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*** OFFICIAL *** COVID-19 CoronaVirus Thread. Fresh epidemic fears as child pneumonia cases surge in Europe after China outbreak. NOW in USA (14 Viewers)

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ProstheticRGK said:
Not enough GPs are having those conversations with their patients, and unfortunately, it's falling to Hospitalists and Intensivists to have that conversation with family, without any rapport or real background on the patient. Plus, there's time constraints of being able to have such an immensely weighty conversation, when 20 minutes can mean a lifetime.
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I agree with this.   However, my wife's hospital has been aggressively pursuing palliative care consults and she says the vast majority of families just refuse to hear it and still want everything done.   And its not just a lack of medical knowledge driving it.   I had a 95 year old end stage dementia bed bound patient with fluid overload sent to the ER last night for a thoracentesis for a pleural effusion by the daughter, who is a nurse, who called demanding to be notified of any medication we ordered to approve it prior to giving it.  What is the goal of care here?  Torturing some old person with painful invasive procedures who has no quality of life?      

And your post about encouraging people to have discussions about their wishes was spot on, but I have had families revoke advanced directives and pull patients out of hospice demanding intubation etc dozens of times over the years.   It's not foolproof.   Once the patient is somewhat stabilized in the ICU they can get everybody together and force the issue if the paperwork is clear, but when the patient rolls into the ER with an O2 sat of 70% and some crazy daughter is screaming at me to "do everything" I'm kinda stuck.

 
prosopis said:
I am driving my daughter to ASU today to drop her off in her dorm. Not sure that I feel good about this but we are going.
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Why?  Sounds like you know this is a recipe for problems.

growlers said:
What is the goal of care here?  Torturing some old person with painful invasive procedures who has no quality of life?
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Mores.  People have attached their belief systems to everything.  This includes everything from pandemic decision making (like mask wearing) to end of life care.  Sadly, those two examples are not more disparate right now.

 
Nick Vermeil said:
The whole family rolled into the Bear Mountain test site today since my 5 year old has been running a 103 fever with sore throat and body aches. They told us we should have results tomorrow!  Would be amazing if true. 

Fingers crossed. 
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No results yet. My son is still symptomatic and my wife is now showing intestinal issues. I keep hitting f5 on the lab page.  

 
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The Z Machine said:
How is that possible?  An advanced directive is that person's voice.  That should be the voice that guides all decisions.
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"They didn't know what they were signing"

"She revoked that"

"That's not her signature- the nursing home filled that out so they can't be sued if she dies there"

"I was never consulted about this"

http://dpbh.nv.gov/Reg/DNR-POLST/EMS_-_DNR_POLST_Forms/

Many people do not realize that, because an Advance Directive is not a medical order, if their heart should stop emergency medical responders (ambulance personnel) are required to attempt resuscitation even if your Advance Directive states that you do not want to be resuscitated. Only a POLST or Out-of-Hospital DNR is effective in avoiding resuscitation efforts.

In real-life ER situations - if the patient are unable to tell me what they want, and are gonna die if I don't do something immediately, and there is a family member screaming at me to do everything, I'm gonna do everything as that can be reversed if the family changes their mind. If the patient dies there is no going back.  An advanced directive means nothing in this scenario (as shown above).  If the patient shows up with an actual out of hospital DNR that looks valid then I will make a judgement call if there is family dissent. Again, keep in mind I am talking about very stressful time sensitive situations, not someone who has already been on a vent for a week and there is an end of life discussion.

Occasionally EMS will tube someone and then the papers show up later (not an advanced directive, but an POLST or DNR) - I've pulled tubes in this situation but if they patient is stable on the vent ethically you typically get family consent.    If they code in the meantime I'll not do CPR and let 'em go, but all this is not as clear cut as you imply.

The hospice revocations are even worse - and more common.  Happens all the time.   If they patient is unable to answer, family can revoke hospice at any time.  Keep in mind it is often the family that decided on hospice in the first place, so logically they can revoke it at any time legally (but maybe not ethically)

 
growlers said:
"They didn't know what they were signing"

"She revoked that"

"That's not her signature- the nursing home filled that out so they can't be sued if she dies there"

"I was never consulted about this"

http://dpbh.nv.gov/Reg/DNR-POLST/EMS_-_DNR_POLST_Forms/

Many people do not realize that, because an Advance Directive is not a medical order, if their heart should stop emergency medical responders (ambulance personnel) are required to attempt resuscitation even if your Advance Directive states that you do not want to be resuscitated. Only a POLST or Out-of-Hospital DNR is effective in avoiding resuscitation efforts.

