One of the most interesting parts of this press release, following it on other boards, is the immediate "We already do that. Nothing new here."
That kind of reply would immediately lead me to think it was just a useless release, but then I see people posting comments along the lines of "No, we don't do that. In fact, we have a policy against doing that because of the danger of aerosolization"
For my hacker/systems wonks, this a great example of group learning happening world wide. I imagine there are many ICUs that do this, and many that forbid it. In such an environment, releases like this aren't submarines or spam; they're recurring prompts to administrators elsewhere that they might be missing something important.
I hate to sound cold, but damn this is an interesting example of how organizations learn. One commenter asked "I wonder how many of those hospitals who forbid intubation are doing it to patients with good insurance"
For the record, as far as I know this is a horrible thing to suggest. But the overall point, that large organizations have incentives that are many times removed from the actual work being done, is a good one.
This kind of conversation facilitation across borders is what the internet was supposed to be doing. I think this is the first time I've seen it working the way we had hoped. What's especially interesting to me is that many of the signals we look for in social forums, like "this is just a spam press release", "nothing new to see", or "there's some ulterior motivation here" voting up or down, etc., are actually counter-indicators and inhibitors of overall progress.
It's seminal. Having read a lot of process and innovation books in 90s and aughts, I really wish I had known to just start with the original text.
Knowledge sharing takes time. We know how to model it. This book (and others) helped me to calm down and try to hasten the process instead of wasting my energy railing and failing.
It's an excellent point. Learning is not the same as science, and we need randomized trials to actually be sure of anything.
Unfortunately, in the middle of a pandemic, that's not going to happen with enough speed to prevent a lot of people dying.
The perfect can be the enemy of the good enough. We don't have to guess or learn about the mass of an electron; that's been well-established through great lab work. But not all decisions are like that. Many times the hardest decisions are those you make with incomplete and contradictory information ... and not making a decision is, in effect, making a decision. This is one of the things that's so interesting here. If it were simple yes/no, what's science and what's speculation, there wouldn't be much interesting learning or decision-making happening.
And unfortunately, there are doctors that will not make a move on an experimental therapy without it going through IRB approval, as I am learning with my own efforts at introducing a portable nebulizer biocidal therapy. Some will not take chances unless they see safety data first - they will let their patients and colleagues die first.
As a former biomedical engineering researcher, this pandemic has been profoundly eye-opening in learning about the resistance to advancing the state of the art of medicine in the USA. (I’m not even speaking about the knee jerk reaction towards banning nebulizers in hospitals thanks to a flimsy NEJM letter last month reporting coronavirus aerosol contaminations.)
> they will let their patients and colleagues die first.
No! They will definitively not let their patients and colleagues die firs! They will prevent you from killing them!
You might believe in youRe therapy, but the vast amount if novel therapies will have (novel) adverse effects and you will haVe to supply the prove that your therapy will do less harm than doing the conventional thing. We have clinical trials to administer new therapies in a controlled and ethical way to cause the least harm. Just trying things will kill more people than it helps. The vast amount of new ideas do more harm than they help.
Look at chloroquine and what a shit show it is, because everybody just tried it willy nilly. The side effect of harming Lupus patients who could not get their medicine alone caused tremendous unintended harm. And that wasn’t even harming because if administering a useless therapy with serious side effects.
Move fast, fail fast and fail often aren great principles for developing software but they have no place in developing therapies. (I actually wanted to hurl swear words at you. But that helps nobody. It is true that medical research is overregulated and could be improved Bit there are reasons for that. Throwing all regulations away is just Trumpish behavior.)
Please explain to me the risks of nebulized ethyl alcohol, which is what I am proposing? Ad hoc dismissals without the consideration of scientific literature reviews of alcohol inhalation - which there are several review papers published - demonstrates a serious lack of critical thought in medicine. Obviously to compare it to chloroquine is absurd.
Your point about supplying the safety data is exactly where the roadblock is found. I’ll update you when the device is approved by the FDA and voila these objections mysteriously disappear ;)
An ad hoc (fallacy) dismissal would be one that doesn't actually address the central question or finds an excuse that is not generalizable to similar circumstance without supporting evidence for the exception. Even if you think the GP's reasoning was wrong, the GP comment did provide specific reasons for their argument, which was itself an argument generalized to medical practice & research. Not ad hoc.
