As an anesthesiologist, if I were asked my opinion on the aggressive ventilator policy being used to combat COVID-19—for example, splitting a ventilator between two patients, as some NYC hospitals are now doing, or refitting anesthesia machines as ICU ventilators—I would say we had pretty much reached the limit of what we can do. But if my own daughter had COVID-19, and her life were at stake, I know I could (and would) do more. The question is whether what I would do as an anesthesiologist, out of desperation to save my own child, can provide a strategy for the country as a whole, if the April peak in COVID-19 cases results in a ventilator shortfall.

The country has roughly 160,000 ventilators. An additional 40,000 ventilators are attached to anesthesia machines in the nation’s operating rooms. It is uncertain whether this number includes the anesthesia machines in outpatient surgery centers, but for the sake of argument let’s say 200,000 ventilators exist in the United States. That might not be enough to manage next month’s expected deluge of severe coronavirus cases, especially when other patients need those ventilators for traditional reasons. Governor Cuomo of New York has asked for 30,000 ventilators for his state alone. Hopefully more ventilators will come online as the automobile companies re-tool to manufacture them, but they may not come fast enough.

We need ventilators to treat the severe acute respiratory distress syndrome (ARDS) that can occur with COVID-19. ARDS increases the pressure a person must generate to take a breath. When the person tires out and grows hypoxic, he or she needs a ventilator. I’ve often observed the high positive pressure needed to force air into the lungs of ARDS patients during surgery. In some cases, especially in ARDS stemming from major trauma or burns, the requisite pressure can be enormous. In the past, when dealing with such patients, and when ventilator therapy was a little different, I would ask the ICU team to transport the patient’s special ventilator with the patient for use during the anesthetic, since an anesthesia machine ventilator cannot reliably generate such high pressures. Instead of giving gaseous anesthesia through the anesthesia machine, I would bypass the machine and use total intravenous anesthesia.

These days, doctors ventilate ARDS patients with lower pressures—up to the “30” mark on the pressure gauge, rather than the “70” mark, or higher, which is hardly more than what I use when ventilating healthy anesthetized adults. This is because ARDS patients are given half the breath size that healthy patients under general anesthesia receive, although the number of breaths per minute is correspondingly increased, often to 35. The old method of ventilating ARDS patients with bigger breaths and slower breathing rates, which mimics how people usually breathe, increases their mortality rate by ten percent, through pressure-induced lung injury.

With my healthy anesthesia patients I sometimes bypass the ventilator on my anesthesia machine when breathing for them. I just manually squeeze the anesthesia bag to a pressure of “30” every few seconds to give a breath. It’s tiresome to do so over a long period, but it is doable, and I often do it. In fact, I don’t even need the anesthesia machine to give these manual breaths. Some of the older disposable anesthesia circuits (called T-piece systems) come with an anesthesia bag attached. When I hook up the circuit to sufficient fresh gas flow, to wash out the patient’s carbon dioxide that exits with each breath, I squeeze the bag and ignore the anesthesia machine altogether. There are many such circuits lying around; at the very least they would be easy to manufacture. In addition, thousands of Ambu bags sit in paramedic trucks, doctors’ offices, recovery rooms, and patient hospital rooms across the nation. They are, by definition, a bag that can be squeezed. I use them often when transporting patients to the recovery room.

A T-piece-like system or an Ambu bag is the kind of contraption I would use on my own daughter if she developed ARDS from COVID-19, and no other ventilator option existed. There will be naysayers to this strategy. “You can’t squeeze a bag 35 times a minute for long,” they will say. True, but I can squeeze 15 times a minute using larger breaths, which may not be optimal, but it’s better than nothing, I would reply. “You can’t squeeze a bag for longer than two hours at a time,” they will say. True, but a father’s dedication can carry one pretty far, and when I grow tired I can get friends and family members to take turns squeezing the bag, I would reply. “You can’t give 100 percent oxygen for long, as you’ll cause oxygen toxicity,” they will say. True, but I have 24 hours before that occurs, I would reply, during which time I’ll send someone to find a gas canister filled with air to mix with the pure oxygen to lower the concentration. “You can’t apply positive-end-expiratory-pressure (PEEP),” they will say. PEEP is the pressure maintained against the lungs at the end of each breath, and used in ARDS therapy to keep the lung’s air sacs open. Although not optimal, there are portable PEEP valves that I can stick onto an Ambu bag, I would reply. They’re better than nothing. T-piece-like systems even come with tiny valves restricting the exit of gas that I can tighten to create a version of PEEP.