In real-life ER situations - if the patient are unable to tell me what they want, and are gonna die if I don't do something immediately, and there is a family member screaming at me to do everything, I'm gonna do everything as that can be reversed if the family changes their mind. If the patient dies there is no going back.  An advanced directive means nothing in this scenario (as shown above).  If the patient shows up with an actual out of hospital DNR that looks valid then I will make a judgement call if there is family dissent. Again, keep in mind I am talking about very stressful time sensitive situations, not someone who has already been on a vent for a week and there is an end of life discussion.

Occasionally EMS will tube someone and then the papers show up later (not an advanced directive, but an POLST or DNR) - I've pulled tubes in this situation but if they patient is stable on the vent ethically you typically get family consent.    If they code in the meantime I'll not do CPR and let 'em go, but all this is not as clear cut as you imply.

The hospice revocations are even worse - and more common.  Happens all the time.   If they patient is unable to answer, family can revoke hospice at any time.  Keep in mind it is often the family that decided on hospice in the first place, so logically they can revoke it at any time legally (but maybe not ethically)
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How do we combat such things?

 
The Commish said:
We are officially the black sheep to that side of her family.  The whole thing sucks :kicksrock:  
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No offense to your wife, but her family sound like awful, selfish idiots. This isn’t even a remotely close call. Wildly selfish and irresponsible. They want to be super cool anti maskers and put your kids in harm’s way over their dumb political views?  They’ve chosen not to see your kids. Full stop. “Want to see my kids? Wear a mask dummy”

sucks you had to go through this, but you and your wife absolutely did the right thing here. 

 
Otis said:
No offense to your wife, but her family sound like awful, selfish idiots. This isn’t even a remotely close call. Wildly selfish and irresponsible. They want to be super cool anti maskers and put your kids in harm’s way over their dumb political views?  They’ve chosen not to see your kids. Full stop. “Want to see my kids? Wear a mask dummy”

sucks you had to go through this, but you and your wife absolutely did the right thing here. 
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No offense taken...we agree and we basically said as much when she brought up my family coming who did what we asked them to do.  It's just a crappy situation all around.  Best part is, they don't talk things out or resolve things so it will be weird (for me anyway) moving forward every time I'm around them.

 
culdeus said:
How are you all dealing with strained relationships with grandparents/parents?

My wife's family has basically decided to just go with the idea that if we all WFH and stay relatively safe we are ok to periodically see eachother.

My family (mainly my mother) is much more risk averse, as is my sister.  They don't want to see anyone except outside with distance.

So I've gotten used more or less to not seeing anyone in my family side.  In the beginning we'd do parks and stuff, but it's hot AF now and I ain't gonna drive 90 minutes each way to sweat my ### off for 15 minutes and go home.  Sorry, not happening.  Maybe I'm the ####### here, but this thing isn't going anywhere and we can wait till it cools off.

The pressure I'm getting is that once school starts my kids will be exposed.  So I need to do this now, as if they will die or something.  I'm like if we are just doing outdoor 6 feet, maybe even with masks what is the ####### difference?  
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Most people we associate ourselves with are reasonable, so no such issues have arisen. I think we have just instinctively purged the crazy from our network over the last few years. And if people in my direct family are being unreasonable then I have no issue telling them. 

Sort of related, we intend to send the kids back to school in September. I sent an email to my coworkers yesterday explaining this and if it makes anyone uncomfortable I'll adapt my working location accordingly. I'll be working a lot of remote anyway, but if the others want me to be 100% I will.

Because, reasonable. 

 
Continued improvement in all metrics in South Florida. Posivity down to around 7% in Broward and 10% in Miami-Dade. Reported deaths over 200 in the state again, but Marc Bevand's prediction 3 weeks ago of a peak for deaths occurring on July 22 was correct  - deaths reported today occured up to 3 weeks ago.  The decline in deaths is slower than the decline in hospital cases and other metrics.

https://mobile.twitter.com/zorinaq/status/1294663141251379202

Also, partial herd immunity appears to be playing a role in the reduction in COVID cased in South Florida, where up to 30% may have been infected.

https://mobile.twitter.com/conarck/status/1294321567854481408

 
trader jake said:
That doesn't make much sense.  I understand words like 'appears' and 'may have' are in there, but at 30% herd immunity has very little to do with an overall reduction in cases.
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Trevor Bedford  of Fred Hutchinson, has some good graphs showing how even low levels of herd immunity can help.

