15 ms·

LA: Ambulance crews to not transport patients with little chance of survival

102 points by belltaco 6y ago

tsjq 6y ago
Euthanasia ?
- mongol 6y ago
  Triage
- crx07 6y ago
  What are they supposed to do? Sometimes dealing with reality involves some pretty uncomfortable choices to make, even when that essentially makes you the bad guy. The real issue here is that the economy was prematurely reopened before it was safe -- we have far more than enough money as a nation to have prevented this scenario from happening and chose a path of destruction out of sheer avarice instead.
  - trhway 6y ago
    >we have far more than enough money as a nation to for example open more beds in preparation for the second wave (which was obvious to come). Instead hospitals were laying off people in the summer.
    - flunhat 6y ago
      I suspect the limiting factor is personnel, not beds (i.e. trained staff to manage covid patients), which can't be increased on short notice. But still -- we have incompetent state & federal leadership that basically knew what would happen yet still didn't do enough to prepare. > Instead hospitals were laying off people in the summer. Yup. One of the dark ironies of this whole mess has been that hospitals have been letting go of staff because they had to suspend (very profitable) elective surgeries to treat (not so profitable) covid patients. Think hip surgeries being postponed and bleeding hospitals dry as a result.
      - trhway 6y ago
        >can't be increased on short notice. i think the 3-6 months that we had would have been enough to train any MD to care for a covid patient, at least for majority of cases and under supervision of existing high specialist. My understanding is that non-covid personnel had their workload significantly decreased, so they could have been trained for covid for the second wave.
        flunhat 6y ago
        You might be right -- at this point, with everything that's gone wrong at the govt level, I'm pretty willing to accept rank incompetence as an explanation.
    - crx07 6y ago
      There are multiple points of failure. Pretending everything was A-OK is the largest one, failing to identify the virus's presence in the country for months was another, denying and downplaying the usefulness of masks was another, underfunding hospitals was another, failing to secure PPE was another, making it painfully difficult to get tested was another. There's a lot of blame to go around on this one. But reopening the economy was the biggest mistake.
  - danhak 6y ago
    There are many factors at play, but in L.A. I don't believe premature reopening is one of them. Bars, indoor dining and gyms have been shut down for pretty much the whole pandemic. Outdoor dining was banned (again) about a month ago. My take is that L.A.'s issues have more to do with housing density, high number of people living with roommates and high number of multigenerational households. Also perhaps some some challenges communicating with an extremely large and diverse immigrant population.
    - crx07 6y ago
      LA is one of the most connected cities in the world. It's not LA's fault necessarily, but the country as a whole should've been on complete lockdown from April until whenever the situation was under control. Our national wealth and GDP have plenty of room for a complete quarantine, even if that means paying everyone's paychecks for a year or longer. We deliberately chose to allow 350,000+ peoples lives to end instead.
    - jchonphoenix 6y ago
      I'll point you to Hong Kong, Singapore, Shanghai, and Tokyo as counterexamples. All of those cities are 3-7x denser than LA, more populous, and culturally multigenerational. I think it's quite clear to anyone who's been paying attention at this point that behavior has more to do with containment than anything else. The US and perhaps LA in particular for some reason or another is unwilling or unable to implement the same behavioral safety measures of other countries and cultures. Mask wearing is the obvious one. If you go to any of those 4 cities I mentioned, 100% of individuals in public are masked, whether indoors or outdoors. 6ft social distance is very strictly followed with public shaming for those that take off their masks or do not follow social distancing guidelines in public.
      - MattGaiser 6y ago
        Indeed. LA is not that densely populated by any global standard.
      - danaliv 6y ago
        At some point, “this is a free country” became “I don’t have to apply impulse control under any circumstances.”
  - cameldrv 6y ago
    The real issue IMO was that the lockdown wasn't strict enough, or enforced. Many, many stores were open, many workplaces were deemed essential, masks were not generally worn in the first phase of the lockdowns, and while indoor dining at restaurants was closed, indoor dining at your friend's house was wide open. The three places that I know of that have gotten cases to zero are China, New Zealand, and Australia, and they all used lockdowns that were far stricter than in the U.S. The problem is that a soft lockdown doesn't bring R low enough to eradicate the virus quickly, and people won't stomach it dragging on for months. I also don't believe that it can be done on the honor system. There must be police writing tickets or worse for violations, or there is a segment of the population that will ignore whatever measures that are enacted. Unfortunately sometimes these are even identifiable groups of people that all socialize together in violation of health orders, so the virus will spread within these communities regardless of whatever the governor puts on a piece of paper and makes a speech about.
    - tsjq 6y ago
      Interesting points indeed. On the other hand, India had a hard lockdown for 6-8 weeks, and yet the numbers zoomed up weeks after that. And now, the numbers are magically going down despite absolute carelessness widespread. Inexplicable
      - crx07 6y ago
        The numbers start going down quickly once infections have been so prolific that crowd immunity is present. I live in Texas, but I'm sure I personally infected no fewer than 10,000-20,000 people last March, including the sorority that purportedly brought it back from Mexico during spring break. No doctor wanted to listen and no hospitals would test me even after I begged some of the best providers in the region. It wasn't until almost 9 months later that the mistake was acknowledged, and it's highly likely that community spread existed even in the US in November 2019 or even October 2019 just based on retrospective serology studies. Places with poor hygiene controls like India have likely had far, far more infections than anyone even can imagine. That might be one of the first places to be immune.
nnx 6y ago
Why are some proven simple yet _useful_ preventative measures not taken? Like, promoting self blood oxygen monitoring with those (cheap!) finger oxymeter devices for all at-risk persons... This would avoid lots of late emergency calls in critical condition due to silent hypoxia that developed in them for days/weeks...
