Coronavirus

[StubbleJumper]

What constitutes "Healthcare system capacity"?

 

My view, with respect to a virus, is it constitutes all the available resources of a country that can be harnessed to ensure it is managed as well as possible: you do whatever it takes as a nation to avoid the red coloured curve in Liberty’s chart.

 

King County is now buying motels to house the surge of people who need to be quarantined. That motel is now part of the health care system. Creative solutions will be found.

 

 

For that county, perhaps it will soon be time to close a few schools so they can be converted into temporary hospitals.  If we are lucky, hopefully we will be able to scoot through until late May or early June without needing to generally do that kind of thing.  Chopping 3 or 4 weeks off the school year isn't the end of the world, but it would be nice to not chop 3 months off the school year.  The return to school in September should loom large in our minds.

 

 

SJ

[Liberty]

Well, that's a nice graphic that depicts the theory of taking protective measures.  Conveniently, the that graphic the protective measures are just adequate to not outstrip the capacity of the health care system  ;D .  But, Castanza's question is the right one.  "What is the capacity of the health care system?"

 

Our dirty little secret in Canada is that we surpass our system capacity nearly every winter when flu season hits its peak.  Principally older people become ill and require hospitalization and, most years, we have more patients than we have beds resulting in people being treated in hallways.  That graphic almost certainly does not fairly depict what will happen in Canada with Covid-19.  Demand will likely exceed capacity relatively early in the outbreak, and there will likely be inadequate hospital capacity for a number of consecutive months.  If I may be permitted a bit of gallows humour, our only saving grace will be that there might be a considerable number of long-term care spaces that become available over the period of the outbreak...

 

For Canada, re-draw that schematic with the system capacity line going through the centre of the word "Measures" and you might have a fairer depiction of what awaits us.

 

 

SJ

 

The graphic is an illustration of a concept, not a prediction or data about current levels of anything. I thought that was incredibly obvious so didn't think necessary to mention.

[StubbleJumper]

Well, that's a nice graphic that depicts the theory of taking protective measures.  Conveniently, the that graphic the protective measures are just adequate to not outstrip the capacity of the health care system  ;D .  But, Castanza's question is the right one.  "What is the capacity of the health care system?"

 

Our dirty little secret in Canada is that we surpass our system capacity nearly every winter when flu season hits its peak.  Principally older people become ill and require hospitalization and, most years, we have more patients than we have beds resulting in people being treated in hallways.  That graphic almost certainly does not fairly depict what will happen in Canada with Covid-19.  Demand will likely exceed capacity relatively early in the outbreak, and there will likely be inadequate hospital capacity for a number of consecutive months.  If I may be permitted a bit of gallows humour, our only saving grace will be that there might be a considerable number of long-term care spaces that become available over the period of the outbreak...

 

For Canada, re-draw that schematic with the system capacity line going through the centre of the word "Measures" and you might have a fairer depiction of what awaits us.

 

 

SJ

 

The graphic is an illustration of a concept, not a prediction or data about current levels of anything. I thought that was incredibly obvious so didn't think necessary to mention.

 

 

Of course it's a concept.  But, it is essential that we not simply drink the Kool-Aid that preventative measures will be adequate to ensure that demand does not outstrip capacity.  The graphic was conveniently drawn to give that impression (and maybe that graphic would be realistic for some countries with greater capacity). 

 

But, let's get real here.  In Canada we have 2.5 hospital beds for every 1,000 people.  That's 2.5 beds for available for all maladies, including cancer, heart attacks and car accidents.  If you are in the camp that expects 60%-70% of your population to catch this in the next 18 months, and if you believe that about 10% of those who catch it will spend 2 or 3 weeks in the hospital, we will almost certainly not have anywhere near adequate capacity.  Hence my suggestion that the capacity line for Canada should likely be drawn through the word "Measures" in the blue curve.

