We will probably know if H1N1 will be a hit or a miss in the next 90 days. The range of possible outcomes is enormous. In an average year we would suffer 35,000 deaths to flu. This comes to .01% of the population. There is no indication that this year will be any different. There are some worrisome issues however.

-Swine flu has its highest mortality rates in the 5-25 age range. This is asymmetric to other flu results. Typically the very young and very old segments of the population would be most affected

-H1N1 ravages the lungs of those severely affected. It is the cause of death.

The vast majority of those who will be acutely impacted will require a ventilator. Without it they will die. The question is, "Is there enough of these machines?" The answer to that is dependent on the number people who become ill. If that number is high, then we do not appear to have the respirators that may be necessary.

To my knowledge there is no national public numbers on this topic. In 2007 New York State provided some information and analysis on this issue. I will use that data to extrapolate some estimates. From the report:


*15% of the admitted patients with pandemic influenza will require intensive care,
*7.5% of the admitted patients with pandemic influenza will require ventilators,
*There are currently 6,100 ventilators in acute care settings in New York State,
*At any given time, 85% of the ventilators in acute care settings are in use, and
*70% of deaths related to pandemic influenza are projected to occur in a hospital.

NY State has a population of 20 million. Prorate the NYS information across the total population of 330mm and you get:

-The total number of respirators is 100k.
-The number of respirators that are available net of other needs is only 15,000.

In a ‘normal' flu season 200,000 patients require hospitalization. Using the NYS number of 7.5% needing ventilation you get to that 15,000 number very quickly. In the event of a severe outbreak, triage of ventilators will be required. If one was concerned about the, End of Life Counseling debate the discussion on how to handle a shortage of ventilators will ring a bigger bell. The first group to go will be those that are being vented and have one of the following:

Severe congestive heart failure; acute renal failure; severe chronic lung disease; AIDS with a low CD4 count; active malignancy with a poor potential for survival; cirrhosis; hepatic failure; and irreversible neurologic impairment, including persistent vegetative state.

This seems to be an easy choice. It is likely that teenagers will be competing for the equipment. But the questions arise if that is not enough. Some thoughts on that by Dr.s' Hick and O'Loghlin, * they propose:

"the Extubation of any patient "who might be stable, or even improving, but whose objective assessment indicates a worse prognosis than other patients who require the same resource." Thus, patient A's continued use of the ventilator appears to depend not only on the estimated survival probability of patient A, but also upon that of newly arriving patient B, whose better health status leads to the extubation and probable death of A, and the intubation of B (at least until C arrives)."

That ‘logic' is going to cause trouble if it comes down to it.

From the NYS report:

"Patient consent, the mainstay of ordinary medical care, will not be the determining factor in allocating ventilators. Threatened and actual legal actions are reasonable concerns in response to any emergency rationing scheme."

At the end of the day what we are really worried about are the lawyers.