- lisper 6y ago
  Vitamin D supplements too. https://pubmed.ncbi.nlm.nih.gov/32252338/ https://pubmed.ncbi.nlm.nih.gov/32252338/
- taxicabjesus 6y ago
  The commonly-used treatments for hypoxia are incredibly damaging. In the beginning "ventilation" was the go-to treatment to pump oxygen into patients' lungs. Doctors eventually realized invasive ventilation was a death sentence. Now they're trying to just use lots of oxygen, but that doesn't work either. A lot of people had COVID-19 before tests were available. What happened to make the disease so much more deadly? I think most the early patients (December 2019, January/February 2020) toughed it out on their own at home.
  - tylerhou 6y ago
    > Doctors eventually realized invasive ventilation was a death sentence. Do you have a source that ventilation itself worsens outcomes, and isn't just correlated with already poor-performing patients?
    - baskire 6y ago
      Here’s a good summary of some findings. “ Among the 2,634 patients for whom outcomes were known, the overall death rate was 21%, but it rose to 88% for those who received mechanical ventilation, the Northwell Health COVID-19 Research Consortium reported.” “ Ventilators are typically used only when patients are extremely ill, so experts believe that between 40% and 50% of patients die after going on ventilation, regardless of the underlying illness.” https://www.webmd.com/lung/news/20200422/most-covid-19-patients-placed-on-ventilators-died-new-york-study-shows https://www.webmd.com/lung/news/20200422/most-covid-19-patie...
baggy_trough 6y ago
https://www.quora.com/What-is-the-current-treatment-for-Covid-19 https://www.quora.com/What-is-the-current-treatment-for-Covi...
- highmastdon 6y ago
  This is great. Of the effectiveness is a as good in the long run, we don’t even need a vaccine since it’s no longer a high risk disease. It’ll be a flu like vaccination where elderly and at-risk people can be using it
  - tdeck 6y ago
    Everyone who can get the flu shot should be getting it. It's free in the US and takes a couple of minutes. It's not just for elderly or at-risk people, and even if you don't mind getting the flu spreading it can be dangerous.
- nharada 6y ago
  I'm a little skeptical of the claims made in that post > If everyone in the world just did one thing differently, talking to their doctor about whether they should start fluvoxamine or ivermectin after they learned they were COVID positive, our hospitals and ICUs would be nearly empty today and there would be very few “long haulers.” Yes, there was a preliminary communication released recently in JAMA showing some evidence that Fluvoxamine treatment has clinical promise. You can read it here: https://jamanetwork.com/journals/jama/article-abstract/2773108 https://jamanetwork.com/journals/jama/article-abstract/27731... The results: "In this randomized trial that included 152 adult outpatients with confirmed COVID-19 and symptom onset within 7 days, clinical deterioration occurred in 0 patients treated with fluvoxamine vs 6 (8.3%) patients treated with placebo over 15 days, a difference that was statistically significant." Not bad results, but seems like a big jump to suggest that all doctors change their treatment procedures based on this study. I'm interested to see larger studies, especially with longer follow-up durations.
  - ImaCake 6y ago
    You are right to be skeptical but it looks damn good. There is a clinical trial under way now with n=800. https://clinicaltrials.gov/ct2/show/NCT04668950 https://clinicaltrials.gov/ct2/show/NCT04668950
sieabahlpark 6y ago
The real question is why did CA make it damn near impossible to build more healthcare facilities?
burnthrow 6y ago
While the headline makes it sound like Grandma isn't getting a ride because she's frail, "little chance of survival" is more specific: > Patients who are not to be transported to hospitals include those whose hearts have stopped and, despite efforts at resuscitation, have no signs of breathing, movement, a pulse or blood pressure and would be declared dead at the scene.
- CyanLite4 6y ago
  It’s protocol to NOT allow EMTs to declare someone dead. An EMT (with a few hours of community college training, mind you) are not trained for advanced resuscitation that only doctors can perform. This absolutely will lead to excess mortality.
  - GavinMcG 6y ago
    Can you describe how? Advanced Cardiac Life Support protocols (ACLS) are fairly standard in both pre-hospital and hospital settings. Specifically because it's critical, paramedics are trained in ACLS. EMT-Bs aren't, but the BLS ambulances they staff shouldn't generally be assigned as the only responding unit for cardiac arrests, anyway. And given that, it's not clear why you think there will "absolutely" be excess mortality.
  - Rebelgecko 6y ago
    LA County sends FD paramedics to pretty much every 911 call
remote_phone 6y ago
Regardless of politics, I think places like LA need to institute a full lockdown. No one leaves their house except to go to the grocery store and pharmacy. No one leaves more than 2 miles away from their residence. It should be enforced by the military. Essentially martial law. It’s not something I suggest lightly. But 6-8 weeks of complete lockdown and pay people to stay home. It’s the only way that California is going to survive this. Yes, I know that the death rate is low, ~0.2%. But when hospitals are full like this we need to have a circuit breaker and the only thing we have is a full, military-enforced lockdown. We should also stop all traffic on the highways. Set up tanks on the I-5 and 101 and turn people back. We have to stop this uncontrolled catastrophe.
- burnthrow 6y ago
  > It’s not something I suggest lightly. Anonymous HN comments lack a certain gravitas.
- highmastdon 6y ago
  There’s enough evidence for medication and preventive supplements (Ivermectin, Vitamin D) that lockdowns aren’t necessary anymore. Other treatments have looked promising when applied early in the disease instead of after hospitalisation. According to combined research (c19study.com) over 800,000 lives could’ve been saved when treated earlier
  - adrianN 6y ago
    If there were such evidence I doubt that so many countries would fuck over their economy with lockdowns, so I have strong doubts about your claim.
    - highmastdon 6y ago
      Turkey has been treating people with HCQ from May onwards, despite outcomes of the now-retracted(!) study once published in The Lancet, and they have a very low death rate. 256/1M Population. (See: https://www.middleeasteye.net/news/hydroxychloroquine-coronavirus-turkey-lancet-study-who-trial https://www.middleeasteye.net/news/hydroxychloroquine-corona...) Their death rate has been on a steady 1% throughout the pandemic where for example Germany is on about 3%. Of course this needs to be corrected for age etc etc.
harikb 6y ago
> Patients who are not to be transported to hospitals include those whose hearts have stopped and, despite efforts at resuscitation, have no signs of breathing, movement, a pulse or blood pressure and would be declared dead at the scene.
