Covid explosion

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Infection_Ag11
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In reply to [removed post] • 8:32a, 11/16/20
AG
JJMt said:
Infection_Ag11 said:
Marcus Aurelius said:
Fenrir said:
Who do you want making those decisions?
Reasonable families. Doctors not empowered to make those decisions in the US. I guess for good reasons. But these are desperate times. This is not the case in other countries. America litigious.


It may sound cold, but we really should allow medical professionals to make the call not to intubate a 100 year old with dementia and respiratory failure. That's not only cruel for the patient, but wasteful to the healthcare industry and puts other lives that could actually be saved at risk. It's obscene the futile care we are forced to provide and the unnecessary pain and suffering and wasted resources it leads to.
Absolutely wrong. Just because you disagree with the family's decision doesn't give you the right to make that decision.

I can't think of a worse idea than giving people who have no connection to the patient at all the right to make life and death decisions.

You use the 100 year old on a vent as your propaganda point, but where does it stop? Who are you to decide the value of another's life?

You are advocating for sweeping changes in national policies off of one anecdotal, bad decision. I thought that you were a numbers guy? You don't like anecdotal stories as evidence. Well, I suppose that's true only if you don't like the anecdotes.


That story isn't anecdotal, it's a recurrent, widespread and pervasive scenario for anyone who routinely cares for critically ill patients. And it's correlation with increased healthcare costs is extensively documented and well understood.

With regards to where it ends, I discussed that previously. It should be an extremely rare occurrence with very specific criteria, as our policies for withdrawing care on brain dead patients without family consent are.

And it's precisely the lack of emotional connection that allows for objective judgements. A family's emotional connection often leads them to ask for things that are harmful to the patient and lead to unnecessary pain and suffering. It is families, not doctors, whose decisions most commonly harm patients.
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Infection_Ag11
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In reply to [removed post] • 8:42a, 11/16/20
AG
JJMt said:
Infection_Ag11 said:
Like I said, it's a conversation nobody is willing to have. And until we are ready to have it, everyone screaming at politicians to fix the problem is entirely pointless and a waste of everyone's time.
Why do you think that you have the right to impose your opinion on death decisions on others?


I'm not discussing situations in which opinion comes into play, I'm discussing scenarios where a physician using objective metrics can guarantee no meaningful recovery for a patient undergoing heroic measures to keep them alive. And we always prefer families make the right decision themselves. Ultimately though if it comes to it I feel we are morally obligated to stop inflicting pointless suffering on another human being when there is no prospect of recovery, even if a family continues to insist we do so.

Quote:
You point to a few outlier situations with which you disagree, and argue for a change in national policy. Why the hell should we do that? Why not leave the decisions to the individuals and families who are actually affected?


There's nothing about that situation that's an outlier. Patients like that undergo heroic measures in ICUs all over the country every single day. I see 1-3 intubated patients >80 with end stage dementia and no hope of recovery EVERY SINGLE DAY in which I'm seeing ICU patients. The vast majority have care quickly withdrawn by reasonable families, and in such case the real fault lies with their primary care physicians who had not discussed out of hospital DNRs prior to that point. But sometimes you have families who just insist on futile care.
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Infection_Ag11
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In reply to Capitol Ag • 8:49a, 11/16/20
AG
Capitol Ag said:
Infection_Ag11 said:
What he is saying is, technically, true. A 40 year old with no risk factors whatsoever dying of COVID is a statistical outlier. Where I disagree with him is the obvious intent of his posts, which is to parlay that fact into a conclusion about the pandemic that is unwarranted.

A healthy 40 year old dying of COVID is an outlier, but a healthy 40 year old experiencing varying degrees of ongoing morbidity associated with their infection is not. And that is where, in the younger populations, this really differs from influenza. Influenza does not regularly lead to previously healthy young people being unable to return to baseline levels of function months after their initial infection.
I am not trying to parlay anything. I am tired of the overuse of statistical anomalies by many whether its the media or whoever. It would be essentially the same as using the threat of a plane crash to scare people into not flying. I believe the American people are being essentially lied to in many ways. By both sides at times. I want facts to set policy and to quell panic. Nothing more. This is worse than the flu. No doubt. But we cannot shut down again either, which too much of the country is still trying to or has done. That just causes more harm than good. And we just do not know the extent of severe long term issues. There are some. As there are with the flu. How that coincides with the flu would be interesting to study as well. Most still do not report long term effects, yet there are some, no doubt. Heck, there really are younger, very healthy people who die from complications due to influenza every year too. Just a fact. Not diminishing Covid, statistically for those under 50, the flu really is more dangerous. That is not debatable. It's how we use that data and information that really matters.

