
What doctors on the front lines wish they’d known a month ago - prmph
https://www.nytimes.com/2020/04/14/nyregion/new-york-coronavirus.html
======
elric
Anecdata: I distinctly remember spending a lot of time lying on my stomach in
hospital beds during several stints of double pneumonia I experienced as a
child, some 30 years ago. It's hard to imagine that front line doctors didn't
know about proning a month ago.

Is this a technique that went out of vogue since my childhood, only to be
replaced with a reliance on sedation and ventilators, and is it making a
comeback due to the lack of ventilators?

Or it it because proning unconscious, intubated patients is hard work and
requires three nurses? I can imagine that being difficult to do when your ICU
is swamped. Here's what that looks like:
[https://www.youtube.com/watch?v=E_6jT9R7WJs](https://www.youtube.com/watch?v=E_6jT9R7WJs)

~~~
the_mitsuhiko
> It's hard to imagine that front line doctors didn't know about proning a
> month ago.

Where do you get the idea they didn’t?

~~~
coldtea
Because there were several articles implying so...

[https://edition.cnn.com/2020/04/14/health/coronavirus-
prone-...](https://edition.cnn.com/2020/04/14/health/coronavirus-prone-
positioning/index.html)

------
carbocation
This is a perplexing article. Prone ventilation has been known to reduce
_mortality_ in severe ARDS from randomized, controlled trials for almost a
decade[1].

Proning is great! It keeps people alive. We are doing a lot of it. It's not
new.

1 =
[https://www.nejm.org/doi/full/10.1056/NEJMoa1214103](https://www.nejm.org/doi/full/10.1056/NEJMoa1214103)

~~~
SilasX
Okay but then how is that something "they wish they knew" a month ago? They
didn't know then?

~~~
carbocation
That's why I'm perplexed. It comes across as trying to make something more
dramatic than it already is. (And, I mean, hospitals being full of patients
with a novel disease is already sufficiently dramatic.)

~~~
SilasX
Sorry, I misread you, we're in agreement there. I think it's partly an issue
of journalists wanting to make their stuff more clickbaity than it deserves to
be.

------
dmurray
> “You put a tube into somebody,” Dr. Levitan said, “and the amount of work
> required not to kill that person goes up by a factor of 100,” creating a
> cascade that slows down laboratory results, X-rays and other care.

I'd hope this could be a generally applicable lesson after the pandemic. In
less overwhelming times, the medical best practice is once someone is in
hospital, prescribe the statistically best treatment even if it costs 100
times as much in resources and manpower. Now they go for simpler treatments
because the resources aren't available to support the others, at least when
the benefit is marginal.

But hospital resources are always stretched to the limit in some way. If you
can treat a patient with 100x less intervention from doctors and nurses, you
can instead treat 100x more patients, or build 100x more hospitals, or spend
some of your hospital money on public health initiatives, all of which would
improve overall health outcomes.

~~~
dmix
Using extreme scenarios to plan for normal life has long been the recipe for
bad policy.

This may make sense where hospital beds/ICU/medical professionals to capita
ratio is low such as in low income neighbourhoods and countries but otherwise
it’s mostly just useful for emergency planning.

The proper solution tends to be higher amounts of hospitals, mental health
centers, supplies, preparation for outbreaks, etc. The actual hard stuff.

Otherwise this mostly amounts to doctors trained to use a generalized but
dangerous hammer in worst case scenarios, in the face of what looks like a
terribly difficult situation with no other solutions, and finding out more
refined soft procedures like proning and flipping people on their sides works
better for certain types of epidemic viruses.