- sneak 6y ago
  Who else does it include? This statement sounds like weasel words to calm people down about what is plainly an unacceptable situation.
  - burnthrow 6y ago
    That's all it includes. For your convenience here is a direct link to the agency memo, from the linked article. http://file.lacounty.gov/SDSInter/dhs/1100458_Directive_6revTransportofTraumaticandNontraumaticCardiacArrest.pdf http://file.lacounty.gov/SDSInter/dhs/1100458_Directive_6rev... As for "unacceptable situation", here's a bit more color from actual local EMS: https://old.reddit.com/r/LosAngeles/comments/kqlgqz/ambulance_crews_told_not_to_transport_patients/ https://old.reddit.com/r/LosAngeles/comments/kqlgqz/ambulanc... > As a former paramedic now assigned to media relations, the first thing I taught my kids about the news? Never react to the headline. While COVID-19 has shaped many pre-hospital care policies, protocols and procedures across California (and beyond) over the past year - including in Los Angeles County, rest assured that the concept of "No ROSC = No Transport" is not in any way new to our region, or most others. > Brian Humphrey Firefighter/Specialist Public Service Officer Los Angeles Fire Department (Above reference would be a separate comment, but this lovely thread sent serial downvoters to my history and I am timed out!)
- andi999 6y ago
  Wait, so normally such patients are transported? For what? Billing purposes?
  - bozhark 6y ago
    Because people can be revived
danielovichdk 6y ago
Firstly the country has not really been serious about the pandemic it seems. On a political scale that is. And since each state can take their own actions it's really difficult to understand why this has not been done before. On the other hand, the weak are the ones that die first. It's the law of nature. So when doctors look at a patient it's of course their job to validate whether or not it's time and money well spent to save a life. How did you think it worked, honestly? Many years ago a story of similar character ran across Denmark, where doctors were being exposed due to the fact that they had to make a life (but how much longer!) or death decision for a variety of patients. And of course they have to imo.
songgao 6y ago
This might be an unpopular opinion but this is a pretty awful headline and it makes it look way worse than what the EMS documents actually say. There’s a bold text [1] “shall not be transported if return of spontaneous circulation is not achieved in the field”. There’s a pretty big difference between abandoning patients with little chance of survival in general, and giving up after failure to achieve ROSC. Perhaps at some point we’ll be at the place where EMS really have to give up without even attempting CPR, but we’re not there yet. That’s not saying the situation is not bad — it’s terrifyingly bad. But a headline designed to make incorrect impression just doesn’t help. [1] https://twitter.com/Pervaizistan/status/1346295476405084168 https://twitter.com/Pervaizistan/status/1346295476405084168 EDIT: link, to focus on the right tweet. typo.
- wbl 6y ago
  When have they ever run out of oxygen before?
  - labster 6y ago
    Hospitals are running out of oxygen in a way: so much is going through the pipes that the upper floors have low pressure, and the oxygen pipes occasionally freeze from adiabatic expansion. In LA.
    - Cthulhu_ 6y ago
      You'd think they would test systems like that at maximum consumption. Mind you, electricity and water systems are also not designed for every outlet to be maxed out. Whomst among us hasn't caused a breaker to trip from having too much stuff on at the same time.
      - WrtCdEvrydy 6y ago
        Why would you? There's almost no cases where you would need oxygen to every room...
kepler1 6y ago
The medical system is stretched to breaking. Vaccine distribution is completely disorganized, despite months of possible preparation time. A ridiculous patchwork of federal, state, county authorities can't get it together to enforce rules and can only ask for voluntary cooperation in a true crisis. I think we will look back on this as one of the great weaknesses of decentralized, democratic, random-walk governance, fueled by misinformation and lack of leadership.
- ixacto 6y ago
  More people will die from covid. But the principals of free speech and assembly should not be sacrificed for something that will be and mostly gone in 6-9months. Yes people have died and that is horrible, but a dictatorship like china is not the answer. Tbh I'm more afraid of the governments authoritarianism than covid. *Disclaimer: yes I wear a mask indoors in public places and outdoors when not able to be 6 feet from everyone. No I don't wear a mask when walking alone outside, that is stupid and just shows how much our messaging on covid sucked even with the middle and upper classes.
  - EliRivers 6y ago
    But the principals of free speech and assembly should not be sacrificed for something that will be and mostly gone in 6-9months. Why not? Ultimately, people are what matters. You know who can't exercise free speech and assembly? Dead people. Why is a 6 month hard lockdown worse than letting people keep walking around for 6 months? This sounds like a moral, absolutist statement you're making; like life is an art project, and the aim is to exercise some particular set of principles. (Free speech? What's the threat to free speech here? Is it the people spreading bullshit and conspiracy about Covid that's getting people killed?)
    - ixacto 6y ago
      Because I don't trust the federal and state governments to act in my best interests. This is not too say that some are acting in the best interests of the people as I am sure some in government do mean well, but not to blindly trust that the government knows best about our public helath. China/Vietnam have stopped covid, that's great but you can't exercise many of the freedoms that are allowed here. Imagine if someone tried to fly a baby Xi balloon in China, or even practice a religion without fearing persecution or death? Or even mention tiananmen square massacre or the death toll from the Great Leap Forward... That is still going on and yet we are looking to China style lockdowns as a model of how to deal with Covid.
ajknvf 6y ago
