How long should the lock down last?

[GeneralVeers]

Honestly, I don't know what to make of it. ICU beds have been reaching capacity in the houston area, most of it isn't covid, but a sizable number. I know we've had ICU patients board in our ED for a while. But then not reporting the numbers, and backtracking on prior statements raises suspicions..

If it's not all COVID, is part of the increase explained by people with decompensated illness who put couldn't see a doctor or get elective procedures for almost two months in TX? Would be interesting to see percentage of ICU taken up by COVID patients.

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[Birdstrike]

Honestly, I don't know what to make of it. ICU beds have been reaching capacity in the houston area, most of it isn't covid, but a sizable number. I know we've had ICU patients board in our ED for a while. But then not reporting the numbers, and backtracking on prior statements raises suspicions..

Oh, so you think they might actually be reducing the ICU numbers, to avoid a shutdown?

 

[MediMike]

I didn't read anywhere in his email saying, "Everyone is a liar." I interpreted what he was saying as simply giving his perspective on what he's seeing as a source to a reporter, like any other source that tells a report about something he saw that happened.

Then how come they get mad when someone posts raw data, not their opinion but raw data, showing less Americans have been dying from it every week for the past 10 weeks?

In his email he said he heard from unnamed sources that numbers were being falsely inflated for the purposes of reimbursement. (People are lying). He HEARD something then he SAID it. Hence, hearsay.

Who is angry with this data? Just because someone interprets data differently or has a different perspective doesn't make them angry. If it did you'd be considered the angriest person on this board. Well, you Veers and Rekt.

 

[Birdstrike]

If it's not all COVID, is part of the increase explained by people with decompensated illness who put couldn't see a doctor or get elective procedures for almost two months in TX? Would be interesting to see percentage of ICU taken up by COVID patients.

Good question. How much of it is from people sick from neglecting non-COVID health problems, and due to the COVID lockdown but not COVID itself? The ED CEO above seems to be saying that's a contributing factor.

 

[Birdstrike]

In his email he said he heard from unnamed sources that numbers were being falsely inflated for the purposes of reimbursement. (People are lying).

It may be a matter of interpretation. For him to allege numbers are "inflated" is not the same as saying he thinks, "Everyone is lying" and COVID cases are zero. My interpretation is that he's saying there's lots of COVID but a significant number have no symptoms are are picked up incidentally.

(People are lying). He HEARD something then he SAID it. Hence, hearsay.

Part of what he reported was heard from other people, correct. But a lot of it was direct observations from information he gathered as CEO of a company. I'd say that's a higher level of evidence that a street rumor from an anonymous person we can't go to to verify anything we said. This is a high level exec of a multi-state, multi-facility healthcare company, who's given his name. He's a real guy. His credentials check out. I checked. Google him and his company.

 

[Birdstrike]

Just because someone interprets data differently or has a different perspective doesn't make them angry. If it did you'd be considered the angriest person on this board.

Wait. I'm not? That makes me kind of sad. Who do I need to topple, to get this title?

 

[Birdstrike]

@MediMike I'm not vouching for the guy. I can't confirm or disprove anything he's saying. The reason I posted his report was to see if anyone in the area he's referring to, Texas, has any first hand knowledge. That's all. If people are seeing something different that's fine. What are you seeing? Is your hospital overwhelmed with critically ill COVID patients?

 

[GeneralVeers]

Arizona is one state that has locked down bars, water parks again. The gyms are supposed to be locked down again, but are suing because the Governor only gave them 4 hours notice this week so we will see how that goes.

I have an ER nurse friend there who says their ICUs are at 89% capacity.....however that's normal pre-Covid utilization apparently.

With most of the evidence showing business lockdowns having modest or no effect, I'm not sure why the rush to re-impose.

 

[GeneralVeers]

Just-saying......

