Medical Discussion of Coronavirus

[Antares]

Did somebody say you were expendable and I missed it?

See Hatton’s post just after yours.

[CordMcNally]

See Hatton’s post just after yours.

She said his posts imply that. I didn't necessarily take that away from his posts but I guess everybody interprets things differently.

[Max Power]

I'm not sure I buy the "sacrifice the old people" as an actual defense. Isn't what we're doing flattening the curve, not decreasing the area under it? Mammograms, screening colonoscopies, and pap smears have all but stopped from our experience. There has to be some morbidity and mortality from that if done on a nationwide scale.

There absolutely is some M&M to that already - and much more to come, and that is what I am getting at. It is already quite apparent at my facility.

Nobody is saying to sacrifice anyone. Nobody is saying any age group doesn't matter. However, if we get rid of diagnostic exams and evidence-based cohort screenings by closing offices and telling people to stay home (or media making them paranoid to go near a health care facility), then we are setting medicine back 100s of years. We are simply putting out fires again... seeing the patients when it is too little, too late and just quick-fixing them. That will be terrible for overall public health. There a million pathologies not named COVID19.

Think about it:
Number of lab orders written is all time low... percent of people following up on labs and other tests ordered is even lower.
Number of med Rx written and filled is now all time low.
Number of heart attacks are now at an all time low.
Number of strokes are at an all time low.
Number of new cancer diagnoses are at all time low.
Number of pts willing to be sent to SNF (and number of SNFs open) after I d/c ruptured spleens, GI perfs, etc from trauma surgery is all time low.
Number of mental health inpatients is now low... yet number off their Rx is surely
Number of skin cancers is all time low.
Gyms are closed, stream movies are booming, and there is little doubt the American BMI average is already creeping up.
Number of prenatal care visits attended has slowed to a crawl.
Number of dental caries observed is at all time low.
Number of pedi ortho deformities dx that will cause arthritis or QOL issues and could be fixed with bracing is record low.
Number of new cases of diverticulosis is all time low.
Number of diagnosis and visits for symptomatic hemorrhoids and GI ulcers is all time low.
(the list could obviously go on and on to affect every specialty and sub-specialty known)

...if you don't want to take it from me, try a Yale cardio:
https://www.nytimes.com/2020/04/06/w...ck-stroke.html

Everyone is so hyper-focused on Corona that we are missing the big picture. We can't treat what we can't diagnose. That doesn't mean the pathologies just disappeared or healed themselves. Just because I don't hear from a post-op doesn't mean they are doing fine... they probably decided to go elsewhere, get infected, or even crumped. We can't fix up what we don't have f/u services open for... they will just die at home or bounce back to ER. The effects of this will get worse and worse. We are practicing preventative and follow-up medicine the way it was in 1700s. There is just not a good enough reason for this. The ER patients with complaint of 'lapsed Rx and renal failure' or 'lapsed Rx and chest pain' will grow and grow. That is going to get more and more apparent.
_____

...Have you been in a hospital where the ED, the floors and the ICU are crushed like never before in any of our lifetimes? Or are you out in some rural area, isolated from what is going on? If our community had taken no action to try to mitigate this health care disaster, the health care workers would have mutinied by walking out, shutting down the hospitals. We would have anarchy, without functioning hospitals, no health care safety net, no civil society, every person left to fend for themselves. Is that what you are advocating?

Not a lot of fellowship trained surgeons - esp who teach - work in the boondocks.

You are citing anecdotal examples, like many other posters have as well, to try to prove that Corona can be severe or fatal for middle aged or healthy people. I am not debating it can, but those are called anecdotes... case studies... opinion... belief... exceptions. That is not EBM. It would be like saying a wet dishrag mask is better than nothing since grandpa Jim wore one and hasn't gotten Corona yet.
The statistics will become more and more clear on COVID19, but truly, they are already in. The age group stratifications of lethality and overall morbidity %s dropping has been duplicated in country after country, hospital after hospital, subgroup after subgroup. Of course it gets people, and of course people die. Perhaps you are just looking for confirmation bias in personal experience and not looking at the cohorts? It would be like me saying a high proportion of all auto accidents are fatal since many of the ones I see are fatal...but it's statistically just not true when I review the EBM.