None of this is to take away from what the Doc is posting about in the OP and subsequent posts on this thread and that is not my intention. It was Bay Fan who hijacked what I was trying to say and totally misrepresented it. Not sure why. I had no beef with her on any of this. I hope this thread can proceed forward without much more debate as there are plenty of other threads available for that. These are just my opinions.

In the end, what we need is to get to a vaccine soon. It's the only way to quell most of this.


The cutoff age where COVID is less fatal than influenza is in the 30-40 range depending on where your data comes from, but the thing that so many ignore is that death isn't the only thing to consider. Yes, if you are 30 you are less likely to die from COVID than from influenza. You are also exponentially more likely to suffer from a post-infectious syndrome that is debilitating for some period of time, and the concern is that some of these patients may never truly fully recover. I've seen plenty of patients in the 20-50 range who were previously healthy and didn't die but had to leave the hospital with home oxygen and many are still on it weeks to months later. I saw a 29 year old marathon runner over the summer who still can't walk from her front door to her care without getting winded six months later. And unlike death in younger populations, these scenarios are fairly common after COVID for weeks to months.

In younger patients the concern is chronic morbidity, NOT mortality. That doesn't mean I'm advocating for lockdowns, but we MUST get away from this idea that the only thing that matters is mortality. Just simply being alive isn't always a meaningful metric.
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Infection_Ag11
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In reply to Knucklesammich • 9:03a, 11/16/20
AG
Knucklesammich said:
I see both sides of it,

That being said, on Friday we had a doctor tell my wife that her mother didn't have a stroke but had a frozen shoulder at a hospital in Central Texas.

This was when they though she only had medicare and they wanted her out of the hospital. When they found out she had Tri Care, suddenly they wanted to run a battery of tests and dig on on the cause. She was brought into the ER with a locked up shoulder, flacid left arm and weakness in her left leg.

As much as I want to trust science, I'm skeptical of those who might use it cynically for their own base ends. Or rather I trust the base science, I trust some individual docstors, I don't trust the healthcare system as a whole.


That's immoral and unethical behavior that, unfortunately, often comes from the top down. Like I said earlier, a far more common scenario than the one we've been discussing here is individual doctors going to bat for patients who the hospital administration or insurance companies want to provide less than optimal care for. Many of us spend hours every week speaking with insurance companies and hospital admin trying to get medications approved and policies in place for certain patients/patient populations.

Doctors trying to "pull the plug" or ignore concerns on the basis of insurance is not nearly as common as the inverse.
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Capitol Ag
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In reply to Infection_Ag11 • 9:12a, 11/16/20
AG
Thank you for the information. No doubt we need that vaccine very soon.
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Infection_Ag11
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In reply to [removed post] • 9:24a, 11/16/20
AG
Quote:
I suspect that for every case in which families decide to needlessly prolong a patient's life (in your opinion), hundreds of thousands make the opposite decision.


That is correct (though the ratio is higher than 1/100000 for sure) which is why I said as much in the post you responded to.

Quote:
And, again, it's not your decision or anyone else's.


It's the patient's decision, but often that is no longer a factor in the critically ill. And that is often our fault for not ascertaining terminally ill patient goals of care in controlled settings prior to that. In the scenarios we are talking about, families )while the legal decision makers) are usually entirely unequipped to make those decisions. Every palliative care study ever done on this topic shows that patient families desire to be told what to do, but in practice they want to have this done in a way in which it superficially appears they have control. They want doctors to make recommendations and then follow them. Only in a minority of cases do you have people who are adamant about continuing futile care, but those cases do account for massive amounts of healthcare spending. LTACHs are a testament to this.

Quote:
To engage in a fight of anecdotes, my dad had a pulmonary embolism when he was 92. His heart stopped and he stopped breathing. He was resuscitated at the location where it occurred, but was then immediately taken to the ER, entubated, and sedated. The doctors kept pressing us to sign an NDR which we refused because, at that time, his Living Will specified the opposite. As it turns out, he was fully resuscitated with absolutely no problems, and has had two more years of quality life with friends, children, grand children and great-grandchildren. Many great-grand children will now have memories of him that they otherwise would not have.