>> I've been thinking of this as: to get to R0 of 1.0 with no immunity we need avoid 60% of transmission events. However, if 20% of the population is immune, then we need to avoid 50% of transmission events. <<

>> Or, with 20% population immunity, we can behave as though Rt is 1.25 and still get an epidemic that no longer propagates. <<

>> Thus, I believe the substantial epidemics in Arizona, Florida and Texas will leave enough immunity to assist in keeping COVID-19 controlled. However, this level of immunity is not compatible with a full return to societal behavior as existed before the pandemic. <<

https://mobile.twitter.com/trvrb/status/1291860670439280640

Here's the graph showing the relationship between social distancing, herd immunity and Rt: https://mobile.twitter.com/zorinaq/status/1292910759114989569

In Miami-Dade, the estimates of population seropositive range from 10 to 30%.

 
trader jake said:
That doesn't make much sense.  I understand words like 'appears' and 'may have' are in there, but at 30% herd immunity has very little to do with an overall reduction in cases.
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Of course it makes sense. Especially when you consider select population groups or occupations make up disproportionate rates of infection. 

So 30% of overall population could be 60% of the groups most likely to get infected. 

 
Covid has really exploded locally, where we went from single digit cases to 1-300+ over the last few days. Unsurprisingly, hospital admissions have picked up as well. We’ve filled up a couple floors and the medical ICU, and it looks likely that the island healthcare system will be overwhelmed in the next couple weeks. Unlike the continental US, we can’t ship patients anywhere, so things may get really ugly.

I’ve taken care of people between the ages of 18 and 80, and not all of them have underlying health conditions. Many of the sickest are obese. Most cases are linked to family clusters, often with multigenerational housing. 

Our hospital executives are telling the media we have plenty of ICU capacity, but that is creative bookkeeping, as patients are being triaged differently. Initially patients requiring more than 6 liters of oxygen were automatic ICU admits. Now we keep people on regular floors even if they require 100% oxygen via non-rebreather mask. So floor nurses are asked to care for multiple patient who’d typically be in intensive care units, where the patient:nurse ratio is not supposed to exceed 2:1. This will likely lead to poor outcomes.

Even if you’ve never personally known someone with COVID, please take the public health warnings seriously. Hawaii had consistently been near the bottom of cases/population, and our residents are pretty compliant with masks/distancing/etc., yet we’re bursting at the seams after cases surged for ~1 month. If things can change so quickly here, I have little doubt infections/healthcare utilization can blow up just about anywhere.

 
Terminalxylem said:
Not really. There is an ongoing scandal regarding inadequate contact tracing - funding allocated to train and hire tracers has barely been touched. It sucks because we had few enough cases to theoretically make if effective, but the horse is out of the barn now. 
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That's a real failure on the part of local+state government and the departments of public health.  Again, wishcasting that this will all go away and you'll be spared.

 
NBA, Yale land the COVID testing breakthrough the NFL (and the general U.S. public) has been hoping for

https://www.yahoo.com/sports/the-nba-and-yale-just-landed-the-covid-testing-breakthrough-the-nfl-and-everyone-else-in-the-us-has-been-hoping-for-183335566.html

In a significant turn of events in COVID-19 testing, the U.S. Food and Drug Administration granted an emergency authorization for the public to begin employing a saliva-based test expected to significantly increase the availability, turnaround time and affordability of combating the coronavirus epidemic in the United States.

Developed by Yale University and jointly funded by the NBA and NBA Players Association, the testing method was granted approval by the FDA on Saturday.

The test — coined SalivaDirect — was developed to throttle up the screening process for a wide swath of Americans. The FDA approval marks a significant turn for testing in the U.S., creating the opportunity to make regular testing more readily available.

The retail pricing and companies that will carry the testing into the public domain are yet to be determined. The developers have revealed that testing could be done for as little as $4, although retail pricing is expected to be higher than that due to the cost of production, marketing, supply lines and retail outlet markups.

