14 ms·

What doctors on the front lines wish they’d known a month ago

130 points by prmph 7y ago

casefields 7y ago
Mirror: http://archive.md/maTHi http://archive.md/maTHi
- huhtenberg 7y ago
  Please enable cookies. Error 1001 DNS resolution error
  - qilo 7y ago
    It's a known issue if you're using Cloudflare DNS servers. Here's explanation from the Cloudflare CEO: https://news.ycombinator.com/item?id=19828702 https://news.ycombinator.com/item?id=19828702
roenxi 7y ago
> This was rebuilding the engine on a car going 100 miles per hour. It isn't ideal, but this environment may make it much easier to rejig care standards. The large number of patients with very similar symptoms would make it straightforward to test ideas out. I would also expect that the dire nature of the situation also makes it practical to experiment in a way that would not be possible normally. It'll be harrowing and traumatic for the doctors, but the circumstances are conducive to promote swift learning about respiratory diseases. The fast way to learn is to be able to break a thing in many different ways. Not normally practical for health due to legislation and community outcry.
okasaki 7y ago
This is paywalled clickbait.
- chki 7y ago
  Clickbait maybe, but as with all Times coverage of the Coronavirus there is no paywall, at least for me.
  - okasaki 7y ago
    I only see the first paragraph and a notice telling me to create an account to continue.
    - tpnCC 7y ago
      If this is what u mean U saw, "Log in or create a free New York Times account to continue reading in private mode.", then u could be in a private browsing-mode, and hence u could not go further than first para. Edit: spelling
      - papermachete 7y ago
        You pay with your privacy.
    - sumedh 7y ago
      If you create an account the corona virus articles are free.
      - clort 7y ago
        if you block third party scripts (from nyt.com in this case) it just shows the whole article
      - dmitryminkovsky 7y ago
        Tracking you makes it very much not free.
        sumedh 7y ago
        You can block those trackers.
- downerending 7y ago
  Annoying to be sure, but you can circumvent the paywall by adding a period to the end of the domain name.
  - garmaine 7y ago
    Why does this work?
    - dmitryminkovsky 7y ago
      I believe that technically all domain names start with (we enter them backwards into the browser) a dot and that dot represents the DNS root. So it works in the browser if you add that root explicitly. No idea for sure why this works but my guess is because the paywall is somehow programmed based on window.location or some backend equivalent that works against the domain without the explicit root.
    - downerending 7y ago
      It's a bug in the paywall code. Bank error in your favor. :-)
  - dmitryminkovsky 7y ago
    Nice hack! Hacking paywalls to get content is irritating though :(
  - thdrdt 7y ago
    But you can run into certificate problems.
- goldenkey 7y ago
  Just click the lock in the address bar and hit Site Settings. Clear the cookies with a couple clicks. Always works for me.
- js4ever 7y ago
  I can see that several peoples have downvoted your comment. Only reason I can imagine is some people's here work for nytimes?? Anyone can provide a better explanation for the downvotes? Why is paywall tolerated for nytimes but not for smaller websites? Why is it acceptable here to have this dual speed system?
  - detaro 7y ago
    A paywall is always tolerated per the site rules if there is a workaround. This paywall has a workaround, which already had been posted when the complaint was made. Complaining about paywalls on the other hand is strictly off-topic. > Are paywalls ok? It's ok to post stories from sites with paywalls that have workarounds. In comments, it's ok to ask how to read an article and to help other users do so. But please don't post complaints about paywalls. Those are off topic. https://news.ycombinator.com/newsfaq.html https://news.ycombinator.com/newsfaq.html
  - bestnameever 7y ago
    > Only reason I can imagine is some people's here work for nytimes?? I think assuming it is from people who work for the nytimes is a stretch. Really - it seems like most people aren't having issues reading the article. I was able to without logging in.
  - IAmEveryone 7y ago
    Yes, I work for the New York Times which is very interested in not being criticized on tiny internet fora. (“Fora” is the plural of “Forums” the Times’ Stylebook makes us use)
nickthemagicman 7y ago
That if you're under 54 corona virus isn't any more deadly than the flu?
- DanBC 7y ago
  You've made a claim (that people under 54 who get covid-19 are not more likely to die than people under 54 who get flu). What stats are you basing that on please? Because I can't find any stats that support this claim.
- ristoalas 7y ago
  Unfortunately, the answer seems "no" so far. Based on for example [1], the infection fatality ratio appears to be 10 times worse than the seasonal flu for people aged 30-39. Also, hospitalisation rate is higher (e.g. in age group 30-39, the study estimates that 3.4% of the infected people were hospitalised), which is higher (even for younger people) than the hospitalisation rate of the flu. [1] https://www.thelancet.com/action/showPdf?pii=S1473-3099%2820%2930243-7 https://www.thelancet.com/action/showPdf?pii=S1473-3099%2820...
  - downerending 7y ago
    Without disputing that (and thx for link), it's worth noting that the "flu" has been killing a large number of people year in and year out for as long as we can remember. The long-term death rate of COVID-19 remains to be seen. The final verdict on how bad it was will depend on whether or not lengthy immunity is attained (including to mutations).
    - watwut 7y ago