 

There's nothing wrong with prevention to change the shape of the curve, but it doesn't really change what is coming.  At a certain point you need to start thinking of ways to push the capacity line a bit higher...

 

 

SJ

[Guest cherzeca]

I have been reading this thread with some amount of incredulity, as I believe (based upon my reading and discussions with three friends who are doctors, one a pulmonologist and all three experts in their fields and published/with privileges at world class hospitals in NYC etc) that what essentially differentiates this coronavirus from a typical flu season is a specific name and a possibly insidious traceable origin.

 

people have referred to a mortality rate of 10X the normal flu, but this has been called into question by recent studies and the CDC, which lately has made the common sensical statement that it cannot be asserted what the mortality rate is with accuracy (just as the mortality rate of the normal flu is only a best guess).

 

if there IS a 10X mortality rate, this would imply that covid19 deaths will approximate 200,000-500,000 in the US.  to date, there are some 250 confirmed cases in the US and I believe 12 deaths.

 

precaution is called for, AS IT IS IN EVERY FLU SEASON, but panic is not called for.  but I find this panic diagnostic, not of the covid19 threat, but of our society's recent loss of common sense and good judgment.

[griezeman23]

 

but I find this panic diagnostic, not of the covid19 threat, but of our society's recent loss of common sense and good judgment.

 

 

+1

[Liberty]

 

Of course it's a concept.  But, it is essential that we not simply drink the Kool-Aid that preventative measures will be adequate to ensure that demand does not outstrip capacity.  The graphic was conveniently drawn to give that impression (and maybe that graphic would be realistic for some countries with greater capacity). 

 

But, let's get real here.  In Canada we have 2.5 hospital beds for every 1,000 people.  That's 2.5 beds for available for all maladies, including cancer, heart attacks and car accidents.  If you are in the camp that expects 60%-70% of your population to catch this in the next 18 months, and if you believe that about 10% of those who catch it will spend 2 or 3 weeks in the hospital, we will almost certainly not have anywhere near adequate capacity.  Hence my suggestion that the capacity line for Canada should likely be drawn through the word "Measures" in the blue curve.

 

There's nothing wrong with prevention to change the shape of the curve, but it doesn't really change what is coming.  At a certain point you need to start thinking of ways to push the capacity line a bit higher...

 

 

SJ

 

No, the concept simply shows that if you can squish down the curve, you get benefits, which is hard to understand for the "well, the genie's out of the bottle, it's all pointless, nothing to be done" crowd. And it does change what is coming, nothing about this is binary.

 

Not shown on the graph is also the possibility of a vaccine, so you could draw a vertical line at some point, and the part of the cruve that gets squished past that line could also have it a lot better by vaccinating the most at-risk populations.

[Gregmal]

I have been reading this thread with some amount of incredulity, as I believe (based upon my reading and discussions with three friends who are doctors, one a pulmonologist and all three experts in their fields and published/with privileges at world class hospitals in NYC etc) that what essentially differentiates this coronavirus from a typical flu season is a specific name and a possibly insidious traceable origin.

 

people have referred to a mortality rate of 10X the normal flu, but this has been called into question by recent studies and the CDC, which lately has made the common sensical statement that it cannot be asserted what the mortality rate is with accuracy (just as the mortality rate of the normal flu is only a best guess).

 

if there IS a 10X mortality rate, this would imply that covid19 deaths will approximate 200,000-500,000 in the US.  to date, there are some 250 confirmed cases in the US and I believe 12 deaths.

 

precaution is called for, AS IT IS IN EVERY FLU SEASON, but panic is not called for.  but I find this panic diagnostic, not of the covid19 threat, but of our society's recent loss of common sense and good judgment.

 

Pretty much. I think sensationalism has taken hold of a lot of really smart individuals and its feeds off itself to create momentum. The market is clearly in "voting machine" mode; one look at whats trending and popular tells one all they need to know there. Stocks with single digit PEs and robust cash flows getting hammered, corona themed pump jobs going bananas reminiscent of the crypto or marijuana bubbles.