That's wonderful, and also entirely unrelated to this discussion. He had a LIVING WILL which conveyed his own desire to continue resuscitative efforts, and he had an acute and readily reversible condition without (I'm assuming) some underlying medical concern that would have made recovery unlikely or impossible. The treatments for pulmonary emboli are well understood and very effective and if such a patient can be resuscitated they have a decent chance of survival.
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In reply to Infection_Ag11 • 9:29a, 11/16/20
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In reply to [removed post] • 9:37a, 11/16/20
AG
Quote:
How to you prevent what you are advocating from sliding into widespread euthanasia?


That's like asking how do you prevent the death penalty from sliding into state sponsored genocide.

Quote:
Why are broad policies better than case-by-case decisions?


It should be a case by case decision, I'm simply stating that I believe there should be a route by which futile care can be withdrawn just as care from brain dead patients can be withdrawn in the cases where it's warranted.

In Texas we already have a policy that kind of allows for this, but in practice it's so difficult and so ripe for litigation that it's almost never employed. Essentially, if enough physicians formally agree that a patient's care is futile then care can be withdrawn without family consent. It requires multiple physicians, the support of hospital admin and patients families have 10 days (I think?) to find another facility which will accept the patient before you can withdraw care. A common "threat" from patient families is that they will transfer their family member against medical advice, not understanding that no other hospital would take them precisely because the care is futile. Sometimes that is actually the epiphany moment for those families.

That process is so difficult and time consuming though that patients usually either die on their own before it can be carried out, hospitals don't want to go through the legal hassle to invoke it, families come to the realization they should withdraw care on their own or a combination of all of these. I think I've seen it done once, and the hospital had to spend a decent amount of resources to have a frivolous lawsuit over it thrown out. Just because a lawsuit has no merit doesn't necessarily mean you won't have to defend yourself against it, and that's a pain many places just don't want to bother with.

IMO, we need something better.
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Infection_Ag11
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In reply to [removed post] • 9:53a, 11/16/20
AG
JJMt said:
Quote:
The treatments for pulmonary emboli are well understood and very effective and if such a patient can be resuscitated they have a decent chance of survival.
That's not at all what his family physician or the specialists at UPMC Pittsburgh were telling us.


I'm sorry then that you dealt with that, but the fact is that pulmonary emboli are one of the more readily reversible causes of PEA arrest. The issue is getting them back and keeping them alive long enough to allow for treatment, but if you can do so they can be saved. I've seen multiple patients recover and walk out of the hospital after a massive PE with the aide of tPA and/or mechanical thrombectomy.

Quote:
They told us that his ability to recover without negative consequences was a "miracle". They had been pushing us hard to agree to a DNR despite the terms of his Living Will.


I mean, sure it's impressive that a 92 year old recovered from a cardiac arrest with NO longterm negative consequences. I would disagree that it's "miraculous", especially if we're jus talking about him surviving at all. I'm not sure if his arrest was before or after getting to the hospital, but in house arrests have a decent shot at recovery. IIRC, in hospital PEA arrests recover enough to leave the hospital around 20-25% of the time. Out of hospital is much lower though.

But again, all of this is trivial fodder given his living will and the fact that he was reasonably healthy before this. If he himself had clearly indicated he would want everything done, then until he arrest went on so long that it was deemed futile they should have just continued. Sure, at some point if a code lasts 30 minutes, an hour, etc you start telling families that person is not likely to survive and will likely have devastating neurological consequences if they do, but an acute PEA arrest in a healthy 92 year old and immediately pushing for a DNR with a living will saying do everything? That's inappropriate IMO, and I think most would agree with me.
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Cepe
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9:57a, 11/16/20
AG
Now I see why Doctor's God Complexes are a thing. . . .
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Fitch
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In reply to cone • 10:28a, 11/16/20
AG
No, not necessarily. Lockdowns aren't the only tools in the tool box. They're a sledge hammer, to carry on the metaphor, and inappropriate to use in most situations.
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Infection_Ag11
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In reply to Fitch • 10:33a, 11/16/20
AG
Fitch said:
No, not necessarily. Lockdowns aren't the only tools in the tool box. They're a sledge hammer, to carry on the metaphor, and inappropriate to use in most situations.



Agreed
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cone
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In reply to Fitch • 10:35a, 11/16/20
AG
so what other NPIs were you describing that will stem these peaks?

