The Crisis is Near Now

A High Frequency Oscillatory Ventilator Design

Some of the news items I have been reading say that there will be a particular shortage of high frequency oscillatory ventilators. Many ICU units do not have any or may only have one. This type of ventilator is required to care for patients with the most damaged lungs.

I found a design for such a device in the IEEE transactions on Biomedical Engineering publication. Here is the drawing.















The link to the PDF is located at this link.
The PDF essentially gives instructions on how to build this ventilator.

This device is much more complex than the basic ventilators I have built, but it seems that it would possible to build such a ventilator from common valves, sensors and control systems substituting for some of the components that are listed. The diaphragm actuator for example could be a large bass (subwoofer) type speaker.

It would be great if someone could build one of these unists and get back to me about how feasible it is and how well it works in testing.

Next week an idea for using ECMO.
Don't know what ECMO is?
Have a look.
http://panvent.blogspot.com/2009/09/using-dialysis-machine-to-do-ecmo.html

Now My Rant
Many of the recent reports that I have read indicate that there is a high likelihood that the current H1N1 pandemic will result in very busy ICU units and shortages of ventilators this fall in Canada. Doctors that work in ICU units that have had to treat H1N1 patients with Acute Respiratory Distress Syndrome (ARDS) say that the patients may have to be on a ventilator for a longer time period than they have seen with patients that got lung function complications in normal seasonal flu.

Here is a link to one such news item from CP.
Intensive care units likely to be main battlegrounds in the war against H1N1
There have been many stories like it originating from hospitals in Canada, the US, India, Australia, UK, Brazil, etc.

When I first proposed the Pandemic Ventilator Project two years ago as a means to alleviate some of the needs for ventilators in a pandemic, I expected it might be used for the H5N1 Avian flu. It seemed like a good insurance plan for a pandemic that, if we were lucky, might not even happen. Things have changed a lot since then. Now it is H1N1, people have actualy died from it, and this pandemic might return stronger this fall and winter, killing even more people. The risk of ventilator shortages has gone from a remote possibility to more likely. A lot has changed in the last six months.

Unfortunately, something that has not changed is the development status of the Pandemic Ventilator Project. As I have said several times before, the project has largely reached the limits of what I can do on my own to develop it. I need people with more ideas, more technical knowledge, more clinical expertise and better management and organizational skills than I possess on my own to carry the project further than I have. It would be a shame if we reach the stage where we really could use a ventilator from he pandemic ventilator project, but no one worked on it beforehand to get it ready in time.

Canada to Buy Ventilators for the H1N1 Flu

I saw an article in the Globe and Mail Today. I posted a comment on the article. Here is my comment:

The potential shortage of ventilators has been an issue with ethicists and planners for a while now. Most feared for the pandemic was the H5N1 Avian flu. Some officials thought that stockpiling ventilators would be a waste of resources because the expected H5N1 pandemic would be so severe that there would not be enough hospital staff or supplies to run them anyway.

With the comparatively mild H1N1 strain, some feel that existing resources will be adequate. The truth of the matter is that predicting the severity of a future pandemic is nearly impossible. It could be anywhere in between these extremes, and can change rapidly during the course of a pandemic as well. Many experts are concerned that with the very high numbers of infections happening with the H1N1 strain, that even a moderate increase in the severity of illness could cause widespread shortages of ventilators.

The Canadian and Ontario governments have not done very much up to this point of addressing the potential of a very deadly ventilator shortage. Governments in the US that have done the most to provide a creditable emergency supply have mostly focused on buying low cost, lower tech ventilators that can be operated by individuals with moderate training levels. The optimal number to purchase is between one and two times the current number of ventilators being used in ICU units.

I have a discussion of some of these issues in my blog at panvent.blogspot.com Pay special attention to an article I wrote more than 2 years ago comparing the government and Canadian Red Cross's inadequate response to the issue of AIDS contamination in the blood supply. http://panvent.blogspot.com/2007/02/trusting-in-pandemic-plans.html


I will be gone fishing for the next 2 weeks.

Building a Pandemic Ventilator

On Thursday May 29, Jeff and I gave a presentation about the Pandemic Ventilator Project to some of my friends and colleagues at work. The presentation went smoothly and was well received. We received encouragement from the attendees to continue working on the project. We had the presentation videotaped so that more people could see it. Thank you Manuel for your help and ideas in videotaping this presentation.

The presentation is about 35 minutes in length overall and is divided into 4 sections below as YouTube videos. The title of the presentation was "Building a Pandemic Ventilator”. It is an overview of what we are tying to achieve with the Pandemic Ventilator Project.



