In the worst-case scenario Colorado could be short as many 10,000 ventilators for coronavirus patients, but hospitals and government agencies are trying to avert a situation in which doctors have to make life-or-death decisions about who gets desperately needed care.
When a person has a severe case of COVID-19, the cells that line the lungs’ air sacs start to die, and the lungs begin to fill with fluid, said Dr. Mike Mohning, a pulmonary critical care doctor at National Jewish Health in Denver. Some people can get enough oxygen through a mask or nasal tube, but if that falls short, a ventilator is the best way to keep patients alive long enough for their lungs to heal, he said.
Ventilators not only provide high concentrations of oxygen, but can apply pressure to keep the lungs’ air sacs from collapsing — though the pressure can also damage the lungs, and not all coronavirus patients recover the ability to breathe unassisted.
In harder-hit areas like Italy and New York, doctors have had to choose which patients get that kind of lifesaving treatment because of a shortage of either the machines themselves, or people qualified to run them.
Denver-area hospitals said they had enough machines to care for patients with severe respiratory distress as of last week, but that the situation could quickly change if there’s a surge of patients. UCHealth said it’s trying to increase its ventilator supply, as did SCL Health, which owns Saint Joseph Hospital and Good Samaritan, Lutheran and Platte Valley medical centers.
None of the hospitals shared how many ventilators they have, saying availability is changing frequently. The machines can cost in excess of $10,000 apiece.
Dr. Andrew French, chief medical officer of St. Anthony North, said Centura Health, the hospital system it belongs to, assesses the ventilator supply in its 17 hospitals in Colorado and western Kansas multiple times each day. They consider not only standard ventilators, but also anesthesia machines that could be converted, and devices similar to those used to treat sleep apnea, he said.
“This allows us to assess where we may want to shift resources at a moment’s notice depending upon patients we are seeing,” he said. “We are attempting to proactively plan for the worst-case scenario.”
“We will run out of healthy staff”
Dr. Ivor Douglas, a pulmonologist and intensive care specialist at Denver Health, said the metro area will be under “tremendous pressure” to provide enough invasive ventilators in the next month, but finding enough people who can operate them could be an even bigger problem. The hospital has sought permission to train students in their final year of medical school to operate ventilators, but so far the Association of American Medical Colleges isn’t allowing that, he said.
“I think that what we will run out of, before we run out of machines, is we will run out of healthy staff,” he said.
Normally, respiratory therapists, pulmonologists or critical care doctors run ventilators, but some hospitals are exploring training others to work under their supervision, said Julie Lonborg, senior vice president of communications at the Colorado Hospital Association. For example, a surgeon who isn’t working because of the ban on elective procedures might be able to assist with caring for patients on ventilators, with back-up from an expert, she said.
Estimates of how many ventilators Colorado would need to avoid wrenching choices vary from as low as 1,041 to as high as 10,000. It’s also not entirely clear how many ventilators might currently be available. The state counts about 900, while the Colorado Hospital Association thinks there are about 1,600, including machines meant for short-term use that could be modified to support patients for weeks.
The number needed will depend on at least three factors: how many people in total develop serious symptoms, how many are sick at the same time and how long they need ventilator support. Lonborg likened it to planning for house guests: you could host 15 guests with one spare bedroom if they spaced out their visits, but not if everyone wanted to come at the same time or if the first guest stayed for a month when you had only planned for a week-long visit.
“The longer the time frame, the more likely we’re going to be able to handle them with the equipment we have,” she said.
So far, the numbers aren’t encouraging when it comes to the length of time that patients will need mechanical support. Scott Bookman, the incident commander coordinating the state’s response to the new virus, said patients may need to be on ventilators for 11 to 20 days. By comparison, most pneumonia or flu patients can breathe on their own within a week, Mohning said.
The number of people who get sick at the same time will depend on how well Coloradans are following the state’s stay-at-home order, Douglas said. If fewer people are interacting and passing germs around at any given time, the odds are better that hospitals will be able to handle the flow of patients.
“We have to double down,” he said. “This is about our social contract with each other.”
Stretching supply, prioritizing patients
Since no one knows exactly how bad the situation could get, everyone is trying to plan for the worse-case scenario, Lonborg said. Unfortunately, that means competing for the limited supply of machines being produced, she said.
“The issue isn’t money. The issue is the supply,” she said.
The state of Colorado is combining hospitals’ orders to speed up the process, because suppliers trust the state will pay its bills and don’t have to consider each facility’s financial situation, Gov. Jared Polis said in a news conference Wednesday. The state has ordered 750 ventilators, though it hadn’t received any yet.
“People fortunately do trust the state of Colorado,” he said.
Bookman said the state is trying to order more ventilators than it anticipates needing, to account for mechanical malfunctions and other problems.
“We want to be prepared to save lives,” he said.
A state task force is working with companies and research institutions to determine if it’s feasible to make ventilators based on publicly available blueprints, according to the Colorado Department of Public Health and Environment, and companies like General Motors and Ford have pledged to retool their factories to produce medical equipment. It’s far from clear if those plans will come through fast enough to meet Colorado’s needs, since projections show cases could peak anywhere between April and July.
Since they don’t know when more machines might arrive, hospitals have started working on plans to move patients or equipment if one area starts to get overwhelmed, Lonborg said. So far, they have enough to care for all COVID-19 patients, but some hospitals have said they could run out of capacity if they get the same number of new patients next week that they have in recent weeks, she said.
There are other ideas to try to stretch the supply, like hooking more than one patient to a single ventilator, but that’s far from ideal, Mohning said. The correct settings for a patient vary based on their size and the level of damage to their lungs, so hospitals would have to try to match patients as closely as possible if they were to share a machine, he said.
“It’ll be a challenge in real life,” he said. “We certainly haven’t come to that here.”
A group of health experts that advises the governor already has begun work on guidelines about how to prioritize patients if hospitals become overwhelmed. The general principle is that patients with a better chance of surviving would get life-saving resources before those with a slimmer chance of living, but quite a few questions remain about how those decisions would play out in real-world situations, with imperfect information.
What everyone wants to avoid is doctors having to decide which patients will get scarce resources, Douglas said. Those decisions, based on who is most likely to benefit from treatment, need to happen at a societal level, he said.
“It cannot be somebody like me who’s sitting in an ICU,” he said.