Fast test promised to be game-changer for sports

The test is expected to be a boon for the general public and professional sports as well. The testing of players and team employees would become an affordable and consistent occurrence, and it could help fans keep themselves safe before and after event attendance. Multiple NFL general managers told Yahoo Sports in early June that medical advisers told them a fast and affordable saliva test would be a game-changer for the league’s fall season.

“There we go,” one NFL general manager said on Saturday afternoon, reacting to the news. “I hope that ends up being the route the league goes!”

The peer review process has yet to take place on the SalivaDirect findings, but the data produced by Yale showed nearly identical results between groups of NBA players and staffers who were given both nasal swab testing and saliva testing. With the funding and backing of the NBA and the players union, that testing took place as the league began to ramp up preparations to finish its season in its Orlando bubble.

Fulfills country’s need for rapid, cheap, widespread testing

While other saliva tests for COVID-19 have been developed — and also received FDA approval — there have been complications with costs from $75 to $150 per test at the retail level. Turnaround times have also been as long as 48 hours. Those are two significant hurdles that the Yale research was hoping to dramatically change, aiming to make the test more affordable and the resting results more rapid. The driving theory behind that reach is that if more Americans can be tested faster and more affordably, the ability to respond to positive tests, while limiting exposure to others, will be dramatically increased.

The Yale test is also aimed at making the processing of tests more widespread in laboratories that meet the standards of an approval process developed by the university. Essentially, if any testing labs can show that they have the equipment to process the results safely, quickly and accurately, they can be considered for approval. That could rapidly expand the network of labs processing results, which could speed up turnaround times and also keep costs at a lower level.

While some professional sports teams are already using the pricier saliva testing methods and the NFL and NFL Players Association approved aggressive nasal swabbing protocols, all sports leagues that hope to host fans would be aided by faster testing methods in the population. Additionally, a fast saliva test could create the opportunity financially and structurally for the NFL and other leagues to have every employee orbiting their operations tested on a regular basis.
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Have had a run of going to places to get takeout only to see the employees not wearing masks, or wearing them covering their mouth but not their nose. I was trying to stick to places I felt more comfortable about too, and places I have frequented for a long time that I wanted to help make sure they stay in business.

Feeling like I can't trust anywhere anymore at this point and should just cook everything at home. :(

 
growlers said:
I have intubated probably 30 or so people with covid since the pandemic started.   When it first hit, we were intubating people early before they crashed (made sense at the time, it's the standard of care for literally just about every prior similar respiratory situation except maybe asthma). But as the pandemic evolved, we now use high flow nasal cannula and will allow people to have O2 sats even in the low 80's sometimes for days to even weeks as these patients do poorly on vents.   But now I wind up going to the ICU every night to intubate people that are essentially corpses whose family refuse to DNR despite the fact that there is simply no way they will live.   I think everyone I've intubated in the last month has died.    About an hour ago I intubated a 72 year old with multiple preexisting conditions who was admitted july 25th, has pneumothoraxes in both lungs and finally became so altered she couldn't hang on.   Family refuses to accept reality.   She will be dead within 48 hours.  I don't understand why this is the culture in america.  

In almost every other country this patient would never get intubated.  It's futile care.   The medical team in other countries, even with advanced healthcare systems with plenty of ventilator availability like australia and europe wouldn't  even offer it as an option.. Not to mention that everyone is risking their own health to take care of these futile cases.  The care of these futile cases sucks up millions and millions and millions of dollars.  A lot of these patients have even had palliative care consults and families still want everything done, even dialysis and massively invasive procedure   Insane.
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great posting.

 
growlers said:
"They didn't know what they were signing"

"She revoked that"

"That's not her signature- the nursing home filled that out so they can't be sued if she dies there"

"I was never consulted about this"

http://dpbh.nv.gov/Reg/DNR-POLST/EMS_-_DNR_POLST_Forms/

Many people do not realize that, because an Advance Directive is not a medical order, if their heart should stop emergency medical responders (ambulance personnel) are required to attempt resuscitation even if your Advance Directive states that you do not want to be resuscitated. Only a POLST or Out-of-Hospital DNR is effective in avoiding resuscitation efforts.