Further, if the GP had prior assumptions about these possible treatments being wrong, you commit the same error in the opposite direction with your casual assumption that your approach is right, that the FDA will not only approve the thing, but that the objections will also lose all validity. Even if approved, the objections may still have merit. The objection need not be completely wrong in order for the FDA to decide the balance of risk weighed in favor of approval.
Finally, the idea of using nebulized ethyl alcohol is interesting! I hope it works. It is, however, extremely easy to find information on the dangers of inhaling alcohol fumes. If it is a viable treatment path, patients are likely to be extremely sensitive to dosing levels. Recipients would also, by definition, be high-risk, making the safety issues more uncertain. It is not, on it's face, unduly obstructionist to be highly skeptical of such a treatment without a decent amount of evidence.
Edit: I even partly agree with your sentiment that this is a time when some (very careful) risks may need to be taken that ordinarily wouldn't be. But your comment conveys a strong sense of arrogance, of unassailable certitude. I hope I am wrong in that assessment: Someone looking to take these sorts of risk right now should be approaching them with the utmost humility. This makes your tone very disturbing.
Thank you for your reply, but I never claimed an ad hoc fallacy? Nor did I claim infallibility? I am insinuating the disregard for novel therapies in a pandemic because there is no data conceived (ad hoc dismissal or excuse), and not because of an intuitively perceived judgment on its harm, which is readily discernible from the collection of scientific literature on alcohol inhalation I have found and can share, is a testimony to healthcare bureaucratization.
For instance, the banning of nebulization in hospitals for fear of viral aerosolization published in a faulty NEJM letter[1] is preposterously cautious. By this logic, Lysol disinfectant sprays ought to be banned too, even though it’s recommended by the CDC. So this “arrogance” you sense is probably because it is apparent to me I am hungrier to save lives than (many) doctors and hospital administrators who won’t take a chance to even measure the risk to accumulate much needed experimental evidence; even if their patients are willing! Hippocratic Oath is the retort.
Frankly, “no data no dice” does not cut it when confronting such a global humanitarian challenge. The medical profession appears to be just that - licensed occupational employees motivated about retaining their jobs. Hence my snarky expectation that this will be an easier, ie quicker, sale if/when the nebulizer has been rubber stamped by the FDA. No one was ever fired for buying IBM
Also, thank you for a thoughtful response. I can appreciate your eagerness to save lives too, but I would not so easily cast doctors as any less eager. A doctor that avoids experimental treatment is doing so precisely because they believe they are acting in a patient's best interests.
Front-line doctors simple have a different perspective: There are many prospective treatments that might show promise. Most will not work. Many may have their own catastrophic effects. At the same time, doctors must make immediate decisions on how to treat patients, without the luxury of time to review all prospective experimental treatments, most of which lack sufficient data to make a rapid determination of their risk. And remember their foundational, ancient oath: "First, do no harm". If that oath engenders a certain amount of conservatism in treatment choices, you should not berate the doctors themselves as deficient: Your issue is with the fundamental philosophy of medical practice.
I am glad you are hungry to save lives. But remember humility: Any number of significant failures that cost lives can be found will minimal searching, and undoubtedly most involved were eager to save lives as well. The drug combo FenFen comes to mind: I'm sure the researchers involved were eager to save lives and improve the health of obese people, but they're efforts caused serious heart problems in up to 30% of those taking the drug. Medical history is littered with failures and death. You must remember that. If doctors are conservative in their treatment choices, they have good reason, and should not be condemned for it. You'll win no people to your cause if you vilify those you seek to convince, all you will do is attract people who are already inclined to agree with you.
My apologies, when you said "ad hoc dismissal", I assumed you meant the fallacy. Your phrasing was an appropriate way to state that someone had committed that fallacy.
You don't need to have a placebo to do a controlled trial, you can just have a control arm of people you administer nothing to. How are you going to know if you have an improvement if you don't have something to compare your treatment to, though?
You need the placebo for the double blind RCT, which is still kind of the gold standard. But pronating patients is hard to do in a double blind fashion, so it is less of an issue here.
The double blind part is very difficult, but at least they can have a randomized control group [1]. It doesn't sound very difficult.
Also, in most cases the control group get the "standard" treatment, because "do nothing" (taking literally the GP) is too bad. And you want to be sure that the new treatment is better than the "standard" treatment.
[1] A real randomized control group, not an unrelated bunch of guys in another city of France.
> How are you going to know if you have an improvement if you don't have something to compare your treatment to, though?
