Can someone explain to me why what we are doing isn't overreacting

[monstro]

@puzzlegal

Well, IF a lot of us have mild cases and IF that confers useful immunity, then the total death toll will be a whole lot lower than if that’s not happening.

But we can see the death toll with our own eyes and it’s crazy bad.

Just because we aren’t all going to die doesn’t take away from that.

[asahi]

@Shmendrik

Is there any evidence that even relatively strong “social distancing” measures will be sufficient to prevent the collapse of the healthcare system, given the necessity of people circulating for food production, distribution, and essential industry? Have we actually seen this work anywhere? Like I said, for logistical reasons we can’t achieve a Wuhan level of distancing anywhere else.

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We’re probably too late to stop the initial wave of COVID-19 infections, which are now putting a strain on the health system. The question is what do we do now? I personally don’t believe that Wuhan is COVID free, but they clearly slowed the spread of the infection, and that has given them time to play catch up. It has given them time to perhaps implement better testing and a more robust in the event of additional outbreaks.

Ideally, we would have had in place a better surveillance system and had a more systematic approach to catching COVID cases extremely early - and the data (though it’s still early) seem to suggest that early detection and treatment is the key. We’re way, way behind in that regard. It should be pointed out that the reason we’re having to shutter stores and offices is due to the lack of rapid identification and early treatment. Extreme social distancing is arguably not ideal, but in the absence of surveillance and treatment, it’s the best option for allowing the medical system to get on top of COVID.

And I disagree: we actually could impose an authoritarian style lock-down if the president in coordination with governors wanted it done. But nobody has the grapefruits to pull the trigger for political reasons.

[Stranger_On_A_Train]

@panache45

In the early years of the AIDS epidemic, we had no idea that a virus was responsible, or how the disease was spread. We didn’t know how to “stay out of its way”, and many places, like gay establishments, were shut down because of this ignorance. There were even suggestions to isolate all gay men on an island somewhere. Or worse.

Actually, even after researchers knew how HIV was being transmitted and that AIDS (then often referred to as “Gay-Related ImmunoDeficiency Syndrome” by those on the Religious Right) there was opposition within the Reagan Administration to releasing information. It was then-Surgeon General C. Everett Koop–who was an evangelical Christian and die-hard conservative–who essentially defied he administration and sent out the infamous “Understanding AIDS” pamphlet to every household, which pissed off a lot of people on both the left and right but kicked off the national conversation on how we should be viewing and treating patients with AIDS. (William F. Buckley wanted to tattoo all gay men and intravenous drug users, and his was far from the most extreme proposal.)

We need this kind of devotion to truth and duty right now. Instead, what we’re getting is inadequate at best and dangerously misinformed at worst.

Stranger

[The_Librarian]

@Stranger_On_A_Train

First of all, it is pretty much confirmed via community transmission with no traceability that the SARS-CoV-2 virus is spread at least in part via aerosol vectors. This isn’t the same as “airborne”, where the pathogen can actually spread in dry air without droplets, but it is still bad; it means that while cleaning door knobs and washing hands is still good practice, it isn’t sufficient to assure no transmission. Nor is just following the 6 foot/2 meter guidelines for spacing; if you are outside in a part with a light breeze dispersing any aerosols your likelihood of getting enough of a viral load for transmission, but in a confined area where an aerosol will not be dispersed, it means it could hang in the air for minutes.

There is no real “debate on what kinds of masks are effective or how effective they are”. Ordinary surgical masks that do not seal around the face are only good for stopping droplets from being openly emitted by the wearer, and do nothing to protect the wearer from inhaling aerosolized pathogen. N95 respirator masks are much better insofar as they prevent aerosols from directly entering the respiratory system but pathogen can become embedded in the mask and eventually make its way through, especially as the mask becomes saturated with moisture from the breath of the wearer and the ability for the mask to capture droplets and hold it until the moisture evaporates and the virion (virus-containing particle) desiccates degrades. This is why staff in emergency wards and ICUs–who are being required to wear the same respirator mask for days–are covering it with a surgical mask (which mostly just serves to keep it from looking soiled) and face shields (which actually protect against direct impaction from aerosols but make it very difficult to communicate with patients or perform a thorough examination).

