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Project Xtreme

by: rrteacher

Tue May 29, 2007 at 18:17:03 PM EDT

(one last promotion for polling purposes - promoted by DemFromCT)

Poll results here

What does the public think about us using newly trained help in saving them or their loved ones lives? Take the poll. The safeguards are that extenders
newly trained to operate ventilators will be trained by respiratory therapists and directly supervised by them in the field. -DemFromCT

Recently, the Agency for Healthcare Research and Quality, the R&D arm of HHS, looked at the issue of all hazards and pandemic response in the face of a serious HCW shortage, specifically, not enough respiratory therapists to provide ventilator care in a pandemic.  The value of mechanical ventilation in H5N1 illness is being hotly debated presently, but the reality of respiratory illness in bio terrorism and nature is a concern, none the less.  AHRQ contracted with a group in Colorado to develop a program for "extenders", to be used in a "readiness" or "just in time" format.  The material is very basic.  Any feedback is welcome.  The report, posted here, does not include the training program, 6 part DVD. 
rrteacher :: Project Xtreme
To receive a copy of the Program DVD and a report/guidance document, e-mail;


and request;
AHRQ Publication No. 07-0017


Richard Mitchell, RRT-NPS

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Project Xtreme | 59 comments
Please Comment
This program has receive a great deal of criticism from RT professionals.  I am looking for public opinion here.  What would you want for your mother, spouse, child?  This could make a difference.



Richard Mitchell, RRT-NPS
Dartmouth Hitchcock Medical Center/CHaD

IMHO-now-at a pandemic-free moment in time, I would prefer good hospice level comfort for myself and loved ones. Access to adequate morphine to promote sedation, relax respiratory distress and relieve pain and anxiety.

I see what ARDS is like in a hospital ICU now. Terribly poor outcomes frequently despite top-notch care and easy access to meds,staff and equipment.

It is better to look ahead and prepare than to look back and regret.

[ Parent ]
I am skimming it
I can see med techs doing phlebotomy duties, they already do this in doctor's offices

I can see nurses that work specialties being used in others as when I used to work we were "pulled" to other floors during staffing shortages though that can be a big problem with a floor nurse doing maternity or critical care for sure. but in an emergency....

Still you would not want me as your nurse if you were having a breech birth as I know almost nada about maternity nursing though I could deliver a normal birth fine but be freaking the whole time.

I have intubated patients in the past,drawn abgs, given resp treatments and can do most all of what is on the list and have done it except ventilator maintenance,circuit change, and setup as a critical care nurse years ao.

I don't know if it is more specialized now than what it was years ago when I was nursing.We used to multitask in those days. We mixed our drugs ont he floor and did blood typing using slides on the floor in those days. the dark ages. :)

  Anything having to do with the mechnics of the machine itself would be foreign to me and I don't know anything about specialty gas administration.

I cannot see a physical therapist having the necessary skills for this at all but their job description may be different now than what it was years ago.

The program is only for treating adults? when there will be a greater need for pediatric RTs if this happens?
I think if it was made into a course like ACLS with yearly recertifications, maybe it might work and would certainly be needed during a pandemic.

Can you tell me why the rts are so against the plan? I can certainly see a major liability problem. RTs would be monitoring the extenders I am assuming.

Life is not so short but that there is always time enough for courtesy. Ralph Waldo Emerson

Extreme Resistance
Thank You Moj,

Most therapists initially were concerned about turf protection.  Based on the fear that a cleaver (not so, really), hospital administrator could hire less qualified, or NOT qualified HCWs and use this material.  Currently, if a student is working under my supervision, that student is working under my license umbrella.  This is so in most states.

So the liability issue is a concern.  Fact is that most states have declared emergency clauses that circumvent the license requirement.  But the liability issue is as much over this as everything else we have discussed here.

Project Extreme excluded pediatrics for the same concerns, I believe, and also since pediatric/infant ventilation is more of the "next level" stuff.  I think where we will be in trouble IS pediatrics, based on current H5N1 and 1918 H1N1 predilection for this age group.

I will say now, I would include recruiting help where I could and use this and other material, (more of my own stuff) to get the best help I could get.  That would include pediatrics. 

Richard Mitchell, RRT-NPS
Dartmouth Hitchcock Medical Center/CHaD

I have a few volunteers at my hospital
non-RTs , to test the system and drill... ie, can they learn, as judged by RTs?

That could both help allay fears (done right) and instill fear (done wrong), but the idea would be 'must have RT supervision' to even attempt learning, for now.

[ Parent ]
RRteacher - that is a real and *valid* concern.
Boot them out later by denying them insurance after the pandemic.

  Yes, swift, cruel and effective.

  Their reward is pay(?), certificate of appreciation, reconition and some education in case they want to be board certified.

