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| ‘The Other Option Is Death’: New York Starts Sharing of Ventilators | ‘The Other Option Is Death’: New York Starts Sharing of Ventilators |
| (3 days later) | |
| A New York hospital system has begun treating two patients instead of one on some ventilators, a desperate measure that could help alleviate a shortage of the critical breathing machines and help hospitals around the country respond to the surge of coronavirus patients expected in the coming weeks. | A New York hospital system has begun treating two patients instead of one on some ventilators, a desperate measure that could help alleviate a shortage of the critical breathing machines and help hospitals around the country respond to the surge of coronavirus patients expected in the coming weeks. |
| NewYork-Presbyterian Hospital, began “ventilator sharing” this week, said Dr. Laureen Hill, chief operating officer at the Presbyterian/Columbia University Irving Medical Center system. Doctors have developed protocols for the maneuver and now are rapidly scaling it up while also sharing their methods with the federal and state governments and other hospitals. | NewYork-Presbyterian Hospital, began “ventilator sharing” this week, said Dr. Laureen Hill, chief operating officer at the Presbyterian/Columbia University Irving Medical Center system. Doctors have developed protocols for the maneuver and now are rapidly scaling it up while also sharing their methods with the federal and state governments and other hospitals. |
| Ventilator sharing has been explored in a few scientific studies and has been used twice in crisis situations — the immediate aftermath of the 2017 Las Vegas shooting and, as of several days ago, by an emergency physician, Dr. Marco Garrone, for coronavirus patients in Italy. This is believed to be the first time that it has been put forth as a longer-term strategy in the United States. | Ventilator sharing has been explored in a few scientific studies and has been used twice in crisis situations — the immediate aftermath of the 2017 Las Vegas shooting and, as of several days ago, by an emergency physician, Dr. Marco Garrone, for coronavirus patients in Italy. This is believed to be the first time that it has been put forth as a longer-term strategy in the United States. |
| “We’re doing something that hasn’t really ever been done before,” said Dr. Jeremy Beitler, a pulmonary disease specialist at NewYork-Presbyterian/Columbia. “Now is the time to do it.” | “We’re doing something that hasn’t really ever been done before,” said Dr. Jeremy Beitler, a pulmonary disease specialist at NewYork-Presbyterian/Columbia. “Now is the time to do it.” |
| Gov. Andrew M. Cuomo of New York said on Thursday that the state had approved the new method, which is also being studied by federal officials. And this week, the Food and Drug Administration granted emergency use approval to a device called VESper, developed by the South Carolina-based Prisma Health, that adapts one ventilator for use with four patients. | Gov. Andrew M. Cuomo of New York said on Thursday that the state had approved the new method, which is also being studied by federal officials. And this week, the Food and Drug Administration granted emergency use approval to a device called VESper, developed by the South Carolina-based Prisma Health, that adapts one ventilator for use with four patients. |
| The New York action reflects the intense need felt worldwide to make ventilators serve more of the sickest Covid-19 patients. | The New York action reflects the intense need felt worldwide to make ventilators serve more of the sickest Covid-19 patients. |
| On March 14, Dr. Charlene Babcock, an emergency physician at Ascension St. John Hospital in Detroit, posted a YouTube video showing how to modify a ventilator to keep not one but four people breathing. It has already has more than 724,000 views. | On March 14, Dr. Charlene Babcock, an emergency physician at Ascension St. John Hospital in Detroit, posted a YouTube video showing how to modify a ventilator to keep not one but four people breathing. It has already has more than 724,000 views. |
| Generally, when patients are mechanically ventilated, a flexible tube is placed into their windpipe, and a finely calibrated pump sends oxygen-rich air into the lungs. In the video, Dr. Babcock uses a T-tube and three adapters to split two valves into four ports, and suggests positioning the patients headfirst around the machine. Dr. Babcock and her colleague Dr. Greg Nyman had published a study of the hack in 2006 — but tested it on four lung simulators, not patients. | Generally, when patients are mechanically ventilated, a flexible tube is placed into their windpipe, and a finely calibrated pump sends oxygen-rich air into the lungs. In the video, Dr. Babcock uses a T-tube and three adapters to split two valves into four ports, and suggests positioning the patients headfirst around the machine. Dr. Babcock and her colleague Dr. Greg Nyman had published a study of the hack in 2006 — but tested it on four lung simulators, not patients. |
