New York Times Talks Ventilators

Dr. David Sunwall, Director of the Utah Health Department, notified my Father and I about a great Article in the New York Times "Hospitals Short on Ventilators if Bird Flu Hits ." This article addresses the problem of a ventilator shortage during a pandemic and his numbers agree well with our estimates. The article mentions the Vortran Automatic Resuscitator as a cheap and efficient example of a vent that could be stockpiled and used during a disaster or pandemic (http://www.vortran.com/automatic-resuscitator.htm). This vent is purely pressure controlled and seems to operate akin to the magnet and bobbin "minivent" described in Anesthesia ( Cohen AD, The minivent respirator. Anesthesia. 1966 Oct; 21(4):563-8). The vent doesn't generate the optimal pressure/volume curve for ARDS, but hey, it only cost 50$.

The article also points out that even if we had all the necessary vents, we wouldn't have enough people to monitor them. One idea to remedy that would be to include ventilator theory and operation as part of Advanced Disaster, Cardiac, and Trauma Life Support curriculums. Also, Basic courses should also include vent theory as they do Automatic Cardiac Deffibrillator (ACD) operation.

This article also corrects my last email. The Strategic National Stockpile has 4,000-5,000 vents total, and not per cache. I support additional research in feasibility of using such a emergency vent for a pandemic scenario as well as investing money in stockpiling such devices.

Local versus Global Disaster Preparation

Now, more than ever before we face the possibility of natural or man-made disasters. Natural disasters come in the form of tsunami, asteroid impacts, earthquake, volcano, and hurricane. Man-made disasters include nuclear detonation and bioterrorism. There are also disasters that are a result of natural and man-made influences such as a dam break or forest fire. Local and national governments plan and prepare for disaster but their preparation does not supplant individual and family preparedness. It is the duty of every individual to be prepared for difficult times.

In addition to dividing disasters into natural vs. Man-made, it is more useful to define disasters in terms of their range of influence; such as individual, local, regional, and global. Similar principles of preparedness are applicable to each type, but each requires are different type of preparedness.

The most important aspect of any type of preparedness, whether individual or global, is spiritual preparation. If you feel your life is in-line with the will of God then you will be prepared for any eventuality. The scriptures promise, "If ye are [spiritually] prepared, ye shall not fear."

Individual Disasters can include lost work, disability, death of a loved one, or home fire. It is important to save, get out of debt, and have a strong social support network as well as an array of coping mechanisms. Disasters are stressful and those who deal best with stress can deal with it through exercise, sports, music, or humor. Other characteristics of people who successfully weather adversity include being adaptable, creative, and optimistic. These people make lemonade out of lemons and see the silver lining around even the darkest cloud.

Local and national government have done well preparing for and responding to local disasters such as earthquake and flood. Hurricane Katrina was actually a regional disaster involving 4 US states and exceeded the US's ability to respond. Therefore, it was a true disaster by definition. That said, many other disasters such as earthquake or forest fire are more local in extent. Therefore, local and national governments have the resources to respond in a timely manner. However, even the most timely response, aide may not reach you for up to 72 hours. So, the best preparation for a local catastrophe is a 72-hour kit.

A 72-hour kit is placed in 2-3 duffle bags or backpacks that can be picked up and carried at a moments notice. It should contain food, water purification, medical essentials, radio, and other essentials for keeping warm and dry for 3 days until outside help can arrive. It is also important to bring important papers with you such as title to home, cars, etc.

Regional and global catastrophes are true disasters. These have such a wide area of effect that no government could adequately prepare. That said, individuals can effectively and economically prepare for these broader threats. Such disasters may not directly cause harm but have such broad effects generally that there are disruptions of transportation, utilities, and the economy. In such instances, having a supply of food stuffs to preserve life for 1 year is the best manner of preparation. This involves the storage of commodities such as wheat, beans, rice, oil, sugar, powdered milk, and medicines. Stockpiling canned food is very inefficient. Canned food is mostly water. Dry-pack storage of wheat, beans, rice is the most economical, efficient, and effective way to store food. To learn how to create an emergency food storage go to http://www.providentliving.org/ and http://www.emergencyessentials.com/.

