> It’s much harder to ramp up production of medical professionals.
I have a mixed opinion on this. In particular, I don't think we really need to create more skilled medical professionals, we just need to change the way they work.
Most of doctors have exposure to the basics of intubating and ventilation through medical school. Those without direct critical care experience would likely be absolutely terrible at it. However, they all still have the baseline knowledge. They're able to assess patients, read charts, and report on vitals.
I just asked my wife (a psychiatry resident) if she could intubate/ventilate a patient. Here response was, "If I were the last person alive, I could intubate. You wouldn't want me to do it, but I could do it. I don't know how to run a vent, but I'm sure I could figure it out if I consulted with a doctor/therapist that does". I think most non-critical care doctors would express the same opinion.
What I'm getting at is we have a large amount of doctors that can act as multipliers for intensivists, hospitalist, ER docs, and pulmonologists. They are able to do much of the time consuming work while relying on specialists to guide overall care plan and intervene the on most challenging cases.
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Given how medicine works, the chances of actually seeing this in action are low. But....it's an options.
The question in a lot of ways is how many exponential doublings do we have to have before this situation switches in peoples' minds from a peace-time inconvenience to essentially real war.
Right now, the death rate still isn't higher than a flu epidemic but just the number of known infections promises a lot worse and the potential doublings after that are terrifying.
It seems like there's an endless dialogue of:
A: How would you accomplish X?
B: I wouldn't, X is not what I do.
But we need to give the final answer:
A: I didn't ask whether you can do X. I'm telling you, "do X or many people die, you are all we have at this point. Think outside the box".
The question in a lot of ways is how many exponential doublings do we have to have before this situation switches in peoples' minds from a peace-time inconvenience to essentially real war.
Indeed. I was organizing some people to make face shields and was looking for a big room. When I talked to the city about using a school gym, one of the criteria was that everyone needed to have background checks. Because it would be in a school!
"The question in a lot of ways is how many exponential doublings do we have to have before this situation switches in peoples' minds from a peace-time inconvenience to essentially real war."
The millions of people who would die in a worst-case scenario are mainly demographics that society is already used to neglecting: the elderly, the terminally ill, those with lifelong chronic illnesses where any infection could be a killer, etc.
Therefore, I would expect this to continue to be considered more of a peacetime inconvenience than a real war. A frequent response to this is, "But they could overwhelm the healthcare system so you or me couldn't be treated for our needs!" Well, if the bulk of the population is left inconvenienced and unemployed for too long, I can imagine some ugly scenarios where the population demands, broadly speaking, that those demographics simply be triaged out of treatment so that they don't overwhelm the healthcare system for everyone else. This is said to be already happening in Italy to a degree.
Well, if the bulk of the population is left inconvenienced and unemployed for too long, I can imagine some ugly scenarios where the population demands, broadly speaking, that those demographics simply be triaged out of treatment so that they don't overwhelm the healthcare system for everyone else.
People imagining such triaging seem to think that a willingness to be appalling brutal means such brutality could be achieved with limited costs.
Italy's situation is far from the worst-case scenario. It's death rate is not that much higher than a seasonal flu, it's just the death-process that is far more messy.
Which is to say, let the infection rate get high enough and you'll have hospitals crowded with the young and healthy even if carry the old directly to the morgue.
Moreover, authorities shouting "all clear" in the midst of this dreck isn't going just summon a phalanx of consumers ready to go to restaurants, death chance or not.
In short, just because you're evil doesn't mean you aren't stupid too.
If you read my parent post in context, I hope it's clear that I mean currently in Italy, people are not dying at a rate higher than the seasonal flu BUT this has a big potential change if the infection rate were to shoot up (we know this is prevented by extreme quarantine measures, enforced by the army).
Your point still isn't clear or accurate. The worldwide CFR is over 4%. In Italy, it's currently at over 11%. The flu is nowhere near that level of risk. It's normally around 0.1% depending on demographic. Are you saying that the seasonal flu in Italy normally kills 11% of those who become infected? If that's the case, the facts don't bear that out.
That’s not true. Once you start getting into the tens of millions of deaths worldwide, that’s going to include a lot of young people and medical staff and people who will die of other treatable diseases or injuries because half of the doctors in the country are sick or otherwise occupied.
