Corona Virus, general conversation

Another great article from The Atlantic:

The Curve Is Not Flat Enough

Hospitals are poised to face the kind of life-and-death decisions that industrialized countries typically encounter only in times of war and
natural disaster.

Two weeks ago, a man came to an emergency room in New York with pain in the lower-right quadrant of his abdomen. A CT scan showed inflammation around a fingerlike projection at the base of his colon. Combined with a fever, this was a classic case of appendicitis. Surgeons took the man to the operating room and removed his appendix.

The next day, recovering upstairs, the man still had a fever. Doctors ordered a test for the coronavirus. A day later, his results came back positive.

Under usual circumstances, a person with a dangerous, infectious respiratory disease such as COVID-19 requires special precautions in a hospital. Everyone who enters the patient’s room—even to ask how they’re doing or to pick up a lunch tray—is required to don a fresh gown, gloves, and a mask. If the worker must get in close contact with the patient, the mask has to be an N95 respirator, and a face shield is required to guard the eyes. Without exception, every piece of this gear must be discarded in a biohazard dispenser upon leaving the room. An errant mask or glove or gown, coated in virus, can become lethal.

After the man with appendicitis (a patient of one of the doctors I spoke with for this story) tested positive, the hospital implemented such
precautions. And staff members who’d cared for him went into two weeks of isolation.

Today, if every hospital employee who had a close encounter with a COVID-19 patient disappeared for two weeks, the medical workforce would
quickly become depleted. A safe alternative would be to minimize potential exposures by testing everyone who stepped foot in the hospital: The virus has an average incubation period of five days, which means people can spread it in the absence of symptoms. The U.S. does not have that testing capacity

The next best thing might be to require some form of mask and other personal protective equipment (PPE) for /all/ staff, and possibly even patients, presuming that anyone could be a disease transmitter. The U.S. does not have enough medical supplies to do this either.

Last week, the Illinois Department of Public Health sent a notice to clinics that only those people “hospitalized with severe acute lower respiratory illness” could be tested for the coronavirus. California and New York, similarly, have restricted testing to health-care workers and patients who plainly seem to have the disease. The lack of widespread screening means the coronavirus may well be present in countless hospital wards without anyone realizing it.

Accordingly, many emergency-room workers are now behaving as if they’re already infected and separating from their families. One ER physician
told me he has been sleeping in the guest bedroom for weeks. Other doctors have sent their families off to stay at second homes.

The majority of workers who keep America’s hospitals running don’t have the salary to afford extra bedrooms, much less extra properties. For
technicians, respiratory therapists, first responders, cleaning staff, and many others, doing their job is an act of moral complexity. Without
adequate PPE, they’re putting their own health at risk every time they report for duty, as well as that of their families. They also may have other urgent reasons for staying home: being sick themselves, for one, or caring for children who are out of school or for family members who have fallen ill. Not working, for the minority who could financially manage this, isn’t an easy choice either, given that it means increasing the burden on colleagues and putting them at greater risk of getting infected. And this isn’t even to mention the obligation workers at all levels of the hospital hierarchy feel to their patients.

With the United States now leading the world in COVID-19 diagnoses, the demands on the medical system are increasing with each passing day.

Nowhere is that more evident than in New York City, the current epicenter of the crisis, where major academic hospitals are being forced
to radically restructure how they deliver care. In talking with dozens of hospital workers over the past few weeks (most of whom asked not to be named for fear of professional repercussions), I heard that dermatologists are staffing emergency departments and cardiologists are taking ICU shifts. Medical students at NYU are being invited to graduate early so they can enlist as interns and begin practicing medicine immediately. Governor Andrew Cuomo has asked retired doctors to return to service as the city’s convention center is turned into a field hospital. On Thursday, Avril Benoit, the executive director of Doctors Without Borders—the group known for deploying teams to war zones and other medical deserts—told me she was working on plans to deploy resources to New York City.

