What do I need to know about coronavirus?

[Birdstrike]

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Pence says there's been 'irresponsible rhetoric' from people downplaying the coronavirus

Trump said Monday that the “fake news media and their partner, the Democrat Party, is doing everything to inflame the coronavirus situation.”

www.nbcnews.com

I'm surprised to see you come out in favor of eternally quoting Mike Pence's words as irrefutable Gospel

 

[doctalaughs]

I agree the media isn’t serving a positive goal currently. However, if the entire US population becomes infected rapidly and 5 percent dies (15 million) in the next year - will we continue to say they “whipped up too much hysteria?” Is an “unconstitutional” total lockdown (aka Wuhan style) worth avoiding that?

maybe. But really if that scenario comes to pass and we retrospect compare it to another country that actually prepared well that ends up having less than 1 percent mortality.... it will truly be too little too action to late.
Only time will tell.

 

[Birdstrike]

I agree the media isn’t serving a positive goal currently. However, if the entire US population becomes infected rapidly and 5 percent dies (15 million) in the next year

In your opinion, what is the percent likelihood of this happening?

if that scenario comes to pass and we retrospect compare it to another country that actually prepared well

In the United States we are taking certain actions due to COVID-19. What other measures do you propose be taken that aren't currently being put in place?

 

[evilbooyaa]

In the United States we are taking certain actions due to COVID-19. What other measures do you propose be taken that aren't currently being put in place?

South Korea tests 10,000 people a day. In the US we have tested a total of approximately 11k people at this time-point? This is wrong, in my opinion, and we should be pouring significant governmental resources into this avenue.. The fact that testing is not available for every person who self-suspects (worried well, doesn't have to be in ERs, can be at the local level) is a significant issue in my mind.

Yes, the panicking and hoarding toilet paper is not the answer, but the average american just is not taking this seriously enough right now. We are on the same path of case explosion as Italy was (only like 8-10 days behind), and if we continue on this path, it will be days to weeks, not months or years, before we realize that we should have been more aggressively testing and quarantining.

 

[Birdstrike]

Confession: I'm not immune.

I had a patient in the ED once who was a health 20-year-old guy. He came home from work and told his roommate he had a slight headache and kicked his feet up in his recliner, but said, "I'm fine, just gonna take a nap." An hour later the roommate came back around and the guy was unresponsive, with vomiting, spit, blood and sputum out of his mouth, on his shirt, in his hair and everywhere. He came by ambulance to see Dr. Birdstrike trying harder to die than anyone I've ever seen. The only clues were "headache" and then "unresponsive, near death." Unresponsive, only guppy breathing, I intubated him first of course, through the spit, sputum, vomit, blood and boogers, and we started IV's, drew blood, put in orders yadda, yadda, yadda. His chest x-ray showed bilateral interstitial pneumonia, his WBC was very high and his head CT looked so frickin' bad, after only 60 minutes of symptoms, that the radiologist was calling, on a non-contrast scan, brain edema consistent with brain parenchymal infection with enlarged ventricles, likely increased ICP. The guy was presumed septic, meningitic, crashing, near death, needed ICU care (which we had) but also neurosurgery for a likely shunt (which we didn't have at that particular facility) if he lived. I transferred him.

A few days later we go the call that although he died quickly, all of his cultures ended up growing out meningococcus. Now, I tend not to be a panicker. And after taking care of countless patients with bad, communicable diseases and getting through it just fine, my senses have become probably excessively dulled to the prospect of getting seriously ill from any of them. But the sheer rapidity and brutality with which which this perfectly healthy kid died, struck me. Meningioucoccus is farking brutal and you can catch it, especially if you're the guy that intubated through the spit, sputum, vomit and blood. And it doesn't have a 98 or 99% survival rate. You did from it and you die badly. Or you live, maybe with no arms and legs. So, I took prophylaxis, sweated for a few days and then forgot about it for 15 years until right now.

 

[bravotwozero]

With regards to the stock market, I don't think it's merely 'panic' causing a bear market, but real economic forces that are related to the outbreak as well as other events. The Saudi oil price war with the Russians isn't helping, but obviously the travel and hospitality sectors are taking big financial hits for obvious reasons, all of which is bad for business, and subsequently, shareholders.

Also, I'm hearing reports the virus does not tend to survive in temperatures above 27 degrees celsius, which may be why the outbreak isn't as severe in some of the hottest regions. Maybe others can chime in and confirm?

 

[doctalaughs]

In your opinion, what is the percent likelihood of this happening?

In the United States we are taking certain actions due to COVID-19. What other measures do you propose be taken that aren't currently being put in place?

I think that is worse case scenario with low (less than 5 percent) probability.
I do think there is a much higher probability the final death count will dwarf influenza (greater than 300k) when this is done given our piss poor preparedness.

I would ramp up diagnostic testing yesterday. Contract to buy millions tests from overseas. Send a team to copy what the Koreans are doing. Better tracing of contacts and mandatory cities and school quarantines now based on actual positive real-time testing data. Free drive by testing in thousands of places.

everyone with a sniffle or just wondering gets an easy access test.