Seven to ten days from now, when the virus is everywhere and emergency rooms and ICU wards are packed to capacity, and physicians and nurses (and receptionists, and nurses aids, and EMTs, and everyone else who is on the front lines of the response) start suffering en masse, the question isn’t going to be “Are we overreacting?”; it is going to be, “Given everything we saw from China, and Italy, and Spain, why didn’t we react quickly enough?” At this point there is no excuse other than blithe ignorance of what is happening right now in nations that didn’t respond to the warnings of the epidemiological community to argue that the current measures to just stay at home and stop mingling with people as if this is a mild outbreak of cold or some disease that only affects old people who are going to die soon anyway. There is no “debate”; there are no “both sides make reasonable arguments”; and there is no fact-based analysis that doesn’t involve the difference between a few hundred thousand deaths and millions of avoidable deaths because of a lack of hospital capacity.

Stranger

Thread winner!
Most Pit threads leave a shred of dignity. This is just brutal.
Excellent post.

[Shmendrik]

@asahi

And I disagree: we actually could impose an authoritarian style lock-down if the president in coordination with governors wanted it done. But nobody has the grapefruits to pull the trigger for political reasons.

No, it’s literally impossible, regardless of political will. It only works when you have a large functional uninfected area which can send supplies, healthcare workers, food, etc. When the whole country is infected, that’s impossible. You’d literally have people starving to death in their homes.

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[asahi]

I suggest that everyone who thinks we might be overreacting read this ProPublica article.

A Medical Worker Describes Terrifying Lung Failure From COVID-19 — Even in...

A Medical Worker Describes Terrifying Lung Failure From COVID-19 — Even in His Young Patients

“It first struck me how different it was when I saw my first coronavirus patient go bad. I was like, Holy shit, this is not the flu. Watching this relatively young guy, gasping for air, pink frothy secretions coming out of his tube.”

Before the virus came to New Orleans, his days were pretty relaxed, nebulizing patients with asthma, adjusting oxygen tubes that run through the nose or, in the most severe cases, setting up and managing ventilators. His patients were usually older, with chronic health conditions and bad lungs.

Since last week, he’s been running ventilators for the sickest COVID-19 patients. Many are relatively young, in their 40s and 50s, and have minimal, if any, preexisting conditions in their charts. He is overwhelmed, stunned by the manifestation of the infection, both its speed and intensity. The ICU where he works has essentially become a coronavirus unit. He estimates that his hospital has admitted dozens of confirmed or presumptive coronavirus patients. About a third have ended up on ventilators.

And here’s the money line:

His hospital had not prepared for this volume before the virus first appeared. One physician had tried to raise alarms, asking about negative pressure rooms and ventilators. Most staff concluded that he was overreacting. “They thought the media was overhyping it,” the respiratory therapist told me. “In retrospect, he was right to be concerned.”

Like many hospitals across the country, across the globe: not anywhere near prepared.

Patients will be on minimal support, on a little bit of oxygen, and then all of a sudden, they go into complete respiratory arrest, shut down and can’t breathe at all.

As others have pointed out: seemingly fine one moment, fighting for their lives the next.

That seems to be what happens to a lot of these patients: They suddenly become unresponsive or go into respiratory failure.”

Here’s another money quote: once you suffer from acute respiratory distress…you’re in a world of shit.

It’s called acute respiratory distress syndrome, ARDS. That means the lungs are filled with fluid. And it’s notable for the way the X-ray looks: The entire lung is basically whited out from fluid. Patients with ARDS are extremely difficult to oxygenate. It has a really high mortality rate, about 40%. The way to manage it is to put a patient on a ventilator. The additional pressure helps the oxygen go into the bloodstream.

What’s not mentioned in the article, but what public health experts have said in terms of the importance of slowing the spread and flattening the curve is this: the aim is to make it so that ICU teams are dealing with a handful of these patients. Instead, they’re dealing with a flood.

In my experience, this severity of ARDS is usually more typical of someone who has a near drowning experience — they have a bunch of dirty water in their lungs — or people who inhale caustic gas.

Gasping for air, trying to rip out their ventilator tube because they feel the sensation of being choked.

I was like, Holy shit, this is not the flu. Watching this relatively young guy, gasping for air, pink frothy secretions coming out of his tube and out of his mouth.