I assume masks are already in place.
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In reply to cone • 10:52a, 11/16/20
AG
Avoiding super spreader opportunities and taking precautions to avoid bringing the bug into next-of-kin households are the two most readily implemented w/o the heavy hand of the gov't. Capping indoor occupancy at food & beverage places, while making it easier to close streets and sidewalks for outdoor dining would go a long ways to developing a middle way forward.
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Fenrir
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In reply to Infection_Ag11 • 10:58a, 11/16/20
Infection_Ag11 said:
Like I said, it's a conversation nobody is willing to have. And until we are ready to have it, everyone screaming at politicians to fix the problem is entirely pointless and a waste of everyone's time.
I certainly agree with this in principle.
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Infection_Ag11
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In reply to Fenrir • 11:05a, 11/16/20
AG
Fenrir said:
Infection_Ag11 said:
Like I said, it's a conversation nobody is willing to have. And until we are ready to have it, everyone screaming at politicians to fix the problem is entirely pointless and a waste of everyone's time.
I certainly agree with this in principle.


And that's fine, I just hope people can understand that with that stance comes the impossibility of addressing the issue of healthcare costs in America without fundamentally overhauling the system (and such an overhaul would almost certainly include rationing of resources as they do in every other first world medical system anyway).

So my overarching point here is people can't have their cake and eat it to. You can keep your demented grandparent in the ICU for days to weeks before they pass, or you can fix the biggest contributor to excessive American healthcare spending. You cannot do both, no matter how much you complain to insurance companies and politicians about tort reform and medication costs and insurance reimbursement.
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Knucklesammich
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In reply to Infection_Ag11 • 11:07a, 11/16/20
Infection_Ag11 said:
Knucklesammich said:
I see both sides of it,

That being said, on Friday we had a doctor tell my wife that her mother didn't have a stroke but had a frozen shoulder at a hospital in Central Texas.

This was when they though she only had medicare and they wanted her out of the hospital. When they found out she had Tri Care, suddenly they wanted to run a battery of tests and dig on on the cause. She was brought into the ER with a locked up shoulder, flacid left arm and weakness in her left leg.

As much as I want to trust science, I'm skeptical of those who might use it cynically for their own base ends. Or rather I trust the base science, I trust some individual docstors, I don't trust the healthcare system as a whole.


That's immoral and unethical behavior that, unfortunately, often comes from the top down. Like I said earlier, a far more common scenario than the one we've been discussing here is individual doctors going to bat for patients who the hospital administration or insurance companies want to provide less than optimal care for. Many of us spend hours every week speaking with insurance companies and hospital admin trying to get medications approved and policies in place for certain patients/patient populations.

Doctors trying to "pull the plug" or ignore concerns on the basis of insurance is not nearly as common as the inverse.
I agree with you, I think individuals are doing the right things, its when things get systemic and abstracted where the problems occur.

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94chem
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11:18a, 11/16/20
Quote:
In younger patients the concern is chronic morbidity, NOT mortality. That doesn't mean I'm advocating for lockdowns, but we MUST get away from this idea that the only thing that matters is mortality. Just simply being alive isn't always a meaningful metric.
Are you kidding? That is the only metric in American health care. It is the definition of success.
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Fenrir
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In reply to Infection_Ag11 • 11:32a, 11/16/20
I'm not entirely sure what you think my stance is. I think the failure to communicate is across the board by and large. Individuals not discussing their wishes with their family before they get old and incapable of doing so, families holding out for hope that a miracle will happen, and medical professionals putting off the difficult conversations onto others or avoiding it entirely. I'm more than good with pushing for a change in how we as a society treat end of life care (although the stats I recall seeing would suggest we are ahead of a lot of other Western nations in % of dying patients receiving hospice/palliative care as it is). I just disagree with the concept of a doctor making the call.
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Infection_Ag11
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In reply to 94chem • 11:41a, 11/16/20
AG
94chem said:
Quote:
In younger patients the concern is chronic morbidity, NOT mortality. That doesn't mean I'm advocating for lockdowns, but we MUST get away from this idea that the only thing that matters is mortality. Just simply being alive isn't always a meaningful metric.
Are you kidding? That is the only metric in American health care. It is the definition of success.


I understand all too well, I'm just saying it shouldn't always be the case. I see things worse than death every day.
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Marcus Aurelius
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12:41p, 11/16/20
AG
My 40 y/o just passed. Bummed.
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aginlakeway
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In reply to Marcus Aurelius • 12:42p, 11/16/20
AG
Marcus Aurelius said:
My 40 y/o just passed. Bummed.

I am sorry to hear that.

He had no issues before he got covid? How far along was he when he got to the hospital?
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Marcus Aurelius
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In reply to aginlakeway • 1:02p, 11/16/20
AG
No comorbidities. He was transferred from another hospital intubated. Sick as hell from start. Our thoracic surgeons refused to ECMO him. Pissed.
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BiochemAg97
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In reply to Fitch • 1:03p, 11/16/20
AG
Fitch said:
cone said:
I'm just wondering if there's an end to these regional peaks in sight

two weeks?

two months?


