the military is now. Under the berry amendment a lot of what the military buys needs to be 100% domestic. A significant fraction of military spending is to ensure that the logistics are in place in case of a greater need in the future, not just to fulfill current needs and training, or any specific mission.

This is a great 99PI podcast about the US Army Natick center, which develops military rations.


Part of the mission is to develop the technology and then commercialize it. Now you have a number of factories that are capable of switching into ration production if the need arises.

Things like powdered cheese, condiment packets, and retort packaging came out of this research.

Off-topic, but my podcast list has been so enriched through reading HN comment. Thanks for the link.

Same reason there are rules about ships going between US ports been manufactured in the US - to keep strategic ship building capacity in the event of a war.

That well meaning law means there’s one cruise ship that fits the requirements, all the others visit one foreign port. https://en.wikipedia.org/wiki/Pride_of_America

It looks like the cargo ship law, Jones Act, is more successful in creating capacity.

Even then, it took a special exemption from Congress since it was towed to and finished in Germany after the initial company filed bankruptcy.

> Norwegian Cruise Line Ltd acquired the unfinished ship and was towed to Germany for completion as Pride of America for their newly launched NCL America division. > A special exemption on the part of the U.S. government allowed the modified, mostly German-built ship to attain U.S. registry. [1] https://en.wikipedia.org/wiki/Pride_of_America

I was going to say: surely the US military maintains a manufacturing core?

I’m a metal fabricator by trade, and one thing you quickly notice is: with a machine shop and a fabrication shop you are tooled up to build the machines to manufacture almost anything.

Folks, military physician here, operating at the national level on the analysis that informs these projects. The recent post on HN about the MIT $100 ventilator is one of the things that got this rolling.

Manufacturing is spinning up. What I really need is developers on this project:


Josh you should put a call to action on the repo. There are no issues listed. I don't see links to anywhere that would let me help listed on the readme.

How can I contact you?

There is an app already in use in the Netherlands. They are field testing at scale and releasing better versions twice a day. Next monday it will be distributed to all hospitals and most citizens. Dutch PBS prime time news had a 5 minute documentary on the app yesterday March 18th.

From the README file on the coronavirus-diary:

Coronavirus Diary is a mobile application that allows users to record their medical status, location, and activities to an encrypted vault on their device. If the user experiences symptoms in line with the disease, they will be prompted to contact their physician.

In the case that a user contracts the disease, they can release their historical data to a physician to aid in treatment, research, and containment effort.

There are a lot of software projects spinning up -- how do we know that this one is going to see active use?

As an example for my concern -- I've had a consistently-updated pull-request[1] outstanding for the JHU data repository for more than a week. It is their prerogative not to pull, but it means my contribution is largely wasted.

The coronavirus-diary project has one contributor, no issues, and no pull requests.


OP here (and no, I'm not josh). We need the project to get from 1 to 2 to 10 to N. That 1 to 2 bit is hard. Please, push a bit.

JHU is bandwidth-constrained. Put your effort where it can have effect.

What help do you need? - testers? - docs? - code reviews?

Need more developers:

* security engineer

* iOS engineer

* Android developer

* Dart engineers

* Flutter developers

* Engineers with health industry experience

* backend infrastructure

* backend security

Goal: 1-2 months to MVP deployment. Maybe sooner if people pile on.

Wow...really? A MIT project with HN post is what kicked this off. As in...no one thought of this until then?

welcome to the information age, where even the top brass can't make sense of it all and consequences will never be the same

Machine shops are Turing complete. You can use a machine to fabricate the machine you are using.

Very few are. Making ball bearings, for example, requires very special machines that no regular shop has.

...but you can make machines in machine shops, as pointed out above. or machines to make machines, if needed.

or in the simpler case you might fall back to scraped and oiled ways and bushings

'Their Optical Section performs optical alignment on shafting, masts, and other equipment.'

That's me! Norfolk Naval Station is just one shipyard in the area. There are similar yards with all of the same equipment. BAE/Colanna/NASSCO/NNSY/Lyons/ECSR. It's the same story in San Diego, Pascagula, Jacksonville, Hawaii.


That's the cleanest link I came across to illustrate the point. I think people forget how much end-to-end manufacturing capability the military retains (especially the Navy), even in these days of outsourced procurement pressure.

Required to buy from USA manufacturers for nearly every thing. There are a substantial number of small shops supporting the US Navy.

This should be distributed geographically, meaning the pork could be spread around, meaning it is remotely possible to pass.

I love this idea. Non-wartime competition with contractors.

Manufacture of medical devices has specific regulation around Good Manufacturing Processes [1] (GMP, one of many GxPs). This requires a Quality Management System [2] (QMS) and very specific training for everyone involved. Pretty much any manufacturer that is not already manufacturing in accordance with 21 CFR Part 820 [3] and related regulations will have a ton of work to establish a suitable QMS.

I'd like to think that at least some auto workers already have some taste of working under the eye of regulators and auditors and as such their adjustment to GMP has the potential to be smooth. The days of leaving empty beverage containers in the hollow of a door are long past, right?

Management that is not experienced in FDA regulations will try to ignore or short-cut them. In the best of cases, this turns into fines and manufacturing delays. In the worst of cases, it turns into deaths due to defective product or manufacturing delays. Every level of management needs to be experienced in GxP.

The most reasonable path to getting a QMS in place and having compliant manufacturing would seem to be to have the manufacturing capacity be leant to an established manufacturer that has a solid QMS, the expertise to adapt it to the new reality, and a solid relationship with the FDA. That is, the auto manufacturer's management would need to be out of the picture or 100% subservient to the experienced medical device manufacturer.

Once that is worked out, I suspect that manufacture of the devices is comparatively easy. Put another way, it's probably easier to switch from sedans to tanks than it is to switch from SUVs to almost any medical gizmo.

1. https://en.wikipedia.org/wiki/Good_manufacturing_practice 2. https://en.wikipedia.org/wiki/Quality_management_system 3. https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/CFR...

I think you are a bit confused about the position the country is in right now.

Regulations and regulators can and will be damned in an emergency.

Of course, all reasonable precautions should be taken when producing medical equipment. But if someone needs a ventilator, they are going to die without it. It doesn't matter that there is a small chance that complications arise or some flaw in the ventilator causes it not to work correctly. They would have died without the ventilator in nearly 100% of cases.

Like many regulations right now, they will be temporarily suspended within reason.

Sure, the regulatory regime needs to be relaxed to quickly bring on more manufacturing capacity. I believe it will be. Throwing it out entirely and allowing anybody to manufacture and sell medical devices from their garage is not going to happen.

That being said, auto manufacturers likely have no experience manufacturing these devices. The don't know which optimizations will be dangerous. They may not recognize they are doing anything different from an experienced manufacturer.

When quality breaks down, it will be important to have appropriate records to know which other devices are also defective so that they can be replaced, repaired, or used with appropriate caution. If manufacturing is still ongoing, corrective action in the manufacturing plant will be needed. GxP regulations require this type of record keeping for very good reason.

An experienced manufacturer will be needed to get manufacturing going and to supervise it to ensure it has an acceptable level of quality. Even if the experienced medical device manufacturer has legal indemnity, failures of the temporary factory could stain its reputation. I find it unlikely that any reputable medical device manufacturer would want to take on supervision of an inexperienced workforce in an unproven facility without the force of the regulation they are accustomed to as a means to force behavior that they know leads to predictable outcomes. Surely, experienced members of a quality organization and the FDA will figure out how to right-size some of the practices called for by regulation.

> Throwing it out entirely and allowing anybody to manufacture and sell medical devices from their garage is not going to happen.

The situation we are in is the same as a doctor doing an emergency tracheotomy in a restaurant using a pen sterilized with some gin. No one really wonders what the serial number is of that pen or whether it was made with the high quality requirements of surgigcal equipment.

The machines produced in a mobilization shouldn't even be compared with those produced in peacetime. They should be compared to nothing at all. So when the question arises "is this device safe"? The relevant answer is "well this patient is dying on a stretcher in a tent next to a thousand others like him, so we'll use it".

It follows that it's important that these devices are either destroyed or quality certified after the fact. These can't be used in five years in during a routine surgery, of course.

If GM makes 10,000 ventilators and they all turn out defective, that could be worse then never making the ventilators at all.

GM won't make ventilators. They'll make plastic parts, hoses, valves etc. It's not that GM couldn't pivot to building something else, but they can't do that within weeks. They can probably start churning out metal or plastic parts whose speciifcations can be verified by the ventilator manufacturer before they are assembled into one of their ventilators.

I'm hoping that what they are asking car manufacturers to do is allow the medical industry to use their equipment (e.g. plastic molding equipment) to supply parts that either can't be sourced at all because of the crisis, or can't be supplied in the volumes needed.

Correct, this is also why we can skip animal trials for vaccine development but not human trials.

A vaccine that is supposed to be deployed across the board will affect many millions of people and if even a minuscule issue exists we may cause way more harm than good!

The situation is dire and we need fast countermeasures but regulations exist for a reason. This is about health & safety after all.

A vaccine is given to healthy people. A drug that is given to a small number of people that are so sick that they will die within days and there is no other cure, has different safety requirements from a vaccine that is given to a huge number of people that are healthy. In the vaccine case, even a relatively rare (1/10000) side effect might mean that the vaccine is worse than the cure. Not so with the treatment of dying people.

Safety wise, using untested equipment is the same as the drug for dying people scenario, not the vaccine scenario.

