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There 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 doe

by drpgq 6y ago

There 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 6y ago
I 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 6y ago
  I 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 6y ago
  But 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 6y ago
    Possible. 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 6y ago
      I 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 6y ago
  Do 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 6y ago
    Is 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 6y ago
  On 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 6y 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 6y ago
So, if that was your grandmother and you had a choice of giving her a 10% chance, you wouldn't?
- kerkeslager 6y ago
  So, 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 6y ago
    Yes 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 6y ago
      Yeah. 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 6y ago
      If 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 6y ago
The 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 6y ago
90% isn’t inevitable. A 1/10 odds of survival is greater than quite a few cancer treatments, yet we still try.
- kerkeslager 6y ago
  Well, 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 6y ago
    Late 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 6y ago
      The 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 6y ago
        That'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 6y ago
The 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 6y ago
  Speaking of vaping, what do you think about the nicotinic covid hypothesis?

by drpgq 6y ago

tootie 6y ago

I 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 6y ago
I 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 6y ago
But 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 6y ago
  Possible. 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 6y ago
    I 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 6y ago
Do 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 6y ago
  Is 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 6y ago
On 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 6y 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 6y ago

So, if that was your grandmother and you had a choice of giving her a 10% chance, you wouldn't?

kerkeslager 6y ago
So, 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 6y ago
  Yes 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 6y ago
    Yeah. 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 6y ago
    If 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 6y ago

The 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 6y ago

90% isn’t inevitable. A 1/10 odds of survival is greater than quite a few cancer treatments, yet we still try.

kerkeslager 6y ago
Well, 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 6y ago
  Late 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 6y ago
    The 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 6y ago
      That'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 6y ago

The 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 6y ago
Speaking of vaping, what do you think about the nicotinic covid hypothesis?