 

Everywhere you turn its another dramatic reveal of "OMG more cases" when the truth shouldn't shock anyone. Given the carnage, that should be expected. Then you ask yourself, ok, so more cases...but what not revealed are the severity or context on any of them, except fo course, the scary ones where people are gravely ill or dying.

 

I actually found out yesterday an investor of mine, in Europe has it. He's in good spirits, texting away on his phone, chilling in his house; albeit uncomfortably. Thats most of the cases....But you're not hearing that anywhere. Its a constant barrage of panic inducing snippets and disgruntled or frustrated(rightfully so) healthcare workers screaming "THIS IS THE END", many of these with obvious political biases.

 

I tend to give less credence to the numbers and more to the narrative when the numbers are what everyone else is focused on, and when no one else is paying attention to the numbers, instead fixated on a narrative, I try to give the numbers my attention. More reports out today from retailers again confirming, at least to date, no noticeable difference in demand. Positive reports on China activity. Again, its not to say this cant evolve into something much bigger, but the "OMG MOAR CASES" and "LOOK AT THIS PARABOLIC CHART" stuff is just noise.

 

Obviously its a pretty big concern, we just lost a significant portion of market capitalization lol. But the way folks are acting you'd think by 1,000 US cases the market should be cut in half.

 

EDIT: and to further make a point, now, because of all the noise, look at how many idiots are inundating hospitals or hotlines with inquiries because of common allergies or a small cold! If our goal is to overwhelm the hospitals and drain our resources, the propaganda machines are certainly doing all they can.

[Guest cherzeca]

it's a buying opportunity.  you wont call the bottom but we are in a correction zone dip, and I dont see the conditions for a GFC 2.0, so all clear to buy.  I could be wrong, and acknowledging that I will buy stock nowhere near in the amount of my dry tinder, since I dont want to have to go back to work again

[thepupil]

You’re right, 102 years of medicine and healthcare advances may help fight this relative to 1918

 

I work in healthcare. The only advances that we have come up with in that time that are effective against this are 1) hand washing, 2) contact isolation, 3) mechanical ventilation (but by this point it is already way too late). Also, we severely lack # of ICU beds and resources which will become apparent soon. It is already apparent we lack resources if you look at how testing for this has rolled out.

 

Can someone help me reconcile dalal's (and some others' I've read, including healthcare professionals) view that we haven't really made advances in fighting this stuff and this headline today from Gilead / Seeking alpha.

 

how should one handicap this?

 

 

Gilead up 3% ahead of expected COVID-19 drug data readout

Mar. 6, 2020 1:56 PM ET|About: Gilead Sciences, Inc. (GILD)|By: Douglas W. House, SA News Editor

Evercore ISI's Umer Raffat says that preliminary data from a China-based study of Gilead Sciences' (GILD +3.4%) remdesivir for the potential treatment of COVID-19 could be available this month, ahead of the expected release in April. The study began in early February at Wuhan's Jinyintan Hospital, in the epicenter of the outbreak.

 

Health experts believe that the antiviral will show sufficient efficacy to warrant widespread deployment in an effort to corral the outbreak. A little over a month ago, the first confirmed case in the U.S., a man in Seattle, responded well to treatment. All symptoms, except his cough, resolved within a week.

 

Remdesivir (GS-5734), a nucleotide prodrug that blocks a key enzyme needed for viral replication, is also being developed for Ebola virus infection.

 

 

 

[Gregmal]

Theres nothing. Just fear mongering and stock promoter speak. Cases are up 78% and compounding at a greater rate than Warren Buffett in his prime! Truth? 3 to 6 to 13....Big whoop. We should be expecting much more than 10 cases in NY. Does each extra dozen warrant -2% on the S&P?