A similar example is this: in normal circumstances these devices are operated by ICU doctors. In a time of crisis you can already see this delegated to doctors that have never used a ventilator, and only given a brief introduction or even just a pamphlet describing it.

I suspect that within the next months there will be places where recently trained nurses perform the duties of ICU doctors. And laid off hotell staff perform nursing duties.

> regulations exist for a reason. This is about health & safety after all.

They do, but most regulations are surprisingly flexible in a crisis. E.g. already the rest time requirements for truck drivers are lifted in many countries to keep supply lines.

In the military (where a crisis is planned for) there are two different sets of safety requirements, with a stricter one that only applies in peacetime (e.g. max speeds, minimum distances bewteeen vehicles, requirements to use ear protection and pretty much every single safety requirement there is)

> That being said, auto manufacturers likely have no experience manufacturing these devices. The don't know which optimizations will be dangerous. They may not recognize they are doing anything different from an experienced manufacturer.

Given that this is a crisis, the existing ventilator manufactures need to send over a couple experienced ventilator engineers to help.

And open source all their blueprints, schematics and software.

Getting a supply chain for parts up and running is going to be the tricky part.

Producing safe medical devices is about more than just schematics. It is a social process with people having a huge impact on how safe the result is. All the blueprints in the world have no value if you don’t know whether they’ve been followed and the materials used are correct. And when there are defects you need to have socialized how people are to respond to those defects or your not building a competent organization. I see many comments about blueprints on here that miss the point. It’s like saying your software product is just the source code. The reality is that you have to build a competent knowledgeable organization around those blueprints or what you’re making will kill or injure patients.

I agree that we are in a unprecedented situation but I am not sure that the regulations will just be “damned”.

Liability will be damned.

If there's a military requisition of ventilators, the government alone sets the standards and quality. And the government alone gets to complain about violations. Maybe it wants ISO 9000, but I imagine they'll take 1960s class ventilators if they can be ready by a date certain.

You, citizen, can sue the government and allege that the MASH ventilator spec was reckless and deprived you of your constitutional rights. And you will be laughed out of court at ISO 9000 levels. With few exceptions, soldiers don't get sued for shooting people with guns, and battlefield surgeons don't commit malpractice.

Just to add to this: We don't put pilots in jail for shooting down an enemy aircraft. In an extreme case, we cannot file a lawsuit for mistakenly launching nuclear missiles because of miscommunication - war would have ensued.

I think people are too hung up on the societal fabric, daily life and normal circumstances that when an emergency arrives at your doorstep, you're too clumsy, too weak and too ignorant of what the reality demands.

I am with you but the issue with medical devices and therapeutics is that if at least a base set of regulations is not followed than a potentially corrupt fix to the Corona virus (e.g. faulty vaccine) may introduce a lot of health issues and harm on a scale even higher than Corona just by itself.

That's how it's an emergency when regulations are ignored. If everyone's following regulations and life is as usual -- it's not an emergency

Honestly, you're spitting the truth... and I don't understand why people don't understand this point?

There is a really simple to solution to this: the government limits prices and mandates based on how badly the regulation is skirted. Basically limit profit so it matches the dubious use-value. (Neither utility nor profit is actually linear wrt units produce, but just smart about that and know your adversary.)

Maybe GM could be renting space and manpower to a ventilator manufacturer?

This should apply to the vaccine testing protocols too.

We cannot wait for 18 months for a vaccine.

I think there is way too much potential for unintended consequences in relaxing vaccine development regulations. The Cutter Incident in the 50s was a turning point on this: during the race to market a polio vaccine, 120k doses were produced that actually contained the live virus, infecting thousands and causing additional outbreaks.


It seems that in time of actual crisis, we're all libertarians.

Well, maybe we're (almost) all pragmatists.

I have pretty libertarian impulses. I'm pretty pleased to see a lot of pointless (or point-light) regulations get kicked to the curb, although I certainly wish the circumstances weren't necessary.

I also hate immigration restrictions of all sorts. But... okay, right now, travel restrictions make some sense. I'll take it (and then fight to undo them in 12 months).

It turns out, some of the things I really really care about, my preferences would do harm in a pandemic. Maybe that's true outside of a pandemic, too -- but it's a lot easier to recognize when the magnitude of the effect is large!

I think at the end of the day, that's part of what's driving all this pragmatism: the effect size of "getting policy right" is suddenly much larger than it usually is. Life is no longer close to being a zero-sum game, and everybody can see it. That's what "we're all in this together" means, and people are acting like they believe it.

Only those who can afford medical care will receive it?

Only if you subscribe to the weird capitalist modern bastard child of libertarianism, which should really be called something else, given that actual libertarians would probably hate it with a passion.

Personally I’m in favor of a (partially) centrally planned emergency economy manufacturing and distributing (and possibly rationing) medical equipment, pharmaceuticals, personal protective gear, antiseptics, etc. where needed around the country; paying for medical costs of anyone who catches COVID19; directly disbursing cash to residents who are quarantined, isolated, or lose their jobs during the crisis; banning evictions, doing whatever possible to delay personal/small business expenses like rent or loan payments; directly hiring large numbers of young people without dependents to do socially necessary jobs like distributing food to quarantined people or tracing contacts of anyone infected or manning phone hotlines to call people who don’t follow mass media and to screen patients before they talk to medical personnel; forcing media outlets to play regular publicly produced informational content and shutting down media outlets spreading misinformation; and so on..

I would hardly call that libertarian, but YMMV.

I've designed medical devices. They're not rocket science. Yes, being tolerant of a single-point-of-failure is important, but not in this climate. Military should cut through fines. And as for lives, they just need to be more safe than not having a ventilator. You don't put a healthy patient on a ventilator.

I think if 10,000 come out which kill people, that's a problem, but it's not a particularly hard one to catch. If 10,000 come out where 1% kill people, that wouldn't pass any sort of bar in normal times, but these are not normal times. That's much better than not having them at all.

Wonderful. I'd rather have an unregulated ventilator and maybe live than no ventilator and die for sure.

You're overlooking additional options like "The patient would have survived without a ventilator, but one was used to improve their condition and it turned out it was a defective GM ventilator because who needs regulations"

Also "the ventilator was fine but 12 months later it's still in service - who's going to throw out a working ventilator? - and now it's killing people because who needs regulations"

You can't just throw out all the regulations. "Any treatment" is not better than No Treatment. You have to identify which regulations are appropriate to discard in the situation - many, sure, but not all. You wouldn't want someone 3D printing your ventilator with materials that will off-gas toxic fumes and kill you when you would have survived (barely) without the ventilator...

> You can't just throw out all regulations

It needs to be emphasized over and over that this is a national emergency. Think "War". Would you rather have a surgeon operate your wounded brain matter with rusted implements or watch you die?

When youre living in a city where every hotel, every gymnasium and every school is full of ill people going through pneumonia - I am sure you would change your mind.

Another way to think is - if COVID-19 had a mortality rate of 100%, and R0 of 3; what would you do about regulations? We are lucky this virus isn't as deadly as Ebola (50% CFR) and as contageous as measles (R0 6-7). If there is death to humanity looming in the future, that's the virus its waiting for a human contact in some bat cave. What regulations then?

Medical devices have a lower fault tolerance and higher need for traceability because manufacturing defects mean lost lives.

In your example using rusty tools for brain surgery is a good analogy, as it highlights the false dichotomy you've created. A surgeon could also potentially stabilize you for long enough to search for less obviously deadly impliments. Or decide that, rusty tools or not, you're too far gone to help, and divert their attention to people who have a fighting chance.

Emergency doesn't mean we abandon common sense and decide rogue medicine is the only way forward. Even during a time of war, you'd need your tanks to operate as intended, not randomly fire or seal off the interior so tightly it causes suffocation.

This isn't fiddling with your laptop's inner workings. Medicine has a high enough need for precision that doing it poorly, or even forgetting one minor, necessary step in the process will cause more death and suffering than if you had just sat on your hands. The tight regulations are there for a reason. That doesn't mean we need bureaucracy for sake of bureaucracy, but some skeleton regulatory infrastructure will need to be observed for manufactuers efforts to save more lives than it loses.

Rogue medicine is a waste of resources and lives that will only serve to make this situation worse, as will unreliable medical devices.

Unfortunately the ventilator alone is insufficient. You also need a medical team to administer it, and they may choose not to expose themselves to the liability of using a ventilator of unknown provenance.

I’m not a doctor but in this setting it seems that letting you die of a disease is much more palatable than killing you in an attempt to treat it.

No one cares about any of this stuff. Rules need to be tossed aside to minimize loss of life. All FDA rules surrounding drugs need to be suspended for COVID19 patients. We need to start doing what china did and start using non approved anti-virals to save people's lives.

We need to start vaccinating at risk populations(75 or older) with the trial vaccine if it is shown to be effective in the upcoming weeks. We cant wait a year.

Woah there. Don't be so hasty to throw out the baby with the bathwater.

Don't need another Thalidomide dropped on us just because things are looking a bit grim. It's one thing to ask "Do we really need to let this stand in our way right now?"; It's an entirely different kettle of fish to say "Screw it, if it kills the virus anything goes!"

>Woah there. Don't be so hasty to throw out the baby with the bathwater.

Agreed. I may absolutely hate the documentation I have to complete as a microbiologist in a GMP company, but there is a reason for it. I just wish that GMP wasn't filled with so much BS. The parent comment here is being ridiculous and deserves to be argued against.

