Category: Coronapanic

The Wuhan-on-the-Hudson fiasco continues to unfold. They have all of the economic suffering of economic and societal shutdown and all of the exponential growth that was seen in countries that made no effort to “flatten the curve” (ft.com shows New York state actually growing faster than Lombardy during comparable weeks!).

My friends who work in health care there say that some hospitals are fairly quiet while others, just a mile or two away, are packed. There is no mechanism for sending patients who can wait a couple of hours for care to upstate hospitals that are more or less empty, nor even a mechanism for balancing the load among hospitals within New York City. (Let’s not even talk about New Jersey; they’re just as overwhelmed as NYC, but nobody in American media cares if someone in New Jersey dies, even if it is from COVID-19.)

The New York Department of Health has a $88 billion annual budget (see page 45; it is a bit confusing because in some years the “annual budget” really includes two years of Medicaid; you could also say that the real budget is closer to $94 billion because they moved mental health and “addiction services” out). This is partly for public health functions, such as the ones that left the state without any preparations for a flu or flu-like outbreak, and mostly to pay for unlimited procedures to be applied to those with low-income or no income (Medicaid; New York funds a lot of stuff that other states won’t fund and, correspondingly, had less money available for public health).

How much is $88 billion? Mexico spends about $1050 per person on health care. That includes health care for the rich, middle class, and poor. Mexico’s population is roughly 130 million so this works out to about $136 billion. In other words, with only 20 million people, New York spends close to as much on public health and welfare health insurance as Mexico does to care for its entire population, including cosmetic surgery for the richest people in Polanco. (How are the results in the Mexican system? Mexican life expectancy is about one year less than American life expectancy.)

Comparisons between coronavirus and war are common. What if we wanted to have a military force with supersonic fighter jets, nuclear-powered submarines, an aircraft carrier, nuclear weapons, ballistic missiles, nearly 1 million active-duty troops, and 2 million reservists? Somewhere around $70 billion is what Russia spends. In other words, New York state spends more for public health and welfare health care than Russia spends to fund what might be the world’s most powerful military (let’s hope that we never find out who is actually the strongest!).

Related:

• Suppose that everyone with COVID-19 got a ventilator: “What You Should Know Before You Need a Ventilator” (NYT, by a physician)
• Same newspaper, same day, but by a journalist: “‘Code Blue’: A Brooklyn I.C.U. Fights for Each Life in a Coronavirus Surge” (mostly contradicts the above and implies that an application of massive quantities of medical personnel and machines can save the typical patient seriously afflicted with COVID-19)
• Medicaid spending by state (most recent data is from FY2014; California was spending $4,200/year on a Medicaid enrollee. New York was spending $7,800)
• “Transgender programs flourish following New York Medicaid coverage” (New York taxpayers will fund a gender transition every year (or every month) for those who don’t work)
• NYS Infertility Demonstration Program: “The program subsidizes higher level infertility treatments in vitro fertilization (IVF) and gamete intra fallopian transfer (GIFT) for privately insured women for whom these procedures are not covered by insurance.” (Let’s most ignore the transgender exclusionary language (“women”) here, but remind readers that some men need IVF too!) If you struggle to make ends meet without subsidies, New York taxpayers will pay to generate some additional likely welfare recipients via IVF

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Pre-plague, our government was trying to put billionaire Robert Kraft in prison under the theory that it is legal to pay a woman by the month (half his age!), but not legal to pay a woman by the hour.

Now that the plague is here and, despite spending many $trillions on exotic medical procedures since the SARS outbreak, we forgot to buy any masks or ventilators. Who is helping to patch up the hole that we created? Robert Kraft! “New England Patriots plane brings back more than 1 million N95 masks from China” (USA Today):

The Patriots and government officials needed to overcome several bureaucratic and logistical obstacles. The plane remained grounded for less than three hours while the supplies were loaded. The crew did not exit the plane; otherwise, they would have been forced to quarantine for 14 days upon entering China. Flight crew members needed expedited visas that were processed quickly through a cooperative Chinese consulate in New York.