I’d be wary to practically apply this beyond the next viral epidemic.

~~~
ethbro
If you read through the Red Dawn email chain NYT pieced together through FOIA
requests [1], which gives an overview of initial professional thinking
(January / February), there's a great insight in the first few emails.

No other emergency grows exponentially.

Nuclear detonation, dirty bomb, power outage, hurricane, tainted food, etc. At
worst they grow linearly at a high rate.

Consequently, highly contagious pandemic response must be fundamentally unlike
any other response.

There are references to this bearing out in their prior wargaming of
scenarios. All players (mistakenly) escalated linearly based on intuition.

When in reality you're talking about needing 10x resources every week, ceteris
paribus.

[1]
[https://int.nyt.com/data/documenthelper/6879-2020-covid-19-r...](https://int.nyt.com/data/documenthelper/6879-2020-covid-19-red-
dawn-rising/66f590d5cd41e11bea0f/optimized/full.pdf#page=1)

------
canada_dry
After watching this video [i] it seems like there's an opportunity here to
completely rethink/redesign of the related equipment. I.e. instead of a normal
bed, one that allows for a device to temporarily enclose the patient (like a
tanning bed) inflate like a blood pressure cuff, rotate/turn the patient, then
deflate and be removed for use on the next bed (i.e. the bed and rotating
machines are co-operative, but separate).

Also, the ventilator and assoc. monitors need to be redesigned such that
rotating the patient easily/automatically repositions the equipment with the
rotation.

[i] [https://youtu.be/E_6jT9R7WJs?t=65](https://youtu.be/E_6jT9R7WJs?t=65)

~~~
inamberclad
Rotating beds are already used with intubated patients quite frequently.

~~~
canada_dry
Example [i]. The issue is that the cost to equip care facilities with these
beds. My suggestion is to separate the rotating function such that a much less
expensive general purpose bed can be used.

[i] www.arjo.com/en-us/products/medical-beds/critical-care/rotoprone/

------
casefields
Mirror: [http://archive.md/maTHi](http://archive.md/maTHi)

~~~
huhtenberg

        Please enable cookies.
        Error 1001
        DNS resolution error

~~~
qilo
It's a known issue if you're using Cloudflare DNS servers. Here's explanation
from the Cloudflare CEO:
[https://news.ycombinator.com/item?id=19828702](https://news.ycombinator.com/item?id=19828702)

------
rasz
Since January leaks from Chinese health care warned about all of this. Was
there internet ban in US I was unaware of? Or a widespread belief in
exceptionalism?

~~~
shalmanese
It's not even leaks, it's included in the Official Coronavirus Treatment Plan:

"(4) Salvage therapy: for patients with severe ARDS, a recruitment maneuver is
recommended.

When human resources allow, prone ventilation should be carried out for 12
hours or more every day. "

[https://www.chinalawtranslate.com/coronavirus-treatment-
plan...](https://www.chinalawtranslate.com/coronavirus-treatment-
plan-7/?lang=en)

There's simply a shocking degree of arrogance from the West to refuse to learn
even the most basic things from Asia about this.

For example, people are finally grudgingly admitting that CT scans could play
a useful role in diagnostics after months of CDC & ACR denialism:
[https://www.statnews.com/2020/04/16/ct-scans-alternative-
to-...](https://www.statnews.com/2020/04/16/ct-scans-alternative-to-
inaccurate-coronavirus-tests/)

edit: More details in Jack Ma Foundation produced Handbook of COVID-19
Prevention and Treatment

(3) Prone Position Ventilation Most critically ill patients with COVID-19
respond well to prone ventilation, with a rapid improvement of oxygenation and
lung mechanics. Prone ventilation is recommended as a routine strategy for
patients with PaO/FiO2 < 150 mmHg or with obvious imaging manifestations
without contraindications. Time course recommended for prone ventilation is
more than 16 hours each time. The prone ventilation can be ceased once
PaO/FiO2 is greater than 150 mm Hg for more than 4 hours in the supine
position.

Prone ventilation while awake may be attempted for patients who have not been
intubated or have no obvious respiratory distress but with impaired
oxygenation or have consolidation in gravity-dependent lung zones on lung
images. Procedures for at least 4 hours each time is recommended. Prone
position can be considered several times per day depending on the effects and
tolerance.

[https://www.alibabacloud.com/universal-
service/pdf_reader?cd...](https://www.alibabacloud.com/universal-
service/pdf_reader?cdnorigin=video-intl&pdf=Read%20Online-
Handbook%20of%20COVID-19%20Prevention%20and%20Treatment.pdf)

~~~
carbocation
MGH is proning a bunch of awake patients (who have the physical strength to do
so) and about ~30% of our ventilated patients.

There is no "shocking degree of arrogance from the West" but there may be a
failure of adequate reporting, in this article and others, of what we are
doing in hospitals.

