Medical Devices in the Age of COVID-19

In response to the shortage of ventilators, respiratory equipment, and personal protective equipment, people throughout the entire maker community are working on designing and manufacturing cheaper alternatives.

As a result, the medical device industry has come under more scrutiny. People have realized that most medical equipment is rather simple at its core. However, this is a double edged sword. They have also realized that medical equipment is expensive for a reason, and that a lot of thought goes into designing the equipment for a vast variety of patients and scenarios.

It’s a surprising dichotomy.

Brian McManus, from the YouTube channel Real Engineering, provides some excellent constructive criticism on the open source maker efforts. He explains exactly why ventilators are complex devices that need to take into account a large number of factors, such as the breathing rate and air flow of patients. The vast majority of simple low-cost “ventilator” designs simply don’t take these other critical factors into account and are instead automated BVMs. Of course, we don’t want to disparage the community effort, but it’s important to keep this in mind.

Dossier

“A Guide to Designing Low-Cost Ventilators for COVID-19,” by Real Engineering, April 4, 2020. https://www.youtube.com/watch?v=7vLPefHYWpY

“How to Help Your Hospital (Fight COVID-19 Locally) – Smarter Every Day 233,” by Smarter Every Day, April 7, 2020. https://www.youtube.com/watch?v=sbEj7M3aZIg

“Do Some Surgical Implants Do More Harm Than Good?” by Jerome Groopman, April 13, 2020. https://www.newyorker.com/magazine/2020/04/20/do-some-surgical-implants-do-more-harm-than-good

The Heroes During Disasters

Society has taken to calling those that continue to provide essential services through the pandemic heroes. This refrain continues to be used by society through every disaster, but this time it’s different. This time, essential workers are not there by choice.

Despite this, they are still forced to grapple with the prospect of their own mortality. And not just their own; when they go home, they are putting their families at risk as well. It is a difficult choice for many. Some feel pressured to continue to work by their civic duty and professional responsibilities, as is the case for many physicians and healthcare professionals. Far more, such as grocery workers and restaurant employees, feel pressured by their employers or their financial situation.

The impacts are therefore disproportionately felt by those at the bottom rungs of society whose work can often only be done in-person. In contrast, the wealthy can settle down in their home offices and use their laptops to continue doing the vast majority of their work remotely. In between are physicians and healthcare professionals. Traditionally seen as wealthy, they are nonetheless still at risk, particularly those caring for COVID-19 patients.

People have thus lauded healthcare workers, calling them the heroes of our age. That refrain has gone on to be used for all essential workers. But this hero talk obscures greater truth.

It can be difficult to focus on seemingly anything other than the coronavirus and COVID-19. But, as a consequence of this pandemic, a lot of the subtle issues that have always plagued our society have come to the front and center. These are trying times, and so, we should use them to reflect and ponder, think of solutions, and most importantly act on them today so that they are no longer problems tomorrow.

We have quickly realized that the world is more interconnected and interdependent than ever before. And while this comes with amazing benefits under normal circumstances, these are not normal circumstances. It seems that with every passing day, we have drifted away from normalcy; from those halcyon days we remember.

Sadly, even back then, the same problems existed. But they were swept under the rug. No one cared enough to address them because everything was moving forward, the world was becoming a better place. Society had a collective optimism about the future. And that was reflected in its values, its books, its movies. Slowly we moved into the idea of a cyber-dystopia. You can see it everywhere in the popular media of our time.

Finally, society has realized that the people we once overlooked, are in fact the ones we depend on the most. Take the grocery store employees, for example.

Working in a grocery store has earned me and my co-workers a temporary status. After years of being overlooked, we suddenly feel a sense of responsibility, solidarity, and pride. . . . A sign attached to the shirt read NOT ALL HEROES WEAR SCRUBS.

I’m grateful to be acknowledged for the risky work we’re doing. Being in an environment where morale is up despite global uncertainty is encouraging. But I have a problem with all this hero talk. It’s a pernicious label perpetuated by those who wish to gain something—money, goods, a clean conscience—from my jeopardization.

[. . .]

Unlike medical personnel and emergency responders, we didn’t sign up for potentially life-threatening work.

[. . .]

Cashiers and shelf-stockers and delivery-truck drivers aren’t heroes. They’re victims. To call them heroes is to justify their exploitation. By praising the blue-collar worker’s public service, the progressive consumer is assuaged of her cognitive dissonance. When the world isn’t falling apart, we know the view of us is usually as faceless, throwaway citizens. The wealthy CEO telling his thousands of employees that they are vital, brave, and noble is a manipulative strategy to keep them churning out profits.