Drowning in their own blood.

When someone has an infection, I’m used to seeing the normal colors you’d associate with it: greens and yellows. The coronavirus patients with ARDS have been having a lot of secretions that are actually pink because they’re filled with blood cells that are leaking into their airways. They are essentially drowning in their own blood and fluids because their lungs are so full.

Like I said, even if you survive, I’m guessing this is not the kind of experience the average person would want to go through.

[Stranger_On_A_Train]

By the way, I don’t know how many people have ever seen someone on a ventilator, but you basically have a big tube stuck down your trachea that is pushing air through with enough force to partially inflate your lungs. It is horrifying experience (I am told; I’ve never been on one myself) and patients generally have to be sedated, which given the condition that you have to be in to have to be respirated is actually a relief. “Drowning in their own blood,” is something out of a horror movie, and it is no occurring on a routine basis in every hospital in New York City and soon to come to your town.

Stranger

[asahi]

I’ve been on a ventilator: a lung collapsed during surgery when I was 15.

I remember trying to pull the tube out because I felt I could breathe on my own, but the nurses/docs kept reinserting it. Intubation wasn’t painful IME but I was on some pain meds and still recovering from general anesthesia. WHat it was, was weird. It goes against your natural instincts to leave a tube inside your body.

[Shmendrik]

@Stranger_On_A_Train

By the way, I don’t know how many people have ever seen someone on a ventilator, but you basically have a big tube stuck down your trachea that is pushing air through with enough force to partially inflate your lungs. It is horrifying experience (I am told; I’ve never been on one myself) and patients generally have to be sedated, which given the condition that you have to be in to have to be respirated is actually a relief. “Drowning in their own blood,” is something out of a horror movie, and it is no occurring on a routine basis in every hospital in New York City and soon to come to your town.

Stranger

OFFS. Patients are always sedated on a ventilator, unless they are comfortable being awake for it. They are invariably sedated for the process of inserting the big tube down their trachea. And “drowning in their own blood” is a crappy description of ARDS. This is a horrible enough disease without vaguely accurate lurid descriptions. ARDS could probably better be described as having your lungs turn to leather, if you want a horror movie phrase.

Expertise in one field doesn’t really make people experts in all fields, however much they may think they are.

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[asahi]

@Shmendrik

OFFS. Patients are always sedated on a ventilator, unless they are comfortable being awake for it. They are invariably sedated for the process of inserting the big tube down their trachea. And “drowning in their own blood” is a crappy description of ARDS. This is a horrible enough disease without vaguely accurate lurid descriptions. ARDS could probably better be described as having your lungs turn to leather, if you want a horror movie phrase.

Expertise in one field doesn’t really make people experts in all fields, however much they may think they are.

Sent from my Pixel 4 XL using Tapatalk

Um…ok.

[Blue_Mood]

A great explanation:

@Aspidistra

One mistake you’re making is the same mistake EVERYONE made until well into this epidemic - underestimating the incredible infectiousness of this disease (which means a rate of transmission that’s through the roof), combined with the fact that it’s infectious all the way through its incubation period. This means that when and if you decide that actually you were wrong and you’d like to slow the rate of infection, whatever you do will do absolutely nothing for five days at least, and it takes maybe 10 days to 2 weeks for the full effect of whatever you did to actually be seen, and you get to decide if it was enough.

So this is how it looks in practise. You’re the mayor of a city of 1 million, you’ve calculated that if the disease just sweeps through it will take out 1% which is 10,000 and this is sad but survivable.

Here’s some other plausible ballpark numbers: You have 200 ICU beds in your city (20 per 100,000 - that’s the norm in the US), 5% of infections need an ICU bed, and half of them are normally full (with other illnesses). Say on March 20th 0.1% of your population has an infection, which means that 1,000 are infected, 50 need ICU beds and of those, 40 will be okay with that care, but 10 will die anyway. Oh, and your growth in the infection rate is 20% (very low, for the ‘not doing anything’ scenario. Here’s how it plays out from here.