I think within 2 weeks it will be apparent whether this should have been done. Closing the borders to Europe is a beyond idiotic response if we already have tens of thousands infected and spreading this at Costco while hoarding toilet paper and doctors who can only screen severe cases.

 

[d2305]

Inovio Pharmaceuticals has a vaccine ready to go. Let everyone sign waivers and mass immunize those who want it. They did it in '76 for the swine flu.

 

[Birdstrike]

Also, I'm hearing reports the virus does not tend to survive in temperatures above 27 degrees celsius, which may be why the outbreak isn't as severe in some of the hottest regions. Maybe others can chime in and confirm?

Not sure if true, but if it is, it's a good thing as temperatures are rising as winter comes to a close.

 

[evilbooyaa]

Also, I'm hearing reports the virus does not tend to survive in temperatures above 27 degrees celsius, which may be why the outbreak isn't as severe in some of the hottest regions. Maybe others can chime in and confirm?

We don't know. To say that it is responsive to temperature is assuming a lot of things about COVID-19 that we don't know at this time.

Will Warm Weather Kill Coronavirus?

U.S. President Donald Trump said he hoped the virus would go away in April 2020 because the "heat generally speaking kills this kind of virus."

www.snopes.com

 

[miacomet]

Inovio Pharmaceuticals has a vaccine ready to go. Let everyone sign waivers and mass immunize those who want it. They did it in '76 for the swine flu.

And that was a fiasco.

 

[norski]

Like the US, Norway has been slow to react, and it'll probably screw us deeply, no lube, for a long time.

With a small, widespread population of 5 million nationally, strict regulations for screening (pcr media is scarce), more riches, business protectionism from the govt side of things, and a stubborn will to travel rather than brains*, we're just reached 7-800 or so confirmed symptomatic covid patients, and today, our first death.

Today was also the day our govt finally laid down the law; docs and nurses are effectively forbidden to leave the country, lockdown of all schools, universities and daycare facilities is put in place, 14 day retroactive quarantines on anyone going outside the Nordic countries after Feb 27. With some sort of pay, though.

Our anesthesia dept of nine (2 docs, 7 nurses) are in for a pretty rough spring (no EM specialty here). The WA account cited in this thread is pretty chilling.

Best of luck to all of you in the States.

*As my asymptomatic family and I got back from Germany this saturday, I'm off for another ten days,if a critical personnel amendment fails to pop up.

Sent from my LYA-L29 using SDN mobile

 

[miacomet]

Not sure if true, but if it is, it's a good thing as temperatures are rising as winter comes to a close.

A

LMAO at "total lockdown". Not possible in a country the size of the US with a population of 400 million. Probably would be unconstitutional as well. My understanding is that the law states anyone forcibly quarantined has the right to a hearing within 2 days.

Complete nonsense.

Anyone see the first few episodes of "Fear The Walking Dead"?

Also please post stats on young people who are getting ARDS and dying in Seattle from this virus.

OK, I agree. Not lockdown- but we need to encourage social distancing, which is happening, finally. We need to increase testing, which is happening, finally. Unfortunately, none of this happened in a calm, orderly fashion, like it would in Korea. There had to be denial, politicization, and then panic before anything got done, and of course, now we will overdo it. It's the American way.

I don't have great data on Seattle. No one does. About anything. Which is a bit strange....

You aren't making sense about quarantine (which is a pointless measure right now)- it's state law, every state is different, and the law is actually incredibly vague in many states.

 

[VA Hopeful Dr]

Also, I'm hearing reports the virus does not tend to survive in temperatures above 27 degrees celsius, which may be why the outbreak isn't as severe in some of the hottest regions. Maybe others can chime in and confirm?

So what you're saying is that climate change may save us all?

 

[bravotwozero]

Also, how accurate is the COVID-19 test? Why have there been people who tested negative initially and then positive afterwards?

By law, we are quite decentralized in terms of our government structure. However, decentralization is NOT a good thing when you're trying to respond to a pandemic. The countries that have been successful in containing the outbreak did so in anything but a decentralized manner.

 

[Apollyon]

@Birdstrike 's story about meningitis made me think of what Rahm Emanuel said 8 yrears ago: "Never let a good crisis go to waste".

 

[ShockIndex]

In the United States we are taking certain actions due to COVID-19. What other measures do you propose be taken that aren't currently being put in place?

The measure that nobody outside of Ohio seems to want to discuss is K-12 schools. While children are unlikely to have severe symptoms, they are almost certainly an infectious reservoir. Closing schools and daycares would significantly flatten the curve, but the impact on the economy and healthcare system would be profound. How many single parent households are led by a bread winner who is a cop, nurse, paramedic, doctor, etc.? Imagine all of them calling out for work to provide childcare.

 

[rokshana]

We prepare better for hurricanes than we are for this...live in hurricane country...j cantore is here abouts every year..

 

[GeneralVeers]

Like the US, Norway has been slow to react, and it'll probably screw us deeply, no lube, for a long time.