Historical data? Past experiments? Sure, they might have biases, but the higher sample size of historical data can help with that.
I think (specific) control groups make sense when you're talking about small effects or very specific cases (for example, the control group will undergo the standard treatment instead of the new treatment)
This is "decision making under conditions of uncertainty." [0]
It's not that your questions are bad, it's that in practice medical professionals have to operate without answers to them. Doing so involves communication with peers about their own observations of what may work better/worse, such as in this article. Double-blind randomized trials are not the only source of actionable information: Case studies also form a significant pillar of knowledge, especially pending results from more systematic studies.
One of the lesson of the physics lab is that unless you have calibrated very carefully all the equipment and experimental setup, you can't mix the measurements of one day with the measurements of another day.
For example one day we have very weird results trying to compare two measurements of the same day about something related with the speed of sound. After a lot of time trying to understand the problem we notice that one measurement was from 9am when the temperature was like 10°C(50°F) and the other was from 1pm when the temperature was like 25°C(77°F). The following days we tried to take all the measurements as close as possible.
The same applies to benchmarks in computers. A few days ago I got an improvement for a program that reduced the runtime from 85s to 59s. Until I noticed that one was with the notebook plugged in an the other with the batteries. I tried again both with the notebook plugged in and the improvement was only from 65s to 59s. Still a nice improvement but not fantastic.
Quoting again part of the original comment I'm repliying
> Learning is not the same as science, and we need randomized trials to actually be sure of anything.
Unfortunately, in the middle of a pandemic, that's not going to happen with enough speed to prevent a lot of people dying. The perfect can be the enemy of the good enough.
Without a randomized control group it is very difficult to be sure if a small improvement of the survival rate is real. So you can't learn if the new method or the old method is better.
Yes, absolutely correct. We just don't always have time to wait: Doctors must take action now. Knowing a majority of people that end up ventilators will die means the balance of risk weighs at least a little more heavily towards novel treatments than in less critical cases.
Case studies of those attempts are exactly the kind of data points that can provide a great deal of information and hypothesis generation for more systematic studies.
> The study included all sequentially hospitalized patients between March 1, 2020, and April 4, 2020, inclusive of these dates.
> As of April 4, 2020, for patients requiring mechanical ventilation (n = 1151, 20.2%), 38 (3.3%) were discharged alive, 282 (24.5%) died, and 831 (72.2%) remained in hospital.
If you ignore the 831 patients that were still in the hospital, and consider only the 38 that survived and the 282 that died, you get 282/(282+38)=88%. It is a very short time. What are the odds for people that survive more than 4 days in the hospital?
Did the team this post get the better results using the same accounting method? Did they apply this method only to the people that would need a ventilator or to more people because it is cheaper and easier to setup and maintain? (IIUC they used ventilator for the worse cases anyway.)
> And with numbers like that, I think it's perfectly ethical to try anything reasonable.
Do you want the best possible treatment to each patient, or you prefer that each doctor tries his/her pet theory in production?
"The proning and the high-flow nasal cannulas combined have brought patient oxygen levels from around 40% to 80% and 90%, so it’s been fascinating and wonderful to see"
People die, if their oxygen levels are getting too low. This method gets them up again. Sounds like "working" to me.
We aren’t treating oxygen levels. Higher oxygen levels now that result in lower oxygen levels later might actually be a bad thing.
I have no doubt that proning increases the readings we are getting on pulse ox monitors, sometimes pretty immediately. I’ve seen it, literally first hand, in a number of my patients. But I have no idea if it saves lives. Many of those same patients still got intubated and some died.
Understanding impact on surrogate markers isn’t enough.
If the effect size is large, the benefits of randomization go down. A very effective treatment would be evidently very effective without the burden of statistical proof. The randomization is critical when you are looking to differentiate small effects from random noise.
That said, large effect sizes in one hospital don’t control for confounding variables.
Randomization is not required to neutralize random noise, which is... random.
It’s required to prevent systematic biases like giving the drug that you think might help to the patients with better prognosis (instead of wasting it on those that are very likely to die anyway).
Well, in the long term they're probably better at saving lives than case studies such as this one. But until such time as they're available, collaboration, discussion, and cases studies are what we have to work with. Becoming paralyzed by uncertainty pending systematic studies will kill more people.