 

 

[Viking]

Here is some more sensationalism reporting:

- The 10 year bond has fallen from 1.88% (Jan 1) to 0.72% (today).

- oil is at $41.59 (down 9.4% on the day)

- credit spreads are starting to widen

 

Nothing to see here. Move along :-)

[Guest cherzeca]

"Remdesivir (GS-5734), a nucleotide prodrug that blocks a key enzyme needed for viral replication, is also being developed for Ebola virus infection."

 

it is my understanding this has been in development for awhile against other viruses (treatment, not a vaccine), and has already shown efficacy and safety in early testing on covid19, but more to come on that certainly. 

[Viking]

You’re right, 102 years of medicine and healthcare advances may help fight this relative to 1918

 

I work in healthcare. The only advances that we have come up with in that time that are effective against this are 1) hand washing, 2) contact isolation, 3) mechanical ventilation (but by this point it is already way too late). Also, we severely lack # of ICU beds and resources which will become apparent soon. It is already apparent we lack resources if you look at how testing for this has rolled out.

 

Can someone help me reconcile dalal's (and some others' I've read, including healthcare professionals) view that we haven't really made advances in fighting this stuff and this headline today from Gilead / Seeking alpha.

 

how should one handicap this?

 

 

Gilead up 3% ahead of expected COVID-19 drug data readout

Mar. 6, 2020 1:56 PM ET|About: Gilead Sciences, Inc. (GILD)|By: Douglas W. House, SA News Editor

Evercore ISI's Umer Raffat says that preliminary data from a China-based study of Gilead Sciences' (GILD +3.4%) remdesivir for the potential treatment of COVID-19 could be available this month, ahead of the expected release in April. The study began in early February at Wuhan's Jinyintan Hospital, in the epicenter of the outbreak.

 

Health experts believe that the antiviral will show sufficient efficacy to warrant widespread deployment in an effort to corral the outbreak. A little over a month ago, the first confirmed case in the U.S., a man in Seattle, responded well to treatment. All symptoms, except his cough, resolved within a week.

 

Remdesivir (GS-5734), a nucleotide prodrug that blocks a key enzyme needed for viral replication, is also being developed for Ebola virus infection.

 

This, of course, would be a game changer (and stocks will rock if it provides a cure and can be deployed quickly). I have no idea how accurate it is but we can only hope. The potential for this was also briefly mentioned in Liberty’s recent sensationalism post.

[Read the Footnotes]

You’re right, 102 years of medicine and healthcare advances may help fight this relative to 1918

 

I work in healthcare. The only advances that we have come up with in that time that are effective against this are 1) hand washing, 2) contact isolation, 3) mechanical ventilation (but by this point it is already way too late). Also, we severely lack # of ICU beds and resources which will become apparent soon. It is already apparent we lack resources if you look at how testing for this has rolled out.

 

Can someone help me reconcile dalal's (and some others' I've read, including healthcare professionals) view that we haven't really made advances in fighting this stuff and this headline today from Gilead / Seeking alpha.

 

how should one handicap this?

 

 

Gilead up 3% ahead of expected COVID-19 drug data readout

Mar. 6, 2020 1:56 PM ET|About: Gilead Sciences, Inc. (GILD)|By: Douglas W. House, SA News Editor

Evercore ISI's Umer Raffat says that preliminary data from a China-based study of Gilead Sciences' (GILD +3.4%) remdesivir for the potential treatment of COVID-19 could be available this month, ahead of the expected release in April. The study began in early February at Wuhan's Jinyintan Hospital, in the epicenter of the outbreak.

 

Health experts believe that the antiviral will show sufficient efficacy to warrant widespread deployment in an effort to corral the outbreak. A little over a month ago, the first confirmed case in the U.S., a man in Seattle, responded well to treatment. All symptoms, except his cough, resolved within a week.

 

Remdesivir (GS-5734), a nucleotide prodrug that blocks a key enzyme needed for viral replication, is also being developed for Ebola virus infection.