During World War II, Ford and General Motors rallied to the cause by building tanks and manufacturing ammunition instead of cars. These
companies have now begun making ventilators, the devices that push air into the lungs of people who can’t breathe on their own. But without more widespread testing and basic protective equipment, the problem will be less the number of ventilators, and more the number of health-care workers available to operate them. The United States has entered its coronavirus rationing era, and the kind of medical care many people are used to isn’t going to be available all the time. The ubiquitous curve is being flattened by shutdowns and social distancing, but it is not flat enough. Those who might end up in a hospital, which is to say all of us, can do at least one thing to help relieve pressure on the medical system and its
overtaxed, dwindling workforce.

On a gray Monday in October 2018, a group of biomedical scientists convened in Saranac Lake, New York, to conduct a war game. The enemy was
“Disease X,” a hypothetical doomsday pathogen. The scientists weren’t working for the government, but, like that of many experts who have
gathered to offer guidance to bureaucrats and politicians, their goal was to take an inventory of existing U.S. capabilities, assess “gaps,” and suggest measures to “improve our position,” according to meeting records shared by Stephen Thomas, the chief of the infectious-disease division at SUNY Upstate Medical University.

One team was told to be risk-averse, modeling the steps the U.S. would take to be optimally prepared to save as many lives as possible. The other was risk-tolerant, modeling what the country would do if it chose to save money and roll the dice, hoping that things wouldn’t get too bad. A risk-averse approach would involve roughly doubling the country’s 170,000 mechanical ventilators, bulking up its strategic national stockpile of masks
and medications, and expanding the ability to immediately scale up testing and vaccine development. It would also shore up supply chains of all sorts and create protocols to boost personnel in times of emergency.

America rolled the dice. For just one example, the federal government has invested only about $500 million annually in the strategic stockpile, maintaining about 12 million N95 masks and 16,600 ventilators. This is enough to equip an area hit by a localized disease outbreak, natural disaster, or terrorist attack. But it is nowhere near what could be necessary in a Disease X pandemic.

In January of this year, some Chinese scientists warned that a Disease X had arrived, based on genetic sequencing they’d performed. This novel coronavirus, SARS-CoV-2, was almost identical to others that had been found in bats and was capable of hijacking an enzyme in human cells to cause acute respiratory failure.

When I first spoke with Thomas in February, before New York had a single confirmed case, he told me his chief concern: “ICU beds will be limited,
and that will mean rationing of expertise in the intensive-care setting. That’s a whole different type of medicine than most of us are used to
practicing.” Thomas had spent 20 years in the Army developing “medical countermeasures” against infectious diseases, and, like other military
experts who plan for disaster scenarios, he sounded coolheaded in talking about the looming catastrophe. He remained so when he told me on
March 16 that his hospital had gotten its first case. At 10 p.m. that day, he emailed and said it had gotten its second. By March 20 he had seven. On Tuesday afternoon he wrote, “We are doing ok. Running out of PPE and trying to build a reliable supply chain.”

When we spoke by phone late Tuesday night, as he was driving home from the hospital, he sounded tired. I asked him to think back to the Disease X war game. The coronavirus “is much worse than what I had envisioned,” he said. “You never think the planets are going to align. You get used
to the near misses. I’m taken aback by the scope, the speed, and how relentless it is. It’s amazing.”

Many doctors are nonetheless being asked to operate as usual. Last week an internal-medicine physician with whom I trained in residency told me
she’d been chastised by the head of her department for wearing a surgical mask at work. She feels unsafe without one, given the lack of
certainty about who has the virus—not to mention the worry that she herself could be an asymptomatic carrier.

Across the world, people are implored to avoid contact with anyone outside a small circle of family members or cohabitants. In clinics and
hospitals, doctors aren’t doing their job if they are unwilling to get within inches of people, many of whom are in high-risk groups, and often
do so without any protection. “This week we got an order that no masks are allowed for routine care and just walking around inside the
hospital,” John Mandrola, a cardiologist in Kentucky, told me. He said his initial reaction was opposition, but he has now accepted that shortages demand rationing.