  Saving lives can not be used to buy food and is often offset by loosing those people that even Dr. McCoy could not save. So some greif counseling should be made available. 

  Not everyone is cut out to be a HCW.


[ Parent ]
If a loved one were gasping for breath, I'd want any help I could get.
I guess over time (and through failure?) there would be some notion of which patients can be helped even in the absence of the full RT treatment, with gases and __?__.  So having extenders filling in can probably save more lives than just turning people away for lack of staff.  The real RTs should not be held accountable for their deputies' failures, if there's no malice or drunkenness, etc., involved. 

But I thought there was a shortage of ventilators.  From Susan C's post about the battlefield-like scene of end-stage ARDS, a lot of auxiliary staff is needed too.

"The truth does not change according to our ability to stomach it."  Flannery O'Connor

staff and stuff
this is staff. vents are stuff, and a different fix. Both need to be approached.

[ Parent ]
Yes much is needed.
  I believe this is only for staff.
  Vents are needed.
  Gas, maks, tubes and consumables are needed.
  Power is needed.
  Repair technitions are also needed.
  Computers for making charts and tracking stuff would be nice
  Time keeping software so people can get paid would be nice.
  Place to but lung and body fluids

  The list goes on, so do we. There is an answer.

  If a town can raise millioins for roads, build a school or a bridge then why not a flu tax to pay for stuff.

  I like my idea of a lottery. Sell tickets to buy vents. A winnin tiket gets you a guarunteed a vent if you need one. Yes they are transferable. So yes Kobies vent may once again be up for grabs :o) LoL

"Odds of winning are 1 in 300,000 - better than most  million dollare lotteries. Odds of dying - pretty good. No purchase necessary to skip this offer. "


[ Parent ]
just my thoughts
Many, many years ago, I was employed as an aide at a very small hospital.Long before I even had a hope or idea of going to nursing school.
  no classes, I was completely trianed OTJ.
  As time went on I was first taught how to do sterile dressings, wound irrigations. Next, I was taught how to do sterile suctioning of intubated patients, good mouth care,and what to look for as far as problems.
  Next, it was me and the ER doc running the ER..all 2 gurneys in one small room.When I needed an IV or meds I had to call to the medical floor for these.I did all the charting on all of this. I would leave the completed charts in a pile so the shift super could countersign.
  As, I said, a long, long time ago.
  Actually, once I finished school, and passed boards,I was rather PO`d that I`d been doing nursing work for aides pay for so long.For me, nursing school taught me the the deeper reasons,ie pathology,physiology of what I had been doing.
  So, with all said, I would have no problem in working with anyone who was taught how to assist .Many of this stuff is just procedures. I could teach my 9 year old GS how to put in an IV.
  No, these folks wouldn`t know the whys or howscomes, but would know the get it dones.And, into a pandemic,that`s all we`ll need.

There is no pleasure in having nothing to do; the fun is in having lots to do and not doing it." -Mary Wilson Little

Any port in a storm
This might sound sarcastic or flippant but it's not meant that way at all.

If there are enough ventilators to even make it an issue of who is running them then I believe that it just makes sense to have someone, even someone who is minimally trained, try to help the people in need. If you are that bad off that you need a vent and you don't get one you will very likely die. I'd take a slim chance of survival over none any day.

Nobody made a greater mistake than he who did nothing because he could do only a little- Edmund Burke

What is option #3

  I worry about the precedents it sets.

  But what are my choices?

  Watch my son die a horrible death as I sit by helpless

  Let a semi trainded person with little experiance try with good or questionable hospital grade equipment in a hospital setting where they can ask for help.

  Take him home and do it my self with a reversable shop vac?

  Go over to "Bob's" house and have him try it with a foot operated tent pump?

  Buying a snake oil salesman's "Ronco home power vent for 4 easy payments of $19.99" (as seen on TV)

  Yes I fear a slippery slope. Using marginaly trained personel in life critical applications is wront. HC work because of the people not the machines. Machines are a force multiplyer not a substitute. Semi skilled folks are not a substitute but better than nothing or un-slilled folks.

  Yes - semi skilled folks can do more damage than good. Even professionals make mistakes.

  BTW, I hope no Bob's nor Ron Popeal (owner of Ronco) where hurt or offended during the writing of this post.

  Please correct me if I am wrong.

But this is a force multiplier.
By the time we get knee deep in ventilators, the ventilator problem will be significantly addressed, but probably not solved.  My first choice would be people who already provide ventilator care. EMS and Nursing.  Everyone says, "but they will be busy".  Doing what?  Caring for patients with respiratory illness and respiratory failure. 
There are systemic manifestations but I'll bet the nasty ones, (sepsis, MSOD, encephalitis) ALL show up after the ventilator.  Ask any nurse if the respiratory therapist in their unit provides ALL the respiratory care/services/procedures.  Nurses are already doing it.  Paramedics as well in the field  Diagnosis won't be a snap necessarily, but won't be a mystery either.
There is a whole chain of recruit candidates I would follow before I got to Home Depot Associates.
I just hope that if it is H5N1, it trades some lethality for transmissibility during reassortment or recomumbojumbo.
The Indonesia cases, specifically the ventilator requiring cases have a 100% mortality rate.  This could all be academic.