So when given a choice to a 65 year old to die or take an unapproved drug. We should let them die. We are going to run out ventilators and will ration them. Our hospitals are already at capacity. Italy is at 8% mortality rate and climbing. We need to do anything to cut icu rate and spread. Virus is showing long term effects even in children. Known long terms issues is worse than hypothetical issues. Cautious thinking is why western civilization has failed to contain the virus.

>So when given a choice to a 65 year old to die or take an unapproved drug.

Did not say that. Allow them to elect to take the drug, however, we still need to follow up, and keep track of the outcomes. Data is critical to avoid outcomes where we end up dropping bombs on houses to put out the housefire. Again, see Thalidomide.

>We are going to run out ventilators and will ration them.

Likely. I also believe that there should be a much greater tolerance allowed for expediting supply chains to make components for new ones; but data is also key. A fabrication method that results in immediate complications needs to have a quickly followed audit trail to ensure remedial action can take place quickly to minimize additional harm. That doesn't mean you can't compromise on some non or less critical tolerances while you're at it.

>Virus is showing long term effects even in children.

Noted, let's try not to add onto that by releasing something untested that causes severe side-effects as well.

>Known long terms issues is worse than hypothetical issues.

Difference: the known long term issues from the virus alone would happen with or without intervention in some portion of the population. Long term issues that arise as a complication via treatment would not happen except that weren't diligent enough.

Many of the GxP's are, in fact, written in blood. I'm fine with getting adventurous and experimenting, but we need to be tracking outcomes so interventions can take place at the first sign of trouble too.

It isn't easy. Quality never is. There is a damn good reason for you to put in the extra work to make it happen regardless.

Yeah, I'm personally not too concerned with the "stuff" end of things. This is America; in spite of rhetoric to the contrary, we remain a manufacturing powerhouse. Apply enough money and we'll get whatever "stuff" we need on pretty short order.

I think the big problem is medical technicians and doctors. My feeling is that we should be focusing on training up medical people on a massive scale, as that's something that the USA is notoriously bad at. Perhaps the military could provide medical technicians the fastest? lots of healthy young people who are trained in the use of serious PPE? (I wonder how the procedures differ between nuclear, chemical and biological threats like these?)

People talk about beds... but the problem isn't physical beds. I could make you a physical bed. the problem is doctor and medical technician labor to make the bed useful.

The problem is threefold. We need: 1. ventilators 2. PPE 3. healthcare personnel (respiratory therapists). In the short term we should train existing doctors, physician assistants, and nurse practitioners in respiratory therapy ASAP. But without PPE they put themselves at risk, and without ventilators the patient may die anyway.

We need all three, and there's a worldwide shortage. That is the bottleneck.

I'm not questioning the need. I'm just saying that it seems to me a lot more realistic that we'll be able to short-term ramp-up production of 1 and 2 than it is to think we'll be able to adequately ramp up 3.

The stories I hear from medical people I know (and this is just anecdotal) is that they are only given serious PPE when they know there is an infection, but it's less clear if that's just standard policy or if that is due to limited supply.

I do agree that if PPE isn't used early and often here, we're going to be short medical personnel, and I think getting those back online is probably going to take longer than throwing money at manufacturers to build more PAPRs.

It’s not that we’re bad at training medical personnel. It’s that the AMA acts as a cartel to limit the number of physicians train to keep income high. We just need to allow more people into medical schools and make more residencies available.

The number of hospitals and hospitals beds is also controlled by certificates of need.

Certificates of Need were something _hospitals_ themselves lobbied for. It's a case of "this is awesome when it protects me, and an aberration when I'm on the losing end".

Certainly politicians enacted such things, but I'm not losing sleep over the hospitals. Only us mortals, stuck with the cost of the system.

Yeah, remove the limiter, and how long does it take to make a doctor? I mean, sure, some people are saying that this thing is still gonna be here in four years (I am not a medical person, but that's what some of them say. something about the type of virus this is that will make a vaccine difficult) so that might not be a bad idea, but... I think we probably need to be focusing on how we can increase medical capacity four weeks from now more than four years from now.

Hell, we'll make it so med students can get a proper night's sleep during their residencies while we're at it.

the disrespect for sleep the medical profession has is insane.

If someone is gonna be cutting on me, I want them to have a good night's rest. They tell me to sleep consistently and well quite often. seems like if it's good for me it would be good for them, too.

it's a hazing ritual

if too many make it to be doctors, the pay won't be as good.

We should cut about $50-100B out of the military budget and make it for training medical personnel without raising tuition because it doesn't matter if there's no population to defend or recruit from.

It's easy if we are willing to cut red tape and willing to prioritize people over pets. Veterinarians need almost no training to do the job. Test runs done for emergency preparation have proven that veterinarians do a better job than all medical professionals who aren't already specialized in respiratory care.

>Test runs done for emergency preparation have proven that veterinarians do a better job than all medical professionals who aren't already specialized in respiratory care.

That's amazing.

> Yeah, remove the limiter, and how long does it take to make a doctor?

Undergraduate entry medical degrees in Ireland are either five or six years with summers off and ample other holidays. Post graduate is four years like the US but pre-med doesn’t exist. You have to learn the necessary content yourself ahead of time and if you fail the exams that’s your problem. You can get in with a degree with no science content whatsoever as long as you have high enough grades in your Bachelor’s. I believe during WWII the US ran some schools at three semesters a year so people were done in two years, eight months. A newly graduated doctor then has residency, a year of 60-100 hour weeks of on the job training. If some of the generalist training was cut you might be able to get someone able to do routine medical care in their specialty, like a nurse practitioner in three years.

We need to do whatever we can to increase capacity, and that involves breaking up the AMA cartel. This isn’t a two weeks and gone crisis, sorry.

Two weeks...

The problem with this is that until we have better means to train people without exposing them to real situations, increasing the number without lowering the overall skill level is an incredibly hard problem.

There's no shortage of people with ailments... A lot just go untreated or are queuing for a long time.

No, but there is a sufficiently large number of problems that relatively few people suffer from that even with people specialising there are plenty of problems where getting people to a point where they are competent enough to participate in operations on real people, and then get them enough experience to be able to do it unsupervised is a challenge.

We can specialize more, but that has its own problems in terms of e.g. availability to deal with urgent cases. And ultimately we do not get away from the fact that giving enough people enough experience even with relatively rare situations is a big challenge.

Eventually we will be able to simulate the situations well enough, and this problem will go away, but it simply is not as simple as throwing more bodies at it.

Well there are about to be a lot of real situations.

For one specific type of illness. But we do not need staff that knows how to handle only rare exceptions, and that is the problem.

Training people to respond to this one situation so that they can respond to this one situation is fine. After covid19 is resolved they wont be needed anyway.

Just an idea (that would never happen)-

Why not make it like Engineering?

You do your 4 year undergrad and at your first job, no one trusts you. Your supervisor/senior engineer checks Everything you do. You are reserved for paperwork and unskilled manual labor which is also checked. After a few years (4) you get some Freedom, but still checked by your seniors. Anything important, even when you are a senior engineer goes through your Managers and directors.

I don't see why this system wouldn't work in medical. We build airbags and bridges. Both safety critical.

I would even say having 1 physician is more dangerous than having a team of Engineers with less Schooling.

The medical system works pretty much like this. After studying medicine you have a long practical education where nobody trusts you.

Yes, but we also have the “fellowship bottleneck” and limited med school seating we use to keep doctor salaries artificially high.

In addition to training new doctors, we should also just loosen restrictions for doctors to enter the US and use their medical expertise.

When choosing a primary physician at one of the San Francisco Kaiser Permanente campuses, I noticed that a substantial number of doctors had overseas medical training. Which was fine by me--I'm an enthusiastic Kaiser member and support their cost management strategies--but I found it interesting.

Kaiser also recently opened their own medical school: https://en.wikipedia.org/wiki/Kaiser_Permanente_Bernard_J._T...

So they're now using a mixed strategy of both out-sourcing and in-sourcing medical training to address high costs.

> So they're now using a mixed strategy of both out-sourcing and in-sourcing medical training to address high costs.

Not as much as they could though - there are still federal caps on the number of fellowship seats available as well as pretty strong restrictions for physicians coming from overseas (although if I recall correctly, California has less stringent restrictions than most)

We discuss insurance as a big part of the cost problem, but regulatory capture on the supply end is another huge (and unnecessary) factor.

You don't need full MDs for respiratory therapy, or for many medical treatments. PAs and RNs can do a lot, and it's far easier and less expensive to attain those certifications than full MD.

For sure and we should also expand the jobs that PAs and RNs are allowed to do.

Doctors wouldn't let either of those things happen because it would lower their salary. The AMA is a powerful lobbying association, no way any law that lowers doctor salary would pass.

Lobbying power can be confronted by other considerable lobbying interests. Large healthcare conglomerates would seem to have considerable interest in reducing labor costs.

A crisis like this would be the perfect opportunity to fix some of these supply side issues. Lobbying is less effective when voters are paying attention and the government is in crisis-response mode.

How do you think medical education works? Because it's basically exactly this.

No. there is an extra 4+ years of classes.

There are two extra years of classes for med students, at which point they begin doing rotations through all the different specialties. During rotations, they are essentially “reserved for paperwork and unskilled labor which is also checked.”

This process continues in intern year and residency, during which time they gradually build competency and trust.

Much of medicine in the US is delivered by nurses, who have a training regime even more similar to what you suggest.

Categorically false for modern medical school. My daughter started rotations almost immediately, alternating with classes every couple of months throughout. She rarely did 'paperwork' (computers), had close patient contact immediately and was doing procedures almost from the start, under close supervision. Her final rotations had her in the operating room, handling her own patients from triage to discharge, doing night shifts etc along with a resident.