| “Here’s my disclaimer: This is off-label use for a ventilator,” she says in the video. “If it was me, and I had four patients, and they all need intubation, and I only had one ventilator, I would simply have a shared discussion meeting with all four families and say, ‘I can pick one to live, or we can try to have all four live.’” | “Here’s my disclaimer: This is off-label use for a ventilator,” she says in the video. “If it was me, and I had four patients, and they all need intubation, and I only had one ventilator, I would simply have a shared discussion meeting with all four families and say, ‘I can pick one to live, or we can try to have all four live.’” |
| NewYork-Presbyterian is using ventilator sharing for only two patients at a time who need settings on the ventilator that are very similar. Dr. Beitler emphasized that each patient is still receiving the same amount of oxygen and level of care as previously. Sharing will not immediately double ventilator access, he added, because many patients will need their own. | NewYork-Presbyterian is using ventilator sharing for only two patients at a time who need settings on the ventilator that are very similar. Dr. Beitler emphasized that each patient is still receiving the same amount of oxygen and level of care as previously. Sharing will not immediately double ventilator access, he added, because many patients will need their own. |
| The hospital has not yet run out of ventilators, but Dr. Beitler said it was better to try the technique now than “when you have absolutely no choice.” Notably, he believes the technique will not increase staffing needs. | The hospital has not yet run out of ventilators, but Dr. Beitler said it was better to try the technique now than “when you have absolutely no choice.” Notably, he believes the technique will not increase staffing needs. |
| Officials are desperate for ventilators because they expect the need to far outstrip their supply in the coming weeks. Even after a shipment of 4,000 of the complex machines from the federal government and other emergency efforts, the state is expecting a shortage in the thousands. “Our single greatest challenge is ventilators,” Mr. Cuomo wrote on Twitter on Wednesday. “We need 30,000 ventilators. We have 11,000.” | Officials are desperate for ventilators because they expect the need to far outstrip their supply in the coming weeks. Even after a shipment of 4,000 of the complex machines from the federal government and other emergency efforts, the state is expecting a shortage in the thousands. “Our single greatest challenge is ventilators,” Mr. Cuomo wrote on Twitter on Wednesday. “We need 30,000 ventilators. We have 11,000.” |
| With about 175,000 ventilators in hospitals and the federal stockpile, other states are also braced for shortages. Coronavirus patients often need to stay on ventilators for days or weeks. | With about 175,000 ventilators in hospitals and the federal stockpile, other states are also braced for shortages. Coronavirus patients often need to stay on ventilators for days or weeks. |
| The subject of splitting ventilators is “highly controversial” among respiratory specialists, said Dr. Josh Farkas, an assistant professor of pulmonary and critical care medicine at the University of Vermont. | The subject of splitting ventilators is “highly controversial” among respiratory specialists, said Dr. Josh Farkas, an assistant professor of pulmonary and critical care medicine at the University of Vermont. |
| “While this is a technique that potentially could work for maybe a few hours, there are some significant hurdles,” said Dr. MeiLan Han, a pulmonologist at the University of Michigan Health System and a spokeswoman for the American Lung Association. | “While this is a technique that potentially could work for maybe a few hours, there are some significant hurdles,” said Dr. MeiLan Han, a pulmonologist at the University of Michigan Health System and a spokeswoman for the American Lung Association. |
| Among the concerns are the inability to monitor the impact on each individual; the potential for cross-contamination of infectious pathogens; and the possibility that instead of one person receiving lifesaving treatment, multiple patients would get dangerously subpar therapy. | Among the concerns are the inability to monitor the impact on each individual; the potential for cross-contamination of infectious pathogens; and the possibility that instead of one person receiving lifesaving treatment, multiple patients would get dangerously subpar therapy. |