"Fast isn't important.  You got to be willing"
J.B. Birchfield
The Shootist

Richard Mitchell, RRT-NPS
Dartmouth Hitchcock Medical Center/CHaD

[ Parent ]
I fear you are not kidding

  "The Indonesia cases, specifically the ventilator requiring cases have a 100% mortality rate.  This could all be academic."


  Lets umm, lets still work on a plan should it not be academic or helpful in other emergencies.


[ Parent ]
Interesting question, for sure,
but I think your answers will depend on whether the person believes that in the event of full-blown pandemic any vents will be available - personally, I don't believe that ventilator treatment will be an option.  That makes it hard for me to concentrate on who I think should be providing ventilator support.

suppose you are one
of the lucky/unlucky few who gets put on one. what now?

[ Parent ]
So, supposing . . .
I suppose I'd be perfectly willing to have anybody that knew anything to whatever they thought best.

It's a hard call for me - with chronic medical problems, I know I would be triaged right on out of consideration for vent support, unless I was one of so few survivors at that point that they were willing to waste the resource.

I've had to accept being expendable, and knowing it.

Now, if it were my 30 year old daughter and not me, I know I'd be willing to try anything and everything to save her - although with the potential long term sequelae of such an illness, I am not sure that mere survival will be very desirable.

[ Parent ]
Got Vent?

  Lets say you where one of the few in the hospital and the Pediatrician (only doc available) says you need a vent, it would help. You will most likly not make it without one.

  There are no technicians and the doctor has been called away.

  Would you strap youself in and try to work the machine?

  Would you Google "ventilation tips techniques" for help?

  Could you make it worse with a vent?

  Based on a previous post of 100% mortality with a vent should one try?

P.S. after seeing what sleep aepnea (sp?) folks can go through my hat is off to the will of the human spirit.

[ Parent ]
The slippery slope in a pandemic...
will be more like a greased ski jump! 

Do I like the idea of non-licensed/certified personnel performing critical functions?  NO! 

But, do I think it might be warranted?  YES! 

IMHO, I would rather see a proactive stance taken now, to create a program in which a group of ancillary, support providers would be educated.  The groups to be assisted should be in charge of the training/educating/credentialing. 

Is there a chance that a tight-wad CEO would try and utilize those "emergency" providers now, to short change current providers?  You betcha!  I could almost guarantee it!  But I would not even consider advancing this concept unless there was some effort at providing protection from such an event - perhaps at the federal or state level.  Professional organizations should also weigh in on this subject. 

If the HPAI CFR remains as high as the current stats when  H2H, we will all be glad if there is ANYone in the hospital to even turn the lights on (IF there ARE lights, vents, circuits, endotracheal tubes)!  HCWs will be significantly affected, not only from massive exposure, probable lack of sufficient PPEs, but also from their own family situations. 

The military has always used off-the-bus, brand new recruits to fulfill healthcare jobs.  Whole professions get broken down into 6 week "schools" in which subsets of tasks are taught.  After completion and experience, another school is attended. 

This is not a new concept.  The military already has it down pat.  There is no need to reinvent the wheel.  Investigate their programs and see if it could be adapted on a civilian level.  The big difference now is the litigation potential in the private sector.

As one post commented, training could be in "steps."  There is no need to start a new provider by taking care of a critically ill ventilator patient.  But, instead, start with O2 therapy, respiratory treatments, maintaining supplies, etc.  There will be enough for all to do.

Ya know, I'm not so sure I'd want to be one of the "support" technicians anyway.  They just might be the ones who get all the scut work with high exposure.  And since intubation is one of the most dangerous tasks one can perform in a panflu...hmmmm....

Protection of practice and people
License laws are provided primarily to protect the public, not protect my job.  None the less, most state licenses for respiratory care can only be circumvented by a declaration by the governor or HHS.  I'm not to worried about that aspect.  After the pandemic and things get back to normal, we could always offer "life experience" credit for respiratory care training.

Richard Mitchell, RRT-NPS
Dartmouth Hitchcock Medical Center/CHaD

[ Parent ]
Would a full-face acrylic shield, over an N-95 mask, be good protection during intubation?
If so, the new recruits should acquire them now.