If it is so essential to shut down the cities and healthcare to focus on basically nothing but Corona to prevent your anarchy scenario, then why are Tokyo and Cairo and Dubai and other cities bigger and more dense with international airports busier than NYC doing okay? Why are huge densely populated places with crummy health care and poorer sanitation such as Dehli and Mexico City faring ok? Why are places like Sau Paulo and numerous southern hemisphere (even southern US) capitals who are resisting lockdown orders doing ok? Shouldn't they all be rabid zombies by now with national guard shooting them in the streets? Hmm, let me review the literature.
I don't doubt that your work seems harder right now and that there are casualties. Mine would be the same way if a flash ice storm caused a bunch of MVAs or a gang war broke out near my center. That is medicine. That last word is yours, but the anecdotal myopia is just not EBM, and I find it short-sighted. Forward thinking is what modern EBM is founded on. There will likely have to be a compromise soon in the medical community between EBM and short term hysteria. Again, millions of other pathogens affecting humans besides <1% lethal COVID19. The last word is yours... take care and thanks for your service.

[G]

She said his posts imply that. I didn't necessarily take that away from his posts but I guess everybody interprets things differently.

So I really don't care--and I wish we had a true medical discussion thread--but revisit post 402.

[StarTrekDoc]

I'm not sure I buy the "sacrifice the old people" as an actual defense. Isn't what we're doing flattening the curve, not decreasing the area under it? Mammograms, screening colonoscopies, and pap smears have all but stopped from our experience. There has to be some morbidity and mortality from that if done on a nationwide scale.

Timeline for all these preventative services --- YEARS.
Timeline for COVID - 2 weeks.

We can afford to delay preventative services for a little bit. Those semi-urgent ones like intermittent hernia symptoms, recurrent cholecystitis, medically managed angina that's progressing, afib conversions, surveillance screenings of abnormals. Those are the ones the need to be restarted sooner than later of will become problematic.

[G]

Think about it:
Number of lab orders written is all time low... percent of people following up on labs and other tests ordered is even lower.
Number of med Rx written and filled is now all time low.
Number of heart attacks are now at an all time low.
Number of strokes are at an all time low.
Number of new cancer diagnoses are at all time low.
Number of pts willing to be sent to SNF (and number of SNFs open) after I d/c ruptured spleens, GI perfs, etc from trauma surgery is all time low.
Number of mental health inpatients is now low... yet number off their Rx is surely
Number of skin cancers is all time low.
Gyms are closed, stream movies are booming, and there is little doubt the American BMI average is already creeping up.
Number of prenatal care visits attended has slowed to a crawl.
Number of dental caries observed is at all time low.
Number of pedi ortho deformities dx that will cause arthritis or QOL issues and could be fixed with bracing is record low.
Number of new cases of diverticulosis is all time low.
Number of diagnosis and visits for symptomatic hemorrhoids and GI ulcers is all time low.
(the list could obviously go on and on to affect every specialty and sub-specialty known)

I think Rona highlights things that are essential and nonessential, even in medicine. Your point about downstream effects is certainly granted, but it is refreshing working in an ER and having a diagnosis for pretty much every belly pain patient that come in. As opposed to "abdominal pain of uncertain etiology" which is about 95% of the time pre-Rona. We're talking CT scans 100% actionable over my last few shifts!

[StarTrekDoc]

There absolutely is some M&M to that already - and much more to come, and that is what I am getting at. It is already quite apparent at my facility.

It's been one month of -stay-at-home orders. - the sky isn't falling and we didn't stop medical care on everything.....we hit the pause button.