The problem is that X includes a nonzero risk to human life/limb that is the responsibility of the person doing X. If you are in charge of a hospital and just let Y people die because there's not enough qualified doctors to run ventilators then you can easily wash your hands of it as though it's not your fault. If you let less-qualified people run ventilators and Y/10 die from human error but you prevent 8Y/10 people from dying then all the families of the Y/10 that died from error are going to hold you responsible even though you minimized the number of overall deaths.
We have spent decades holding people systemically dis-incentivizing people from doing positive things in bad situations by assigning responsibility in this perverse "who was the last one to touch it" manner. Society has made its bed and now it gets to lay in it. Nobody is gonna be the one that bucks the trend and reduces and sort of real or perceived safety standard in order to increase volume of care until the situation becomes so obviously bad that not doing so is indefensible.
I don’t think there’s going to be a mindset change in the population. The absolute worst estimates are between 0.5 and 1 percent of the population dying.
> Thr absolute worst estimates are between 0.5 and 1 percent of the population dying.
There are news reports right now on HN on how the real death rate on countries that are not falsifying reports might be up to 4 times the assumed rate.
The hypothesis is supported by the increase in total deaths compared with the baseline, and after subtracting deaths linked to covid19.
This being true, we might be looking into 2 to 4% of the population.
You just asked a person qualified to give you their professional opinion and then you turned around and more or less completely undercut that professional opinion.
You need the experience and you need the detailed instruction. That's why there are certification programs around the operating of complex healthcare machinery. Just like you don't want a front-ender doing back-end or systems work you don't want your psychiatry residents to operate an ICU.
> Just like you don't want a front-ender doing back-end or systems
This is not the argument I'm making though. That implies the front dev has no oversight.
I'm making the argument that a frontend development can successfully complete features with the guidance/oversight of a backend dev. The results might not be ideal, but it can provide an acceptable outcome.
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> You need the experience and you need the detailed instruction. That's why there are certification programs around the operating of complex healthcare machinery.
These programs are focused on developing individuals who can robustly and independently manage this complex machinery.
Should we also discredit airline pilots because laypeople have landed planes in emergencies? Or discredit sports professionals because many can kick a ball?
There are exactly 6 known instances of talk down landings that I'm aware of. All concerned general aviation and in one of them the person had prior flight experience. Several of those ended in a crash. A general aviation plane is in no way comparable to a large airliner, and no instance of such a landing has ever been recorded, nor has it been attempted.
Life is not a movie, some stuff is just hard and requires a long time of training before we'll let you go 'solo'. One mistake and someone ends up dead, there are no do-overs, there is no undo button.
The last thing ICU's need right now is on top of all the stress already going on there to be overrun by eager rookies that are trying to help.
The best we can do - and this is happening in some places - is to move up the training schedule and to graduate ICU nurses early. This is need for several reasons: to man the extra ICU capacity that is coming online and to take the place of those who have died or can't take it anymore due to psychological stress.
I think this sort of language is why a lot of non-professionals are sort-of balking. Life currently is like a movie. A zombie or some similar disaster movie, a situation where things are changing fast, where the normal plans are expected to fail.
...and requires a long time of training before we'll let you go 'solo'. One mistake and someone ends up dead, there are no do-overs, there is no undo button.
We are talking about a situation, coming up in X many days, when it won't be a matter of the authorities "letting" people try but a matter of the entire health system being overwhelmed. What are the other, workable plans you have for people dying in the parking lots of the emergency room? And yeah, this is a different world, one where we expect people to end up dead and we're asking how to decrease that are much as possible.
This horrible movie is the consensus of most projections. The question is not "could we deal with this? Can we play doctor, please!" but rather "how should we best deal with an ongoing disaster where we're assured, the doctors will be gone. Surely there's something one could beside 'die in place'?".
The last thing ICU's need right now is on top of all the stress already going on there to be overrun by eager rookies that are trying to help.
If the ICUs have a different, workable plan for when they are overrun with a massive number of patients, I'll be tremendously happy. The only thing I hear is "this won't work" "but what can we do?" "don't you understand that this won't work"....
