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In NYC, almost 9 in 10 Covid-19 patients on ventilators don't make it
- generalpass 7y ago> “We are only reporting observations in this report,” said Karina Davidson, senior vice president for research at Northwell Health. “So we can’t say if mechanical ventilation had been withheld from these patients there would have been a different survival rate.”
- nl 7y agoI think this is an important point. I've seen others on HN claim this means ventilators are killing people. It's possible there are alternative protocols that can be used prior to ventilator use. It's also possible these alternative protocols could have increased the survival rate. But that's still different to ventilators killing the patient.
- drpgq 7y agoThere was an early study out of China that said the same thing. I remember when it came out it and governments were worried about ventilators I thought well does the number of ventilators really matter? If it almost inevitable they're going to die anyways, it is just an example of US medicine heroically prolonging the end when often is isn't worth it.
- tootie 7y agoI think from a medical perspective, it's between using a ventilator to give them a 10% chance of survival or letting them just die. No doctor can ethically just not even try to save a life.
- jgalt212 7y agoI think that's the decision they are making now, but I think in earlier days, when less was known, ventilators were seen an extreme, but still necessary tool.
- gedy 7y agoBut my understanding is also that current ventilator protocols are/were maybe too aggressive with COVID? E.g. blood oxygen below some %, they need ventilator.
- malandrew 7y agoPossible. My understanding is that blood clotting is showing up in the lungs in autopsies. Vent settings set too high can rip apart the alveoli.
- AnimalMuppet 7y agoI was reading just yesterday that clotting was showing up in several places, not just the lungs. Covid seems to do something to make blood more clot-prone, and they were looking at using blood thinners to help that aspect of the problem. So it may not be the fault of the ventilators being set too high.
- Trasmatta 7y agoDo we have any evidence that it is actually giving them that 10% chance, or are the people that survive on the ventilators just the same ones that would have survived without it?
- SketchySeaBeast 7y agoIs there any possible way we could test for that? I suppose we could look at retrospectives of those who weren't given treatment during triage, but I imagine they probably are given less of the peripheral support as well once the decision has been made.
- kerkeslager 7y agoOn the contrary, sometimes the ethical thing for doctors to do is to not try to save a life. The Hippocratic Oath says "First, do no harm"[1], and sometimes it's harmful to try to save a person's life with interventions that decrease quality of life, especially when those interventions have a low probability of success. [1] Actually, the Hippocratic Oath doesn't say that, but I think not doing harm is more relevant to the modern social contract of being a doctor than the actual Hippocratic Oath is. The original contains promises to not use a knife on someone (so no modern surgery) and to never give a woman a pessary to cause an abortion (technically modern abortion doctors follow this because that's not how abortions are done now, but they're certainly not following the spirit of the oath).
- DanBC 7y ago> No doctor can ethically just not even try to save a life. There's a culture in the US of trying all treatment, even if it's hopeless. That's why "how doctors die" keeps getting discussion on HN. Doctors do not want this for themselves, and they don't really want it for their patients, but they're forced into it by the systems in which they work. https://hn.algolia.com/?q=how+doctors+die https://hn.algolia.com/?q=how+doctors+die Some other places don't have that. They have the concept of "a good death". If you're almost certainly going to die then is it better to do so in peace, or would you rather have someone breaking your ribs and maybe puncturing a lung to give you maybe a 1 in 100 chance of living for an extra two weeks? Talk to your family about how you want to die. Create advance directives ("living wills") and make sure people know where it is. In the UK this is a useful site: https://compassionindying.org.uk/making-decisions-and-planning-your-care/scotland/advance-directives/make-advance-directive/ https://compassionindying.org.uk/making-decisions-and-planni... https://compassionindying.org.uk/library/ https://compassionindying.org.uk/library/
- TomMarius 7y agoSo, if that was your grandmother and you had a choice of giving her a 10% chance, you wouldn't?
- kerkeslager 7y agoSo, if it was your grandmother and you had a choice to make her suffering worse for her last 48 hours, you would? Two can play the "appeal to grandmother" game, but I'd rather just discuss this based on the facts.
- TomMarius 7y agoYes I would, because I know she wishes to at least try. The point is that you can't decide for others - unfortunately the socialized healthcare of today is making this a public policy question, which is very wrong.
- AnimalMuppet 7y agoYeah. My dad would want us to try the ventilator. My mom wouldn't. I'm leaning toward "no ventilator" for myself, if it comes to that.