      Yeah, but I don't understand what is significance of that claim. We have flu vaccine and general push to make people vaccinate every year. Up to mandating it for hospital workers at some places. Some employers are organizing them for free for employees. We do close schools here and there for a week or so when flu is getting large to get it under control. We do close hospitals for visits at this times.
elric 7y ago
Anecdata: I distinctly remember spending a lot of time lying on my stomach in hospital beds during several stints of double pneumonia I experienced as a child, some 30 years ago. It's hard to imagine that front line doctors didn't know about proning a month ago. Is this a technique that went out of vogue since my childhood, only to be replaced with a reliance on sedation and ventilators, and is it making a comeback due to the lack of ventilators? Or it it because proning unconscious, intubated patients is hard work and requires three nurses? I can imagine that being difficult to do when your ICU is swamped. Here's what that looks like: https://www.youtube.com/watch?v=E_6jT9R7WJs https://www.youtube.com/watch?v=E_6jT9R7WJs
- Scoundreller 7y ago
  > Or it it because proning unconscious, intubated patients is hard work and requires three nurses? I think in this situation, it’s letting these patients be managed without sedation or intubation.
- the_mitsuhiko 7y ago
  > It's hard to imagine that front line doctors didn't know about proning a month ago. Where do you get the idea they didn’t?
  - coldtea 7y ago
    Because there were several articles implying so... https://edition.cnn.com/2020/04/14/health/coronavirus-prone-positioning/index.html https://edition.cnn.com/2020/04/14/health/coronavirus-prone-...
- kbenson 7y ago
  > Is this a technique that went out of vogue since my childhood I think it's just as likely that maybe the knowledge is unevenly distributed, and if a doctor at the hospital is aware of it then it may spread, but may not spread beyond that hospital easily. It also may not spread until there are cases that benefit from it so other doctors can observe or hear about it. Just like in software engineering, there are things that are taught, and then there are things that are learned over time, imparted by a mentor, or spread through a group. Doctors seem to have a better handle on this, as they do residencies to learn a lot of the practical skills that are hard to teach in a classroom, but that does probably lead to those skills learned in residency being fairly variable.
elisharobinson 7y ago
please perma ban NyT .
dmurray 7y ago
> “You put a tube into somebody,” Dr. Levitan said, “and the amount of work required not to kill that person goes up by a factor of 100,” creating a cascade that slows down laboratory results, X-rays and other care. I'd hope this could be a generally applicable lesson after the pandemic. In less overwhelming times, the medical best practice is once someone is in hospital, prescribe the statistically best treatment even if it costs 100 times as much in resources and manpower. Now they go for simpler treatments because the resources aren't available to support the others, at least when the benefit is marginal. But hospital resources are always stretched to the limit in some way. If you can treat a patient with 100x less intervention from doctors and nurses, you can instead treat 100x more patients, or build 100x more hospitals, or spend some of your hospital money on public health initiatives, all of which would improve overall health outcomes.
- Someone 7y ago
  ”I'd hope this could be a generally applicable lesson after the pandemic.” It may be news to (some) doctors, but that is not a lesson this pandemic taught us. In cost-utility analysis (https://en.wikipedia.org/wiki/Cost–utility_analysis https://en.wikipedia.org/wiki/Cost–utility_analysis), different interventions are compared against each other and against the “do nothing” approach.
  - virvar 7y ago
    If the WHO is right in that having contracted Covid doesn’t make you immune, then the strategy of going for herd-immunity is not only losing more people, it’s losing them for no reason.
- dmix 7y ago
  Using extreme scenarios to plan for normal life has long been the recipe for bad policy. This may make sense where hospital beds/ICU/medical professionals to capita ratio is low such as in low income neighbourhoods and countries but otherwise it’s mostly just useful for emergency planning. The proper solution tends to be higher amounts of hospitals, mental health centers, supplies, preparation for outbreaks, etc. The actual hard stuff. Otherwise this mostly amounts to doctors trained to use a generalized but dangerous hammer in worst case scenarios, in the face of what looks like a terribly difficult situation with no other solutions, and finding out more refined soft procedures like proning and flipping people on their sides works better for certain types of epidemic viruses. I’d be wary to practically apply this beyond the next viral epidemic.
jordanbeiber 7y ago
Here in suffering Sweden 80% of covid patients in intensive care survive. I read that 80% of NY ICU patients on ventilation dies. Are we perhaps using less mechanical breathing devices here i Sweden? Edit: this didn’t come out right... couldn’t find total icu death rate but have read stories about high mortality in NY.
- garmaine 7y ago
  In ICU and on ventilation are not the same thing.
  - walshemj 7y ago
    Exactly I have been in an ICU and I was on those annoying nasal oxygen and not itubated
    - greedo 7y ago
      Trust me, having a canula is much more pleasant than intubation.
  - jordanbeiber 7y ago
    No true that. Couldn’t find this data for us/ny. It seems like there’s been a high focus on ventilator supply so I was just guessing a lot of severe icu cases would be put on one. I have no idea, but would like to know.
