orthopa

Orthopa, the problem is that what you're saying doesn't seem to align with evidence. It seems fairly clear that a bunch of people have died in Italy, Iran, and China as a result of COVID-19. You seem to be claim is that millions in the USA have been infected a long enough time ago that we'd already be seeing lots of deaths if COVID-19 were a big deal. But USA has not seen lots of deaths. So, to be credible, you need to make it simple for us to understand this disconnect. Are Americans just more robust than the Italians, Iran, or Chinese? Do Americans have some sort of herd immunity that makes them less likely to die? Are Italy, Iran, and China simply pretending to have all these deaths, when really, they don't? Is there something about American culture that allows millions to catch COVID-19, but nobody to die? If you don't have some explanation for this disconnect between your hypothesis of millions infected but nobody dying, the most reasonable thing for people to believe is that your hypothesis is wrong. Particularly considering that there doesn't actually appear to be any evidence for your hypothesis except "some people got sick this flu season and didn't die, and it's conceivable that those people had COVID-19". (That said, I don't think you're ignorant. I think you've got the "I'm smart and know a lot about the topic, so my hypothesis unsupported by evidence must be right, and I'll defend it unto death" thing going. Pretty well all smart people make that mistake occasionally.) I guess you certainly to posit that I am anchored. But its hard to argue with my own experience, my own 2 eyes and my medical knowledge. If I'm wrong in the end I'm certainly willing to eat crow.

I don't disagree with you that people are overreacting about the overall health position. My problem is that governments & businesses are reacting by shutting everything down and spreading fear, meaning businesses are not operating normally. Until people feel confident in going out and mingling properly, I think there will be a problem. In Europe movement is going down, and it feels like this will happen much more in the US. I suppose perhaps one question is if Asia will now outperform as they're ahead of the curve, and share prices have suffered comparatively with the US for so long. But I still suspect that things are too interconnected. No question this is becoming a big problem economically.

I have said it before, and I'll say it again. I think it is very easily explained that there are multiple sides to this and each side is right. I'll explain in a moment. First a question. Orthopa, what percentage of the beds in your hospital are available on an average day? What about ventilators? Also, how many total patients have you personally seen that you believe have COVID-19? Were any diagnosed as COVID-19? I just called the hospital and talked to the charge nurse on each floor. Hospital is ~ 85% full but that is very fluid and changes by the hour as people are admitted and discharged. Ventilator only used in ICU. 80% full. Don't know any of the diagnoses though. Now mind you this is a suburban hospital in town with 9 other hospitals within 20 miles. That could vary in each one. In that data I suggested I saw 165 of those patients. None were tested for corona. All in the group looked at were diagnosed with viral illness.

https://www.yahoo.com/news/dont-panic-says-us-woman-recovered-coronavirus-055155667.html Was I a bit early maybe? This was about a week ago. We will see. Ill be sure to check back and quote this when we get a similar narrative above in the media. 8)

Seems to? LOL. This is what is GOING ON!!!! Again. I treat patients in an ER and have been seeing this for weeks!!!! We just went back and retrospectively called all of our negative flu swabs from my clinic for 6 weeks. All 1450 people recovered NO ONE DIED. There were 2 hospital admission. Again no way to know if these were corona positive but again.....we are in a pandemic right?? ??? ??? ??? ??? are you holding cash or mostly invested? Mostly/fully invested. Eventually as more people are tested we will find the death rate plummets and thousands and thousands if not millions had the virus and recovered and were asymptomatic.

I would invite everyone to go back and read my first post in this thread. I dont have time look now, then read the yahoo article gregmal posted. That being said realize in this thread I have been called "ignorant", a "cabbage brain", "blind", and have had very little offer. 8)

Seems to? LOL. This is what is GOING ON!!!! Again. I treat patients in an ER and have been seeing this for weeks!!!! We just went back and retrospectively called all of our negative flu swabs from my clinic for 6 weeks. All 1450 people recovered NO ONE DIED. There were 2 hospital admission. Again no way to know if these were corona positive but again.....we are in a pandemic right?? ??? ??? ??? ???

