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"What They're Bidding For Is People's Lives": Dr. Kanter Talks Impending Ventilator Crisis

Apr 3, 2020
Originally published on April 3, 2020 6:18 pm

Across the globe, there is massive demand for a limited supply of ventilators, which are needed to save critically ill COVID-19 patients.

Gov. John Bel Edwards has said that if the current rate of infection persists and new ventilators are not made available, the state will run out of the life-saving devices by next week.

Dr. Joseph Kanter from the Louisiana Department of Health said the state is scouting for ventilators, but the global supply chain is like a “crazy, chaotic flea market.”

Of the 5,000 that the state requested from the Strategic National Stockpile, the feds sent 150. That shipment only bought Louisiana a day before supplies run out, currently slated for April 7.

Betsy Shepherd: Can you talk about Louisiana's growing demand for ventilators and the difficulty we're having sourcing them?

Dr. Joseph Kanter: This is happening across the country now. As we're looking at the growth of this outbreak, we're going to have more patients that require lifesaving care than the existing hospital system is equipped to deal with. Hospital systems are typically sized to meet the demands of the normal population of that area. So we're going to have more sick patients than available beds, ICU beds, staff, doctors, nurses, techs. But in a very finite sense, it boils down to ventilators.

COVID-19 is a respiratory disease, it hits people's lungs. When people die, it's from respiratory failure. So ventilators are a lifesaving device and we're on track to outstrip our demand.

We've signed a number of purchase orders for large quantities, but we are as a state competing with every other state right now and with hospitals across the country and even with the federal government to purchase ventilators on the private market. It's the most absurd thing you've ever imagined. Imagine a crazy, chaotic flea market where everyone's bidding over everyone else and what they're bidding for is people's lives. That's the system right now that we're living in.

Do you think that that process could be made more efficient and more lives could be saved if the bidding process were regulated?

Yes, without question. And we've called for that. We would like the federal government to do more to coordinate this response across the nation. It is absurd to have states competing against one another for something like ventilators. It duplicates a lot of people's work and it does a very poor job of assuring that these lifesaving resources go to where they're most needed.

And so right now, theoretically, they could go to the highest bidder?

Sure. And that's exactly what's happening on the private market right now.

What are the guidelines for distributing new ventilators Louisiana receives to hospitals throughout the state?

There are no set-in-stone rules here. And one of the things that's notable about this outbreak is public health systems and hospitals and doctors and everyone has to make decisions on the fly and take the available information and do their best job to make sense of it and make decisions. So when we get ventilators in from the strategic national stockpile, for example, or from a private vendor that we purchased, we do our best to allocate that based on need. And so we look at where the majority of the cases statewide are, what the projections will be in the coming couple of weeks, how much those projections are anticipated to outstrip the current supply and what the ability of a hospital would be to use those ventilators. The majority of the ventilators that have come to Louisiana have come to the New Orleans region. And then in that region, they've gone to hospitals that we anticipate would have the physical space to care for patients, but not the equipment.

Given the trajectory and the difficulties in procuring these ventilators from manufacturers and from the federal government, it seems that there will be a shortage. Can you talk about some of the things that hospitals are talking about in order to stretch the ventilators further?

It's certain that there will be a shortage if the current trends hold and we don't get more. I am fairly confident that we will receive more ventilators from one means or another. But that doesn't mean that we're letting off the gas pedal on this. Hospitals are looking across the board now of how they can approach patient care if that zero-hour came.

The A-plus standard in the hospital-grade, critical care ventilator. It is able to measure very accurately how the patient responds to the breaths being given and gives a high degree of control to the critical care physician. This type of ventilator is even more important during COVID-19 than it is during another type of illness, because not only your patients sick and needing a ventilator but they're sick with a respiratory disease, which means these patients are extremely hard to ventilate because their lungs are diseased.

Now if that doesn't become available, then hospitals go to second-best choices. And that could mean a portable ventilator, a smaller device that is used to transport patients from room to room or on an ambulance. They're not as good for this disease. A second option would be a non-invasive ventilation device called a BiPAP machine. A BiPAP machine is almost like a CPAP machine that people wear at night in their home, but a little bit more sophisticated. It blows air through a mask into someone's face.

Going down from there, you really get into some tough choices. Other options would be you could manually bag a patient, which means squeezing what's called an ambu bag and you have to squeeze every five seconds. We actually did this during Katrina until the power was restored or until patients were evacuated. But it requires the person there to bag round the clock. And you also lose a lot of the benefits of a hospital ventilator because you can't really fine-tune the breaths that are given.

And then there's been discussion about if you can attach two or three or four patients to a single ventilator machine. And the federal government actually put out some guidance towards this yesterday. And the guidance was prefaced by a joint statement from a number of physicians that basically said please don't do this. What happens when you try and hook multiple patients up to the same machine is they all split the same settings, so it's not as effective. You don't get to fine-tune a setting to the individual patient. That machine can't monitor what the patient's doing because they can't sense which patient is doing what. And to do this, you have to have multiple patients very close to each other, which is a setup for transmission of infections. So it's a horrible, horrible solution. It's going to be a very dark place if that's where we actually get to.

Will socio-economics be a factor in access to ventilators? For example, if you are a person that doesn't have in-network access to a hospital that has ventilators, will you still be able to get a ventilator?

Our intention is to allocate ventilators purely based on the number of lives that will be saved, regardless of who those individuals are and regardless of what their socio-economic status is. It's 100 percent agnostic to what that hospital is and what type of patients go there.

Now, I want to pause there and kind of take the conversation in a little bit more nuanced direction. When we talk about limited ventilator supply, that conversation leads to “crisis standards of care.” That's a term to mean what doctors do when they have to decide who gets a lifesaving intervention. So if it comes to the point that we do not have enough ventilators and doctors are forced to choose which patient gets a ventilator, that's crisis standards of care. This is a conversation that nobody is comfortable having. But it is a conversation that critical care physicians are having across the region right now. It would be malfeasance for them not to be having these conversations.

The general principle of crisis standards of care is you want to save the most lives and you want to direct resources towards patients who would most benefit from those resources. So, for example, if you had a hypothetical 60-year-old with a number of underlying health conditions like obesity and diabetes, hypertension and renal disease and on dialysis versus a 60-year-old with none of those conditions, we would expect that the healthier of those two individuals would have a greater chance of surviving with a ventilator. And so the resource would be guided towards that individual. This becomes challenging because populations that have health inequities or health disparities are disadvantaged in that thought process. And that's something that our system really hasn't done a good job of dealing with is how do you accommodate the underlying health inequities when you have these types of conversations.

We've seen news headlines of different companies Ford and G.E. trying to manufacture new ventilators. Do you see that helping out anytime soon?

I see that helping other cities that will have outbreaks after ours. As those companies ramp up production, maybe they're looking at completion months from now. But it won’t help us here when we're projected to hit our day zero.

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