~~~
shalmanese
Except it's applied to literally every part of the Asian pandemic response
from masks to contact tracing. Asian countries have been saying for months
that there's not some magical technological solution to contact tracing, the
tech helps maybe 10%. The rest of it is just plain on the ground shoe leather
pounding, public communication and talking to people.

Watch as Western countries start discovering as they roll out their automated
contact tracing apps how little the tech plays a role in an effective contact
tracing system.

~~~
dkdk8283
Contact tracing is a severe invasion of privacy and just another tool to
increase surveillance. I will never submit to such measures.

~~~
shalmanese
Just so we're clear, can you explain succinctly the key details of how contact
tracing has been implemented in the various countries that have rolled it out
and which parts you object to?

There's a lot of parameters in the "design space" of contact tracing. If
you're objecting to simply the most extreme version of it, then duh, anyone
would, including the Chinese.

~~~
pastage
That is hard to answer can you anser what kind of contact tracing are you
missing in "the West", and what level of privacy invasion are you comparing it
against.

In the first stages of Corona we did a lot of old school contact tracing.

~~~
shalmanese
But this is what I mean when I say "shocking degree of arrogance from the West
to refuse to learn even the most basic things from Asia about this."

There's many different ways of doing contact tracing that involve myriad
tradeoffs. Every Asian country that has rolled it out has had negotiations
between the citizens and the government over the various dimensions and how to
balance between competing concerns (yes, even China). Every country has landed
in a slightly different form of contact tracing based on existing resources,
societal norms and degree of urgency.

It's shockingly arrogant to assume that Asian citizens haven't grappled
seriously with these issues and, even if they have landed in a different
position than you would prefer, that the conversations they're having don't
have any value.

I've yet to read a single English language piece on Asian contact tracing that
has accurately described how contact tracing works on the ground in a nuts and
bolts way across multiple countries. Instead, all I read are exoticised,
fetishized pieces that focus on technological bells and whistles or highlights
a bunch of theoretical privacy violations that either aren't a big deal in
practice or easily gotten around with some simple design tweaks.

Then, you get people who go off half cocked and make sweeping statements about
an entire category of methods while having done literally no research on how
it actually works in a real world context.

~~~
pastage
FWIW that is not my picture, but you are too unspecfic, you do not give any
accurate description either, and if there is no such info in "the west" how
can I be arrogant, ignorant maybe? The people who care about privacy do not
care about how things seem to work for the masses, what is important is the
edge cases of privacy.

That does not mean there are other voices in the West. But I do not know what
you are looking for, and what you think is bad information.

~~~
shalmanese
Just as a simple example, how do you enforce home quarantine? In Hong Kong,
they use a bluetooth bracelet, in Taiwan, they're using a combo of a cell
phone tower gate + requiring you to answer the phone and police checking on
you if you don't. In China, they have a hardware door sensor that will alert
authorities if it's opened. In South Korea, I think they're also using cell
phone tower gates.

Each approach has different pros & cons when it comes to privacy and
effectiveness. Which one specifically do people think is acceptable and
unacceptable?

------
killIdeas
Oxygen and laying prone is not exclusive to hospitals. I'm wondering if we can
get oxygen tanks ready for home use.

Reduce hospital load, reduce healthcare costs, get rid of the need to flatten
the curve.

(Waiting for a my job to begin, waiting for my son to get his surgery)

~~~
misja111
>> get rid of the need to flatten the curve.

This. A policy of flattening the curve will probably have to last for one or
two years until either a vaccine is found or there is enough herd immunity.
This will not only destroy our economy but the isolation will be a
psychological challenge for many as well.

We have to take one step back and think why we wanted to flatten the curve in
the first place. And that is because our hospitals don't have enough capacity.
So why don't we do something about that? IMO that, in combination with some
moderate curve flattening, is the only acceptable solution in the long term.