 

I agree with Dalal for the most part, but having studied drug development, I would also say that there is some chance we will get lucky and a known agent or preexisting drug may prove efficacious. Since it is new, the search for a treatment for this novel virus might prove to be low hanging fruit where drug development is as easy as it was 20-60 years ago back when random assay's might get lucky. In the old days it was as simple as throwing pasta against the wall to see if anything sticks compared to what most pharma and bio research consists of today.

 

So there's a chance we will get lucky. We might even get very lucky.

 

That doesn't mean the risks to society should be dismissed, even if we get lucky. If we manage to dodge a bullet, it won't mean there was never a bullet.

[mloub]

Another doctor here. (Never realized how many of us frequented this board until now!).

 

For non-medical folks the concept of Healthcare Capacity is squishy and abstract, but for those in the system it is very concrete.

 

The capacity to ventilate patients (breath for them using a breathing machine is one example of very specific healthcare capacity).

 

While the recorded mortality rate of Coronavirus is about 2% (give or take), we know that about 10% of identified infected patients develop severe pneumonia. Severe pneumonia effects your lungs capacity to exchange oxygen. If it gets severe enough, you would need a ventilator. The ability to ventilate patients using a machine is a very specific kind of healthcare capacity. In the Western world patients who are on a breathing machine are in the ICU and get round the clock monitoring. So they have a nurse at their bedside (that's 3 shifts of nurses per day), they have a respiratory therapist nearby to help trouble shoot issues with the machine (pressure settings, secretion suction, tube displacement, etc), and usually a team of doctors who round on them and oversee everything and make adjustments as needed.

 

I don't have hard statistics, but I would be shocked if the number of ventilators (even counting those in operating rooms and in storage) exceeded 200-300 per 1,000,000 residents in most healthcare systems.

 

That is the biggest bottleneck, imho. And that capacity is already being used at anywhere from 50-100% just dealing with the existing reasons people need ventilation (i.e. after major surgeries, from trauma, infection, etc). If you get a sudden wave of folks needing ventilatory support, they will most likely not be able to get it. We will be triaging folks who will get a ventilator and those who won't based on their overall chances of surviving the illness. This would be heart wrenching and very painful for healthcare workers, and patients' families.

 

We had the same discussions when SARS and H1N1 hit. I remember as a young trainee sitting in on an ICU meeting where they were hashing out how they would portion the 40 ventilators in their ICU if those infections began spreading widely. It was a very sobering discussion.

 

When I see some of our political leaders speaking about Coronavirus, I often find myself wondering if theyv'e counted the ventilators in their jurisdictions and worked backwards with the math to seem how many infections their systems could handle before reaching the venitlator breaking point. That is the kind of math most frontline workers are doing in their heads, and frankly that is why they are so focused on containing the outbreak. They understand the consequences if they don't.

 

M.

 

EDIT: Found this article after my original post. Looks like someone did a survey in canada and found we have capacity for 100-160 ventilated patients per million residents. (They expressed it as 10-16/100,000). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4426537/

 

[mcliu]

Same thing happened end of 2018 when yield curve inverted slightly, people panicked.

Then they saw stock prices fall, and they panicked some more.

In 10 years, this will be mostly forgotten like SARS.

 

I could be wrong and this is the start of the apocalypse.

[StubbleJumper]

 

Of course it's a concept.  But, it is essential that we not simply drink the Kool-Aid that preventative measures will be adequate to ensure that demand does not outstrip capacity.  The graphic was conveniently drawn to give that impression (and maybe that graphic would be realistic for some countries with greater capacity). 

 

But, let's get real here.  In Canada we have 2.5 hospital beds for every 1,000 people.  That's 2.5 beds for available for all maladies, including cancer, heart attacks and car accidents.  If you are in the camp that expects 60%-70% of your population to catch this in the next 18 months, and if you believe that about 10% of those who catch it will spend 2 or 3 weeks in the hospital, we will almost certainly not have anywhere near adequate capacity.  Hence my suggestion that the capacity line for Canada should likely be drawn through the word "Measures" in the blue curve.