In real-life ER situations - if the patient are unable to tell me what they want, and are gonna die if I don't do something immediately, and there is a family member screaming at me to do everything, I'm gonna do everything as that can be reversed if the family changes their mind. If the patient dies there is no going back.  An advanced directive means nothing in this scenario (as shown above).  If the patient shows up with an actual out of hospital DNR that looks valid then I will make a judgement call if there is family dissent. Again, keep in mind I am talking about very stressful time sensitive situations, not someone who has already been on a vent for a week and there is an end of life discussion.

Occasionally EMS will tube someone and then the papers show up later (not an advanced directive, but an POLST or DNR) - I've pulled tubes in this situation but if they patient is stable on the vent ethically you typically get family consent.    If they code in the meantime I'll not do CPR and let 'em go, but all this is not as clear cut as you imply.

The hospice revocations are even worse - and more common.  Happens all the time.   If they patient is unable to answer, family can revoke hospice at any time.  Keep in mind it is often the family that decided on hospice in the first place, so logically they can revoke it at any time legally (but maybe not ethically)
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I am so sorry that this is a significant part of your life. I can only imagine the stress.

I believe it is a form of torture to keep people alive past their expiry. Unfortunately expiry is a large gray slice at the end of life. 

My wife and I have no kids and we are both quite clear on our stances on this with one another. We're just now 65 and expect to alter those stances as we get closer to 85. 

Everyone should be forced to carry one of those odds cards like they have for Blackjack or Poker. 

Another huge problem is the ones who slowly decline with no life-ending events, but just end up spending 10 years staring at a tv and not really know what's going on. Then you start getting to a line where I would want an assisted suicide in place, but I don't see how that will ever happen when we still have ventialtor farms.

 
GregR said:
Have had a run of going to places to get takeout only to see the employees not wearing masks, or wearing them covering their mouth but not their nose. I was trying to stick to places I felt more comfortable about too, and places I have frequented for a long time that I wanted to help make sure they stay in business.

Feeling like I can't trust anywhere anymore at this point and should just cook everything at home. :(
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I'm still pretty comfortable getting drive-thru fried chicken or pizza. Neither has to be touched and is cooked at high enough temps to kill about any bug. Not comfortable with much else, especially at "family" restaurants. To many points in the process where things could go wrong.

 
GregR said:
Have had a run of going to places to get takeout only to see the employees not wearing masks, or wearing them covering their mouth but not their nose. I was trying to stick to places I felt more comfortable about too, and places I have frequented for a long time that I wanted to help make sure they stay in business.

Feeling like I can't trust anywhere anymore at this point and should just cook everything at home. :(
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Yup. Been ordering our pizza for delivery for the last 2+ months even though we live right behind the plaza where the pizza place is. Ordered for pickup this last week and when I went in 2 of the workers had their masks dangling from one ear. I get that it’s hot working near a pizza over in a tiny space, but they’ve got like 8 people crammed into a tiny space. I know that fomite transmission is very improbable, but I just don’t want any part of that for awhile. 

 
proteus126 said:
Are the tests effective if you are "pre-symptomatic"?  I'm assuming you are feeling fine, but had to get tested due to a recently past exposure to a positive.
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You're supposed to wait a couple days after an exposure before being tested. And yes, you can test positive when presymptomatic - at least one study showed the viral burden in the nasopharynx was highest one day before symptoms developed.

 
Terminalxylem said:
You're supposed to wait a couple days after an exposure before being tested. And yes, you can test positive when presymptomatic - at least one study showed the viral burden in the nasopharynx was highest one day before symptoms developed.
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Gotcha.  I'm surprised that a single test is considered sufficient.  What if you were one of those folks who doesn't develop symptoms until, say, Day 9 post-exposure.  If you were tested on Day 3, what are the chances that you may not have developed a significant viral burden yet?

 
Dropped off daughter at college yesterday. I'm revising my estimate down from one month before they got to all online to something less than that. Entire apartment complex moved in Saturday & Sunday. Most everyone started with masks but after about the 2nd or 3rd trip of stuff the masks were gone and by the end of the day, no masks. She's living "off campus" so no testing required before move in. On campus housing (mostly freshman & upper classmen) needed a test before going into dorms then mask police everywhere enforcing mask usage. Most everyone lives off campus so even at a 2% infection rate, there's no way this doesn't spread quickly if it catches fire.