Things have changed rapidly in medical education. At least some places.

More medical personel would be great. Another option would be to train contact tracers, much easier to train than medical personel. That is one of the reasons for Singapore's success, I belive. https://www.bbc.com/news/world-asia-51866102

Until we lock down, I suspect that it is far too late to trace contacts. I know of at least 3 different secondhand exposures to Covid, just for me.

Just spitballing here, but to what extent can we streamline or automate COVID-19 treatment for non-comorbid cases?

My feeling is that we should be focusing on training up medical people on a massive scale, as that's something that the USA is notoriously bad at

Or just lock down nationally now, including full lockdown in major cities, and none of this will be necessary. The only reason this is going to get out of control in the US is the lack of testing and the lack of controls being imposed.

By the time they are imposed, it will be too late and more people are going to die because of that.

Nationally lock down now, and once we unlock down the virus will come back from foreign countries and be just as much of an issue.

Slightly more of an issue in fact, because we will have just shot ourselves in the foot in terms of capability to deal with it via manufacturing.

Exactly. The goal of the lockdowns is to reduce the number of concurrent cases, thereby allowing time for medical infrastructure to scale up.

I wish this was true, but from all appearances the medical infrastructure is not scaling up at a reasonable pace... i.e.

> The Trump administration has not yet formally asked GM to use its network of plants and suppliers to make any medical equipment, the person said. (From the Article)

> Tesla makes cars with sophisticated hvac systems. SpaceX makes spacecraft with life support systems. Ventilators are not difficult, but cannot be produced instantly. Which hospitals have these shortages you speak of right now? (From twitter 9 hours ago https://twitter.com/elonmusk/status/1240492347835604992)

It's a very difficult problem. Here is a paper outlining the cost in lives of your proposal.


This is a messaging failure.

We cannot just lockdown and “none of this is necessary.” There is no scenario short of locking down for 10 years that would be able to manage with the number of critical beds we actually have. We need to dramatically upscale capacity (which means training new doctors) and quarantine.

It cannot be an either/or.

You're forgetting the development of a vaccine. With enough time (10 years is way more than enough), a vaccine will be developed and deployed, and that capacity won't be needed because far fewer people will contract the disease and develop symptoms requiring hospitalization.

The problem is, developing and testing a vaccine takes some time. How much time do we have before the global economy totally collapses?

> With enough time (10 years is way more than enough), a vaccine will be developed and deployed

Based on what? It’s been more than 10 since SARS and we still don’t have a vaccine. I think you’re making a lot of assumptions about immunization when it is far, far too early to know. Also, the point is that we don’t want to be quarantined for 10 years, we want to build the capacity now.

They probably never developed a SARS vaccine because it didn't turn into a major worldwide pandemic. There's lots of diseases that don't have vaccines mainly because it's seen as not worth the effort or cost. SARS and MERS looked scary at first but never got this big.

As an addition here, look at Ebola. It was perfectly feasible to create a vaccine, but no one bothered as long as it was confined to Africa. As soon as white people in western nations started getting it, then suddenly there was a huge effort to create a vaccine.

I agree with you... last week.

I mean, sure, we should lock down now, but my feeling is that it's mostly too late for the urban areas.

The rural areas might have a chance... they need to lock down hard right now. But... from talking to rural family... I'm not sure that's culturally possible.

Yes you're probably right.

No this isn't true. The competition to get any residency slot is insanely difficult. There are people who graduate from medical school that apply to hundreds of residencies every year and still don't get anything.

There are more residency spots than med school grads. If a grad doesn't match its because they didn't list undesirable programs, not because all the slots filled.

This is definitely great and uplifting news but I am not sure why GM or Ford is the one on top of list for this endeavor? There are a bunch of second source assembly houses that build medical equipment for the big players. Seems like it would make more sense for them to build it with some sort of FDA fast pass.

Discretion, I work for a carmaker company but my opinion is of my own only.

> why GM or Ford is the one on top of list for this endeavor?

Ford and GM were massive manufacturers when WWII reared its head. That gives them a rich history of wartime production [1].

The principal cost in these sorts of shifts can be bureaucratic. Having cultural capital to call on is invaluable.

[1] https://en.m.wikipedia.org/wiki/Automotive_industry_in_the_U...

> Having cultural capital to call on is invaluable.

How similar is the culture today compared to 75+ years ago?

> How similar is the culture today compared to 75+ years ago?

Doesn’t matter. “We did this before and must do it again” is a powerful call to action. That cultural capital spins up the bureaucratic flywheel.

I first heard the song "We Did It Before and We Can Do It Again" on some old Looney Tunes.


As a local, I don't know the exact differences in culture today compared to 75 years ago. Though after hearing enough ranting from workers, line bosses, and industrial engineers about exciting topics like quality control, line efficiency, production planning since I was young... I personally think the culture is pretty valuable, especially given the size of the manufacturing workforce.

I think a more pressing question is if any workers will want to come in if GM and Ford commit to this.

On the surface it’s very different. But in practice it’s surprisingly close as successfully running any truly large scale manufacturing means direction flows down from the top and innovation flows up from the bottom. Automation may be replacing a lot of labor, but cars are also vastly more complex and have far tighter tolerances.

Mary Barra volunteered in a meeting. That's why GM's getting the press. Later on in the article it mentions other manufacturers currently working to do this in Britain.

The industry that can help is the kind that can quickly provide the parts that ventilator manufacturers can't source. If a molded plastic part is missing, the auto industry would be able to answer that I think. I'm not sure though how much of such manufacturing actually takes place at the car manufacturers themselves, vs. how much they are just assembling such parts sourced from other sources? I imagine the industries that can really help are these specialized plastic part manufacturing companies (for example). Assembly lines for cars won't help, it's the part production that can help.

Considering how we've massively bailed GM out with public funds, they may as well be considered to be partly responsible for the health of the public.

Quote from a recent Scott Manley episode seems appropriate:

    We choose to do these things not because they are easy, but because we asked ourselves "how hard could it be?"[0]
I'm pondering how long would it take GM to modify their ERP systems to handle an entirely new business line. Never mind that... how long would it take them to define the requirements for the plan to determine the framework for the project to explore the changes needed to the organization? Turning on a dime is not something a large corporation is good at, no matter how well-meaning. It takes time for people to learn how to do unfamiliar things, it takes time to organize large groups of people, it takes time to even decide what the requirements are.

Many HN readers work in software development. We constantly deal with stakeholders who have completely unrealistic timeframe expectations. Do we really think GM could, in effect, create an entirely new division in a couple of sprints? How long do you think simply creating new injection molds would take? Does GM even know how to handle the kinds of plastics used in ventilators?

Edit: Think war-room. The worst thing a manager can do during an emergency is try to create new processes or add people to make things go faster. My job is to let the folks who already know what to do do it. Sweep all obstacles out of the way. Order pizza, arrange for day-care, rent the hotel across the street. The only really quick ways to increase availability of medical equipment is to give existing manufacturers whatever help they need to run 24x7, and to help their suppliers run 24x7.

At this point, anyone who is "offering to help" is going to be of little use. If you have the infrastructure in place, you had better be doing everything you can to be ramped up. If you need resources you should be screaming for them--no one else is going to be able to tell you what you need or what to do. If you don't have the infrastructure, knowledge, or contacts, then you're just going to get in the way.

[0] https://www.youtube.com/watch?v=graC_Vib1IE @8:40

"Do we really think GM could, in effect, create an entirely new division in a couple of sprints?"

Actually, such things are done with some frequency, and the way you do it is precisely that you don't make "GM" do it. You spin people off entirely, fund them, take ownership of the resulting entity, and then tell GM qua GM to just take a hike. Run it as a startup that happens to have a really, really big brother.

In my observations, it's an unstable structure. Eventually the sponsor in the parent organization loses interest or power, and then someone in the parent corporation decides that their organization needs credit for what this little startup is doing, and sucks them back in, of course completely destroying the whole thing in the process. Behold the awesome destructive power of basic politics. Still, it can work for a while. In this particular case, "a while" is all we need.

AIUI, for at least a good long while, this was almost an officially unofficial way to get Microsoft to do something it lacked confidence in to do directly or couldn't get the organization as a whole to move on; grab a few of your buddies & spin yourself out, prove it works, and get acquihired back in.

FWIW automanufacturers in China did this. So this isn't anything, or out of the realm of possibility (we do have more red tape in the US, i.e. see what happened w/ the Seattle Flu Study when people tried to be helpful).

I don't have any English source for this. But Boris Johnson requested the same in England, too.

A quick search finds some articles stating they will do this, but nothing about results. But of course politicians and CEOs would never make empty promises...

Wikipedia says one Chinese manufacturer, Geely, sold 1.5 million vehicles last year [0]; that probably includes 700K Volvos [1] (they bought Volvo from Ford in 2010), so I'm guessing 600-700K domestic Chinese-produced vehicles. If they had successfully switched production, we'd be talking, what, 100s of thousands of devices a month? But not a word. If they were even making a few 10s of thousands a month I don't think we'd be having this conversation.

[0] https://en.wikipedia.org/wiki/Geely#Figures

[1] https://en.wikipedia.org/wiki/Volvo_Cars#Annual_sales_(all_m...

UK asks automakers to join efforts to scale up ventilator production: https://uk.reuters.com/article/uk-health-coronavirus-britain...

Yeah - I mean I didn't have an English source for the same initiative that in China.