| “When we ventilate a patient, there’s two things we’re trying to control: pressure and volume,” Dr. Han said. “And for this to work, every single patient would have to be OK with the same setting.” While she wasn’t speaking specifically about the NewYork-Presbyterian method, she noted that patients tend to have unique, dynamic needs. | “When we ventilate a patient, there’s two things we’re trying to control: pressure and volume,” Dr. Han said. “And for this to work, every single patient would have to be OK with the same setting.” While she wasn’t speaking specifically about the NewYork-Presbyterian method, she noted that patients tend to have unique, dynamic needs. |
| “If you have one set of lungs that’s in pretty good shape, that one’s going to blow up beautifully,” she said. “But if you have another set of lungs that has a really dense pneumonia from Covid, that set of lungs may get nothing. There’s no way to regulate that.” | “If you have one set of lungs that’s in pretty good shape, that one’s going to blow up beautifully,” she said. “But if you have another set of lungs that has a really dense pneumonia from Covid, that set of lungs may get nothing. There’s no way to regulate that.” |
| There have been three follow-up studies to Dr. Babcock’s. A 2008 study of four sheep kept the animals breathing for 12 hours. In a tiny 2009 study, two healthy, awake volunteers shared a split ventilator for 10 minutes. And a 2012 study on test lungs concluded that the findings “cannot support the use of this concept for mass-casualty respiratory failure.” | There have been three follow-up studies to Dr. Babcock’s. A 2008 study of four sheep kept the animals breathing for 12 hours. In a tiny 2009 study, two healthy, awake volunteers shared a split ventilator for 10 minutes. And a 2012 study on test lungs concluded that the findings “cannot support the use of this concept for mass-casualty respiratory failure.” |
| “There is no way to monitor the individual patients without some invasive monitoring or additional monitors for each patient,” said Dr. Richard Branson, a co-author of the 2012 study, a pulmonologist at the University of Cincinnati College of Medicine and editor in chief of the journal Respiratory Care. | “There is no way to monitor the individual patients without some invasive monitoring or additional monitors for each patient,” said Dr. Richard Branson, a co-author of the 2012 study, a pulmonologist at the University of Cincinnati College of Medicine and editor in chief of the journal Respiratory Care. |
| The lack of evidence is what alarms Dr. Branson. “I think the time to try an untested treatment not previously used in humans is not in the midst of a pandemic,” he said. | The lack of evidence is what alarms Dr. Branson. “I think the time to try an untested treatment not previously used in humans is not in the midst of a pandemic,” he said. |
| But the pandemic is straining the normal rules. | But the pandemic is straining the normal rules. |
| One of the authors of the 2008 sheep study is Dr. Lorenzo Paladino, an associate professor at SUNY Downstate Health Sciences University in Brooklyn. He and several colleagues kept four adult sheep alive on a single ventilator for 12 hours. | One of the authors of the 2008 sheep study is Dr. Lorenzo Paladino, an associate professor at SUNY Downstate Health Sciences University in Brooklyn. He and several colleagues kept four adult sheep alive on a single ventilator for 12 hours. |
| Updated June 12, 2020 | Updated June 12, 2020 |
| So far, the evidence seems to show it does. A widely cited paper published in April suggests that people are most infectious about two days before the onset of coronavirus symptoms and estimated that 44 percent of new infections were a result of transmission from people who were not yet showing symptoms. Recently, a top expert at the World Health Organization stated that transmission of the coronavirus by people who did not have symptoms was “very rare,” but she later walked back that statement. | So far, the evidence seems to show it does. A widely cited paper published in April suggests that people are most infectious about two days before the onset of coronavirus symptoms and estimated that 44 percent of new infections were a result of transmission from people who were not yet showing symptoms. Recently, a top expert at the World Health Organization stated that transmission of the coronavirus by people who did not have symptoms was “very rare,” but she later walked back that statement. |