In fact, taking the standard precautions—using fresh masks and gowns—has become impossible in hospitals in the hardest-hit areas, even when
treating people with florid cases of COVID-19. One New York doctor told me she keeps her mask in a brown paper bag until it is time to put it on
again, though other doctors at her hospital leave theirs lying out on a countertop. Another physician has been taking his mask home and
“sterilizing” it in his oven at night.

This reuse of equipment is a form of rationing, though it may not usually be considered as such. It began weeks ago, when the U.S. surgeon
general urged people not to buy face masks. It continued last week when the New York Department of Health implored residents to “only seek health care if you are very sick.” It continues in New York with the cancellation of “elective surgeries,” which now include even cancer treatments that
can reasonably be postponed. Many if not most sick people are not getting tested, and not everyone will be treated by the doctor they might expect. Deciding who gets to see the chief of infectious diseases and who is relegated to the retired ophthalmologist will involve rationing via triage.

At a small hospital in Sleepy Hollow, New York, James Lindsey works overnight as the sole doctor in the ER, a setup that is standard in all but the biggest medical centers. Lindsey told me that though he hasn’t yet felt unable to manage on his own, he has had to intubate more patients than usual. That involves inserting a tube into a person’s trachea, in order to force air into their lungs (via a ventilator). When a person can’t breathe on their own, intubation is the default action taken by all doctors and paramedics in the U.S., as is attempting to restart the heart with electric shocks, in between rounds of chest compression that often break ribs. In a typical ER, this process involves a team of people. The question on the minds of Lindsey and others is: What happens if or when there are more patients who need to be kept alive than there are equipment or personnel to help them?

Already, ventilators in New York City are in short supply. “Everything is chaotic, and the staff is stretched really thin,” one physician wrote to me yesterday. She has had to pronounce two people dead who have been utterly alone, owing to the rule against visitors that hospitals have
established for COVID-19 patients. “It’s really eerie and sad to have no family or visitors around to grieve their deaths,” she told me.

New York’s major medical centers are poised to face the kind of life-and-death decision making that industrialized countries typically
experience only in times of war and natural disaster. And unlike with a hurricane, when the sudden force of nature makes obvious that not everyone can be saved, the drawn-out advance of the coronavirus will make these decisions more difficult to accept. We have failed to shore up protections for health-care workers. We have set ourselves up to experience the same shortages of vital care that have already happened in Italy. The rationing is already here.

“The assumptions in a pandemic scenario are that personal and community good can be expected to fall out of alignment,” Thomas told me in one of his emails. “Difficult decisions will need to be made.” Deciding how to allocate limited resources is a nightmare scenario for any physician, a
violation of the oath to do no harm. As Thomas put it, “Doctors should not be put in the position of dispensing of justice.”

In an attempt to lift some of the burden from individual providers, Thomas’s hospital and others around the country are convening emergency
meetings to develop guidelines for rationing, according to who is least likely to benefit from treatment. The goal is to make the guidelines
objective, accurate, and easy to use, as well as to minimize the waste of resources. The instructions could be as strict as age limits for
intensive care, or withholding care from people who have the lowest chance of survival, such as those suffering from heart failure or
emphysema. On Thursday, /The Washington Post reported that Northwestern University’s medical center, in Chicago, was considering putting every patient with COVID-19 on “do not resuscitate” (DNR) status. This would mean that if their heart stops, no “code blue” would be called; instead, a time of death would be noted.

As of Friday afternoon, Thomas’s county was up to 110 confirmed cases.“Winter is coming,” as he put it. But Thomas maintains hope that a
blanket DNR policy will not be necessary. “Assess, make decisions, reassess, make another decision. Repeat” is how he described the coronavirus-treatment playbook to me. “We can do this … as long as we have PPE and vents.”

Although explicit, widespread rationing by health-care providers is unprecedented in the modern history of the United States, it is constantly happening around the world. “Our doctors face moral dilemmas and impossible choices every day,” said Doctors Without Borders’ Avril Benoit. “Even while COVID-19 is requiring reallocation of resources, we still have women who need emergency C-sections and children with malnutrition. We are converting trauma and burn clinics to care for the disease. You do the best you can with what you have. And many of our locations will not be able to do more than isolate people and provide palliative care.”

