Ventilators are only part of the story: We need critical care trained practitioners

The media and policymakers have spent a lot of time focusing on the shortage of ventilators in the country. Elmhurst Hospital in Queens – one of the hardest-hit locations in the country, and where I work – received a donation of 40 desperately needed machines from Tesla a couple of weeks ago. There was a brief moment to rejoice before putting these to use.

Healthcare workers and the general public alike are gripped by the imagery of having to decide who gets a ventilator and who doesn’t. But the equipment is only part of the story. We need critical care trained physicians, nurses, and respiratory therapists to manage the patients once they are placed on these machines, and we need them in large numbers.

Mechanical ventilation can save lives, but it can also cause serious harm. It requires knowledge of complex respiratory physiology, close nursing supervision of sedation levels and medication drips, and respiratory therapy monitoring of vent parameters and blood gases. When ventilators are mismanaged, they can be set to deliver air pressures that cause further injury to patients’ lungs; when sedation levels are not closely monitored, patients can become agitated to the point of traumatically removing their breathing tubes prematurely. In short, without appropriate infrastructure, staffing ratios, and expertise, there is likely to be iatrogenesis in large quantities.

According to a recent study, only about half of US hospitals had even a single intensivist on their staff; this is in line with the number of hospitals that are able to deliver ICU level care. Even major academic medical centers have critical ICU bed shortages and are being forced to rapidly upgrade ill-equipped wards.

And it should be noted, that of the estimated 200,000 ventilators in our national supply, approximately 30% are full-featured, while the rest are either older models or non-traditionally used machines. These require even more specialized knowledge, or years of experience, to manage and troubleshoot. It is not just a matter of calling upon any licensed clinician.

What then is there to do? In a perfect world, a city or a state would be able to look at the sum total of its resources and the sum total of its need and allocate accordingly. There should never be a ventilator in storage or a critical care practitioner at home when there is a patient in need. This is the goal behind Governor Cuomo’s recently announced Central Coordinating Team here in New York.

Alas, our healthcare system is fractured. Fear fuels an isolationist mentality – a line you probably hear around many hospitals right now is that where Elmhurst is today we may be in a week. This drives bigger systems, with a relative surplus of critical care staff, to hang on to what they have, even when their neighbor is already in crisis. They, understandably, want to make sure that they not only have adequate active staff, but also a reliable pool of backup when the front line inevitably falls ill. But the smaller, poorly resourced hospitals don’t even have adequate staffing for an active front line.

The most straightforward recommendation is that these hospitals will need to get their practitioners up to speed, and quickly. There simply isn’t enough time to churn out fully trained intensivists or critical care nurses. Hospitals will need to deliver focused crash courses on ventilator management, as well as the basic tenets and protocols in appropriately treating acute respiratory distress syndrome. This should include broadening nursing competencies and scope of practice to allow for complete guideline-based management. Experienced and well resourced critical care departments around the country can help develop these focused curricula.

But fear, if channeled the right way, can also fuel cooperation. Telemedicine, including tele-ICU care, has been elevated from the new kid on the block to a major mode of care delivery in these last few weeks. One of the advantages of different regions of the country peaking at different times, is that while some critical care departments are burdened, others are waiting, and it is in their interest to gain experience with this new virus, even if remotely, before the tidal wave hits. Once hard-hit regions like New York and Seattle peak and begin to recover, they can leverage their experience and return the favor.

One way or another, we need to find a way to match the machinery with the appropriate know-how. Until we do so, all the ventilators in the world won’t save us.

Eric Bressman is an internal medicine chief resident who blogs at Insights on Residency Training, a part of NEJM Journal Watch.

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