Ventilator venting

This piece is my personal perspective on the COVID19 triggered ventilator-related work among the engineering/scientific community of Pune. I was associated with the College of Engineering, Pune (CoEP) team as a volunteer with the aim of developing low-cost ventilators in collaboration with B.J.Medical College & Sassoon Hospital, Pune.

We started working on ventilators shortly after the national lockdown was declared on the 21st of March 2020. I joined the team as a volunteer having no previous connection with CoEP institution. Our initial ideas about what ventilators were, were shaped by what we saw on websites like YouTube where various designs were posted by many people, hardly of Indian origin (yes, we suck at documentation and we doubly suck at sharing information!). Sadly only a few were actually verified, and this some problem with opensource/openhardware sharing, but that’s another story. To us, an amateur medical devices team glued by a solidarity to make something for the disaster at the door, each idea seemed rational. Some seemed more beautiful and ambitious, others less glamorous. Seasoned design engineers are always better at filtering out fantasy from workable ideas, but it takes many years of hands-on experience to get the ‘seasoned’ tag. We didn’t have that.

Prototype to product – a reflection

It’s pertinent here to reflect on how we think as engineers. It seems we think using only what we know – our vocabulary (not only linguistic, but experiential) determined by our experience and understanding of the past. For example, an economist may only be able to handle any decisions limited by her/his experience and learnings and language. Similarly a tool-room machinist will approach a problem from her/his comfort-zone of past familiarity. We were no different when it came to choosing which designs to begin with. Given our repertoire of tools we in the group had experience with – 3D printers and LASER cutters, lathe, milling, stepper motors, servos etc – we appreciated or rejected ideas. I mean we had a significant comfort-zone bias driving our decisions rather than rational studies and evaluations of what is needed.

However, very few of us had actually made projects which resulted into real products in our pre-COVID day-jobs (academicians, research assistants, managers-made-from-former-engineers and prototype developers we were). This is an important distinction on which it is justified to pause and clarify. What distinguishes a product from a project? When a project begins, the plan is like this:

1. Understand the physics and math to a practical level. This stage also involves collaborative discussions, YouTube videos cringe viewing, forum discussions and knocking on the doorsteps of ‘experts’ for their blessings and if possible, some insight.
2. Identify a couple of experiments that we need to do in order to establish our hold on the concept, to prove to ourselves that our ideas are not pure fantasy.
3. Then we begin with the planned experiments.
4. Often the case is – most of our ideas are fantasy and fail. But by this time we are in deep shit, too much invested in money, time and pride. So this leads to more than the initially planned number of experiments. Rationally planned experiments give way to juggad, hack-jobs, significant head scratching (+ adding more of white to an already grey zone) and a whole unintended learning curve resulting in enlightened maker(s) who rightfully doubt their engineering credentials. One learns truely the hard-way (my repeated experience).
5. Somewhere in-between our original concept moves to a functional prototype. This is where things look wonderful and joy is written everywhere.

Most projects, especially academic ones stop here. A lot of school/college projects stop here. Many potential innovators stop here. Most people can only care to think to this point. Functionality is proved, everyone involved is happy what else is needed? Pride and confidence is restored and all that. And so arrives the most tempting time to give up, the most tempting time to jump on to the next concept-to-functional-prototype challenge, where the stakes are too low. I used to be locked in this eternal cycle for many many years before i learnt to look beyond. Now, what’s in there beyond? This part is the real struggle, the real un-glamorous donkey work, but a necessary path to the real stuff. It’s the making of a product. Here’s what a product must be:

1. It should be functional.
2. It should be functional for many years to come.
3. It should be functional without the need of its makers’ constant presence nearby, as it was in pre-product stages.
4. It should be functional for many kinds of users – even non-expert ones who may manipulate the product beyond its anticipated functional envelope. Meaning it should be really really user-tolerant! (My best example of this is the Hero Honda Splendor bike. Just the most abuse friendly thing i have seen)
5. It must be of a good design. This is an artistic as well as functional aspect of a product that humans will use. Often the most neglected end of many Indian products. (What is a good design? – i love this designer’s philosophy) .
6. It should be easy to make, so that manufacturing steps and costs are low and comprehendable to production machinists. This is called design for manufacturing.
7. Overall its cost must be acceptable to the end user.
8. If it ever reaches this stage, if this product fails in the field, like all real machines do (good ones less than bad ones), there should be a machine doctor to fix it and give the relationship between the product and its user a just lifetime.
9. And of course, each product must evolve because there are always feedbacks and failures where the product doesn’t work as intended. Meaning, the above cycle(s) are repeated to transform from a mere prototype to a mature product.