Wouldn't it make more sense to make masks and other PPE first?

You don't need a ventilator if you don't get sick in the first place, masks are much faster to put into immediate production, and impacting the curve earlier is going to have a much bigger effect than later.

I mean make everything. But I have family members working in hospitals right now and they are asking me to search the internet and find masks for them. Not ideal.

Can’t say I agree. Surprisingly few people wear masks even when they are available - my local hardware stores have had plenty in stock and yet they barely get used. Finally, the benefit of masks is questionable since most people are now performing social distancing.

Ventilators are needed for serious cases and cannot be produced as quickly as masks. While masks may or may not help, more ventilators will definitely help.

Because masks don't help prevent you getting it https://www.who.int/emergencies/diseases/novel-coronavirus-2...

Your link says “ If you are healthy, you only need to wear a mask if you are taking care of a person with suspected 2019-nCoV infection.” - in other words, it does help prevent someone from getting it.

The reason health organizations outside of Asia are not recommending mask wearing by the general public is there are not enough to go around, so they are trying to stop the public from hoarding them when the masks are vital equipment needed by medical providers.

Wearing the masks also helps prevent infected persons (some of whom are asymptomatic with this coronavirus) from spreading it, if previous research on flu viruses is considered applicable. https://www.hsph.harvard.edu/news/features/face-masks-flu/

“These results suggest an important role for aerosols in transmission of influenza virus and that surgical facemasks worn by infected persons are potentially an effective means of limiting the spread of influenza.”

But it helps asymptomatic infected people to infect others

i was thinking, if this ends up being long term, better make full spacesuits for everyone

Everyone is going to get sick. The best thing you can do is get sick now and let your immunity act as your PPE.

As a 5th generation Detroiter; this offer makes me very, very proud.

I grew up in Ann Arbor. Can we open up Willow Run again? :)

> Australia's military is on standby to dispatch more engineers and health professionals to deal with the outbreak of coronavirus as the nation's response to the global pandemic ramps up.

> The Australian Defence Force has already deployed specialist staff to work with the federal Department of Health as part of its response to the spread of COVID-19.

> ADF engineers have also been sent to the regional Victorian town of Shepparton to help manufacture face masks to combat a global shortfall.


> Discussions are also taking place for engineers and other specialist staff within the ADF to help establish pop-up fever clinics.

> The ADF has appointed three-star general John Frewen to head a new taskforce to lead the military's response to the pandemic.

This made me feel a twinge of patriotism. Something I haven’t felt in a long time.

I listened to today's episode of "The Daily" [1] and it had me feeling similarly.

I can't find a transcript, but he basically said, "Put aside the political differences. Forget about the hit to the economy. We are at war with this virus and human lives are at stake. Do your part."

[1] https://www.nytimes.com/2020/03/18/podcasts/the-daily/cuomo-...

We are Americans, we have gone through a lot in this country. In dire times, when humans get together to solve problems - I get goosebumps and tears in my eyes. In our normal day to day life, consuming media and seeing how fragmented this nation has become - incidents like this bring us all together to fight a common enemy. We should have the onus and the courage to help everyone in the world, not just the US. Our image is blemished but the fabric of our principles is still strong. I've never felt patriotism in my whole life in America - but times like this, fuck its amazing.

It's times like this that make us so great. We've been riding on success for so long, it's been easy to forget how we have a goal in the world and that our existence is not guaranteed.

Definitely, most city dwellers I know do not feel proud of being an American, but they only choose to do so to avoid nationalism and patriotism from clouding their judgement - not because of the lack of the American spirit.

The American spirit is always there. They will always seek truth, keep a tab on the government and fearlessly criticize authority, value freedom of speech, liberty and freedom of press. This isn't unique to US, but to Canada, EU, UK, Switzerland, India, Japan, Korea, Australia, New Zealand and many other democracies around the world.

A line at the top says "Musk tweets Tesla will make ventilators if there’s a shortage". Well, the "if" part does not really seem to be a question.

With US cases at 10^4 today, and a doubling time of 2.5 days (note 1), and with the estimates of available stockpile, it seems well past time to get started on this. I doubt that making a ventilator is as simple as knitting a scarf.

Another way to contribute would be to figure out a way to make masks quickly.

There's lots to do, and help from the innovative and diligent will be greatly appreciated by those who remain.

1. Doubling time inferred from a regression in log space of the last 2 weeks of data provided at https://github.com/CSSEGISandData/COVID-19/tree/master/csse_....

Viral spread is more complicated than a simple exponential curve. This is even visible when just eyeballing graphs in log space, e.g. here: https://mackuba.eu/corona/#total

The world-wide total numbers are a very unfortunate choice of graph. It overlays the earlier development in China and their static number of cases (no new ones) with exponential growth in the rest of the world (= the beginning of a logistic curve looks like an exponential).

Better look at each of the different countries.

China and South Korea as examples when the problem is managed ; Italy, Germany and Spain as examples when country did not yet.






While we do need some equipment, instead of treating the symptoms, we could lock ourselves down and avoid the surge.

We saw China stop the problem a month ago. South Korea seems to have stopped the problem with testing.

Buy ourselves a month so we can ramp up testing.

The US just past South Korea and France yesterday in covid-19 cases.

We have 9400 cases and 150 deaths.

By the way, China is reporting no new domestic cases.


China didn't just hunker down though. They built out hospital capacity.

The US can and should be doing that as well.

We've got the most advanced logistics networks the world has ever seen installed on our phones.

We've got thousands of young, unlikely to die people who clearly need to be put to work. Time to build and ship hardware like it's WW2.

Will blunt the economic impact of this pandemic, and hopefully the pandemic itself.

China destroyed data and tried to cover up when the outbreak first started, now they are kicking journalist out of the country.

I would not believe anything they are saying at this point in time.

That's an over reductive view, and throws out the baby with the bathwater. China is not a monolithic entity, and while the CCP has, and exerts a lot of control, it is not omnipotent. The number of cases as reported by China will always be suspect, but we are already seeing some information from China being borne out elsewhere. In particular, Italy has been showing similar numbers as China - Covid-19 is particularly lethal to those over 80, less so in children. There are other bits of information we can learn from them, even if we never believe the number of cases is accurate.

As far as the emergency hospital situation and the number of cases in China, I'm sure the US government has been keeping track of the situation via spy satellite. The CCP would never have let the fact that one of the hospitals collapsed escape the country otherwise.

Need both I’m afraid

Cases are irelevent - that’s a function of how widespread the tests are. Do more tests, find more cases. Test people with symptoms find more cases. Allow anyone to take a test find less symptoms.

Yes, South Korea tested themselves out of the problem.

We should be able to ramp testing up quickly, much quicker than building ventilators.

How long did it take South Korea to control the outbreak?

China records no new local cases:


For every problem there is a solution that is simple, neat—and wrong.

-H. L. Mencken

We need to lock ourselves down, and some counties in California and elsewhere have already done so.

We also need equipment and doctors.

This is something I've been hoping to see since the pandemic started.

But, I'm pretty ignorant regarding this industry and I've also wondered this:

There are numerous manufacturing plants within the US, but how easy is it switch from manufacturing knew product to another? Is the equipment and machine used generally the same?

I'm working on the setup of a new factory line. It's amazingly complex and makes just one thing... a washing machine bowl. Here's a video of an older version of the line. https://vimeo.com/306316617

If a place makes plastic parts of similar size, switching just means changing out the dies/molds that form the plastic. Auto part suppliers, often not the actual auto companies, should have no problem with this.

Meanwhile, actual ventilator manufacturers are not getting many orders:


Manufactures like Hamilton Medical that are local here are currently working overtime and also work on Saturdays to keep up with demand.

They are not raising prices, but they're also not selling to new customers, as they're afraid intermediate buyers are taking advantage and raising prices on their end.

They also said they have about 2-3 months of runway until their supplies dry up, since parts from China aren't coming in. They did however get supplies ordered in December, because they anticipated the crisis.

How did they know to order more supplies in December?

China reported the new novel strain of the coronavirus to the WHO on December 31. [1] If correct, then this means they were monitoring the news, and reacted immediately, and on the very same day of the fresh report.

[1] https://www.cdc.gov/mmwr/volumes/69/wr/mm6905e1.htm

It's been widely known outside of China that this a novel SARS-like disease was spreading since December 20th, they just didn't confirm that it was novel until the 31st.

I can't find any article on google dated before december 30 about "pneumonia china".

We just didn’t know how serious this would get. We had H1N1, swine flu, ebola, SARS, MERS, none got out of hand this crazy.

Our own president and task force kept on downplaying it for so long and giving us the wrong information. Even CDC was downplaying for a long time.

Perhaps this shows that industry experts, with skin in the game, are better at determining the relevant trends than the people and institutions you mention.

China spent more than a week attempting to cover coronavirus up. By the time the Chinese government made a statement the problem was pretty well known among the Wuhan medical community.

Hamilton are also facing problems supply chain problems. The last thing I read about them a few days ago (in the Swiss press) was that Romania had stopped exporting a component they needed because they didn't seem to understand it wasn't a "medical device" but only a component for one. I assume that got resolved quite quickly.

It also sounds like many patients don't need a full hospital ventilator. A CPAP machine could do. Those are already made in bulk for sleep apnea patients.

Hospitals are hamstrung by their bureaucracies and financial policies. The best thing that can be done is an independent assessment of need and start "airdropping" supplies if a shortage is apparent.

Did no one bother to actually read the article? It says that there can potentially be a shortage but that there isn't currently.

