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What doctors on the front lines wish they’d known a month ago

nytimes.com

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Re: What doctors on the front lines wish they’d known a month ago

#91

Post by oldgradstudent »

This was the single scariest piece I've read in a while. The video is even worse. Especially Dr. Hardin from Massachusetts General Hospital at 5m:37sec in the video:

> I'm arguing for evidence-based medicine, which is something we all purported to agree with before the outbreak hit.

> We have large randomized controlled trials. The patients in those trials had met the same diagnostic criteria that are current patients meet. We should apply the results of the trials.

This is a new disease, the assumption that previous trials apply without even a bit of skepticism is fanatical.

Re: What doctors on the front lines wish they’d known a month ago

#92

Post by oldgradstudent »

shalmanese wrote: post #60
rasz wrote: post #55

Since January leaks from Chinese health care warned about all of this. Was there internet ban in US I was unaware of? Or a widespread belief in exceptionalism?

It's not even leaks, it's included in the Official Coronavirus Treatment Plan: "(4) Salvage therapy: for patients with severe ARDS, a recruitment maneuver is recommended. When human resources allow, prone ventilation should be carried out for 12 hours or more every day. " https://www.chinalawtranslate.com/coronavirus-treatment-plan... There's simply a shocking degree of arrogance from the West to refuse to learn even…

> There's simply a shocking degree of arrogance from the West

Not sure it is Western arrogance rather than standard medical arrogance.

The video accompanying the NYT piece (5m:37sec) one doctor says:

> We have large randomized controlled trials. The patients in those trials had met the same diagnostic criteria that are current patients meet. We should apply the results of the trials.

This is insane for a new disease.

Re: What doctors on the front lines wish they’d known a month ago

#93

Post by DanBC »

misja111 wrote: post #88
barkingcat wrote: post #84

Earlier quoted context omitted.

conceptually, flattening the curve is meant to turn an exponential infection curve into something more manageable. We are flattening the curve, yes, initially because hospitals don't have capacity, but the root of this issue is the exponential nature of infection transmission. If we have the ability to build hospitals at a rate to match O(2^n) time then we can let everyone out and declare quarantine over! But as you…

I was writing that we should both create hospital capacity and have some moderate flattening of the curve. Of course we shouldn't let the virus run free. But unless you are hoping for a vaccine to be invented soon, which would of course be wonderful, you have to face the other scenario and that is that we have to slowly build up herd immunity. Herd immunity means that people have to get infected and a percentage of t…

> Herd immunity

What does her immunity actually mean though? What other diseases do we try to tackle using herd immunity? How many deaths would make herd immunity acceptable or not acceptable?

There are 350m people in the US. We need to get about 60% of them to have had covid-19. That's 210m people. We don't know how fatal covid-19 is yet, so here are some lower numbers:

  0.1% =   210,000 deaths
  0.2% =   420,000 deaths
  0.5% = 1,050,000 deaths
And once we've killed off all these people what have we achieved? Covid-19 would be in the population and will come back every year as a seasonal respiratory illness, killing off more people every year until we get a vaccine.

Re: What doctors on the front lines wish they’d known a month ago

#94

Post by tathougies »

misja111 wrote: post #78
killIdeas wrote: post #67

Oxygen and laying prone is not exclusive to hospitals. I'm wondering if we can get oxygen tanks ready for home use. Reduce hospital load, reduce healthcare costs, get rid of the need to flatten the curve. (Waiting for a my job to begin, waiting for my son to get his surgery)

>> get rid of the need to flatten the curve. This. A policy of flattening the curve will probably have to last for one or two years until either a vaccine is found or there is enough herd immunity. This will not only destroy our economy but the isolation will be a psychological challenge for many as well. We have to take one step back and think why we wanted to flatten the curve in the first place. And that is becaus…

But our hospitals do have enough capacity. So far we have not seen widespread hospital overruns as predicted. Army field hospitals were set up and then taken down with no one treated. New York wanted 40000 ventilators but only needed 5000. Surely we should increase availability, but the original predictions that inspired this level of lockdown have not come to pass and with the information we have now, we know they are just delaying the inevitable.

Re: What doctors on the front lines wish they’d known a month ago

#95

Post by irq11 »

maxerickson wrote: post #90
misja111 wrote: post #78

Earlier quoted context omitted.

>> get rid of the need to flatten the curve. This. A policy of flattening the curve will probably have to last for one or two years until either a vaccine is found or there is enough herd immunity. This will not only destroy our economy but the isolation will be a psychological challenge for many as well. We have to take one step back and think why we wanted to flatten the curve in the first place. And that is becaus…

We have to smash the curve so that we don't need the hospital capacity. It turns out that getting the number of infected down close to zero would also be good for the economy. I don't understand why so many people think that the best possible plan is for everyone to get infected. The best possibilities involve a few percentage points of the global population getting infected, no where near everyone.