There are a lot of comments that are kind of close to right but missing context here. This is extremely common, and like all of prehospital care is heavily protocol driven. Dead people encountered by EMS / public safety are a much larger superset than those typically "saved" in a hospital setting, and those that meet the criteria to either stop, or not begin resuscitation really have no reason to be transported. The link below is an example of EMS protocols that would cover this. Here's a snippet. "Discontinuation of Prehospital Resuscitation" 1. Discontinuation of CPR and ALS intervention may be implemented prior to contact with Medical Control if ALL of the following criteria have been met: Patient must be 18 years of age or older, or family of a minor is agreeable after consultation with the APP or District Chief. Adequate CPR has been administered. Airway has been successfully managed with verification of device placement. Acceptable management techniques include orotracheal intubation, nasotracheal intubation, Blind Insertion Airway Device (BIAD) placement, or cricothyrotomy. IV or IO access has been achieved. Rhythm appropriate medications and defibrillation have been administered according to protocol. Persistent asystole or agonal rhythm is present and no reversible causes are identified after a minimum of 25 minutes of resuscitation. Failure to establish sustained palpable pulses or to establish persistent/recurring ventricular fibrillation/tachycardia or lack of any continued neurological activity such as eye opening or motor responses All EMS paramedic personnel involved in the patient’s care agree that discontinuation of the resuscitation is appropriate 2. If all of the above criteria are not met and discontinuation of pre-hospital resuscitation is possibly indicated or desired, contact Medical Control. 3. The Deceased Subjects Policy should be followed. http://www.wakegov.com/ems/medical/Documents/WCEMSS%20Standards%20Practice%202020%2012.11.20.pdf http://www.wakegov.com/ems/medical/Documents/WCEMSS%20Standa...
herdrick 6y ago
I can't believe they're rationing oxygen. I administered welding oxygen to my girlfriend every day for about 6 weeks when she had Covid. It's cheap, easy, and perfectly safe. I assumed that when things got bad someone would just suspend the regulation requiring medical certified oxygen.
- kenhwang 6y ago
  From what I've read, its a hospital infrastructure problem, not a material shortage problem. The pipes that deliver oxygen to the machines can't deliver oxygen any faster because they're freezing up from the amount of oxygen being used.
  - herdrick 6y ago
    You would carry it into patients' rooms and ambulances in tanks.
    - kenhwang 6y ago
      There's also a shortage of said tanks. https://www.latimes.com/california/story/2020-12-29/oxygen-supply-shortages-bedevil-hospitals-already-overwhelmed-by-covid-19-patients https://www.latimes.com/california/story/2020-12-29/oxygen-s...
      - herdrick 6y ago
        Welding tanks are different, and not in shortage.
- philjohn 6y ago
  That struck me as odd as well, although, there could indeed be a shortage. In UK hospitals it's not so much that there's a shortage, but the oxygen distribution network/lines in hospitals aren't sized for the number of patients requiring it.
jessriedel 6y ago
I'm disappointed that all the discussion seems to be operating at a non-quantitative level. ("If there's any chance, we have to try" against "If circulation can't be reestablished on scene, there's essentially no hope".) Presumably there are academic article that make an attempt at this.
- schwartzworld 6y ago
  People overestimate the efficacy of CPR because they see people in the movies come back to life after 4 chest compressions and a second of mouth-to-mouth. I wonder if that is the sort of thing driving the discussion
  - ajknvf 6y ago
    That's likely part of it. Unwitnessed cardiac arrests and those where no electrical activity is present in the heart are pretty rare to get back. Cold temperature and submersion in water are two neat caveats though. They can be viable a lot longer, in part due to the Diving reflex. https://en.wikipedia.org/wiki/Diving_reflex https://en.wikipedia.org/wiki/Diving_reflex
  - jessriedel 6y ago
    I've spent some time in hospitals and I don't overestimate the <1% efficacy, but I'm still frustrated by the innumeracy of the discussion. There are biases in the other direction: medical professionals who watch 100 people die for every 1 saved become desensitized to death and round that to zero. They're not economists, and they don't understand the statistical value of life implies it's worth spending $20,000 for just a 0.3% of survival.
RickJWagner 6y ago
I can't imagine the incredible agony of being the EMT who has to decide if someone gets a ride or not. Covid is horrible in so many ways.
covid21 6y ago
Is there a site that shows statistics (over time) of hospital capacity over time in LA? It sounds to me like one of the typical articles that tries to induce panic without actually providing much information or context. Whenever I see such articles here in Germany, I go to the official statistics for ICUs, and inevitably it always turns out to be bullshit. Some of the things that are hyped to be a consequence of Covid also turn out to be seasonal, even shortage of oxygen does not seem to be unusual. This is the German site I refer to: https://www.intensivregister.de/#/aktuelle-lage/zeitreihen https://www.intensivregister.de/#/aktuelle-lage/zeitreihen
- cactus2093 6y ago
  So you won’t be satisfied until people are literally dropping dead in front of you, huh?
  - covid21 6y ago
    What makes you think that? Quit the bullshit.
    - dang 6y ago
      We've banned this account for repeatedly breaking the site guidelines. Could you please not create accounts to do that with? We're trying for a different kind of site here. https://news.ycombinator.com/newsguidelines.html https://news.ycombinator.com/newsguidelines.html
  - dang 6y ago
    This comment breaks the site guidelines badly. Would you mind reviewing them and sticking to the rules when posting here? Note these ones: "Please respond to the strongest plausible interpretation of what someone says, not a weaker one that's easier to criticize. Assume good faith." "Comments should get more thoughtful and substantive, not less, as a topic gets more divisive." https://news.ycombinator.com/newsguidelines.html https://news.ycombinator.com/newsguidelines.html
cactus2093 6y ago
I still cannot comprehend why we had to let it go this far. Why have all measures in California been completely voluntary this whole time? I can get a ticket if I jaywalk or leave my car parked somewhere for too long, but if I walk into a Walmart with no mask on and start yelling at everyone in the store potentially exposing dozens of people to covid I’ll just get politely escorted out with no penalties. Something so ridiculously simple we could have started with is just ticketing for not wearing a mask in public. If we needed to ratchet it up further, ticketing gatherings with people outside the same household, which is obviously more difficult to enforce but just start with the ones that happen in public. Maybe do a “see something, say something” campaign to encourage people to report private gatherings they see in their neighborhoods and police come and break up gatherings and give tickets. What we’ve been doing instead with all these ever-changing vague optional guidelines is just so stupid. Either leave everything open, or actually enforce the so-called “orders”.
cosmiccatnap 6y ago
It's almost like things related to healthcare shouldn't be privatised because then their interests are directly related to profit as are their disinterest such as the lives of soon to be unemployed (see: deceased persons) revenue streams (see: human beings)