I think you have an excellent understanding of this at this point, and apparently able to put it down on paper better then me. Thanks. Just trying to make sure I fully understand the various perspectives. Again, apologies again for the comment before re: the profession you've chosen. It meant no disrepect. I do want to ask you - if you were to take a step back and think about your position, where could you be wrong? I could be wrong by how much of a hit this will be to the ICU/need for respirator, ie breakdown of health system. I can only think back to working during the H1N1 outbreak and the 17-18 flu season and that volume load which was ~15 million cases if I recall correctly. The system was stretched, but did not collapse, My opinion is the virus has been here for 6 weeks/months and cases are vastly under reported. So in my mind we are currently in an environment of where many think we will be from documented patient 1 say 4-6 weeks from now, already! Its in this mind frame I have a hard time rectifying a wickedly high death rate and medical system collapse if we are operating in this environment currently. I certainly could be wrong on this, I hope I'm right of course. We will see. The fact of the matter is if the cases are severely under estimated and we are handling it now maybe we are further along on the curve then we think, and handling it fine. Thanks, that's a helpful perspective to understand the disconnect given your view. So a few follow up questions / thoughts: 1) If it's been here for that long, is it possible that people are dying in smaller numbers and we haven't been seeing them due to the deaths being dispersed and thus not counted as COVID19 related deaths? Is there a national database to check real time death rate (regardless of cause of death)? 2) Is it possible that the density of our cities decrease R0 vs. other countries (along with an advanced heads up from seeing what happened in Wuhan)? 3) Is CFR lower than what we have been told? Or maybe virus has mutated? I don't know what else could cause a disconnect between your hypothesis that it's been here for a while, and the lack of impact we are seeing. Either you are wrong about the date of arrival and the number of people in the population, or the R0/CFR rates are wrong or changing significantly, or we're not capturing the impact somehow. What else could it be? I think where you are getting off track is that corona virus does not equal death. It does not equal ICU. It does not equal respirator. The vast, vast, vast, vast majority of people, even elderly will not DIE. People dont believe it has been here for a long time because there have only been a small number of deaths.....but again. Corona does not equal death!!! You do not have to die to have corona. You do not have to be tested to have corona virus.

Hopefully this is (I think it will be) a short term, hopefully first half shock to the economy but its hard to not think about Calabria talking about "when the sun is shining". Im not sure that an extended market swoon would necessarily force mnuchins hand in any negotiation in to the absence of legal action but surely would make raising billions of capital more difficult if things continue the way they are. This would have to continue on for some time to ripple through but it would be a real pisser if it started to hit retained earnings making hitting capital mileposts harder/take longer.

I think you have an excellent understanding of this at this point, and apparently able to put it down on paper better then me. Thanks. Just trying to make sure I fully understand the various perspectives. Again, apologies again for the comment before re: the profession you've chosen. It meant no disrepect. I do want to ask you - if you were to take a step back and think about your position, where could you be wrong? I could be wrong by how much of a hit this will be to the ICU/need for respirator, ie breakdown of health system. I can only think back to working during the H1N1 outbreak and the 17-18 flu season and that volume load which was ~15 million cases if I recall correctly. The system was stretched, but did not collapse, My opinion is the virus has been here for 6 weeks/months and cases are vastly under reported. So in my mind we are currently in an environment of where many think we will be from documented patient 1 say 4-6 weeks from now, already! Its in this mind frame I have a hard time rectifying a wickedly high death rate and medical system collapse if we are operating in this environment currently. I certainly could be wrong on this, I hope I'm right of course. We will see. The fact of the matter is if the cases are severely under estimated and we are handling it now maybe we are further along on the curve then we think, and handling it fine.

