> “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.”
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.
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.
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.
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.
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.
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.
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?
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.
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).
> 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.
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.
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.
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.
I'm not in the US. But it seems like a public public policy question in the US as well - if any of the reports on the web are accurate, at least.
I would like to hear from you how does a unconscious person decide. The family decides for them, no? That's my assumption, so that's why I am talking about people's grandmothers.
> I would like to hear from you how does a unconscious person decide. The family decides for them, no?
I'm not sure why you think this is a rebuttal to anything I said--you're the person who said: "The point is that you can't decide for others". Is your grandmother not an other you're deciding for?
Ideally, the way an unconscious person decides is by deciding before they're unconscious and writing it down in a living will. Since you've said, "I know she wishes to at least try", ostensibly your grandmother has at least told you her what she wants verbally.
But absent that, I don't believe that "you can't decide for others" because de facto many families are put in the position where they do decide for others--their loved ones who didn't leave any indication of what they wanted in these sorts of situations.
My objection isn't to you bringing up grandmothers. My objection is to you framing it in a one-sided way, like, "So, if that was your grandmother and you had a choice of giving her a 10% chance, you wouldn't?" That doesn't acknowledge the fact that there are lots of very good reasons why one might consider not giving their grandmother an extra 10% chance of living in a difficult situation.
Well what I meant by others was unrelated/unknown people, especially politicians deciding about "numbers". Sorry I worded it wrong, I am used to seeing a family as a singular unit. There definitely are people who do not want to try and my goal is not to force treatment on them, but to not allow others (see above) to prevent them from getting that treatment.
Okay, but as far as I know, nobody wants to prevent people from getting life extension treatment if they want it. So I'm not sure why you felt you had to make that point.
And again, you said:
> So, if that was your grandmother and you had a choice of giving her a 10% chance, you wouldn't?
That's a pretty odd way of "wording it wrong", if what you intended to say was "Families should make the choice, not governments."
I was answering to people saying that because the chance is only 10% then maybe it's not worth it, and that's why I made that point, I don't understand why are you talking about some unrelated life extension stuff, this is infectious disease and its treatment. I wanted to personalize it because then it's harder to say no compared to talking about abstract dehumanized numbers, or unknown and unrelated people (from policy maker perspective); and I thought it's obvious that "do not treat" should be respected. English is not my native language, I will do better next time.
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.
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.
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.
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.
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.
I won't argue with you on the nature of the disease because I simply don't know enough about it, but that's sort of irrelevant to my point.
My point isn't that people should never be put on ventilators.
My point is that the decision to ventilate or not isn't just based on whether it increases the chances of survival. You need to also look at the suffering it causes.
It may be that, as you're claiming, it doesn't cause more suffering, so in that case it makes sense to give it a try. I'm more inclined to think that that question needs to be asked on a case by case basis, however.
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.
I 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!?
The 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.
The 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.
The 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....
My prior is that a similar number of units will wind up back on that market once demand picks back up. Demand might not pick back up, or Airbnb hosts might be more cautious in the future about going all in on Airbnb, but if people want Airbnbs, the market will probably provide them.
I’m sure some people will want to buy up units for dedicated short term rentals, but the question is whether they’ll be allowed to. The politics of this has been discussed to death, but I can’t help but wonder if banks will be unwilling to allow their borrowers to get quite so heavily leveraged going forward in the short term rental space.
The effect, whether large or small, will be much greater to Medicare than Social Security. Nursing homes residents are far more exposed than the general retired population.
If managed, not many will die or be scarred from this virus. The latter might be a large liability if left uncontrolled. No country let this spread uncontrolled as of yet. Some country lockdown too late, and do later full shutdown.
This pandemic is like an individual getting sick, but now it's the world. It's a massive opportunity to redefine what life on earth is supposed to be and gain clarity to unlock new creative potentials. Individuals do this routinely after shocks, so the same is available to the collective.
Your comment comes across as repulsive because it seems you believe the following:
1) People with conditions like diabetes are a burden, and having fewer of them will save us money.