"The truth does not change according to our ability to stomach it."  Flannery O'Connor

[ Parent ]
Protection during procedures
Was referring to laws protecting medical practice and patients, but I would use a PAPR, preferably by 3M

Richard Mitchell, RRT-NPS
Dartmouth Hitchcock Medical Center/CHaD

[ Parent ]
Posted 2/06 on CE, excerpt
..Just recently, we have seen the medical leadership in our country and the world change their position from "get more ventilators" to "we won't have enough ventilators", or people to operate them for that matter. We do still have time to improve those numbers.

A good illustration of one of our problems is the Thompson, M1A1 sub-machine gun. Invented around the time of WWI, it fast became a very effective and highly prized weapon of war. Called the "trench broom", it was very complex, expensive, difficult to build and care for and heavy. The widespread use of the Thompson was due mainly to the fact that it was the only allied sub-machine gun in mass production at the beginning of WWII. It had several weaknesses; e.g. weight and control. Late in WWII, the M3A1, "Grease Gun" was introduced.

The .45 caliber M3/M3A1 was far easier to manufacture than the Thompson, and has a number of excellent design features in addition. The low cyclical rate of fire makes the gun easier to control than most sub-machine guns, not only the Thompson. The weapon's straight line of recoil thrust also adds substantially in controlling the gun in automatic fire. The gun's loose tolerances allow for reliable operation even if very dirty and, with its bolt and guide rod design make it more reliable than the Thompson under adverse conditions. It had a built in oiler and was easy for soldiers to care for.

Necessity is the mother of invention. There is little chance that all the manufacturers of next-level generation ventilators together, could provide enough to meet a pandemic surge. Dr. Osterholm's points are well taken on that. But the alternative of an inexpensive and simple ventilator that could provide 4th generation modes with out 4th generation "AI" is a reasonable approach. These ventilators would require very sophisticated sensors and a very powerful processor. Both would be organic.

The point here is that there are already "Grease Gun" that could be stamped out at a rate to meet the demand.  All vents are pretty much made to order.  We could make enough with the right incentive.

Richard Mitchell, RRT-NPS
Dartmouth Hitchcock Medical Center/CHaD

I think GM could stamp them out

  Good example

  I think once the video and audio portion of the program hit most engineers and line workers could stamp out vents en mass. When people belive they are the heros pay and time fade away.

  Case in point: Liberty ships. 14,245 displacement tons built in 4 days and 15 1/2 hours after the keel was laid. New assembly tecbniques called welding where used. Women entered the all male workforce from bow to stern. Yes the 441 foot long, 56 foot wide ship worked. 

  Question - will GM. GE or even China start stamping out vents before H5N1 gets here?

  Its not just the USA that needs protecting.

  In my opinion - technology and raw materials are not holding us back.


[ Parent ]
If the virus remains fatal? Who keeps the grid up? What are people eating?
Who still has their imported meds? (Who ever got the health care 'families ready for panflu year? Or bought enough hcw PPE?) How are the bodies getting legally death.cert and buried?

Public panflu year awareness and preparation would save more saveable lives than wondering how many cross-trained new RTs can dance on the head of how many yet-to-be-built ventilators.

Extreme societal effort to be able to survive an extreme panflu year is not occurring.
What happened to the ethics of full and fair disclosure?

No one has even demonstrated that they can keep the grid up a few weeks into panflu year.

The virus has shown no signs of dropping in virulence.

We're saying, Boxing Day Tsunami may be coming, you wouldn't put a tsunami warning system in when scientists said you needed one, you wouldn't replant the mangroves, now scientists are recording the 9+ earthquake in progress, at least get a communication out to all radio stations and get villagers and tourists far away from the beaches, but, they're talking about developing a program to JIT-teach lifeguards and laypeople CPR or swimming?
That won't save people when an unprecedentled wave hits.

"Just in time" is Just Not In Time .

What is their point? :-/

Moot debate
Correct me if I'm wrong, but this issue is moot, no?

Even if we had ample respiratory therapists to treat H5N1 patients, we have a critical shortage of actual respirators. That, to the best of my knowledge, is not expected to be remedied. So what's the point of this exercise? Am I missing something here?

Should have said "...actual shortage of ventilators."

[ Parent ]
it's never moot
if you or a family member is the one who might get a vent. And it is never moot for the folks who still need to operate them. They care about this, Edna Mode, and want to think it through.

The big picture (many might not be able to get near a vent) needs to be balanced with the small picture (milder pandemic, severe but we do have 40 vents at this hospital with 40 chances to save a life, need for hospitals to triage their own ICUs despite whatever else is happening, etc).

No one is saying 'this is the answer' they are saying 'this is a way to best use whatever resources we have'.

[ Parent ]
yet not use the big resource of an informed preparing public. n/t

[ Parent ]
Ventilator Shortage
Not really, No.  I have only once, in the last five years, had borrow or rent a ventilator.  We have exactly the number we need.  I have never had to provide protracted, (days), manual ventilation in a normal setting.