 

There's nothing wrong with prevention to change the shape of the curve, but it doesn't really change what is coming.  At a certain point you need to start thinking of ways to push the capacity line a bit higher...

 

 

SJ

 

No, the concept simply shows that if you can squish down the curve, you get benefits, which is hard to understand for the "well, the genie's out of the bottle, it's all pointless, nothing to be done" crowd.

 

Not shown on the graph is also the possibility of a vaccine, so you could draw a vertical line at some point, and the part of the cruve that gets squished past that line could also have it a lot better by vaccinating the most at-risk populations.

 

 

You do not need to be insulting or condescending simply because others view the situation differently from you (I have generally found that it is best not to assume that I am the only one who has found Jesus). 

 

It is a completely valid thought process to question the potential efficacy of prevention measures and to advocate for preparedness measures, which might have a more tangible outcome.  If you are in the camp that you expect 80% of your cases are of the mild variety and that those 80% of people will largely continue with their day-to-day life, there's a limit to changing the shape of that curve.  If you are in the camp that the development of a potential vaccine is likely to take 12-ish months, ramping up production of it another couple of months, and then actually getting people vaccinated yet another couple months, then the vertical line appears in exactly the correct place on that graphic....which is to say that it appears so far to the right hand edge of the timeline that you cannot even see it.  We should certainly hope for a vaccine, but you are far better off to plan to not have one for the next year or year and a half.

 

 

SJ

[cubsfan]

Another doctor here. (Never realized how many of us frequented this board until now!).

 

For non-medical folks the concept of Healthcare Capacity is squishy and abstract, but for those in the system it is very concrete.

 

The capacity to ventilate patients (breath for them using a breathing machine is one example of very specific healthcare capacity).

 

While the recorded mortality rate of Coronavirus is about 2% (give or take), we know that about 10% of identified infected patients develop severe pneumonia. Severe pneumonia effects your lungs capacity to exchange oxygen. If it gets severe enough, you would need a ventilator. The ability to ventilate patients using a machine is a very specific kind of healthcare capacity. In the Western world patients who are on a breathing machine are in the ICU and get round the clock monitoring. So they have a nurse at their bedside (that's 3 shifts of nurses per day), they have a respiratory therapist nearby to help trouble shoot issues with the machine (pressure settings, secretion suction, tube displacement, etc), and usually a team of doctors who round on them and oversee everything and make adjustments as needed.

 

I don't have hard statistics, but I would be shocked if the number of ventilators (even counting those in operating rooms and in storage) exceeded 200-300 per 1,000,000 residents in most healthcare systems.

 

That is the biggest bottleneck, imho. And that capacity is already being used at anywhere from 50-100% just dealing with the existing reasons people need ventilation (i.e. after major surgeries, from trauma, infection, etc). If you get a sudden wave of folks needing ventilatory support, they will most likely not be able to get it. We will be triaging folks who will get a ventilator and those who won't based on their overall chances of surviving the illness. This would be heart wrenching and very painful for healthcare workers, and patients' families.

 

We had the same discussions when SARS and H1N1 hit. I remember as a young trainee sitting in on an ICU meeting where they were hashing out how they would portion the 40 ventilators in their ICU if those infections began spreading widely. It was a very sobering discussion.

 

When I see some of our political leaders speaking about Coronavirus, I often find myself wondering if theyv'e counted the ventilators in their jurisdictions and worked backwards with the math to seem how many infections their systems could handle before reaching the venitlator breaking point. That is the kind of math most frontline workers are doing in their heads, and frankly that is why they are so focused on containing the outbreak. They understand the consequences if they don't.

 

M.