2) The housing crisis is caused by overpopulation, not by perverse incentives or inequality of opportunity.
3) Younger people create more economic output.
4) You are excited about all of this -- specifically, about all of these people dying.
Sick people are not weak sheep in a herd. You have no idea what their net output or effect on society is. Many of the dead are talented doctors or nurses who had asthma or asymptomatic heart issues.
If you're excited about hundreds of thousands of people dying, keep it to yourself. Many of the rest of us will lose loved ones before this is over.
> Many of the dead are talented doctors or nurses who had asthma or asymptomatic heart issues.
Many of them are, but most of them aren't. This isn't a pleasant subject, but when you're talking about events at this scale, general trends count for something. I'm growing pretty weary of the moral grandstanding in these conversations.
Are you saying that I am morally grandstanding myself? Maybe so, but I'm not claiming to be "repulsed" nor claiming that people are acting "immoral and insane", as others in this conversation are. I have made an attempt to express my feelings using mild language.
If your point is that I shouldn't engage with people who make me weary, maybe your right, and maybe I shouldn't bother responding to you either. On the other hand, perhaps responding calmly might move the needle of the conversation back towards the civil, if only slightly.
The latter. If you are aware that a specific subject only results in you being regarded as immoral, it is likely impossible to be perceived as “civil” regardless of what words you use to express yourself.
I don't understand your 4th conclusion at all. He never once said he's excited, you are assuming quite a lot...
People are allowed to analyze world events and their consequences like this without having to individually pander to everyone who was personally affected.
This is like yelling at someone for analyzing the effect of WW2's aftermath on Europe.
> I don't understand your 4th conclusion at all. He never once said he's excited, you are assuming quite a lot...
It was the combination of the unnecessary exclamation marks and the lack of speculation that people dying is bad. All of the speculation was about the people being bad for the economy, and how things may get better when they're gone.
> This is like yelling at someone for analyzing the effect of WW2's aftermath on Europe.
OK, let's run with your analogy. What if someone wrote the following:
After WW2, will the tax burden of education young men suddenly go down!?
Will we see better classroom ratios because so many young people have died!?
Will hospitals have more space because the population is lower!?
It's theoretically valid speculation, but it's also only representing the positive side of millions of deaths.
You have packed a lot of assumed motivations into that reply. We have but this to go on:
"I wonder what effect it will have on future of the countries."
Though you might find it repulsive, I have no problem thinking out loud about the possible outcomes.
You are excited about all of this
You have no idea what the parent's mental state is on this, and of the possible interpretations, you have chosen the least charitable one. Moral grandstanding might best be left "<kept> to yourself" as well.
Thanks for saying this. Since 3 others are criticizing you for the same reasons I'll just reply directly to you.
You can take smt88's reply as language criticism or moral criticism. The use of !? in two out of four paragraphs in econcon's post certainly implies excitement, and choosing only to focus on the "positive silver linings" certainly sends a particular message.
I'm sure there's a way to talk sensibly about this very cynical speculation of what might happen to society in a pandemic like this, but econcon's way of phrasing it is not the way. If the language of a post sends a certain message about the underlying morals of the post, I see no reason not to start criticizing that.
The use of !? in two out of four paragraphs in econcon's post certainly implies excitement
You claim insight into another's mind based on colloquial use of punctuation marks!? "Forensic grammarian here, let me take a look...yup, it is clear that they are excited for people to die." Seriously lame. To support my point, I'll point out that I most usually use "!?" as a WTF indicator, or other expression of surprise or disgust. To my recollection, not once have I used it to indicate positive excitement. 'cuz there ain't no style guide on using "!?".
But, man, someone really, really wants to get butt-hurt over that comment, all other indicators be damned.
This is a very immoral and insane way of looking at this problem. Supposedly dispassionate, "rational," mathematical economics has wreaked havoc just because it focuses on numbers and output and forgetting that we are dealing with humans who have feelings and people they love and who love them.
You comment is so extremely apathetic and reeks of eugenic desires. Everyone grows old, no one is born with the same chances as everyone else, we are all people of the earth.
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’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?
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.