All engineering needs feedback to guide implementation, especially in complex systems. And it's essential in black box systems like biological organisms. This is why the words engineering and medicine intersect mostly in relatively uncomplicated areas like prosthetics or eyeglasses. In immune systems, engineering is used only in the earliest stages, like to reduce search spaces in development of synthetic antigens and antibodies for vaccines, never to guide clinical trials. There feedback drives all decisionmaking under the purview of statisticians only. Engineering, and especially intuition, plays no role al all.
Is this well known in media reports for a while? I stopped following closely quite a while ago so mostly just pick things up from forum, but this seems newish to me? Last I heard was that some doubts were arising here and there about the usage/safety for covid patients.
The on the ground reports from NYC in This week in virology has been talking about moving away from respirators for at least 3 weeks. Now the ability of reporters looking for sensational news to actually listen to the professionals or read studies is a completely different issue. I wish they could just ask some of them to write opinion pieces to lay out the facts as they exist.
One of the most active figures in this debate has been a New York doctor named Cameron Kyle-Sidell. He frequently posts interesting sources on Twitter:
Yes, rather absurdly, I learned about him like a month ago on ZeroHedge when they started following him; he was brushed off for weeks, his message being, "Look at patient behavior, this is not actually ARDS, our ventilator strategy is probably wrong."
Crazy to think that so many doctors around the world, experts, and policy makers didn't really question the fundamental nature of the disease, and perhaps telling that it took an ER doctor in NYC posting on youtube for a month to bring it proper attention.
Also, how does this affect the actual death rate numbers in NYC if unnecessary deaths caused by outcomes of ventilator use are factored into the picture? Could change the picture quite drastically.
It's not like we're going around incubating healthy people -- you have to be pretty sick to get put on a ventilator. Even if the treatment turns out to be a net negative, most of these patients didn't have very good odds in the first place, so it's pretty unlikely it would affect the death rates "drastically."
I distinctly remember months ago of a Chinese doctor in China claiming this same thing. I thought it was a bit far fetched at the time but I'm getting incredible deja vu with this new release.
It's not just the Chinese. Doctors have been concerned about the abnormally high death rate for ventilators for months too. I've been seeing comments to the effect of looking for alternatives to ventilators because there were indications that did more harm than good. I guess not every hospital had this idea, but I know the sentiment was around for a while.
Dr Ignaz Semmelweis had this ludicrous theory, back in 1846, of “cadaverous particles” causing high deaths in women who had just given birth. Despite evidence that it worked, he spent the rest of his life trying to get people to listen. The doctors of the day were so threatened by the possibility that they were the ones killing their patients that they rejected the practice.
We haven’t culturally evolved much further it seems. ”Wacky” ideas are routinely rejected by mainstream science; eg ulcers being caused by germs rather than stress, and can be cured as such. What societal changes need to come about that this doctor doesn't have to make YouTube videos for a month?
Probably because there are so many ludicrous theories that are just plain wrong, and likely they outnumber the crazy ideas that will turn out to be true. Just look at MMS / injecting bleach debacle going on.
You attribute this to a lack of cultural evolution, but the problem is that wacky ideas that might be right are frequently difficult to discern from outright pseudo-science.
The idea of "cadaverous particles" in fact appears to be at least partly a bit of pseudo-science: There are no such things. Semmelweis had accidentally stumbled onto germs, but he didn't know it, and therefore his reasoning was flawed even if it gave a correct result; If the doctors stopped dissecting corpses, that would have reduced things just as much as the mid-wife ward. If he'd understood why washing hands actually worked, he could have had the mid-wives do so as well and save many more lives.
I also don't think it's correct, at least using the Semmelweis example, to say that "we haven't culturally evolved". Semmelweis's failure to spread what he learned was at least as much victim of his own personality as anything else: "Semmelweis was not very tactful. He publicly berated people who disagreed with him and made some influential enemies".
Side note, my wife spent two years studying in Vienna. As a result my daughter was born at Semmelweis Hospital. I took some time to read about Semmelweis and he seems to have been ahead of his time. Great contributor to medicine.
There’s a saying, “progress is made one funeral at a time”, especially in science but also in other areas; smbc had a good comic about it too a whole back (am in mobile and can’t find it now).
Linus Pauling famously and successfully used all his night to reject the idea of quasicrystals. The Updated concept of crystals was adopted shortly after his death; i can’t say I was able to track the history - there is an enormous amount of whitewashing - but it seems initially everyone rejected quasicrystals, but eventually people started to look at ahechtman’s evidence - and accept it, except not publicly because the luminaries of the field led by Pauling rejected it. And then Pauling’s funeral allowed the science to finally advance.
