COVID 19 - Thoughts from a frontline doc

Discussion in 'Cop Talk' started by PicardMD, Mar 28, 2020.

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  1. pblanc

    pblanc

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    You seem to be positing that because there is no cure at present, hospitalization for supportive care for covid-19 infection is of no value so far as outcome is concerned. That is clearly not the case.

    Even if the majority of patients with severe covid-19 infection who develop ARDS severe enough to require ventilator support die, if you are one of the minority who survive treatment will have made a big difference to you personally.

    It is hard to track the hospitalization rate for covid-19 across the country because most states are not reporting it. But on Thursday March 26, Governor Cuomo reported that there were 5327 patients hospitalized in New York State of which 1290 were in the ICU. Over the weekend new reported deaths from that state have dropped off despite the fact that hospitalizations had been increasing sharply in the week prior and NY is now reporting new deaths of under 200/day despite the fact that multiple thousands of new cases have been reported daily since Thursday.

    I think it is safe to conclude that a majority of those people who were sick enough to require hospitalization for covid-19 infection are not dying.
     
  2. ranger1968

    ranger1968

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    This, exactly.

    I cannot figure out why this concept , so simply explained above by SAR, is so hard for some people to understand.
     

  3. TheDreadnought

    TheDreadnought

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    Read my full post. It’s because medical care doesn’t appear to be making a difference if 86% of patients on a ventilator subsequently die.
     
  4. TheDreadnought

    TheDreadnought

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    We don’t have any evidence, thus far, that hospitalization is making much of a difference in more than a few cases, however.

    How many trillions of dollars of economic damage are we willing to inflict for the sake of a handful of people, some of whom are likely near the end of their natural lifespan anyway?

    It may be cold, but the “every effort at any cost” mentality is the very reason our healthcare system is so screwed up right now.

    Before this virus 80% of healthcare expenditures were spent on people who died within 2 years. That’s not a smart approach and is why a lot of people can’t even afford health insurance.
     
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  5. steveksux

    steveksux Massive Member

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    Covid patients are taking way more beds than ventilators, so even if all vent patients were dying instead of 86% most covid patients in hospitals are surviving

    Randy


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    Last edited: Mar 30, 2020
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  6. G26-Has-my-6

    G26-Has-my-6

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    it's interesting you say this, because it is something I have wondered about as well considering the death toll in hot spots and with seemingly healthy, young medical professionals like the late Dr. Li Wenliang in Wuhan. this is something I hope is studied more. Whether it's intensity of exposure, duration of exposure and/or exposure from multiple infected people, it's something that jumps out at me as well.
     
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  7. pblanc

    pblanc

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    As far as I can tell, the 86% mortality rate for ventilator dependent patients with severe covid-19 came from a report from China on the outcome for a very small number of patients (n=22) of which 19 died. If there is another source for that number, I would like to know of it.

    Obviously, 22 is a very small sample size and we do not know the status of those patients when the decision was made to admit them or intubate them and institute ventilator support, nor do we know how the level of medical care they received stacks up against what care ventilator dependent patients are receiving in the US.

    Here is a short article addressing this issue written by a physician who happens, like me, to be a retired surgeon and goes by the pen name "Skeptical Scalpel" which sort of gives you a notion of where he or she is coming from. But it is pretty well done:

    https://www.physiciansweekly.com/mortality-rate-of-covid-19-patients-on-ventilators/

    He or she posted a query on Twitter as to what the observed mortality rate was in the US for covid-19 patients requiring ventilator support and received estimates ranging from 25-75% from people he or she judged to be in a position to know.

    There is also a link in that article to data from the Intensive Care National Audit and Research Center for the UK that gave the mortality rate for a group of 165 patients that had been treated in critical care for covid-19, although the percentage requiring ventilator support was not given. Of these 165 critical care patients, just over half (86) survived and were discharged.

    So once again, hospitalization, intensive care, and even ventilator support are not of no value in the treatment of covid-19 infections.
     
  8. pblanc

    pblanc

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    Physicians unfortunately are not clairvoyant and outcomes for many diseases and conditions are not predictable in advance. If physicians could determine with certainty when a given person was going to die or predict with a high degree of certainty a fatal outcome in advance, then I suppose medical and surgical care could be delivered in a more cost-effective manner.
     
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  9. steveksux

    steveksux Massive Member

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    I thought I read somewhere around 70% never get off the vent here, not 86%. Worth trying to save that 1/3 of patients rather than leaving them to die.