- watwut 7y ago
  Obviously, not everyone in ICU is on ventilator. This is true in both countries. If there was dishonest statistical comparison, this is the one.
  - jordanbeiber 7y ago
    It is a question though. I have no idea.
rasz 7y ago
Since January leaks from Chinese health care warned about all of this. Was there internet ban in US I was unaware of? Or a widespread belief in exceptionalism?
- shalmanese 7y ago
  It's not even leaks, it's included in the Official Coronavirus Treatment Plan: "(4) Salvage therapy: for patients with severe ARDS, a recruitment maneuver is recommended. When human resources allow, prone ventilation should be carried out for 12 hours or more every day. " https://www.chinalawtranslate.com/coronavirus-treatment-plan-7/?lang=en https://www.chinalawtranslate.com/coronavirus-treatment-plan... There's simply a shocking degree of arrogance from the West to refuse to learn even the most basic things from Asia about this. For example, people are finally grudgingly admitting that CT scans could play a useful role in diagnostics after months of CDC & ACR denialism: https://www.statnews.com/2020/04/16/ct-scans-alternative-to-inaccurate-coronavirus-tests/ https://www.statnews.com/2020/04/16/ct-scans-alternative-to-... edit: More details in Jack Ma Foundation produced Handbook of COVID-19 Prevention and Treatment (3) Prone Position Ventilation Most critically ill patients with COVID-19 respond well to prone ventilation, with a rapid improvement of oxygenation and lung mechanics. Prone ventilation is recommended as a routine strategy for patients with PaO/FiO2 < 150 mmHg or with obvious imaging manifestations without contraindications. Time course recommended for prone ventilation is more than 16 hours each time. The prone ventilation can be ceased once PaO/FiO2 is greater than 150 mm Hg for more than 4 hours in the supine position. Prone ventilation while awake may be attempted for patients who have not been intubated or have no obvious respiratory distress but with impaired oxygenation or have consolidation in gravity-dependent lung zones on lung images. Procedures for at least 4 hours each time is recommended. Prone position can be considered several times per day depending on the effects and tolerance. https://www.alibabacloud.com/universal-service/pdf_reader?cdnorigin=video-intl&pdf=Read%20Online-Handbook%20of%20COVID-19%20Prevention%20and%20Treatment.pdf https://www.alibabacloud.com/universal-service/pdf_reader?cd...
  - carbocation 7y ago
    MGH is proning a bunch of awake patients (who have the physical strength to do so) and about ~30% of our ventilated patients. There is no "shocking degree of arrogance from the West" but there may be a failure of adequate reporting, in this article and others, of what we are doing in hospitals.
killIdeas 7y ago
Oxygen and laying prone is not exclusive to hospitals. I'm wondering if we can get oxygen tanks ready for home use. Reduce hospital load, reduce healthcare costs, get rid of the need to flatten the curve. (Waiting for a my job to begin, waiting for my son to get his surgery)
- maxerickson 7y ago
  You are proposing slowly letting it run until there is herd immunity, which would likely kill tens of millions of people worldwide. We should aim to do better than that.
- e40 7y ago
  Coworker of mine who happens to be Chinese bought portable oxygen for use in this situation. She bought it in February, after looking at videos about what was going on in Wuhan. We all thought she was kind of crazy. Doesn’t look so crazy now.
- misja111 7y ago
  >> get rid of the need to flatten the curve. This. A policy of flattening the curve will probably have to last for one or two years until either a vaccine is found or there is enough herd immunity. This will not only destroy our economy but the isolation will be a psychological challenge for many as well. We have to take one step back and think why we wanted to flatten the curve in the first place. And that is because our hospitals don't have enough capacity. So why don't we do something about that? IMO that, in combination with some moderate curve flattening, is the only acceptable solution in the long term.
  - barkingcat 7y ago
    conceptually, flattening the curve is meant to turn an exponential infection curve into something more manageable. We are flattening the curve, yes, initially because hospitals don't have capacity, but the root of this issue is the exponential nature of infection transmission. If we have the ability to build hospitals at a rate to match O(2^n) time then we can let everyone out and declare quarantine over! But as you know, an O(2^n) algorithm is extraordinarily hard to keep up with once n approaches any large number. That's the curve we're trying to flatten - by changing the approach, changing the "algorithm" so to speak, by not allowing people to interact so they have less chance of infection. If you are able to build a new hospital in a week, and then continue building a new hospital every day after that and then one every hour after that, and then a new hospital every few seconds after that, then you have a chance to keep up with an exponential curve (well, until the virus runs out of people to infect, so until it reaches 100% of the global population).
carbocation 7y ago
This is a perplexing article. Prone ventilation has been known to reduce mortality in severe ARDS from randomized, controlled trials for almost a decade[1]. Proning is great! It keeps people alive. We are doing a lot of it. It's not new. 1 = https://www.nejm.org/doi/full/10.1056/NEJMoa1214103 https://www.nejm.org/doi/full/10.1056/NEJMoa1214103
- epmaybe 7y ago
