Medical Discussion of Coronavirus

[doctorbone]

There’s a lawsuit going on between a patient’s wife and a university hospital in Cincinnati. The husband is on vent. The wife got a pulmonologist in another city (who’s never seen the patient. Is this even allowed?) to prescribe ivermectin for the husband.

A judge ordered the hospital to administer the med. he’s still on vent and the wife is still fighting to keep him on ivermectin. I can’t believe the court would overstep its judicial power and tell doctors how to practice medicine. SMH.

[Jaqen Haghar MD]

Here's an interesting graph. I suppose in absolute terms, the difference is not that big, but it does make for a striking visual (assuming they're not playing fast and loose with the data).

Of course they are cherry picking the data out of political motivations. You could also invert the graph during previous waves when the Northeastern US had higher mortality than the south, but I doubt that came up from whoever created that graph. This country is honestly sick with politics from both sides. Extreme fringe elements on both ends drive the narratives.

[Lordosis]

Would you hold your child out of school if masking was optional?

No. My kids would go to school either way. We are happy there is masking but I have seen kids mask and I know how poorly they wear them. Not my kids but kids in general.

[Hatton]

Sorry to hear it hit bro's household. We only just started boosters recently so minimal data on this. I can ask around. How long ago were his initial doses?

Since not COVID+ himself; no monoclonal; but get early (<72 hours) if onset symptoms.

He tested negative. Only my nephew who is in his forties tested positive. He is vaccinated. Evidently caught it at a neighborhood kid party.

[G]

Would you hold your child out of school if masking was optional?

Only if my child had a comorbidity. Although I wouldnt think poorly of someone if they did.

But be prepared for home school regardless, due to exclusion/quarantine protocols.

Good luck.

[G]

I don't want to sound like a ivermectin fan, because I'm not. But I think being forced to credential someone who wants to do this, while bad, is not that bad. At the end of the day you have a doctor (who presumably is fully licensed and has nothing else objectionable on his record), who based on his experience wants to prescribe a treatment, you have a patient who is informed of the risks and (lack of) benefits thoroughly, and the patient decides they want to do it.

In an ideal situation, you would just have doctor and patient go to a facility that doesn't object and let them prescribe and receive ivermectin happily ever after. Unfortunately, transferring such patients to another facility is not really an option. So what you've got is a situation where the judge has to balance the patient's autonomy over the hospital's. Since the appropriate remedy is not practical (i.e., go elsewhere) and the drug is fairly benign, I don't think the judge's solution is that terrible.

Don't get me wrong. If I'm the hospital, I fight it to the bitter end for a variety of reasons. But if I lose, this is not a hill I'm going to die on. However, with only very minor changes to the narrative, I absolutely would die on that hill.

AR, I get what you are saying, but I'm weary of the "customer is always right" medicine. A) If they had gotten vaccinated, they probably wouldnt even be in hospital. B) If the doctor is such a superstar, he should at least be on the medical staff of a real hospital with other real doctors. C) Words (or in this instance, malpractice) matter.

[FIREshrink]

Of course they are cherry picking the data out of political motivations. You could also invert the graph during previous waves when the Northeastern US had higher mortality than the south, but I doubt that came up from whoever created that graph. This country is honestly sick with politics from both sides. Extreme fringe elements on both ends drive the narratives.

So data is correct... I made this point months ago, it's not political. In a large national survey at the time, no single demographic factor was more closely associated with vaccine acceptance/refusal than political affiliation. Put another way, being a self identified Republican was the single greatest risk factor for the ideology of vaccine refusal. I think we also know that Republicans are more likely to support the ideology of mask refusal. Seems highly relevant to me, like knowing that smoking and radon and asbestos exposure are the greatest risk factors for lung cancer, now we know who to screen and potentially what interventions need to be tailored to reach this population, which is suffering disproportionately from the pandemic. In the early days of the HIV pandemic, it was useful to know it was mostly a disease of gay men, right? That's not political, that's basic epidemiology, now you target and tailor your public health message.

[wideopenspaces]

I don't want to sound like a ivermectin fan, because I'm not. But I think being forced to credential someone who wants to do this, while bad, is not that bad. At the end of the day you have a doctor (who presumably is fully licensed and has nothing else objectionable on his record), who based on his experience wants to prescribe a treatment, you have a patient who is informed of the risks and (lack of) benefits thoroughly, and the patient decides they want to do it.

In an ideal situation, you would just have doctor and patient go to a facility that doesn't object and let them prescribe and receive ivermectin happily ever after. Unfortunately, transferring such patients to another facility is not really an option. So what you've got is a situation where the judge has to balance the patient's autonomy over the hospital's. Since the appropriate remedy is not practical (i.e., go elsewhere) and the drug is fairly benign, I don't think the judge's solution is that terrible.

Don't get me wrong. If I'm the hospital, I fight it to the bitter end for a variety of reasons. But if I lose, this is not a hill I'm going to die on. However, with only very minor changes to the narrative, I absolutely would die on that hill.

I guess I don't know why you'd assume the doc is otherwise unobjectionable if he's willing to prescribe a medication with no benefit at this stage of the game. Also, it takes 60-90 days to credential someone. Why does the quack get to jump the line? I don't think this is a precedent we want to set.

[Perry Ict]

Am I the only one who is getting tired and rolling my eyes when I see such headlines

" EU bans travelers from USA due to rising cases of COVID and high baseline rate"
" This state has 1000 COVID cases compared to this wonderful state that has only 375 cases".