My point is, we have the capacity to build many and even with the just-in-time-economy going in the crapper, we will have the capability to build some vents.  Like the models I have alluded to.

As many have pointed out, if needing a vent means dying anyway, I would rather die off than on one.  But if we find out, (and it won't take long to discover), that providing more will save lives.  We can and will make them.

I know I am a little focused on this issue, but I am one of the necessary specialists who will work with other specialists and all the generalists to get this done.  Without fluids, vents will be useless.  Without power and/or oxygen, vents will be useless.  Without people to provide care, vents will be useless. 

Our problem seems to be a lack of confidence rather than a lack of logistic capability.

Richard Mitchell, RRT-NPS
Dartmouth Hitchcock Medical Center/CHaD

[ Parent ]
My 'lack of confidence' stems
from believing that, in the event of a pandemic severe enough to require large numbers of new vents and staff, the power grid will be of limited availability.

When you consider that it is possible that the power grid could go down within a short time of the appearance of pandemic flu, you have to accept that in that situation it wouldn't matter about vents.

I think a lesser pandemic could be best prepared for by increasing the number of vents available as well as staff to treat patients using them.  That just seems obvious.

I just think you have to look at it both ways - all three ways, if you want to add the possibility that as opposed to a severe or a mild pandemic, there's no pandemic at all.  I just pretty much don't bother with that last scenario anymore.

[ Parent ]
how about O2 ?
So, even if you can get all the vents that are needed, where is all the O2 going to come from? Even a huge tank or three will need resupplied, and then all the JIT kicks in. Are the suppliers able to fractionate out what`s needed, and do they have drivers to deliver it, and do they have fuel for those trucks ?
  I guess I`m a big pessimist, I still don`t think we`ll have any kind of funtioning medical care after the first week or two, unless , and that`s a big unless, the current candidate for PI attunates very markedly.
  ARDS and MSOF are a he**ish things to fight, even these days with plenty of supplies,equipment, and personal.

There is no pleasure in having nothing to do; the fun is in having lots to do and not doing it." -Mary Wilson Little

[ Parent ]
we know our state
can't resupply everyone at once, but sometimes you need to plan for something staggered or something smaller than what you're referring to. You really need to try and plan for everything.

Not having anything is actually easier to plan for than having 3 when 500 is needed.

[ Parent ]
O2, No Problem
We'll get Mad Max to drive it here from Australia.  He might be available.  Sorry, couldn't resist that.  Currently, Oxygen is free.  Either afford the industry that makes it Utility Protection or have portable O2 generators stationed at hospitals.  We intend to discuss this issue at the July conference.  The ventilator I have in mind is completely pneumatic, so as long as we have gas or fuel, it will work.  We might see if the Professor has any ideas.  They were rescued off the Island, Right?  Couldn't resist that either.

I believe if I ask this question to non-flubie normals (Muggles), I would get a straight up answer.  In favor or not.  Like asking someone if they would prefer dying by freezing or fire.  One fast and painful, one slow and painless.  But just theoretical.

Everyone here sees the grim realities and counts the bodies in their dreams.  For me, I see a lot of dead right in my face. I have learned to do the math around that in small numbers, but not on a scale like this.

HHS isn't really asking for us to help them plan, but if they ask you, "OK, we came up with Project Extreme, a contingency plan to build emergency ventilators and a way to fractionalized O2 on sight if we can keep some diesel flowing.  What do you think?".  Would we throw up are hands with more questions and say "what's the use?", or would we say, "OK, so far so good, who are you going to recruit, where are these vents being built and with what materials and how much fuel is needed to produce 1 cubic foot of liquid O2?"

Richard Mitchell, RRT-NPS
Dartmouth Hitchcock Medical Center/CHaD

[ Parent ]
I think Mad Max used Nitrus oxide. Cool Car. n/t

[ Parent ]
Cactus, clawdia
Multiple wall or hurdles.

  yes, imho, we will loos parts or all of the power grid - but not power.

  No - hospitals do not have adiquate generators to run the hospital and the AC and the kitches/test equipment.

  No - schools or other places we might put people with vents do not have the power they need.

  Yes this can be fixed.

  Yes I do expect parents to try and bring their generator from home to run the vent.

  Your points are valid and real - the problems are fixable. I do not think technology or the lack of materials is the limiting factor.

  While hand bagging a patient may be a killer - how come there is not a hand pump version of a vent?

  We need solutions for more than just our country.


[ Parent ]
Moot? Yes.
Given the fact that "moot" properly means "open to discussion or debate" then yes, the subject is moot.

[ Parent ]
Moot. Yes II
2 : deprived of practical significance : made abstract or purely academic

[ Parent ]
Moot? D'oh!!!!
If there was ever a totally academic exercise based on much abstraction and little facts, this is it.  I work in an industry where a significant majority of the science and technology is less than 50 years old.  There are roots, but they are distant.  Most every thing we do, we make up as we go along.