| Touching contaminated objects and then infecting ourselves with the germs is not typically how the virus spreads. But it can happen. A number of studies of flu, rhinovirus, coronavirus and other microbes have shown that respiratory illnesses, including the new coronavirus, can spread by touching contaminated surfaces, particularly in places like day care centers, offices and hospitals. But a long chain of events has to happen for the disease to spread that way. The best way to protect yourself from coronavirus — whether it’s surface transmission or close human contact — is still social distancing, washing your hands, not touching your face and wearing masks. | |
| A study by European scientists is the first to document a strong statistical link between genetic variations and Covid-19, the illness caused by the coronavirus. Having Type A blood was linked to a 50 percent increase in the likelihood that a patient would need to get oxygen or to go on a ventilator, according to the new study. | A study by European scientists is the first to document a strong statistical link between genetic variations and Covid-19, the illness caused by the coronavirus. Having Type A blood was linked to a 50 percent increase in the likelihood that a patient would need to get oxygen or to go on a ventilator, according to the new study. |
| The unemployment rate fell to 13.3 percent in May, the Labor Department said on June 5, an unexpected improvement in the nation’s job market as hiring rebounded faster than economists expected. Economists had forecast the unemployment rate to increase to as much as 20 percent, after it hit 14.7 percent in April, which was the highest since the government began keeping official statistics after World War II. But the unemployment rate dipped instead, with employers adding 2.5 million jobs, after more than 20 million jobs were lost in April. | The unemployment rate fell to 13.3 percent in May, the Labor Department said on June 5, an unexpected improvement in the nation’s job market as hiring rebounded faster than economists expected. Economists had forecast the unemployment rate to increase to as much as 20 percent, after it hit 14.7 percent in April, which was the highest since the government began keeping official statistics after World War II. But the unemployment rate dipped instead, with employers adding 2.5 million jobs, after more than 20 million jobs were lost in April. |
| Mass protests against police brutality that have brought thousands of people onto the streets in cities across America are raising the specter of new coronavirus outbreaks, prompting political leaders, physicians and public health experts to warn that the crowds could cause a surge in cases. While many political leaders affirmed the right of protesters to express themselves, they urged the demonstrators to wear face masks and maintain social distancing, both to protect themselves and to prevent further community spread of the virus. Some infectious disease experts were reassured by the fact that the protests were held outdoors, saying the open air settings could mitigate the risk of transmission. | Mass protests against police brutality that have brought thousands of people onto the streets in cities across America are raising the specter of new coronavirus outbreaks, prompting political leaders, physicians and public health experts to warn that the crowds could cause a surge in cases. While many political leaders affirmed the right of protesters to express themselves, they urged the demonstrators to wear face masks and maintain social distancing, both to protect themselves and to prevent further community spread of the virus. Some infectious disease experts were reassured by the fact that the protests were held outdoors, saying the open air settings could mitigate the risk of transmission. |
| Exercise researchers and physicians have some blunt advice for those of us aiming to return to regular exercise now: Start slowly and then rev up your workouts, also slowly. American adults tended to be about 12 percent less active after the stay-at-home mandates began in March than they were in January. But there are steps you can take to ease your way back into regular exercise safely. First, “start at no more than 50 percent of the exercise you were doing before Covid,” says Dr. Monica Rho, the chief of musculoskeletal medicine at the Shirley Ryan AbilityLab in Chicago. Thread in some preparatory squats, too, she advises. “When you haven’t been exercising, you lose muscle mass.” Expect some muscle twinges after these preliminary, post-lockdown sessions, especially a day or two later. But sudden or increasing pain during exercise is a clarion call to stop and return