Why all this tangent and how is this relevant to this post? This is only to put in perspective our developments on the ventilator project. Ventilators used in the hospitals are products. Lives depend on them. They must work, day in day out, in all conditions. They are used by doctors all over the world, as diverse as they can be. Nothing must fail within a set time, else lives could be lost. As an engineer, its the first time i am worried to such an extent about my work, so much so that i wish the situation doesn’t arise where any of these amateurish ventilators would be needed. Because we don’t have the robustness and the development man-years that form the foundations of a well-designed mature product. I have heard that usually ventilators undergo severe testing of over 4-5 years before they are approved. From my experience so far as a product developer, reaching functionality takes 5-6 prototypes, and making a product takes many many more. All i am pointing to is this – developing a medical grade product is amazingly complex and a lot of hard work. Being humble is of utmost necessity if we are to do anything serious.

Challenges faced

So whats a ventilator? Ventilators do 1 key job – push in air into the patient’s lungs as if pumping a balloon and let the patient exhale automatically (deflation of a balloon). Why? because some diseases like the COVID19 affect the breathing efficacy of the patient’s lungs, its ability to absorb oxygen into the blood severely decreased resulting in tiredness out of excessive breathing to compensate for lack of O2. This tired lung needs a support system, so a ventilator.

The complication is, that like a balloon our lungs have a safety limit. And a very very sensitive one. Different people, depending on physical body conditions and age have different volumes that can be pumped in. There’s also the peak pressure that must always be respected while doing the pumping, else we’ll damage the lungs significantly! And all the while maintaining the timing of the pumping, else the pumping may be in conflict with the patient’s natural cycle and speed of inhalation/exhalation! Add the complexities of pumping in a restrained manner rather than an explosive manner. The machine should also give the doctors options to set these variables as per the patient. So one has to design 3 parts: A) the action making air pumping part B) The sensing and monitoring part that measures the action taken as well as patient’s response and C) the interface between machine and the doctor.

There are many ways to do the mechanics of the above – using compressors (like the ones you use to fill car tyres with air), using blowers, or using AMBU bags (Bag-Valve-Mask). Most ventilators function on pressureized air and O2 lines, and that’s what serious high-end machine designs are based on, like the design IISER Pune chose to follow. But we chose the humble Ambu bag way, despite that it is the least liked option by doctors and governments because it has its limitations. However, its cheap, easy to make and does not depend on pressurized gas lines only available in modern hospitals. Hence, given the crisis and lack of proper ventilators in many areas of the country and worldwide, this option (first suggested by a student team of the MIT, USA in 2010) became one of the most popular approaches among the amateur ventilator makers all over the world. We were no different.

Along with the technical challenge of getting all of the above working (which we are still struggling with) we had other challenges. Due to the lockdown, getting parts hitherto taken for granted, became a huge bottleneck. Importing electronic components from abroad was out of the way. Lack of city to city courier services eliminated the remaining options. Pune has a few shops – our last bet. So we were left to jugaad off the electronics too (See my post on it).

We’v been working on the ventilators for the past 2-3 months. We have made some 3-4 prototypes, all ambu based. Currently we are able to do all the 3 things – drive the device, sense essential parameters and interface them to the operator. All things work and functional but we are far from a fully functional prototype. The kind doctor at B.J.Medical College will have the final say and from time to time gives valuable feedback on our work.

Criticism

Given the background, i would like to list some criticisms of us as a community that came about on solidarity and clear intention to solve or mitigate COVID19 related problems.