March 21st. 200 more people are infected, 10 need an ICU bed. Your ICU occupancy rate is 100 non-covid, 60 covid, 40 free. If this has been growing steadily all feb/march then one of those covid patients resolves (either by dying or getting better), so now you have 41 free beds.
March 22nd. 240 new infections, 12 need a bed, 1 case resolves so you have 30 free beds
March 23rd. 288 new infections, 14 need a bed, 1 resolves and you have 17 free beds. You realise you’re going to run out of beds VERY quickly if this keeps up, so you announce sweeping restrictions. Total lockdown! Nothing happening in the town except essential infrastructure, healthcare, groceries
March 24th. nothing happens to the infection rate, it’s still 20%, because all the new cases are people who actually got infected 5 to 10 days ago before there was a lockdown. 345 new cases, 17 need a bed, 1 resolves, so now you’ve got one ICU bed for all tomorrow’s cases
March 25th. nothing happens to the infection rate, 415 new cases, 21 need a bed, one gets it, the other 20 are all going to die. 16 of them would have lived if the hospital hadn’t been overwhelmed.
March 26th.nothing happens to the infection rate. 497 new cases, 25 need a bed, 2 can get one because today TWICE as many old cases resolved, other 23 die, 18 of them excess-deaths (would have lived with care)
March 27th.nothing happens to the infection rate (we’re still getting the cases that were infected on the 22nd and before, right?). 598 new cases, 30 need ICU, 28 can’t get it, 22 excess deaths
March 28th. Finally the infection rate twitches down slightly, to 18% (this is based off the Italy data). That still translates to 645 new cases, 32 ICU need, 30 can’t get it, 24 excess deaths
March 29th. Infection rate 16%, 676 new cases, 34 ICU need, now we’re up to 4 resolving per day but that still means 30 out of luck and 24 excess deaths, again
March 30th. Infection rate 14%, 683 new cases, 34 ICU need, 4 resolve, 30 no bed, 24 excess deaths.

It’s now been a week since you decided you needed to do something about slowing the spread of the disease and in that time 100 of your citizens died purely from lack of medical care, rather than from the disease.

Here’s how it goes in week 2

March 31: 12% rate 671 cases, 4 resolve, 30 no bed, 24 excess deaths
April 1: 10% rate 626 cases, 8 resolve, 23 no bed, 18 excess deaths. OK that’s still bad but it’s less than yesterday. Maybe you’re winning!
April 2: 8% rate 551 cases, 8 resolve, 15 no bed, 12 excess deaths
April 3: 8% rate 595 cases, 8 resolve, 22 no bed, 17 excess deaths
April 4: 8% rate 643 cases, 12 resolve, 20 no bed, 16 excess deaths
April 5: 8% rate 695 cases, 12 resolve, 23 no bed, 18 excess deaths
April 6: 8% rate 750 cases, 12 resolve, 25 no bed, 20 excess deaths.

At this point you realise that 8% is as low as your rate of increase is likely to go, because people still have a certain degree of contact/transmission risk through healthcare workers, grocery stores and other essential services. Your total number of infections in the city is now about 10,000 - that’s 1% of the population, nowhere near herd-immunity levels or even bringing-down-the-transmission-rate levels. You’ve got about another month till it starts to reach vaguely-plausible lessened-transmission levels, during which time you keep having about 1% of new cases die because sadly they’re just gonna, and a growing number, getting up to four times that dying because they couldn’t get a hospital bed. By the end of the outbreak you actually have close to 50,000 dead in the city, the vast majority of which died through lack of medical care. Oh, and I never modelled-in ‘20% of your ICU staff had to go into isolation because they caught the disease off their patients, and now you only have 160 beds’

You don’t get re-elected

Plus great conclusion!

[Euphonious_Polemic]

Yeaaaa, OK. I guess if you feel that the lurid “drowning in your own blood” is much better expressed as “lungs turning to leather”… go for it. Whatever.

You just keep on being you.

[Shmendrik]

@Euphonious_Polemic

Yeaaaa, OK. I guess if you feel that the lurid “drowning in your own blood” is much better expressed as “lungs turning to leather”… go for it. Whatever.

You just keep on being you.

It’s a better reflection of the pathophysiology, that’s all. Look, being a fucking rocket scientist doesn’t qualify you to discuss ICU care, or to suddenly become an epidemiologist who’s decided that the R0 of this thing is 4-6, or whatever the hell. That’s just dilettantism.