> 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.
the 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.
The 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.
Kids don't get infected - is that due to contact tracing?
Epidemiologists are just as confused here as anyone else. They have never seen anything like this disease, there is no data, there is no evidence to anything claimed here. You can't compare to any epidemics before.
The best evidence is the absurd statements by epidemiologists at CDC yesterday:
1. It is extremely important to maintain social distancing to save lives!
2. The next wave in the winter might be much worse due to the current social distancing that will be pushing many of the vulnerable into the winter months where the risks of coinfections are higher.
Uhh? What? Do you see the absurdity in these statements? They make no sense, as if they had no idea what to do.
> Epidemiologists are just as confused here as anyone else. They have never seen anything like this disease, there is no data, there is no evidence to anything claimed here.
Of course they have! There are a lot of coronaviruses. And we already have experience with SARS and MERS. Obviously this isn't exactly the same but suggesting that epidemiologists don't know any more than the rest of us commenting in Hacker News is absolutely absurd.
We don't all get to be experts on this just because we've decided that we're clever. Or maybe we should all be burning down 5G masts as well, after all, who knows?
what you are doing is a classic fallacy, you take an absurd example and equate my opinion to that. What's 5G got to do with it?
Neither SARS or MERS are even remotely similar to COVID-19. The mechanisms are different, the spread is different etc.
I have also never stated an epidemiologists knows as much as an average hacker news reader.
What I said they are just as confused and unable to decide what is right or wrong and what the right course of action is. That is a completely different statement.
I note how you never addressed the obviously contradictory statements by the CDC.
> Neither SARS or MERS are even remotely similar to COVID-19.
Again, you have absolutely zero authority to make that statement, unless you forgot to mention that you are an infectious disease specialist. Same with “children can’t be infected”, in your reply you’re making statements about what “you would” do but do you have any data showing that children are being tested at the same rate as adults?
We could spend forever in a back and forth over things like CDC statements (which aren’t contradictory, but whatever) but it would just be dancing around the central point: you don’t know. You aren’t qualified to speak about it authoritatively. If an epidemiologist tried to weigh in on and online debate about the merits of Rust vs Go I’d say the same thing, but luckily for us they don’t.
Having an opinion on things is just fine, but this thread (I’m not singling you out here) is full of authoritative statements with no scientific basis.
> you take an absurd example and equate my opinion to that. What's 5G got to do with it?
The only reason it’s absurd is because you and I both know enough about 5G to know that the idea of it spreading COVID-19 is silly. How can you be confident that the assumptions you’re making aren’t equally absurd to an epidemiologist?
I have read numerous scientific papers on both SARS, MERS and
COVID-19. It is pretty clear that the diseases are not similar at all. (SARS - MERS yes, SARS - COVID no). Are seriously claiming that scientist consider the diseases similar? They don't.
On the CDC statements I don't get what your point is. These are statements by the CDC to the population.
In the first they want people to tighten the lockdown. In the second they predict that tighter regulations will lead to more deaths in the winter.
There is no interpretation there, this is what they announced to the public. The two statements together make no sense. Notably you say "I could spend forever on back and forth" but you don't offer anything - and perhaps the CDC statements should not be like that. The statements are so because as I said along, the CDC are also confused and unsure what to right course of action is.
most likely not, considering the agressive testing of contacts, the first person you would test are the family members, yet only 3% of cases are for people under 18
A small number of other countries with well organized governments, good epidemic response teams, manageably small populations and strong IT infrastructure.
Now imagine all of this being done effectively in a country with several hundred million people, many of them extremely (and not entirely unjustifiably) opposed to privacy invasions and mistrustful of their government in many ways. That's the U.S I speak of in case it's not obvious.
Now go a bit further and imagine this same mass testing and contact tracing procedure in the majority percentage of the wider world that actively lacks good government, good administration, has terrible infrastructure (clinical especially but of any kind in general) and is largely poor. It doesn't require an epidemiology degree to see the difficulties.