 

EDIT: Found this article after my original post. Looks like someone did a survey in canada and found we have capacity for 100-160 ventilated patients per million residents. (They expressed it as 10-16/100,000). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4426537/

 

Thanks - nice to see some real quantification of what the actual capacity and constraints are all about. Great contribution.

[Read the Footnotes]

What constitutes "Healthcare system capacity"?

 

My view, with respect to a virus, is it constitutes all the available resources of a country that can be harnessed to ensure it is managed as well as possible: you do whatever it takes as a nation to avoid the red coloured curve in Liberty’s chart.

 

King County is now buying motels to house the surge of people who need to be quarantined. That motel is now part of the health care system. Creative solutions will be found.

 

In the USA, there are roughly 2.8 beds per 1,000 people. Canada is a bit lower, China about 30% higher.

 

Early reports indicated that roughly 20% of patients received hospitalization. If that were the experience in the United States, then with a population of 330 million people, we could house at most 4,620,000 patients, under the ridiculous assumption that all elective procedures are cancelled, and that all unscheduled accidents, illnesses and disease are cancelled indefinitely. That works our to 1.4% representing an upper limit on how much of the population could suffer from the illness at once without the need of temporary hospitals etc. In practice the real number would obviously be much lower.

 

Beds are not going to be the bottleneck in the system. Roughly 19% were reported to need support breathing, primarily meaning the provision of oxygen. More disturbingly, 5% needed assistance breathing.

 

So the real limit is likely not the number of beds or the number of respirators, but the number of ventilators. Making things worse, many needed ventilation for weeks.

 

If 5% of those affected need access to a ventilator, that provides a much lower estimate of the bottleneck and system capacity. There are roughly 20 full feature ventilators per 100,000 people in the USA. Doing the math again with 5% needing access would give you an estimate of a maximum capacity for 1,320,000 people to be sick at once in the USA, or only 0.4% of the population. Again these estimates assume no elective procedures and no other illnesses. The number is a little fuzzy because access varies substantially by region, and ventilators can be repurposed from the OR, but might need reprogramming which has been done before in these types of situations.

 

Given estimates that 40% of the population could contract the virus within the first year, it quickly becomes evident that the system capacity could be exceeded. When the access to oxygen therapy and ventilation is not available, the outcomes previously were terrible. The death rates absolutely skyrocket. If the patient needs oxygen or needs life support and it's not there, it will not go well for that patient.

 

Standard of care may have already improved, and social distancing may help dramatically. Every days delay might make a difference in the outcomes. In that case these inputs may not be relevant. Early detection seems to make a big difference. Antiviral treatments might also make a big impact.

 

So although the bad news is that this is a exponential process with multiple tipping points, and when the final tipping points are crossed the case fatality rates skyrocket.

 

The good news is that this is not a determinate process, we are all players in the game and can change the outcome. There are many things that we can do and that have already been done to delay the spread, to buy time and to prepare.

 

Hopefully leadership at all levels around the world will improve. There are many encouraging reports along those lines in North America today.

[StubbleJumper]

Another doctor here. (Never realized how many of us frequented this board until now!).

 

For non-medical folks the concept of Healthcare Capacity is squishy and abstract, but for those in the system it is very concrete.

 

The capacity to ventilate patients (breath for them using a breathing machine is one example of very specific healthcare capacity).

 

While the recorded mortality rate of Coronavirus is about 2% (give or take), we know that about 10% of identified infected patients develop severe pneumonia. Severe pneumonia effects your lungs capacity to exchange oxygen. If it gets severe enough, you would need a ventilator. The ability to ventilate patients using a machine is a very specific kind of healthcare capacity. In the Western world patients who are on a breathing machine are in the ICU and get round the clock monitoring. So they have a nurse at their bedside (that's 3 shifts of nurses per day), they have a respiratory therapist nearby to help trouble shoot issues with the machine (pressure settings, secretion suction, tube displacement, etc), and usually a team of doctors who round on them and oversee everything and make adjustments as needed.

