Eric Gjerde, CEO of Airon Corporation, a small ventilator maker in Gainesville, Florida, has been getting far more business than he’d like in recent weeks. An Italian company asked him for 2,000 machines. His distributor in California, working with state officials there, asked for 500 more. Normally, his company sells 50 “in a good month,” Gjerde says, and they only keep so many parts on hand. He told the Italians no, and he told the Californians he’d do his best. “America has to come first,” he says.
On Monday, the California distributor came back to him: Could he send another 200? “Of course they want them today, and you just can’t do that,” Gjerde says. “Making ventilators is not a trivial process.” But again he said he’d do what he could.
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As the number of Covid-19 cases surges, state governments and hospitals are clamoring for more ventilators and facing a dearth of supplies. The machines are a critical component in treating the most severe cases of the disease, in which inflammation restricts the amount of oxygen a person’s lungs can take up on their own. Ventilators vary widely in cost and size, from portable units used at home and in ambulances to much larger machines found in intensive care units, but their purpose is the same: They force oxygen into the patient’s lungs, usually through intubation.
Some estimates suggest demand for ventilators may quickly overwhelm US hospitals’ supply, which includes about 160,000 machines, plus 12,000 more in federal reserves, according to a recent tally by Johns Hopkins researchers. Not all of those machines are suited to critical care and, of course, many of them are already in use by people with other respiratory conditions.
Whether the nation will face a shortage depends on whether social distancing measures can flatten the curve, reducing the number of people who need hospitalization at the same time, says Craig Coopersmith, director of critical care at Emory University School of Medicine. “Right now we’re OK, but there will be shortages if the pandemic becomes severe enough,” he says. For a preview, doctors need only look to the hardest-hit parts of Italy and China.
Days after telling governors to fend for themselves in obtaining critical supplies like ventilators, President Donald Trump on Wednesday announced he would invoke the Defense Production Act to ramp up the manufacture of critical supplies, including ventilators. Passed in 1950 at the start of the Korean War, the act allows the federal government to step in to ensure the steady flow of goods, including military weapons but also food and health supplies.
On Tuesday, Secretary of Defense Mark Esper also announced that his agency would distribute 2,000 ventilators from their own reserve to the Department of Health and Human Services, but noted that these machines are different from ones normally used in civilian settings and would require special training from defense personnel.
It’s unclear what the immediate effect of Trump’s announcement will be, although it will allow federal agencies to order needed supplies from manufacturers. The question is whether new machines can be produced quickly enough. “The problem I have is that people have been seeing this coming for a long time and governments and hospitals just have not stockpiled,” Gjerde says. “These can sit in a box and never be touched.” For now, he’s had to say no to international orders, despite having distributors in Taiwan and Italy beg him for more.
Retooling a complex supply chain to build more machines quickly will be difficult. Airon relies on suppliers across the Midwest to make the valves and tubing, while another supplier in Washington makes each machine’s casing. A few parts come from China. Gjerde’s looking into whether he can get the circuit boards he needs produced locally.
More top-down coordination could potentially help, says Chris Brooks, chief strategy officer of Ventec, a ventilator maker based near Seattle. The company, which typically ships 100 machines per month, has seen immediate demand for thousands of machines. “Our hope is that we don’t need as many ventilators as people are saying,” he says.
In the United Kingdom, the British government is pushing for large manufacturers to switch from making cars and airplane engines to ventilator equipment. But Gjerde says that even the best engineering teams that are not used to making medical machinery will find it hard to reorient quickly. “They don’t know the nature of the beast,” says Gjerde, who’s received an offer of aid from an auto parts manufacturer in Canada. For certain components, it might be feasible, he says, but “it’s just too dangerous to be thrown into the hands of people who don’t know what they’re doing.”
In the meantime, some have taken to creative hacks, like open-sourcing schematics for the design of ventilator parts for 3D printing. In Italy, the approach was used to quickly produce much-needed valve replacements, reportedly over the objections of a ventilator manufacturer that threatened a patent lawsuit. On Twitter, ER doctors have traded tips on how to split ventilator tubes between multiple people.
Those solutions aren’t ideal. Methods like splitting tubes come with concerns about the proper calibration of machines that must now feed oxygen to several users with potentially different needs, and will likely result in patients sharing pathogens. “Ultimately, we’ll have to figure out what’s actually practical,” Coopersmith says. Those methods could be used in a pinch in remote areas, he says, or if the situation gets bad enough that neighboring hospitals are no longer in a position to share resources. “This is different from anything I’ve seen in my lifetime,” he says.
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In the meantime, medical professionals should be preparing for difficult choices, says Govind Persad, a bioethicist at the University of Denver who studies how to allocate scarce medical resources. “I think people are being very hopeful if they think we’re not going to see shortages,” he says. An important step would be to have guidance from governments and medical associations that covers which patients to prioritize for life-saving measures like ventilator access. He points to guidance from New York State and Australia on rationing critical resources so that decisions are made more fairly. Otherwise, hospitals risk falling into a first-come, first-served stance that doesn’t prioritize patients by their level of need. “Once someone is on a ventilator, it’s incredibly hard to take them off,” he says.