 

[MediMike]

@MediMike I'm not vouching for the guy. I can't confirm or disprove anything he's saying. The reason I posted his report was to see if anyone in the area he's referring to, Texas, has any first hand knowledge. That's all. If people are seeing something different that's fine. What are you seeing? Is your hospital overwhelmed with critically ill COVID patients?

I totally get it, just saying he is a lawyer and who trusts a lawyer amiright? And he's got a single perspective of a guy who runs FSEDs, is not in-hospital and who knows if he's running his mouth about the situations there. We'll all interpret his statements from our own biases

I'm up in the PNW and we are receiving overflow from an overwhelmed section of the state, intubated folks, multiple pressors, ages 50s-60s, standard American comorbidities, not from SNFs, full code (think I hit all your exclusion criteria there)

I have no idea what's happening in TX other than what I've seen re: TCM overflowing to TX children's etc.

 

[bravotwozero]

If it's not all COVID, is part of the increase explained by people with decompensated illness who put couldn't see a doctor or get elective procedures for almost two months in TX? Would be interesting to see percentage of ICU taken up by COVID patients.

I can't give you exact figures on that, but yes I am seeing a lot of everything, not just covid. Plenty of cvas, brain bleeds etc.

Oh, so you think they might actually be reducing the ICU numbers, to avoid a shutdown?

I suspect this is the case. Don't think the hospitals will cut down elective procedures unless they literally have a gun to their heads, too much at stake finanically.

 

[GeneralVeers]

I suspect this is the case. Don't think the hospitals will cut down elective procedures unless they literally have a gun to their heads, too much at stake finanically.

I'd rather the governors use this approach. Instead of re-shutting down, lean on hospitals to expand critical care capacity. Threatening their bottom line is a great way to make them comply.

 

[miacomet]

I realize that "elective" surgery includes many procedures that really can't wait, and while I appreciate my hospital system's bottom line, the fact that we are running out of beds and PPE yet still doing cosmetic plastic surgery is not exactly reassuring. Total joints, cataracts etc I get, but nose jobs?

We really need to figure out a different formula for funding hospitals.

 

[Rekt]

I realize that "elective" surgery includes many procedures that really can't wait, and while I appreciate my hospital system's bottom line, the fact that we are running out of beds and PPE yet still doing cosmetic plastic surgery is not exactly reassuring. Total joints, cataracts etc I get, but nose jobs?

We really need to figure out a different formula for funding hospitals.

If your hospital is running out of PPE now, that's a failure of your administration. There's enough to go around. I'm betting that most of the procedures you're thinking are pointless are at ASCs anyway.

 

[GeneralVeers]

If your hospital is running out of PPE now, that's a failure of your administration. There's enough to go around. I'm betting that most of the procedures you're thinking are pointless are at ASCs anyway.

Also most cosmetic stuff doesn't take up a bed overnight. They spend a bit of time in the PACU then go home.

 

[miacomet]

If your hospital is running out of PPE now, that's a failure of your administration. There's enough to go around. I'm betting that most of the procedures you're thinking are pointless are at ASCs anyway.

We still have a shortage of N95s. Are other hospitals really able to use N95s as designed? I'm not aware of a single hospital system that is using them as intended; there is still a worldwide shortage. Like, you put one on, and then throw it out when you are done?

No, they are taking place in my hospital. And the rest of the hospitals in my system. It's true many are day surgeries. But that doesn't fix the PPE issue.

 

[southerndoc]

Of the confirmed positives, what were the ages, acuity levels and DNR status?

All of the discharges were stable of course -- sats >93% (ambulatory), no lab derangements if tested, etc.

Some of the admits were people in their 30's and 40's. One guy I admitted 2 nights ago was 23 years old. He's now on a ventilator. I haven't tubed a COVID patient during this wave, but I've had a ton that were hypoxemic (85-90% on room air) getting Lasix, Decadron, and proning.

During the last phase we had 71 of our 72 ventilators in use, opened up another ICU (a vascular recovery unit), and had OR ventilators scheduled to be used next. We're nowhere near that close now, but who knows where it goes.