  I agree it was a weird focus of the article based on the title. There are also problems associated with proning, including but not limited to: body habitus, loss of airway, hypotension, loss of venous access. I imagine that proning isn't always an option for some patients, and was basically told as much by an ICU attending last week. I guess I'm trying to say that proning isn't a magic bullet, it's just one of many tools in a doctor's toolbox to try and save lives.
- SilasX 7y ago
  Okay but then how is that something "they wish they knew" a month ago? They didn't know then?
  - carbocation 7y ago
    That's why I'm perplexed. It comes across as trying to make something more dramatic than it already is. (And, I mean, hospitals being full of patients with a novel disease is already sufficiently dramatic.)
    - SilasX 7y ago
      Sorry, I misread you, we're in agreement there. I think it's partly an issue of journalists wanting to make their stuff more clickbaity than it deserves to be.
- andrewtbham 7y ago
  The proning is not the point. The point is to delay using a ventilator.
oldgradstudent 7y ago
This was the single scariest piece I've read in a while. The video is even worse. Especially Dr. Hardin from Massachusetts General Hospital at 5m:37sec in the video: > I'm arguing for evidence-based medicine, which is something we all purported to agree with before the outbreak hit. > We have large randomized controlled trials. The patients in those trials had met the same diagnostic criteria that are current patients meet. We should apply the results of the trials. This is a new disease, the assumption that previous trials apply without even a bit of skepticism is fanatical.
azranoman 7y ago
what is iq option? how to use https://coinmarket01.blogspot.com/2020/04/what-is-iq-option-how-to-use.html https://coinmarket01.blogspot.com/2020/04/what-is-iq-option-...
canada_dry 7y ago
After watching this video [i] it seems like there's an opportunity here to completely rethink/redesign of the related equipment. I.e. instead of a normal bed, one that allows for a device to temporarily enclose the patient (like a tanning bed) inflate like a blood pressure cuff, rotate/turn the patient, then deflate and be removed for use on the next bed (i.e. the bed and rotating machines are co-operative, but separate). Also, the ventilator and assoc. monitors need to be redesigned such that rotating the patient easily/automatically repositions the equipment with the rotation. [i] https://youtu.be/E_6jT9R7WJs?t=65 https://youtu.be/E_6jT9R7WJs?t=65
- inamberclad 7y ago
  Rotating beds are already used with intubated patients quite frequently.
  - canada_dry 7y ago
    Example [i]. The issue is that the cost to equip care facilities with these beds. My suggestion is to separate the rotating function such that a much less expensive general purpose bed can be used. [i] www.arjo.com/en-us/products/medical-beds/critical-care/rotoprone/
LorenPechtel 7y ago
If patients are in shape to be on the phone why do they feel the need to put in a breathing tube?? I have measured my O2 saturation being in the 80s and my reaction was "so that's the effect of being this high up"--and I continued to head up the mountain. I had been there before, I knew I wasn't getting into too much. (I forgot to check on the summit itself. I don't expect to be there this year but I'm going to check again next year.)
- vvanders 7y ago
  You had the option of heading back down the mountain at any time. Respiratory infection do not behave the same way.
yters 7y ago
How many covid-19 deaths are due to the disease vs treatment?
andrewtbham 7y ago
I am following Cameron Kyle-Sidell on twitter (one of the doctors in the video). He has a possible theory on what it's going on. https://twitter.com/cameronks/status/1251233871137574913 https://twitter.com/cameronks/status/1251233871137574913
- andrewtbham 7y ago
  why in the fuck was this voted down?? I want a fucking answer. I am sick of this site... Mark my fucking words... I am good at discerning fake news from stuff that shows promise. This is not a 5G tower theory of the disease... this is promising insight that points toward the truth. I am going to link back to this comment and this downvote as the problem with social media. there are too many ignorant stupid self righteous people that think they're doing the right thing.. and they are fools. fuck you hacker news
  - andrewtbham 7y ago
    good ideas are suppressed.... wisdom of the unwashed masses and fools rises to the top.
  - deleted 7y ago
    [deleted]
  - Der_Einzige 7y ago
    Yeah the HN userbase can be extremely frustrating to deal with. Your comments will be flagged and you'll likely get some admin telling you to read the HN guidelines as though it means anything or matters. But I want you to know that someone else on this site sees the bullshit within the community that exasperated you so much. The HN crowd will upvoted BS posts and downvote substantial discussion on basically a random whim. The admins are known to very insulting label good posts as things such as "tedious ideological boilerplate" or "political flame bait" when they personally don't like what was posted. The userbase treats upvotes and downvotes exactly the way they're used on Reddit. This place is basically just nerd Reddit. Unfortunately your claim about the virginity of the userbase is both unnecessary (and guaranteed to find the wrath of the powers here) and most likely wrong because the folks here really do make money. You gotta play the game by their rules or they grey you out. Use those coding skills we all supposedly have to make a new platform and make it better so you can steal away the part of HNs userbase whose worth a damn. That's likely the only way to "fight da powah" since you're obviously very unhappy about this whole ordeal...
neonate 7y ago
https://archive.md/WzwVN https://archive.md/WzwVN