How to Survive the H5N1 Avian Flu Pandemic

There is something everyone can do to prepare for the H5N1 avian flu pandemic. You don't need a vaccine. You don't need Tamiflu. Protection is as easy as self-quarantine. You lock yourself in your home, you don't visit, you don't have visitors. According to the lastest H5N1 avian flu pandemic poll conducted by Harvard, this is exactly what Americans plan on doing. However, this means you can't visit the grocery store or the hospital. So, your family must have commodities such as wheat, beans, rice, oil, sugar, powdered milk, and medicines, to keep you alive for at least 3 months. Stockpiling canned food is very inefficent. Canned food is mostly water. Storage of dry wheat, beans, rice is the most economical, efficient, and effective way to stockpile. To learn how to create an emergency food storage for the H5N1 avian flu pandemic go to http://www.providentliving.org/ and http://www.emergencyessentials.com/.
http://avianpandemicflu.blogspot.com/

Top 10 US Disaster Threats

10. Pacific Northwest Megathrust Earthquake. Geologists know it’s just a matter of time before another 9.0 or larger earthquake strikes somewhere between Northern California and Canada. The shaking would be locally catastrophic, but the biggest threat is the tsunami that would ensue from a fault line that’s seismically identical to the one that caused the deadly 2004 tsunami in Indonesia.
9. New York Hurricane. Major hurricanes have made direct hits on the boroughs before, but the interval between them is so long that people forget, and officials fear they might not take evacuation orders seriously. The larger problem: It would take nearly 24 hours to make a proper evacuation of New York City, but hurricanes move more swiftly as they race north, so real warning time could be just a few hours.
8. Asteroid Impact. Scientists can’t say when the next devastating asteroid impact will occur. Odds are it won’t be for decades or centuries, but an unknown space rock could make a sucker punch any time. Many experts say planning to deal with a continent-wide catastrophe should begin now.
7. Los Angeles Tsunami. An earthquake fault just off Southern California could generate a major quake and a $42 billion tsunami that would strike so fast many coastal residents would not have time to escape. Add to that the unprecedented destruction from the earthquake’s shaking, and the situation would be reminiscent of Hurricane Katrina.
6. Supervolcano. It probably won’t happen for hundreds or possibly even millions of years, but nobody really knows when Yellowstone will blow again, destroying life for hundreds of miles around and burying half the country in ash up to 3 feet (1 meter) deep.
5. Midwest Earthquake. It has been nearly two centuries since a series of three magnitude-8 quakes shook the then-sparsely populated Midwest, centered near New Madrid, Missouri. Another big one is inevitable. Now the region is heavily populated, yet building codes are generally not up to earthquake snuff. What’s more, geology east of the Rockies causes quakes to be felt across a much wider region. Shelves would rattle from Boston to South Carolina. Some homes along the Mississippi would sink into oblivion.
4. Heat Waves. Heat waves kill more U.S. residents than any other natural disaster. As many as 10,000 people have died in past events. As urban areas get hotter, electricity systems are strained and the population ages, the risk grows.
3. East Coast Tsunami. It seems no coast is immune to the threat of tsunami. For the Eastern United States, the likeliest scenario is waves kicked up by an asteroid splashing into the ocean. Astronomers already have their eye on one rock that could hit in the distant future, but the cosmos could hold a surprise, too.
2. Gulf Coast Tsunami. A fault line in the Caribbean has generated deadly tsunamis before. Up to 35 million people could be threatened by one in the not-to-distant future, scientists say.
1. Total Destruction of Earth. Okay, so nobody is spending too much time worrying about what to do if the planet is annihilated, but at least one person has seriously pondered whether and when it could happen. From being sucked into a black hole to being blown up by an antimatter reaction, there are scientifically plausible risks of an event that would render this whole list moot.
http://www.livescience.com/forcesofnature/top10_naturaldisasterthreats_us.html

Strategic National Stockpile

Dr. Phillip Coule, director of the MCG Center of Operational Medicine reported today that each strategic national stockpile (SNS) cache will contain 2-5,000 univents/minivents as well as antibiotics and other medications. These ventilators will be available to treat victims of the impending H5N1 avian flu pandemic. I am pleased that the Department of Health and Human Services is taking such steps in preparing our country for any eventuality. Ofcourse, this news does not supplant individual and local preparation for the H5N1 avian flu pandemic. http://www.mcg.edu/news/2005NewsRel/Stories/DisasterPrep091305.html