- kerkeslager 7y agoIf your point was that you can't decide for others, then asking what people would decide for others was a pretty unclear way for you to communicate that point. It seems more likely to me that you're backpedaling and can't admit you were wrong. Unfortunately, many people are put in the situation where they do have to decide for others: loved ones who didn't leave living wills. And that decision shouldn't be made on comparing the alternatives, not just assuming we should always try to extend life as fast as possible no matter the suffering. The idea that socialized healthcare is somehow making this a policy question is just shoehorning your political agenda into a discussion where it's irrelevant. First of all, assuming you're in the US, we don't have socialized medicine. And any reasonable implementation of socialized medicine wouldn't make this a public policy question. If anything, the capitalist medical system we actually have is forcing people to make this decision with cost in mind, rather than making the decision purely based on compassion, ethics, and what your grandmother would want. If you think your grandmother would want to be put on a ventilator, fine, but that choice may not be available to you--if there's one ventilator, you can't afford it, and someone else who wants it can afford it, it's the capitalist medical system that refused to build a second ventilator in the first place that will be deciding to give it to the other guy.
- christkv 7y agoThe other thing that was never mentioned is that a ventilator requires trained staff. An anesthesiologist, an operator and likely a nurse which also are in short supply so adding a ton of additional respirators makes little sense.
- ashtonkem 7y ago90% isn’t inevitable. A 1/10 odds of survival is greater than quite a few cancer treatments, yet we still try.
- kerkeslager 7y agoWell, actually, not everyone does try. Doctors are much more likely to choose palliative care over life-saving care for themselves late in life[1]. Many treatments simply cause the patient to suffer while providing little chance of longer-term quality of life, so there's a strong argument to be made for letting a person die more comfortable rather than marginally extending their life with more suffering. [1] https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0098246 https://journals.plos.org/plosone/article?id=10.1371/journal...
- SketchySeaBeast 7y agoLate in life isn't necessarily going to match up with everyone who needs support in this case. The virus hurts the oldest the worst, but I can't see a good rationale for not placing a 0-60 year old on a vent.
- kerkeslager 7y agoThe rationale is that they may not want to breathe their last breaths through a machine, which is uncomfortable and interferes with communication with their loved ones, when that machine only marginally improves their chances of a positive outcome. I'm open to the idea that 0-60 year olds should be treated differently from 60+ year olds, but that decision should be based at least in part on a difference in survival rates, not just how much life they have left. I'm 33, and if you told me that a ventilator would only increase my survival chance by 10%, I'd unequivocally choose to take the chances to die more comfortable and capable.
- SketchySeaBeast 7y agoThat's certainly a person choice, but given the nature of the disease, if you get to that point, you're going to pass uncomfortable and unable to communicate with your loved ones. It's the nature of this particular beast. I don't want a doc not ventilating me just for a more comfortable end of life, because it won't be. At least on a ventilator I'll be in a coma.
- malandrew 7y agoThe ventilators became more of a signaling issue. Tons of people with no medical knowledge making a big issue about it to signal to others that they care about something they think people should care about. Every politician and vocal amateur healthcare system critic were commenting most on it. It was as absurd as the disproportional outrage over the vaping deaths last year. Any one who knew anything about vents was making the point that the number of vents only matters if you happen to have enough qualified medical professionals like intensivists and anesthesiologists to operate them. I wonder if the 9 out of 10 dying is because patients are really too far gone and vents are useless or because of a mismatch in number of vents versus number of professionals that can successfully use them.
- dr_dshiv 7y agoSpeaking of vaping, what do you think about the nicotinic covid hypothesis?
- freeMoneySry 7y agoWe are flattening the curve for this. Oxygen can be done at home. And would reduce infections too.
- egberts1 7y agoVentilator makes rusting of the avioli even faster. That’s what some medical whitepapers are saying.
- tomatotomato37 7y agoDo we have any "iron lung" negative displacement ventilators still in service or did every single one get phased out? I've heard those are easier on the lungs in concept and I'm wondering if some got dug out of basements to fight covid-19 and their success rates
- inportb 7y agoWe have cuirass ventilators now.
- ashtonkem 7y agoI’m no expert, but the videos out of Italy showed patients in personal pressurized plastic bubbles rather than being intubated, so maybe that’s the same thing?
- rzzzt 7y agoAs of 2018, there were only 3 in service in the US: https://people.com/health/polio-survivor-last-3-people-use-iron-lung/ https://people.com/health/polio-survivor-last-3-people-use-i... There were quite a few interviews done in recent years with people who still rely on them; one recurring difficulty they talk about is that both expertise and availability of parts became scarce over time, so it becomes harder and harder to keep the machines running.