home. | Exercise researchers and physicians have some blunt advice for those of us aiming to return to regular exercise now: Start slowly and then rev up your workouts, also slowly. American adults tended to be about 12 percent less active after the stay-at-home mandates began in March than they were in January. But there are steps you can take to ease your way back into regular exercise safely. First, “start at no more than 50 percent of the exercise you were doing before Covid,” says Dr. Monica Rho, the chief of musculoskeletal medicine at the Shirley Ryan AbilityLab in Chicago. Thread in some preparatory squats, too, she advises. “When you haven’t been exercising, you lose muscle mass.” Expect some muscle twinges after these preliminary, post-lockdown sessions, especially a day or two later. But sudden or increasing pain during exercise is a clarion call to stop and return home. |
| States are reopening bit by bit. This means that more public spaces are available for use and more and more businesses are being allowed to open again. The federal government is largely leaving the decision up to states, and some state leaders are leaving the decision up to local authorities. Even if you aren’t being told to stay at home, it’s still a good idea to limit trips outside and your interaction with other people. | States are reopening bit by bit. This means that more public spaces are available for use and more and more businesses are being allowed to open again. The federal government is largely leaving the decision up to states, and some state leaders are leaving the decision up to local authorities. Even if you aren’t being told to stay at home, it’s still a good idea to limit trips outside and your interaction with other people. |
| Common symptoms include fever, a dry cough, fatigue and difficulty breathing or shortness of breath. Some of these symptoms overlap with those of the flu, making detection difficult, but runny noses and stuffy sinuses are less common. The C.D.C. has also added chills, muscle pain, sore throat, headache and a new loss of the sense of taste or smell as symptoms to look out for. Most people fall ill five to seven days after exposure, but symptoms may appear in as few as two days or as many as 14 days. | Common symptoms include fever, a dry cough, fatigue and difficulty breathing or shortness of breath. Some of these symptoms overlap with those of the flu, making detection difficult, but runny noses and stuffy sinuses are less common. The C.D.C. has also added chills, muscle pain, sore throat, headache and a new loss of the sense of taste or smell as symptoms to look out for. Most people fall ill five to seven days after exposure, but symptoms may appear in as few as two days or as many as 14 days. |
| If air travel is unavoidable, there are some steps you can take to protect yourself. Most important: Wash your hands often, and stop touching your face. If possible, choose a window seat. A study from Emory University found that during flu season, the safest place to sit on a plane is by a window, as people sitting in window seats had less contact with potentially sick people. Disinfect hard surfaces. When you get to your seat and your hands are clean, use disinfecting wipes to clean the hard surfaces at your seat like the head and arm rest, the seatbelt buckle, the remote, screen, seat back pocket and the tray table. If the seat is hard and nonporous or leather or pleather, you can wipe that down, too. (Using wipes on upholstered seats could lead to a wet seat and spreading of germs rather than killing them.) | If air travel is unavoidable, there are some steps you can take to protect yourself. Most important: Wash your hands often, and stop touching your face. If possible, choose a window seat. A study from Emory University found that during flu season, the safest place to sit on a plane is by a window, as people sitting in window seats had less contact with potentially sick people. Disinfect hard surfaces. When you get to your seat and your hands are clean, use disinfecting wipes to clean the hard surfaces at your seat like the head and arm rest, the seatbelt buckle, the remote, screen, seat back pocket and the tray table. If the seat is hard and nonporous or leather or pleather, you can wipe that down, too. (Using wipes on upholstered seats could lead to a wet seat and spreading of germs rather than killing them.) |