 

I don't have hard statistics, but I would be shocked if the number of ventilators (even counting those in operating rooms and in storage) exceeded 200-300 per 1,000,000 residents in most healthcare systems.

 

That is the biggest bottleneck, imho. And that capacity is already being used at anywhere from 50-100% just dealing with the existing reasons people need ventilation (i.e. after major surgeries, from trauma, infection, etc). If you get a sudden wave of folks needing ventilatory support, they will most likely not be able to get it. We will be triaging folks who will get a ventilator and those who won't based on their overall chances of surviving the illness. This would be heart wrenching and very painful for healthcare workers, and patients' families.

 

We had the same discussions when SARS and H1N1 hit. I remember as a young trainee sitting in on an ICU meeting where they were hashing out how they would portion the 40 ventilators in their ICU if those infections began spreading widely. It was a very sobering discussion.

 

When I see some of our political leaders speaking about Coronavirus, I often find myself wondering if theyv'e counted the ventilators in their jurisdictions and worked backwards with the math to seem how many infections their systems could handle before reaching the venitlator breaking point. That is the kind of math most frontline workers are doing in their heads, and frankly that is why they are so focused on containing the outbreak. They understand the consequences if they don't.

 

M.

 

EDIT: Found this article after my original post. Looks like someone did a survey in canada and found we have capacity for 100-160 ventilated patients per million residents. (They expressed it as 10-16/100,000). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4426537/

 

 

 

That is interesting.  In general, I have always understood the driving principal of triage to be that the sickest should be given priority for treatment.  But, with a shortage of ventilators, is that the best allocation of resources?  Or should the limited capacity be dedicated first to the patients who have the best prospect to respond to treatment?

 

 

SJ

[mloub]

Triage is best thought of as a two part process.

 

The first, as you mentioned, is that the sickest should get your attention. You would then formulate a plan (based on the resources you have available). If you are resource constrained, the second part of triage is deciding who gets the resources you have available (manpower, drugs, ventilators, etc). The modern thinking is to provide those resources to those most likely to survive with the given resources. In essence it is a utilitarian argument - you try to save the maximum number of lives possible. So given one ventilator and two patients who need it, you give it to the patient most likely to live if they get it.

 

This has been the thinking with organ transplants, which has probably been one of our most resource contrained treatments in medicine for a long time.

 

 

 

[ERICOPOLY]

I was at Costco today and it seemed like most people were wiping their carts down.

 

I bet the number of deaths from the common flu will decline, and those lives saved won't go reported as an offsetting headline.

[StubbleJumper]

Triage is best thought of as a two part process.

 

The first, as you mentioned, is that the sickest should get your attention. You would then formulate a plan (based on the resources you have available). If you are resource constrained, the second part of triage is deciding who gets the resources you have available (manpower, drugs, ventilators, etc). The modern thinking is to provide those resources to those most likely to survive with the given resources. In essence it is a utilitarian argument - you try to save the maximum number of lives possible. So given one ventilator and two patients who need it, you give it to the patient most likely to live if they get it.

 

This has been the thinking with organ donations/transplants, which has probably been one of our most resource contrained treatments in medicine for a long time.

 

 

Clearly there will be some heart-wrenching decisions on the front lines.

 

 

SJ

[mloub]

I was at Costco today and it seemed like most people were wiping their carts down.

 

I bet the number of deaths from the common flu will decline, and those lives saved won't go reported as an offsetting headline.

 

I was at a recent public health talk where they showed that flu infections \were significantly lower than expected in our region in February. They attributed it to the public taking more precautions around Coronavirus, so yes, you can argue that is one benefit of the outbreak! Hopefully we can keep it up in future flu seasons.

 

M.

 

[Jurgis]

Another doctor here. (Never realized how many of us frequented this board until now!).

 

Will the real Mike Burry please stand up?  ;D