Richard Mitchell, RRT-NPS
Dartmouth Hitchcock Medical Center/CHaD

[ Parent ]
Sounds like management where I work!
Most every thing we do, we make up as we go along ;-)

[ Parent ]
Each obstacle in its turn
There will be a severe shortage of mechanical ventilators, qualified staff and necessary parts and supplies.

Various layers of government are working on increasing the supply of mechanical ventilators.

Even without the anticipated high levels of absenteeism (40%+), the increased need will mean increased relative shortage of staff and supplies. 

Supplies can be stockpiled (whether they will be is a different question.)

Staff cannot be bought off the shelf. 

But if lower skill functions can be delegated to emergency (JIT) trainees, it would free up the existing staff to attend to the higher skill/knowledge functions.  Don't put much stock in the supervision, because during the peak there may be little available supervisory capacity.  But when facing the hard reality of no help and poor help, those on the vents might benefit from at least another set of somewhat trained eyes, ears and hands. 

The other thing is that if I think I have something to offer, that my presence might make some difference - I am more likely to be willing to face the increased risk that would come from volunteering.  So some training might mean more hands on deck.  Not perfect, but better than nothing

Which is what most of us will have because under any foreseeable scenario for a severe pandemic, there will not be anywhere near enough staffed and operational vents to handle more than a small portion of those in need.  Will there be any training in back-woods medical approaches for those pandemic victims that are still Just at Home?

ITW(Joel J)
Courage is resistance to fear, mastery of fear - not absence of fear.
- Mark Twain

The Bigger Picture
I see more a quality of life (or end-of-life) issue here.  The statistics are not good for survival of persons who end up on a ventilator.  By placing a person on a vent you'd perhaps be "squeezing a few more hours--perhaps days" survival from them, but will those hours be quality toward recovery or more time suffering by having a tube down your throat and unable to talk to your loved ones during your final moments?  I care for patients on ventilators and see every day what patients and families deal with when a patient is very ill and near end-of-life.  If the inevitable is going to occur, why not consider making time spent quality time for all--patient and familiy?  There are less invasive means of providing oxygen therapy.  Granted, not as controlled and not the absolute maximum, but why try to put everyone on a vent because one is available and personnel available to care for a vent?  Yes, vent use will be triaged.  And I'm not saying that no one should be on a vent.  I'm suggesting we look at not trying to put everyone on a vent and train lay people take care of patients on vents.  I fear it would be disasterous for all involved--the layperson, the patient, and the family left behind.

excellent points
I think it's not lay people, it'd be physician assistants, NICU nurses, (and people like you) etc. who are trained.

and parallel to that the many 'triaging ' plans are under discussion as well.


[ Parent ]
ARDS survivors generally have no chronic lung damage if they escape MSOD, LT steroid use during FP phase, practitioner induced injury.  A good percentage perhaps.  I suppose hoping for the best and planning for the worst leaves us somewhere in the middle.

Richard Mitchell, RRT-NPS
Dartmouth Hitchcock Medical Center/CHaD

[ Parent ]
Think About It
Intubating and placing someone on a ventilator is more than meets the eye.  Having a tube in one's throat is very uncomfortable and it is instinctive to want to pull it out.  Patients who are on ventilators are restrained so that they can't pull the tube, and/or sedated to the point that they don't have the mental and physical capability to pull the tube.  If sedation is used, (and it often is in order to maintain patient comfort while on a ventilator), the person taking care of a vent patient needs to be knowledgeable and vigilant in sedation management which includes being able to safely titrate the medication which can affect blood pressure.  That means checking the blood pressure frequently around the clock.  Since the person is confined to the bed and unable to get out of bed to go to the bathroom or turn oneself, a caregiver has to be atuned to helping that person with their elimination needs while in bed and repositioning the patient to prevent bedsores.  There is also the issue of nutrition and hydration.  The tube down the throat prohibits being able to eat or drink. That means an additional tube down the throat into the stomach for tube feeding.  Providing nutrition this way requires training in assessment and management to make sure the tube remains properly placed (preventing tube feeding from going into the lungs)and knowledgeable of measures to take to make sure the tube feeding is being tolerated.  Again, just a reminder, it's often not possible for the person on the vent to be able to let you know something is wrong--if they are nauseated, feeling too full, having abdominal discomfort, etc.  Yes, hydration can be provided intravenously.  Total nutrition (TPN) can also be provided intravenously, but that has special concerns also.  It generally requires a central line which requires training to manage safely to insure proper placement and prevent complications such as blood infections.  It also requires frequent blood draws/lab samples to monitor blood sugars and electrolyte values and liver function which all can change dramatically and within a short period of time. 