> Life currently is like a movie. A zombie or some similar disaster movie, a situation where things are changing fast, where the normal plans are expected to fail.
No, because after a movie you get to go home, no matter how terrible it was. And in real life you don't get to go home. So you will have to trust in the people that have spent their lives preparing for stuff like this while we, the software smartasses were 'changing the world' with our SaaS toys.
Right now the best programmer is worth less than a mediocre ICU nurse, and that will remain so for a while. Afterwards we can all go back to pretending they don't matter but right now this is how it is.
> We are talking about a situation, coming up in X many days, when it won't be a matter of the authorities "letting" people try but a matter of the entire health system being overwhelmed.
That's a past station in some places.
> What are the other, workable plans you have for people dying in the parking lots of the emergency room?
I don't have any plans. They will die. Because we were too stupid to listen to those sounding the alarm when it mattered.
> And yeah, this is a different world, one where we expect people to end up dead and we're asking how to decrease that are much as possible.
We can decrease it as much as possible by stopping to move around so much. And yet, that seems to be too much to ask. Just now in another thread some religious guy claiming an exception just because the risk was low. I sincerely hope they'll all be fine, I also hope that if they are not that they'll trust their god rather than to hog precious ICU capacity needed by people who were careful and who did not seek this out on purpose.
> If the ICUs have a different, workable plan for when they are overrun with a massive number of patients, I'll be tremendously happy. The only thing I hear is "this won't work" "but what can we do?" "don't you understand that this won't work"....
The ICU staff is working double shifts and around the clock in plenty of places. They too get ill, plenty of them have already died. It's a bit late to stick your oar in now and make it your mission, I totally sympathize with the intentions but this isn't your fight other than to stay put, tell other people to stay put and accept that this story will not have a Hollywood ending for many people.
From what I have read the Italians have repurposed all kinds of doctors to be able to treat Covid patients as best they can with all available equipment. So I don't think it's too far out to say that in New York and other places you will see doctors stepping up and learning on the job in order to treat this disease. You will also see doctors coming into New York from other places to help.
Yes, and for doctors that may make more or less sense. But that's very far from the ideal situation: that we had managed to keep things under control when we could and that right now we stay home as much as possible to reduce the load on the system. But since people aren't even doing that (see this gem of a thread: https://news.ycombinator.com/item?id=22724268 ) I fail to see why we should at the same time break things even further.
Let's first all stay the fuck home, then ensure good personal hygiene and if and when infected self isolate as much as possible and leave the rest to the HCWs who are risking their lives in the most literal way possible.
All this well intentioned backseat driving isn't going to move the needle, not even a little bit.
This is a good point. Preventative medicine is the best medicine. That's true in general, but is especially true during this type of crisis.
We should also be more strict about isolation measures and lockdown, both individually and as a matter of policy and enforcement. That would keep our hospitals from flooding, to a much greater degree than an army of respiration therapists and ventilators would.
> All this well intentioned backseat driving isn't going to move the needle, not even a little bit.
But how else shall we spend our weekends locked indoors without pointless arguments on the internet? ;)
The ICU staff is working double shifts and around the clock in plenty of places. They too get ill, plenty of them have already died. It's a bit late to stick your oar in now and make it your mission, I totally sympathize with the intentions but this isn't your fight other than to stay put, tell other people to stay put and accept that this story will not have a Hollywood ending for many people.
This language of addressing each posters as if they personally had this intention is pretty bizarre. It's very much the language of "proper authorities are taking care of that." I don't personally have any intention of jumping but I'm part of a community and part of a situation where the proper authorities aren't taking care things.
> The only thing I hear is "this won't work" "but what can we do?" "don't you understand that this won't work"....
I find it doubly frustrating because the majority of these are asserted as fact, typically based on flawed reasoning, when what they really are, are estimations/predictions.
If this lack of concern (if not outright disdain) for correctness becomes too prevalent within a society, I worry that it may affect the quality of our decision making.
The flawed decision making was right at the start, when this thing could have been bottled up, and then after that at just about every junction where decisions were postponed. Now it's too late and everybody and their brother will start telling the ICU personnel how to clean up our messes?