With a small, widespread population of 5 million nationally, strict regulations for screening (pcr media is scarce), more riches, business protectionism from the govt side of things, and a stubborn will to travel rather than brains*, we're just reached 7-800 or so confirmed symptomatic covid patients, and today, our first death.

Today was also the day our govt finally laid down the law; docs and nurses are effectively forbidden to leave the country, lockdown of all schools, universities and daycare facilities is put in place, 14 day retroactive quarantines on anyone going outside the Nordic countries after Feb 27. With some sort of pay, though.

Our anesthesia dept of nine (2 docs, 7 nurses) are in for a pretty rough spring (no EM specialty here). The WA account cited in this thread is pretty chilling.

Best of luck to all of you in the States.

*As my asymptomatic family and I got back from Germany this saturday, I'm off for another ten days,if a critical personnel amendment fails to pop up.

Sent from my LYA-L29 using SDN mobile

1 death out of 700?

Also it would be illegal in the US to forbid doctors and nurses from traveling.

 

[Birdstrike]

I just read several news outlets that are saying there are going to be "480,000 Americans dead!" from COVID-19 by the end of the season. Another one is claiming "an average of 3,060 America will die every day through the end of this year!" Yet another, "Congressional doctor predicts up to 70,000,000-150,000,000 American coronavirus!" by end of year, which at a 1% death rate equals 700,000-1,500,000 Americans dead. I'm not talking about social media. I'm talking about widely read news outlets across the political spectrum.

If these turn out to be false, and it's absolutely certain they will, will they be prosecuted for Inducing Panic, to the fullest extent of the law and sued for the billions of dollars of economic damages they will have caused? Because the reporters and the so called "experts" making these predictions are smart enough to know, and do know, these claims are total bullsh*t. They abso-frickin-lutely know it's bullsh*t. They're sitting there all calm on their podcast, listing the numbers, cracking a slight smile, pleased at all the attention they're getting for "how smart" and how much of an "expert" they are and they know they're lying, and that we will not come even close to these numbers. They know that the way these things play out are never as simple as plugging in their two or three estimated numbers and it all plays out perfectly, linearly and exactly as they predict. They know that they can still advise the public to wash their hands, avoid crowds, get tested and stay home if sick, without peddling mass panic-inducing lies. They know that if what they were saying was true the wouldn't have left their own damn house to do the interview or even have shown up to work. And they also know that they can get away with making blatantly false and outlandish predictions like this easily, because proving them wrong requires waiting months, compiling stats and that by the time anyone is able to do that, people will have moved on to something else and largely forgotten the details.

"Inducing Panic Law and Legal Definition: Inducing panic is when a person causes the evacuation of any public place, or otherwise cause serious public inconvenience or alarm, by doing any of the following:

1. Initiating or circulating a report or warning of an alleged or impending fire, explosion, crime, or other catastrophe, knowing that such report or warning is false"

 

[GeneralVeers]

I just read several news outlets that are saying there are going to be "480,000 Americans dead!" from COVID-19 by the end of the season. Another one is claiming "an average of 3,060 America will die every day through the end of this year!" Another claims, "Congressional doctor predicts up to 70,000,000-150,000,000 American coronavirus!" by end of year, which at a 1% death rate equals 700,000-1,500,000 Americans dead. I'm not talking about social media. I'm talking about widely read news outlets across the political spectrum.

If these turn out to be false, and it's absolutely certain they will, will they be prosecuted for Inducing Panic, to the fullest extent of the law and sued for the billions of dollars of economic damages they will have caused? Because the reporters and the so called "experts" making these predictions are smart enough to know, and do know, these claims are total bullsh*t. They abso-frickin-lutely know it's bullsh*t. They're sitting there all calm on their podcast, listing the numbers, cracking a slight smile, pleased at all the attention they're getting for "how smart" and how much of an "expert" they are and they know they're lying, and that we will not come even close to these numbers. They know that the way these things play out are never as simple as plugging in their two or three estimated numbers and it all plays out perfectly, linearly and exactly as they predict. They know that if what they were saying was true the wouldn't have left their own damn house to do the interview or even have shown up to work.

"Inducing Panic Law and Legal Definition: Inducing panic is when a person causes the evacuation of any public place, or otherwise cause serious public inconvenience or alarm, by doing any of the following:

1. Initiating or circulating a report or warning of an alleged or impending fire, explosion, crime, or other catastrophe, knowing that such report or warning is false"

That all sounds like Right Wing Propaganda you are spouting.....

 

[Birdstrike]

That all sounds like Right Wing Propaganda you are spouting.....

Of course.

.


.Lol

 

[rokshana]

1 death out of 700?

Also it would be illegal in the US to forbid doctors and nurses from traveling.

I somehow doubt it...

I’m sure there is some sort of language in privileges or licensing that says if a national state of emergency is declared, we as healthcare personnel have to be available.
But of course they can make that it has its consequences... quarantine for 2 week, unable to return to work, suspension of staff privileges, etc... remember , they can always hurt you more...

 

[GeneralVeers]

I somehow doubt it...

But of course they can make that it has its consequences... quarantine for 2 week, unable to return to work, suspension of staff privileges, etc... remember , they can always hurt you more...