Hope not because I really like where she is at and she's looking forward to getting back to some kind of normal (and out from under mom & dad). Hoping for the best  :thumbup:

 
My nephew tested positive last week.  22 years old, he's very athletic, in great shape, no health issues at all, but this thing kicked his butt.  He had aches, pains and lethargy.  He spent all day in bed on Tuesday.  Felt better after that though.  Makes me wonder about my kids heading to college when their cousin had a pretty rough go of it.

My nephew lives with my sister & brother in-law.  They both felt sick last week, but she tested negative and he didn't bother getting tested.  The line was too long.  

If that negative test for my sister is correct, I have to wonder if she's got some immunity or something because it's not plausible to have not been massively exposed when your kid has it and you took care of him, right?  Or she just had a false negative?

 
parasaurolophus said:
Hospitalizations down to 357 in WI

ICU down to 137. 

1233 ventilators available.
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I have given up trying to make heads or tails of the data in WI on this thing. Today hospitalizations are at 347. ICU is at 105. They don't even give the Ventilator availability numbers anymore because it isn't even relevant(although you can find how many in use and figure out yourself if so inclined).

Those numbers were April 19 after like a month of being shut down. Current is after months of being almost completely open

I can go eat at a restaurant, sit at a bar, gym, go to the mall, etc. Only thing I cant do is go to a theater, because they just arent open because studios arent really releasing movies. 

I was arguing the state should be opening up more then because those numbers were well below capacity. Today, numbers are identical after fully opening. (technically lower, but they bounce up and down from day to day in that same range and have been there pretty much ever since. Some weird days where there were massive spikes or dips that fixed themselves the next day so I always assumed those were just discharge and admittance lags. ICU is definitely way down though). 

ETA: technically I think Dane county has an inside dining restriction right now so state isn't fully open, but they put that back in place and I don't think it really mattered for hospitalizations. 

 
Last edited by a moderator:
parasaurolophus said:
I have given up trying to make heads or tails of the data in WI on this thing. Today hospitalizations are at 347. ICU is at 105. They don't even give the Ventilator availability numbers anymore because it isn't even relevant(although you can find how many in use and figure out yourself if so inclined).

Those numbers were April 19 after like a month of being shut down. Current is after months of being almost completely open

I can go eat at a restaurant, sit at a bar, gym, go to the mall, etc. Only thing I cant do is go to a theater, because they just arent open because studios arent really releasing movies. 

I was arguing the state should be opening up more then because those numbers were well below capacity. Today, numbers are identical after fully opening. (technically lower, but they bounce up and down from day to day in that same range and have been there pretty much ever since. Some weird days where there were massive spikes or dips that fixed themselves the next day so I always assumed those were just discharge and admittance lags. ICU is definitely way down though). 

ETA: technically I think Dane county has an inside dining restriction right now so state isn't fully open, but they put that back in place and I don't think it really mattered for hospitalizations. 
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I have also been waiting for the other shoe to drop in Wisconsin (I live on WI/IL border) and it just never happens. It has to remind one of Sweden's experience, although many people like to say the Swedes are a generally healthier people overall with lower obesity rates, etc. That doesn't exactly apply to Wisconsin.

 
parasaurolophus said:
I have given up trying to make heads or tails of the data in WI on this thing. Today hospitalizations are at 347. ICU is at 105. They don't even give the Ventilator availability numbers anymore because it isn't even relevant(although you can find how many in use and figure out yourself if so inclined).

Those numbers were April 19 after like a month of being shut down. Current is after months of being almost completely open

I can go eat at a restaurant, sit at a bar, gym, go to the mall, etc. Only thing I cant do is go to a theater, because they just arent open because studios arent really releasing movies. 

I was arguing the state should be opening up more then because those numbers were well below capacity. Today, numbers are identical after fully opening. (technically lower, but they bounce up and down from day to day in that same range and have been there pretty much ever since. Some weird days where there were massive spikes or dips that fixed themselves the next day so I always assumed those were just discharge and admittance lags. ICU is definitely way down though). 

ETA: technically I think Dane county has an inside dining restriction right now so state isn't fully open, but they put that back in place and I don't think it really mattered for hospitalizations. 
Click to expand...
Its called beer.

 
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