~~~
maxerickson
We have to smash the curve so that we don't need the hospital capacity.

It turns out that getting the number of infected down close to zero would also
be good for the economy.

I don't understand why so many people think that the best possible plan is for
everyone to get infected. The best possibilities involve a few percentage
points of the global population getting infected, no where near everyone.

~~~
irq11
This simply isn’t possible, and it’s a maddeningly irresponsible shifting of
the goalposts. The public was sold these extreme tactics on the basis of
preventing _excess_ deaths, not locking down society for years on end until
the virus (hopefully) goes away.

Respiratory viruses, once endemic, have never been completely suppressed. Even
China is seeing a resurgence in cases. What we’re doing now isn’t sustainable
or ethical, and we have to move on to smarter tactics soon.

~~~
maxerickson
The lockdowns are a necessary step to smarter tactics working.

My point is that if we move forward as if letting lots of people get infected
is a 'smarter tactic', it's going to be worse in all ways. More death, more
economic damage.

~~~
irq11
No, you’re still shifting the goalposts.

The point of “flattening the curve” is not — and was _never_ — to reduce the
_area under the curve_. This is a contagious respiratory virus, and it’s going
to spread until there is herd immunity. Maybe there will be a vaccine in 12-18
months. Maybe not. But regardless, we can’t go on for that long with over 30%
of society out of work.

Most people are going to get this virus. If you don’t understand that, you are
scientifically illiterate. You are pushing on the ocean to prevent the tide.

Trying to forestall the inevitable by keeping us all locked in our homes will
inflict such massive economic and social collateral damage that it’s simply
unthinkable. We won’t stop the virus, and we’ll burn down our society trying.

~~~
maxerickson
I never conceded that flattening the curve was not about reducing the area, so
I have not moved any goalposts.

I was going to make a comment on this article about the meme being too
effective, in that it convinced people that the only point was to reduce the
load on the medical system. Of course the goal is to reduce the load on the
medical system, but that's step one, to get though the first wave of
infections and to a situation where the spread is potentially controllable.

------
jordanbeiber
Here in suffering Sweden 80% of covid patients in intensive care survive. I
read that 80% of NY ICU patients on ventilation dies.

Are we perhaps using less mechanical breathing devices here i Sweden?

Edit: this didn’t come out right... couldn’t find total icu death rate but
have read stories about high mortality in NY.

~~~
garmaine
In ICU and on ventilation are not the same thing.

~~~
walshemj
Exactly I have been in an ICU and I was on those annoying nasal oxygen and not
itubated

~~~
greedo
Trust me, having a canula is much more pleasant than intubation.

------
roenxi
> This was rebuilding the engine on a car going 100 miles per hour.

It isn't ideal, but this environment may make it much easier to rejig care
standards.

The large number of patients with very similar symptoms would make it
straightforward to test ideas out. I would also expect that the dire nature of
the situation also makes it practical to experiment in a way that would not be
possible normally.

It'll be harrowing and traumatic for the doctors, but the circumstances are
conducive to promote swift learning about respiratory diseases. The fast way
to learn is to be able to break a thing in many different ways. Not normally
practical for health due to legislation and community outcry.

------
neonate
[https://archive.md/WzwVN](https://archive.md/WzwVN)

------
yters
How many covid-19 deaths are due to the disease vs treatment?

------
andrewtbham
I am following Cameron Kyle-Sidell on twitter (one of the doctors in the
video). He has a possible theory on what it's going on.

[https://twitter.com/cameronks/status/1251233871137574913](https://twitter.com/cameronks/status/1251233871137574913)

------
LorenPechtel
If patients are in shape to be on the phone why do they feel the need to put
in a breathing tube?? I have measured my O2 saturation being in the 80s and my
reaction was "so that's the effect of being this high up"\--and I continued to
head up the mountain. I had been there before, I knew I wasn't getting into
too much. (I forgot to check on the summit itself. I don't expect to be there
this year but I'm going to check again next year.)

~~~
vvanders
You had the option of heading back down the mountain at any time. Respiratory
infection do not behave the same way.