Karleigh Frisbie Brogan

This sentiment is echoed by others in the industry: “We didn’t sign up to be heroes, and we certainly didn’t sign up to be martyrs,” says Maria Leon

I’m not sure that doctors and nurses did either.

I’ve been to disasters all over the world, and I have always seen health-care providers pour in to help. Usually, within an hour, there are more than are needed—nurses, lab workers, X-ray technicians, doctors. No one has to ask; they just show up. And then they work nonstop until someone makes them take a break or they fall exhausted. It’s what we do.

But that sort of bravery, that work ethic, is not boundless. No one is so fearless or stupid as to discount all risks.

[. . .]

This is the dark secret of planning for a pandemic that can also kill health-care providers and their families. When we prepare for disasters, we plan using the mnemonic “Staff, stuff, space, and systems.” We can always make more space by wedging an extra bed in, or by repurposing another building. We can buy more stuff, supplies, and equipment. We can find new supply lines, reboot our computer systems. But we cannot conjure up doctors and nurses and health-care technicians. Physicians take at least 11 years to train after high school. Nurses at least four. Techs take years or months.

The United States needs its health-care workers to see it through this crisis. But there are no replacements on the shelf. They can’t be built, trained, or repurposed from other jobs. Unless the country does dramatically more to provide them with the equipment they need to do their job safely, to assure them they will be cared for if they fall ill, and to provide their family with a measure of security, it risks losing them. What happens when they need to be quarantined? When they start to die? Or don’t come to work?

Thomas Kirsch

Despite the sacrifices that doctors, nurses, and other clinicians make, I’m not sure that many of them would have imagined that their own mortality, much less the mortality of their loved ones, would be at stake as a result of their work.

Society has now come to grips with a question that no one really wants to know the answer to: are physicians, healthcare professionals, grocery store workers, and other essential workers still responsible for coming in to work?

I hope we don’t come close to the answer that we all know.

Clap for me and other healthcare workers at seven o’clock if it makes this pandemic feel more bearable. I concede, your cheers help us trudge on. Just know that cheers and hollering don’t change the outcome. This is my fervent plea – that we change what we can after all this is over.

KP Mendoza

Mendoza’s poignant call reminds us of the stakes. No one can escape the pandemic, much less its drastic effects. This will live on for the rest of our lives, perhaps longer. It is now up to us if it will result in good, or no action at all.

Dossier

“No One Is Supporting the Doctors,” by Steven McDonald, April 18, 2020. https://www.theatlantic.com/ideas/archive/2020/04/doctors-already-manage-alone/610249/

“Calling Me a Hero Only Makes You Feel Better,” by Karleigh Frisbie Brogan, April 18, 2020. https://www.theatlantic.com/ideas/archive/2020/04/i-work-grocery-store-dont-call-me-hero/610147/

“I Did Not Sign Up for the Military. I Signed Up for Walmart,” by Anna North, April 23, 2020. https://www.vox.com/2020/4/23/21229942/coronavirus-grocery-store-workers-walmart-covid-pandemic

[Facebook Update], by KP Mendoza, April 14, 2020. https://www.facebook.com/kp.mendoza.23/posts/10216675050615188

“America’s Other Heroes,” by David Goldfein, March 31, 2020. https://www.theatlantic.com/ideas/archive/2020/03/americas-other-heroes/609145/

“The Reason Hospitals Won’t Let Doctors and Nurses Speak Out,” by Theresa Brown, April 21, 2020. https://www.nytimes.com/2020/04/21/opinion/coronavirus-doctors-nurses-hospitals.html

“What Happens If Health-Care Workers Stop Showing Up?” by Thomas Kirsch, March 24, 2020. https://www.theatlantic.com/ideas/archive/2020/03/were-failing-doctors/608662/

Electrification of Last Mile Delivery

The sight of a USPS postal van driving around, or stopped by the side of the road with its blinkers on, is a familiar site for most Americans. And rightly so; these vehicles have been on the roads for over 26 years, well past their intended duration of use.

David Roberts suggests that now might be the perfect time for the electrification of the USPS postal van fleet. His arguments are wide-ranging, including environmental, economic, and political. I want to focus on the environmental and practical reasons why electrification makes a lot of sense, particularly for the type of operations that the postal vans do on a daily basis.

There are two aspects to postal logistics, each with very different requirements and timeframes. The main logistics operations occur mostly behind the scenes, overnight, at large postal sorting facilities, warehouses, and airports, across the country. But what most people see and experience is the “last mile,” that is, the actual delivery of items to its final destination at homes and businesses.