1. Community
   1. Multiple teams in Pune and India are working on ventilators. However there seems to a secretive air about them. No one discloses the design and the parts within. No one says how rigorously they have tested their designs. No one says where they have failed and the bottlenecks in their design, so that others can learn and do better. No one documents. And certainly no one puts documents on the web for everyone’s access and reaction. This includes me and my group. This is the worst thing we could do as a community, and bypasses all the original reason we got into making this.
   2. When we went to buy parts, parts related to ventilators were bought en-masses by whoever reached the shops first in the initial days. Our team members also harbored this instinct to horde – so that we could have enough suppose we hit upon the jackpot of a successful design. And probably in the process also starve other teams of crucial parts, to get an edge. Why this selfish behavior?
   3. When contacted, repeatedly, people working in other teams didn’t respond back. I can name the team here – the IISER guys! These are tax-payer funded people, we in the CoEP are also tax-payer funded and we don’t talk to each other? Why so much arrogance?
   4. There was no discussion within the development community as to the design and challenges or progress status. There was a Slack group named Open Breath Tech where some discussion was taking place initially. But after IISER Pune’s initial interest and involvement died down, this group kind of became silent. I posted my needs, design of electronic ideas, and services (free and voluntary) on it, but no response. Others offered too.
   5. When some people came to know that we were working on ventilators, many people contacted as wanting to join in the efforts.
      1. Job seekers, freshers straight out of college sending in their CVs.
      2. Idea people – people who thought they had great ideas and could help. One even went so far as to wanting to sign some NDA and stuff even at these times of crisis!
      3. Factory owners who offered to help for production or R&D.
   6. One of the most important problem in getting help from the above interested people was lack of permissions. Even in our group, we volunteers got permission from the B.J.Medical college, but not from the district collector. Yet we somehow got past trusting police officials. Point is, shouldn’t the DM and administration actively help in such efforts by the city engineers?
   7. As developers, we didn’t know what was needed. Luckily in collaboration with B.J.Medical docs, we kept on getting some cues. But why one design over the other, cost of different designs, design specs, etc. were all flying in the air. There was no coordinated effort. We were often relying on info from YouTube about cases and practices in the US and Europe while being totally blank about requirements in our own locality.
   8. Whenever a group made a prototype, they created a huge noise about their ‘success’ (we are also guilty here, see ToI article “Expert team creates prototype of low-cost mechanical ventilator in Pune“). Media and social media gave much coverage. Technical limitations and challenges were swept under the carpet by the makers as well as the ill-informed ignorant non-homework doing media. All this made this social crisis into a personal competition – men fighting for their ego cup. And here is the relevance of the section above on prototype vs product. It’s relatively super easy to make a functional prototype, but extremely hard to keep at it and make something really useful. After making a proto and making huge fuss about it, the teams have not really updated if they have made other protos. No one knows.
2. Criticism of the government’s role/actions:
   1. The government added to the noise, by converting it into hackathons and competitions. It could have instead helped in making good specification plans and studies of ventilator requirements in cities, villages, etc. It could have coordinated various groups.
   2. When there is competition of the artificial kind like now in between ventilator makers, there is even less sharing, even less growth and farther we are from developing good machines in the shortest of times. Why do this?
   3. India is a diverse country, and so it can be assumed our ventilator needs could be as diverse across – language, training, cost, service, accessibility barriers. Before jumping into making, some of us should have just studied the landscape of ventilators specific to our country to better inform the developers. There could be different categories of ventilators specified so that we could pick and choose according to our strengths which ones to work on. Who could do this survey?
   4. No forum was available that could make a healthy and regular collaboration between doctors and health staff on one hand and engineers/scientists on the other. We were and are all blind and whimsical as to our designs and choices.
   5. Its obvious – ventilators are glamorous. On the other hand – facemasks – they are not glamorous but easy to make and visible. If visibility could be a driving factor, it does not matter if its difficult or easy to make, they will be made it seems. However, there are many things that are of high impact and absolutely necessary but without the public-frenzy inviting glamour. I guess many people just went for the most glamorous of the projects while other things were not looked into until lately:
      1. Automated spirit/soap dispenser unit for public areas like hospitals, public washrooms, travel depots, etc.
      2. Proper quarantine facilities, how they should be designed keeping in mind long term stay?
      3. Disinfection units for healthcare workers, to avoid the significant jump in hospital wastes.
      4. Breathable PPEs for hot non-AC Indian climate.
      5. Communication design – this was a big big mess!
3. Criticism of my own group: I have deep respect for my colleagues with whom i was lucky to work and learn, especially the team head Prof. Sandip Anansane who kept it all together and drove to this point through tough times. These are good dedicated men (sadly no women). They have been very open and passionate about this project. Yet, the critical self observes:
   1. Our initial focus was to make a device that will be low cost, easy to manufacture and use materials locally available in large quantities. However, we dropped this most important focus point. The current design is bulky, costly and requires some serious machining facilities.
   2. Our group lacks much expertise. This also implies that progress is extremely slow and dangerous. In the most deepest of engineering challenges, its lonely as there is no scope of discussion or debate. Often there is only 1 person who does bulk of the engineering and calls the shots.
   3. Many times this 1 person dominance leads to whimsical designs, which distracts from the goal. There are not many checks and balances.
   4. Being an engineering college, it misses tools and facilities commonly used in the industry. Tools had to be discovered in one drawer or the other, from one department or the other. Sheet metal bending for cabinet and enclosure making, a fundamental need of any engineering work was not available on the campus. Modern LASER/Plasma metal cutting tools were missing.
   5. Tool dexterity is severely poor in this top engineering school. Example – if one knows machining, he does not know electronics and vice-versa.
   6. And all this despite CoEP being the top engineering institute in Pune and one of the top in Maharashtra with crores of machinery, funding and talent pool available at its disposal. Why is it that we were the only team working in such a large college? Where are the others?
4. Self-criticism:
   1. My colleagues will complain that i have not been a good team player, often going on with my ideas and concepts and imposing others to follow.
   2. I am guilty of shifting between too many designs and ideas, too quickly without completing previous ones. This may have scared and worried my teammates immensely. And i didn’t quite give convincing reasons why i did so.
   3. If i was leading an aspect of the project, i didn’t really break it up and ask for other’s help and contribution to it so that everyone can be involved and the task can be done faster. This may be kind of an insult to my teammates.
   4. ?…. I am sure there are many more. Probably my teammates can add here.

This concludes my rant.