Covid 19 Sci/med discussions only

[Arik]

That’s the exact point point I am trying to make.

You have relatively young, healthy people that take a huge viral load or have the worst luck with a bad cascade. You just have to get them over the hurdle.

You have people with minor levels of underlying disease or a treatable / controllable significant condition, like a 50-60 year old with an unknown nearly occluded coronary artery that with a stent would buy him possibly 25 more normal years. We all should want resources available for them.

But we tie up resources with end stage, terminal condition patients in futile, end of life care.

Hospice/DNR patients. These get sent to the ED all the time by families who freak out and change their mind. With a big use of resources and man hours. These are terminal condition patients with no survivability that are supposed to be kept comfortable at home with resources allocated for this in exchange for not tying up futile effort resources. Should family members be allowed to break the patient’s pre-existing wishes tying up resources?

Palliative chemotherapy/radiation therapy patients. These are terminal patients they are just trying to keep more comfortable before they die. Is this a valid use of resources to put them on a vent? If the vent fails to oxygenate them and the family is demanding ECMO does that make any sense?

Ok that makes more sense. Still, how do we pick and choose who gets what? Not pointing fingers, just thinking out loud

[Life's a Hillary]

Ok that makes more sense. Still, how do we pick and choose who gets what? Not pointing fingers, just thinking out loud

Starting to sound like death panels more than anything we’ve actually encountered if it were to happen

[Arik]

Starting to sound like death panels more than anything we’ve actually encountered if it were to happen

It's something no one wants but may have to happen. Which is what Italy did. Logically there is no reason to keep a 90 year old on a vent when a 30 year old is waiting for a turn. Only so much medications/equipment/room and who has a better chance of survival along with a longer productive life. A 90 year old isn't going to be productive even without this virus.

[ramairthree]

Starting to sound like death panels more than anything we’ve actually encountered if it were to happen

These decisions are made all the time.
The situations already exist.

It’s not sentencing someone to death.

It’s a question of having a resource preserving efficient way to let someone go comfortably now or a few hours from now, instead of two days or two weeks from now after tying up massive resources, manhours, equipment, room, etc. that will not change the outcome.


I know there is a ton of talking going on out there about such healthy pretty young people dying left and right,
And those outliers do exist.

But when you speak with multiple emergency medicine and critical care physicians,
The words “train wreck” are commonly used to describe the patient’s baseline medical conditions. A minority of which are due to bad luck, bad family genes, etc. The majority of which are caused by choices and behaviors which self inflicted the medical conditions.

I have taken a lot of enmity for my descriptions of people and their medical conditions, accused of making up crazy examples, etc.
But these are literally the patients that show up to ERs and get admitted to the ICU.

There is a significant dissonance between how I grew up in rural, cold, mountainous America hours from cities and medical centers and current cultural American, urban, etc. ways.

When I was a kid and 92 year old great grandpa fell down on the farm and had a stroke that paralyzed half his body and he could not speak, and he was having trouble swallowing and losing the ability maintain his airway he gestured hell no to any more care and died. When 89 year old grandpa was feeling too week to drive a tractor or chop wood anymore and hurt everywhere and they finally got him to go to a doctor for the first time since his appendicitis decades earlier he had a big lung cancer that had spread and he said F it and went home with pain medicine and stayed there for a few months before dying at home with friends and family shortly after his 90Th birthday. When 90 year old grandma broke her hip on an old step that broke, they wanted to operate on her carotids, do a heart cath, go to a nursing home, etc. she said hell no, went home, and died in her sleep a couple of years later. When my 90 year old uncle was getting to much back pain for his walks he took aspirin. A few months later He woke up one morning paralyzed from the waist down. He had prostate cancer that had spread all over. And a huge blood clot that could kill him at any minute. He opted for comfort care. I could continue to go on, but hopefully this paints a little more where I’m coming from, and why - when your 85 year old aunt gets thrown of a horse with a Marlboro dangling from her lips and gets a skull fracture and head bleed and everyone is cool with not starting the plug, let alone having to pull the plug, you let her die in peace and comfort and chalk it up as a win.

[WillBrink]

Starting to sound like death panels more than anything we’ve actually encountered if it were to happen

When things get bad enough it's referred to as triaging, before that it's given names like "death panels" and such. Make no mistake, if/when it's bad enough, there are death panels or what ever one wants to call them. If we don't wait until it's a totally desperate triaging situation as the Italians found themselves, now you're behind the curve and it's real ugly place to be. Perhaps some pre thought on that as ramairthree is suggesting makes more sense. We don't have the stomach for it, and understandably some will raise moral/ethical Qs, and fear of liability trumps pretty much everything, it will not happen regardless. So, they'll wait until it's similar to the Italian level event, be triaging in exremis situation, and done. Who lives and who does not based on resources and other variables done in a calculated calm way freaks people out (even though it's actually done all the time...) and no one wants to chosen to not get a treatment. I can see both sides of it. Just depends on what's considered the priorities.