This simply isn’t possible, and it’s a maddeningly irresponsible shifting of the goalposts. The public was sold these extreme tactics on the basis of preventing excess deaths, not locking down society for years on end until the virus (hopefully) goes away.

Respiratory viruses, once endemic, have never been completely suppressed. Even China is seeing a resurgence in cases. What we’re doing now isn’t sustainable or ethical, and we have to move on to smarter tactics soon.

Re: What doctors on the front lines wish they’d known a month ago

#96

Post by watwut »

jordanbeiber wrote: post #62
watwut wrote: post #58

Earlier quoted context omitted.

The easy to find part is that not everyone in ICU is not attached to ventilator. Most people are not attached there.

The data out there indicate a 50% ICU death rate in general. Ventilators seem to exacerbate the condition for covid patients. Sweden seem to have better success with intensive care than average. Are we perhaps intubating less. Train of thought ^.

ICU death rate heavily depends on whether the hospitals are overflown or not. The Italia or Spain ICU is not giving the same care now as it used to.

The trajectory of cases and deaths in Sweden does not seem special to me, generally they seem to follow similar curve as other countries so far.

Re: What doctors on the front lines wish they’d known a month ago

#97

Post by maxerickson »

irq11 wrote: post #95
maxerickson wrote: post #90

Earlier quoted context omitted.

We have to smash the curve so that we don't need the hospital capacity. It turns out that getting the number of infected down close to zero would also be good for the economy. I don't understand why so many people think that the best possible plan is for everyone to get infected. The best possibilities involve a few percentage points of the global population getting infected, no where near everyone.

This simply isn’t possible, and it’s a maddeningly irresponsible shifting of the goalposts. The public was sold these extreme tactics on the basis of preventing excess deaths, not locking down society for years on end until the virus (hopefully) goes away. Respiratory viruses, once endemic, have never been completely suppressed. Even China is seeing a resurgence in cases. What we’re doing now isn’t sustainable or eth…

The lockdowns are a necessary step to smarter tactics working.

My point is that if we move forward as if letting lots of people get infected is a 'smarter tactic', it's going to be worse in all ways. More death, more economic damage.

Re: What doctors on the front lines wish they’d known a month ago

#98

Post by rovolo »

IkmoIkmo wrote: post #81
shalmanese wrote: post #65

Earlier quoted context omitted.

So couldn't it just be that New York is admitting many more sicker people into their ICUs vs Sweden's ICUs performing better?

Can be lots of things, there's lots of evidence that data quality is extremely poor right now, but not enough to be able to say accurately what all the data should be. For example, in the Netherlands, in a blood test about 3% of the population was found to have antibodies, while the number of people confirmed to have corona via tests is at 0.15% of the population. We're looking at a 1:20 confirmed/actual rate. That t…

Just a note on the "3% prevalence of antibodies": we need to consider the false positive rate and selection bias for general population antibody tests as well. A biologist I follow was skeptical about a study showing that 1.5% of Santa Clara had antibodies for SARS-CoV-2. I don't know anything about the study in the Netherlands, but the 20x or 100x undercount ratio is going to be very sensitive to the antibody test specificity.

https://twitter.com/CT_Bergstrom/status/1251344851984986118

https://twitter.com/CT_Bergstrom/status/1251346572656304128

> In the supplement they say 2 out of 371 + 35 known negative samples tested positive. This means that the 95% confidence interval for the false positive rate is [0.06%, 1.77%]. In their samples from Santa Clara County they had 50 / 3,349 = 1.5% test positive.

Re: What doctors on the front lines wish they’d known a month ago

#99

Post by dchichkov »

dmurray wrote: post #20

> “You put a tube into somebody,” Dr. Levitan said, “and the amount of work required not to kill that person goes up by a factor of 100,” creating a cascade that slows down laboratory results, X-rays and other care. I'd hope this could be a generally applicable lesson after the pandemic. In less overwhelming times, the medical best practice is once someone is in hospital, prescribe the statistically best treatment ev…

>> In less overwhelming times, the medical best practice is once someone is in hospital, prescribe the statistically best treatment even if it costs 100 times as much in resources and manpower.

And the way this "statistically best treatment" is calculated doesn't take into account complications from the treatment! Examples: complications from financial stress to cover the costs of the treatment, side-effects of the therapy unrelated to the original condition, infections with drug-resistant strains of hospital bacteria.

Re: What doctors on the front lines wish they’d known a month ago

#100

Post by carbocation »

SilasX wrote: post #89
carbocation wrote: post #76

This is a perplexing article. Prone ventilation has been known to reduce mortality in severe ARDS from randomized, controlled trials for almost a decade[1]. Proning is great! It keeps people alive. We are doing a lot of it. It's not new. 1 = https://www.nejm.org/doi/full/10.1056/NEJMoa1214103

Okay but then how is that something "they wish they knew" a month ago? They didn't know then?

That's why I'm perplexed. It comes across as trying to make something more dramatic than it already is. (And, I mean, hospitals being full of patients with a novel disease is already sufficiently dramatic.)
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