The WWII mobilization was a shitshow when it started. Kaiser Shipyards in Richmond, California turned out ships at an amazing rate  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.)
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.
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.
It looks like the cargo ship law, Jones Act, is more successful in creating capacity.
> 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.
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.
Manufacturing is spinning up. What I really need is developers on this project:
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.
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.
As an example for my concern -- I've had a consistently-updated pull-request 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.
JHU is bandwidth-constrained. Put your effort where it can have effect.
* 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.
or in the simpler case you might fall back to scraped and oiled ways and bushings
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.
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.
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.
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.
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.
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.
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.
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)
Given that this is a crisis, the existing ventilator manufactures need to send over a couple experienced ventilator engineers to help.
Getting a supply chain for parts up and running is going to be the tricky part.
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.
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.
We cannot wait for 18 months for a vaccine.
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.
I would hardly call that libertarian, but YMMV.
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.
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...
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?
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.
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.
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.
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!"
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.
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.
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.
We need all three, and there's a worldwide shortage. That is the bottleneck.
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.
Certainly politicians enacted such things, but I'm not losing sleep over the hospitals. Only us mortals, stuck with the cost of the system.
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.
if too many make it to be doctors, the pay won't be as good.
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 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.
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.
In addition to training new doctors, we should also just loosen restrictions for doctors to enter the US and use their medical expertise.
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.
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.
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.
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.
Things have changed rapidly in medical education. At least some places.
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.
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.
> 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)
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.
The problem is, developing and testing a vaccine takes some time. How much time do we have before the global economy totally collapses?
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.
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.
Discretion, I work for a carmaker company but my opinion is of my own only.
Ford and GM were massive manufacturers when WWII reared its head. That gives them a rich history of wartime production .
The principal cost in these sorts of shifts can be bureaucratic. Having cultural capital to call on is invaluable.
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 think a more pressing question is if any workers will want to come in if GM and Ford commit to this.
We choose to do these things not because they are easy, but because we asked ourselves "how hard could it be?"
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.
 https://www.youtube.com/watch?v=graC_Vib1IE @8:40
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.
I don't have any English source for this. But Boris Johnson requested the same in England, too.
Wikipedia says one Chinese manufacturer, Geely, sold 1.5 million vehicles last year ; that probably includes 700K Volvos  (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.
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.
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.
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.”
> 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.
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."
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.
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_....
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.
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.
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.
I would not believe anything they are saying at this point in time.
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.
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.
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:
-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.
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?
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.
China reported the new novel strain of the coronavirus to the WHO on December 31.  If correct, then this means they were monitoring the news, and reacted immediately, and on the very same day of the fresh report.
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.
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.
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."
Some numbers for a conservative estimate where only low-risk people are infected: https://news.ycombinator.com/item?id=22590692
This double request structure is stupid.
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.
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.
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.
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 ) counts in its data for the USA all ICU beds, while the European numbers come from a study that explicitly exclude :
"...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  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 ) 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.
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!
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.
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.
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
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.
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?
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.
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.
 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.
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.
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).
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.
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.
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?
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.
IYHO, would that be more or less time that manufacturing fully new units?
If only billionaire Elon Musk knew someone who could pay.
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.
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.
 Sigh... I know, I know. American lawyers and legal system.
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 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.
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.
-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.
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-...
-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.
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.
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.
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.
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.
Can you elaborate? This ventilator documentation says for invasive and noninvasive ventilation
This still prevents future prices from increasing, which is good thing.