    Randy


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  10. Dukeboy01

    Dukeboy01 Pretty Ladies!

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    Not sure what is so hard to understand. The country only has so many ICU beds. Left unchecked, this virus is calculated to have the potential to fill them all up. It is filling them up in the hotspots, like NYC and New Orleans. That's what's happened in northern Italy.

    If all the ICU beds in your town are filled up with Covid 19 patients, then other things that three weeks ago were bad, but survivable, suddenly become deadly again.

    Your position seems to be that we're going to just tell Covid 19 patients "Tough beans, go home and down in your own lung fluid." We aren't doing that and won't unless or until the system does crash. Then we might, but there's going to be a window of days or weeks when the Covid 19 patients have overrun the hospitals but nobody's pulling the trigger on the "Tough beans" option yet. That's when 50 year- olds with heart attacks who would have made it without much drama in September are dead.

    This guy is ER nurse in SoCal. Doc Picard is nice. This guy is less so.

    https://raconteurreport.blogspot.com/2020/03/todays-reality-check.html?m=1

    Here's his post from today.

    https://raconteurreport.blogspot.com/2020/03/more-local-color.html?m=1

    Sounds like you may get your wish for the med system to kick Covid 19 patients to the curb. Money quote:

     
    Last edited: Mar 30, 2020
  11. pblanc

    pblanc

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    The model developed by the researchers at the University of Washington that a lot of States seem to be basing their estimates of when the epidemic will peak locally also predicts that a shortage of total hospital beds and ICU beds will likely occur in mid-April at least in some areas.

    You can read the preprint for their submission here: http://www.healthdata.org/sites/def.../covid_paper_MEDRXIV-2020-043752v1-Murray.pdf

    The model upon which their projections are made require a lot of assumptions to be made on the basis of data that is rather sketchy at this time, and the 95% confidence intervals are quite large. But for what it is worth, they estimate an excess demand for hospital beds in the US of 7,977-251,059, and an excess demand for ICU beds of 2,432-57,584 by sometime in April. Peak demand is predicted to occur in mid-April for about one-third of states, but not until May in others. They predict the shortage to be most severe in New York, New Jersey, Connecticut, Michigan, Louisiana, Missouri, Nevada, Vermont, and Massachusetts.

    In their paper they estimate that annual bed-day utilization rates in US hospitals prior to the covid-19 pandemic were 66% on average, ranging from 54% in Idaho to 80% in Connecticut. Most US hospitals are appropriately staffed to handle the expected capacity rates. Expanding utilization even up to licensed capacity would require additional human resources and staffing beyond current licensed capacity would require human resources that may not currently exist.

    The biggest bottleneck is probably the availability of suitably trained ICU nurses. Of course, some beds can be opened up by curtailing non-essential and elective procedures, but ICU admissions for treatment of trauma or many medical conditions unrelated to covid-19 cannot be deferred. And unfortunately, there will be attrition among health care providers because some will catch the virus.

    If a critical shortage of hospital resources does occur, it won't be possible to solve it just by throwing money at the problem.
     
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  12. TheDreadnought

    TheDreadnought

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    Won’t surprise me if we get there. To your point, maybe Covid-19 patients shouldn’t qualify for vents. Save them for people that can be helped.

    But my post wasn’t actually about what gets done at the hospitals. My post was that social distancing isn’t improving the situation, just putting it in stasis for whenever we do give up.

    If we’re already starting to abandon ventilation under these extreme conditions, then the fight is already over. We lost. Things are going to get out of control no matter what. Open things back up. The survivors will be immune a year from now and then 6 months after that there will be a vaccine for the new peeps.

    Clinging to this idea that we can stop or ameliorate what is coming is like the couple that gets laid off and starts getting increasingly desperate to save their big house and fancy cars, instead of just accepting the situation and making the necessary changes right away.
     
  13. PicardMD

    PicardMD Make It So!!

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    Social distancing is important. Flattening the curve is important so that we don't get a large influx of patients all at once. That will kill our capacity and make things worse.

    Few points I think I wasn't very clear on -

    1) While the percentage of hospitalized COVID patients needing ventilator ICU level care is significantly higher than the flu, majority of hospitalized COVID patient do not need ventilators or ICU care. They need supportive care such as oxygen, bronchodilators, IV fluid for kidney injuries... etc and they recover and go home. They tend to stay longer than flu patients in general. We need these people to trickle into the hospital, not showing up all at once because we don't have enough beds. So flattening the curve is EXTREMELY important for this group of patients. For this group, COVID is entirely survivable with proper supportive care, and not survivable if they don't get the needed supportive care. A hospital bed is likely the difference between life and death for this group, who are the majority of hospitalized COVID patients. And don't forget, each COVID patient we have takes a bed away from another patient who needs the bed unrelated to COVID, so they are at risk as well.