We already have this rule. Any travel out of the country means no work for 14 days upon return.

 

[NYEMMED]

A buddy of mine was put into self quarantine. Cannot work for 14 days. EM doc with no income....

Makes me worry about having to miss out on 2 weeks of work. Then annoyed we don’t get paid for a work related hazard...

 

[bravotwozero]

Inovio Pharmaceuticals has a vaccine ready to go. Let everyone sign waivers and mass immunize those who want it. They did it in '76 for the swine flu.

No they don't. Phase two.

 

[ShockIndex]

I just read several news outlets that are saying there are going to be "480,000 Americans dead!" from COVID-19 by the end of the season...Yet another, "Congressional doctor predicts up to 70,000,000-150,000,000 American coronavirus!" by end of year, which at a 1% death rate equals 700,000-1,500,000 Americans dead. I'm not talking about social media. I'm talking about widely read news outlets across the political spectrum.

If these turn out to be false, and it's absolutely certain they will, will they be prosecuted for Inducing Panic, to the fullest extent of the law and sued for the billions of dollars of economic damages they will have caused? Because the reporters and the so called "experts" making these predictions are smart enough to know, and do know, these claims are total bullsh*t.

I’m absolutely convinced that 100-150M Americans infected over the next year is a plausible, if not probable, scenario. That is 1-1.5M dead. Even if the virus slows down this Spring, it will re-emerge next Winter in force. These were the numbers quoted on EMRAP yesterday by Mel Herbert and Dave Talan (triple boarded in EM, IM, and ID).

(fast forward to 4:00 for stats)

I have no reason to think that they are bull****ting us.

At this point, the strategy is to flatten the curve so that those 150M are infected over the longest time possible so that our healthcare system can best accommodate them. Success from a healthcare perspective means that mortality stays under 1%. Failure means a bunch of infected people overwhelm the system at once and the death rate from this virus (and many other treatable conditions) soars.

Of course, success from a healthcare perspective will require that we risk collapsing our economy under austere social distancing measures. That will have an impact on mortality that is much harder to capture.

 

[GeneralVeers]

A buddy of mine was put into self quarantine. Cannot work for 14 days. EM doc with no income....

Makes me worry about having to miss out on 2 weeks of work. Then annoyed we don’t get paid for a work related hazard...

At least my group (Envision) will pay something to those quarantined. We are trying to get it to come out of Workman's Comp which it should.

 

[miacomet]

I’m absolutely convinced that 100-150M Americans infected over the next year is a plausible, if not probable, scenario. That is 1-1.5M dead. Even if the virus slows down this Spring, it will re-emerge next Winter in force. These were the numbers quoted on EMRAP yesterday by Mel Herbert and Dave Talan (triple boarded in EM, IM, and ID).

(fast forward to 4:00 for stats)

I have no reason to think that they are bull****ting us.

At this point, the strategy is to flatten the curve so that those 150M are infected over the longest time possible so that our healthcare system can best accommodate them. Success from a healthcare perspective means that mortality stays under 1%. Failure means a bunch of infected people overwhelm the system at once and the death rate from this virus (and many other treatable conditions) soars.

Of course, success from a healthcare perspective will require that we risk collapsing our economy under austere social distancing measures. That will have an impact on mortality that is much harder to capture.

What's sad is we could have avoided the ongoing economic and social disruption had we tested and isolated aggressively from the beginning, and opened fever clinics like China or drive through testing like Korea and Australia. Now, we will pay the price for an unknown amount of time- presumably until there is a vaccine or herd immunity.

EMTALA is really becoming impossible under these circumstances, and dangerous. The most successful countries have tried to keep non-sick people out of the ED, with good reason.

 

[thegenius]

This article highlights the ineptitude of the US response Compared to s Korea.

How this South Korean company created coronavirus test kits in three weeks | CNN

Before there were any cases of novel coronavirus confirmed in South Korea, one of the country's biotech firms had begun preparing to make testing kits to identify the disease.

www.cnn.com

1 company producing more tests per DAY (actually per hour) than the USA has managed in the last 2 months....

I predict history will tell this administration had one of the most bungled, incompetent responses conceivable resulting in hundreds of thousands of extra deaths in this country.

It will not be that high. mainly because we are going into hibernate mode.

See, with the flu, nobody cares about it and it spreads like crazy. each year we have 30-60M cases of influenza. But nobody washes their hands, wears masks, buys all the water at Costco, and thinks there is a mass conspiracy. They just come to the ER and demand a medicine that doesn't work and a work note for 5 days.

with COVID-19, we are going into world wide hibernate mode. That will help prevent the spread of disease.

 

[thegenius]

Yes, the panicking and hoarding toilet paper is not the answer, but the average american just is not taking this seriously enough right now. We are on the same path of case explosion as Italy was (only like 8-10 days behind), and if we continue on this path, it will be days to weeks, not months or years, before we realize that we should have been more aggressively testing and quarantining.

Not sure where you get that from. The entire US, the entire world is shutting down. Going into hibernate mode. Costco has no goods. People are buying everything in sight. You can't even buy a pair of pants. There is one shift left to buy.