How to Survive the H5N1 Avian Flu Pandemic

There is something everyone can do to prepare for the H5N1 avian flu pandemic. You don't need a vaccine. You don't need Tamiflu. Protection is as easy as self-quarantine. You lock yourself in your home, you don't visit, you don't have visitors. According to the lastest H5N1 avian flu pandemic poll conducted by Harvard, this is exactly what Americans plan on doing. However, this means you can't visit the grocery store or the hospital. So, your family must have commodities such as wheat, beans, rice, oil, sugar, powdered milk, and medicines, to keep you alive for at least 3 months. Stockpiling canned food is very inefficent. Canned food is mostly water. Storage of dry wheat, beans, rice is the most economical, efficient, and effective way to stockpile. To learn how to create an emergency food storage for the H5N1 avian flu pandemic go to http://www.providentliving.org and http://www.emergencyessentials.com.

Worst-Case Scenario for H5N1 Avian Pandemic Flu

During Hurricane Katrina we witnessed how vulnerable the US is to disasters. New Orleans was a scenes of mass hysteria. The health system was also grossly ill-prepared. Hundreds of patients in skilled nursing facilities were left behind to die. Charity Hospital was a nightmare. Short-staffed, no power, no food, no medicine. Staff hand-ventilated critically ill patients hour-after-hour, day-after-day; with the hope, "they are coming to save us." But noone came.
After 5 days without rescue, hospital staff became exhausted, hopeless, and disheartened. Such severe physical duress and emotional torment can only be paralleled to that which was experienced by the Donner party. And in the moment of dark desperation a few could not squeeze the Ambu bag any more and resorted to euthanasia. I do not condemn but mourn.

During a severe H5N1 avain flu pandemic there will be massive disruptions of transportation, economy, and utilities. The first pandemic wave will last 6 weeks. At its peak, a hundred thousand US citizens could die in one day. The supermarket shelves will be stripped bare in a few hours of the first day. As the pandemic rages on and the food runs out, I can't imagine the acts of desperation that will transpire. The hospital can run up to a week without resupply and less without power. There will not be any vaccine, there will not be any Tamiflu (not that it helps anyways), there will be no ventilators, there is no treatment. The nightmare of New Orleans and Charity Hospital will flood over every city and hospital across the country and across the world.

Beware of the belief that because we are so technologically advanced that we won't fair as poorly as they did in 1918. The US may be the only world superpower, but we as Americans are weak. We are so much less self-sufficient and less independent than 1918. With NAFTA and World Trade, we import our food from Brazil and Mexico and our N95 masks from Taiwan. In 1918 food was locally grown and harvested. Americans knew how to cultivate a garden, how to save, how to rashion, and how to make due. We are emotionally weak. In 1918, women died in childbirth, and babies died in infancy. All Americans in 1918 knew how to deal with loss. Today, we cannot emotionally manage the loss of a few who volunteer their lives for their country and to pay the price of freedom for their brothers. Even if the eventual H5N1 avian pandemic flu virus isn't as virulent as in 1918, we will fare much worse.

Avian Flu to Pandemic

The current H5N1 avian flu strain spreads primarily via the GI tract. This is why is doesn't spread efficiently person to person. People who come into close contact with chickens and their "dropping" are at the greatest risk to contract the disease. After contracting the virus, the immune system "overreacts" to the virus which result in multi-organ failure. While seasonal flu targets infants and the elderly with weak immune systems, pandemic flu kills healthy young people with strong immunity.

Researchers are currently studying the evolution of H5N1 avian flu to see what changes are necessary to cause it to be efficently spread human to human. Studying the latest cases in Turkey show that these changes are happening before our eyes. First the virus is obtaining mutations which allow it to replicate at cooler temperatures, such as those found in the human respiratory tract. Sequence of virus isolated from victims in Turkey also show new mutations which allow more efficent binding of the virus to cell receptors in lung tissue. It is this conversion from GI to respiratory that will allow efficent human to humanspread. The flu virus will increase in communicability by specializing on attacking lung tissue and then be transmissible by droplet rather than by fecal-oral route. Other similar mutations will result in the impending pandemic.