You obviously aren't going to change your opinion because you've made it clear where you stand (at last for today), so this is as far as we go. I've posted citations I think are worth readers' time. I can understand all sorts of opinions in life, but this is one I think is plainly ignorant. You may have a lot of healthcare experience, but most every doctor and organization with on-the-ground experience or oversight of this disease contradicts you. You want people on this board to respect your experience but you refuse to acknowledge the more relevant experience of others saying you are wrong. It's hubris. And be thought a fool by everyone with a strong opinion? Better to remain silent. ;) @orthopa I think what folks are saying when saying testing is important is that identifying as many spreaders as possible is key to containment. You can't catch them all. Don't let perfect be the enemy of the good. Some folks spread to 1 person. Some spread disease to dozens. You want to eliminate as many spreaders as possible so that the disease population can't reach escape velocity. Basically to the point above about the number sick at any given time being semi-controllable. Whats your plan for asymptomatic people/kids who don't seem to be affected and dont go to the doctor? I already answered. You can't catch everyone. Any additional you do catch early can moderate the number sick at any given time. You might not be able to control total number to get sick, but spreading that number out over a longer period leads to far better outcomes in aggregate. That's why people are testing. Further, WHO says adult to child transmission is more common than reverse, as opposed to seasonal flu. To the "it's been here for 1+ month" comment, viruses compound when no one has immunity. I don't disagree with this point on spreading it out, but what exactly is the threshold (number of patients a hospital can hold)? Healthcare capacity is derived and constructed off of averages and then scaled according to population. A pandemic by nature is already over-capacity right? If I had to guess the threshold is quite low and I'm doubtful any solutions will be effective. The US is especially difficult to contain and isolate due to its size, efficiency and reliance on individual travel (interstate) compared to small countries like Germany (who funny enough just announced 3/4 of their citizens are likely to be infected). If small countries that heavily rely on public transit can barely contain this thing how can a vast country like the US contain it? I guess scale could make quarantining sections of the country possible, but with the reliance on individual transit it feels like a bucket full of holes trying to carry water. For some reason I have it in my head you are an engineer. Recall the concept of load factor. In theory, it is what you say, a planned amount that is certain to be overwhelmed in situations like this. In practice, pop-up hospitals/clinics/designated testing areas can absorb certain types of healthcare traffic that provide additional capacity. The military is capable of providing healthcare that is highly scalable and I'm sure they have procedures the broader population could copy. We can already see the pop-up additional capacity concept being used in WA. Nope Im a physican that works in the ER/Urgent care. Im the "ignorant" fuck adding no value that would walk in to see if you went to the hospital with these symptoms.

I think you have an excellent understanding of this at this point, and apparently able to put it down on paper better then me.

Has everybody in this discussion actually concocted a model for this? Seriously, 15 minutes with a spreadsheet can be quite instructive. You soon learn that the potential of flattening the curve is driven largely by your assumptions of 1) How many people seek medical help and are instructed by physicians to self isolate, vs how many have mild symptoms and just continue with day-to-day life; and 2) What is the effective R0 for those who self-isolate vs the R0 of those who have mild cases and just continue on with business as usual. If you are in the camp that there is a large group that is not destined to self-isolate, there's not much that can be done to flatten the curve. Seriously, if people haven't already done so, go ahead and model it. And by the way, if somebody disagrees with your modelling assumptions, don't accuse him of not understanding math or being stupid. SJ BINGO!!

Everything you are saying is based on this assumption, which has no proof! Obviously the lack of testing in the US means this could be true. But extremely unlikely based on what we are seeing in other countries. In Ontario, we have tested just under 3000 people and 36 were positive. That is just over 1% positive from people deemed high risk of the virus. This is not a virus that has been silently going around for months. You are just wrong on this. And repeating it 50 times does not add value. https://www.latimes.com/science/story/2020-03-10/us-coronavirus-cases-far-above-official-tally-scientists "An analysis of the novel coronavirus’ spread inside the United States suggests that thousands of Americans are already infected, dimming the prospects for stomping out the outbreak in its earliest stages." "Released into a country of about 330 million, each of these travelers was assumed to have passed the virus to 2 to 2.5 people, each of whom in turn infected another 2 to 2.5 people, and so on. Tote up the nodes on this rapidly branching network of contacts and the number of victims balloons quickly, the researchers wrote." "That only accounts for U.S. residents whose infections originated with people carrying the virus directly from Wuhan, the epicenter of the outbreak in China. In reality, many more people likely have brought the virus here from other hot spots, including Italy, South Korea and the rest of Asia. Each virus carrier who arrived from those places would set off his or her own cascade of infections" "But estimates of the coronavirus’ reproductive rate in circumstances where it is spreading undetected has ranged between 5 and 6, so the researchers may have greatly underestimated the number of infections in the United States, Burke said. “The overall conclusion is, it’s very likely there’s a significant burden of disease we have yet to uncover,” Chowell said. Some of that will likely show up as testing for the disease becomes more commonplace, he said. But much of the outbreak’s unseen underside may never be counted." https://www.washingtonpost.com/health/coronavirus-may-have-spread-undetected-for-weeks-in-washington-state/2020/03/01/0f292336-5bcc-11ea-9055-5fa12981bbbf_story.html Its been in the country for months. Maybe you believe it, if you read online instead? ???