With the imminent peak in COVID-19 cases, policymakers fear they may have to ration care. Plans to do so already exist. For example, the media recently leaked a memo from the Henry Ford Health System that discusses the rationing of ventilators as a “worst case scenario.” In Italy, rationing has become the norm. In one well-publicized case, an Italian priest, in an act of charity, surrendered his ventilator to a much younger person and died as a result. In the sterile, unemotional boardrooms where policymakers make decisions about health care, the inability to think outside the box is understandable. Only when a crisis hits home do people really start to innovate in ways previously considered unthinkable.

Rationing positive-pressure ventilation in COVID-19 patients need not occur. In a worst-case scenario I can envision enormous tents filled with ICU-like beds, built alongside hospitals already full, with ARDS patients lying in those beds, spaced 20 feet apart and surrounded by some friend or family member taking a turn at ventilating a loved one, and using an Ambu bag or T-piece-like system hooked up to the tent’s source of oxygen and air. Rather than a family member or a friend, maybe it will be a volunteer who has recovered from COVID-19 and is immune. Maybe it will be a National Guardsperson taking a turn at the Ambu bag. (President Trump recently activated National Guards units for service.) Naysayers will say this is beyond the call of duty for reservists, yet American soldiers saw much more onerous duty in World War II battlefronts. Asking them to take turns squeezing a bag, assuming they wear proper protection while doing so, would not be beyond the call of duty.

Two days ago, officials in NYC announced they were exploring the possibility of using manual ventilation to compensate for the lack of ventilators. Yet their unease when making the announcement was palpable, which may detract from getting the program off the ground in quick time. In regard to the plan, Governor Cuomo said, “The short answer is ‘no, thank you.’ If we have to turn to this device on a large-scale basis, that’s not an acceptable situation.” Yet detailed instructions for how to manage a crisis do not always come with that crisis. Established rules for how to care for a disease in normal times cannot always guide decisions during a situation with no precedent. I know this as a physician. I know what these government officials are thinking and feeling. The inner voice of judgment whispers a way forward, but established protocols for how to manage a disease in normal times clouds their minds. The protocols make their minds afraid to deviate from the prescribed path. The idea that officials should manage a crisis not through universal rules, but through a half-conscious sense of the vital elements in a situation, unnerves them—as it has unnerved me occasionally, as a doctor, when facing highly unusual situations. But now is not the time for government officials to embrace habit or crave routine. Doing so will not save them or the COVID-19 patients with ARDS. Practicing medicine for 30 years taught me that conventional treatment algorithms do not always apply, although doctors wished they did. Rules and guidelines have exceptions, and the COVID-19 crisis is one of those exceptions.

Why not plan for this? In 2018, President Trump signed the Right to Try Act, which allows patients with terminal disease to try experimental therapies that have not yet received FDA approval. Such patients will die without any therapy; perhaps an experimental therapy will work, so why not let them try, goes the thinking. The same principle applies during a ventilator shortage. Patients (and their loved ones) have the right to try when not trying leads to certain death.

Medical professionals typically resist inviting laypeople to help provide health care in a crisis, as they jealously guard their turf. Just recently, for example, the American Society of Anesthesiology expressed concern that legislators might allow more nurse anesthetists to practice independently of anesthesiologists during the COVID-19 crisis. Nurse anesthetists are not even laypeople; they are co-professionals; and yet there is still wariness. The Society makes a good argument for why the practice should not occur during a period of normalcy, but the COVID-19 crisis is not a period of normalcy.

A longstanding trend in health care makes the assistance of laypeople feasible in another way. The division of labor, meaning occupational specialization, has intensified in health care—indeed, in all fields—over the past 40 years, much to the chagrin of many health care workers. Doctors and nurses often train and specialize in carrying out a few technical procedures over the course of their careers. This causes some doctors and nurses to grow bored with their work, while also making them very good at what they do—better than what a generalist can do when performing the procedure only sporadically. Consistent with this trend, medical practice has become a series of tasks. Fortunately, a couple of those tasks are uncomplicated. Semi-skilled laborers can learn to perform them in a few days.

We can use this trend in health care to our advantage during the COVID-19 crisis, as laypeople can be trained very quickly to perform uncomplicated tasks in an ICU setting. Their presence can free up trained medical professionals to engage in more important duties. A layperson, for example, can be trained to suction a COVID-19 patient’s endotracheal tube or to help turn the patient prone every few hours, which assists in ventilation of the lungs.

The scheme is not perfect, but an imperfect scheme put into action is sometimes better than a perfect one accomplished too late. New ventilators may not come online until after the peak in COVID-19 cases has passed. Allowing a layperson to function as a “human bellows” during that peak may help some ARDS patients survive when the alternative is no ventilator at all—and certain death. It may also free up the more sophisticated ventilators to be used in the most complicated ARDS cases.

Now is no time to adhere closely to traditional rules and regulations. We must ignore the person who insists that something can’t be done simply because it has never been done before. In this spirit will I stand ever ready in April, endotracheal tube and Ambu bag at my side.