19 ms·

> “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 tha

> “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.
- ethbro 7y ago
  If you read through the Red Dawn email chain NYT pieced together through FOIA requests [1], which gives an overview of initial professional thinking (January / February), there's a great insight in the first few emails. No other emergency grows exponentially. Nuclear detonation, dirty bomb, power outage, hurricane, tainted food, etc. At worst they grow linearly at a high rate. Consequently, highly contagious pandemic response must be fundamentally unlike any other response. There are references to this bearing out in their prior wargaming of scenarios. All players (mistakenly) escalated linearly based on intuition. When in reality you're talking about needing 10x resources every week, ceteris paribus. [1] https://int.nyt.com/data/documenthelper/6879-2020-covid-19-red-dawn-rising/66f590d5cd41e11bea0f/optimized/full.pdf#page=1 https://int.nyt.com/data/documenthelper/6879-2020-covid-19-r...
- Ericson2314 7y ago
  I don't want Patriot act thinking—we agree there—but the US is so used to assuming it's rich/powerful beyond belief and then getting poor outcomes. We have general efficiency and cost disease issues that emergency planning can absolutely teach us how to address.
- dchichkov 7y ago
  A patient coming to a doctor, in the similar condition, is 4 times more likely to come out with a prescription in the United States when in Europe. Why? Because it is profitable. What is the result? Well, life expectancy in the United States had been going down. Ref. https://www.nature.com/articles/d41586-019-02686-2 https://www.nature.com/articles/d41586-019-02686-2 This epidemic might be an opening to shift the current equilibrium of over-medication and over-use of expensive treatments with questionable efficacy. The proper solution could be changing the incentives structure in the medical system. From profit and executive compensation aligned structures that over-sell services and drugs into something that is connected with long-term public health.
amelius 7y ago
Instead of ventilation, wouldn't a heart-lung machine (or other types of external oxygenators) be the preferred method if cost was not an issue? https://en.wikipedia.org/wiki/Extracorporeal_membrane_oxygenation https://en.wikipedia.org/wiki/Extracorporeal_membrane_oxygen...
- Retric 7y ago
  That has significant risks of infection. I think a negative pressure ventilator like the iron lung are probably the lowest risk of adverse effects. But, it’s going to hamper other treatment options, and works on a relatively narrow range of issues. https://en.wikipedia.org/wiki/Negative_pressure_ventilator https://en.wikipedia.org/wiki/Negative_pressure_ventilator Positive pressure ventilators however cover a wider range of medical issues though at increased risks. External oxygenators are really a last resort which should be avoided whenever possible.
- didgeoridoo 7y ago
  Check out the “Side Effects” section of that page. ECMO is brutal, and requires a very tight balance of anticoagulation to prevent clotting on one side and bleeding on the other. There are only a few hundred ECMO machines in the US. I suspect that’s less due to cost, and more due to the limited number of patients per year for whom ECMO has a good chance of being a net benefit.
e40 7y ago
My company has been working with a hospital in the Bronx for several years. We’ve been working on a system that is designed to tell when intubation is actually needed and when it is not. They already knew, a long time ago, that intubation increased mortality, but no one expected the mortality rate they are seeing with COVID-19.
dchichkov 7y ago
>> 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. And the way this "statistically best treatment" is calculated doesn't take into account complications from the treatment! Examples: complications from financial stress to cover the costs of the treatment, side-effects of the therapy unrelated to the original condition, infections with drug-resistant strains of hospital bacteria.

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.

ethbro 7y ago
If you read through the Red Dawn email chain NYT pieced together through FOIA requests [1], which gives an overview of initial professional thinking (January / February), there's a great insight in the first few emails. No other emergency grows exponentially. Nuclear detonation, dirty bomb, power outage, hurricane, tainted food, etc. At worst they grow linearly at a high rate. Consequently, highly contagious pandemic response must be fundamentally unlike any other response. There are references to this bearing out in their prior wargaming of scenarios. All players (mistakenly) escalated linearly based on intuition. When in reality you're talking about needing 10x resources every week, ceteris paribus. [1] https://int.nyt.com/data/documenthelper/6879-2020-covid-19-red-dawn-rising/66f590d5cd41e11bea0f/optimized/full.pdf#page=1 https://int.nyt.com/data/documenthelper/6879-2020-covid-19-r...
Ericson2314 7y ago
I don't want Patriot act thinking—we agree there—but the US is so used to assuming it's rich/powerful beyond belief and then getting poor outcomes. We have general efficiency and cost disease issues that emergency planning can absolutely teach us how to address.
dchichkov 7y ago
A patient coming to a doctor, in the similar condition, is 4 times more likely to come out with a prescription in the United States when in Europe. Why? Because it is profitable. What is the result? Well, life expectancy in the United States had been going down. Ref. https://www.nature.com/articles/d41586-019-02686-2 https://www.nature.com/articles/d41586-019-02686-2 This epidemic might be an opening to shift the current equilibrium of over-medication and over-use of expensive treatments with questionable efficacy. The proper solution could be changing the incentives structure in the medical system. From profit and executive compensation aligned structures that over-sell services and drugs into something that is connected with long-term public health.

amelius 7y ago

Instead of ventilation, wouldn't a heart-lung machine (or other types of external oxygenators) be the preferred method if cost was not an issue? https://en.wikipedia.org/wiki/Extracorporeal_membrane_oxygenation https://en.wikipedia.org/wiki/Extracorporeal_membrane_oxygen...

Retric 7y ago
That has significant risks of infection. I think a negative pressure ventilator like the iron lung are probably the lowest risk of adverse effects. But, it’s going to hamper other treatment options, and works on a relatively narrow range of issues. https://en.wikipedia.org/wiki/Negative_pressure_ventilator https://en.wikipedia.org/wiki/Negative_pressure_ventilator Positive pressure ventilators however cover a wider range of medical issues though at increased risks. External oxygenators are really a last resort which should be avoided whenever possible.
didgeoridoo 7y ago
Check out the “Side Effects” section of that page. ECMO is brutal, and requires a very tight balance of anticoagulation to prevent clotting on one side and bleeding on the other. There are only a few hundred ECMO machines in the US. I suspect that’s less due to cost, and more due to the limited number of patients per year for whom ECMO has a good chance of being a net benefit.

e40 7y ago

My company has been working with a hospital in the Bronx for several years. We’ve been working on a system that is designed to tell when intubation is actually needed and when it is not. They already knew, a long time ago, that intubation increased mortality, but no one expected the mortality rate they are seeing with COVID-19.

dchichkov 7y ago

>> 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. And the way this "statistically best treatment" is calculated doesn't take into account complications from the treatment! Examples: complications from financial stress to cover the costs of the treatment, side-effects of the therapy unrelated to the original condition, infections with drug-resistant strains of hospital bacteria.