102 points by belltaco 6y ago

tsjq 6y ago

Euthanasia ?

mongol 6y ago
Triage
crx07 6y ago
What are they supposed to do? Sometimes dealing with reality involves some pretty uncomfortable choices to make, even when that essentially makes you the bad guy. The real issue here is that the economy was prematurely reopened before it was safe -- we have far more than enough money as a nation to have prevented this scenario from happening and chose a path of destruction out of sheer avarice instead.
- trhway 6y ago
  >we have far more than enough money as a nation to for example open more beds in preparation for the second wave (which was obvious to come). Instead hospitals were laying off people in the summer.
  - flunhat 6y ago
    I suspect the limiting factor is personnel, not beds (i.e. trained staff to manage covid patients), which can't be increased on short notice. But still -- we have incompetent state & federal leadership that basically knew what would happen yet still didn't do enough to prepare. > Instead hospitals were laying off people in the summer. Yup. One of the dark ironies of this whole mess has been that hospitals have been letting go of staff because they had to suspend (very profitable) elective surgeries to treat (not so profitable) covid patients. Think hip surgeries being postponed and bleeding hospitals dry as a result.
    - trhway 6y ago
      >can't be increased on short notice. i think the 3-6 months that we had would have been enough to train any MD to care for a covid patient, at least for majority of cases and under supervision of existing high specialist. My understanding is that non-covid personnel had their workload significantly decreased, so they could have been trained for covid for the second wave.
      - flunhat 6y ago
        You might be right -- at this point, with everything that's gone wrong at the govt level, I'm pretty willing to accept rank incompetence as an explanation.
  - crx07 6y ago
    There are multiple points of failure. Pretending everything was A-OK is the largest one, failing to identify the virus's presence in the country for months was another, denying and downplaying the usefulness of masks was another, underfunding hospitals was another, failing to secure PPE was another, making it painfully difficult to get tested was another. There's a lot of blame to go around on this one. But reopening the economy was the biggest mistake.
- danhak 6y ago
  There are many factors at play, but in L.A. I don't believe premature reopening is one of them. Bars, indoor dining and gyms have been shut down for pretty much the whole pandemic. Outdoor dining was banned (again) about a month ago. My take is that L.A.'s issues have more to do with housing density, high number of people living with roommates and high number of multigenerational households. Also perhaps some some challenges communicating with an extremely large and diverse immigrant population.
  - crx07 6y ago
    LA is one of the most connected cities in the world. It's not LA's fault necessarily, but the country as a whole should've been on complete lockdown from April until whenever the situation was under control. Our national wealth and GDP have plenty of room for a complete quarantine, even if that means paying everyone's paychecks for a year or longer. We deliberately chose to allow 350,000+ peoples lives to end instead.
  - jchonphoenix 6y ago
    I'll point you to Hong Kong, Singapore, Shanghai, and Tokyo as counterexamples. All of those cities are 3-7x denser than LA, more populous, and culturally multigenerational. I think it's quite clear to anyone who's been paying attention at this point that behavior has more to do with containment than anything else. The US and perhaps LA in particular for some reason or another is unwilling or unable to implement the same behavioral safety measures of other countries and cultures. Mask wearing is the obvious one. If you go to any of those 4 cities I mentioned, 100% of individuals in public are masked, whether indoors or outdoors. 6ft social distance is very strictly followed with public shaming for those that take off their masks or do not follow social distancing guidelines in public.
    - MattGaiser 6y ago
      Indeed. LA is not that densely populated by any global standard.
    - danaliv 6y ago
      At some point, “this is a free country” became “I don’t have to apply impulse control under any circumstances.”
- cameldrv 6y ago
  The real issue IMO was that the lockdown wasn't strict enough, or enforced. Many, many stores were open, many workplaces were deemed essential, masks were not generally worn in the first phase of the lockdowns, and while indoor dining at restaurants was closed, indoor dining at your friend's house was wide open. The three places that I know of that have gotten cases to zero are China, New Zealand, and Australia, and they all used lockdowns that were far stricter than in the U.S. The problem is that a soft lockdown doesn't bring R low enough to eradicate the virus quickly, and people won't stomach it dragging on for months. I also don't believe that it can be done on the honor system. There must be police writing tickets or worse for violations, or there is a segment of the population that will ignore whatever measures that are enacted. Unfortunately sometimes these are even identifiable groups of people that all socialize together in violation of health orders, so the virus will spread within these communities regardless of whatever the governor puts on a piece of paper and makes a speech about.
  - tsjq 6y ago
    Interesting points indeed. On the other hand, India had a hard lockdown for 6-8 weeks, and yet the numbers zoomed up weeks after that. And now, the numbers are magically going down despite absolute carelessness widespread. Inexplicable
    - crx07 6y ago
      The numbers start going down quickly once infections have been so prolific that crowd immunity is present. I live in Texas, but I'm sure I personally infected no fewer than 10,000-20,000 people last March, including the sorority that purportedly brought it back from Mexico during spring break. No doctor wanted to listen and no hospitals would test me even after I begged some of the best providers in the region. It wasn't until almost 9 months later that the mistake was acknowledged, and it's highly likely that community spread existed even in the US in November 2019 or even October 2019 just based on retrospective serology studies. Places with poor hygiene controls like India have likely had far, far more infections than anyone even can imagine. That might be one of the first places to be immune.

nnx 6y ago

Why are some proven simple yet _useful_ preventative measures not taken? Like, promoting self blood oxygen monitoring with those (cheap!) finger oxymeter devices for all at-risk persons... This would avoid lots of late emergency calls in critical condition due to silent hypoxia that developed in them for days/weeks...