The admitting teams discuss realities of cardiac arrest in COVID and many choose to become DNR.

 

[xaelia]

I'm up in the PNW and we are receiving overflow from an overwhelmed section of the state, intubated folks, multiple pressors, ages 50s-60s, standard American comorbidities, not from SNFs, full code (think I hit all your exclusion criteria there)

Yakima is overrun.

'It's a scary situation': COVID-19 outbreak exceeding hospital capacity in Yakima County

YAKIMA, Wash. -- The Yakima Health District says the healthcare system in Yakima County was exceeding capacity due to the ongoing COVID-19 outbreak, and that hospitals were running out of beds. But Virginia Mason Memorial Hospital tells KIMA-TV the problem for them isn't a lack of beds, but...

komonews.com

Some of the largest outbreaks we've been seeing in OR have been in rural counties – correctional facilities and church services.

 

[miacomet]

Ongoing PPE shortages are indeed a thing: https://www.washingtonpost.com/nati...e-updates-us/#link-ABZHYLJLNZFAFH472ICPI4HORM

 

[wholeheartedly]

I’d like to clarify something. I’m working as a hospital epidemiologist and infection preventionist and so from grad school alumni I‘m friends with lots of epidemiologists at several state health departments and CDC. We talk pretty regularly and I haven’t come across anyone who thinks prolonged shutdowns are a solution. The general consensus seems to be if we could get people to start taking a few effective steps and stop being idiots in large groups indoors that would help a lot and we could hopefully keep things from getting to a point of shutting anything down. (Also, if you think governors are actually doing what the public health folks are recommending, you would be mistaken. It’s going both ways too, stronger reactions than recommended and weaker ones).

My biggest concerns are hospital capacity, keeping this out of our nursing home, and keeping staff safe. But I’m also concerned that while everyone is focused on mortality, we’re going to have morbidity from this virus bite us in the ass later even from so called “mild” cases, so I’m not sure shooting for natural herd immunity in the young is actually an economically wise longterm solution.

Second, I work closely with our supply chain manager and PPE and supply shortages are still a huge concern. We‘re still getting questionable hand sanitizer from a distillery. We still can’t get any of our normal disinfectants. We can’t get isolation gowns for 3 months. We keep running low on medium gloves. N95s are still hard to come by. We’re barely scraping by on surgical masks. It’s not as bad as a month or two ago and we’re limping along while we get partial orders of some stuff and trying to find substitutes for others, but it’s really not going to take much to completely break the U.S. PPE supply system again. It’s not really an admin problem because all hospitals get supplies from the same few companies. We’ve been given permission to order PPE from anywhere we can for whatever price so long as we think it’s not counterfeit, so the issue truly is availability.

 

[Siggy]

Second, I work closely with our supply chain manager and PPE and supply shortages are still a huge concern. We‘re still getting questionable hand sanitizer from a distillery. We still can’t get any of our normal disinfectants. We can’t get isolation gowns for 3 months. We keep running low on medium gloves. N95s are still hard to come by. We’re barely scraping by on surgical masks. It’s not as bad as a month or two ago and we’re limping along while we get partial orders of some stuff and trying to find substitutes for others, but it’s really not going to take much to completely break the U.S. PPE supply system again. It’s not really an admin problem because all hospitals get supplies from the same few companies. We’ve been given permission to order PPE from anywhere we can for whatever price so long as we think it’s not counterfeit, so the issue truly is availability.

For masks and hand sanitizer, one thing you can do is ask your staff to save the unused masks and individual packets of hand sanitizers when they do procedures. For example, when I do a central line, there's now an unused mask from the central line kit (which I no longer need since I'm wearing a mask anyways) and the 2 masks in the central line dressing kit (which I used to just throw away anyways). The dressing kits also have hand sanitizer in it.