It's not clear what you mean by asymptomatic, but WHO and many others say they believe asymptomatic cases are extremely rare. China for example went back and retested old samples that were collected and tested only for influenza A and B, or for other tests. They found almost 0% in the general population. That would indicate that there are not people running around China who have it and don't know. On the other hand, it is believed that asymptomatic transmission can happen early before symptoms present. It is important to note that though everything MacIntyre said is accurate, it is believed that as in other viral infections newly infected patients who are asymptomatic are believed to shed the virus much less than patients whose disease has progressed. For example, viral loads could be expected to be higher later, and coughing and sneezing would increase the risk of droplet infection. Asymptomatic people would be less likely to be coughing and sneezing, and the viral load per droplet likely lower too. These are just a few of the reasons recently innoculated asymptomatic people are believed to be less infectious. So while what MacIntyre said is accurate, extrapolating that there are thousands of asymptomatic spreaders who will have no illness or mild illness does not reflect the current scientific conventional wisdom at this point as far as I know. https://newyork.cbslocal.com/2020/03/09/coronavirus-update-new-jersey-patient-speaks-out/ "Cuomo also made a surprise announcement. One of the latest cases is a top transportation official in charge of the airports: Rick Cotton, executive director of the Port Authority. Cotton is in his mid-70s and is asymptomatic." “He’ll be working from home and the senior team that work with Rick will also be tested,” Cuomo said. Maybe its just in Singapore and New Jersey there are asymptomatic people? No way it could be in Ontairo like KC said. They tested all 3000 people. Your shedding the disease regardless, even if less. Still no bueno, and undetected, untested.

Everything you are saying is based on this assumption, which has no proof! Obviously the lack of testing in the US means this could be true. But extremely unlikely based on what we are seeing in other countries. In Ontario, we have tested just under 3000 people and 36 were positive. That is just over 1% positive from people deemed high risk of the virus. This is not a virus that has been silently going around for months. You are just wrong on this. And repeating it 50 times does not add value. The danger of loudmouth cabbage brains is they convince people in charge and that leads to danger for all of us. This is not an extinction event, but it sure makes you realize exactly how we would approach a real extinction threat—in the same way. This thread is toxic. Why do you keep replying and reading if this thread is toxic?

Everything you are saying is based on this assumption, which has no proof! Obviously the lack of testing in the US means this could be true. But extremely unlikely based on what we are seeing in other countries. In Ontario, we have tested just under 3000 people and 36 were positive. That is just over 1% positive from people deemed high risk of the virus. This is not a virus that has been silently going around for months. You are just wrong on this. And repeating it 50 times does not add value. How many asymptomatic people were tested? Have you been tested? Secondly whats your read on the bloomberg singapore article?

And be thought a fool by everyone with a strong opinion? Better to remain silent. ;) @orthopa I think what folks are saying when saying testing is important is that identifying as many spreaders as possible is key to containment. You can't catch them all. Don't let perfect be the enemy of the good. Some folks spread to 1 person. Some spread disease to dozens. You want to eliminate as many spreaders as possible so that the disease population can't reach escape velocity. Basically to the point above about the number sick at any given time being semi-controllable. Whats your plan for asymptomatic people/kids who don't seem to be affected and dont go to the doctor? I already answered. You can't catch everyone. Any additional you do catch early can moderate the number sick at any given time. You might not be able to control total number to get sick, but spreading that number out over a longer period leads to far better outcomes in aggregate. That's why people are testing. Further, WHO says adult to child transmission is more common than reverse, as opposed to seasonal flu. To the "it's been here for 1+ month" comment, viruses compound when no one has immunity. I don't understand "why bother trying, just make fun of the try-hards" attitude just because we can't be perfect in prevention. Best not waste time arguing with brains turned to cabbage. They keep on pounding it in as Munger says. He’s not the only one with healthcare experience. Anyone who mocks those who look at graphs, reads Taleb, etc is in for a reckoning. Edit: it is clear there are countries doing a good job vs not and clear which way the U.S. is headed. What we have to fight is inertia and those saying “just another flu” or “nothing can be done”. Those things are categorically false just by observing how certain countries are approaching this right now. Hi Dalal, you couldnt go a whole month again could you??? Where are we supposed to be case wise on your graph again?

