Pandemic triage plan addresses tough ventilator decisions

[Amish Country]

Hi All

I know we have some fantastic medical resources keeping a close eye on this board so I have a question here. How about manual one use ventilators? They are cheap under $15.00 I think when I checked earlier this year. It doesn't take a PhD to squeeze a bag. How about some discussion on this? Especially for more rural areas that are some distance from major health care facilities and may have little more to rely on than EMTs, fire fighters, local volunteers and the grace of God?

I favor inexpensive low tech solutions that do not require a lot of modern info-structure to run and that most importantly will work.

 

[NurseNalts]

Re: Pandemic triage plan addresses tough ventilator decisions

A comment on the hand-held respirator use? I agree with your point that if you cannot afford or obtain mechanical ventilation, or maybe do not have the electrical back up power to sustain the machines, then the hand helds would be an option, however not a very easy one.

My background is in cardiopulmonary nursing and one of my first jobs was on a unit for patients with long-term ventilator dependence. On one weekend I worked, we had a serious of power outages due to several severe thunderstorms and tornadoes that ripped through the area. I was responsible for 4 vent dependant patients, was on a unit with 16 patients total, 3 other nurses and 1 nursing assistant. Even with the help of a few available staff, we barely had the hands to man the ambu's for the brief period while we waited for back up generators to kick in, and dear God, if they had failed, it would have been terribly desperate! There was a brief delay in the back up generator starting and we crammed beds together, trying to maintain isolation, while we jumped from one ambu to the next to maintain adequate respirations!

There would be no simple answer, and if I could, I would want to get intubation supplies, oxygen, ambu's, defibs, the works. I at least want to get my hands on some IV set-ups and solutions!

Then again, if you can't breath, than nothing else really matters, so better off to have them, than nothing at all!

 

[Blue]

Re: Pandemic triage plan addresses tough ventilator decisions

A comment on the hand-held respirator use? I agree with your point that if you cannot afford or obtain mechanical ventilation, or maybe do not have the electrical back up power to sustain the machines, then the hand helds would be an option, however not a very easy one.

My background is in cardiopulmonary nursing and one of my first jobs was on a unit for patients with long-term ventilator dependence. On one weekend I worked, we had a serious of power outages due to several severe thunderstorms and tornadoes that ripped through the area. I was responsible for 4 vent dependant patients, was on a unit with 16 patients total, 3 other nurses and 1 nursing assistant. Even with the help of a few available staff, we barely had the hands to man the ambu's for the brief period while we waited for back up generators to kick in, and dear God, if they had failed, it would have been terribly desperate! There was a brief delay in the back up generator starting and we crammed beds together, trying to maintain isolation, while we jumped from one ambu to the next to maintain adequate respirations!

There would be no simple answer, and if I could, I would want to get intubation supplies, oxygen, ambu's, defibs, the works. I at least want to get my hands on some IV set-ups and solutions!

Then again, if you can't breath, than nothing else really matters, so better off to have them, than nothing at all!

Yes, you can only do so much before you become exhausted. Wasn't this what happened in that hospital in New Orleans? They ran out of everything
and it was dark, no power for days...Can't see anyone using an ambu bag for very long.

 

[Amish Country]

Re: Pandemic triage plan addresses tough ventilator decisions

There are no ventilators in my township. Period. Zip. I even checked with the local veterinarians. There are no silver bullets. No magic wands. No easy answers. There are opportunities and choices. Thank you for explaining the short comings of this one.

This leads to the next question: what is the probability of saving some one using a manual ventilator? Would it be more humane to let the Lord take them? Would it just be prolonging an already tortured life or would there be a chance of recovery? I'm not sure this can be answered.

If the answer to the few expensive automatic ventilators is just get more cheap manual ones. This seems like an attractive answer. My concern is it worth the effort and expense to purchase them and most importunely will they work when the time comes?

 

[Highlander]

Re: Pandemic triage plan addresses tough ventilator decisions

These are very interesting questions and comments. As a paramedic, not even a cardio-pulmonary nurse or specialist, I submit the following thoughts:

The manual ventilators are meant for short-term use only. In a major city, we had only to mange a patient for ten minutes or more to the nearest emergency room.
I remember when the nifty, small and inexpensive ventilators came on the market, only a few inches long; but they are driven by an oxygen tank and/or compressed air and require a level of expertise to use.
The big thing in emergency medicine for some time, now, is to not over-ventilate the patient both during CPR and other applications. How does a lay-person assertain the correct amount, rate and speed of ventilation? How does one do this when terrified or fatigued?
Not having the required expertise and applying these measures can kill your patient.

Therefore, I decided to approach this problem from another angle. How can one develop and maintain optimum respiratory health? What can one do when that respiratory health is compromised? What can one do if a patient's lungs are filling with fluid that is non-invasive?
NurseNalts is right, without the ability to breathe, you have nothing. Having come to the same conclusion years ago led me to my great admiration for respiratory therapists. I honed-in on studying primarily this area of emergency medicine.

 

[Laidback Al]

Re: Pandemic triage plan addresses tough ventilator decisions

Amish Country, I have absolutely no medical background at all. But from what I have read by specialists on this and other forums, hand ventilation will only work in the short run.

