Now the U.S. has lots of ventilators — but too few specialists to operate them
By Andrew Jacobs
As record numbers of coronavirus cases overwhelm hospitals across the United States, there is something strikingly different from the surge that inundated cities last spring: No one is clamoring for ventilators.
The sophisticated breathing machines, used to sustain the most critically ill patients, are far more plentiful than they were eight months ago, when New York, New Jersey and other hard-hit states were desperate to obtain more of the devices, and hospitals were reviewing triage protocols for rationing care. Now many hot spots face a different problem: They have enough ventilators but not nearly enough workers with the years of training to operate them.
Since the spring, U.S. medical device-makers have radically ramped up the country’s ventilator capacity by producing more than 200,000 critical care ventilators, with 155,000 of them going to the Strategic National Stockpile. At the same time, doctors have figured out other ways to deliver oxygen to some patients struggling to breathe — including using inexpensive sleep apnea machines or simple nasal cannulas that force air into the lungs through plastic tubes.
But with new cases approaching 200,000 per day and a flood of patients straining hospitals across the country, public health experts warn that the ample supply of available ventilators may not be enough to save many critically ill patients.
“We’re now at a dangerous precipice,” said Dr. Lewis Kaplan, president of the Society of Critical Care Medicine. Ventilators, he said, are exceptionally complex machines that require expertise and constant monitoring for the weeks or even months patients are tethered to them. The explosion of cases in rural parts of Idaho, Ohio, South Dakota and other states has prompted local hospitals that lack such experts on staff to send patients to cities and regional medical centers, but those intensive care beds are quickly filling up.
Public health experts have long warned about a shortage of critical care doctors, known as intensivists, a specialty that generally requires an additional two years of medical training. There are 37,400 intensivists in the United States, according to the American Hospital Association, but nearly half of the country’s acute care hospitals do not have any on staff, and many of those hospitals are in rural areas increasingly overwhelmed by the coronavirus.
“We can’t manufacture doctors and nurses in the same way we can manufacture ventilators,” said Dr. Eric Toner, an emergency room doctor and senior scholar at the Johns Hopkins Center for Health Security. “And you can’t teach someone overnight the right settings and buttons to push on a ventilator for patients who have a disease they have never seen before. The most realistic thing we can do in the short run is to reduce the impact on hospitals, and that means wearing masks and avoiding crowded spaces so we can flatten the curve of new infections.”
Medical association message boards in states like Iowa, Oklahoma and North Dakota are awash in desperate calls for intensivists and pulmonologists willing to temporarily relocate and help out. When New York City and hospitals in the Northeast issued a similar call for help this past spring, specialists from the South and Midwest rushed there, but because cases now are surging nationwide, hospital officials say that most of their pleas for help are going unanswered.
Dr. Thomas Dobbs, the top health official in Mississippi, said more than half the state’s 1,048 ventilators were still available but that he was more concerned with having enough staff members to take care of the sickest patients.
“If we want to make sure that someone who’s hospitalized in the ICU with the coronavirus has the best chance to get well, they need to have highly trained personnel, and that cannot be flexed up rapidly,” he said in a news briefing Tuesday.
Dr. Matthew Trump, a critical care specialist at UnityPoint Health in Des Moines, Iowa, said the health chain’s 21 hospitals had an adequate supply of ventilators for now, but he is worried that out-of-state staff reinforcements might be unlikely to materialize as colleagues fall ill and the hospital’s ICU beds reach capacity.
“People here are exhausted and burned out from the past few months,” he said. “I’m really concerned.”
The domestic boom in ventilator production has been a rare bright spot in the country’s pandemic response, which has been marred by shortages of personal protective equipment, haphazard testing efforts and President Donald Trump’s mixed messaging on the importance of masks, social distancing and other measures that can dent the spread of new infections.
Despite an overall increase in the number of ventilators, some researchers say many of the new machines may be inadequate for the current crisis. Dr. Richard Branson, an expert on mechanical ventilation at the University of Cincinnati College of Medicine and an author of a recent study in the journal Chest, said that half of the new devices acquired by the Strategic National Stockpile were not sophisticated enough for COVID-19 patients in severe respiratory distress. He also expressed concern about the long-term viability of machines that require frequent maintenance.
“These devices were not built to be stockpiled,” he said.
The Department of Health and Human Services, which has acknowledged the limitations of its newly acquired ventilators, said the stockpile — nine times as large as it was in March — was well suited for most respiratory pandemics. “These stockpiled devices can be used as a short-term, stopgap buffer when the immediate commercial supply is not sufficient or available,” the agency said in a statement.
Dr. Nikhil Jagan, a critical care pulmonologist at CHI Health, a hospital chain that serves Iowa, Kansas and Nebraska said many of the coronavirus patients who were arriving at his emergency room now were less sick than the patients he treated in the spring.
“There’s a lot more awareness about the symptoms of COVID-19,” he said. “The first go-around, when people came in, they were very sick right off the bat and in respiratory distress or at the point of respiratory failure, and had to be intubated.”
But the promising new treatments and enhanced knowledge can only go so far should the current surge in cases continue unabated. The country passed 250,000 deaths from the coronavirus Nov. 18, a reminder that many critically ill patients do not survive. The daily death toll has been rising steadily and is approaching 2,000.
“Ventilators are important in critical care, but they don’t save people’s lives,” said Branson of the University of Cincinnati. “They just keep people alive while the people caring for them can figure out what’s wrong and fix the problem, and at the moment, we just don’t have enough of those people.”
For now, he said there was only one way out the crisis: “It’s not that hard,” he said. “Wear a mask.”