Building a Pandemic Ventilator Part 1
9:08
Presented at Grand River Hospital May 29 2008.
The purpose and origins of the Pandemic Ventilator Project and the history of home made ventilators.




Building a Pandemic Ventilator Part 2
6:42
Presented at Grand River Hospital May 29 2008.
A description of how the Pandemic Ventilator actually works.




Building a Pandemic Ventilator Part 3
9:16
Presented at Grand River Hospital May 29 2008.
Some pandemic planning ideas and the future of the Pandemic Ventilator Project.




Building a Pandemic Ventilator Part 4
9:52
Some discussion, questions and a demonstration of Jeff’s Pandemic Ventilator.

Dr. Eric Toner Blog post

Here is an interesting interview with Dr. Eric Toner about pandemic planning with regards to H5N1. Dr. Toner is with the Center for Biosecurity at the University of Pittsburgh Medical Center. I have referenced articles from this group before. There is a lot of useful information available at the UPMC Biosecurity site, and it is frequently updated.

Dr. Toner talks about how severe a pandemic arising from the H5N1 virus could be, and compares this worst case scenario to the projections commonly used by the CDC flusurge software. In case you are interested in alternative projection models to flusurge, check out the panalysis spreadsheet.


Here is the PDF of the Toner interview

If you would prefer to listen to the audio version the links are here:
Part 1 “What is Avian Flu?” (4:23)
Part 2 “The difference in Death Rate Assumptions” (2:50)
Part 3 “Why we need Hospital Interventions” (6:03)
Part 4 “Why Not Enough is Being Done” (8:40)

You can also go to the Health Business and Policy website directly for the HTML version

Health and Business Policy has more pandemic related interviews available here.

Be aware, most of the information on the Health and Business Policy site seems to be older, from about mid 2006.

How Many Ventilators Does New York Really Have?

A couple of weeks ago, I posted a piece on how hard it is to get good numbers on the quantity of ventilators available. I checked through some documents from the New York State Workgroup on Ventilator Allocation in an Influenza Pandemic. Last year they published some preliminary information and asked for public input on setting up guidelines for ventilator use in a pandemic or similar emergency. I sent in some information to them about the Pandemic Ventilator Project and some of my ideas about how to expand the availability of ventilators and clinical capacity in a crisis, but they never asked me for more details. They recently published some guidelines based on that exercise in Disaster Medicine and Public Health Preparedness. I will have to see about getting a copy of that article and reviewing it.

Anyway, I found two documents by the same workgroup stating the number of ventilators in New York. Unfortunately they quote two different numbers. One is 60% higher than the other. Here are the details:

First we have:
Allocation of Ventilators in an Influenza Pandemic: Planning Document
NYS Workgroup on Ventilator Allocation in an Influenza Pandemic
NYS DOH/ NYS Task Force on Life & the Law
Feb 13, 2007 (listed access date)
Available here:

On page 9, it states:

• the population of New York State is approximately 19 million,
• there are currently 3,981 adult and pediatric ICU beds staffed,
• 15% of the admitted patients with pandemic influenza will require intensive care,
• 7.5% of the admitted patients with pandemic influenza will require ventilators,
• there are currently 6,100 ventilators in acute care settings in New York State,
• at any given time, 85% of the ventilators in acute care settings are in use, and
  
• 70% of deaths related to pandemic influenza are projected to occur in a hospital.

And then we have:
New York State Workgroup on Ventilator Allocation in an Influenza Pandemic
New York State Department of Health/ New York State Task Force on Life & the Law
March 15, 2007
Available here:


On page 1, it states:

a) Community Demographics
New York State has an estimated population of 19,254,630, which represent 6.5% of the total United States population. Approximately 13% of New Yorkers are age 65 or older; an estimated 18%of the state population over the age of 5 is disabled.

b) State & Local Public Health Infrastructure
NYSDOH is empowered to issue voluntary, non-binding guidelines for health care workers and facilities; NYSDOH is also empowered to issue binding regulations for hospitals that would app to standards of care during a pandemic.

c) Health Care Delivery System
There are more than 650 nursing homes in New York State housing 120,000 beds. Of the 240 hospitals in the state, 44 are classified as trauma centers, and 13 are classified as critical access hospitals (CAH) in rural areas. There are 3,981 adult and pediatric staffed intensive care unit beds throughout the state. There are currently 3,861 mechanical ventilators in acute care settings in New York State; at any given time, 85% of these ventilators are in use.


So here we have 2 documents. Both are produced by the same workgroup on ventilator allocation. Both of these documents list Gus Birkhead and Tia Powell as contributors. One of the documents says that New York State has 6,100 ventilators in acute care settings, and the other document says that they have 3,861 ventilators in acute care settings. Both of them say that they have 3,981 ICU beds.