Patients, too, make rationing decisions. Every time we weigh whether or not to go to the doctor or to take medication, we’re balancing costs and
benefits. Many people—an estimated third of U.S. adults—also make decisions about what they want should they become very ill. In the form of advance directives, they give instructions about when medical professionals should extend their lives with so-called extraordinary measures, and when they shouldn’t.

The directives can be elaborate or spare but generally land on a spectrum between prioritizing comfort and prolonging life, should the two become mutually exclusive. The most common designations are “full code” and “DNR,” but directives can also get very specific. The options are not binary, care or none. A person who voluntarily designates as “DNR” wouldn’t be abandoned—he or she would still get IV fluids, oxygen, and medication, especially for pain.

After determining advance directives, you should share them with family members or friends who might be communicating with medical professionals on your behalf. Have nuanced conversations with people close to you about what you do or don’t want in various dire scenarios. This eases the burden on them.

It eases the burden on medical providers as well. Too often, Lindsey said, a person is found unconscious by paramedics, then shocked back to
life and brought to the hospital, or put on a ventilator, and only hours later a family member shows up with an advance directive that indicates
that this was not what the patient wanted. “This was a tragic and challenging scenario pre-COVID, particularly if an individual’s directives weren’t followed during that period of resuscitation,” he said. But in the midst of this pandemic, the delay puts “all the providers in the chain of care” at unnecessary risk of exposure. And it takes a ventilator out of use for someone who might have wanted it.

As straightforward as it is to establish an advance directive and talk through what kind of care you want with your family, many of us avoid doing precisely that. Who wants to talk about the possibility of getting sick and dying? Thomas does. “I’m still a relatively young person, and my wife and I have that discussion relatively often,” he told me. “It should be had frequently, but especially now.”
 
The coronavirus pandemic is set to move into a new, more dangerous phase next week, with three more big cities likely to be afflicted badly, as
New York has been.

New York is worse off than anywhere else in the United States, with 44,000 confirmed cases, half of the nationwide total. New York City alone has reported 23,000 cases and 365 deaths. City doctors say the hospitals there face a worse calamity than during the AIDS epidemic or the 9/11 terrorist attacks.

But New York’s mitigation efforts appear to be working as the state’s new cases have begun to level off, U.S. Surgeon General Jerome Adams said Friday. So, the city had decelerated infections and reached an inflection point, even though the worst is yet to come and the Jacob K. Javits Convention Center has been converted to a temporary hospital in preparation for an influx of patients.

But three other cities face growing crises, Adams said. “We also see hot spots like Detroit, like Chicago, like New Orleans that will have a worse week next week than what they had this week,” he said Friday on CBS This Morning.

In each city, cases are increasing by the hundreds every day. Michigan health officials confirmed 2,856 cases as of Thursday, up 564 in 24 hours. By Friday, the case count had jumped to 3,000. Detroit and neighboring Wayne County account for half of all cases in Michigan, according to Fox 2 Detroit.

Chicago officials announced a total of 1,489 coronavirus cases, up from 1,149 Thursday and 950 Wednesday. Chicago hospitals are preparing for an inevitable surge. From Friday, all University of Chicago Medicine health system staff, even those who don’t work with patients, were obliged to wear masks at all times on campus.

New Orleans also expects a surge next week. The city accounts for 1,170 of Louisiana's total 2,746 confirmed cases. The death toll in New Orleans has reached 57, half the state total.

Mayor LaToya Cantrell is scouting for overflow sites for hospitals, which are likely to hit capacity by the second week of April.

Gov. John Bel Edwards said the state is on the same trajectory as Spain and Italy, where hospital systems are overwhelmed and thousands have died of the virus.

"We see that now the places that have been aggressive about staying at home, about keeping under groups of 10 have been successful," Adams said Friday. New Orleans, though, did the opposite. It is thought to have been hit hard because of massive Mardi Gras celebrations, which packed
the streets until late February.