I can't even easily imagine the mechanics of effective mass testing and contact tracing in places like India, Latin America or large parts of Africa, with hundreds of millions of barely documented residents living lives steeped in informality.(I live in Latin America and have actually seen how poorly government in my country manages even basic testing)
It's good that testing and contact tracing are attempted where possible and continued wherever they work, but let's be realistic about the fact that a majority of the world outside these places will drive the dynamics of the virus with a social weight well beyond that of the minority population of regions where the above work, and in that same majority part of the world, mass testing and contact tracing have very little chance of effectively being applied.
In essence, remember that most people don't live in the well-structured bubbles of small European and Asian states with relatively efficient, modern administrations.
- all of these things slow down our progress in studying the real answer
...without absolutely any evidence to back it up, or with any kind of disclaimer attached. In an environment where people are literally burning down cellphone masts because they think it's giving them COVID I don't think it's unreasonable to ask someone making such strident assertions where they're getting their conclusions from.
That the ventillators are not useful is stated in the top post.
That our progress is slowed down because of the measures is also obvious and evident. The whole world is slowed down, why would you think research is not?
As for contact tracing - if you think it a bit through and consider all the possible problems with both performing and enforcing it - not to mention the asymptomatic carriers and the windows of time in which that even makes sense to do it simply appears to be unfeasible.
Not to mention that it is an approach that no one has ever tried to do before at this scale. Saying that the we will scale up a process in the US to a national level in a few months is absurd.
I am simply pointing out that it is very unlikely that it would work and perhaps resources should be spent elswhere.
"The only rational solution is finding improvements in therapeutics. The solution is not to keep people from getting infected, but to keep people from dying of the diseases. And that is a far closer and more achievable goal than any other."
Regarding this point: what improved therapeutics have you seen arise? Is a ventilator a therapeutic?
not putting people on ventilators actually improved their chances, having people face down, or rotating them regularly improves their chances, and of course the myriad other important medical decisions that are made
hospitalization rates are actually going down, even where cases and deaths are the same
>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.
Barring that more evidence be supplied for that point, I can counterbalance it by saying, "contract tracing will be amazing because large-scale social distancing will push the case count down to a level where it is feasible. Quick cheap and accurate tests are coming soon and will make it even easier. The whole economy will be able to go back to normal in a couple months." Do I know if that's true? No, but I don't know if the above claim is true either.
this is a fallacy because it equates the chances for something working to that of not working. We all know how complex process tend to turn out.
If someone claims to write a brand new e-commerce website that serves the entire United States and rivals Amazon in just three months. Would you consider that a realistic promise? Would only devops and programmers have sufficient expertise to express valid concerns on its feasibility?
There may be a general pessimism appropriate for anything complicated, but predicting the outcome of a complicated thing is complicated, which means that we should be pessimistic about the reliability of pessimistic predictions.
> The next such fallacy is that of testing and contact tracing
That is an odd opinion. Australian and NZ and some other relatively successful countries are well past flattening the curve and have both new cases and active cases rapidly heading towards zero and have only had a small number of deaths.
Most retail is open here. Most schools are open. Lots of job losses in hospitality and tourism with bars and restaurants closed and borders shut. Testing is freely available to anyone with any cold-like symptom at all and I expect that testing will be extended to people with no symptoms at all, probably in teaching, law enforcement and healthcare so we have a sort of early warning system.
We seem to have a reasonable path back to being a productive society while other countries still seem a mess and are only managing to keep their death rates down through massive restrictions. I struggle to understand what the rest of the world is going on about sometimes. Experts have been saying how to deal with a problem like this for a long time. But nobody much seems to have taken them seriously.
An 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.
Using 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
That'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.
I 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.
There 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.
I 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.
HANG 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.
Additionally 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.
This 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.
I 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?
> 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.
Another 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.
Ideally 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.
Even 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.
Please 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.
Germany 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.
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[ 3.2 ms ] story [ 140 ms ] threadI'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.
[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).
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
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-planni...
https://compassionindying.org.uk/library/
Two can play the "appeal to grandmother" game, but I'd rather just discuss this based on the facts.
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.