It could be, I'm not overly familiar with those details, and therefore hold no opinion. Only when I sense I have a fairly decent understanding of a situation do I form any opinions on it (or more accurately, this is how I try to approach things!). And often even not then, as I have awareness of and profound respect for the ~multidimensional complexity of reality, where many of the variables and associations involved are completely invisible from an individual human perspective.
Regardless, is this somehow related to my comment above?
I now don't remember where I saw this, nor can I find it... but I swear I had seen something in the past week or two comparing how much retraining different medical professions needed to quickly get useful for staffing ventilator technology, and veterinarians came out on top; so like, people are (unless I dreamth this?!) looking into reusing people.
The US did a disaster prep simulation for virulent flu, that involved a shortage of ventilator scenarios. They took people with something approximating medical backgrounds, including nurses, other kinds of docs and vetinarians, and gave them training in how to use a ventilator. After two days they were given a test and the vets had the best score.
Doctors that don't know how to properly operate a vent are currently a problem in the US. Not blaming them, as there doesn't seem to be any real alternative.
I don't think you can pick a single /r/medicine thread as evidence of a widespread problem. My wife and every other doctor to ever practice medicine can give you anecdotal examples of other doctors mismanaging patients.
Another thing to consider is this is a rapidly changing/progressing disease and there are no standards. The opinion of a recently graduated fellow has different biases than an experienced attending. They can both be correct while disagreeing on the specifics.
Nah, we don't have all those doctors for the sick. We have doctors for every type of plastic surgery you can imagine, doctors for aging, doctors for athletic training, doctors that specialize in hips, others in just ankles, also shoulders only, others that only do laser eye surgery, others that only do teeth, some just for gums, some only do tooth implants. And on and on.
There is a shortage of doctors that actually treat sick people.
Do you have any idea how long it took your wife to learn to achieve the level of skill she is at? Let's say this was WW3, and we somehow lost 75% of these specialized personnel, what would be a ballpark estimate to get a reasonably intelligent person with no medical experience up to a "functional" level?
> what would be a ballpark estimate to get a reasonably intelligent person with no medical experience up to a "functional" level?
It really depends and I'm speaking out of my comfort zone here.
Becoming a doctor takes a really long time because it includes a LOT of background and general medicine knowledge. Doctors know a lot about medicine outside their speciality.
Med school is 4 years (2 years of bookwork focus and 2 years of clinical focus) and builds on undergrad significantly. Residency is 3+ years. I'd say the majority of people with STEM backgrounds could have function acceptably as a general doctor with 2 to 5 years of postgrad training. Surgeons are built much more on experience so that's very hard to fast track.
In my opinion, the real measure is the ability to handle edge cases/unusual cases. Specialized/limited scope workers, especially those with the direct support of an experienced individual, could pick up tasks much, much more easily as long as an expert is there to take over the challenging cases.
Sorry, I probably should have been more clear, I was referring to teaching someone only the skills necessary to operate a ventilator, in a supporting role to a properly trained medical professional, who would handle the more complex situations.
I'm willing to consider that it isn't possible, but if that is the case, I'd be keen to know the particulars of why. If there happened to be a documentary on respirators that covered some of the complexity involved, I would be on my couch watching it.
I have a mixed opinion on this. In particular, I don't think we really need to create more skilled medical professionals, we just need to change the way they work.
Most of doctors have exposure to the basics of intubating and ventilation through medical school. Those without direct critical care experience would likely be absolutely terrible at it. However, they all still have the baseline knowledge. They're able to assess patients, read charts, and report on vitals.
I just asked my wife (a psychiatry resident) if she could intubate/ventilate a patient. Here response was, "If I were the last person alive, I could intubate. You wouldn't want me to do it, but I could do it. I don't know how to run a vent, but I'm sure I could figure it out if I consulted with a doctor/therapist that does". I think most non-critical care doctors would express the same opinion.
What I'm getting at is we have a large amount of doctors that can act as multipliers for intensivists, hospitalist, ER docs, and pulmonologists. They are able to do much of the time consuming work while relying on specialists to guide overall care plan and intervene the on most challenging cases.
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Given how medicine works, the chances of actually seeing this in action are low. But....it's an options.