 

[NYEMMED]

At least my group (Envision) will pay something to those quarantined. We are trying to get it to come out of Workman's Comp which it should.

Would be great for those that can, then there’s independent contractors....

 

[Birdstrike]

I’m absolutely convinced that 100-150M Americans infected over the next year is a plausible, if not probable, scenario. That is 1-1.5M dead. Even if the virus slows down this Spring, it will re-emerge next Winter in force. These were the numbers quoted on EMRAP yesterday by Mel Herbert and Dave Talan (triple boarded in EM, IM, and ID).

If you go through life believing these three false beliefs, you'll always be a sucker for every induced panic, and mass hysteria that comes along.

1. Because something bad happens somewhere in the world, it'll happen to me.
2. The media won't exaggerate, induce panic or lie to me for their own financial benefit.
3. Experts aren't often wrong.

I didn't listen to the EMRAP you're referring to, but if Mel Herbert and Dave Talan said 1-1.5 million Americans are going to die from COVID-19 in the next year, they're wrong, fantastically wrong. And I would go so far as to say they know it's not going to happen, but they're saying it anyways. It will probably be their most listened to podcast of the whole year.

The truth:

1. When something bad happens some where in the world, it probably won't happen to you.
2. The media will knowingly exaggerate, lie and even go so far as to induce panic often, and will benefit financially from it.
3. So called "experts" are frequently wrong, often spectacularly so.

 

[Painted]

If any of you are in a FB group for ER doctors you may be advising the Whitehouse....

 

[evilbooyaa]

Not sure where you get that from. The entire US, the entire world is shutting down. Going into hibernate mode. Costco has no goods. People are buying everything in sight. You can't even buy a pair of pants. There is one shift left to buy.

It's slowly happening. Cancellation of things that lead to large gatherings (NBA/NHL/March Madness) is a good start. These were not the case (or I was not aware of them) when I made that post.

I still maintain we should have followed South Korea's lead and made testing available to all who had any symptoms. Right now, most places (including LA County) will only test you if you 1) have symptoms and have a travel history to 'justify' it OR 2) have symptoms severe enough to require hospitalization. I think this is a critical error and will be the independent variable when this is all retrospectively analyzed.

IMO, People are much less likely to self-quarantine appropriately if they are told to stay at home for 14 days (again, with no travel history, as 2 of the 3 most recent cases reported in Los Angeles county were by community transmission) just for symptoms without being able to actually get tested and confirm they have the disease.

 

[Dr Mantis Toboggan]

Emdocs?

Obvi Kushner needs to get his advice from here.

If any of you are in a FB group for ER doctors you may be advising the Whitehouse....

 

[ShockIndex]

What's sad is we could have avoided the ongoing economic and social disruption had we tested and isolated aggressively from the beginning, and opened fever clinics like China or drive through testing like Korea and Australia. Now, we will pay the price for an unknown amount of time- presumably until there is a vaccine or herd immunity.

EMTALA is really becoming impossible under these circumstances, and dangerous. The most successful countries have tried to keep non-sick people out of the ED, with good reason.

So far, there are 2 demonstrated models of containing this virus: extreme social isolation across large population segments (China) and high-volume testing coupled with quarantine for the positives (S. Korea). The former seems to be effective in a centrally planned, quasi-communist dictatorship where the leadership is more than happy to make people disappear for non-compliance. The latter seems to work in a country with only 50M people and 1% of the land mass of the US, but the jury seems to be out on the Korean model.

Thinking that either model could have (or should) have been implemented in the US last month is probably a mistake. We are a free an open society of 350M people with a stunning amount of international travel from hotspots in both Europe and Asia.

 

[WilcoWorld]

Keep in mind, when COVID-19 sweeps through a nursing home, not only are these people elderly, they're very likely to have DNR orders on file. So if they get sick and it's a survivable COVID-19 infection that's treatable with aggressive care, they may die anyways, because they're allowed to die, pre-existing DNR orders. So when you go to Seattle, for example, on this really great COVID-19 tracking map and you see 30 deaths in Seattle alone (which is 75% of the deaths in our whole country) out of 373 cases, and conclude a death rate of 8%, you have to ask, 1) How many were in nursing home patients, and 2) How many of those patients were DNR?

It's already been reported that 18 of those deaths in Seattle were from one nursing home. How many others were from other nursing homes in Seattle? How many of those patients were DNR?

I realize that the fact a patient was DNR doesn't make the virus any less lethal to this population, in fact more so. Also it doesn't make their death any less tragic or ease the pain of the family. But epidemiologically it does make a big difference. It means, 1) Nursing homes need to be under the strictest isolation precautions because COVID-19 is incredibly dangerous in that setting, which so far everyone seems to understand, but it also means that, 2) Just because COVID-19 swept through a nursing home and killed 18 extremely elderly patients most of whom were under DNR orders, doesn't mean it's going to sweep through your house, kill everyone in your family and collapse the country's health care systems. It might do that. But it might not. It might sweep through your house and give you all nothing but the sniffles, anti-bodies against COVID-19 and a lifetime supply of TP. Or maybe you won't get it at all.