The last mile delivery is a perfect example where an electric drivetrain particularly suits the demands. Roberts argues that electrification solves several problems at once.

For last mile delivery, an electric drivetrain is particularly well-suited. For example, electric drivetrains have (1) more torque and acceleration, and negligible energy loss during idle, (2) fewer moving parts for less need of maintenance, (3) reduced emissions where they are difficult to control, i.e. at the vehicle rather than a power plant, and (4) significantly cheaper for the USPS in the long run. I discuss this topic in more detail, specifically in the context of aviation and its requirements, in my earlier post on the Dilemma of Electric Aviation.

The post office primarily delivers during the daytime. Therefore, the vehicles can easily be charged overnight when electricity costs are significantly reduced. Electricity infrastructure is already widespread and so retrofitting post offices with charging stations does not seem to be too challenging.

While I am certainly not an expert on electric grid optimization, I suppose that charging postal vehicles during the night would create a baseline demand to help absorb the excess output of traditional power sources, such as natural gas or nuclear. These types of power plants must remain functional at all times, (1) as a backup source and (2) as they cannot easily be switched on and off rapidly.

Additionally, Amazon has made some advances in partnership with Rivian, developing a vehicle platform that could also be adapted for the postal service.

Interestingly, Roberts pointed out that these vehicles, which collectively drive to almost every address in the United States every day, would be a powerful platform for mounting weather sensors. This is a fascinating application that I would not have thought of. While this certainly does not require electrification, I think it is interesting.

Earlier this year, when I wrote about the dilemma of electric aviation, where I mentioned that ground-based transport would likely be the biggest driver of electric innovation. I think that the electrification of the USPS postal van fleet would be a powerful statement and would likely contribute positively to the public perception of electric vehicles.

Roberts argues that now is a great time to act. I’m inclined to agree and I think that such action would be an incredibly large step in the right direction.

Dossier

“A No-Brainer Stimulus Idea: Electrify USPS Mail Trucks,” by David Roberts, April 22, 2020. https://www.vox.com/energy-and-environment/2020/4/22/21229132/usps-coronavirus-electrify-postal-trucks

“The Dilemma of Electric Aviation,” by Sahil Nawab, January 10, 2020. http://www.sahilnawab.com/blog/the-dilemma-of-electric-aviation/

Empathy in Medicine

Years ago, in religion class, we learned about virtue. This is a lesson that has stuck with me ever since. Here, I use virtue in a strictly philosophical sense. Aristotle defined virtue as the balance between two extremes of a trait. Specifically, he noted that balance does not necessarily mean the exact middle point. Rather, Aristotle used the concept of the golden mean to emphasize that virtue relies on moderation.

When Aristotle wrote about this, he used the example of courage. He defined courage as the golden mean between bravery and cowardice. Someone who is brave is rash, and has no fear. Someone who is cowardly is so overwhelmed by fear that he fails to act.

However, with courage, there is no absence of fear. Rather, someone who is courageous acts despite that fear. It is in facing that fear that makes courage a virtue. And so, to exhibit the virtue of courage requires moderation between the two extremes.

Likewise, empathy in medicine is a virtue.

In order to effectively treat patients, physicians need to emotionally distance themselves from the patient. They must not let emotion cloud their judgement. In most hospitals, there are rules against treating family and friends for this very reason.

Yet, as the ones responsible for presiding over some of the darkest times in patients’ lives, physicians must have empathy. Patients rely on them for support and guidance, and without empathy, physicians are no more than mere technicians.

Dr. Stuart quotes Brené Brown, “Rarely, if ever, does an empathetic statement start with ‘At least.’ . . . Rarely can a response make something better. What makes something better is connection.”

That last part stood out to me. We often have the idea that we can solve any problem, and this is especially true in medicine. We can be overcome by hubris; we think that we have the power to stop death in its tracks.

This serves as a stark reminder that all we really have is the human connection.

It can be hard as a doctor to keep my “empathy tank” full. I’ve had bad days when I diagnose a 25-year-old with a terminal illness, and later find I have trouble caring when a friend calls to complain about a snack-stealing roommate. I worry that the coronavirus era will strain our collective ability for empathy, but I also have hope that we will rise to the challenge.

Jessie Stuart

Dossier

“The Least Empathetic Thing to Say, by Jessie Stuart, April 9, 2020. https://www.wsj.com/articles/the-least-empathetic-thing-to-say-11586458213

What Should Med School Curriculum Focus On?

Earlier this year, I commented on a discussion from the Wall Street Journal about modern medical education.