Yes, management of an endotracheal tube and a ventilator machine can be done expeditiously.  It's the ramifications of that tube placement that people need to be aware of.  A caregiver can manage at one time many more non-ventilated patients than ventilated patients.  If all of the above can't be effectively and safely managed, (not mentioning the end-of-life communication and quality time lost discussed earlier), I question expending valuable caregiver time and energy in that direction.

Again, I'm not saying no one should be on a ventilator.  I just feel we need to be judicious in decisions made so as not to stretch resources too far so that no one gets good care.

again, excellent points
this can stretch personnel resources a bit, but not a lot.

[ Parent ]
"A bit"?
I sincerely caution against minimizing the points above.  Ask anyone who has had a loved one on a ventilator in the hospital.  Ask any RN who takes care of a ventilator patient. 

[ Parent ]
I have my own critical care experience
and I agree with you.

[ Parent ]
Glad to have nurses like you
I sure am glad there will be nurses there.  Not only with the depth and experience of years of critical care experience like you obviously have.  But also with the ability to, in the face of overwhelming numbers and shrinking resources, be able to come up with ways to abbreviate BS and maximize effectiveness with the kind of creative "what if" spirit that pervades here.  This group here has always been about finding answers.

Thank You


Richard Mitchell, RRT-NPS
Dartmouth Hitchcock Medical Center/CHaD

[ Parent ]
Please let us know so we can say "we could not provide" instead of "if somone only told us."
Critical Car RN,

  I am sure there is more to this than reading a manual.

  If with all the Kings horses and all the Kings men we can not put Humpty back together again - let us know.

  If with enough rescources of drugs, consumables, people, power, O2, experianced RTs, space, vents and beds it can be done the let us know that.

  Over the years many impossible things have been done.

"If you look at world views over the centuries most of 'what was known or believed as fact' has been disproven one or more times. This is either a very comferting or a deeply distubing fact." - from the book and movie "What the bleep do we know"

[ Parent ]
My Concern Is Not Enough Manpower and Supplies
No one will know until it happens, how short the resources will be.  I only know there currently exists a critical care nurse shortage.  It is occurring today without AI.  I have worked as an RN traveler throughout the US and have seen not only shortage of manpower, but shortage of supplies with normal patient loads.  Nurses will get sick along with the rest of the population.  (In fact, statistics show proportionately much greater numbers due to their exposure to ill populations).  Nurses who take care of ventilator-endotracheal tube patients are at even higher risk because of greater production of aerosolized finer influenza particles while intubated.  Nurses will be afraid to come to work out of fear of infecting not only themselves, but their families. 

Hospital employers need to think of ways to maximize what resources they may have to work with.  Adding patient-care complexity and resource consuming ventilators will not do that.  Focus needs to be on educating nurses (and all staff) about AI.  It must be a mandatory education requirement occurring asap so that personal home preparedness measures can be taken.  Some facilities are planning to declare a pandemic disaster and intend for workers to remain on the premises, housing workers on site.  Child and dependent care provision needs to be considered and some sort of assistance provided.  Mandatory education on CORRECT use of PPE's need to occur.  Nurses need to have the guarantee that adequate PPE's will be available.  Nurses need to have the awareness in advance (to become mentally prepared) that they will probably be working out of their area of expertise.  They will be working much harder and much longer.  There will be some nurses that will decide that a nursing career and taking care of others is not more important than their own life or their family's life. 

We can think as altruistically as we want, that people will step up to the plate and do what is right by showing up to work and placing themselves in potential jeopardy with every ill-patient encounter.  Yes, some will, but some won't, even further exacerbating the problem.

[ Parent ]
And if the PPEs and other supplies were considered
"too expensive" to bother purchasing by the hospitals and they and local and state health officials did not buy antivirals and order pre-pandemic vaccine,
("for something that might not happen, and then, we'd be wrong!") did not warn the public to prepare workable community contingency plans, and just tried to surprise the hospital staff (instead of letting them plan for their families during panflu year) and try ordering them locked down in the hospital,
I think the officials are as much a problem as the virus.

We want experienced hcw alive post-pandemic; we don't want to lose them in the first wave, not to mention the rest of pandemic.

If pandemic comes looking like H5N1 does now in Indonesia or something,
I hope officials won't pretend it is seasonal flu and
throw everyone but themselves under the juggernaught, waiting for it to stop.
(But, hope is not a plan, and a plan is not preparedness.)

[ Parent ]
Prophylactic antivirals
Health care staff have been informed that due to the constant exposure to the virus that we will be experiencing, we will NOT receive prophylactic antiviral coverage, because prophylaxis dosing should occur with each exposure.  This would use up the supply in no time.

HCW's would only receive antiviral treatment should they become ill. 