Hand ventilation will help with the mechanical aspects of air exchange into the lungs. However, as Highlander points out regarding fluid build up, not only do you need to get oxygen into the lungs, but the circulating blood must be able to absorb the oxygen. Ventilation may get air and/or oxygen into the lungs but the patient must be healthy enough to absorb the oxygen.

How about it from you HCWs out there. Is my understanding correct?

 

[NurseNalts]

Re: Pandemic triage plan addresses tough ventilator decisions

There are lots of sites out there that can explain the anatomy and physiology of respiration and mechanical ventilation. We can get the knowledge, but the standard for providing medical care in a real life pandemic situation is very likely not to be the same as daily operations or standards of practice. The expectation for aggressive care and interventions that we have now may not be able to be fulfilled.

The bottom line as I see it, if we are presented in a situation where mechanical/hand held ventilation is needed, it is a desperate moment! Even if we are a trained professional in a controlled environment, with the proper knowledge, supplies and adequate staffing resources, it is critical.

I can ambu, and have been trained to assist to intubate, but in a pandemic setting, with supplies probably so limited, the supplies would have to be used for those who are most likely to survive.

Would you even be able to get and maintain an adequate airway? Let alone have the oxygen resources to provide adequate supplement? And then there is the issue of so much excess fluid accumulating in the lungs, without suction capabilities, adequate ventilation would be extremely difficult. Think of it like trying to blow through a blocked straw, doesn't work.

And what about our own personal strength, God forbid I would have to make the choice, but say I did have a hand held ventilator, I could maintain at least chest expansion and oxygenation IF I provided constant manual ventilation. What about the other family members I have to care for? Would you sacrifice the one for the sake of the rest? My plan is to never have to make that decision, that's why I am here af FT!

I far prefer to focus on the "ounce of prevention is worth a pound of cure" approach. I need to be "prepared .... not scared!" I can ponder these what/if questions all night, but if I don't have my house in order, I better get to work!

And hospitals will have far too little available staff, with probably far too few family members available to help manually ventilate a patient for any length of time if automatice ventilation is not available. They will triage there resources for the greatest benefit to the most patients. If they didn't, even more lives would be lost.
I would never want to make those decisions, and pray no one will have to!

 

[DRJJ]

Re: Pandemic triage plan addresses tough ventilator decisions

According to Dr. Woodson, The Bird Flu Manual, hydration is the critical home nursing skill and will require hours of nursing care daily for very ill patient with good likelihood of recovery. It involves feeding oral hydration fluid a spoonful or a few drops at a time to a patient who is so weak that they cannot lift a glass or suck on a straw or on a baby bottle. Doesn't leave much time for manual ventilation.....

 

[sara.smiles]

WARNING: Disturbing concept

WARNING: Disturbing concept

Yes, you can only do so much before you become exhausted. Wasn't this what happened in that hospital in New Orleans? They ran out of everything and it was dark, no power for days...Can't see anyone using an ambu bag for very long.

And now for a truly disturbing concept.. having been an animal breeder for many years, I know when an animal is beyond help...and have easy access to vets who can humanely euthanise an animal... but I have also had to comfort animals in dying when no vet help was available.

Watching end stage suffocation (Cheyne-Stokes breathing) is a painful and traumatic experience..

Each of you may want to privately explore options for assisting the terminally ill with making the least traumatic departure as possible.

 

[DRJJ]

Re: Pandemic triage plan addresses tough ventilator decisions

Yes, Sara.Smiles.

I have had 2 recent deaths in my family and 2 friends who died with fairly acute respiratory distress and complications. At the last one...the week before Thanksgiving and thinking of bird flu...I seriously considered confiscating the liquid morphine and fentanyl patches which were left over and saving them for bird flu.

I do not look forward to that aspect of treating the sick and dying without easy access to opiates. The hospice people are wonderful and many the time was they delivered morphine or patches to the door at 2 AM, because my need for them had unexpectedly increased substantially.

Ultimately, I decided not to retain the morphine, because of respect for hospice and the support they provide to the dying. I agree that death by bird flu will be a nightmare. I have approached my physician for prescriptions for the drugs that Dr. Woodson recommends, and have been unsuccessful in obtaining prescriptions, but I will twist his arm hard when the pandemic level is raised.

In reading the description of influenza in the late stages (and transit from onset to late stage may be very fast...hours or days) it is clear that a sick individual could not make informed consent or self administer substances which would terminate their suffering prematurely. So any "assistance" outside of the hospice path would constitute legal murder. DR. Woodson suggests diazapam (Valium) which would reduce the respiratory panic somewhat and be entirely legal, providing it was prescribed for the patient to whom it was administered and it was not administered at lethal doses.

When my mother was dying two years ago, she considered self-termination, but didn't follow through. By attending some meetings (The hemlock society is one), it may be possible to acquire useful information about alleviating suffering during the death process. I didn't attend and am speculating about the potential usefulness of this organization. It is possible that they have Bird Flu watchers as well and have or would be willing to provide support and guidance for those of us who are attempting to prepare.

Not an event I am looking forward too...

 

[sharon sanders]

Re: Pandemic triage plan addresses tough ventilator decisions

Please note that FluTrackers policy on euthanasia is that we follow the various laws passed by the various local, state, national governments. We do not advocate anything that is illegal. Please follow the law in your jurisdiction.

End of life issues are very difficult and what is acceptable in one family, religion, or culture may be completely unacceptable in another.

Thank you for understanding.


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