Governors and mayors are rushing to increase hospital capacity, particularly of ventilators. New York Gov. Andrew Cuomo is bracing for far more cases even after imposing a lockdown on his state and has asked the federal government for tens of thousands of ventilators.
 

Road

Adventurist
As somebody who's in the high risk category, I suppose it's possible I've become a little obsessive . . .
.
As an incurable infohound myself, and prone to oversharing here around the homestead, I initiated early this morning what I'm calling the Crisis Kitty Pizza Fund.

A brass apple we use for loose change and bills from returning returnables was put front and center on the kitchen table to hold the pizza fund. It's a reminder that anyone in the house who brings up anything to do with the virus crisis by name, number, or death projection, etc. has to shut up and put a dollar in the kitty.

Basically, no mentions to each other about something we just read, saw on social media, or heard on the news until after 8p. We said sending each other virus crisis humor would be allowed.

No one has had to pay a dollar yet all day.

We may never get pizza at this rate. . .

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Venting a bit here... forgive me
I have laid off 238 people thanks to this bullshit. Thankfully I and 11 (12 out of 250) of my employees are still working, although under lower pay and some have limited hours. I am thankful for the chance to still work and earn and also that my company is continuing benefits for those who have been laid off. I wonder when/if the folks making these decisions will ever be affected like my employees have?
:mike
It is all I can do to not lock the gate and completely hunker down. The apocalypse has to be just a wee bit closer for me to do that... but we are getting there.
 
Ok, a pastor at one of those mega-churches was arrested in Florida for ignoring public health orders and holding two services on Sunday that hundreds of people attended.

https://nypost.com/2020/03/31/flori...ces-in-violation-of-coronavirus-restrictions/

What do you guys think? Should first amendment religious freedom trump public health orders? Or not?

I will note that in NY, they didn't ORDER churches closed, but REQUESTED they do so, and most churches went along with that.
 

Dave

Adventurist
Founder
Senior Staff
Editor
I think it’s a slippery slope. In times like these, throughout recorded history, houses of worship have served a vital role in keeping the fabric of society intact.

I think requesting them to close is reasonable (for a time as the virus runs its course). And I think most people would agree.

Ordering them shut, while scientifically correct, may incite a variety of negative second and third order effects among society. And we certainly don’t need that nonsense right now.

Sadly, it’s a catch 22.
 

Mike

Adventurist
Founding Member
Considering these health orders are at a National, state and local level, they need to be heeded by everyone, as ignoring them puts hundreds of people at risk. In San Diego, almost all churches have gone to online, live streaming of services. Technology allows services to continue, keeping our 1st amendment rights without putting people at risk. No one is saying churches can no longer have any services, which would go against their rights, they are asking to not allow people to congregate together in person.
 
Considering these health orders are at a National, state and local level, they need to be heeded by everyone, as ignoring them puts hundreds of people at risk. In San Diego, almost all churches have gone to online, live streaming of services. Technology allows services to continue, keeping our 1st amendment rights without putting people at risk. No one is saying churches can no longer have any services, which would go against their rights, they are asking to not allow people to congregate together in person.
THIS!

I remember growing up in NH when we got big snowstorms and couldn’t drive to church kneeling in front of the coffee table and watching the service on the black and white TV!

Around here one of the churches held service at an old drive through where people could stay in their car and listen to the preacher over the PA system...

There are ways to get around this while still being socially responsible.
 
Just read an article about a "social media influencer" who, after getting tired of being in her NY brownstone with her husband and 5 kids for the last several weeks, rented an RV and took all of them on a cross country road trip. She's received both support and backlash for the decision.

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Doug

Adventurist
Senior Staff
Founding Member
I haven't read all of the "order"s but from what I've seen, they're not the type that have true enforceability, with the possible exception of LA County. They rely on people doing the right thing. Most do, some don't, some don't out of spite. They rely more on public pressure for enforcement than anything else.
 
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