[ Parent ]
Administrators CEOs and bean-counters can do bedside care themselves.
More expendable. Panflu and other patients triaged as "expected to die" weren't going to take up the skills of the hcw anyway; aren't hcw supposed to be for people that might be able to recover from whatever is wrong with them? ("Managing Mass Medical Care with Scarce Resources")

Constant exposure to the virus currently looks quite fatal, no?

No one has a duty to their employer to be forced into a situation likely to result in death (ok except military; that's their deal) and proper equipment is supposed to be provided responders for their protection.

Show the public how much supplies the hospitals and local and state officials have actually bought - what if pandemic breaks out next week?

[ Parent ]
I'm not surprised.
It's what I've expected, though not seen stated.  I have my doubts that in the event of pandemic there will be antivirals for HCWs for very long.  The supply will be used up in no time anyway - I would favor giving antivirals prophylactically to HCWs as long as they last, simply because it would help to keep HCWs who are willing to work on their feet and working.  In the end, we will run out of Tamiflu not because it was not available, but because it could have been bought and was not. 

I think individuals should have some option available that would allow them to and stockpile Tamiflu, and that certainly health care workers should be encouraged to do so for their own use. I know the obstacles to something like that, but this would be an extraordinary action due to an extraordinary threat. 

I have seen it stated before that it is estimated that 40% of HCWs will not continue to work in the event of pandemic influenza.  I suspect that when all is said and done, that 40% will be too low a figure.

It's already obvious that things like gloves and masks in any health care setting will, at some point, run out.  And then what?  Do they expect HCWs to work without PPE, or do they accept the fact that after a point there will be very little care of any kind available?  I wish we were seeing more stockpiling on an institutional level of PPE, but I think that's another gap yet to be filled.  It's a bad thing to be lacking.

And medicine . . . where will all the needed antibiotics, antipyretics, anti-nausea, anti-diarrheal drugs, and all the chronically needed meds, as well as painkillers and sedatives for palliative care, if nothing else, where will these things come from?  I have yet to hear anyone say that hospitals, clinics, etc., are making any effort to stockpile meds. 

I worry about these things the way some people worry about how many weeks for which to prep, or whether schools will close. 

[ Parent ]
Health care workers...stay home.

Personally, I don't think health care workers should go to work.  If they have had the foresight to prepare to SIP, I think they should take care of themselves and their families the same as the rest of the population. 

We will need health care worker after the pandemic plays out.  Then will be the time to regroup and restore.

Why should people put themselves in harms way for a lost cause?  Especially when the people who are ill became that way because they didn't stay home. 

Yes, I plan to take care of myself and my own...
Everyone should make it their own responsibility and not rely on any system or entity.  Any place where people are congregated for care, whether it be in a hospital or an alternate care setting will likely be a SuperDome/Katrina experience.  My advice is to provide good basic care for yourself and your family and try your hardest to stay out of the healthcare system. 

That's not to say that I won't be going to work.  I will, but not with the cheap N95 masks provided at work that are not adjustable for secure fit.  I will provide my own and will work until my supplies run out.  I will consider everyone in the workplace as a potential virus shedder and wear my mask and gloves at all times. 

I will work and live away from home away from my loved ones as long as they stay well.  I will be my family's miscellaneous supply source person so they do not have to go out and risk exposure.  If family become ill, I will go home to care for them.

If I become ill at work, I will not go home and risk exposure to others.  My plans have yet to evolve how best they should proceed in my complete absence.

I don't have faith in antivirals nor vaccines, as they are today.  Antiviral resistance is already occurring and will continue to evolve as it did with the amantadines, and current vaccine effectiveness is @ 45%--after getting a vaccine in 2 doses 28 days apart.

We must all keep in mind that although the virus is quite lethal, there are people who experience low level illness and survive. We must do what we can to maximize our immune systems and help our body's ability to fight the virus naturally. I am well aware of the cytokine storm that occurs where the immune system goes awry.  I believe that there could be some measures we could take that may help mitigate that reaction.

[ Parent ]
Great Advice!
"My advice is to provide good basic care for yourself and your family and try your hardest to stay out of the healthcare system."

Yes, yes yes!!!!!!!!! Stand on the roof and scream it!

And people should start this NOW! Try your best to stay out of hospitals,rehabs etc. Wash your hands alot and make sure your doctors and nurses do the same. Eat as healthy as you can ,make sure you take care of your teeth and gums (great entryway for germs). The super-bugs are getting stronger not to mention whatever the next pandemic throws at us.

No one can take of yourself like yourself. Strong neighborhoods=strong support sytems. This will 'make or break' us during the next pandemic.

It is better to look ahead and prepare than to look back and regret.

[ Parent ]
CCRN, well said! n/t

Experience has taught me that there are few conspiracies, but much incompetence

[ Parent ]
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