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May 01, 2020

Veterinarians pledge ventilators, supplies to human medicine

Shortages of personal protective equipment cause practitioners to make tough decisions
Published on April 15, 2020

Veterinarians pledged hundreds of ventilators for human use as a surge of COVID-19 cases risked shortages.

N95 ventilator mask

Some also described efforts to conserve or donate personal protective equipment, such as gloves and masks, amid supply chain issues as the stress on human health care strained supplies. That threat of shortages expanded as the coronavirus causing the disease spread to more communities daily this spring.

As COVID-19’s spread accelerated—the U.S. leading the world in confirmed coronavirus cases with about 400,000 people as of April 7, according to Johns Hopkins University—leaders of the American College of Veterinary Emergency and Critical Care started a database of ventilators that could potentially be used for human health care. The zoo veterinarian and veterinary anesthesiology colleges added to the effort in the days afterward.

Dr. Elizabeth B. Davidow, president-elect of the ACVECC, led the effort to create the ventilator database. She had read newspaper articles describing a coming shortage of ventilators in human health care and heard ACVECC members were receiving inquiries from human health care providers about ventilators. She also talked with a human health care administrator at the University of Washington Medical Centers, and he described his institution’s search for backup ventilators.

She proposed to fellow leaders in the college developing a list so that, when hospitals call, the criticalists could refer them to someone nearby. To enter a ventilator into the spreadsheet, the form is available at jav.ma/ventilatorlist.

Dr. Davidow said she has enjoyed seeing how many people have been willing to help out.

Dr. Davidow also is a clinical assistant professor of emergency and critical care at Washington State University College of Veterinary Medicine, which pledged its two ventilators to nearby Pullman Regional Hospital, if needed. The town of Pullman, which includes the campus, had its first reported COVID-19 case March 23, she said.

At press time, available figures indicated Seattle and surrounding King County had 3,460 test-confirmed COVID-19 cases and 226 deaths. The state had almost 8,700 confirmed cases out of nearly 88,000 people tested, with 394 deaths, according to the Washington State Department of Health.

Veterinarians respond to call for help

States have asked for PPE and ventilators from the Strategic National Stockpile, the nation’s safety net of human medical-equipment supplies, to treat COVID-19 patients who develop acute respiratory distress syndrome as well as non–COVID-19 patients. So far, those totals have fallen short, leaving states to look for these items on the open market.

A strategy document for Washington state’s government, updated March 22, indicated the state requested 1,000 ventilators from the Strategic National Stockpile to treat non–COVID-19 patients and was working to buy another 500 ventilators to treat COVID-19 patients who develop acute respiratory distress syndrome, according to a copy of the plan available from the Washington State Hospital Association.

New York Gov. Andrew Cuomo said in public statements and briefings that New York struggled to buy medical equipment, including ventilators, because of global competition for the same products.

“Everybody wants to buy a ventilator, everybody wants to buy oxygen, everybody is trying to buy the same equipment, and it’s terribly scarce,” he said in a March 16 public briefing.

He said in a March 24 briefing that the state needed at least 30,000 ventilators. Thus far, the state had procured 7,000, but had only received 400 from the federal government.

Dr. David Smith, director of the New York State Department of Agriculture and Markets’ Division of Animal Industry, sent a letter to the New York State Veterinary Medical Society asking for veterinary hospitals to donate supplies, including ventilators, or other support for the COVID-19 response by contacting covid19assistanceatexec [dot] ny [dot] gov.

The New York State Department of Health posted a notice in late March saying it needed the help of “qualified health, mental health, and related professionals to supplement our health care capacity on a temporary basis to treat seriously ill coronavirus patients including those that may need to be intubated.”

Dr. Christopher Byers, who is an emergency and internal medicine veterinarian in Omaha, Nebraska, said his hospital pledged its ventilator to the University of Nebraska Medical Center, which houses a federal quarantine facility that has been used to isolate and treat COVID-19 patients.

He noted that, in addition to the hospitals and clinics that pledged ventilators through the ACVECC database, he knew dozens more that pledged their ventilators directly to local hospitals.

Veterinarians and physicians tend to use the same ventilator models for people and pets. He noted that his hospital, VCA MidWest Veterinary Referral & Emergency Center, uses pediatric settings to treat dogs and cats using a ventilator bought from a distributor of human medical supplies.

The Phoenix Zoo offered its three ventilators through the ACVECC database. Dr. Kristin Phair, director of veterinary services at the Phoenix Zoo, said two of the zoo’s ventilators are from a product line commonly used in human medicine, and the other has more variability, able to ventilate “anywhere from a mouse up to a lion,” she said.

“All of our machines do specifically say ‘for veterinary use’ on them, so it would be adapting a machine to human purposes,” she said. “But, for ventilation purposes, a lot of the parameters are all very similar.”

The zoo closed, and the veterinary staff postponed most routine care. Even in normal times, when veterinarians conduct routine care requiring anesthesia, the zoo tends to use only one machine at a time and have a surplus, she said.

“We felt like, if there is a need currently and if the machine can be utilized safely, then we have an obligation to contribute in any way that we can,” Dr. Phair said.

Dr. Khursheed Mama, who is a professor of anesthesiology at Colorado State University College of Veterinary Medicine & Biomedical Sciences, said anesthesiologists at veterinary colleges indicated to her they are willing to share their equipment. She noted that the life support ventilators used by criticalists are better designed for long-term care than the machines used by anesthesiologists for short-term administration of anesthetic gases and oxygen, but anesthesiologists are joining criticalists in checking their inventories.