When this specialization occurs, the virus will cause overwelming damage to lung tissue. Victims will suffer respiratory failure and require mechanical ventillation or die. Even with mechanical ventillation, victims will develop ARDS (acute respiratory distress syndrome). No one really understands the cause of this syndrome. But we do know that 50% of ARDS patients die inspite of being on a vent. Without mechanical ventillation, death rates will be far worse. In spite of the perfect cell-based vaccine, a mountain of Tamiflu, we are going to need hundreds of thousands more ventillators than we currently have and could hope to produce. Could there be a way to "Macgyver" a ventillator out of common hospital supplies, wall suction, air, O2, PleuraVac and what is known as a PEEP valve. If we could come up with a cheep alternative to the expensive ventillator machines, potentially hundreds of thousands of lives could be saved from H5N1 avian flu pandemic.

"MacGyver'ed" Ventilators?

During a moderate to severe flu pandemic or other respiratory virus, there will be a critical shortage of ventilators. Due to labor shortages, it will be impossible to hand bag-ventilate all patients who require ventilator support. Ventilators are very complex and expensive machines. Therefore, It is not practical to stockpile such equipment. However, if a simple unit could be developed or instructions drawn up for a simple and cheap (plastic and tubes) vent device, it may be practical to produce and stockpile them or construct them using stockpiled components. Also, there may be alternative ways to automatically assist with ventilation on a large scale.

Ventilator Schematic

Focus on Pandemic Flu Treatment

The Department of Health and Human Services (HHS) has taken the lead in preparing the country for a potential pandemic. HHS goals include: tracking the global spread of the H5N1 influenza virus, early human detection, assisting with local preparation, increasing stockpiles of antiviral drugs, developing vaccines against potential pandemic virus strains, and enhance domestic vaccine production capacity.1 These goals illustrate HHS focus on early detection, containment, and prevention. However, in addition to these goals, a comprehensive plan should also include preparation for the grave complications associated with influenza infection.

During a moderate to severe flu pandemic, an estimated 20-50 % or 60-150 million people in the US would become infected. 1-10 % or 3-30 million would die from Acute Respiratory Distress Syndrome (ARDS). ARDS was and will be the most common complication and cause of death in pandemic flu patients. The 3-30 million expected to die will be in need of positive pressure ventilation. Sadly, the US only has 100,000 ventilators.2 ARDS is a deadly respiratory complication of pneumonia resulting in 50 % mortality with mechanical ventilation and 100 % mortality without it. That said; if ventilators could be provided to all 3-30 million people who would develop ARDS, 1.5-15 million lives could potentially be saved.

Stockpiling modern ventilators is an impossible proposition. Vents average between $10-50,000 each and are complex mechanical and electronic machinery.3 Although ventilators are complex, the functions of oxygenating and ventilating a patient are simpler processes that can be performed short-term with a bag and mask. The challenge is automating these processes.

Very little research has been done to address disaster-associated ventilator shortages. A PubMed search produced one article published in 1994 in Critical Care Medicine. This research group recognizes the inadequate surge capacity of the US healthcare system during catastrophes because of the lack of ventilators. Accordingly, they illustrate 2 novel ideas to mechanically ventilate multiple patients using one ventilator.4 Simple ideas like this could make a significant impact during a pandemic.

Aspects of additional research should involve a comprehensive literature search, and design and testing of simple ultra-cheap ventilator systems. These “mini-vents” could be more practically and economically mass-produced and stockpiled. Also, plans to “MacGyver” a ventilator using common “off-the-shelf” hospital and hardware store equipment could also be developed and tested.

One exciting idea involves an alternative form of mechanical ventilation used in very premature babies in the NICU called High Frequency Oscillatory Ventilation (HFOV).5 It turns out that portable ball/tire pumps work about the same as these HFOV machines but cost between $10-50 instead of $10-50,000. If proven feasible after testing, units could be stockpiled at a cost of $10/unit. Additional units could be procured by utilizing available stock at local hardware stores as needed. This idea could prove a substantial value in comparison to Tamiflu with costs $8/pill.