| Taking one’s temperature to look for signs of fever is not as easy as it sounds, as “normal” temperature numbers can vary, but generally, keep an eye out for a temperature of 100.5 degrees Fahrenheit or higher. If you don’t have a thermometer (they can be pricey these days), there are other ways to figure out if you have a fever, or are at risk of Covid-19 complications. | Taking one’s temperature to look for signs of fever is not as easy as it sounds, as “normal” temperature numbers can vary, but generally, keep an eye out for a temperature of 100.5 degrees Fahrenheit or higher. If you don’t have a thermometer (they can be pricey these days), there are other ways to figure out if you have a fever, or are at risk of Covid-19 complications. |
| The C.D.C. has recommended that all Americans wear cloth masks if they go out in public. This is a shift in federal guidance reflecting new concerns that the coronavirus is being spread by infected people who have no symptoms. Until now, the C.D.C., like the W.H.O., has advised that ordinary people don’t need to wear masks unless they are sick and coughing. Part of the reason was to preserve medical-grade masks for health care workers who desperately need them at a time when they are in continuously short supply. Masks don’t replace hand washing and social distancing. | The C.D.C. has recommended that all Americans wear cloth masks if they go out in public. This is a shift in federal guidance reflecting new concerns that the coronavirus is being spread by infected people who have no symptoms. Until now, the C.D.C., like the W.H.O., has advised that ordinary people don’t need to wear masks unless they are sick and coughing. Part of the reason was to preserve medical-grade masks for health care workers who desperately need them at a time when they are in continuously short supply. Masks don’t replace hand washing and social distancing. |
| If you’ve been exposed to the coronavirus or think you have, and have a fever or symptoms like a cough or difficulty breathing, call a doctor. They should give you advice on whether you should be tested, how to get tested, and how to seek medical treatment without potentially infecting or exposing others. | If you’ve been exposed to the coronavirus or think you have, and have a fever or symptoms like a cough or difficulty breathing, call a doctor. They should give you advice on whether you should be tested, how to get tested, and how to seek medical treatment without potentially infecting or exposing others. |
| If you’re sick and you think you’ve been exposed to the new coronavirus, the C.D.C. recommends that you call your healthcare provider and explain your symptoms and fears. They will decide if you need to be tested. Keep in mind that there’s a chance — because of a lack of testing kits or because you’re asymptomatic, for instance — you won’t be able to get tested. | If you’re sick and you think you’ve been exposed to the new coronavirus, the C.D.C. recommends that you call your healthcare provider and explain your symptoms and fears. They will decide if you need to be tested. Keep in mind that there’s a chance — because of a lack of testing kits or because you’re asymptomatic, for instance — you won’t be able to get tested. |
| On Tuesday, while tending to Covid-19 patients at Kings County Hospital, he received a call inviting him to Washington to discuss his research with federal officials, he said. | On Tuesday, while tending to Covid-19 patients at Kings County Hospital, he received a call inviting him to Washington to discuss his research with federal officials, he said. |
| On Wednesday, he met with federal officials at FEMA’s headquarters to explore the possibility of establishing protocols for how to put multiple patients on one ventilator, he said in an interview Wednesday evening. | On Wednesday, he met with federal officials at FEMA’s headquarters to explore the possibility of establishing protocols for how to put multiple patients on one ventilator, he said in an interview Wednesday evening. |
| “We spent the day writing out physician protocols on how to use this,” Dr. Paladino said. The idea, he said, was that the federal government could issue guidance to doctors and hospitals nationwide. | “We spent the day writing out physician protocols on how to use this,” Dr. Paladino said. The idea, he said, was that the federal government could issue guidance to doctors and hospitals nationwide. |
| He acknowledged that there were risks. | He acknowledged that there were risks. |
| “Nobody believes this is the best way to ventilate somebody — this is for the doomsday scenario when we run out of ventilators,” Dr. Paladino said. “It’s suboptimal, but the other option is death.” | “Nobody believes this is the best way to ventilate somebody — this is for the doomsday scenario when we run out of ventilators,” Dr. Paladino said. “It’s suboptimal, but the other option is death.” |
| Jesse McKinley contributed reporting. | Jesse McKinley contributed reporting. |
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