I would like to hear from you how does a unconscious person decide. The family decides for them, no? That's my assumption, so that's why I am talking about people's grandmothers.
I'm not sure why you think this is a rebuttal to anything I said--you're the person who said: "The point is that you can't decide for others". Is your grandmother not an other you're deciding for?
Ideally, the way an unconscious person decides is by deciding before they're unconscious and writing it down in a living will. Since you've said, "I know she wishes to at least try", ostensibly your grandmother has at least told you her what she wants verbally.
But absent that, I don't believe that "you can't decide for others" because de facto many families are put in the position where they do decide for others--their loved ones who didn't leave any indication of what they wanted in these sorts of situations.
My objection isn't to you bringing up grandmothers. My objection is to you framing it in a one-sided way, like, "So, if that was your grandmother and you had a choice of giving her a 10% chance, you wouldn't?" That doesn't acknowledge the fact that there are lots of very good reasons why one might consider not giving their grandmother an extra 10% chance of living in a difficult situation.
And again, you said:
> So, if that was your grandmother and you had a choice of giving her a 10% chance, you wouldn't?
That's a pretty odd way of "wording it wrong", if what you intended to say was "Families should make the choice, not governments."
[1] https://journals.plos.org/plosone/article?id=10.1371/journal...
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.
My point isn't that people should never be put on ventilators.
My point is that the decision to ventilate or not isn't just based on whether it increases the chances of survival. You need to also look at the suffering it causes.
It may be that, as you're claiming, it doesn't cause more suffering, so in that case it makes sense to give it a try. I'm more inclined to think that that question needs to be asked on a case by case basis, however.
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.
Oxygen can be done at home. And would reduce infections too.
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!?
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.
This pandemic is like an individual getting sick, but now it's the world. It's a massive opportunity to redefine what life on earth is supposed to be and gain clarity to unlock new creative potentials. Individuals do this routinely after shocks, so the same is available to the collective.
1) People with conditions like diabetes are a burden, and having fewer of them will save us money.
2) The housing crisis is caused by overpopulation, not by perverse incentives or inequality of opportunity.
3) Younger people create more economic output.
4) You are excited about all of this -- specifically, about all of these people dying.
Sick people are not weak sheep in a herd. You have no idea what their net output or effect on society is. Many of the dead are talented doctors or nurses who had asthma or asymptomatic heart issues.
If you're excited about hundreds of thousands of people dying, keep it to yourself. Many of the rest of us will lose loved ones before this is over.
Many of them are, but most of them aren't. This isn't a pleasant subject, but when you're talking about events at this scale, general trends count for something. I'm growing pretty weary of the moral grandstanding in these conversations.
If your point is that I shouldn't engage with people who make me weary, maybe your right, and maybe I shouldn't bother responding to you either. On the other hand, perhaps responding calmly might move the needle of the conversation back towards the civil, if only slightly.
I think english is not the OP's first language and I believe they were (perhaps unwittingly clinically) discussing long term impacts and trends.
How you interpreted this as some sort of gleeful desire to watch old/sick people die speaks more of you than them.
People are allowed to analyze world events and their consequences like this without having to individually pander to everyone who was personally affected.
This is like yelling at someone for analyzing the effect of WW2's aftermath on Europe.
It was the combination of the unnecessary exclamation marks and the lack of speculation that people dying is bad. All of the speculation was about the people being bad for the economy, and how things may get better when they're gone.
> This is like yelling at someone for analyzing the effect of WW2's aftermath on Europe.
OK, let's run with your analogy. What if someone wrote the following:
After WW2, will the tax burden of education young men suddenly go down!?
Will we see better classroom ratios because so many young people have died!?
Will hospitals have more space because the population is lower!?
It's theoretically valid speculation, but it's also only representing the positive side of millions of deaths.
Though you might find it repulsive, I have no problem thinking out loud about the possible outcomes.
You are excited about all of this
You have no idea what the parent's mental state is on this, and of the possible interpretations, you have chosen the least charitable one. Moral grandstanding might best be left "<kept> to yourself" as well.
