Bioethics Discussion Blog: The Influenza Pandemic Has Arrived But There Are Not Enough Ventilator Machines!

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Tuesday, March 18, 2008

The Influenza Pandemic Has Arrived But There Are Not Enough Ventilator Machines!

The news of the outbreak of flu at first came in little spurts from various communities across the United States. And there was bad news with each bulletin; patients were dying from the flu… a whole lot of the patients who were sick. The government labs then came out with the news that the sickness was due to a particularly virulent strain of influenza virus. We had all known that this might happen and now everyday came the news that the sickness had spread across the country to little towns and big cities and the influenza sickness was everywhere. The patients, many of whom were previously healthy, were developing pneumonia and becoming short of breath and would quickly die if they were not put on the ventilator to allow them to breathe. Even then, many died because of other organs that failed including the heart. More sickness and more deaths and there was no dramatic medication avilable to abruptly cure the illness. But it became obvious that some patients supported by the ventilator machine could be kept alive long enough for their own body defense mechanisms and other supportive treatments would allow them to survive the illness.

Unfortunately, by now, so many patients were sick, couldn’t breathe and had to be put on a ventilator but there were far too many patients who needed the ventilator than the number of ventilators available. How and to whom should the ventilators be allocated?

This is only one of the issues that will appear when a serious influenza pandemic strikes our country or other countries throughout the world. It is wise, therefore, to be proactive and plan ahead for the day when the deadly flu arrives. Planning, of course should be done by the appropriate governmental agencies but also there are reasons why these plans should be devised by input from the public. That is because, decision about how to set up the triage of patients involves issues which are less medical or clinical but are actually societal.

If patients are found clinically to need the ventilator to survive, to whom should the ventilator be given? Only to the young? Would there be a cut off age? Only to the previously healthy and how healthy? Should leaders of elected government be given priority? Should those in prison be ignored? Should the poor be given first chance at a machine? Should sick healthcare workers and emergency first responders who are most needed to care for others and are at greater risk be given first chance at a ventilator? Who are the ones most needed? Are they the doctors? the nurses? the respiratory therapists who operate the ventilators or who else and in what order? If someone is on the ventilator, at what point should the patient be taken off and another patient allowed to use the machine? Patients who had chronic lung problems and were already on a ventilator at the time of the epidemic, should they be allowed to continue use or should they be taken off and the machine used for an acutely ill flu patient? All of these questions and more need the public input. As I already noted, the issue involving the limited number of ventilators available is only one concern in a pandemic. Others would include isolation of the infected, where patients should be treated if all hospital beds are taken and many issues of the management of education, business, economy, government including other issues of public safety.

It is not too early to start a discussion by the public on these questions. For the present, on this blog, let’s discuss the ethical allocation of ventilator machines. ..Maurice.

1 Comments:

At Wednesday, March 26, 2008 7:11:00 AM, Blogger Dreamer said...

A lot of pandemic plans already incorporate a triage triage protocol, and lay out the guidelines pretty explicitly. The one I am most familiar with is the Ontario Health Plan for an Influenza Pandemic. I did a review of it on my blog recently (http://panvent.blogspot.com/2008/02/review-of-ontario-health-plan-for.html)
There are links to the plan there and others as well. I do not have a fundamental objection to the ethics of these triage plans as they are written. They nearly all use the same fundamental formula of trying to do the most good for the most people with the limited resources available. Other goals are to be as fair as possible and to avoid some forms of discrimination. Some plans do allow for discrimination based on other medical conditions. Some take age into account and others do not.

Now when you are stuck in a bad situation with limited resources, I think it is fundamentally ethical to triage the resources in this manner. In fact, I think it would be unethical not to. The thing is, if you suspect ahead of time that this shortage may develop, you must also do everything that is reasonably possible to alleviate that shortage as well. In the case of ventilators, I do not believe this is being done. Every time this issue comes up, I hear the same story, "there will be a massive shortage, we need more ventilators, they are too expensive so nobody buys them".

Usually we cannot rely on governments and bureaucracies to properly plan and prepare for high impact but low (in the immediate term) probability events such as a pandemic (or New Orleans flooding). It does not have a good political payback. My solution is a more grassroots approach.

During the polio epidemic, ordinary people built ventilators to save the lives of children afflicted with paralysis to save those lives when they ran out of commercially made iron lungs. Popular Mechanics even published plans to build them in their edition of January 1952. Modern ventilators may seem to be incredibly complex devices, but to an engineer they are just a collection of valves, sensors and a control system. Even commercially made ventilators from 1952 had very basic control systems. In 2008 we can use a modern industrial controller (PLC) to control ordinary valves, and construct a ventilator that is reliable and can perform many of the functions with the safety alarm systems that many commercially available ventilators have. Most of the hard stuff is in the software that is easily and cheaply reproduced once it is developed.

The Pandemic Ventilator Project (www.panvent.blogspot.com) is working on a design that will allow people to build ventilators even after a pandemic begins using PLCs, ordinary solenoid valves, piping and plastic bags. Please have a look at the site.

The ventilator shortage situation has not fundamentally changed in the last 2 years. There was a shortage then, there is a shortage now. I think my project is a rational way to at least partially solve this problem. It is however, small, unfunded, and little known. It has not gotten the attention of any of the major planning groups.

 

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