 

[Birdstrike]

Study out of North Carolina, Wake Forest:

-12-14% already have COVID-19 antibodies
-Extremely rapid rate of rise in % positive

 

[Birdstrike]

North Carolina has shown a steady, linear rise in COVID cases for over 3 months. The daily death rate stopped increasing 2 months ago, and has actually been falling for nearly a month. That’s three months for the death rate to catch up to the increase in cases and it hasn’t. It’s doing the opposite.

NY Times COVID tracker 7/1/20:

 

[TwoHighways]

I probably got the covid and didn’t even realize it.

#nutritionalketosis
#baselineCRP<0.5
#cpeptide<1.4
#insulinsensitive
#ALT&AST<25

 

[Birdstrike]

I probably got the covid and didn’t even realize it.

#nutritional ketosis
#baselineCRP<0.5
#cpeptide<1.4
#insulinsensitive
#ALT&AST<25

BMI?

 

[TwoHighways]

BMI?

6’1
Haven’t stepped on a scale in months. I’d image I’m in the ballpark or 185-190. Not a huge fan of the metric in general. You can be fat and metabolically healthy or skinny with NAFLD (a common occurrence in Asian populations).

 

[Birdstrike]

6’1
Haven’t stepped on a scale in months. I’d image I’m in the ballpark or 185-190. Not a huge fan of the metric in general. You can be fat and metabolically healthy or skinny with NAFLD (a common occurrence in Asian populations).

I was just messing around. We’re all BMI 20 on here.

 

[TwoHighways]

I am a bit curious as to why SE Asians get type 2 diabetes at much lower BMI’s than Africans and Europeans. Obviously, they accumulate liver fat faster. Is there genetic variation in lipoprotein lipase expression? Are the adipocytes in Asians more insulin resistant? Are Asian livers more insulin resistant? Does beta cell fatigue occur faster?

Probably some literature out there on all of this. I’ve got stuff to do right now unfortunately. I just wish more of our public health resources went to correcting the underlying problems that drive so much of our healthcare spending.

 

[TJRock]

We still have a shortage of N95s. Are other hospitals really able to use N95s as designed? I'm not aware of a single hospital system that is using them as intended; there is still a worldwide shortage. Like, you put one on, and then throw it out when you are done?

No, they are taking place in my hospital. And the rest of the hospitals in my system. It's true many are day surgeries. But that doesn't fix the PPE issue.

As of 6/29, the Texas Medical Center reports more than a 30 day supply of masks, gloves and gowns.

 

[miacomet]

As of 6/29, the Texas Medical Center reports more than a 30 day supply of masks, gloves and gowns.

Peachy. So does my hospital system. We still have to reuse and reprocess N95s.

Sounds like the situation in Houston is totally being whitewashed: VICE - Houston Hospitals Deleted and Changed Charts That Track ICU Capacity
also https://www.newsweek.com/houston-moves-covid-19-patients-other-cities-we-dont-have-capacity-1514600

 

[Dr Mantis Toboggan]

Peachy. So does my hospital system. We still have to reuse and reprocess N95s.

I’ve gone PPE prepper. Totally rely on my own respirators and eye/face protection. I do use my hospitals gloves and rewashable gowns though, which I am grateful for.

 

[miacomet]

I’ve gone PPE prepper. Totally rely on my own respirators and eye/face protection. I do use my hospitals gloves and rewashable gowns though, which I am grateful for.

Wow. How did you manage to purchase enough N95s?

 

[Dr Mantis Toboggan]

Wow. How did you manage to purchase enough N95s?

I went the reusable route. Envomask for low risk encounters. 3M half face with cartridges for high risk stuff. Applied for the Amazon healthcare designation so I have access to much of that there. Used eBay before I got that.

 

[turkeyjerky]

Here in AZ our ICU's are full. Last week we had 'plenty of capacity' despite >24 hr boarding times. Now they're admitting that we basically have no empty beds.

Our PPE supply is in the "green zone". We get one mask and one gown per day (able to access more if needed) and are supposed to wear ponchos over the gown while in a patient's room. N95s are available but can be hard to find at times and supply definitely seems limited.

