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The U.S. is currently facing a shortage of ventilators. Here’s how they work and why they are so important in fighting COVID-19.

USA TODAY

As the coronavirus scuds across the USA, killing thousands and depleting medical resources, the pandemic is playing out precisely as emergency officials around the country assumed when they drafted response plans over the past decade:

A spreading disease would overwhelm hospitals, raising a strong possibility that physicians would have to choose which patients get life-sustaining care and which would die because of a shortage of medical equipment.

This heart-wrenching choice, known as the “crisis of care” dilemma, is an anticipated last resort in a severe pandemic, according to a USA TODAY review of 14 states’ preparedness plans. 

Those plans predict state and local emergency management agencies, with limited caches of supplies, would afford little help. They would plead with neighboring states and vendors for masks, gowns and ventilators. In a pandemic, inventories would be depleted worldwide, and factories would not be able to churn out products fast enough.

At that point, states would turn to the U.S. government’s Strategic National Stockpile, which houses only a fraction of what is needed nationwide. Last week, the stockpile was 90% depleted.

US coronavirus map: Track the outbreak in your state

As coronavirus patients fill hospitals, supply chains have become a laissez faire battleground. Hospitals and states are in a bidding war for resources, in some cases competing with the federal government.

“Everybody’s vying for the same things, so nobody’s going to give up anything,” said Brock Long, who was the Federal Emergency Management Agency’s administrator from 2017 to 2019 and is executive chairman of Hagerty Consulting, an emergency management advisory firm.

“FEMA is at the mercy of a public health system that was not designed to handle a pandemic of this magnitude,” he said. 

In short, the coronavirus pandemic threatens to overwhelm the U.S. health care system not because there was no plan but because that was the plan – at least as a last resort.

The nation has no coordinated storage system for emergency medical supplies. There is no list of state or local caches, let alone an inventory of what’s in them, confirmed a Department of Health and Human Services spokesperson who asked to be unnamed because she did not want to appear to speak on behalf of offices within the department.

The federal government doles out money to encourage local preparations, but states are not required to use it for supplies, according to the spokesperson. 

Emergency planners have long known a day of reckoning might come. That’s why many state pandemic plans spell out who should get life-sustaining care.

Health care workers in China and Italy faced these choices weeks ago as caseloads peaked. New York and other hard-hit locations in the USA nearly ran out of ventilators last week, though there are no known reports of patients dying because of a shortage.

The coronavirus pandemic appears to be relatively mild compared with an outbreak imagined by HHS for an exercise last year. In that scenario, dubbed “Crimson Contagion,” authorities battled a fictional flu that sickened 110 million Americans and killed 586,000, according to The New York Times.

A lack of readiness cannot be blamed on ignorance, said Dr. Ashish Jha, facultydirector of Harvard’s Global Health Institute. “We have known forever that we were going to get hit by a pandemic like this,” he said. “This was the scenario everybody talked about.”

Frontline heroes Who lives, who dies

In the past few weeks, hospitals in hot spots such as New York, Washington and Louisiana have sought thousands of ventilators to mechanically breathe for patients whose lungs have been weakened by the coronavirus.

The National Stockpile contained slightly more than 9,000 ventilators as of April 3, when New York Gov. Andrew Cuomo said his state would need 37,000.

State plans don’t simply anticipate hospitals could run out in a pandemic; they spell out how to ration the devices. 

Breathing machines: How ventilators work, and why COVID-19 patients need them to survive coronavirus

During a shortage, patients with organ failure are not eligible for ventilation. Those with high chances of survival get priority. In some states, so do health care workers and children. There is disagreement about excluding patients based on old age. 

In Colorado, if there are not enough supplies during a pandemic, patients are excluded from critical care treatment if they have severe dementia, incurable cancer or end-stage multiple sclerosis. 

In New York, Arizona and Alabama, a color-coded chart helps doctors determine which patients are eligible for ventilators during a shortage. Patients who fall in green or yellow get treatment. Those in red may be excluded. Those in blue get “palliative care” to reduce suffering before death.

There is no uniform guidance on how to decide between two patients who are equally qualified for lifesaving care. Some state plans say that should be handled on a first-come, first-served basis. Others say that’s unfair and advocate a random method such as a coin toss.