When I studied computational linguistics, my professors told me that a great deal of promising research on linguistics in the US had been similarly stifled by Noam Chomsky and his adherents, the result being a relative stagnation in "continental" linguistics compared to that seen in Europe.
Yes it is. Frankly my view of the medical professional community is much lower now. MDs are really just glorified infantry on the frontlines. The lack of creativity, which presupposes degrees of original and independent thought, is striking.
There are, rightly or wrongly, strong incentives to not be creative. To do the thing the medical consensus recommends, even if it is incredibly flawed, leaves the doctor personally safe. To try an experimental idea on your own could get you sued for medical malpractice. Which is I suppose to say, that MDs have been given a strong incentive by our system to suppress creativity.
(Personally, I think there’s a good reason for this in normal times. Medical research is hard and personal opinion will never compare to years of research, especially when lives are on the line. In times where years of research aren’t actually an option though...)
Of course we need to factor in malpractice lawsuits, administrative restrictions, tidal paperwork etc. etc. into anything which may have happened to medical professionals' creativity.
I don't doubt that this works well but there is a good reason that other hospitals are not using this approach. As the article mentions:
"This approach is not without risk, however. HFNCs blow air out, and convert the COVID-19 virus into a fine spray in the air. To protect themselves from the virus, staff must have proper personal protective equipment (PPE), negative pressure patient rooms, and anterooms, which are rooms in front of the patient rooms where staff can change in and out of their safety gear to avoid contaminating others."
"UChicago Medicine’s Emergency Department recently doubled its number of anterooms, thereby doubling its capacity to give ?high-flow nasal cannula to patients. The main hospital also added negative pressure rooms on two floors, making it safer and easier to take care of COVID-19 patients."
Not all hospitals have the ability to double the number of negative pressure rooms or even provide needed PPE to all caregivers.
A ventilator on the other hand allows for a HEPA filter in-line that prevents the spread of the disease within the hospital.
The article mentions 40% O2 sat to 80 or 90%; aren't the latter still really low? I'm certainly no doctor, but wikipedia[1] claims "Prolonged hypoxia induces neuronal cell death via apoptosis, resulting in a hypoxic brain injury" and suggests that 80-85% is considered severe and 86-90% moderate.
Granted, both are a hell of a lot better than 40%!
It adds, "Mild and moderate cerebral hypoxia generally has no impact beyond the episode of hypoxia; on the other hand, the outcome of severe cerebral hypoxia will depend on the success of damage control, amount of brain tissue deprived of oxygen, and the speed with which oxygen was restored."
So I guess my questions are:
* How does this stack up against an intubated ventilator, assuming one is available?
* My understanding is the patients needing respiratory support are often on ventilation for 1-2 weeks; how much damage would one expect from having severe hypoxia for that duration?
Being on a ventilator is traumatic. So much so that they generally put you under. Can you imagine waking up with a tube through your mouth and down your throat forcing you to breathe? It happens and people panic and have to be restrained. People get PTSD.
> The article mentions 40% O2 sat to 80 or 90%; aren't the latter still really low? I'm certainly no doctor, but wikipedia[1] claims "Prolonged hypoxia induces neuronal cell death via apoptosis, resulting in a hypoxic brain injury" and suggests that 80-85% is considered severe and 86-90% moderate.
Yeah, unfortunately I can't find it now, but I remember reading a "what the fuck is going on, these patients should be dead!" statement from a doctor a week or two ago about exactly that.
I wonder how they decide which patients would get the cannula instead of a ventilator?
Otherwise, intubation w/ a ventilator generally requires some form of sedation-- I wonder if that sedation has an impact on the body's ability to fight back.
Two viruses may be possible, but other diseases certainly can have similar ranges of problems: The Flu might case different type of lung problems-- pneumonia, bronchitis, exacerbate asthma. Or it might hit your stomach, or result in ear infections by allowing other opportunistic infections to fester, or seizures. It may cause pericarditis or other heart problems, or strokes. So it is not unreasonable to assume that Covid-19 might cause the same symptoms through 2 different mechanisms.
From what I've read here and elsewhere, they're putting everyone they would normally put on a vent on high flow. They only move to the vent when not doing so in the near term would likely result in death. That means, among other things, that they tolerate lower SpO2 levels than they would otherwise.