OFF TOPIC ALERT

DNR orders only apply once a patient has stopped breathing AND does not have a pulse.

When a patient with an out of hospital DNR order shows up to my ED with a STEMI - I activate the cath lab, when they're septic - I draw cultures and start antibiotics, when they have a PE - I assess for CV instability and anticoagulate. When they show up with a viral pneumonia causing respiratory distress - I provide ventilatory support unless they ALSO have expressed a do not intubate preference.

Your post is conflating DNR with comfort care. Please stop. This confusion makes it harder to have constructive code status discussions.

 

[ShockIndex]

It's slowly happening. Cancellation of things that lead to large gatherings (NBA/NHL/March Madness) is a good start. These were not the case (or I was not aware of them) when I made that post.

I still maintain we should have followed South Korea's lead and made testing available to all who had any symptoms. Right now, most places (including LA County) will only test you if you 1) have symptoms and have a travel history to 'justify' it OR 2) have symptoms severe enough to require hospitalization. I think this is a critical error and will be the independent variable when this is all retrospectively analyzed.

IMO, People are much less likely to self-quarantine appropriately if they are told to stay at home for 14 days (again, with no travel history, as 2 of the 3 most recent cases reported in Los Angeles county were by community transmission) just for symptoms without being able to actually get tested and confirm they have the disease.

That assumes that we had an accurate test 2 months ago. It also assumes that we fundamentally changed our healthcare infrastructure to provide on-demand testing to a population of 350M people. No country has ever done that. Who was going to perform it? Pay for it? Keep track of the positives? Account for the undocumented? You get the picture.

 

[Birdstrike]

Cancellation of things that lead to large gatherings (NBA/NHL/March Madness) is a good start.

Cancelation of sporting events, which are entertainment-only non-essential activities is fine. If leagues that had tournaments through WWII, Vietnam, 9/11, Hong Kong flu, swine flu, H1N1 and all the other crises we went through that's fine. It will reduce spread of COVID-19 (40 USA deaths) and influenza (20,000 deaths currently). So, good. Cancel away, leagues, schools, Broadway, large gatherings. That's great. But, what do we do in May when COVID-19 is still here and the case count and death count are even higher? Do we keep all the sports leagues, schools, Broadway canceled all summer? Though next winter virus season when COVID-19 is STILL here?

Did influenza go away after it killed 400,000 worldwide (COVID-19 is 1/100th of that right now) in 2009?

In 2009, H1n1 had killed 1,000 Americans before a national emergency was even declared. How come?
Why were't all the leagues, Broadway, school and canceled then, even after the death count went over 10,000?

Again, I'm not saying don't cancel. Cancel. That's fine. But why haven't we always done this, and are we always going to do this?

I still maintain we should have followed South Korea's lead and made testing available to all who had any symptoms. Right now, most places (including LA County) will only test you if you 1) have symptoms and have a travel history to 'justify' it OR 2) have symptoms severe enough to require hospitalization. I think this is a critical error and will be the independent variable when this is all retrospectively analyzed.

I agree large scale testing is a must. S Korea had the test kits. We're slow to ramp up. That needs to be fixed. But massive, large scale testing, like we swab strep and flu patients is important. Mainly to prove that for every known case there's probably ten or a hundred out there who aren't dying and that the death rate 1/100th of what people think. That will be the most reassuring thing to everyone. And when they see Tom Hanks turns out fine. And Justin Trudeau and his wife turn out fine. And Ted Cruz turns out just fine. And the basketball and soccer players turn out just. And your neighbor had it and he's fine. And you had it and you're fine. Then America will be back to it's no-hand washing, non-vaccine taking apathy.

 

[evilbooyaa]

That assumes that we had an accurate test 2 months ago. It also assumes that we fundamentally changed our healthcare infrastructure to provide on-demand testing to a population of 350M people. No country has ever done that. Who was going to pay for it? Keep track of the positives? Account for the undocumented? You get the picture.

I'm not pontificating in the past about 2 months ago. South Korea has a kit and has taken steps at the national level to create pop up testing clinics. We, as a country, did not take it seriously enough to even attempt to replicate that. We still aren't as we aren't willing to use the South Korea kit. For what reason, I don't know, and I don't want to speculate on politics/media as I don't want to make the discussion political.

If you think you have symptoms suggestive of COVID-19, it should NOT be as hard as it currently is to get tested. I'm not saying to test all 350m Americans or those without any symptoms, but the current method of 'self-quarantine for 14 days but if you don't have a travel history and/or don't need hospitalization we're not even going to test you' is not OK. If you have symptoms you should be able to get tested for COVID-19, regardless of travel history, as we know that community transmission is an issue.

Cancelation of sporting events, which are entertainment-only non-essential activities is fine. If leagues that had tournaments through WWII, Vietnam, 9/11, Hong Kong flu, swine flu, H1N1 and all the other crises we went through that's fine. It will reduce spread of COVID-19 (40 USA deaths) and influenza (20,000 deaths currently). So, good. Cancel away, leagues, schools, Broadway, large gatherings. That's great. But, what do we do in May when COVID-19 is still here and the case count and death count are even higher? Do we keep all the sports leagues, schools, Broadway canceled all summer? Though next winter virus season when COVID-19 is STILL here?