An overview of Florida’s plan estimates 71,000 people may be hospitalized in an influenza pandemic in which vaccines are in short supply. Up to 18,000 could die. “Demands on health care services under these conditions would overwhelm the state’s delivery system.”

Tough choices: Which coronavirus patients will get lifesaving ventilators? Guidelines show how hospitals in NYC, USA will decide

Frontline heroes A quest for supplies

America’s pandemic response network involves thousands of local, state and federal agencies and hundreds more regional coalitions representing hospitals, nursing homes, clinics and other health care providers. During an outbreak, each has a role, like antibodies in the human immune system. 

The medical supply chain is a key part of that system, yet, by all accounts, it is destined to come up short in a severe pandemic.

Hospitals generally keep just a few days or weeks of inventory on hand. Local and state medical caches are undersupplied or nonexistent.

In 2007, the Congressional Research Service studied state preparedness plans for a flu pandemic. Fewer than half even mentioned keeping caches of ventilators and other supplies, and the federal stockpile couldn’t amass the amount of drugs and equipment needed.

“The federal government is not going to have enough supplies,” said Long, the former federal administrator. “If your plan is to call FEMA 911, that is not good.”

Many state plans, however, say just that. 

The New Jersey pandemic influenza outlook says the state would obtain ventilators and other critical health care equipment from the Strategic National Stockpile and the state’s own stockpile.

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Wisconsin’s plan predicted an influenza pandemic and said there wouldn’t be enough hospital staff, beds or equipment. The state began stockpiling in 2007, said Joe Cordova, emergency response coordinator, but nearly all the supplies were used during the H1N1 pandemic of 2009. Because of federal funding cuts, they were never replaced.

“We could no longer afford a state stockpile,” Cordova said. The remaining protective supplies expired. 

John Walsh, co-director of the Vanderbilt University Medical Center Program in Disaster Research and Training, said government agencies generally have sound, detailed plans for routine crises such as flu or hurricanes but not for “black swan events.”

In the book “Three Seconds Until Midnight,” he and his co-authors warn the country is not prepared for a pandemic on the scale of the Spanish flu of 1918.

“The plans all look great, and they practice them,” Walsh said. “The details are what get everybody in a real bind. … When you get down to it, they don’t know what supplies they’ll need until they start running out.”

Lesley Ester, a California nurse, said she’s been forced to buy her own protective equipment because medical centers failed to prepare for a pandemic. “The fear is our hospital administrations are sending us to war without the proper equipment,” Ester said. “And they are willing to watch us die.”

Overwhelmed and discouraged: Mask, equipment shortages push nurses to brink across nation

A bottom-up response system

Although public attention has focused on the federal government, America’s emergency response starts in cities and state capitals.

That bottom-up structure has been apparent in public health campaigns to limit the spread of the coronavirus. Instead of federal directives to ban public gatherings and close schools, America has seen a staggered and confusing series of actions by businesses, mayors and governors. 

Coronavirus in the USA: How all 50 states are responding – and why eight refuse to issue stay-at-home orders

FEMA stresses that disaster operations are federally supported, state-managed and locally executed. That means hospitals, cities and counties bear the burden of care. The U.S. government offers information, advice and money, as well as backup supplies: The Strategic National Stockpile was created by Congress in 1999 “to supply states and communities with large quantities of essential medical material during an emergency.”

Over time, purchases diminished, and supplies expired. Seven years ago, HHS officials completed a study that, by happenstance, focused on the year 2020.

The critical finding: Between budget cuts and increased demands, it might be impossible to meet the demands of a crisis. Federal funding for two key state and local readiness programs has dropped by more than a third, from $1.3 billion in 2004 to $846 million last year.

The Hospital Preparedness Program, overseen by HHS, distributes about $265 million each year for regional pandemic planning. 

States dole out that money to 476 health care coalitions, which organize regional planning for about 31,000 counties, cities, hospitals and other health care enterprises,

Early warning: Coronavirus response delayed despite health officials’ private alarm

Frontline heroes Limited supplies from Florida to Colorado

In southern Colorado, Emily Brown, chair of the San Luis Valley Healthcare Coalition, said her group gets $139,000 a year from the Hospital Preparedness Program.