lisper 6y ago
Vitamin D supplements too. https://pubmed.ncbi.nlm.nih.gov/32252338/ https://pubmed.ncbi.nlm.nih.gov/32252338/
taxicabjesus 6y ago
The commonly-used treatments for hypoxia are incredibly damaging. In the beginning "ventilation" was the go-to treatment to pump oxygen into patients' lungs. Doctors eventually realized invasive ventilation was a death sentence. Now they're trying to just use lots of oxygen, but that doesn't work either. A lot of people had COVID-19 before tests were available. What happened to make the disease so much more deadly? I think most the early patients (December 2019, January/February 2020) toughed it out on their own at home.
- tylerhou 6y ago
  > Doctors eventually realized invasive ventilation was a death sentence. Do you have a source that ventilation itself worsens outcomes, and isn't just correlated with already poor-performing patients?
  - baskire 6y ago
    Here’s a good summary of some findings. “ Among the 2,634 patients for whom outcomes were known, the overall death rate was 21%, but it rose to 88% for those who received mechanical ventilation, the Northwell Health COVID-19 Research Consortium reported.” “ Ventilators are typically used only when patients are extremely ill, so experts believe that between 40% and 50% of patients die after going on ventilation, regardless of the underlying illness.” https://www.webmd.com/lung/news/20200422/most-covid-19-patients-placed-on-ventilators-died-new-york-study-shows https://www.webmd.com/lung/news/20200422/most-covid-19-patie...

baggy_trough 6y ago

https://www.quora.com/What-is-the-current-treatment-for-Covid-19 https://www.quora.com/What-is-the-current-treatment-for-Covi...

highmastdon 6y ago
This is great. Of the effectiveness is a as good in the long run, we don’t even need a vaccine since it’s no longer a high risk disease. It’ll be a flu like vaccination where elderly and at-risk people can be using it
- tdeck 6y ago
  Everyone who can get the flu shot should be getting it. It's free in the US and takes a couple of minutes. It's not just for elderly or at-risk people, and even if you don't mind getting the flu spreading it can be dangerous.
nharada 6y ago
I'm a little skeptical of the claims made in that post > If everyone in the world just did one thing differently, talking to their doctor about whether they should start fluvoxamine or ivermectin after they learned they were COVID positive, our hospitals and ICUs would be nearly empty today and there would be very few “long haulers.” Yes, there was a preliminary communication released recently in JAMA showing some evidence that Fluvoxamine treatment has clinical promise. You can read it here: https://jamanetwork.com/journals/jama/article-abstract/2773108 https://jamanetwork.com/journals/jama/article-abstract/27731... The results: "In this randomized trial that included 152 adult outpatients with confirmed COVID-19 and symptom onset within 7 days, clinical deterioration occurred in 0 patients treated with fluvoxamine vs 6 (8.3%) patients treated with placebo over 15 days, a difference that was statistically significant." Not bad results, but seems like a big jump to suggest that all doctors change their treatment procedures based on this study. I'm interested to see larger studies, especially with longer follow-up durations.
- ImaCake 6y ago
  You are right to be skeptical but it looks damn good. There is a clinical trial under way now with n=800. https://clinicaltrials.gov/ct2/show/NCT04668950 https://clinicaltrials.gov/ct2/show/NCT04668950

sieabahlpark 6y ago

The real question is why did CA make it damn near impossible to build more healthcare facilities?

burnthrow 6y ago

While the headline makes it sound like Grandma isn't getting a ride because she's frail, "little chance of survival" is more specific: > Patients who are not to be transported to hospitals include those whose hearts have stopped and, despite efforts at resuscitation, have no signs of breathing, movement, a pulse or blood pressure and would be declared dead at the scene.

CyanLite4 6y ago
It’s protocol to NOT allow EMTs to declare someone dead. An EMT (with a few hours of community college training, mind you) are not trained for advanced resuscitation that only doctors can perform. This absolutely will lead to excess mortality.
- GavinMcG 6y ago
  Can you describe how? Advanced Cardiac Life Support protocols (ACLS) are fairly standard in both pre-hospital and hospital settings. Specifically because it's critical, paramedics are trained in ACLS. EMT-Bs aren't, but the BLS ambulances they staff shouldn't generally be assigned as the only responding unit for cardiac arrests, anyway. And given that, it's not clear why you think there will "absolutely" be excess mortality.
- Rebelgecko 6y ago
  LA County sends FD paramedics to pretty much every 911 call

remote_phone 6y ago

Regardless of politics, I think places like LA need to institute a full lockdown. No one leaves their house except to go to the grocery store and pharmacy. No one leaves more than 2 miles away from their residence. It should be enforced by the military. Essentially martial law. It’s not something I suggest lightly. But 6-8 weeks of complete lockdown and pay people to stay home. It’s the only way that California is going to survive this. Yes, I know that the death rate is low, ~0.2%. But when hospitals are full like this we need to have a circuit breaker and the only thing we have is a full, military-enforced lockdown. We should also stop all traffic on the highways. Set up tanks on the I-5 and 101 and turn people back. We have to stop this uncontrolled catastrophe.

burnthrow 6y ago
> It’s not something I suggest lightly. Anonymous HN comments lack a certain gravitas.
highmastdon 6y ago
There’s enough evidence for medication and preventive supplements (Ivermectin, Vitamin D) that lockdowns aren’t necessary anymore. Other treatments have looked promising when applied early in the disease instead of after hospitalisation. According to combined research (c19study.com) over 800,000 lives could’ve been saved when treated earlier
- adrianN 6y ago
  If there were such evidence I doubt that so many countries would fuck over their economy with lockdowns, so I have strong doubts about your claim.
  - highmastdon 6y ago
    Turkey has been treating people with HCQ from May onwards, despite outcomes of the now-retracted(!) study once published in The Lancet, and they have a very low death rate. 256/1M Population. (See: https://www.middleeasteye.net/news/hydroxychloroquine-coronavirus-turkey-lancet-study-who-trial https://www.middleeasteye.net/news/hydroxychloroquine-corona...) Their death rate has been on a steady 1% throughout the pandemic where for example Germany is on about 3%. Of course this needs to be corrected for age etc etc.

harikb 6y ago

> Patients who are not to be transported to hospitals include those whose hearts have stopped and, despite efforts at resuscitation, have no signs of breathing, movement, a pulse or blood pressure and would be declared dead at the scene.