In association with mechanical ventilation, it is the generally accepted that patients who are expected to be mechanically ventilated for long periods of time such as is required to recover from ARDS, do better with a tracheotomy (tube in neck) rather than being intubated (tube in mouth). Also, tracheostomy tubes are associated with less ventilator-associated pneumonia (VAP). Patients who receive HFOV must be paralyzed and sedated. Paralytic medications, tracheostomy tubes, pressurized oxygen and broad-spectrum antibiotics to treat VAP will be in short supply and must also be stockpiled.

In addition to its current goals, HHS must focus on resolving the impending pandemic-associated ventilator shortage as well as develop goals to treat victims of pandemic flu as a part of its comprehensive plan. If a simple alternative to modern ventilators could be found, it could result in the biggest mortality benefit to those who will eventually become stricken with this deadly disease. These ideas could also be utilized in other disaster scenarios such as natural disaster, bioterrorism attack with nerve agent, and major industrial accidents.

1. News Release, Secretary Michael O. Leavitt, Department of Health and Human Services, Thursday, Jan. 5, 2006. http://www.hhs.gov/news/press/2006pres/20060105a.html

2. Osterholm, MT. Preparing for the Next Pandemic, NEJM. May, 2005 352:1839-1842.

3. Blanch, PB. An Evaluation of Ventilator Reliability, Respiratory Care. August 2001.
http://www.rcjournal.com/contents/08.01/08.01.0789.asp

4. Sommer DD, Improvised automatic lung ventilation for unanticipated emergencies. Crit Care Med. 1994 Apr;22(4):705-9.

5. Ritacca et al. Clinical review: High-frequency oscillatory ventilation in adults. Critical Care. 2003, 7:385-390.
http://ccforum.com/content/7/5/385

Critical Ventilator Shortage

The last couple months I have been participating with the development of our hospital's pandemic flu plan in compliance with recommendations by the Department of Health and Human Services. Among other issues, we discussed a critical ventilator shortage in even a mild pandemic. Restating the problem: the US has 100,000 vents, and the flu pandemic could produce 3 million or more vent-dependent patients. Since our meeting I have been researching simple vent designs which could be cheaply produced and stockpiled or "MacGyver'ed" from components found at a hardware store and in the hospital. So far we have been discussing:

Emerson ventilator http://www.jhemerson.com/pdfs/Branson%20-%20A%20tribute%20to%20John%20H%20Emerson%20
Bird mini-ventilator (Percussionaire/Oscillitron)http://www14.inetba.com/percussionaire/oscillitronpage.htm
Multiple people on single vent
Sommer DD, Improvised automatic lung ventilation for unanticipated emergencies. Crit Care Med. 1994 Apr;22(4):705-http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8143481&query_hl=3&itool=pubmed_docsum
Magnet and Bobbin MiniventCohen AD, The minivent respirator. Anaesthesia. 1966 Oct; 21(4):563-8.
HFOV using modified portable air compressor
HFOV using modified oil vs diphragm air compressor
HFOV using modified shop vac or other vacuum
HFPPV using modified shop vac or other vacuum
HFJV using modified portable air compressor

Treatment for Pandemic Flu

http://www.medpagetoday.com/InfectiousDisease/URItheFlu/tb/2774 reviews info about using the chemotherapy drug etoposide as a treatment for pandemic flu. This drug is already effective for treatment of hemophagocytic lymphohistiocytosis (HLH), a disease which is a result of the over-reatction of the bodies immune system to EBV. Etoposide is human Cipro, targeting topoisomerase. It seems that young adults who die of H5N1 look exactly like young adults with HLH. This means it will be more important to have vents available so that victims of pandemic flu can get this medicine and recover.

Flu Pandemic Severe-Case Estimates:

1918 "Spanish" Flu
World Population = 1.8 Billion
US Population = 100 Million
Attack Rate = 20%
World Infected = 360 Million
US Infected = 20 Million
Death Rate = 1%
World Deaths = 20 Million
US Deaths = 675,000

2006 Flu Pandemic
World Population = 6.5 Billion
US Population = 300 Million
Attack Rate = 20%
World Infected = 1.3 Billion
US Infected = 60 Million
Death Rate = 1%
World Deaths = 65 Million
US Deaths = 3 Million
World Ventilators = 100,000
US Ventilators = 100,000