And be thought a fool by everyone with a strong opinion? Better to remain silent. ;) @orthopa I think what folks are saying when saying testing is important is that identifying as many spreaders as possible is key to containment. You can't catch them all. Don't let perfect be the enemy of the good. Some folks spread to 1 person. Some spread disease to dozens. You want to eliminate as many spreaders as possible so that the disease population can't reach escape velocity. Basically to the point above about the number sick at any given time being semi-controllable. Whats your plan for asymptomatic people/kids who don't seem to be affected and dont go to the doctor? I already answered. You can't catch everyone. Any additional you do catch early can moderate the number sick at any given time. You might not be able to control total number to get sick, but spreading that number out over a longer period leads to far better outcomes in aggregate. That's why people are testing. Further, WHO says adult to child transmission is more common than reverse, as opposed to seasonal flu. To the "it's been here for 1+ month" comment, viruses compound when no one has immunity. I don't understand "why bother trying, just make fun of the try-hards" attitude just because we can't be perfect in prevention. So your ok with catching 50 for every 50 that run free? Looks like your in cahoots with those in charge in Singapore.

https://www.bloomberg.com/news/articles/2020-03-11/singapore-warns-of-complacency-while-new-virus-infections-surge “It was premature to perceive Singapore’s epidemic as under control, as we know there is asymptomatic transmission and that some cases may have been missed,” said Raina MacIntyre, professor of infectious diseases at the University of New South Wales. “There could have been undetected chains of transmission in the community as a result.” The asymptomatic likely number in the thousands, just like all over the rest of the world. Again you test everyone or your wasting your time.

And be thought a fool by everyone with a strong opinion? Better to remain silent. ;) @orthopa I think what folks are saying when saying testing is important is that identifying as many spreaders as possible is key to containment. You can't catch them all. Don't let perfect be the enemy of the good. Some folks spread to 1 person. Some spread disease to dozens. You want to eliminate as many spreaders as possible so that the disease population can't reach escape velocity. Basically to the point above about the number sick at any given time being semi-controllable. Whats your plan for asymptomatic people/kids who don't seem to be affected and dont go to the doctor?

Weren't we just arguing about this in my example of extended contact at airport ? Now because he says it, its true? LOL Orthopa, do you think you can slow down a bit and try to communicate a little more clearly? I think you are making some good points, but it seems your points may not be getting across clearly or that you may even be misunderstood. This post in particular makes me think that is the case. I also thought your earlier point about testing the role of testing in a diagnosis is likely a good point, but was probably too hasty to get your point across. Maybe some other medical professionals could weigh in on that, especially if you're to busy to respond. I dont know how much more I can slow down. I have probably posted 50 times? Trying to get some points across. Am I completely right?, of course not but I have experience FWIW. Others have graphs, twitter links, and or political angles which are underwhelming at best sometimes. Again points that I have made that I believe are true FWIW (we are allowed an opinion right?) 1. The virus has been here for months, likely early January and has been seen/dealt with in the health system under other diagnoses for months. 2. The first test confirmed, was not the first test here. 3. There was nothing the government or any nation in the world could do to stop the initial spread 4. Older people and those most at risk will die. There is no cure, and viruses kill people. Elderly people should take appropriate precautions. 5. Because the virus has been here for months testing is borderline useless and your going to chase your tail the entire time. This is due to numerous contacts and the extended incubation period. 6. If you don't test everyone the virus will continue to spread quickly, again via asymptomatic people and kids. Best policy is to test everyone, but its impossible and too late. 7. Best way to prevent spread is standard precautions! This includes isolation, hand washing, yada, yada. NOT TESTING. 8. If a patient test positive and there has been minimal definite contacts say someone who is home bound with a handful of contacts testing may make sense but these are limited cases. 9. The the spring/summer will bring a reprieve in new cases and hopefully that was well as the fact that nearly everyone will have been exposed or infected this will limit virgin hosts. 10. A vaccine is useless if the virus mutates significantly. 11. The number of cases are vastly under reported, probably numbering in the millions by now in the US. 12. If someone you know or yourself had a cold/URI/flu symptoms that tested negative, and was "way worse" then the common cold there was very high chance it is/was the corona virus. 13. Every case of the virus is not severe, so don't model it as such. Corona virus dx does not = ICU and ventilator. 14. I believe eventually those in charge medically will come to the conclusion that its inevitable that this becomes a pandemic with everyone getting infected in time. 15. If your human, you will get the virus in your lifetime. Nothing you can do. 16. Flattening the curve makes sense but I question when the curve will bump as the virus again likely has been here for months.

Uh oh, another spike in cases in N. Korea. Will need another response model to slob on next. Germany? France? Uk?

Looks like they have it in WA https://www.npr.org/2020/03/08/813486500/coronavirus-drive-through-testing-centers Well its not available in New York. Where can we source them? NY will need about 40 million of them.

Weren't we just arguing about this in my example of extended contact at airport ? Now because he says it, its true? LOL