“I’ve never seen so much red tape in so many ways and obstacles that we had to overcome,” Patriots owner Robert Kraft told the WSJ. “In today’s world, those of us who are fortunate to make a difference have a significant responsibility to do so with all the assets we have available to us.”

Kraft, Baker, the U.S. State Department and others wrote to the Chinese government and consulate between March 24 and March 30 to obtain permission to pick up the masks and the proper permits, the WSJ reported.

According to the WSJ, the Kraft family paid nearly $2 million — roughly half the cost — for the masks.

This reminds me of Andrew Mellon. A rich guy who became Secretary of the Treasury under Republican presidents, he became Target #1 for FDR. From TIME:

Beyond tax rates, a broader New Deal tax philosophy took its toll. Tax authorities had once drawn a clear line between tax avoidance — the use of legal deductions — and criminal tax evasion. Roosevelt blithely blotted out that line, conflating evasion with avoidance. Anyone who seemed to pay too little became a target of F.D.R.’s prosecutors. One of those targets was Andrew Mellon, Treasury Secretary under Warren Harding and Hoover. Roosevelt’s Treasury Secretary, Henry Morgenthau, told prosecutor Robert Jackson, a future Roosevelt appointee to the Supreme Court, that when it came to Mellon, “you can’t be too tough.”

Wikipedia says that FDR’s prosecution of Mellon, for tax fraud, lasted from 1933 until after his death in 1937: “Months after Mellon’s death, the Board of Tax appeals handed down a ruling exonerating Mellon of all tax fraud charges.”

While Roosevelt was demonizing and trying to imprison Mellon, what was he up to? Donating his art collection and his money to create the National Gallery of Art (independent today and not part of the Smithsonian).

Kraft has a ways to go before donating the same percentage of his $billions to the nation that Mellon did, but can we say that he is on track to be our next Mellon?

Related:

• family law in Massachusetts (it would be a lucrative hour of work if a pregnancy could be obtained with Kraft here in the Bay State)

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What numbers do Americans care most about right now? I would love to know the following:

• what percentage of people in the Boston area are already infected with coronavirus (settle the Oxford v. Imperial College debate)
• how close to being overwhelmed are local hospitals in terms of beds and ICU beds in case someone in our family is unlucky enough to need one?

We can’t get the first number because nobody will go out and do a test for active virus in a representative subset of Boston-area residents. This wouldn’t be complete because it wouldn’t measure people who were infected and are now over COVID-19, but if the number is only 0.1% then it is time for double-secret lockdown to stop the spread!

With the second number we could decide whether to drive for an hour or two to a less-busy region before dropping a sick person off at a hospital ED. This would avoid the situation that I’ve heard about from friends who work in health care in NYC. A hospital in one neighborhood is overflowing while a hospital two miles away has empty rooms.

The Florida state government isn’t doing anything about the first number, but they’re gathering and publishing data regarding the second. See “Coronavirus: Here’s how many hospital beds are available in Florida” for a map.

How about Massachusetts? We are a “data dumb” state in which this information is perhaps not available to anyone. Doctors affiliated with individual hospitals can get stats for their own hospital and my moles inside two of the biggest Boston hospitals say that they still have rooms and ICU beds available. This is contrary to the prophecies from University of Washington, We supposedly ran out of ICU beds in the state on March 27 and ran out of hospital beds today.

Related:

• https://philip.greenspun.com/blog/2020/03/26/about-2-5-percent-of-boston-hospital-beds-occupied-by-covid-19-patients/
• “Online checkbook is one step in efforts to publicize state’s accounts” (Sarah Palin’s successful effort to make records of all state spending available online)

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In “Fair Allocation of Scarce Medical Resources in the Time of Covid-19” (NEJM) a group of physicians ponders the big question that we were predicted to have to deal with right around now: who lives (with a ventilator) and who dies (because there aren’t enough ventilators; though actually most COVID-19 patients who do get a ventilator will die nonetheless).