The coalition, which covers six rural counties, has no stockpile, Brown said. Instead, federal money goes to training, exercises and a preparedness coordinator. “We’ve been given directions we’re not supposed to be putting money into supplies,” she said.

Brown, who is public health director for Rio Grande County, said residents are high-riskbecause of age, chronic illnesses and poverty. Having few acute-care beds, she worries the coronavirus will hit rural towns such as Del Norte after supplies have been sapped by metro hospitals.

Brown said her office has about a hundred N95 respirators and a small supply of masks. The state maintains a small cache for disaster relief. “I know it’s not enough,” she said. “We always kind of anticipate we won’t get the resources we’ll need.”

The Emerald Coast Healthcare Coalition, covering 10 counties in the Florida Panhandle, gets about $300,000 from the federal government each year. It does not buy supplies with that money.

Instead, said Ann Hill, the coalition’s executive director, a related nonprofit group built up a stash of 15,000 N95 masks and 250 protective suits. They have been distributed already, she said.

In New Jersey, millions of recently donated personal protective items have been placed in warehouses.

Gov. Phil Murphy signed an executive order last month requiring health care facilities to inventory their supplies and count patients every day. That data is fed into a dashboard that state police use to figure out where supplies are most needed.

Texas offers a telling example of the dynamics of preparedness, politics and finances.

During a drill in 2006, hospital officials warned they were “not prepared to manage the surge that would result from even a mild influenza pandemic.” Hospitals “will be unable to function.”

Five years ago, emergency planners said the state needed a cache in case of a coronavirus outbreak. They urged mass purchases of protective equipment, but a bill to pay for it fizzled in the Legislature.

Last week, Texas officials instructed health care providers to stretch out personal protective equipment as cases climbed. 

Frontline heroes Coping with ‘lifeboat ethics’

Years ago, HHS began trying to organize the constellation of agencies, nonprofit groups and health care facilities that share responsibility during a pandemic. It created requirements for states to conduct exercises and submit planning documents,including state readiness reviews that were to be evaluated and ranked by federal inspectors. 

A 186-page guidebook contains vague directives to assess the number of hospital beds, health care workers and medical supplies. States are required to submit details about warehouse door sizes, their number of forklifts, refrigeration temperatures, ramp heights and other minutiae.

They are urged to use a national system “to manage the large and quick-moving inventory they may receive from the Strategic National Stockpile.”

The HHS spokesperson said those reports are not due until 2022. States will receive preparedness grants even if they don’t meet the requirements. She said materials submitted to date, as well as state ratings, are not being publicly divulged in part because of national security considerations.

Jim Blumenstock, chief program officer for health security with the Association of State and Territorial Health Officials, said federal grants are not designed to build caches at the local or state level; they are supposed to finance training and exercises to ensure that command operations, communication networks and distribution plans work.

Blumenstock said the U.S. preparedness system is “a good model” that is working as planned, even though the coronavirus has depleted supplies. The problem, he said, is that this is a historic pandemic.

“It is the worst-case scenario,” Blumenstock said. “When you have limited resources, you have to prioritize what is best for the greatest number of people.”

James Thomas, who has foreseen this sort of event, said he hopes medical workers don’t have to employ “lifeboat ethics” – deciding “who you’re going to toss overboard.”

“We knew in advance we weren’t going to have enough ventilators and respirators,” said Thomas, an associate professor of epidemiology at the University of North Carolina’s Gillings School of Global Public Health. “We could say, ‘Well, that’s nobody’s fault.’ … (But) we knew what needed to be done and didn’t succeed.

“The argument is we can’t afford it and we have these other crises. So what we end up with is the tyranny of the urgent. We just run from fire to fire,” Thomas said. “And look what COVID is doing to our economy.”

For this story, USA TODAY reviewed pandemic plans for the following states: Alabama, Arizona, California, Colorado, Florida, Illinois, Michigan, Minnesota, Missouri, New Jersey, New York, Ohio, Texas and Wisconsin.

Contributing: USA TODAY Network reporters Gabrielle Canon, Michael Diamond, Joel Engelhardt, Steven Foley, Arpan Lobo, Kevin McCoy, John Moritz, Nick Penzenstadler, Dinah Voyles Pulver, David Robinson and Kristen Shamus

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