Reading Dr. Goldfarb’s new arguments during the COVID-19 situation, I’m beginning to understand his argument. It’s surprising to hear that “American medical training as a whole doesn’t include a strong grounding in public-health issues or disaster preparedness.” In hindsight, this seems to be a striking omission from the curriculum.

Adding this to the curriculum may be a good idea. Dr. Goldfarb argues that “doctors should learn to fight pandemics, not injustice.”

Above all, the medical profession should abandon the fantasy that physicians can be trained to solve the problems of poverty, food insecurity and racism. They have no clinical tools with which to address these issues.

Stanley Goldfarb

I agree that physicians certainly do not have the tools to solve poverty, food insecurity, or racism. However, I’m not sure that any physicians actually believe in this fantasy. Certainly, more of the curriculum should focus on clinical issues such as pandemic response or disaster preparedness in general. Maybe that will come at the expense of training on societal issues.

However, that part of the curriculum isn’t important because it teaches physicians to solve these problems or treat them directly. Rather, by being aware of these issues and biases, physicians can take a much more nuanced approach to treating patients in the broader context of society.

While I do agree that physician training should be focused on actually treating patients. Responding effectively to global issues that have an effect on treatment, such as climate change, social determinants, or natural disasters, is just as important. Ultimately it is important to be aware of these issues and how they impact the health and healthcare of the patients that physicians treat.

Dossier

“Med School Needs an Overhaul,” by Stanley Goldfarb, April 13, 2020. https://www.wsj.com/articles/med-school-needs-an-overhaul-11586818394

“Discourse on Modern Medical Education,” by Sahil Nawab, January 24, 2020. http://www.sahilnawab.com/blog/discourse-on-modern-medical-education/

Middle School is About Lunch

It’s no surprise that our childhood has a significant impact on our future lives. Though I think most of us might not expect how much sway middle school truly holds. A number of books and films illustrate this as Julie Beck points out. “It’s really rare to see a coming-of-age story set in middle school. It’s much more often high school or even college.” Yet this dearth of literature belies the importance of that age.

‘Middle school is about lunch.’ [. . .]

Initially, the biggest shift middle school brings is one of context. Most American students move from spending the bulk of the day in one classroom and with one set of classmates—a social bubble of sorts—to multiple classrooms and multiple new classmates. Their number of potential social possibilities swells. Children are entering a period of maximum concern over acceptance or rejection and over how they will be perceived.

No wonder lunch looms large. In many schools, it is the time in the day when these preteens have the most agency. It is why the movies are filled with so many scenes of anxious children holding a tray and not being sure where to sit.

Lydia Denworth

The impact of surrounding friends is often taken in a negative context, i.e. “peer pressure.” But that idea is somewhat outdated. Denworth cites Steinberg’s research into the “peer effect,” explaining that “pressure doesn’t have to come into it, merely presence.” And this presence can have a genuine positive impact.

Too often educators and parents fail to appreciate the potential upside of these strong ties. Teachers often separate friends, whose banter can be disruptive in the classroom. Yet when researchers record student conversations during class, there is evidence that while kids are problem solving or working together, students collaborate more effectively with their friends. “Their dialogue is much deeper, cognitively more complex, than when we ask kids to work with just any classmate,” Juvonen said. “It’s really interesting that we as adults in the society often regard friendships more as a nuisance and a distraction rather than give them the value that they really deserve.”

[. . .]

But Steinberg and his colleagues have also shown that teenagers learn faster when they’re with their peers than they do by themselves. And they engage in more exploratory behavior when they’re with their peers.

Who the peers are becomes very important. “Parents shouldn’t worry about peer pressure or peer influence,” Steinberg said. “They should worry about who the peers are that their kids are hanging around with.” When kids hang around with students who get better grades, their own grades go up over time. . . .

“The question really is, whom are they influenced by and what is it they are being pressured to do?”

Lydia Denworth

Dossier

“The Outsize Influence of Your Middle-School Friends,” by Lydia Denworth, January 28, 2020. https://www.theatlantic.com/family/archive/2020/01/friendship-crucial-adolescent-brain/605638/?utm_source=feed

“In Middle School, ‘You’re Trying to Build a Parachute as You’re Falling,'” by Julie Beck, August 1, 2018. https://www.theatlantic.com/family/archive/2018/08/bo-burnham-on-the-incredible-honesty-of-middle-schoolers-online/566579/

“How Middle School Failures Lead to Medical School Success,” by Jessica Lahey and Tim Lahey, March 19, 2013. https://www.theatlantic.com/national/archive/2013/03/how-middle-school-failures-lead-to-medical-school-success/274163/