[ABNAK]

When things get bad enough it's referred to as triaging, before that it's given names like "death panels" and such. Make no mistake, if/when it's bad enough, there are death panels or what ever one wants to call them. If we don't wait until it's a totally desperate triaging situation as the Italians found themselves, now you're behind the curve and it's real ugly place to be. Perhaps some pre thought on that as ramairthree is suggesting makes more sense. We don't have the stomach for it, and understandably some will raise moral/ethical Qs, and fear of liability trumps pretty much everything, it will not happen regardless. So, they'll wait until it's similar to the Italian level event, be triaging in exremis situation, and done. Who lives and who does not based on resources and other variables done in a calculated calm way freaks people out (even though it's actually done all the time...) and no one wants to chosen to not get a treatment. I can see both sides of it. Just depends on what's considered the priorities.

In an emergent, overwhelming situation like a pandemic yeah, triage may have to take place unfortunately. However, in normal times it is indeed known as a "Death Panel" and should NEVER exist (outside of those emergent situations) in a society as advanced as ours. Sorry if it hurts the penny-pincher's feelings but that is how I see it. A "check these boxes and you don't get care" policy should ONLY take place in really fvcked-up circumstances, not as normal-times, standard procedure.

[ramairthree]

In an emergent, overwhelming situation like a pandemic yeah, triage may have to take place unfortunately. However, in normal times it is indeed known as a "Death Panel" and should NEVER exist (outside of those emergent situations) in a society as advanced as ours. Sorry if it hurts the penny-pincher's feelings but that is how I see it. A "check these boxes and you don't get care" policy should ONLY take place in really fvcked-up circumstances, not as normal-times, standard procedure.

Why?

These decisions are made on smaller scales every day.

Perfectly sane, first world, humane, westernized countries with socialized medicine have policies on futile, end of life care.

Not having those polices here has significant adverse affects on other people.

Using all the emergency release blood products up on the end stage cirrhosis patient that complies with none of their care before they die, or the hospice gastric cancer Do Not Resuscitate patient rushed to the ER before they die, instead of ending the codes and pronouncing death without using them up, means ZERO blood products are available for the family in the minivan that got blind sided by a drunk or the cop or homeowner that for got shot by a thug.

I am not a hurt feelings penny pincher, and I am not criticizing you. I want to genuinely know why that is how you see it.

You are the single emergency medicine physician or surgeon on call. The gastric cancer patient has just arrived with an irreversible medical issue and bleeding from both ends. Joe Average Dude has just arrived after being T boned with a ruptured spleen and liver laceration. There 8 units of PRBC and 4u of FFP ready to go. They both have horrible anatomy, bloody, messy airways. Nobody can get an IV on either one. They have both just went into PEA. The emergency physician has time to intubate and do a cordis and start the transfusion on one while the other one dies. When the surgeon arrives he can only take one to the OR.

Why is it that you feel the end stage gastric cancer patient should be a consideration to treat in this scenario, or at all even when there is not a competing patient instead of comfort care?

Or, to be more COViD specific,
An 87 year old with metastatic lung cancer with hits to liver, bone, and brain, a single COPD lung, a pacemaker, ischemic cardiomyopathy, paralyzed on one side from a stroke arrives in septic shock and pneumonia and is hypoxic. What is the rationale for your opinion that a policy of comfort care and meeting the natural end of his life “should NEVER exist”.

Slippery slope? Religious? Never give up stubbornness ?

We’re not talking about some elective valve replacement or a bypass or a sort of patient who is going to be temporarily on a vent and walk out the hospital situation here.

Again, genuinely would like to know your rationale. Not an attack.

[ABNAK]

I don't like it but if it was an Italy-type situation you do what you have to do. I do not think it should apply in pre or post emergent society.

As a taxpayer I end up contributing $$$ for a LOT of stuff I wouldn't if given my druthers, as do you. You are also aware that we don't live in a "perfect" world. As long as I (and all of us) have to shell out tax funds for Shaniqua in the 'hood or Methie Sue in the trailer park I'd be okay with a terminal patient who discovers at the last minute he's afraid to die being put on a vent. Wanna take that choice away with a "Death Panel" checklist? Better damn sure start with yanking Shaniqua's and Methie Sue's cornucopia of government bennies. But we all know that'll never happen so it is what it is.

I have seen patients themselves revoke DNR orders. It more often than not is the family doing it, but sometimes the patient does it. Who am I to second-guess those on Death's doorstep, especially since it their ass on the line and not mine. Always easy to do until it's you on the precipice (not you specifically, trying to choose words carefully to not get threads locked). A mile in someone else's shoes, yada yada.

You and I agree that if it is a SHTF situation you triage accordingly. I just do not feel it should be standard, non-emergent medical policy. Someone who "checks boxes" may not mean squat to many people, but they do to someone else and surely themselves, and we don't live in Zimbabwe.....resources are aplenty in the richest nation on this planet.

[AKDoug]

I just had a discussion via FB messenger with my daughter who is a med lab tech. They've gotten their first Abbott rapid testing machine at the clinic she works at and can get results within 5 minutes for a positive and 13 minutes for a negative. The hold up, she says, is simply a math problem. She figures that she can realistically see testing 4 people an hour with proper protocols in place using the one machine. Even if they ran it 24 hours a day it would take them 50 days to completely test the 4800 people in the geographic area she works in.

Currently Abbott can produce the ability to do 4 million tests this month, and 20 million a month from June onward. That is a long time to get everyone tested.

This is just another tid-bit to wrap people's head around when they say complete testing must be done before we open the country back up.

[prepare]

So how does this corona virus ever end? Supposedly patient zero spread it right? So as long as there is one single person that has it does it just continue to spread? Forever?