Thread by @gbosslet

I have been chewing on the @SCCM @aarc_tweets @ASALifeline @APSForg @AACNme @accpchest “Consensus statement on multiple patients per ventilator”, published jointly on March 26:
bit.ly/2UIdrai

I disagree with the sentiment of this statement.
Here is why.
1/

The following come from a self-described medical minimalist and a skeptic when it comes to new medical technologies. I am far more likely to tell people to “slow down” than to “check out this new toy”. You can ask @GrahamCarlos @ryanboente @erinmcrowley @tjelle13
2/

The statement is not published in a format that allows for comment, or this would be a letter to the editor.

I agree with much of the substance of the statement- they point out issues well worth considering that need worked out before splitting a vent is definitively safe.
3/

But it takes a very hard line on splitting a ventilator for multiple patients: “The above-named organizations advise clinicians that sharing mechanical ventilators should not be attempted because it cannot be done safely with current equipment.”
4/

They cite 11 reasons for this. 8 are engineering problems that have potential solutions (yellow); 2 are related to a single acute deterioration in one patient (blue), likely also an engineering issue; and one (green) relates to ethical concern regarding excessive risk.
5/

Had this statement been written 6 months ago, I would have endorsed it. However, publishing it as we stare down the critical care challenge of our lifetimes ignores scenarios on our doorstep in which the alternative to split vents is allocation triage.
6/

I don’t know an intensivist that wouldn’t do anything to provide needed respiratory support to a patient who they think could return to wellness after some vent time. Turn a V60 into an invasive vent, move them to the OR and use an anesthesia cart- whatever.
7/

So a hard-line “no” at a time when we may very well need ingenuity like this seems short sighted. Like if Houston told the astronauts on Apollo 13 not to try and build the replacement CO2 filter on the lunar module because something could go wrong.
bit.ly/2QSAFsZ
8/

I would rather have seen a statement that pointed out these issues and said something like “Clinicians exploring sharing mechanical ventilators should do so with trepidation and it should only be done out of abject necessity."
9/

"Close attention should be paid to the following issues, because each puts patients at risk. They should work with experts in engineering and ventilator design to create systems to mitigate this risk and allow for dual monitoring of flow and pressure rates to each patient.”
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There are more potential statements to be made about alleviating the engineering issues around sharing vents (individual alarm mechanisms, etc), but you get my drift. Less “thou shalt not” and more “here are the issues that give us pause and that will need careful thought”.
11/

I agree completely with their ethical concern. This would be assuaged with 2 caveats: 1) sharing a ventilator only be attempted when dictated by scarcity and all other options are exhausted, and 2) informed consent is obtained.
12/

Even a medical minimalist like me would be OK with some experimentation and innovation (with safeguards) in a setting in which the alternative is triage and allocation and turning away some we could save.
13/

I worry that the strong tone in this statement may stifle unavoidable and necessary innovation in the setting of the coming disaster and urge @SCCM @aarc_tweets @ASALifeline @APSForg @AACNme @accpchest to reconsider the tone and language of this guidance.
fin/