The fed has 13000 and the military an extra 2000. It currently seems more hamstrung by bureaucracy or lack of information. Hospitals have to request their state governments which have to then request them from the federal government. Only one state has requested them so far.

"“We have received, so far, only, I think, one request for just several ventilators,” he said. In contrast to Fauci’s disclosure that the stockpile contains nearly 13,000, Azar said the number was not disclosed for national security reasons."

For some context, we might have a shortage of over 100,000 ventilators in the US if we fail to flatten the curve (or over a million if we don't take any precautions).

Some numbers for a conservative estimate where only low-risk people are infected: https://news.ycombinator.com/item?id=22590692

If we really don't flatten the curve, then the estimates are over 400,000 shortage.

The problem is that, if you wait to act until the shortage is actually upon you, you’ll act too late. These things take time to make and distribute. You have to act before the tidal wave hits if you want to have them in place when it does.

The first problem to solve is information and distribution. Get organized quickly first so that hospitals know that they can request them and that their requests are quickly met.

This double request structure is stupid.

Unless the US central bank is hoarding ventilators, "the feds" have 13000, not "the fed".

Read article and assumed the hospitals aren't anticipating the need for whatever their reasons are. We just barely have enough vents in hospitals as is and they are in use.

>>Did no one bother to actually read the article? It says that there can potentially be a shortage but that there isn't currently.

By the time we see a shortage is late, way too late. Lungs need oxygen and cannot wait for purchase orders and negotiations. You'll need MILLIONS of them, and doctors that know how to use them, like yesterday.

Currently there is more than enough. The problem is lack of information and lack of distribution. Making more without solving those problems is ineffectual.

You can do both simultaneously - make more while solving the issue of communication and distribution. Again, you seem to miss the point - while there are currently enough, it is likely there will not be enough in the near future. If we don't produce more before that point, it is too late.

You're gonna need 20 million of them

Right, because no one has stepped up to write a check. Hospitals are businesses, they're not going to do this on their own. GM is a business, they're not donating those ventilators, they're trying to make a sale into a new market. States, most of them, can't do it because their budgets are fixed by their constitutions and they can't take a loan or write a bond without a referendum.

There's basically one entity in this country with the ability to actually make this happen, and the people trying to point out that it isn't doing anything useful are fighting downvotes here just to be dark enough to read.

Whoever thought that running your healthcare system in a commercial fashion was the right idea in the first place? A lot of fundamental decisions are going to be re-thought in the aftermath of this virus' impact, but for now we can ignore all that and focus on what matters: eradicating the thing. And if GM making ventilators on a war footing is what it takes I'm all for it, let's divert some of those funds to them and give the hospitals what they need.

The US has more intensive care unit beds per capita than any other country. Among developed nations they will not come out of this with the highest COVID death toll per capita. The Italian healthcare system is closer to the not for profit ideal and it’s not doing great right now.

I’m not sure where you’re getting that from. There is no universally accepted definition of “intensive care unit bed“ due to fundamentally different approaches to healthcare in different countries.

What you can easily compare are hospital beds for acute care - this is a much bigger pool than just icu.

You can also easily compare number of doctors per capita.

In both of these measures the US system lags behind places like Italy.

I agree with the parent. There are a number of places in these comments where the number of ICU beds per capita seem to be justification for personal viewpoint; all cite the same sources.

In the interest of avoiding possible hubris, I think it's worth noting that the numbers in the Statisica chart on ICU beds/100k persons (included in the oft cited link [1]) counts in its data for the USA all ICU beds, while the European numbers come from a study that explicitly exclude [2]:

"...private healthcare providers, neonatal and paediatric intensive care beds, coronary care, stroke and pure renal units"

The 34.7/100k number for the US does not exclude the above. According to [1] the US has:

"There are 68,558 adult beds (medical-surgical 46,795, cardiac 14,445, and other ICU 7318), 5137 pediatric ICU beds, and 22,901 neonatal ICU beds."

Attempting to match the criteria of both studies gives the USA about 46,795 beds. Assuming 320 MM people gives 14.5, not 34.7, per 100k. I haven't looked at the sources for other countries, but we can expect differences in methodologies of ICU bed counting.

I think this casual sort of comparison of national capabilities (like [3]) which lacks rigor is more dangerous than useful. I hope one will take a deeper dive if they're evaluating risks based on the numbers that have been posted.

[1] https://sccm.org/Blog/March-2020/United-States-Resource-Avai... [2] https://link.springer.com/article/10.1007%2Fs00134-012-2627-... [3] https://en.wikipedia.org/wiki/List_of_countries_by_hospital_...

There are many factors to why Italy isn't do great. Including their population skews on the older side and they have the oldest population in Italy...which unfortunately has a 1 in 5 chance of dying if they catch the virus.

I think the healthcare system and medical supply chain are two separate things. A universal healthcare system (for E.g. Sweden) still has a normal supply chain. The only difference is the profit motives are not present and the government can effectively pump money in without violating economic principles of supply/demand and pricing.

A commercialized health care system has lots of perverse incentives leading to price increases and profiteering. This sets the weakest fraction of the population up for losing all they've built up in the last 3 months of their life while barely impacting the strong. It also means that those hospitals don't care about overpaying for their supplies and medication (but not their workforce) because they get to pass those costs on to those already weakened people.

FWIW: Gall bladder operation in NL all in: 1500 euros, non-subsidized and paid for out of pocket because I wasn't paying into the local healthcare system when it happened. Same procedure in the USA: $24000!


The US has had a private healthcare system for its entire history. Economics and incentives were the same throughout that history. Meanwhile prices only became stupid very recently.

A commercialized health care system also has absolutely no incentive to keep excess capacity for emergencies. It seems to be very good at finding the optimal efficiency point, which essentially is very close to "no unused resources in the nimal situation". But societal resiliency requires that health care, utilities, food supply, etc, has some excess capacity just because at some point something will happen. A public system can at least be responsive to the value society puts on resiliency.

Medicare and state licensing agencies more or less control the hospital bed capacity in the US, not commercial incentives.

Want to build a hospital in many states? Better be able to convince the licensing agency there is need for the beds. Want to build a hospital and accept Medicare? Better meet all the structural requirements they put in place.

Open the March update pdf here and look at the "excess" column on page 4:


The state has big impact on the capacity of the medical system.

> A commercialized health care system also has absolutely no incentive to keep excess capacity for emergencies.

I disagree, I'd say it's the opposite.

A commercial system can value surge capacity for peaks just like an online retailer does; the capacity to handle extra load means extra profit.

Whereas in a public health systems like the UK NHS everything is geared towards routine operational targets such as A&E waiting times. There is no budgetary or promotional reward for having reserve capacity.

Incidentally the NHS has just identified an unintended reserve: a pool of nurses who have been sitting in nadministrative middle-management roles for years. They are being retrained and redeployed now, but it illustrates the lack of efficiency in the system. A private provider would not have 'wasted' nursing staff in those positions.

this assumes that health care scales in the same way that an online retailer does, no?

the retraining nurses is somewhat of a point in the opposite direction -- the NHS has an easy pool to pull in because of the inefficiency. if all of the nurses were being used efficiently to begin with, there would not be an easy group to bring in.

scaling the number of doctors and nurses available takes a bit more time than hiring a bunch of people to put items in boxes

>A commercial system can value surge capacity for peaks just like an online retailer does; the capacity to handle extra load means extra profit.

Sure it can, but that's obviously not the reality and spinning up extra servers is not the same as adding extra physical rooms and beds. This analogy doesn't make any sense.

>ncidentally the NHS has just identified an unintended reserve: a pool of nurses who have been sitting in nadministrative middle-management roles for years. They are being retrained and redeployed now, but it illustrates the lack of efficiency in the system. A private provider would not have 'wasted' nursing staff in those positions.

You're right. A private company would just fire the nurses instead.

Private providers are not immune to oversights and waste.

Atleast they get punished for it, unlike public systems which might get punished once every 20 election cycles.

How does that square with a system that has the most critical care beds per capita:


As user lima-lima pointed out above, this most probably is an artifact resulting from different definitions of what constitutes an ICU bed - for example pediatric and neoanatal beds are included for the US, but excluded in the European numbers.

It also fails the sniff test: The US has less total hospital beds than almost every other industrial nation, but at the same time the most ICU beds?

It only has less total beds if you exclude outpatient facility beds.

Are these included in the count of the other countries? This is exactly what I mean: Without the same definitions for all countries, the numbers per se are not really comparable.

Second most at best. Turkey has 46 / 100k.


Interesting, the last number I saw was 10x less. That is comforting

Yes, definitely, American healthcare system needs a reboot - this might be a good time to do that. The only difference is that I would be paying about the same but the insurance would cover the rest. The problem being - if you're well off, you pay $1500, if you're not, you pay $24000 and potentially go broke. That is the problem with the American healthcare system.

it may have been mentioned already but in the US healthcare prices are negotiable. It's strange because you can't go to a US grocery store and haggle over the price of cucumbers like you can in many other nations but you can do that with healthcare.

So $24000 is like the asking price, you can come back and say "yeah well, i'll write you a check right now for $2500 otherwise you're sol.". Once a provider realizes what the max they're going to get is then, magically, that becomes the price.

To anyone who doesn't know this, don't you dare pay out of pocket what the bill says. Never. What's on the bill is not based in reality at all.