 

[thegenius]

How do you reuse gowns? Are these the blue, plastic ones?

 

[bravotwozero]

No, they're cloth. you wipe them down.

 

[xaelia]

Cases -> Hospitalizations -> Deaths

I don’t see how this is controversial.

Some case increases may not lead to hospitalizations, depending on demographics.

And I don’t know what it is specifically about certain hot spots that makes them different than otherwise superficially similar areas of the country. I don’t offer any specific explanation, I am simply saying places like Houston, Dallas, Phoenix, etc. need to figure out what it takes to turn off the casehose real fast. I’m not saying it’s bars, elective surgeries, daycares etc. specifically because those are all debatable points. But there is a real problem that needs to be addressed, not just “no point in steering now”.

 

[Birdstrike]

Cases -> Hospitalizations -> Deaths

I don’t see how this is controversial.

I agree, it's not controversial as you state it. But there is a difference between,

A) 100 Cases -> 20 hospitalizations -> 5 deaths, and
B) 100 Cases -> 15 hospitalizations -> 0-1 deaths.

I'd like to think the current increase in cases in the states that are having increases, won't convert to deaths in as high a ratio (B) as they were back in March/April (A). We may be progressing from A to B, or we may not. We can only hope so.

And I don’t know what it is specifically about certain hot spots that makes them different than otherwise superficially similar areas of the country. I don’t offer any specific explanation, I am simply saying places like Houston, Dallas, Phoenix, etc. need to figure out what it takes to turn off the casehose real fast. I’m not saying it’s bars, elective surgeries, daycares etc. specifically because those are all debatable points. But there is a real problem that needs to be addressed, not just “no point in steering now”.

I agree that states having case surges need to address their situations. At the same time, I think it's worth pointing out where things are going better. The states doing terrible in April (Northeast) are doing better now, and the southern states, worse. Is it all because of shutdowns being reversed in southern states? Is the Northeast doing well only because they were shut-down or is there some (partial) herd immunity in play?

I think that's an important question, because the northeast states are starting to reopen and if their current situation is only because of the previous shutdowns, roles will reverse again, as the northeast reopens and the outbreaks burn out in the south. Or if there's an element of (partial) population immunity in the northeast, and can they reopen without having cases surge again?

I think those are hugely important questions, because if the states doing well right now don't figure it out, they may end up right back where they were in April and where the southern states are now. Roles may reverse, once again. Or maybe they won't, if this is all about some partial herd immunity developing with less effect from shutdowns.

I don't know. I want COVID to go away as much as anyone. You think I enjoy obsessing about these numbers daily? Obviously if I didn't think COVID was important, I wouldn't waste my time.

 

[xaelia]

I agree, it's not controversial as you state it. But there is a difference between,

A) 100 Cases -> 20 hospitalizations -> 5 deaths, and
B) 100 Cases -> 15 hospitalizations -> 0-1 deaths.

A) is the CFR we observed based on awful testing coverage. We can agree that's not the case.

I'll go with restating B and resolve 0-1 to 0.5:

B') 200 Cases -> 30 hospitalizations -> 1 death.

B' x 50% of the U.S. population is still 800,000 deaths. It sounds OK until you make the numbers large. With 130k already dead, it seems that's not a terrible estimate of the endpoint should 50% become infected. And then there's morbidity, too. I don't know what the answer is to keep the COVID down to a dull roar, but it's somewhere between party time and lockdown. Reasonable people can disagree, but it would be nice if it were less a political decision and more a scientific decision (that also weighs economic harms).

 

[Birdstrike]

I don't know what the answer is to keep the COVID down to a dull roar, but it's somewhere between party time and lockdown. Reasonable people can disagree, but it would be nice if it were less a political decision and more a scientific decision (that also weighs economic harms).

Hitting that sweet spot is the challenge.

 

[TwoHighways]

Obesity, NAFLD, and age are what will cause cases to lead to hospitalization and deaths.