First-- and I'm sure you weren't suggesting this, but I feel I need to mention-- it's extremely dangerous to pressurize a person's lungs above the surrounding environment[1]. Not to mention that pressurizing the inside of the throat could pressurize the middle ear and blow out your eardrums.
Second, I'm not a physician, I'm a physicist. What follows is for curiosity's sake.
I suspect that the goal is to maximally enrich the patient's airstream in oxygen, whenever it is that they happen to breathe in. In a patient with fluid-filled alveoli, the surface area available for diffusion of oxygen into the bloodstream is greatly diminished. Additionally, the distance that oxygen needs to diffuse before it reaches hemoglobin is increased: rather than just the lining of alveoli and capillaries, it has to first dissolve into the fluid gunk filling the space, then diffuse through the fluid, then pass through the lining of the alveolus and capillary. To top it off, water doesn't have great solubility for oxygen, and atmospheric air is mostly nitrogen anyways.
Each of these passive transport phenomena occurs at a rate that depends on the gradient (roughly...) of available O2. This concentration is greatest in the air, and lowest in the bloodstream adjacent to the alveoli, where hemoglobin binds up oxygen. One way to increase the rate of dissolution and diffusion is to increase the concentration gradient. That means enriching the airstream in O2.
The main problem with CPAP in a clinical setting is that it's not sealed and filtered like a proper ventilator, so it aerosolizes and disperses virus at high pressure. It's the same concern that they mention in this article about dispersal and the need for negative pressure rooms and more PPE. It's being used on some patients who aren't bad enough to require intubation.
Sounds like a promising strategy to manage patients, assuming the hospital has the necessary negative pressure rooms, etc. Especially since ventilators don’t even seem to be very effective. We’ve been seeing stories last few days that the large majority (88%) of folks put on ventilators in NYC, end up dying.
Be careful with that number. It's 88% of the cases that had resolved after ~4.5-5 days, which was only 25% of the cases included in the study.
If there is some bias in the study population, the overall rate can change quite a lot (for example, a possibility is that the weakest patients succumb in that period, with stronger patients coming off the ventilators after a longer period...).
That 88% number is pretty misleading. They only looked at: (number of patients who died) / (number of patients who died + number of patients discharged alive). And didn't consider the other patients on ventilators who are still alive, but still in the hospital (many likely no longer on ventilators).
Don't get me wrong, the fatality rate for intubated patients is going to be high. but probably more like 40-60%.
Hospitals are losing money on covid patients, and the more treatment they require (ICU, ventilator, medication), the more the hospital is losing. They do get paid about three times more for an intubated patient, but they lose more money too.
Hospitals make their profit off voluntary procedures like shoulder and knee surgeries and the constant flow of voluntary tests and procedures ("I just want to get this checked out"). They lose a lot of money when people spend three weeks in the ICU.
This is especially true when a huge percentage of the patients are Medicare or completely uninsured. Privately insured patients with good policies are better, but they still aren't getting rich off those people.
I have no sympathy for the hospital systems or the entire medical industry that has created a massive bureaucracy full of perverse incentives, exploitation, overbilling, and accounting games, but in this particular situation, even with the massive federal handouts, they're not making bank.
These patients still need the care and monitoring you'd get in an ICU, and there's zero indication the "medical establishment" is opposed to it - high-flow oxygen is used regularly in hospitals in a variety of scenarios.
I'm an intensivist based in Sweden. From my perspective there is absolutely nothing new in this article. We have been using HFC for years if not decades.
As I understand it, what's new is that it's being used under these circumstances. The ARDS algorithm would have these patients be intubated. Instead, they're putting these patients on HFC and letting them get hypoxic, reasoning that the mixture of damage caused by the infection and the vent is what's fatal.
Edit: Also, people have been avoiding HFC for COVID-19 because of aerosolization risks.
when i was an EMT if someone had O2 sats in the 50s and was conscious i would’ve told you that the pulse ox was broken. And it it wasn’t broken, i’d be yelling for a paramedic to tube my patient asap.
My non-medical understanding is that the long term damage threat of the disease is primarily due to to organs dealing with low oxygen for long periods of time. Would you say it's fair to say that an approach which saved more lives by not addressing would probably leave a greater proportion with organ damage?
Our* guidance has been HFNC only in negative pressure rooms because of the aersolization risk.
We've converted a huge number of beds to negative pressure in order to maximize use of HFNC. Anecdotally, I feel like it works, but would be great to see a trial.