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[crowmanyclouds]

Folks might want to look at the protocols for being extubated, kinda involves being certain the patient is capable of breathing on their own.
When they did it to me it was 4 to 6 hours of fully conscious hell with a tube stuck down my throat.

CMC fnord!

[Snowboarder_Bo]

@Shmendrik

Is there any evidence that even relatively strong “social distancing” measures will be sufficient to prevent the collapse of the healthcare system, given the necessity of people circulating for food production, distribution, and essential industry? Have we actually seen this work anywhere?

This strikes me as a ludicrous question since the whole pandemic isn’t even 3 months old yet. Why don’t you tell us why you think it would be better NOT to do social distancing? :dubious:

[Ulfreida]

@Shmendrik

Is there any evidence that even relatively strong “social distancing” measures will be sufficient to prevent the collapse of the healthcare system, given the necessity of people circulating for food production, distribution, and essential industry? Have we actually seen this work anywhere? Like I said, for logistical reasons we can’t achieve a Wuhan level of distancing anywhere else.

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My current understanding is that no, it won’t. It would have if it had been instituted when we knew it should be done, instead of a month too late.

Testing and tracking and isolating positive testers would really help even now, but that is impossible with our system of governance, apparently.

Frankly, if I have ever been fed up with our system of governance before, it was as nothing compared to this extreme rage I feel all the time. It’s really unhealthy.

[madsircool]

@Stranger_On_A_Train

Actually, even after researchers knew how HIV was being transmitted and that AIDS (then often referred to as “Gay-Related ImmunoDeficiency Syndrome” by those on the Religious Right) there was opposition within the Reagan Administration to releasing information. It was then-Surgeon General C. Everett Koop–who was an evangelical Christian and die-hard conservative–who essentially defied he administration and sent out the infamous “Understanding AIDS” pamphlet to every household, which pissed off a lot of people on both the left and right but kicked off the national conversation on how we should be viewing and treating patients with AIDS. (William F. Buckley wanted to tattoo all gay men and intravenous drug users, and his was far from the most extreme proposal.)

We need this kind of devotion to truth and duty right now. Instead, what we’re getting is inadequate at best and dangerously misinformed at worst.

Stranger

It was those Religious Righters in the NYT who first published the acronym GRID

https://en.wikipedia.org/wiki/Gay-related_immune_deficiency

And it was many gay activists who fervently opposed the closing of bathhouses which led to FAR more deaths then anything the Reagan Administration did. Randy Shilts And the Band Played On is a Pulitzer Prize winning account of the first years on the HIV epidemic. The Red Cross was also grossly incompetent in its handling of the epidemic.

Canadian Red Cross apologises for distributing HIV infected blood

SWISS RED CROSS FACES AIDS PROBE (Published 1994)

[Moriarty]

@asahi

And I disagree: we actually could impose an authoritarian style lock-down if the president in coordination with governors wanted it done. But nobody has the grapefruits to pull the trigger for political reasons.

By ‘political reasons’, are you perhaps referring to the US Constitution? See, there’s a little secret that governors and mayors imposing ‘stay at home’ orders don’t want to say too loudly: It would not be legal in this country to just deny people the right of free association because the government has declared an emergency. For reasons, our constitutional rights are not negotiable.

(Please understand that I am not say that we should not be involved in a mass quarantine; I’m just responding to the notion that the government could lock everybody in their homes, if only the current elected leaders had the gumption to do it).

[asahi]

@Moriarty

By ‘political reasons’, are you perhaps referring to the US Constitution? See, there’s a little secret that governors and mayors imposing ‘stay at home’ orders don’t want to say too loudly: It would not be legal in this country to just deny people the right of free association because the government has declared an emergency. For reasons, our constitutional rights are not negotiable.

(Please understand that I am not say that we should not be involved in a mass quarantine; I’m just responding to the notion that the government could lock everybody in their homes, if only the current elected leaders had the gumption to do it).

Within certain limits, martial law is likely constitutional provided that it spells out its intended effect and follows other relevant laws.

[Moriarty]

@asahi

Within certain limits, martial law is likely constitutional provided that it spells out its intended effect and follows other relevant laws.

By ‘other laws’, do you mean the first amendment? How, pray tell, can a martial law abide by the restriction against Congress pass a lawing respecting the right of the people to peaceably assemble?