They’re silent on the question of whether taxpayers should have priority over convicted felons and undocumented migrants on welfare. They have not considered whether a beloved film actor such as Tom Hanks should be preserved ahead of a merely well-liked tire salesman. Should Eric Yuan, a founding engineer of Webex and the founder of Zoom, tech companies that have enabled Americans to learn and work through the plague times, get priority over a strip mall “massage” parlor manager? The docs can’t say.

But there is one thing that they do know: “Critical Covid-19 interventions — testing, PPE, ICU beds, ventilators, therapeutics, and vaccines — should go first to front-line health care workers and others who care for ill patients…”

In other words, the doctors think that doctors should be #1 for the ventilators!

[Coincidentally, I looked at all of the same issues and came to the conclusion that golden retriever owners should be #1 for the ventilators. After all, a golden who loses her master/mistress/zistress/theiress is more bereft than most other dogs would be.]

Related:

• https://philip.greenspun.com/blog/2020/04/02/why-the-u-s-is-out-of-ventilators-and-why-it-might-not-matter/

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“Navy will remove 2,700 sailors from aircraft carrier hit by coronavirus” (NBC):

The Navy plans to move 2,700 sailors from the aircraft carrier USS Theodore Roosevelt to quarters in Guam as the number of sailors testing positive for the novel coronavirus has increased to 93, said acting Navy Secretary Thomas Modly.

But “Experts tell White House coronavirus can spread through talking or even just breathing” (CNN).

Unless these sailors can stay in individual apartments forever, won’t they just get coronavirus as soon as they come out?

I understand the “flatten the curve” argument for the general civilian population, which includes obese diabetics, 85-year-olds with heart issues, etc. Does the “flatten the curve” religion apply to a population of young healthy sailors who generally retire before age 40? They’re not all chain-smoking next to the JP-5 fuel tanks, are they? How many could possibly require ventilator support (and, with it, an 86% chance of death)?

Also, won’t all of our Navy crews eventually get hit with coronavirus? Angela Merkel, Ph.D. in physics, estimated that 70 percent of Germans would get it (though possibly after a few extra weeks via flattening of the curve). Does that mean the entire U.S. Navy is going to be parked alongside the Carnival and Royal Caribbean fleets?

Is it time to sell some of these ships to the Chinese? (They can finish up work on the Australian ferry boats with guns: “The Navy spent $30B and 16 years to fight Iran with a littoral combat ship that doesn’t work”)

(Separately, isn’t it kind of ironic that our main naval dispute recently has been with China and now a virus from China (not to say “a Chinese virus”) has disabled our Navy!)

Charleston, South Carolina Patriots Point (more familiar to the British as “Traitors Point”):

Update: the sailors who said that they were worried about getting coronavirus all packed themselves into a hangar as tightly as Spring Breakers at a beach bar (YouTube). This was to bid farewell to the captain. If they didn’t have COVID-19 before, surely they do now!

Related:

• “Brazil confirms first indigenous case of coronavirus in Amazon” (Guardian): The 20-year-old from the Kokama tribe tested positive for the virus in the district of Santo Antonio do Iá, near the border with Colombia, 880km (550 miles) up the Amazon river from the state capital Manaus (i.e., even they can get those littoral ships 550 miles up the Amazon, our young fit sailors won’t escape)

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In “State-by-state model of hospital bed and ICU demand” I wrote:

The biggest question mark for me is their forecast of ventilator usage (19,000 best-estimate for peak; 40,000 worst-case). If the data nerds are right, we have way more ventilators in the U.S. than we need to handle this challenge. We had at least 62,000 ventilators in service back in 2009 (source), plus another 100,000 older models in storage. Presumably a lot of the in-service ones are tied up with people who are sick with chronic conditions, but all of the older models should be available and that is a more than adequate resource. If these folks are right, everyone who is freaking out about ventilator supply is wrong.

A friend sent me a link from a critical care nurse that explains why the U.S. might well run out of ventilators. From April 1:

Yes our threshhold to intubate and ventilate is much lower than normal. We now have an abundance of patients (that turn out to be negative a day or two later) that are now on a ventilator and occupying an icu bed who would have probably been fine with a less invasive respiratory intervention.