You can take smt88's reply as language criticism or moral criticism. The use of !? in two out of four paragraphs in econcon's post certainly implies excitement, and choosing only to focus on the "positive silver linings" certainly sends a particular message.
I'm sure there's a way to talk sensibly about this very cynical speculation of what might happen to society in a pandemic like this, but econcon's way of phrasing it is not the way. If the language of a post sends a certain message about the underlying morals of the post, I see no reason not to start criticizing that.
You claim insight into another's mind based on colloquial use of punctuation marks!? "Forensic grammarian here, let me take a look...yup, it is clear that they are excited for people to die." Seriously lame. To support my point, I'll point out that I most usually use "!?" as a WTF indicator, or other expression of surprise or disgust. To my recollection, not once have I used it to indicate positive excitement. 'cuz there ain't no style guide on using "!?".
But, man, someone really, really wants to get butt-hurt over that comment, all other indicators be damned.
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.
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.
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.
Except that other countries have documented success with this. Are you an epidemiologist?
Oh, the movie sucked? Are you a professional movie critic? Have you ever directed a movie?
Oh, incarceration rates are unfair? Are you a lawyer? Have you committed a crime? No? How could you possibly know.
Bailing out a bank is unethical? Are you working in the financial industry? No, how could you know what is fair.
Epidemiologists are just as confused here as anyone else. They have never seen anything like this disease, there is no data, there is no evidence to anything claimed here. You can't compare to any epidemics before.
The best evidence is the absurd statements by epidemiologists at CDC yesterday:
1. It is extremely important to maintain social distancing to save lives!
2. The next wave in the winter might be much worse due to the current social distancing that will be pushing many of the vulnerable into the winter months where the risks of coinfections are higher.
Uhh? What? Do you see the absurdity in these statements? They make no sense, as if they had no idea what to do.
Of course they have! There are a lot of coronaviruses. And we already have experience with SARS and MERS. Obviously this isn't exactly the same but suggesting that epidemiologists don't know any more than the rest of us commenting in Hacker News is absolutely absurd.
We don't all get to be experts on this just because we've decided that we're clever. Or maybe we should all be burning down 5G masts as well, after all, who knows?
Neither SARS or MERS are even remotely similar to COVID-19. The mechanisms are different, the spread is different etc.
I have also never stated an epidemiologists knows as much as an average hacker news reader.
What I said they are just as confused and unable to decide what is right or wrong and what the right course of action is. That is a completely different statement.
I note how you never addressed the obviously contradictory statements by the CDC.
Again, you have absolutely zero authority to make that statement, unless you forgot to mention that you are an infectious disease specialist. Same with “children can’t be infected”, in your reply you’re making statements about what “you would” do but do you have any data showing that children are being tested at the same rate as adults?
We could spend forever in a back and forth over things like CDC statements (which aren’t contradictory, but whatever) but it would just be dancing around the central point: you don’t know. You aren’t qualified to speak about it authoritatively. If an epidemiologist tried to weigh in on and online debate about the merits of Rust vs Go I’d say the same thing, but luckily for us they don’t.
Having an opinion on things is just fine, but this thread (I’m not singling you out here) is full of authoritative statements with no scientific basis.
> you take an absurd example and equate my opinion to that. What's 5G got to do with it?
The only reason it’s absurd is because you and I both know enough about 5G to know that the idea of it spreading COVID-19 is silly. How can you be confident that the assumptions you’re making aren’t equally absurd to an epidemiologist?
I have read numerous scientific papers on both SARS, MERS and COVID-19. It is pretty clear that the diseases are not similar at all. (SARS - MERS yes, SARS - COVID no). Are seriously claiming that scientist consider the diseases similar? They don't.
On the CDC statements I don't get what your point is. These are statements by the CDC to the population.
In the first they want people to tighten the lockdown. In the second they predict that tighter regulations will lead to more deaths in the winter.
There is no interpretation there, this is what they announced to the public. The two statements together make no sense. Notably you say "I could spend forever on back and forth" but you don't offer anything - and perhaps the CDC statements should not be like that. The statements are so because as I said along, the CDC are also confused and unsure what to right course of action is.
