Ventilators
Ventilators vary widely in cost and size, but their purpose is the same: They force oxygen into the patient’s lungs, usually through intubation.
 

It's funny how Gwyneth Paltrow rarely suggests how to hit a cross-court topspin backhand, Elon Musk doesn't tend to tweet about giving pathos to a portrayal of Richard III, and I'm pretty sure Novak Djokovic hasn't espoused his views about payload distribution for a geosynchronous satellite launch. But yet they all seemed to understand medicine well enough to inform millions of people.

Now, I would single out Novak there as having the worst comprehension of science out of the three as he's an anti-vaxxer, not to mention his strange dietary neuroses. But although it might sound bizarre, there is now an anti-venter movement, who are sadly not people opposed to that slit at the back of a suit. They are people who are against the use of ventilators in the treatment of COVID-19. This video is about three examples of the same erroneous thought process and, in my opinion, the biggest challenge facing science in 2020.

If you're like me, you know more about managing critically ill patients than doctors and scientists who've dedicated their entire careers to it and so you should drink Dunning-Kruger. It's the only choice for the self-educated gentleman. Dunning-Kruger: it'll give you confidence, although I don't think you need any help with that. Cheers.

I recently popped up in a Real Engineering video, which made my year because I love that channel. The video was about ventilators. We've all heard how they're an essential bit of kit in the fight against COVID-19 and how thousands more are needed, and this led to an outpouring of well-intentioned engineers trying to design ventilators, but most of them were next to useless because they're just too basic.

Modern ventilators allow the patient to control breathing, whereas these kind of mindless pumpjack bag squeezers deliver mandatory breaths at a set rate, which I'm sure you can imagine is a very unpleasant experience unless you're deeply sedated and paralyzed, which we don't like doing in intensive care, except maybe in the first few hours or day after intubation. After that, we try to keep patients lightly sedated so they're not aware of what's going on around them, but they're breathing for themselves and yet they have far fewer complications that way.

When they're getting better, we try to wean them off the ventilator, which can take a long time, and that's where all those advanced settings and modes of proper ventilators come in useful. Crash intubation and ventilation of COVID patients is not why we need many ventilators. It's their ongoing support and that weaning process.

Here, in the U.K., the government rather botched the whole ventilator thing quite royally. Instead of doing what industry leaders had suggested to the government, which was to repurpose factories to make ventilators using existing plans from ventilator manufacturers under license, the U.K. government took a different approach.

Boris Johnson hosted a call with 60 captains of industry from the U.K. -- household names like JCB, Rolls-Royce, Airbus, Honda -- and the focus was on making something from scratch from the bottom up. As has so often been the case with this virus, military metaphors were drawn. It would be a crowning moment in British manufacturing, akin to the Spitfire during the Second World War.

Medical advisors said, "Okay, but we don't need those basic bag-and-a-bottle pumpjack machines. We need the product to be fit for purpose." But it soon became apparent that what was being proposed was woefully under-equipped to meet what was needed. Instead of listening to experts, British politicians had felt that they understood the problem better and tasked people with a proven track record in an entirely unrelated field, the job of solving the problem.

Donald Trump: "Ventilators are big machines that are very complex and are very expensive. You need real, real ... you need a group of people that really know what they're doing. We took auto lines. We took a lot of different people ... I don't believe you need 40,000 or 30,000 ventilators. You know, you go into major hospitals sometimes, they'll have two ventilators. Now, all of a sudden, they're saying, 'Can we order 30,000 ventilators?' ... But this is a very unforeseen thing. Nobody ever thought of these numbers. Nobody ever saw numbers like this ... We are now the king of ventilators all over the world. Ventilators, ventilators, ventilators."

Now, I'm really not interested in getting bogged down into an analysis of Donald Trump's actions on ventilators, but I think it's clear that the so-called king of ventilators has also elected not to listen to those with experience and knowledge in the field, and instead decided upon his own course of action.

I do wish to stay in America for my next example, which brings us to the great Elon Musk, and I don't mean great sarcastically there. I do think he is an immensely impressive character, but that doesn't make him immune to criticism. People warned me that if I do criticize him, his bhakts will come after me, but I consider myself a big fan of Elon myself.

Regular viewers will know how obsessed I am with space. I share his love of memes, clean energy, and electric cars. He's much more interesting than other billionaires. I just wish he'd develop some insight into the limits of his own knowledge.