130 points by prmph 7y ago

casefields 7y ago

Mirror: http://archive.md/maTHi http://archive.md/maTHi

huhtenberg 7y ago
Please enable cookies. Error 1001 DNS resolution error
- qilo 7y ago
  It's a known issue if you're using Cloudflare DNS servers. Here's explanation from the Cloudflare CEO: https://news.ycombinator.com/item?id=19828702 https://news.ycombinator.com/item?id=19828702

roenxi 7y ago

> This was rebuilding the engine on a car going 100 miles per hour. It isn't ideal, but this environment may make it much easier to rejig care standards. The large number of patients with very similar symptoms would make it straightforward to test ideas out. I would also expect that the dire nature of the situation also makes it practical to experiment in a way that would not be possible normally. It'll be harrowing and traumatic for the doctors, but the circumstances are conducive to promote swift learning about respiratory diseases. The fast way to learn is to be able to break a thing in many different ways. Not normally practical for health due to legislation and community outcry.

okasaki 7y ago

This is paywalled clickbait.

chki 7y ago
Clickbait maybe, but as with all Times coverage of the Coronavirus there is no paywall, at least for me.
- okasaki 7y ago
  I only see the first paragraph and a notice telling me to create an account to continue.
  - tpnCC 7y ago
    If this is what u mean U saw, "Log in or create a free New York Times account to continue reading in private mode.", then u could be in a private browsing-mode, and hence u could not go further than first para. Edit: spelling
    - papermachete 7y ago
      You pay with your privacy.
  - sumedh 7y ago
    If you create an account the corona virus articles are free.
    - clort 7y ago
      if you block third party scripts (from nyt.com in this case) it just shows the whole article
    - dmitryminkovsky 7y ago
      Tracking you makes it very much not free.
      - sumedh 7y ago
        You can block those trackers.
downerending 7y ago
Annoying to be sure, but you can circumvent the paywall by adding a period to the end of the domain name.
- garmaine 7y ago
  Why does this work?
  - dmitryminkovsky 7y ago
    I believe that technically all domain names start with (we enter them backwards into the browser) a dot and that dot represents the DNS root. So it works in the browser if you add that root explicitly. No idea for sure why this works but my guess is because the paywall is somehow programmed based on window.location or some backend equivalent that works against the domain without the explicit root.
  - downerending 7y ago
    It's a bug in the paywall code. Bank error in your favor. :-)
- dmitryminkovsky 7y ago
  Nice hack! Hacking paywalls to get content is irritating though :(
- thdrdt 7y ago
  But you can run into certificate problems.
goldenkey 7y ago
Just click the lock in the address bar and hit Site Settings. Clear the cookies with a couple clicks. Always works for me.
js4ever 7y ago
I can see that several peoples have downvoted your comment. Only reason I can imagine is some people's here work for nytimes?? Anyone can provide a better explanation for the downvotes? Why is paywall tolerated for nytimes but not for smaller websites? Why is it acceptable here to have this dual speed system?
- detaro 7y ago
  A paywall is always tolerated per the site rules if there is a workaround. This paywall has a workaround, which already had been posted when the complaint was made. Complaining about paywalls on the other hand is strictly off-topic. > Are paywalls ok? It's ok to post stories from sites with paywalls that have workarounds. In comments, it's ok to ask how to read an article and to help other users do so. But please don't post complaints about paywalls. Those are off topic. https://news.ycombinator.com/newsfaq.html https://news.ycombinator.com/newsfaq.html
- bestnameever 7y ago
  > Only reason I can imagine is some people's here work for nytimes?? I think assuming it is from people who work for the nytimes is a stretch. Really - it seems like most people aren't having issues reading the article. I was able to without logging in.
- IAmEveryone 7y ago
  Yes, I work for the New York Times which is very interested in not being criticized on tiny internet fora. (“Fora” is the plural of “Forums” the Times’ Stylebook makes us use)

nickthemagicman 7y ago

That if you're under 54 corona virus isn't any more deadly than the flu?

DanBC 7y ago
You've made a claim (that people under 54 who get covid-19 are not more likely to die than people under 54 who get flu). What stats are you basing that on please? Because I can't find any stats that support this claim.
ristoalas 7y ago
Unfortunately, the answer seems "no" so far. Based on for example [1], the infection fatality ratio appears to be 10 times worse than the seasonal flu for people aged 30-39. Also, hospitalisation rate is higher (e.g. in age group 30-39, the study estimates that 3.4% of the infected people were hospitalised), which is higher (even for younger people) than the hospitalisation rate of the flu. [1] https://www.thelancet.com/action/showPdf?pii=S1473-3099%2820%2930243-7 https://www.thelancet.com/action/showPdf?pii=S1473-3099%2820...
- downerending 7y ago
  Without disputing that (and thx for link), it's worth noting that the "flu" has been killing a large number of people year in and year out for as long as we can remember. The long-term death rate of COVID-19 remains to be seen. The final verdict on how bad it was will depend on whether or not lengthy immunity is attained (including to mutations).
  - watwut 7y ago
    Yeah, but I don't understand what is significance of that claim. We have flu vaccine and general push to make people vaccinate every year. Up to mandating it for hospital workers at some places. Some employers are organizing them for free for employees. We do close schools here and there for a week or so when flu is getting large to get it under control. We do close hospitals for visits at this times.

