Aarti Kinikar using homemade bubble CPAP during the H1N1 epidemic

Aarti Kinikar’s response to a ventilator shortage during the 2009 H1N1 Influenza Pandemic began with a treatment she already knew and materials her hospital could readily obtain. Rather than treating scarcity as a fixed instruction to ration, she and her staff adapted bubble CPAP for babies with flu: an improvised, inexpensive breathing-support system that helped some patients and freed ventilators for others. The episode makes resourcefulness—not only the allocation of scarce equipment—a central part of disaster medicine.

Outbreak and shortage

In the account, the book’s narrator visits Pune, India, in 2010 and looks back to the previous year’s H1N1 outbreak. Health officials, worried about the spread of flu, directed symptomatic patients to a small number of local hospitals. Those facilities were quickly overwhelmed. At a public hospital where expensive resources were often scarce, Kinikar watched babies die because there were not enough ventilators.

Kinikar was a pediatrician accustomed to working amid shortages. The immediate problem was not simply how to choose which child would receive a ventilator, but whether the hospital could support children’s breathing by another means. She had previously used bubble CPAP—continuous positive airway pressure—to help newborns with premature lungs breathe. Commercial CPAP devices cost thousands of dollars; the method’s importance in this crisis lay partly in the possibility of making a workable alternative from inexpensive, available materials.

Adapting bubble CPAP

Kinikar’s staff assembled a homemade system from plastic tubing and saline bottles already available at the hospital, at a cost of a few dollars’ worth of supplies. The approach had worked for premature babies, but applying it to older infants with flu was a new step. Kinikar did not know whether colleagues would support a technique with little scientific backing. In her judgment, however, the choice was not between a proven treatment and an equally sound alternative: it was between trying something that might work and doing nothing while a baby died.

The book links that decision to Kinikar’s habitual encouragement to her students to keep thinking. In this instance, thinking meant carrying knowledge from one clinical situation into another, testing an available technique under pressure, and accepting uncertainty rather than treating the shortage as an unchangeable limit. The improvised equipment mattered not as a substitute for judgment but as the material means through which judgment could become action.

One patient, then many

The account first describes the change through one baby. After the child showed signs of improvement on a ventilator, Kinikar decided to try weaning him from the machine early and supporting his breathing with the makeshift bubble CPAP instead. His mother watched warily as staff made the change. The baby did well on the improvised system, and the ventilator could then be used to help another child.

That transfer of equipment gave the intervention consequences beyond the first patient: supporting one baby without a ventilator made that ventilator available to someone else. Over the weeks of the pandemic, Kinikar used bubble CPAP to support the breathing of hundreds of children at her hospital. Her colleagues credited her quick thinking with saving lives. The book does not present the device as a universal solution; it shows how a locally available technique expanded the hospital’s options when conventional equipment was in short supply.

From improvisation to preparedness

The episode follows a discussion of disaster guidelines and situational awareness. Frederick “Skip” Burkle Jr. worried that rigid criteria could lead to rationing even when it was not needed, and argued for reassessing supplies as conditions changed. Kinikar’s response gives that concern a concrete counterpart: rather than accepting the ventilator shortage as a static fact, she changed how the available resources could be used. Her example shifts attention from triage alone to the capacity to adapt care and reduce the pressure to make wrenching allocation decisions.

The account also draws a contrast between this practical ingenuity and a marketplace with little financial incentive to develop inexpensive, low-tech goods for disaster preparedness. It notes federal support for work on cheaper, easier-to-use ventilators and identifies a disaster-focused ventilator line marketed by St. Louis-based Allied Healthcare Products. These developments do not erase the shortage Kinikar faced; they underline the broader preparedness question her improvised system raises: whether useful equipment will be available when ordinary supply and infrastructure fail.

The narrative then carries the idea of Kinikar-style thinking to Bellevue Hospital in New York, where generator fuel pumps failed during Hurricane Sandy. Volunteers passed fuel up thirteen flights of stairs to feed the generators manually. Their improvisation kept backup power from cutting out, while patients were evacuated, and prevented the loss of power from forcing further agonizing choices. The comparison does not equate the two clinical situations. It connects them through a shared practical principle: people facing a resource failure can sometimes change the situation itself, not merely decide who bears its consequences.