You probably think I'm going to hate on him for promising ventilators and delivering CPAP [continuous positive airway pressure] machines, but I'm not. That's not what this video's about. I will, however, translate that sentence because I think it is relevant to my main point. When medics say "ventilator," we mean a machine that delivers ventilation to an intubated patient -- someone with a breathing tube down into their lungs.

Being intubated and ventilated isn't very nice and it can come with all sorts of complications, so we try to avoid it whenever we can. In the last 20 years or so, we have used non-invasive ventilation to do just that. We've managed to prevent millions of people being put on ventilators, and also helped many who would not have been suitable for ventilators. Sometimes these non-invasive masks that fit tightly across the face are referred to as CPAP or BiPAP [bilevel positive airway pressure] machines. Technically they are a type of ventilator, although it's not what people normally understand when you say "ventilator." When Elon delivered CPAP machines instead of invasive ventilators, some people were a bit salty about that. Whatever, I don't really care.

CPAP machines can be converted into invasive ventilators, basic ones, and they have been in New York. As far as I'm concerned, well done, Elon. I'd also like to say well done to Tesla engineers whose design for a ventilator was very impressive and they definitely don't fall into that category of just the mindless bag-squeezing machine.

It was very cool to see all those car parts being used for a medical device. Good job, engineers, as well. But this criticism of Elon, which I don't think was entirely fair, clearly bothered him. It's led to a response where he's now defensively spouting theories about mechanical ventilation on Twitter after condensing medical school and critical care training into, I guess, about a fortnight, which simply betrays a complete lack of understanding about what doctors actually do -- first suggesting we have not evolved to have tubes down our throat. Well, thanks, Elon. That's quite the newsflash. "My personal choice would be a mask, meaning CPAP, at moderate pressure with O2 of 50%," as if this is something that we have not thought of.

Now, I'm not making this up, I promise you. Last week, I looked after a middle-age man with severe COVID lung disease and he was doing well on CPAP with a PEEP [positive end-expiratory pressure] of 6 to 8 centimeters of water and an FiO2 [fraction of inspired oxygen] of 0.5 -- i.e., oxygen of 50%. This is not a strategy we're unfamiliar with, but after 3 days he crashed and had to be intubated. If he had not been, he would have died.

Here, Elon feels that ICUs are jumping the gun and setting PEEP and O2 too high. I don't even know where to start with this one. The very core principle of ventilating a patient is to reduce oxygen and pressure being delivered as much as possible. ITU [intensive treatment unit] nurses are experts at doing exactly this and it's been an absolute fundamental of management for decades.

This is the equivalent of me saying, "Hey, you know, when blasting a radio machine into an earth cycle, jettisoning 90% of the launching missile seems very wasteful. Maybe you could consider reusing some parts of it. Just my opinion."

"Then I wouldn't go much above their natural lung pressure." I really don't understand this, because lungs work using negative thoracic pressure, so it's literally impossible to ventilate anyone without going above their intrinsic lung pressure.

"Depending on the specific pedestrian strength, impact with a self-driving car could result in their internal pressure dynamics being fatally exceeded. I would suggest a pedestrian-avoiding mechanism. A camera should suffice. Just my opinion."

There are other things I'm not too fond of as well, like his promotion of hydroxychloroquine and remdesivir, which may work, but so far -- and I want to say this clearly -- have no evidence to support their widespread use.

More research, yes, please, but so far nothing even near concrete and saying, "Looks promising" to 33 million followers has implications that he should be aware of in view of his previous tweets that have been taken in the wrong way. But I want to give Elon the benefit of the doubt because I do believe he wants to help, and that brings me to the anti-ventilator movement that I mentioned at the top of the video.

A highly intelligent scientific mind like Elon's and conspiracy theorists seem to be referencing the same things. How can this be? Many people online now claim that ventilators are killing people. There have been breathless articles in the news stating that 80% of patients placed on ventilators die.

Now, one interpretation is that ventilators are killing people. Another, more logical, interpretation is that the people being placed on ventilators are so sick that even a ventilator cannot save them. What if I told you that 80% of people who die in motorway crashes were wearing seat belts? Would you conclude that seat belts are killing them or were they just traveling so fast that even the seat belt didn't save them?