------
oldgradstudent
This was the single scariest piece I've read in a while. The video is even
worse. Especially Dr. Hardin from Massachusetts General Hospital at 5m:37sec
in the video:

> I'm arguing for evidence-based medicine, which is something we all purported
> to agree with before the outbreak hit.

> We have large randomized controlled trials. The patients in those trials had
> met the same diagnostic criteria that are current patients meet. We should
> apply the results of the trials.

This is a new disease, the assumption that previous trials apply without even
a bit of skepticism is fanatical.

------
nickthemagicman
That if you're under 54 corona virus isn't any more deadly than the flu?

~~~
ristoalas
Unfortunately, the answer seems "no" so far. Based on for example [1], the
infection fatality ratio appears to be 10 times worse than the seasonal flu
for people aged 30-39. Also, hospitalisation rate is higher (e.g. in age group
30-39, the study estimates that 3.4% of the infected people were
hospitalised), which is higher (even for younger people) than the
hospitalisation rate of the flu.

[1]
[https://www.thelancet.com/action/showPdf?pii=S1473-3099%2820...](https://www.thelancet.com/action/showPdf?pii=S1473-3099%2820%2930243-7)

~~~
downerending
Without disputing that (and thx for link), it's worth noting that the "flu"
has been killing a large number of people year in and year out for as long as
we can remember.

The long-term death rate of COVID-19 remains to be seen. The final verdict on
how bad it was will depend on whether or not lengthy immunity is attained
(including to mutations).

~~~
watwut
Yeah, but I don't understand what is significance of that claim. We have flu
vaccine and general push to make people vaccinate every year. Up to mandating
it for hospital workers at some places. Some employers are organizing them for
free for employees.

We do close schools here and there for a week or so when flu is getting large
to get it under control. We do close hospitals for visits at this times.

~~~
downerending
One implication is that COVID-19 might not be "just the flu". It might
actually end up being far _less_ damaging than the flu, as viewed over
decades. And we don't trash our economy and the lives of the working class
that depend on it due to flu deaths, even though they are still quite
dramatic.

Personally, I'm conservative on this, and have barely left my place in the
last eight weeks. I can work from home and will suffer little even if the
lockdown is quite lengthy. But not everyone is in such a fortunate position,
and I think we need to consider what's happening very carefully.

~~~
mgsouth
New York state has had 1 person in 1,200 [0] die from COVID-19, and is on
track for 1 in 1,000. Do you know 1,000 people? If you lived in NYC, how many
of your acquaintances would have died? How many people you know die from the
flu every year?

Not even the most extreme estimates I've seen suggest that NY has anything
approaching 50% immunity. _Reopening NY and letting people catch CV19 would
double, triple, ? the death rate._

There is no suggestion that NY is special as regards total numbers. (Velocity,
due to population density, assume yes.) _This is not the flu._

[0] A of 2020-04-17 880 deaths per 1M population.
[http://91-divoc.com/pages/covid-
visualization/](http://91-divoc.com/pages/covid-visualization/)

~~~
bequanna
NYC is absolutely not representative of the rest of the country. In fact, they
appear to be the hardest hit locale in the world in no small part due to their
poor and delayed response.

I agree, reopening NYC would be a mistake, but large portions of the US
(especially rural areas) remain largely unaffected by this.

The average age of death in my state (MN) is 88 with preexisting conditions.
Our death rate is 0.0019% (!) with a flattened curve for some time now. Most
of the US is not NYC.

~~~
mgsouth
The point being, an unusually large percentage of the people who contract CV19
die. Lower density == _longer time_ to hit X% infected and Y% dead, but you'll
still get there. (With caveats that X is a bit lower with lockdown, and Y gets
higher when medical system is overloaded.)

Minnesota death rate is, as you say, currently at 19/million, but is growing
at about 10%/day. The curve fits WA state's; continuing along that curve, WA
currently has 79/million and is growing by 3%/day.

~~~
downerending
The question is not "How many will die?". Sadly, many will.

The question is "How much _net_ difference will different reopening schedules
make?". The answer to that is unclear, but remaining in lockdown for six
months could easily kill _more_ people (net).