Depends only on public action/reaction. Lots of virgin timber left out there. Regional "peaks" right now are only a product of interventions interrupting a natural momentum, which, given time, will resume until it finds a valley floor.
Hmm... Sweden had a regional peak without "interventions interrupting the natural momentum". Additionally, the duration of the peak in Sweden was similar to the duration everywhere else, suggesting there is a finite duration to a regional peak regardless of interventions. A series of outbreaks rather than a large sweeping outbreak that gets everyone in one go is pretty normal for diseases.

Interventions interrupting the natural progression should reduce the height of the peak, but not necessarily the duration (mostly because I think the interventions occur too late in the cycle to really short circuit the cycle. But, any reduction in height during the present peak means those people are still susceptible to the next outbreak. Fortunately, we are in a timeframe where buying time to roll out the vaccine means those people who didn't get it this time could be vaccinated and not susceptible to the next potential outbreak.
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aginlakeway
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In reply to Marcus Aurelius • 1:03p, 11/16/20
AG
Marcus Aurelius said:
No comorbidities. He was transferred from another hospital intubated. Sick as hell from start. Our thoracic surgeons refused to ECMO him. Pissed.

Thanks for info. I just wonder how sick he was before he sought medical help.

Again, sorry for the loss.
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cone
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In reply to BiochemAg97 • 1:52p, 11/16/20
AG
Quote:
Fortunately, we are in a timeframe where buying time to roll out the vaccine means those people who didn't get it this time could be vaccinated and not susceptible to the next potential outbreak.
if there ever was a time where lockdowns would be justified, it's now (in that respect)

the tech is here, just waiting to get rolled out. seasonal increase in infectiousness and susceptibility.

i don't know why that's not the case being made by the pro-lockdowners to be honest. the end is coming into sight. you'll get far more buy-in if people know this is the final push.
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Infection_Ag11
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In reply to Marcus Aurelius • 1:53p, 11/16/20
AG
Marcus Aurelius said:
No comorbidities. He was transferred from another hospital intubated. Sick as hell from start. Our thoracic surgeons refused to ECMO him. Pissed.


Unfortunate, seems like the kind of patient ECMO was made for
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Sonic5678
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In reply to [removed post] • 4:19p, 11/16/20
AG
Agree, my father came back many times! I have personal experience with this, this discussion, and doctors and nurses with this attitude. It was the worst experience of my life, but I'm tough now. If you need a patient advocate, I'm your girl.
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cc_ag92
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In reply to Marcus Aurelius • 9:25p, 11/16/20
AG
So sorry to hear that, Marcus. Again, thank you isn't enough, but thank you.
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notex
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In reply to cone • 5:29a, 11/17/20
AG
cone said:
Quote:
Fortunately, we are in a timeframe where buying time to roll out the vaccine means those people who didn't get it this time could be vaccinated and not susceptible to the next potential outbreak.
if there ever was a time where lockdowns would be justified, it's now (in that respect)

the tech is here, just waiting to get rolled out. seasonal increase in infectiousness and susceptibility.

i don't know why that's not the case being made by the pro-lockdowners to be honest. the end is coming into sight. you'll get far more buy-in if people know this is the final push.
One of the reasons is that lockdowns actually drive up cases. Lockdowners are anti-science.

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cone
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10:45p, 11/18/20
AG
hospitals filling up in Montgomery County already

not taking transfers
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jvanbeek
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In reply to cone • 2:10a, 11/19/20
AG
Quote:
i don't know why that's not the case being made by the pro-lockdowners to be honest. the end is coming into sight. you'll get far more buy-in if people know this is the final push.


Just like we had the 15 days to slow the spread? The government should never be given such power expecting it will use it in a limited way. Governments always push to expand their power. Each expansion is a precedent for a further expansion no matter how poorly it turned out. It should be obvious to everyone by now that general lockdowns are not an effective solution to the problem. Perhaps a school, a neighborhood, or a community with a very bad spread might see a benefit to a very limited lockdown, but locking down regions and states for very local problems makes no sense at all! Why would anyone even consider locking down the state of Texas for a problem occurring in a small number of communities?
Jim VanBeek '85, '99
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notex
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In reply to jvanbeek • 6:17a, 11/19/20
AG


Lockdowns don't help at all.
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