Is management of an HFNC patient simple enough that it could be done outside a hospital? I’m imagining a converted stadium or similar area in which patients use HFNC and everyone who isn’t a patient puts on serious PPE before entering and takes it off only when they’re quite far away.
> There was no evidence of human-to-human transmission early on, too.
I have two comments about that:
1) Like somebody else said, if you don't look, you won't find evidence, even if it's there.
2) Wuhan officials were incentivized to say it wasn't contagious, ergo, no lockdown needed.
However, it clearly was being transmitted to non-wet market patients in late Nov./early Dec., and Disneyworld Shanghai was closed Jan. 24, so you have to be wilfully blind to say it's not contagious.
There's no evidence, but should we expect evidence? Has anyone looked?
The Bayesian prior that they should have some level of immunity is pretty high, seems to me. Exactly how long and how strong such immunity is a good question, but it would be really unlikely if there was no immunity.
Yes, it turns out the Tesla devices were actually more practical than first thought.
The caveats are:
1) Would US hospitals accept or recommend them?
2) If US hospitals accepted them, was there an acceptable solution to the aerosolization problem? Wuhan hospitals were segregated into corona and non-corona locations, so aerosolization wasn't a problem for other patients, but I don't know if US hospital systems got that organized.
I highly recommend reading the Wuhan accounts and papers. They really moved fast on improving their response, which the US totally ignored. Only now, Apr. 26, are we catching up to what they found in Jan./Feb. I doubt if it affected the body count much, but time was wasted.
Instead HN wasted months on endless navel-gazing and "IFR vs. CFR" chatter. Really a new low for HN.
With treatment so simple, we have effectively removed the healthcare system as a bottleneck on the rest of society.
I think we can safely reopen fully now and treat any serious cases using our existing healthcare systems in combination with this kind of new knowledge.
The longer we 'suppress the curve', when we are already far below hospital system capacity, the more economic and social damage we cause unnecessarily.
Even if we open up legally, people aren’t going to take risks that can put them in a hospital on oxygen for weeks. It’s not a pleasant experience, ventilator or not. Restaurants will not be full, conferences will still be cancelled, etc.
I’d be curious to hear counterpoints. I could be wrong. It does anyone think this will go away with a long enough lockdown? Or is there any solution other than herd immunity?
You linked to an opinion piece, by a former chief of neuroradiology. The "facts" are, in fact, a lot of supposition.
We don't know if herd immunity works for this virus (there are reports of the disease resurfacing), we don't know the long term effects (there are reports of long term organ damage even for those not incubated) and we don't understand all the manifestations of the disease (there are reports of people 30-40 dying of COVID induced strokes).
The solution is isolate until we can do the hard work of getting mask and other PPE supply chains stabilized, get our health care system back on it's feet, start extensive testing, contact tracing and semi-isolated communities. None of which is possible as long as testing capacity is so limited and people keep exposing themselves unnecessarily.
The more recent numbers from New York put the IFR at 0.5 to 1%, which matches what most organisations (WHO, governments etc) have been assuming for a couple of months now. Also the actual death count from NY makes the Stanford numbers pretty much impossible (0.2% of people in NYC have already died).
If we didn’t have immunity it would be unlike any other respiratory virus known to man. All other corona viruses have non-insignificant periods of immunity.
That kind of reply would immediately lead me to think it was just a useless release, but then I see people posting comments along the lines of "No, we don't do that. In fact, we have a policy against doing that because of the danger of aerosolization"
For my hacker/systems wonks, this a great example of group learning happening world wide. I imagine there are many ICUs that do this, and many that forbid it. In such an environment, releases like this aren't submarines or spam; they're recurring prompts to administrators elsewhere that they might be missing something important.
I hate to sound cold, but damn this is an interesting example of how organizations learn. One commenter asked "I wonder how many of those hospitals who forbid intubation are doing it to patients with good insurance"
For the record, as far as I know this is a horrible thing to suggest. But the overall point, that large organizations have incentives that are many times removed from the actual work being done, is a good one.
This kind of conversation facilitation across borders is what the internet was supposed to be doing. I think this is the first time I've seen it working the way we had hoped. What's especially interesting to me is that many of the signals we look for in social forums, like "this is just a spam press release", "nothing new to see", or "there's some ulterior motivation here" voting up or down, etc., are actually counter-indicators and inhibitors of overall progress.