These patients usually have a boatload of comorbidities and severe existing lung disease already so it isnt a snap to just say “oh youre negative so lets just pull the tube, send you to the floor, and youll be fine”.

Once intubated it can be a long road to extubate with these patients if we even can at all. Under normal circumstances we try everything else first with them before tubing them because we know that once tubed there will be very little chance that many will be able to be extubated without going the trach, PEG, rehab route.

This is why the rapid test will be a Godsend once widely available. We can find out who is positive and needs a tube vs just a routine COPD exacerbation that can get BiPap and not risk infecting staff. Although the sensitivity and specificity would have to be very high on the rapid test or staff would still be at risk.

If so it could free up many ICU beds that are currently being occupied by covid negative patients.

In other words, if you want a near-guarantee that no nurse or physician will get infected you have to intubate and ventilate anyone who might conceivably have COVID-19.

Some background from the same guy, March 31:

Updates at my 200 bed community hospital in NH:

Our ICU is 90% full right now. They are tubing anyone that has a high likelyhood of having the ‘rona if they go into rapid resp failure since using BiPap or Hiflo vapotherm is an exposure risk to staff and will aerosolize the virus and blow it all over the room. Out of these patients, only one has tested positive. The others have all come back negative. The positive is a vented 70+ yo lady with comorbidities who is also fighting sepsis from a bowel perforation unrelated to the virus. We have her on hydroxychloroquine and every big gun IV abx we have at our disposal including azithromycin. For the last three days she has been holding her own and her vital signs have remained stable on low-moderate pressor support.

All of our rooms have now been converted to Neg pressure rooms in the ICU as well as many rooms on the med-surg and tele floors.

As of yesterday, hospital wide, we only had 4 positive inpatients including my patient in the ICU. Only one staff member has come up positive as far as I know (our hospital is rather quiet in reporting staff positives and this info has to be come by through the grapevine). We now have to fill out a questionnaire before work attesting to no covid19 symptoms in order to get a cleared for work pass. All staff members, from contractors, to admin, to clinical must wear surgical masks at all times when in the hospital, unless treating a covid or suspected covid patient. For them, N95 or Papr must be worn with protective gown, headgear, faceshield, and double gloves.

No visitors of any kind or for any reason are allowed in the hospital and have not been for the last 2 weeks.

Its been busy, and we only have a handful of patients so far. Im looking at at least 80 hours this week. While its nice to have job security I could do without the extra dash of impending doom sitting in the pit of my stomach every day I get dressed for work.

From March 21:

In regards to the N95 shortage, I dont blame anyone with the foresight to have prepared for this fiasco and purchased them. I certainly did and had bought a several N95s in the size Ive been fitted for (along with additional food and necessity preps) once it was obvious this was more than the 2003 SARS nothingburger.

I was dumbfounded however upon learning that my hospital was completely unprepared for this 2 weeks ago when they told us they had only 40 disposable N95 masks on hand and 10 papr helmets. For the entire fu**ing hospital! There was a near mutiny in our ICU for a few days once this word got out.

I lay all the blame at the feet of our infection prevention department and their incompetent director, who amazingly still has her 6 figure salary and who seems to do little more than clog up our inboxes with reminders about handwashing and take photo-ops in front of the triage tent outside the ED.

What if God sends a ventilator and critical care team to each of the 330 million residents of the U.S. (including the 22 million undocumented, of course! According to our local church, God loves the undocumented more than anyone else.)? How much would that cut the death rate from COVID-19?

“Respiratory support for patients with COVID-19 infection” (The Lancet):

The ICU mortality rate among those who required non-invasive ventilation was 23 (79%) of 29 and among those who required invasive mechanical ventilation was 19 (86%) of 22.