In Primary care, we initially saw a 50% reduction in visits the first week as everyone went crisis mode shelter-in-place. Over the next three weeks, we learned to pivot to telehealth, reached out to our patients and urged them specifically not to defer ongoing chronic care issues.....and they listened. We're up to nearly 75% of normal activities. That other 25% is largely ANNUAL preventative visits that we are deferring for a short time. If we've been doing it right before COVID, 2 months of DEFERRED screening should not be moving the needle much at all.

Likewise, our specialists are still seeing the active chronic issues; hence they are anywhere from 25-50% of normal operations. What's clearly deferred is what we in the US have always done -- high amounts of elective procedures.

[Lordosis]

It's been one month of -stay-at-home orders. - the sky isn't falling and we didn't stop medical care on everything.....we hit the pause button.

In Primary care, we initially saw a 50% reduction in visits the first week as everyone went crisis mode shelter-in-place. Over the next three weeks, we learned to pivot to telehealth, reached out to our patients and urged them specifically not to defer ongoing chronic care issues.....and they listened. We're up to nearly 75% of normal activities. That other 25% is largely ANNUAL preventative visits that we are deferring for a short time. If we've been doing it right before COVID, 2 months of DEFERRED screening should not be moving the needle much at all.

Likewise, our specialists are still seeing the active chronic issues; hence they are anywhere from 25-50% of normal operations. What's clearly deferred is what we in the US have always done -- high amounts of elective procedures.

I agree my numbers are strikingly similar to yours. Pretty much everything has been moved over to telehealth now. physicals and older children well child checks can definitely wait a few months. Also without elective surgeries we have less pre ops and follow-ups of the pre apps because something was abnormal and last post ops because the surgeons not dealing with my pain well.

If things do stretch on for a year or more then some of these preventative measures will have to be rethought of. it is very reasonable to hold off on a mammogram for a few months but a year or two might make a difference.

I want the world to go back to normal as much as anybody else. But I think until we have a well laid-out plan and are prepared for a possible resurgence it is not wise to proceed.

I predict some places are going to ease restrictions and regret it. They will be the Canary for the rest of the country. Hopefully it is not anywhere near me.

[Anne]

In my anecdotal experience the doctors going on the most about the detrimental effects of a couple month hiatus on elective procedures/routine visits are those who are economically dependent on those visits. But they don’t want to say that so they emphasize all the horrible things that will get missed by pausing routine care for a little while.

People’s reactions to hitting the pause button has been illuminating.

If you were financially on solid footing prior to the pandemic you will be just fine and very well might come out ahead.
If your marriage was on solid footing prior to the pandemic you will be just fine and likely will have a stronger marriage as you weather another storm together.
If you were working out at the gym prior to the pandemic you will be just fine, you have the discipline and knowledge to work our at home for a little while.
If you cared about maintaining a healthy weight prior to the pandemic you will be just fine, you know how to modulate your diet and emotions and not eat crap just because you are stressed and bored.
If you had good basic knowledge of what constitutes a medical urgency/emergency prior to the pandemic you will be just fine, you will know what symptoms really warrant seeking care.

Many people were not on good footing in many of these respects prior to the pandemic and so things are going to fall apart, and it will be blamed on the coronavirus response, I.e. the straw that broke the camel’s back rather than the underlying issue, the diffuse metastatic disease that has been ravaging the camel’s spine.

[G]

In my anecdotal experience the doctors going on the most about the detrimental effects of a couple month hiatus on elective procedures/routine visits are those who are economically dependent on those visits. But they don’t want to say that so they emphasize all the horrible things that will get missed by pausing routine care for a little while.

People’s reactions to hitting the pause button has been illuminating.

If you were financially on solid footing prior to the pandemic you will be just fine and very well might come out ahead.
If your marriage was on solid footing prior to the pandemic you will be just fine and likely will have a stronger marriage as you weather another storm together.
If you were working out at the gym prior to the pandemic you will be just fine, you have the discipline and knowledge to work our at home for a little while.
If you cared about maintaining a healthy weight prior to the pandemic you will be just fine, you know how to modulate your diet and emotions and not eat crap just because you are stressed and bored.
If you had good basic knowledge of what constitutes a medical urgency/emergency prior to the pandemic you will be just fine, you will know what symptoms really warrant seeking care.