- ardy42 7y ago> Do we have any "iron lung" negative displacement ventilators still in service or did every single one get phased out? I've heard those are easier on the lungs in concept and I'm wondering if some got dug out of basements to fight covid-19 and their success rates. I wonder if it would make more sense for non-medical-device companies like GM to produce that type of ventilator, rather than the more modern types. The technology is simpler and the required manufacturing process are probably closer to their core competencies.
- econcon 7y agoI wonder what effect it will have on future of the countries. As majority of the people who are dying have cormobities or they are old that means now government will not have to spend money on pension or healthcare and this will lessen the tax burden!? Less population = more housing Younger population leftover after virus = higher economic output!?
- Causality1 7y agoThe numbers just aren't big enough for that. I'm sure there will be a measurable effect but I doubt a noticeable effect. There are over fifty million seniors in the US alone.
- jdm2212 7y agoThe IFR is estimated to be something like 1%, so the direct effect on housing will be not that large, and also the surviving spouses will continue to occupy the home. At least in the US, pensions and social insurance generally get redirected to the surviving spouse or their minor children (if any). Younger population doesn't imply higher economic output. It implies higher per capita economic output.
- ashtonkem 7y agoThe housing changes in the form of primary residences won’t change much. The housing market changes in the form of short term rental properties re-entering the long term rental space however....
- glofish 7y agothe ventilator hysteria is just of the examples of the irrational fear and irrational hope that people seem to get caught up in. The next such fallacy is that of testing and contact tracing. As if that were a solution to anything at all ... That too will go the way of ventillator hope. I hate to be the bearer of bad news but it will do absolutely nothing. It is not feasible at the scale that people are proposing it and it cannot possibly work without even more disruption than we already have. All it will do is push the disease into the winter when it will be more lethal. The only rational solution is finding improvements in therapeutics. We cannot keep people from getting infected, but we should be able to keep people from dying of the diseases. And that is a far closer and more achievable goal than any other. The virus already exhibits several characteristics that show that many people can easily handle it. Finding out what that is, and enhancing the same defenses in those that are at risk will be a quicker and more effective solution than all other factors combined: masks and lockdown, contact tracing etc. these "solutions" may buy some time right now, but at the same time massively slow down our progress studying the disease.
- untog 7y ago> The next such fallacy is that of testing and contact tracing. Except that other countries have documented success with this. Are you an epidemiologist?
- nradov 7y agoThe countries where contract tracing actually worked such as Taiwan, South Korea, and New Zealand started much earlier in the infection cycle. We should have done the same, but now it's basically too late. Locking the barn door after the horse has run away.
- untog 7y agoAre you an epidemiologist? I'm seeing a lot of very confident opinions in this thread!
- 7y ago
- guylepage3 7y agoAn article I read somewhere was suggesting that doctors should have tried using traditional antibiotics to treat patients instead of intubating them. This of course is strictly anecdotal.
- timerol 7y agoUsing traditional antibiotics against a virus is not particularly likely to help. Traditional antivirals are in a number of studies currently. By my non-expert estimate, remdesivir seems to be the most likely candidate. It's not approved for use in the US yet, but is well on the path: https://www.drugs.com/history/remdesivir.html https://www.drugs.com/history/remdesivir.html
- catalogia 7y agoThat's odd since coronavirus is a virus, not a bacteria, so I wouldn't expect antibiotics to be relevant except insofar as they would suppress opportunistic infections.
- oflannabhra 7y agoI saw this linked from another comment on HN, but Dr Kyle-Sidell, an ICU doc in NYC, is trying to figure out why COVID-19 patients aren't responding to typical treatment protocols on Twitter[0] and YouTube[1]. His current theory is that pulmonary edema at the capillary-alveolar interface could be causing diffusion issues, which a ventilator would not directly address. [0] - https://mobile.twitter.com/cameronks https://mobile.twitter.com/cameronks [1] - https://www.youtube.com/watch?v=NmRlvX3VrAQ https://www.youtube.com/watch?v=NmRlvX3VrAQ
- TMWNN 7y agoI've heard it speculated that the thing to do may be to not put people on ventilators, but give them blood transfusions. Where I heard this: https://science.slashdot.org/comments.pl?sid=16122794&cid=59921250 https://science.slashdot.org/comments.pl?sid=16122794&cid=59... https://www.statnews.com/2020/04/08/doctors-say-ventilators-overused-for-covid-19/ https://www.statnews.com/2020/04/08/doctors-say-ventilators-...