elric 7y ago

Anecdata: I distinctly remember spending a lot of time lying on my stomach in hospital beds during several stints of double pneumonia I experienced as a child, some 30 years ago. It's hard to imagine that front line doctors didn't know about proning a month ago. Is this a technique that went out of vogue since my childhood, only to be replaced with a reliance on sedation and ventilators, and is it making a comeback due to the lack of ventilators? Or it it because proning unconscious, intubated patients is hard work and requires three nurses? I can imagine that being difficult to do when your ICU is swamped. Here's what that looks like: https://www.youtube.com/watch?v=E_6jT9R7WJs https://www.youtube.com/watch?v=E_6jT9R7WJs

Scoundreller 7y ago
> Or it it because proning unconscious, intubated patients is hard work and requires three nurses? I think in this situation, it’s letting these patients be managed without sedation or intubation.
the_mitsuhiko 7y ago
> It's hard to imagine that front line doctors didn't know about proning a month ago. Where do you get the idea they didn’t?
- coldtea 7y ago
  Because there were several articles implying so... https://edition.cnn.com/2020/04/14/health/coronavirus-prone-positioning/index.html https://edition.cnn.com/2020/04/14/health/coronavirus-prone-...
kbenson 7y ago
> Is this a technique that went out of vogue since my childhood I think it's just as likely that maybe the knowledge is unevenly distributed, and if a doctor at the hospital is aware of it then it may spread, but may not spread beyond that hospital easily. It also may not spread until there are cases that benefit from it so other doctors can observe or hear about it. Just like in software engineering, there are things that are taught, and then there are things that are learned over time, imparted by a mentor, or spread through a group. Doctors seem to have a better handle on this, as they do residencies to learn a lot of the practical skills that are hard to teach in a classroom, but that does probably lead to those skills learned in residency being fairly variable.

elisharobinson 7y ago

please perma ban NyT .

dmurray 7y ago

> “You put a tube into somebody,” Dr. Levitan said, “and the amount of work required not to kill that person goes up by a factor of 100,” creating a cascade that slows down laboratory results, X-rays and other care. I'd hope this could be a generally applicable lesson after the pandemic. In less overwhelming times, the medical best practice is once someone is in hospital, prescribe the statistically best treatment even if it costs 100 times as much in resources and manpower. Now they go for simpler treatments because the resources aren't available to support the others, at least when the benefit is marginal. But hospital resources are always stretched to the limit in some way. If you can treat a patient with 100x less intervention from doctors and nurses, you can instead treat 100x more patients, or build 100x more hospitals, or spend some of your hospital money on public health initiatives, all of which would improve overall health outcomes.

Someone 7y ago
”I'd hope this could be a generally applicable lesson after the pandemic.” It may be news to (some) doctors, but that is not a lesson this pandemic taught us. In cost-utility analysis (https://en.wikipedia.org/wiki/Cost–utility_analysis https://en.wikipedia.org/wiki/Cost–utility_analysis), different interventions are compared against each other and against the “do nothing” approach.
- virvar 7y ago
  If the WHO is right in that having contracted Covid doesn’t make you immune, then the strategy of going for herd-immunity is not only losing more people, it’s losing them for no reason.
dmix 7y ago
Using extreme scenarios to plan for normal life has long been the recipe for bad policy. This may make sense where hospital beds/ICU/medical professionals to capita ratio is low such as in low income neighbourhoods and countries but otherwise it’s mostly just useful for emergency planning. The proper solution tends to be higher amounts of hospitals, mental health centers, supplies, preparation for outbreaks, etc. The actual hard stuff. Otherwise this mostly amounts to doctors trained to use a generalized but dangerous hammer in worst case scenarios, in the face of what looks like a terribly difficult situation with no other solutions, and finding out more refined soft procedures like proning and flipping people on their sides works better for certain types of epidemic viruses. I’d be wary to practically apply this beyond the next viral epidemic.

jordanbeiber 7y ago

Here in suffering Sweden 80% of covid patients in intensive care survive. I read that 80% of NY ICU patients on ventilation dies. Are we perhaps using less mechanical breathing devices here i Sweden? Edit: this didn’t come out right... couldn’t find total icu death rate but have read stories about high mortality in NY.