Houston = fat as ****

Phoenix = lots of hispanics, lots of liver dysfunction (they do terrible with fructose, high PNPLA3 gene prevalence)

 

[bravotwozero]

Obesity, NAFLD, and age are what will cause cases to lead to hospitalization and deaths.

Houston = fat as ****

Yeah, funny how that worked out for me. I trained in Detroit - fattest city in America, then ended up in Houston. Not quite Detroit bad, but still one of the fattest.

Still, the vast majority of covid cases we're seeing in the ED are getting discharged, obese or not. On average, I admit about 1-2 covid patients per shift now.

 

[Siggy]

How do you reuse gowns? Are these the blue, plastic ones?

My fellowship hospital had heavy white gowns for the floors that got laundered after every use.

 

[miacomet]

If your hospital is running out of PPE now, that's a failure of your administration. There's enough to go around. I'm betting that most of the procedures you're thinking are pointless are at ASCs anyway.

Interesting. Perhaps it's because we are actually short 30 million N95s? https://www.washingtonpost.com/nati...e-updates-us/#link-B5BECYMULFFGFOS6IX7FFB6LXU

 

[Birdstrike]

The idea of an immediate V shaped economy recovery is likely gone.

V shaped recovery is fantasy thinking at this point.

"Millions of people have returned to work ...likely...to be...shortest recession in American history."-Market Watch, 7/2/20



Great jobs June jobs report out today. Is that a "v-shaped" jobs recovery starting? I don't know, but I'm glad to see the unemployment rate plummeting as quickly as it went up. There's a lot of people that need that, badly. It's great news.

 

[TJRock]

Interesting. Perhaps it's because we are actually short 30 million N95s? https://www.washingtonpost.com/nati...e-updates-us/#link-B5BECYMULFFGFOS6IX7FFB6LXU

Well, the Texas Medical Center reports that they have 1.4 million N95 masks with an estimated 30-day use rate of 300,000.

And I think that there might be a question about the 30 million number. As stated in your link:
"Rear Adm. John Polowczyk, the supply chain task force lead at the Federal Emergency Management Agency, said the supply chain doesn’t take into account what states or private institutions have purchased. He said the numbers do not include California, for example."

 

[onlyletters]

Peachy. So does my hospital system. We still have to reuse and reprocess N95s.

Sounds like the situation in Houston is totally being whitewashed: VICE - Houston Hospitals Deleted and Changed Charts That Track ICU Capacity
also https://www.newsweek.com/houston-moves-covid-19-patients-other-cities-we-dont-have-capacity-1514600

Yea I don't think so.

Seems like before they were reporting ICU capacity without considering surge planning in an effort to get the public to start wearing more masks and improve social distancing. Now they've revised their message when Governor Abbot got pissed off and now they are including their surge capacity. This is the gist of the TMC leadership's response and it's absolutely plausible. I don't think anyone is outright lying to the public. There are different ways to interpret the numbers in the face of surge planning.

Also Ben Taub and LBJ having to transfer to Galveston and Conroe and the likes is nothing new. Every winter during flu season the same thing happens.

 

[Birdstrike]

-U.S. COVID deaths are down
-Unemployment is plummeting
-CHOP has been dismantled
-Jefferey Epstein's pimp has been arrested

It's a great day to be alive

 

[miacomet]

I'm impressed people on this board have enough N-95s. You really don't have to reprocess and reuse them?

 

[miacomet]

Yea I don't think so.

Seems like before they were reporting ICU capacity without considering surge planning in an effort to get the public to start wearing more masks and improve social distancing. Now they've revised their message when Governor Abbot got pissed off and now they are including their surge capacity. This is the gist of the TMC leadership's response and it's absolutely plausible. I don't think anyone is outright lying to the public. There are different ways to interpret the numbers in the face of surge planning.

Also Ben Taub and LBJ having to transfer to Galveston and Conroe and the likes is nothing new. Every winter during flu season the same thing happens.

Do they have enough staff for their overflow ICUs?