Did influenza go away after it killed 400,000 worldwide (COVID-19 is 1/100th of that right now) in 2009?

In 2009, H1n1 had killed 1,000 Americans before a national emergency was even declared. How come?
Why were't all the leagues, Broadway, school and canceled then, even after the death count went over 10,000?

Again, I'm not saying don't cancel. Cancel. That's fine. But why haven't we always done this, and are we always going to do this?

Because this is something new that nobody has innate immunity to yet. Because we don't have a vaccine, yet. The graphs about not overwhelming the health care system with a ton of cases right now are real, and Italy has the insane mortality rate it does BECAUSE it is the left-side of that graph, not the right side. Again, we are on a path to Italy currently, not on a path to South Korea.

I agree large scale testing is a must. S Korea had the test kits. We're slow to ramp up. That needs to be fixed. But massive, large scale testing, like we swab strep and flu patients is important. Mainly to prove that for every known case there's probably ten or a hundred out there who aren't dying and that the death rate 1/100th of what people think. That will be the most reassuring thing to everyone. And when they see Tom Hanks turns out fine. And Justin Trudeau and his wife turn out fine. And Ted Cruz turns out just fine. And the basketball and soccer players turn out just. And your neighbor had it and he's fine. And you had it and you're fine. Then America will be back to it's no-hand washing, non-vaccine taking apathy.

100% agree, especially with the bolded.

 

[Birdstrike]

I'm not pontificating in the past about 2 months ago. South Korea has a kit and has taken steps at the national level to create pop up testing clinics. We, as a country, did not take it seriously enough to even attempt to replicate that. We still aren't as we aren't willing to use the South Korea kit. For what reason, I don't know, and I don't want to speculate on politics/media as I don't want to make the discussion political.

If you think you have symptoms suggestive of COVID-19, it should NOT be as hard as it currently is to get tested. I'm not saying to test all 350m Americans or those without any symptoms, but the current method of 'self-quarantine for 14 days but if you don't have a travel history and/or don't need hospitalization we're not even going to test you' is not OK. If you have symptoms you should be able to get tested for COVID-19, regardless of travel history, as we know that community transmission is an issue.



Because this is something new that nobody has innate immunity to yet. Because we don't have a vaccine, yet. The graphs about not overwhelming the health care system with a ton of cases right now are real, and Italy has the insane mortality rate it does BECAUSE it is the left-side of that graph, not the right side. Again, we are on a path to Italy currently, not on a path to South Korea.



100% agree, especially with the bolded.

In 2009, we had 60 million people get infected with Swine Flu. 300,000 were admitted. 18,000 Americans died. Our health systems didn’t collapse. We did not cancel pro-ball leagues, March Madness and all public gatherings.

We are not “on the road to being Italy.” Our health system is not going to collapse. 1.5 million Americans are not going to die from Coronavirus, because 30 DNR patients in 1 nursing home died.

The mass hysteria and profound overreaction from people who should know better is preposterous.

 

[takeurmeds02]

Maybe I'm truly missing something but what is the value in testing any and everyone? Shouldn't it really be just for those who care for or are around vulnerable populations? Obviously, there's also utility in pinning down diagnosis in critically ill but for the general population that doesn't meet the above criteria, what's the value? If you're sick stay home because there's nothing we could do for you anyway. At this point, if you're feeling bad just assume you have it and if you significantly worsen, go to the ED.

 

[ShockIndex]

I'm not pontificating in the past about 2 months ago. South Korea has a kit and has taken steps at the national level to create pop up testing clinics. We, as a country, did not take it seriously enough to even attempt to replicate that. We still aren't as we aren't willing to use the South Korea kit. For what reason, I don't know, and I don't want to speculate on politics/media as I don't want to make the discussion political.

If you think you have symptoms suggestive of COVID-19, it should NOT be as hard as it currently is to get tested. I'm not saying to test all 350m Americans or those without any symptoms, but the current method of 'self-quarantine for 14 days but if you don't have a travel history and/or don't need hospitalization we're not even going to test you' is not OK. If you have symptoms you should be able to get tested for COVID-19, regardless of travel history, as we know that community transmission is an issue.

Again, why do you think that it is possible for a country that 6X the population and 100X the landmass of S. Korea to replicate its approach? That question has nothing to do with politics and everything to do with practicality.

The reason why we don’t use the Korean “kit” is because it is their home grown method with reported “excellent sensitivity and specificity” that our regulators have not been able to verify. Maybe it is; maybe it isn’t. Our first attempts at testing suffered from quality control and/or performance issues. Had we rushed ahead and implemented widespread testing we would be contending with a bunch of false positives and negatives.

The bottom line is that the American healthcare system is not one system -it is a conglomerate of many systems largely geared toward individual choice and autonomy over population health. It makes perfect sense that our response would not mirror a more homogeneous, smaller society that is already geared toward population health.