garmaine 7y ago
In ICU and on ventilation are not the same thing.
- walshemj 7y ago
  Exactly I have been in an ICU and I was on those annoying nasal oxygen and not itubated
  - greedo 7y ago
    Trust me, having a canula is much more pleasant than intubation.
- jordanbeiber 7y ago
  No true that. Couldn’t find this data for us/ny. It seems like there’s been a high focus on ventilator supply so I was just guessing a lot of severe icu cases would be put on one. I have no idea, but would like to know.
watwut 7y ago
Obviously, not everyone in ICU is on ventilator. This is true in both countries. If there was dishonest statistical comparison, this is the one.
- jordanbeiber 7y ago
  It is a question though. I have no idea.

rasz 7y ago

Since January leaks from Chinese health care warned about all of this. Was there internet ban in US I was unaware of? Or a widespread belief in exceptionalism?

shalmanese 7y ago
It's not even leaks, it's included in the Official Coronavirus Treatment Plan: "(4) Salvage therapy: for patients with severe ARDS, a recruitment maneuver is recommended. When human resources allow, prone ventilation should be carried out for 12 hours or more every day. " https://www.chinalawtranslate.com/coronavirus-treatment-plan-7/?lang=en https://www.chinalawtranslate.com/coronavirus-treatment-plan... There's simply a shocking degree of arrogance from the West to refuse to learn even the most basic things from Asia about this. For example, people are finally grudgingly admitting that CT scans could play a useful role in diagnostics after months of CDC & ACR denialism: https://www.statnews.com/2020/04/16/ct-scans-alternative-to-inaccurate-coronavirus-tests/ https://www.statnews.com/2020/04/16/ct-scans-alternative-to-... edit: More details in Jack Ma Foundation produced Handbook of COVID-19 Prevention and Treatment (3) Prone Position Ventilation Most critically ill patients with COVID-19 respond well to prone ventilation, with a rapid improvement of oxygenation and lung mechanics. Prone ventilation is recommended as a routine strategy for patients with PaO/FiO2 < 150 mmHg or with obvious imaging manifestations without contraindications. Time course recommended for prone ventilation is more than 16 hours each time. The prone ventilation can be ceased once PaO/FiO2 is greater than 150 mm Hg for more than 4 hours in the supine position. Prone ventilation while awake may be attempted for patients who have not been intubated or have no obvious respiratory distress but with impaired oxygenation or have consolidation in gravity-dependent lung zones on lung images. Procedures for at least 4 hours each time is recommended. Prone position can be considered several times per day depending on the effects and tolerance. https://www.alibabacloud.com/universal-service/pdf_reader?cdnorigin=video-intl&pdf=Read%20Online-Handbook%20of%20COVID-19%20Prevention%20and%20Treatment.pdf https://www.alibabacloud.com/universal-service/pdf_reader?cd...
- carbocation 7y ago
  MGH is proning a bunch of awake patients (who have the physical strength to do so) and about ~30% of our ventilated patients. There is no "shocking degree of arrogance from the West" but there may be a failure of adequate reporting, in this article and others, of what we are doing in hospitals.

killIdeas 7y ago

Oxygen and laying prone is not exclusive to hospitals. I'm wondering if we can get oxygen tanks ready for home use. Reduce hospital load, reduce healthcare costs, get rid of the need to flatten the curve. (Waiting for a my job to begin, waiting for my son to get his surgery)

maxerickson 7y ago
You are proposing slowly letting it run until there is herd immunity, which would likely kill tens of millions of people worldwide. We should aim to do better than that.
e40 7y ago
Coworker of mine who happens to be Chinese bought portable oxygen for use in this situation. She bought it in February, after looking at videos about what was going on in Wuhan. We all thought she was kind of crazy. Doesn’t look so crazy now.
misja111 7y ago
>> get rid of the need to flatten the curve. This. A policy of flattening the curve will probably have to last for one or two years until either a vaccine is found or there is enough herd immunity. This will not only destroy our economy but the isolation will be a psychological challenge for many as well. We have to take one step back and think why we wanted to flatten the curve in the first place. And that is because our hospitals don't have enough capacity. So why don't we do something about that? IMO that, in combination with some moderate curve flattening, is the only acceptable solution in the long term.
- barkingcat 7y ago
  conceptually, flattening the curve is meant to turn an exponential infection curve into something more manageable. We are flattening the curve, yes, initially because hospitals don't have capacity, but the root of this issue is the exponential nature of infection transmission. If we have the ability to build hospitals at a rate to match O(2^n) time then we can let everyone out and declare quarantine over! But as you know, an O(2^n) algorithm is extraordinarily hard to keep up with once n approaches any large number. That's the curve we're trying to flatten - by changing the approach, changing the "algorithm" so to speak, by not allowing people to interact so they have less chance of infection. If you are able to build a new hospital in a week, and then continue building a new hospital every day after that and then one every hour after that, and then a new hospital every few seconds after that, then you have a chance to keep up with an exponential curve (well, until the virus runs out of people to infect, so until it reaches 100% of the global population).