sneak 6y ago
Who else does it include? This statement sounds like weasel words to calm people down about what is plainly an unacceptable situation.
- burnthrow 6y ago
  That's all it includes. For your convenience here is a direct link to the agency memo, from the linked article. http://file.lacounty.gov/SDSInter/dhs/1100458_Directive_6revTransportofTraumaticandNontraumaticCardiacArrest.pdf http://file.lacounty.gov/SDSInter/dhs/1100458_Directive_6rev... As for "unacceptable situation", here's a bit more color from actual local EMS: https://old.reddit.com/r/LosAngeles/comments/kqlgqz/ambulance_crews_told_not_to_transport_patients/ https://old.reddit.com/r/LosAngeles/comments/kqlgqz/ambulanc... > As a former paramedic now assigned to media relations, the first thing I taught my kids about the news? Never react to the headline. While COVID-19 has shaped many pre-hospital care policies, protocols and procedures across California (and beyond) over the past year - including in Los Angeles County, rest assured that the concept of "No ROSC = No Transport" is not in any way new to our region, or most others. > Brian Humphrey Firefighter/Specialist Public Service Officer Los Angeles Fire Department (Above reference would be a separate comment, but this lovely thread sent serial downvoters to my history and I am timed out!)
andi999 6y ago
Wait, so normally such patients are transported? For what? Billing purposes?
- bozhark 6y ago
  Because people can be revived

danielovichdk 6y ago

Firstly the country has not really been serious about the pandemic it seems. On a political scale that is. And since each state can take their own actions it's really difficult to understand why this has not been done before. On the other hand, the weak are the ones that die first. It's the law of nature. So when doctors look at a patient it's of course their job to validate whether or not it's time and money well spent to save a life. How did you think it worked, honestly? Many years ago a story of similar character ran across Denmark, where doctors were being exposed due to the fact that they had to make a life (but how much longer!) or death decision for a variety of patients. And of course they have to imo.

songgao 6y ago

This might be an unpopular opinion but this is a pretty awful headline and it makes it look way worse than what the EMS documents actually say. There’s a bold text [1] “shall not be transported if return of spontaneous circulation is not achieved in the field”. There’s a pretty big difference between abandoning patients with little chance of survival in general, and giving up after failure to achieve ROSC. Perhaps at some point we’ll be at the place where EMS really have to give up without even attempting CPR, but we’re not there yet. That’s not saying the situation is not bad — it’s terrifyingly bad. But a headline designed to make incorrect impression just doesn’t help. [1] https://twitter.com/Pervaizistan/status/1346295476405084168 https://twitter.com/Pervaizistan/status/1346295476405084168 EDIT: link, to focus on the right tweet. typo.

wbl 6y ago
When have they ever run out of oxygen before?
- labster 6y ago
  Hospitals are running out of oxygen in a way: so much is going through the pipes that the upper floors have low pressure, and the oxygen pipes occasionally freeze from adiabatic expansion. In LA.
  - Cthulhu_ 6y ago
    You'd think they would test systems like that at maximum consumption. Mind you, electricity and water systems are also not designed for every outlet to be maxed out. Whomst among us hasn't caused a breaker to trip from having too much stuff on at the same time.
    - WrtCdEvrydy 6y ago
      Why would you? There's almost no cases where you would need oxygen to every room...

kepler1 6y ago

The medical system is stretched to breaking. Vaccine distribution is completely disorganized, despite months of possible preparation time. A ridiculous patchwork of federal, state, county authorities can't get it together to enforce rules and can only ask for voluntary cooperation in a true crisis. I think we will look back on this as one of the great weaknesses of decentralized, democratic, random-walk governance, fueled by misinformation and lack of leadership.

ixacto 6y ago
More people will die from covid. But the principals of free speech and assembly should not be sacrificed for something that will be and mostly gone in 6-9months. Yes people have died and that is horrible, but a dictatorship like china is not the answer. Tbh I'm more afraid of the governments authoritarianism than covid. *Disclaimer: yes I wear a mask indoors in public places and outdoors when not able to be 6 feet from everyone. No I don't wear a mask when walking alone outside, that is stupid and just shows how much our messaging on covid sucked even with the middle and upper classes.
- EliRivers 6y ago
  But the principals of free speech and assembly should not be sacrificed for something that will be and mostly gone in 6-9months. Why not? Ultimately, people are what matters. You know who can't exercise free speech and assembly? Dead people. Why is a 6 month hard lockdown worse than letting people keep walking around for 6 months? This sounds like a moral, absolutist statement you're making; like life is an art project, and the aim is to exercise some particular set of principles. (Free speech? What's the threat to free speech here? Is it the people spreading bullshit and conspiracy about Covid that's getting people killed?)
  - ixacto 6y ago
    Because I don't trust the federal and state governments to act in my best interests. This is not too say that some are acting in the best interests of the people as I am sure some in government do mean well, but not to blindly trust that the government knows best about our public helath. China/Vietnam have stopped covid, that's great but you can't exercise many of the freedoms that are allowed here. Imagine if someone tried to fly a baby Xi balloon in China, or even practice a religion without fearing persecution or death? Or even mention tiananmen square massacre or the death toll from the Great Leap Forward... That is still going on and yet we are looking to China style lockdowns as a model of how to deal with Covid.