Now imagine all of this being done effectively in a country with several hundred million people, many of them extremely (and not entirely unjustifiably) opposed to privacy invasions and mistrustful of their government in many ways. That's the U.S I speak of in case it's not obvious.
Now go a bit further and imagine this same mass testing and contact tracing procedure in the majority percentage of the wider world that actively lacks good government, good administration, has terrible infrastructure (clinical especially but of any kind in general) and is largely poor. It doesn't require an epidemiology degree to see the difficulties.
I can't even easily imagine the mechanics of effective mass testing and contact tracing in places like India, Latin America or large parts of Africa, with hundreds of millions of barely documented residents living lives steeped in informality.(I live in Latin America and have actually seen how poorly government in my country manages even basic testing)
It's good that testing and contact tracing are attempted where possible and continued wherever they work, but let's be realistic about the fact that a majority of the world outside these places will drive the dynamics of the virus with a social weight well beyond that of the minority population of regions where the above work, and in that same majority part of the world, mass testing and contact tracing have very little chance of effectively being applied.
In essence, remember that most people don't live in the well-structured bubbles of small European and Asian states with relatively efficient, modern administrations.
- ventilators are useless
- testing and contact tracing will be useless
- all of these things slow down our progress in studying the real answer
...without absolutely any evidence to back it up, or with any kind of disclaimer attached. In an environment where people are literally burning down cellphone masts because they think it's giving them COVID I don't think it's unreasonable to ask someone making such strident assertions where they're getting their conclusions from.
That our progress is slowed down because of the measures is also obvious and evident. The whole world is slowed down, why would you think research is not?
As for contact tracing - if you think it a bit through and consider all the possible problems with both performing and enforcing it - not to mention the asymptomatic carriers and the windows of time in which that even makes sense to do it simply appears to be unfeasible.
Not to mention that it is an approach that no one has ever tried to do before at this scale. Saying that the we will scale up a process in the US to a national level in a few months is absurd.
I am simply pointing out that it is very unlikely that it would work and perhaps resources should be spent elswhere.
Regarding this point: what improved therapeutics have you seen arise? Is a ventilator a therapeutic?
hospitalization rates are actually going down, even where cases and deaths are the same
Barring that more evidence be supplied for that point, I can counterbalance it by saying, "contract tracing will be amazing because large-scale social distancing will push the case count down to a level where it is feasible. Quick cheap and accurate tests are coming soon and will make it even easier. The whole economy will be able to go back to normal in a couple months." Do I know if that's true? No, but I don't know if the above claim is true either.
If someone claims to write a brand new e-commerce website that serves the entire United States and rivals Amazon in just three months. Would you consider that a realistic promise? Would only devops and programmers have sufficient expertise to express valid concerns on its feasibility?
The whole point is to buy time. That's what "flatten the curve" means.
I don't understand why you think any of this would slow down progress of studying the disease at all.
That is an odd opinion. Australian and NZ and some other relatively successful countries are well past flattening the curve and have both new cases and active cases rapidly heading towards zero and have only had a small number of deaths.
Most retail is open here. Most schools are open. Lots of job losses in hospitality and tourism with bars and restaurants closed and borders shut. Testing is freely available to anyone with any cold-like symptom at all and I expect that testing will be extended to people with no symptoms at all, probably in teaching, law enforcement and healthcare so we have a sort of early warning system.
We seem to have a reasonable path back to being a productive society while other countries still seem a mess and are only managing to keep their death rates down through massive restrictions. I struggle to understand what the rest of the world is going on about sometimes. Experts have been saying how to deal with a problem like this for a long time. But nobody much seems to have taken them seriously.
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
[0] - https://mobile.twitter.com/cameronks
[1] - https://www.youtube.com/watch?v=NmRlvX3VrAQ
Where I heard this:
https://science.slashdot.org/comments.pl?sid=16122794&cid=59...
https://www.statnews.com/2020/04/08/doctors-say-ventilators-...
[1] https://www.nytimes.com/2020/04/20/opinion/coronavirus-testi...
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.
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.
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.
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.