 

[evilbooyaa]

Again, why do you think that it is possible for a country that 6X the population and 100X the landmass of S. Korea to replicate its approach? That question has nothing to do with politics and everything to do with practicality.

The reason why we don’t use the Korean “kit” is because it is their home grown method with reported “excellent sensitivity and specificity” that our regulators have not been able to verify. Maybe it is; maybe it isn’t. Our first attempts at testing suffered from quality control and/or performance issues. Had we rushed ahead and implemented widespread testing we would be contending with a bunch of false positives and negatives.

The bottom line is that the American healthcare system is not one system -it is a conglomerate of many systems largely geared toward individual choice and autonomy over population health. It makes perfect sense that our response would not mirror a more homogeneous, smaller society that is already geared toward population health.

Are we willing to not even try to replicate it? I'd understand if it was not to the same efficiency as South Korea given the larger area and population of this country.

Anyways, I think we're just going to have to agree to disagree. I appreciate the opposing viewpoints that we shouldn't bother testing anybody except those already sick enough to require hospitalization of it, but I don't agree with it because it makes quaranting folks that are a degree or two of separation from the person in question impossible, which increases our infection rate.

Perhaps we feel that we are so much better of a health care system than Italy, but there are reports about Washington state hitting dangerous levels of healthcare utizliation. Guess those who believe we are so much better than Italy at healthcare may only see the light if/once we see similar battlefield triaging in a US state. I hope I'm wrong.

 

[Vandalia]

I'm surprised to see you come out in favor of eternally quoting Mike Pence's words as irrefutable Gospel

Not offered for the truth of the matter asserted.

 

[thegenius]

Again, why do you think that it is possible for a country that 6X the population and 100X the landmass of S. Korea to replicate its approach? That question has nothing to do with politics and everything to do with practicality.

Oh for sure politics played some role, and I bet a large role, in the US’s terrible public health response and its ability to test for the virus.

We have the smartest people, and the most resources out of any country to design and use a test kit. And we are woefully behind.

 

[Vandalia]

In 2009, we had 60 million people get infected with Swine Flu. 300,000 were admitted. 18,000 Americans died. Our health systems didn’t collapse. We did not cancel pro-ball leagues, March Madness and all public gatherings.

We are not “on the road to being Italy.” Our health system is not going to collapse. 1.5 million Americans are not going to die from Coronavirus, because 30 DNR patients in 1 nursing home died.

The mass hysteria and profound overreaction from people who should know better is preposterous.

Your example has a mortality rate of 0.03%. The WHO data shows a mortality rate of 3%, one hundred times greater. There was a paper in Lancet published electronically this morning which says that the 3% number may be significantly under-estimated.

So what evidence do you have that the mortality rate here will be 100 times less here?

Your argument seems to be of the form that since no NP board certified by the ABEM has ever committed malpractice, there is no risk to board-certifying nurse practitioners and have them replace EM physicians.

 

[ShockIndex]

Are we willing to not even try to replicate it? I'd understand if it was not to the same efficiency as South Korea given the larger area and population of this country.

Anyways, I think we're just going to have to agree to disagree. I appreciate the opposing viewpoints that we shouldn't bother testing anybody except those already sick enough to require hospitalization of it, but I don't agree with it because it makes quaranting folks that are a degree or two of separation from the person in question impossible, which increases our infection rate.

Perhaps we feel that we are so much better of a health care system than Italy, but there are reports about Washington state hitting dangerous levels of healthcare utizliation. Guess those who believe we are so much better than Italy at healthcare may only see the light if/once we see similar battlefield triaging in a US state. I hope I'm wrong.

Replicate - no. Learn from - yes.

Here is why. The S. Korean approach of widespread testing is predicated on the fact that their healthcare system is a top-down ministry that administers to the needs of more than 95% of their population...which happens to be less than 1/6 of our population. They also had a much higher relative prevalence and possibly better test characteristics then we did when widespread testing was instituted. FWIW, I’m also happy to learn from aspects of the Chinese response, but I have no desire to replicate it with forced isolation at the tip of an AK47 (or M4 in our case).

Also, I never suggested that we should only test hospitalized patients. I believe that testing is driven by the test characteristics (sensitivity/specificity), disease features (lethality, infectivity, etc.), and the prevalence of the disease in the population. I feel this way for troponin for MI, d-dimer for VTE, or RVPs for COVID. So, I agree with the CDC officials that widespread testing using an assay with suspect performance characteristics 3 weeks ago would have been a mistake because the prevalence was low and we would have flooded the system with wide spread false-positives - just like sending a d-diner on every chest pain would be a mistake.

Now that the incidence and prevalence are rising, I agree with more wide spread testing - especially if the test characteristics have improved.

Finally, I believe that the post-mortem on this crisis 5 years from now will show multiple factors contributed to the spread of COVID across the US. Chief among them will be that patients are highly infectious for DAYS before symptomatic. The presence or absence of testing early in the curve will play a minor but significant role in our relatively large and highly mobile country.

 

[NYEMMED]

Turns out I heard Teamhealth has reversed course on their compensation cuts for now secondary to the virus.