Many people were not on good footing in many of these respects prior to the pandemic and so things are going to fall apart, and it will be blamed on the coronavirus response, I.e. the straw that broke the camel’s back rather than the underlying issue, the diffuse metastatic disease that has been ravaging the camel’s spine.

Agree with all of that except the weight part...I'm having a difficult time with that because 1) homeschooling has me at home with easy access to tasty treats and 2) baking is something that is fun, mathematical, educational ... and tasty. For the first week, we couldn't find any flavor of oil nor baking powder...now that that I'd remedied, the gloves are off!

[Anne]

Agree with all of that except the weight part...I'm having a difficult time with that because 1) homeschooling has me at home with easy access to tasty treats and 2) baking is something that is fun, mathematical, educational ... and tasty. For the first week, we couldn't find any flavor of oil nor baking powder...now that that I'd remedied, the gloves are off!

I’m all out of all purpose flour and can’t find it in stock online right now which is probably for the best.

Let me introduce you to Socca if you haven’t already met: delicious, relatively healthy, easy, and garbanzo flour is plentiful on Amazon (I like bob’s red mill brand): https://food52.com/recipes/27014-socca-farinata

[White.Beard.Doc]

Let’s try to find something that we can agree on. After hitting the pause button, we need to find a pathway to open things up again at some point.

Personally, I'm advocating for starting the process for the lower risk folks, if they don’t expose other higher risk folks at home or at work. And as we begin to open, we need to apply universal Covid precautions. Everyone wears a mask. And universal hand washing, and as much social distancing as possible. Dine in restaurants and bars should open late in this process. Massive, reliable testing capacity for both the virus and the antibodies should be a primary goal. And contact tracing with isolation.

Several countries have done this with demonstrated success. However, I fear for our country because every step in our management of this virus has been a messy political battle. The messages to the public are jumbled and ever changing. Hopefully many of our citizens will make good choices despite the inconsistent messages of our governmental leaders.

[Tim]

"I think my main thing was the idea that this thing is somehow "overblown" well, sorry, it is not." It's not overblown where you are.
"Urgent: well, how urgent?" 636 bed hospital with a medical school and 106 cases in the county. I agree we are saying the same thing. The hospital and local staff need to make the decision. The current "electives" prohibit that. Hope no one is floundering, they might even scope a knee or do a colonoscopy while your gone! Good luck.

[White.Beard.Doc]

Not a lot of fellowship trained surgeons - esp who teach - work in the boondocks.

Funny you should mention that, some of my best friends are academic, fellowship trained surgeons...

My point was not an attempt to dispute the data at all. I agree with the data, the old, the sick, and the obese are hardest hit by this disease. And occasionally, but much less commonly, the young and the fit also die. But just the same, two morgues and a refrigerated truck all filled with bodies is actually data, not population wide, not age or comorbidity controlled, but it is hard evidence that in my hospital this is a horrible situation and a lethal disease. I hope that you have been fortunate not to see that kind of impact in your community.

And I am sorry that your practice is likely on a full pause. I cannot begin to imagine how difficult that must be. In the middle of some of my recent 100 hour work weeks, I would have given a lot to trade places with you for a day so that you could benefit from access to work and so I could rest.

What we can agree on is our national priority should now be working towards getting back to normal, as quickly and as safely as we can muster. Let's try to learn from other countries that had a 2 month pause and are now successfully working to open up and to adjust to their new normal.

[StarTrekDoc]

So say we all @wbd....

To that look at both Hong Kong and Singapore. Two island cities that were successful in wave 1 and lossened and wave 2 hit differently because of practices.

Covid will find the weak link and spread. In Singapore it's the migrant workers. If flyover country opens up early it needs to watch the workers population closely. Iowa got a taste already with Smith plant heavily impacted in a large cluster.

Serious social distancing and universal public masking are key. Virus can't swim seven feet