ajknvf 6y ago

There are a lot of comments that are kind of close to right but missing context here. This is extremely common, and like all of prehospital care is heavily protocol driven. Dead people encountered by EMS / public safety are a much larger superset than those typically "saved" in a hospital setting, and those that meet the criteria to either stop, or not begin resuscitation really have no reason to be transported. The link below is an example of EMS protocols that would cover this. Here's a snippet. "Discontinuation of Prehospital Resuscitation" 1. Discontinuation of CPR and ALS intervention may be implemented prior to contact with Medical Control if ALL of the following criteria have been met: Patient must be 18 years of age or older, or family of a minor is agreeable after consultation with the APP or District Chief. Adequate CPR has been administered. Airway has been successfully managed with verification of device placement. Acceptable management techniques include orotracheal intubation, nasotracheal intubation, Blind Insertion Airway Device (BIAD) placement, or cricothyrotomy. IV or IO access has been achieved. Rhythm appropriate medications and defibrillation have been administered according to protocol. Persistent asystole or agonal rhythm is present and no reversible causes are identified after a minimum of 25 minutes of resuscitation. Failure to establish sustained palpable pulses or to establish persistent/recurring ventricular fibrillation/tachycardia or lack of any continued neurological activity such as eye opening or motor responses All EMS paramedic personnel involved in the patient’s care agree that discontinuation of the resuscitation is appropriate 2. If all of the above criteria are not met and discontinuation of pre-hospital resuscitation is possibly indicated or desired, contact Medical Control. 3. The Deceased Subjects Policy should be followed. http://www.wakegov.com/ems/medical/Documents/WCEMSS%20Standards%20Practice%202020%2012.11.20.pdf http://www.wakegov.com/ems/medical/Documents/WCEMSS%20Standa...

herdrick 6y ago

I can't believe they're rationing oxygen. I administered welding oxygen to my girlfriend every day for about 6 weeks when she had Covid. It's cheap, easy, and perfectly safe. I assumed that when things got bad someone would just suspend the regulation requiring medical certified oxygen.

kenhwang 6y ago
From what I've read, its a hospital infrastructure problem, not a material shortage problem. The pipes that deliver oxygen to the machines can't deliver oxygen any faster because they're freezing up from the amount of oxygen being used.
- herdrick 6y ago
  You would carry it into patients' rooms and ambulances in tanks.
  - kenhwang 6y ago
    There's also a shortage of said tanks. https://www.latimes.com/california/story/2020-12-29/oxygen-supply-shortages-bedevil-hospitals-already-overwhelmed-by-covid-19-patients https://www.latimes.com/california/story/2020-12-29/oxygen-s...
    - herdrick 6y ago
      Welding tanks are different, and not in shortage.
philjohn 6y ago
That struck me as odd as well, although, there could indeed be a shortage. In UK hospitals it's not so much that there's a shortage, but the oxygen distribution network/lines in hospitals aren't sized for the number of patients requiring it.

jessriedel 6y ago

I'm disappointed that all the discussion seems to be operating at a non-quantitative level. ("If there's any chance, we have to try" against "If circulation can't be reestablished on scene, there's essentially no hope".) Presumably there are academic article that make an attempt at this.

schwartzworld 6y ago
People overestimate the efficacy of CPR because they see people in the movies come back to life after 4 chest compressions and a second of mouth-to-mouth. I wonder if that is the sort of thing driving the discussion
- ajknvf 6y ago
  That's likely part of it. Unwitnessed cardiac arrests and those where no electrical activity is present in the heart are pretty rare to get back. Cold temperature and submersion in water are two neat caveats though. They can be viable a lot longer, in part due to the Diving reflex. https://en.wikipedia.org/wiki/Diving_reflex https://en.wikipedia.org/wiki/Diving_reflex
- jessriedel 6y ago
  I've spent some time in hospitals and I don't overestimate the <1% efficacy, but I'm still frustrated by the innumeracy of the discussion. There are biases in the other direction: medical professionals who watch 100 people die for every 1 saved become desensitized to death and round that to zero. They're not economists, and they don't understand the statistical value of life implies it's worth spending $20,000 for just a 0.3% of survival.

RickJWagner 6y ago

I can't imagine the incredible agony of being the EMT who has to decide if someone gets a ride or not. Covid is horrible in so many ways.

covid21 6y ago

Is there a site that shows statistics (over time) of hospital capacity over time in LA? It sounds to me like one of the typical articles that tries to induce panic without actually providing much information or context. Whenever I see such articles here in Germany, I go to the official statistics for ICUs, and inevitably it always turns out to be bullshit. Some of the things that are hyped to be a consequence of Covid also turn out to be seasonal, even shortage of oxygen does not seem to be unusual. This is the German site I refer to: https://www.intensivregister.de/#/aktuelle-lage/zeitreihen https://www.intensivregister.de/#/aktuelle-lage/zeitreihen

cactus2093 6y ago
So you won’t be satisfied until people are literally dropping dead in front of you, huh?
- covid21 6y ago
  What makes you think that? Quit the bullshit.
  - dang 6y ago
    We've banned this account for repeatedly breaking the site guidelines. Could you please not create accounts to do that with? We're trying for a different kind of site here. https://news.ycombinator.com/newsguidelines.html https://news.ycombinator.com/newsguidelines.html
- dang 6y ago
  This comment breaks the site guidelines badly. Would you mind reviewing them and sticking to the rules when posting here? Note these ones: "Please respond to the strongest plausible interpretation of what someone says, not a weaker one that's easier to criticize. Assume good faith." "Comments should get more thoughtful and substantive, not less, as a topic gets more divisive." https://news.ycombinator.com/newsguidelines.html https://news.ycombinator.com/newsguidelines.html

cactus2093 6y ago

I still cannot comprehend why we had to let it go this far. Why have all measures in California been completely voluntary this whole time? I can get a ticket if I jaywalk or leave my car parked somewhere for too long, but if I walk into a Walmart with no mask on and start yelling at everyone in the store potentially exposing dozens of people to covid I’ll just get politely escorted out with no penalties. Something so ridiculously simple we could have started with is just ticketing for not wearing a mask in public. If we needed to ratchet it up further, ticketing gatherings with people outside the same household, which is obviously more difficult to enforce but just start with the ones that happen in public. Maybe do a “see something, say something” campaign to encourage people to report private gatherings they see in their neighborhoods and police come and break up gatherings and give tickets. What we’ve been doing instead with all these ever-changing vague optional guidelines is just so stupid. Either leave everything open, or actually enforce the so-called “orders”.

cosmiccatnap 6y ago

It's almost like things related to healthcare shouldn't be privatised because then their interests are directly related to profit as are their disinterest such as the lives of soon to be unemployed (see: deceased persons) revenue streams (see: human beings)