carbocation 7y ago

This is a perplexing article. Prone ventilation has been known to reduce mortality in severe ARDS from randomized, controlled trials for almost a decade[1]. Proning is great! It keeps people alive. We are doing a lot of it. It's not new. 1 = https://www.nejm.org/doi/full/10.1056/NEJMoa1214103 https://www.nejm.org/doi/full/10.1056/NEJMoa1214103

epmaybe 7y ago
I agree it was a weird focus of the article based on the title. There are also problems associated with proning, including but not limited to: body habitus, loss of airway, hypotension, loss of venous access. I imagine that proning isn't always an option for some patients, and was basically told as much by an ICU attending last week. I guess I'm trying to say that proning isn't a magic bullet, it's just one of many tools in a doctor's toolbox to try and save lives.
SilasX 7y ago
Okay but then how is that something "they wish they knew" a month ago? They didn't know then?
- carbocation 7y ago
  That's why I'm perplexed. It comes across as trying to make something more dramatic than it already is. (And, I mean, hospitals being full of patients with a novel disease is already sufficiently dramatic.)
  - SilasX 7y ago
    Sorry, I misread you, we're in agreement there. I think it's partly an issue of journalists wanting to make their stuff more clickbaity than it deserves to be.
andrewtbham 7y ago
The proning is not the point. The point is to delay using a ventilator.

oldgradstudent 7y ago

This was the single scariest piece I've read in a while. The video is even worse. Especially Dr. Hardin from Massachusetts General Hospital at 5m:37sec in the video: > I'm arguing for evidence-based medicine, which is something we all purported to agree with before the outbreak hit. > We have large randomized controlled trials. The patients in those trials had met the same diagnostic criteria that are current patients meet. We should apply the results of the trials. This is a new disease, the assumption that previous trials apply without even a bit of skepticism is fanatical.

azranoman 7y ago

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canada_dry 7y ago

After watching this video [i] it seems like there's an opportunity here to completely rethink/redesign of the related equipment. I.e. instead of a normal bed, one that allows for a device to temporarily enclose the patient (like a tanning bed) inflate like a blood pressure cuff, rotate/turn the patient, then deflate and be removed for use on the next bed (i.e. the bed and rotating machines are co-operative, but separate). Also, the ventilator and assoc. monitors need to be redesigned such that rotating the patient easily/automatically repositions the equipment with the rotation. [i] https://youtu.be/E_6jT9R7WJs?t=65 https://youtu.be/E_6jT9R7WJs?t=65

inamberclad 7y ago
Rotating beds are already used with intubated patients quite frequently.
- canada_dry 7y ago
  Example [i]. The issue is that the cost to equip care facilities with these beds. My suggestion is to separate the rotating function such that a much less expensive general purpose bed can be used. [i] www.arjo.com/en-us/products/medical-beds/critical-care/rotoprone/

LorenPechtel 7y ago

If patients are in shape to be on the phone why do they feel the need to put in a breathing tube?? I have measured my O2 saturation being in the 80s and my reaction was "so that's the effect of being this high up"--and I continued to head up the mountain. I had been there before, I knew I wasn't getting into too much. (I forgot to check on the summit itself. I don't expect to be there this year but I'm going to check again next year.)

vvanders 7y ago
You had the option of heading back down the mountain at any time. Respiratory infection do not behave the same way.

yters 7y ago

How many covid-19 deaths are due to the disease vs treatment?

andrewtbham 7y ago

I am following Cameron Kyle-Sidell on twitter (one of the doctors in the video). He has a possible theory on what it's going on. https://twitter.com/cameronks/status/1251233871137574913 https://twitter.com/cameronks/status/1251233871137574913

andrewtbham 7y ago
why in the fuck was this voted down?? I want a fucking answer. I am sick of this site... Mark my fucking words... I am good at discerning fake news from stuff that shows promise. This is not a 5G tower theory of the disease... this is promising insight that points toward the truth. I am going to link back to this comment and this downvote as the problem with social media. there are too many ignorant stupid self righteous people that think they're doing the right thing.. and they are fools. fuck you hacker news
- andrewtbham 7y ago
  good ideas are suppressed.... wisdom of the unwashed masses and fools rises to the top.
- deleted 7y ago
  [deleted]
- Der_Einzige 7y ago
  Yeah the HN userbase can be extremely frustrating to deal with. Your comments will be flagged and you'll likely get some admin telling you to read the HN guidelines as though it means anything or matters. But I want you to know that someone else on this site sees the bullshit within the community that exasperated you so much. The HN crowd will upvoted BS posts and downvote substantial discussion on basically a random whim. The admins are known to very insulting label good posts as things such as "tedious ideological boilerplate" or "political flame bait" when they personally don't like what was posted. The userbase treats upvotes and downvotes exactly the way they're used on Reddit. This place is basically just nerd Reddit. Unfortunately your claim about the virginity of the userbase is both unnecessary (and guaranteed to find the wrath of the powers here) and most likely wrong because the folks here really do make money. You gotta play the game by their rules or they grey you out. Use those coding skills we all supposedly have to make a new platform and make it better so you can steal away the part of HNs userbase whose worth a damn. That's likely the only way to "fight da powah" since you're obviously very unhappy about this whole ordeal...

neonate 7y ago

https://archive.md/WzwVN https://archive.md/WzwVN