Maybe 15 percent then? My physician friends say ventilation implies a 90 percent risk of death, so the ventilator will delay death and result in a 10 percent reduction in the near-term death rate. The only doc who is optimistic about the ICU and ventilators is a guy who… works in the ICU running ventilators (“critical care”). But he is unwilling to quantify the advantages conferred on patients other than to say that it may help some.

“Mortality rate of COVID-19 patients on ventilators” (Physician’s Weekly):

Probably the best published information we have so far is from the Intensive Care National Audit and Research Center (ICNARC) in the UK. Of 165 patients admitted to ICUs, 79 (48%) died. Of the 98 patients who received advanced respiratory support—defined as invasive ventilation, BPAP or CPAP via endotracheal tube, or tracheostomy, or extracorporeal respiratory support—66% died.

An article in The Guardian said this about the ICNARC study, “The high death rate raises questions about how effective critical care will be in saving the lives of people struck down by the disease.”

A medical school professor, when I asked him whether it was true that the ventilators we read about in the media every day seldom make the difference between life and death: “It’s true, but don’t let facts interfere with my panic.”

So… the epidemiologists currently trying to act as prophets are forecasting ventilator use on the assumption that only patients who need ventilators will get one. However, COVID has caused our health care system to use ventilators at a prodigious rate, just as the system is using masks and other PPE at a prodigious rate.

Related:

• “Texas ‘mom and pop’ business flooded with orders for helmet ventilators amid coronavirus crisis” (NBC), an inexpensive device that might work better than intubation and full-scale ventilation
• while journalists in the NYT imply that you’ll go on the ventilator, watch some cartoons, then go off and hit Starbucks and the gym, the same newspaper got a physician to write “What You Should Know Before You Need a Ventilator”: [COVID-19] causes a gummy yellow fluid, called exudate, to fill the air sacs, stopping the free flow of oxygen. If only a few air sacs are filled, the rest of the lung takes over. When more and more alveoli are filled, the lung texture changes, beginning to feel more like a marshmallow than whipped cream. … These machines can’t fix the terrible damage the virus is causing, and if the virus erupts, the lungs will get even stiffer, as hard as a stale marshmallow. … The heart begins to struggle, begins to fail. Blood pressure readings plummet, a condition called shock. For some, the kidneys fail completely, which means a dialysis machine is also needed to survive. … Eventually, all the efforts of health care workers may not be enough, and the body begins to collapse. No matter how loved, how vital or how needed a person is, even the most modern technology isn’t always enough. Death, while typically painless, is no less final. Even among the Covid-19 patients who are ventilated and then discharged from the intensive care unit, some have died within days from heart damage.

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On the one hand, the U.S. health care system is kind of lame. It consumes a ton of money. New York State spends $88 billion per year on its Department of Health, $4,400/year for every resident, mostly just for people on welfare in New York; Mexico spends about $1,100/year across all citizens, including those with jobs. The U.S. health care system delivers feeble results. Life expectancy in Mexico is 77 versus 78 in the U.S. Despite this prodigious spending, New York has completely failed to protect its residents from something that isn’t truly new.

On the other hand, the U.S. managed to build enough renal dialysis capacity to keep 468,000 Americans with failed kidneys alive. This is a complex procedure that requires expensive machines, and one that did not exist on a commercial basis until the 1960s.

Should this success story give us some hope that the U.S. will, in fact, be able to deal with the surge of demand for ventilation and life support created by the evil non-Chinese coronavirus?

Of course, one issue is that we had decades to build up all of this renal dialysis capability while we have only about one more month to build COVID-19 treatment capacity. But once we have built it, can we sail through the inevitable next wave or two of COVID-19?

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Happy April Fools’ Day! Are the biggest fools those who frantically stocked up on hand sanitizer? What did it turn out to be useful for? Before the coronaplague hit, we had about 8 ounces left in a couple of bottles here. With five people in the household we’ve barely touched any of it. I use a touch after grocery shopping (having locked the car so that nobody comes in and steals the precious mini bottle!), but that’s a once/week activity.

What ordinary consumer has actually ended up needing a large personal supply of hand sanitizer (a.k.a. “Clear Gold”)?

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