    If patients who need non-ICU level hospitalizations cannot get hospital beds, then we are resorting to setting up home oxygen, home health nurse... etc. This will end up needing very close contact with family members who will need to play nurse and care for these patients, and yes, a percentage of these patients will probably survive. But in the process, we just increased the number of exposed/infected in the form of family members, who still need to go to grocery stores, banks, get gas.... etc. Think about that.

    2) COVID patients who need ventilators and ICU level cares will probably die. Yes, that is still a true statement in general, today. The 86% of ventilator patients die is a worldwide figure (take it with a grain of salt when the numbers involve China). Our own experience in the U.S. is from Seattle, early on, where 70% of ventilated COVID patient died. But to put that number in perspective, most of their early patients came from a nursing home with very elderly sick patients to begin with.

    The fact is, we are getting better and better every day. We learn from trial and errors every day with these ventilated ICU patients. We are better this week than last week. We are certainly "light years" ahead today than last month. Internet has allowed critical care docs to share experiences rapidly across the country. While the anecdotal guessiment is about 50% survival, and we are getting better at it each day. (Ventilator management is actually a very complicated science and art. It's not just "intubate and ventilate, set it and forget it" type of thing. There are very complicated strategies on how to ventilate.) So, I expect the survival rate on ventilators to continue to improve.

    3) There are several novel treatments being studied. Some look promising. No, I'm not going into details there because it is too complex. Point is, while there are no effective "antidote" treatments today, I'm hopeful we will get better at it next month. We just need time to prepare and not get overwhelmed.

    So yes, please, practice social distance and flatten the curve. That's the best way for us to come out of this in a timely matter. We need to drink from a fountain, not from a firehose.
     
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  14. PicardMD

    PicardMD Make It So!!

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    While proper replacement in vitamin D deficient patients is a good thing (and I'll even go further to say that we probably under recognize vitamin D deficiency in general), vitamin D replacement is not the cure-all for diseases like some would believe. And taking anti-microbials as prophylaxis long term without clear established indications to do so is ignoring their harmful side effects.

    Problem with nutraceutical science is, people in it tend to confuse anecdotally "published" case reports and theoretical bench science with actual clinical trials and real life effects in humans.

    A member here puts it best in another thread, when someone tells you "vitamin XZY" kills "ABC" microbes in a petri dish, remember so does a Glock. ;)
     
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  15. Sam Spade

    Sam Spade Staff Member Lifetime Member

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    Unless you need a hospital bed for that rollover accident you're in, or that heart attack you have....
     
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  16. ray9898

    ray9898

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    This situation has really surprised me. There are some otherwise bright people, some I know in real life and some I have watched post here for many years that are incredibly dense when it comes to this overall situation and how the pieces of the puzzle come together. It is like they cannot take on more than one piece at a time.
     
  17. ranger1968

    ranger1968

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    Some folks just don't get it.
     
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  18. collim1

    collim1

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    It is an unprecedented situation for most of us. It’s a new danger. It’s invisible. It’s contagious. People are dying. People are losing their jobs. People are going broke. And it’s just getting started.

    It’s a hard pill to swallow.
     
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  19. arkdweller22

    arkdweller22 Cuhootnified Roamer

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    This.
    People are understandably scared of the many variables and unknowns arising from this issue. People who are used to stability and a certain level of surety in their lives.
    Folks have gone from getting anything they want in two days from Amazon to being unsure if they’re going to run out of food or catch something and die next week.
    It stands to reason that folks’ brains will be scrambling to find an explanation. And those explanations will range wildly until all the data is in and hindsight clarifies things.
    It’s easy to judge those who don’t think like us, but a bit of empathy would help soothe their fears. Who knows? Next time it may be you that needs that empathy.

    That’s why this thread is invaluable and we should all thank @PicardMD for taking his time to give us his updates.
     
  20. ray9898

    ray9898

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    I understand that. But, we have people looking at the same graph I am calling it 'nothing more than a cold'.

    People that can't comprehend that if X number of people get sick in a short time our medical system will be overwhelmed.

    People that still compare a full year of flu deaths with the total of a virus in its infancy.
     
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