- framebit 7y agoThere was an article in the NY Times a few days ago from a respiratory doctor who explained that the nature of the physical mechanisms in covid-19 pneumonia mean that the patients' oxygen saturation will go way down before they start feeling short of breath, which accounts for the folks showing up at the ER with ridiculously low saturation. He noted that the celebrities who have recovered from covid-19 generally have really close, constant monitoring of their oxygen levels so problems are detected and treated way before ventilators are needed. [1] https://www.nytimes.com/2020/04/20/opinion/coronavirus-testing-pneumonia.html https://www.nytimes.com/2020/04/20/opinion/coronavirus-testi...
- AnimalMuppet 7y agoWhat do they do to treat that, short of a ventilator? Oxygen?
- dr_dshiv 7y agoThat's what I want to know. Do you just need oxygen tanks at home?
- sgent 7y agoYep, oxygen through nasal cannulas or some sort of oxygen injected into a CPAP / BiPAP system.
- dr_dshiv 7y agoShouldn't this be dealt with at home, then?
- AnimalMuppet 7y agoI don't know, but I suspect that those on oxygen may be sick enough that they should be carefully monitored, and have intervention available if they need it.
- benatkin 7y agoThis doesn't mean that all of the 1 in 10 would have died without ventilators. Elon Musk was getting torn apart for sending CPAP (or APAP/BiPAP/BPAP) machines but if in doubt I'd rather go on one of those than a ventilator.
- joshgel 7y agoHANG ON! This only considers patients already discharged or died at the end of the study some ~300 patients. But there are still ~1000 patients who were on mechanical ventilation that are still in the hospital (so aren't included in the denominator). We don't know their outcomes yet and so this is a best a sensationalist headline. Patients with this disease are on mechanical ventilation for much longer than most patients, so early reports like this don't reflect true eventual outcomes. Maybe it will be similar, but maybe it will be more like 40%, which is the usual mortality rate in ARDS.
- bryogenic 7y agoAdditionally given the expectation of ventilator shortages these hospitals have likely been preferentially providing ventilators to the sickest patients. Mortality in other areas where shortages don't exist will likely be lower.
- happytoexplain 7y agoThis cuts both ways, and I personally don't know which contributes more statistically: Hospitals are also preferentially assigning ventilators to patients more likely to be saved by them. I.e. they prioritize patients who are sick enough to need a ventilator, but not so bad off as to be unlikely to be saved by one.
- edanm 7y agoI thought there weren't shortages? I mean, the expectation was that there might be, but given the social distancing efforts, NYC didn't end up facing shortages, meaning there would be no need to not give some people ventilators?
- eitland 7y ago> but given the social distancing efforts, NYC didn't end up facing shortages Another reason (warning, just from reading the news here and elsewhere) might be that it seems ventilators aren't as useful with Covid-19 as expected, and possibly actively harmful in a number of cases (again, this is just my rehash of what I have read). From what I read doctors now try to use just proning and extra oxygen for as long as possible even if ventilators are available. People actually working in healthcare or who have first hand knowledge should feel welcome to update this.
- gummydog 7y agoAnother detracting factor in the ventilator value calculus is the number of doctors and nurses infected while treating intubated patients. It is very difficult to contain the contamination when removing tubes as the patient always coughs. I'm not sure ventilators save net lives.
- shirro 7y agoIdeally you have a highly functional public health system, testing and tracing, implement quarantine, reasonable isolation measures and border controls and don't need need these heroic medical interventions. By the time you have hundreds or thousands of people on ventilators I think it is clear you have done something wrong. Looking at the results in countries that were pro-active dealing with this pandemic and it is hard to see how it got so out of control in many other countries you would naively expect to have equivalent or better preparedness. We are not out of this yet and perhaps even countries that have just about eliminated this virus will get overconfident and fall to later waves but at the moment it looks like there are some clear winners and losers.
- xiphias2 7y agoEven 100 years ago people knew that masks are critical for controlling pandemics (and not using them led to prison sentence). It seems like healthcare is going backwards by suggesting people against using it.
- RickJWagner 7y agoPlease enumerate the clear winners and losers, and provide your criteria. AFAICT, there are a few countries that have better morbidity rates at this stage of the game, but there's a lot of time left. Sweden is playing an uncommon angle, some say they are being smart, some say otherwise. etc. I think every country is doing what they can, we probably won't be able to tell who has 'won' and who has 'lost' even in a long time. Different concentrations of people per square KM will be a huge variable, for instance.
- sgent 7y agoGermany has done very well (in a traditional manner). Ireland as well. I agree with you that we still have a ways to go -- but every day we last means one more day gained worth of knowledge, trials, etc.