“In other countries, it appears that the shortage of ventilators has been a limiting step in management of patients,” she said.

Rationing, preserving PPE

In a March 11 letter to health care providers, Food and Drug Administration officials acknowledged the U.S. could endure shortages of surgical masks, surgical and isolation gowns, and surgical suits. They recommended a series of changes to conserve that equipment, depending on how severe the deficit becomes. In a crisis, these strategies could include extended use of available equipment, prioritizing supplies, and reusing equipment where transmission risk is low.

The AVMA came out with guidelines on March 20 for use of PPE during the COVID-19 pandemic until certain supplies become more readily available.

“Postponing elective procedures that require the use of PPE is one way of conserving. Conservation strategies can also include safely extending the use of disposable PPE, re-using disposable PPE, or increased use of washable PPE,” state the AVMA guidelines, available at jav.ma/PPEguidelines.

FDA officials indicated in a Q&A the same day that the pandemic continued stressing the supply chain for gloves. The update includes a note that some gloves may protect beyond their expiration dates, although users should inspect for discoloration, holes, or tears, as well as consider when they need protection.

In mid-March, Dr. Byers said he knew of colleagues who were rationing gloves and face masks as supplies ran short.

“I know that they are heeding CDC guidelines and AVMA recommendations to temporarily hold off on elective procedures when medically appropriate,” he said.

VCA Alameda East Veterinary Hospital in Denver also rationed surgical masks as of mid-March. Dr. Christine Guenther, department head for emergency and critical care at the hospital, said her staff had enough gloves for the moment, but she noted medical gloves in human and veterinary medicine come from the same suppliers.

Confirming specific shortages can be challenging because the production and delivery networks are distributed rather than centralized.

Tim Atkinson, executive director of the New York Veterinary Medical Society, is chair of the task force formed by the Veterinary Medical Association Executives to coordinate state veterinary medical associations and see what PPE, ventilators, and other equipment could be available for human medicine. State VMAs sent a survey to members the afternoon of March 24 and, by the next morning, had more than 1,000 responses, he said.

Atkinson predicts those responses will provide a good picture of available inventory and how much could be contributed. He said March 25 that an analysis of the responses was pending, but anecdotes indicated many veterinary hospitals already were low on such supplies.

Ralph Johnson, CEO of the VMAE, said some clinics already donated what they could to human health care, whether through local or statewide connections, whereas he heard officials in at least one state agency were considering a mandate that veterinary hospitals surrender PPE to human medicine.

Such a mandate might be moot if veterinary clinics run out of PPE to share, shifting, for example, to cloth gowns they can launder or sterilize, he said. In Washington state, to conserve and procure PPE, officials have ordered that dentists cancel routine preventive care appointments, announced that they’re working with manufacturers in Washington to produce PPE, and have state prisoners making disposable hospital gowns.

Texas State Sen. Lois Kolkhorst, chair of the Senate Committee on Health and Human Services, has directly requested the veterinary community donate PPE to human health care facilities.

In a message to members, the American Association of Swine Veterinarians noted some states have asked veterinarians to donate or sell excess PPE to health departments and delay elective procedures, the latter of which both preserves equipment and increases physical distancing. AASV leaders also discouraged any hoarding of medical supplies.

CDC information indicates demand for global medical PPE rose with spread of the coronavirus, and countries including China, India, and Taiwan exported fewer medical products to the U.S.

Agency officials were considering whether to distribute N95 filtering respirators that remained in U.S. stockpiles beyond their labeled shelf lives. CDC National Institute for Occupational Safety and Health employees were evaluating the storage conditions at 10 U.S. sites holding respirators made since 2003.

“Based on preliminary information gained in this study, many models have continued to perform in accordance with NIOSH performance standards,” CDC information states.

But the notice also indicates certain small and regular-size Kimberly-Clark models, 46827 and 46727, respectively, may provide insufficient protection beyond their five-year shelf lives.

The CDC notice indicates the expired respirators should provide more protection than surgical masks alone, although the CDC does not recommend using N95 masks beyond their shelf lives in surgical settings.

On March 17, the American Association of Veterinary State Boards sent a letter to the U.S. and Canadian veterinary boards, recommending that “to the extent PPE supplies should be inadequate to supply the needs of veterinary practices, Member Boards should consider such shortages when called upon to review the standard by which such care (veterinary care) has been provided during the time of such shortage. Member Boards are encouraged to allow greater deference to the veterinarian’s professional judgment for unique circumstances that arise during these times of quarantine and resource conservation.”

The AVMA guidelines emphasize the importance of doing more than just conserving PPE. Referencing the hierarchy of controls from NIOSH, the AVMA said the best way to prevent disease transmission is to use a combination of interventions from across the hierarchy of controls.

“Elimination (physically removing the hazard) and substitution (replacing the hazard) are not typically options in the healthcare setting to prevent infectious disease transmission. However, engineering and administrative controls, and PPE can often be used to reduce or avoid exposures to transmissible pathogens in healthcare facilities. Prompt detection, effective triage, and isolation of potentially infectious patients are essential control measures to prevent unnecessary pathogen exposure of patients, healthcare personnel, and visitors in a given facility.”

 

The Food and Drug Administration, Centers for Disease Control and Prevention, and AVMA guidance on preserving PPE are available at jav.ma/fda_ppe, jav.ma/cdc_ppe, and avma.org/coronavirus.