Another statistic that's important to know here is how many people not wearing seat belts -- i.e., people who weren't intubated at the same disease severity -- go on to die. If 100% of them die, then your intervention has actually saved 20%, which is still very unsatisfactory, but it's a long way from saying ventilators are killing patients.

Finally, we come to what I think is the biggest problem facing science today, the role of uncertainty. In science, it's correct to continually update your theories about how things work based on new evidence.

Science is not a set of facts. Science is a method by which we try to work out facts. But when science course-corrects in the public eye, instead of being lauded as improving our models, the public and media seize on it by saying, "Doctors don't know what they're doing. Doctors are killing people."

COVID-19 is a new disease, one we've never seen before. When it first hit our shores, we thought it would behave in the same way that other pneumonias that cause an acute respiratory distress syndrome, or ARDS, do. These patients have stiff lungs and require high pressures, and we were told to intubate early. Many patients did behave just like this, but many did not. The amazing thing about the Internet and social media is we started talking about these experiences.

Elon Musk might think that ITUs are blindly setting everybody to high pressures and oxygen settings, but being a #zentensivist is about making tiny adjustments, watching, waiting, adjusting again, being aggressive in your conservatism, and doing your utmost to do as little as you can to the patient. The idea that Elon has of doctors turning the ventilator up to 11 and just walking off is nonsense.

Another major factor was that CPAP was felt to be a very effective way of aerosolizing SARS-CoV2 [the virus that causes COVID-19 coronavirus infection] into the atmosphere and infecting everybody. With shortages of PPE [personal protective equipment], this also affected decision-making.

Italian groups dealing with some of the worst cases were using helmet interfaces, which also has other benefits. This is footage that I've showed before of my friend's hospital in Bergamo, which I pronounced wrong last time. Apologies.

Indeed, the Italians have led the way in this, and they have been publishing their thoughts about "maybe this disease isn't what we thought." A world-renowned master of mechanical ventilation, Luciano Gattinoni, the guy who literally invented proning patients, turning them on their front, wrote on March the 30th that this is not a typical ARDS.

My buddy here was WhatsApping me at the same time, saying that this isn't typical. In ITUs all over the world, people had already realized that some patients don't need those high pressures and were changing their guidelines.

We all know that this is an incredibly diverse disease in the way it presents. If you take three identical 40-year-olds, one will have a mild illness, one will end up in ITU, and another won't even know they've had it, so why are we surprised that all patients are not behaving the exact same way on a ventilator?

A few days later, a New York doctor called Cameron Kyle-Sidell took to the Internet to say the same thing. As a YouTube doctor, I can hardly criticize that. The content was all very sensible. When a friend sent it to me to fact-check soon after it went up -- you can pause and read my response here [13:05 in the video] if you're interested -- it all seemed fine.

For reasons I think were out of his control, he became hailed as an iconoclastic whistleblower daring to stand up in the face of medical hegemony, a lone voice in a sea of clueless doctors, which has played directly into the conspiracy theorists' hands.

Instead of his views being part of a healthy, normal discussion about the changing understanding of a new disease, they have used it as evidence that doctors don't know what they're doing and that no COVID patient should be intubated -- which I don't think Dr. Kyle-Sidell has ever suggested -- and that the demands for ventilators are part of some fake news plot to discredit Trump or siphon money off to do something. I don't know. I can't keep track of all their crazy theories.

Brilliant people are not brilliant at everything. If you think Elon Musk's views on ventilation are valid, then I assume you think Mark Zuckerberg's attitude towards privacy and Jeff Bezos's thoughts about workers' rights are equally important. Just because he's a cooler billionaire than them, it doesn't mean we should treat him any differently.

This is a scary, previously unseen disease. People want a life ring when adrift in a sea of uncertainty, whether that's hydroxychloroquine, ventilators, or believing the whole thing is a hoax. The reality is that many questions about COVID-19 right now don't have an answer. We're trying to figure it out. We're going to get some things wrong. It's imperative that we're cautious and we don't get sidetracked with half-baked ideas.

Because unlike in Silicon Valley, where mistakes can cause investors to lose money, in medicine lives are at stake.

Rohin Francis, MBBS, is an interventional cardiologist, internal medicine doctor, and university researcher who makes science videos and bad jokes. Offbeat topics you won't find elsewhere, enriched with a government-mandated dose of humor. Trained in Cambridge; now PhD-ing in London.

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