There are a couple possible re-thinkings. The disturbing one is where it is noticed that we are essentially sacrificing a bit of the economy to reduce fatalities. So next time it is decided that company valuations are worth the extra deaths[1]

I submit that rethinking needs to be started early rather than late so the discussion isn't dominated by euphemisms for some very dark path.

[1] As we know, social isolation is to spread out the pace of acute cases so as not to overwhelm hospitals. But it obviously slows the economy considerably. The alternative would be to not to isolate, keeping businesses wide open and allow the medical system to be overwhelmed with its accompanying higher mortality rate.

America has been on the dark path where lives are equated to money for a long time now. It will take something quite dramatic to shock the system to the point where people are willing to re-think it from the ground up. Maybe this is that shock. If not now, then probably never.

Except that quality-adjusted life expectancy changes due to side effects of drugs are valued much more higher than people dying due to being too broke to get any non-ER-care for acute, but not yet emergency-posing illnesses. Even within the drug certification process there is an issue with relatively niche drugs wasting a lot on overly-extensive studies, if you calculate how many people would get how much benefit from getting/affording these niche drugs. IIRC there is about an order of magnitude higher weight on side-effect deaths compared to lack-of-medicine deaths for niche drugs.

to be fair, you can adopt europe/wuhan-style total lockdown but you could also adopt developed-asia-style mass tracing.

The latter seems to have been way more effective in containing the epidemic and less impactful on the economy.

So, there was third option which saves both people and economy, but it's probably politically unfeasible.

It's too early to evaluate the tracing approach. The problem is what happens when other people come in from the outside. This is now a major problem in Beijing; not internal transmission but cases brought by arrivals.

It is perfectly possible to rapidly buy things in a commercial setting. You just need a good credit rating and someone to sign the purchase order or contract. Why should the vendor care if the customer is breaking an internal rule about purchasing?

Because it’s not really about the access to capital, it’s about rules designed for non-pandemics slowing them down during one.

To be clear: I'm certainly not opposed the idea of air-dropping GM-manufactured ventilators to needy hospitals (though I'll admit I don't see how it's ever going to work in time and genuinely think this sounds like marketing on GMs part more than a serious idea).

I'm just saying that the person that needs to get off their ass and move on these ideas isn't Mary Barra but Donald Trump (and McConnell and Pelosi of course).

You need to start thinking of this as a logistics problem, not a tech problem. Ventilators is a solved problem. What is needed is a stream of parts and manufacturing capability. I'm not sure if car manufacturers are the right partners but they do have a lot of people that know how to put stuff together. They can put an assembly line for ventilators together; get a stream of parts going and start manufacturing long before we reach the peak of this epidemic. Their workers are not going to be doing anything else so let's let them have their shot. Meanwhile, other companies could start on parts manufacturing. Some design should be chosen; standardized and then we need to start moving. Everywhere. Ditto portable ICU units, negative pressure environments and training for people to help others during this epidemic. If not many more more lives will be lost.

Let’s throw masks and other PPE onto your list as well.

Those are closer to nanomachine fabrication tasks, but different. Lots of specialized, uncommon, high-precision machines: everything is a one off, there is no bulk, and it's all expensive and fiddly.

Ironically the way to make this stuff cheaper would be a three-fold attack.

* Make MORE things that use the same parts, so that making the raw materials is commodity.

* Reduce waste in use (if sterilizing the filters for reuse / etc is possible, etc).

Part 3: Look for alternatives that are feasible.

A hot-zone (book) style line supplied breathing air positive pressure suit that can be scrubbed clean on the outside, OR a similar glove-box (negative draw?, scrubbed inside?) style phone-booth like I think I saw on TV from South Korea (IIRC) would be much better replacements.

Yes, absolutely. In NL one quarter of the total confirmed infections is hospital employees and other healthcare workers!

As for actual air-dropping - this is actually not that far from reality here in Europe. Two days ago Czech army transport aircraft (nothing fancy, just a A319) got back from Shenzen with 100k quick-tests for the virus, that can give results in about half an hour for a symptomatic infected person. Then the test were distributed to main hospitals via police helicopters.

Reportedly the Hungarian government learned about this operation & are likely to do something similar in the next days.

Also in parallel, Czech Airlines aircraft have been pretty much drafted and sent to China for more stuff - like more tests, respirators and personal protective equipment. And one of the huge Ukrainian AN-124s has been chartered and is already on way for ~100 tons of medical supplies in one go, with more likely to follow.

Basically any classical goods transfer methods are far too slow for this and time is of essence.

the people that are most likely to need the ventilators aren't exactly hospitals' profit centres either.

are those businesses really going to want to fill all their space with Medicare patients? with fewer ventilators, I imagine they can decline care to more people?

Don't states have emergency budgets that become available during state of emergency?

Yes and no, some states are constantly on the border of being insolvent. California has a big 'rainy day fund' but this recession is projected to eat into a significant chunk of it. The way hospitals are funded and administered may make it tricky for a state to buy a bunch of ventilators with state funds and then donate them to a hospital... if you "lend" them then after the crisis the state owns a bunch of used ventilators it needs to offload.

So mothball them the same way the military does equipment. We don't have a shortage of land in this country.

Because the equipment requires very sensitive measurements on the order of tenths of cmH2O and tenth of a milliliter of air, a very small leak in any one of the seals can cause a significant inaccuracy in ventilation and especially in the alarms which govern whether the equipment isn’t overinflating your lungs. This isn’t like a car where you can just start it up periodically to keep seals lubricanted. You need to maintain them or to have a plan for how you’ll check them before putting them into service. And you need biomedical technicians who are trained to repair them and clean them. If you mothball the equipment there is a very real danger that without re-qualifying the equipment it will kill or injure patients.

The biggest effect GMs announcement seems to have had is convincing people that a car company that builds to PSI tolerances can build anything to the kind of tolerance needed to safely ventilate patients. I think this is a PR move and GM and Tesla will study the problem enough internally to determine they have no idea what they’re doing. Worst case we get ventilators from Tesla with the same manufacturing defects and quality issues which their cars have had. I personally would not feel safe on a Tesla or GM ventilator built without FDA oversight.

Absolutely on requalification.

IYHO, would that be more or less time that manufacturing fully new units?

In some cases, it's complicated, yada yada. I'm certainly no expert on state-level budgeting in the US. In the case of NY specifically, I know it's been reported that Cuomo specifically asked the federal government for help getting ventilators and was rebuffed.

Right, because no one has stepped up to write a check.

If only billionaire Elon Musk knew someone who could pay.

Almost all of his wealth is the value of the companies he runs. He's so cash-poor that he couldn't even pay a $75k fine.[1]

1. https://observer.com/2019/10/elon-musk-british-diver-lawsuit...

Let's not exaggerate. His companies are public - he has quick access to hundreds of millions in cash.

As of last night, Musk does not believe there is a shortage.


Because they are not the bottleneck. Intensivists that can operate the vents are the bottleneck


That is some bureaucratic nonsense. Setting up and maintaining a ventilator is not rocket science, you can train other staff to do that job pretty quickly.

Ancillary tasks may suffer from staff shortage, but if you need one, getting a ventilator and minimal care is a lot better than not getting a ventilator.

I don't know how to operate a ventilator, and have zero medical training, but I'm getting frustrated by the comments claiming medicine is trivially easy.

Even using a syringe or blood draw on a patient is something one needs certification to do properly. That isn't bureaucratic nonsense. Having worked with syringes and sterile technique, there are so many ways you can give your patient an infection or otherwise cause them life-altering complications if you don't know what you're doing, even for the actually trivial techniques. Operating a ventilator incorrectly will result in death. Likely a grisly one, as incorrect pressure differentials and human lungs are not a good combination.

Now that doesn't mean we need to stick to these bureaucratic rules as they are for this situation, but the people on here advocating for trying complicated medical procedures while knowing fuck all about medicine (or even biology) really need to take a step back and take an inventory of what they don't know, and can realistically expect to accomplish with neither the technical knowledge nor manual dexterity of a trained clinician. A YouTube video and a technical manual aren't going to cut it, folks.

I am getting frustrated by the comments that miss the big picture. There are likely going to be lots of people that are going to die without ventilator. Now, who with any common sense and decency[1] cares if 30% of them are dying because the device was not used properly/broke/whatever if the only other available option is that 100% of them die?

[1] Sigh... I know, I know. American lawyers and legal system.

In your example, a 30% mortality rate is a very big deal. If we had a hypothetical cure that killed 30% of the people it was administered to, I doubt it would get very far.

I'm not saying the alternative is do nothing. But playing doctor because you think that you're reasonably qualified to administer a ventilator, then we're going to end up with, say 30% mortality rates from patients whose lungs were sucked through a ventilator tube because you guessed the wrong pressure. Or, more realistically, a terrible infection because you decided soap and water in the bathroom sink would be sufficient to clean the apparatus.

And then what do you suppose will happen after 30% of these amateur medical procedures go South? Are you going to throw in the towel, try something even more reckless, or decide that you need to get an actual doctor involved to clean up your mess? At which point, you've just added yet another case to the already overburdened medical system. And at a 30% failure rate, that would become a major burden.

There's a lot of room for action between doing nothing and acting foolishly (such as claiming a 30% mortality rate for botched medical procedures is a rational tradeoff). There are ways to help the situation here that don't involve magically becoming a nurse overnight.

The thing you’re missing is these new RTs wold not just be treating COVID-19 patients. There are tons of people who will need ventilator therapy because they were injured or sick and they would have gotten injured or sick anyway. These are people who can be saved with proper treatment or injured by improper treatment. Barotrauma and lack of tidal volume have implications beyond simply alive or dead. We need people but we must make sure they can actually provide adequate treatment.