It is hard to know what numbers to believe. As I said before, how can you know how many ventilators you have to stockpile if you are not even sure how many you have now? How can you know how far you can extend your resources and clinical skills capacity if you are not even sure how many ventilators those workers are supporting now? A definitive census is needed with plans that list actual (validated) numbers of ventilators that exist, how many will be added for surge capacity and how far it is possible to stretch clinical support capacity.

Maybe in their latest article, Powell and Birkhead can tell us which numbers are the real ones.

WWSEF Science Fair Results

Below is the pandemic ventilator prototype "Norman". Norman was built by one of our developers in his automation and robotics class.

This prototype is named “Norman” after Norman Burn. Norman Burn was the Chief Technician at the Department of Anesthesia at Newcastle. Norman Burn built many of the very first positive pressure ventilators. Some of his “home made” ventilators were used during the polio epidemic in Britain in 1947. (link here)

This developer is a high school student and has contributed to the Pandemic Ventilator Project right from the beginning. He has added many insights to the design of the project and did all the PLC programming for "Max" as well as his current prototype. He entered "Norman" in the Waterloo Wellington Science and Engineering Fair.


The Pandemic Ventilator at the Science Fair


He won 3 awards at this Science Fair:

• Silver Medal in the Senior Engineering Division

• The University of Ontario Institute of Technology Innovation Award for demonstrating the most innovative development, adaptation or use of technology in a science project.

• An Award of Merit
  

In addition to the awards, his project has been accepted to participate in the National Canada Wide Science Fair to be held in Ottawa Canada from May 10 to May 18th 2008.

We congratulate him on his hard work and dedication.


Receiving the Silver Medal Award
for Senior Engineering



Receiving the University of Ontario Institute of Technology
Innovation Award for Demonstrating the Most Innovative Development,
Adaptation or Use of Technology in a Science Project




Receiving the Award of Merit

-------------------------------------------------------------------------------------
Correction

It seems there was an error made at the awards ceremony. Instead of the silver medal he was awarded, he was supposed to have received a gold medal and several university and college scholarships. So, we congratulate Jeff on his gold medal award. Here is a link to the official site.

Here are the awards he was supposed to have received:

• Award of Merit,
• Gold Medal, Senior Engineering,
• University of Ontario Institute of Technology Innovation Award,
• Conestoga College Entrance Scholarship,
• University of Guelph Entrance Scholarship,
• University of Waterloo Entrance Scholarship.
• Wilfrid Laurier University Entrance Scholarship.
  

His project is also entered in the Canada-Wide Science Fair

Some Short Pandemic Info Videos from Youtube

Any Community That Fails to Prepare

U.S. Secretary of Health and Human Services Michael Leavitt comments on the need for all communities to prepare for pandemic in this excerpt from his interview with Charlie Rose that aired on Feb. 14, 2007.



How Does a Pandemic Start?

Dr. Gregory Poland, founder and head of The Vaccine Research Group at the Mayo Clinic discusses how pandemics start and why H5N1 is on track to spark the next pandemic in this excerpt from the BBC Horizon show "Five Things You Need to Know About Pandemic."



Pandemics Happen

U.S. Secretary of Health and Human Services Michael Leavitt addresses the fact that pandemics have happened throughout history in this excerpt from his interview with Charlie Rose that aired on Feb. 14, 2007.



Pandemic Is Hard to Talk About
U.S. Secretary of Health and Human Services Michael Leavitt explains why pandemic is a difficult topic of discussion in this excerpt from his interview with Charlie Rose that aired on Feb. 14, 2007.



Pandemic Preparation Is Good for Any Emergency

U.S. Secretary of Health and Human Services Michael Leavitt explains that preparations for pandemic will serve communities well in the event of other types of emergencies in this excerpt from his interview with Charlie Rose that aired on Feb. 14, 2007.



Preparation Saves Lives

U.S. Secretary of Health and Human Services Michael Leavitt comments on the the fact that pandemics are unlike any other disaster known to humankind in this excerpt from his interview with Charlie Rose that aired on Feb. 14, 2007.



Two Key Pandemic Differences

U.S. Secretary of Health and Human Services Michael Leavitt discusses the two key differences between pandemic and other natural disasters in this excerpt from his interview with Charlie Rose that aired on Feb. 14, 2007.



Why Kids Are at Most Risk During Pandemic

Dr. Gregory Poland, founder and head of The Vaccine Research Group at the Mayo Clinic discusses why children are at the most risk of infection and death during a pandemic in this excerpt from the BBC Horizon show "Five Things You Need to Know About Pandemic."