I'm not suggesting that you or I operate the ventilators, but I refuse to believe that hospitals can't get someone decently qualified to do the job. If the need arise, those 160000 ventilators will be in operation in a heartbeat. The only reason not to get more is if you believe that there won't be that many patients.

I'm sure the hospital nurses can learn via on-the-job training in a day. This is an emergent situation. No one is suggesting pulling a random person off the street to do it

Setting up a ventilator for treating ARDS (caused by the viral infection and inflammatory response) is at the much harder end of respiratory therapy unfortunately. This is also one reason why just building the simplest possible ventilator simply isn't possible / useful here. Yes you could basically build a 1960s design en-masse but at the moment 50% of people on modern vents are surviving so this is no panacea.

The trick will be to find a minimal feature set design, that doesn't use a lot of specialist long lead time components, can be used by people who are less experienced, and is suitable for treating ARDS. That is a much harder problem than the basic one of getting some kind of ventilator mass produced on an emergency basis.

That minimal feature set is a CPAP machine + maybe an oxygen valve of the 3D printable variety.

Modern CPAP machines can generate phenomenal pressures and can be adjusted with simple touch screens. They support automatic pressure reduction on exhalation, and Bluetooth/cloud access to the data in them for remote monitoring via mobile apps.

BTW it's not quite as simple as 'hospital ventilators are hard to use'. Firstly, modern ventilators are much easier because the manufacturers realised that high training costs were limiting their market, so they've got a lot easier to use. Secondly, the US did a previous disaster response training exercise where they trained a bunch of non-specialist medical staff like nurses and even vetinarians how to use the machines. After 2 days of training there was an exam: the vets did best.

CPAP machines generate continuous positive pressures though, they assist breathing. I know they have slow ramp capabilities for comfort reasons (start off at low positive pressure when you fall asleep and then increase) but I don't think they can swing pressure fast enough to enable inhalation and exhalation.

You need: -Gas blending (relatively trivial) -A source of pressure (CPAP has this) -A way of modifying pressure up and down quickly and precisely enough to stimulate breathing (Don't think CPAP has this) -A way of measuring flow and pressure (Does CPAP have this with good time resolution? I doubt it as not required for CPAP) -A controller which uses the flow and pressure data to vary the system pressure (CPAP doesn't have the right software but presumably this is less time constrained than the others)

So I'm really not sure that you can do this with a modified CPAP machine.

BTW I'm not sure that you can print oxygen valves, maybe air valves or patient valves. High pressure inlet oxygen parts need to be oxygen compatible and many 3d printed materials may combust under those conditions.

CPAP machines technically can't but CPAP has become a generic term that also encompasses bi-level/APAP machines that can swing pressure fast enough to track inhalation/exhalation. Both mine do. They're not that old but they're not top-end either.

I don't know how many active machines are pre-APAP/BiPAP/A-Flex (there are different names for it). A comment below says 90% but this seems very high to me.

I wonder if it's possible some doctors don't realise the machines have this feature or it's importance? When I first was prescribed CPAP the machine did not come with bi-level flex enabled, it made it very hard to tolerate. I pushed through it for months but when I "cracked" the doctor-only DRM (i.e. looked up the cheat code on Google) and enabled A-Flex it instantly became way easier to handle the machine and my AHI scores were super low; big success. Doctor was quite happy with my altered configuration. I was just surprised such a basic thing hadn't been explained to me.

I suspect a lot of CPAP machines support bi-flex but it either isn't activated or could be added via a software update. I don't think you need extra components.

Oxygen valves come from here: https://learningenglish.voanews.com/a/volunteers-produce-3d-...

Very interesting, thanks. If that is the case then it may indeed simply be a software thing. Specifically for treating ARDS you need:

-High PEEP (obviously any CPAP machine can do this)

-Low plateau pressure (probably possible, that's just software)

-Low tidal volume and high breathing rate. Breathing rate is just a cycling variable so should be software only issue. Managing low tidal volume will require the machines to have a flow sensor. Do you know if any of your machines do? If so, then this is likely fixable with only software.

My interpretation of that article is it must refer to the patient valve as those are one-time use (as they in contact with contaminated patient exhalations) rather than O2 inlet valves which are not disposable. Patients are breathing high-ish O2 but obviously not HP pure O2 so 3d printed is fine for that.

3D printing is useful for cases like that where due to logistics there is a temporary shortfall in local supply. I suspect that 3 months from now we are unlikely to be using those measures as global production and distribution of ventilator consumables ramp up.

Yes, they all have flow sensors. They track vast quantities of data, in fact they track and record the flow of every breath on SD card and can upload that data via Bluetooth.

There's an open source app called SleepyHead that can show you all the data in detail. It appears the maintainer burned out but the downloads are still available.

So it seems modern CPAP has all that's needed? Doctors can even monitor it remotely or via the cloud. It's intended to let clinics monitor patient progress without needing visits, so it's all pretty easy to use.

A CPAP is fixed pressure, what your thinking of is a APAP or the bilevel type of positive air-pressure machines. And there lies the problem with you're miniumum feature set; not all *PAPs are fully-featured machines. Maybe only 10% or so are suitable for ventilator duty, which means they too are supply-limited

I own two CPAP machines and yes they both implement bi-level/APAP features. CPAP is a bit of an ambiguous term these days; whilst there are technical differences between them, most people call all such devices CPAP machines. For instance,


It's advertised as "CPAP & Bi-Level therapy".

To be clear, I'm talking about the ones that implement bi-level pressure. The difference is (as far as I know) primarily a matter of software; perhaps older machines can be upgraded if pricing/selling upgrades is taken out of the equation?

I've had my machines for I think a couple of years now and they were all bi-level from the start. I'm not sure when that started becoming standard or where you got that 10% figure from, you may well be right. But there are 300,000+ sleep apnea patients being treated in the UK alone. If even only 10% of them use modern machines (seems low given how much better bi-level makes it), that's still 30,000 portable ventilators available to be requisitioned at short notice. Sleep apnea patients don't have a critical need for them.

I was reading some accounts on /r/nursing that its relatively complex. The issue you have is that its quite easy to kill a patient if you fuck it up and there are multiple factors that impact the operation of the machine (e.g. patient weight for example).

Any guides to how to set up a ventilator by chance? Asking for a friend...

Very short guide: Put a mouthpiece on the patient, connect the mouthpiece to the tube from the ventilator, turn the ventilator on.

Longer guide: Read the manual for the specific ventilator and have fun adjusting air mixture, pump frequency, pressure, volume and other stuff. Choose one of several different models of mouthpiece, with or without tubes, depending on patient needs. Learn about different failure modes and associated alarms. Learn how to operate the pump manually in case of electronics failure. Learn how to properly clean the machine.

It isn't nothing, there are some things you can do wrong if you don't know what you are doing. But a trained medical professional should get up to speed with a crash course.

The type of ventillators required by the most serious cases are much more complicated: as I understand it, it involves push a tube down to the lungs, and the machine breathing instead of the patient, i.e. it has to carefully monitor and regulate the pressure etc. Already the "push tube down to the lungs" part is quite a challenge: avoiding damage to the vocal cords, or to the lungs, etc.

Should we then not be damn sure that there are shitloads of the simpler ventilators so that the complicated ones can be fully reserved for the serious cases?

In the hospital they’re all complicated cases. The simpler vents are for home care use. The hospital doesn’t typically do noninvasive ventilation because it’s meant for patients who are awake and outside of a hospital setting.

Tubes down the lungs is definitely a bit tricky, not all patients will require that model though. As for careful monitoring, that is something the machine does on its own, as long as it has been configured correctly for the individual patient.

This is incorrect on many levels. A ventilator always requires intubation. Sometimes that's through the mouth, sometimes through the nasal passage (both cases are referred to as endotracheal), and rarely through a tracheostomy. Ventilators do have some monitoring capability, but require consistent attention from respiratory therapists. The chances of infection (VAP), pneumothorax etc are serious without careful monitoring by a trained, experienced medical professional. These aren't plug and play devices.

Some patients might need supplementary oxygen delivered through a canula, or through a mask, but that's nothing like the procedure used for a vent.

A ventilator always requires intubation

Can you elaborate? This ventilator documentation[0] says for invasive and noninvasive ventilation

[0] https://www.usa.philips.com/healthcare/product/HCNOCTN98/res...

Many vents can also operate in BiPAP or CPAP modes or as pure demand O2 supplies for people who can still breathe. That can be done with a mask.

When treating bilateral interstitial pneumonia, you're almost always intubating. Patients presenting BIP require higher oxygenation than a CPAP style mask can provide. Using a limited availability ventilator with just a mask is a waste at this time.

Nonetheless ramping up supply still solves the problem by driving prices down

If any of them have half a brain, they are maintaining their regular prices and ramping up production and stockpiling them for the inevitable demand in a few more weeks.

This is easily resolved by setting the price of ventilators as part of Title IV of the Defense Production Act (I would imagine) https://fas.org/sgp/crs/natsec/RS20587.pdf

In fairness, if your hourly workers are working overtime to "ramp up production" you need to pay them overtime of 1.5x (In China, it can be double or triple (forgot which one) since their workers were working during Chinese New Year) . Their costs increases and should be able to reasonable increase price to accommodate.

> ramping up production and stockpiling them for the inevitable demand in a few more weeks.

This still prevents future prices from increasing, which is good thing.

Only if they actually decide to drive prices down. There is zero indication this is happening.

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