These headlines might have been useful pre-vaccine but now that vaccines are here and more widely used and that we know that COVID will continue to mutate and not go away any time soon and vaccinated people will get mild COVID, the headlines I would like to see are

500 COVID cases in unvaccinated people and 100 ICU admissions and 25 deaths versus 100 COVID cases in vaccinated people with 5 admissions and one death. This will help both vaccinated and unvaccinated people see the impact of COVID on morbidity and mortality rather than just harping on rising number of COVID cases, which is meaningless by itself. Maybe, just maybe the contrast might push a few unvaccinated people to get the shot.

I agree. I worry that we might be losing the plot with Covid. If a vaccinated individual "contracts Covid" and has nothing worse than the sniffles, that should probably be celebrated ("the vaccine is working!"), not bundled into a headline of "Rising Covid Cases!".

[StarTrekDoc]

So data is correct... I made this point months ago, it's not political. In a large national survey at the time, no single demographic factor was more closely associated with vaccine acceptance/refusal than political affiliation. Put another way, being a self identified Republican was the single greatest risk factor for the ideology of vaccine refusal. I think we also know that Republicans are more likely to support the ideology of mask refusal. Seems highly relevant to me, like knowing that smoking and radon and asbestos exposure are the greatest risk factors for lung cancer, now we know who to screen and potentially what interventions need to be tailored to reach this population, which is suffering disproportionately from the pandemic. In the early days of the HIV pandemic, it was useful to know it was mostly a disease of gay men, right? That's not political, that's basic epidemiology, now you target and tailor your public health message.

True. Good luck getting high profile people to sign on and to PSAs on it. Only Sen McConnell has been outspoken on things -- when asked. Rest dance around the question of even being vaccinated. Trump even got mildly boo'ed when he mentioned it (and hasn't since).

[CordMcNally]

Here's an interesting graph. I suppose in absolute terms, the difference is not that big, but it does make for a striking visual (assuming they're not playing fast and loose with the data).

I get what whoever put this graph out is trying to prove but this is likely a very deceiving graph for multiple reasons.

[Lithium]

It's not a power struggle or a drawn out process unless you let it be. You simply tell them "no". You don't stay in the room and try to convince them to see your side of it. That would be as pointless as trying to explain to drug seekers why you aren't giving them narcs. If the hospital wants to credential the quack then that's on them. Why would this impede discharge? If anything they'll want to leave AMA. The medical staff will back you if it becomes a huge deal. If administration comes calling then stand your ground. Doctors, as a whole, are wimps. There's no better time to show some backbone than now. Maybe if we start showing some backbone the nurses and administrators will actually start respecting us.

You can walk out of the room, but if the patient is still suicidal, you still have to go back the next day. And instead of talking about why they’re really there, the patient just wants to talk about their ************************ ivermectin. Good luck reinforcing any CBT or getting them to work on their safety plan.

When they are just going to go right back on their ivermectin once they discharge from the hospital and have someone else prescribing it, I don’t see how that’s a battle worth fighting. I’m just trying to get the patient out of the hospital and let the quack deal with the quackery.

[CordMcNally]

You can walk out of the room, but if the patient is still suicidal, you still have to go back the next day. And instead of talking about why they’re really there, the patient just wants to talk about their ************************ ivermectin. Good luck reinforcing any CBT or getting them to work on their safety plan.

When they are just going to go right back on their ivermectin once they discharge from the hospital and have someone else prescribing it, I don’t see how that’s a battle worth fighting. I’m just trying to get the patient out of the hospital and let the quack deal with the quackery.

Is this honestly a realistic scenario you see on a routine basis? I'm somewhat shocked at your reasoning for prescribing them unindicated medications. If they were on inappropriate psych medications (not prescribed by you) would you continue them as inpatient? As I tell many of my patients, I can't control what other physicians do but I can control what I do.

[Tim]

I guess I don't know why you'd assume the doc is otherwise unobjectionable if he's willing to prescribe a medication with no benefit at this stage of the game. Also, it takes 60-90 days to credential someone. Why does the quack get to jump the line? I don't think this is a precedent we want to set.

This is a slippery slope. Society sets norms by making "laws". That means a standard is set and violations are subject to some type of "inconvenience", "prohibition", or "punishment". All well and good. But the mechanism is making a law, not the entities or individuals "deciding there was a violation and the appropriate action". Unless something is illegal under a law, a minority of one is perfectly legal and should have the right without having normal privileges taken away.

Should someone have the right to a trial by jury of their peers? (Is an example)
We now have crossed into that no-vaccination automatically disqualifies a person from jury duty. Suitable jurors are defined as "must be vaccinated".

https://www.yahoo.com/news/judge-ruling-over-elizabeth-holmes-112400273.html

There are huge issues. Should a law be federal? Constitutional problems. Should a law be state or local and what is there is a difference between state and local? Huge differences by each state and local authorities. Should a law be left up to public and private entities? Obviously, an individual can't make a law, but they are subject to a huge potential loss of individual choice with some serious erosion or suffering consequences for which there is zero agreement or even written policies or guidelines.

They don't have a vaccine. Is that a crime? There ought to be a law. Unfortunately our political process had not reached a conclusion. Anyone in a position of authority can make a rule and decide the punishment. At the same time, the individual is being found guilty, without a law and punished.

The fact is "guilty" is by mandate for which there is no crime or damage, just it might happen (a future unintentional event) is defined as a violation of law, mandate or policy. Making a future result illegal is the question of law.

Tobacco, alcohol and marijuana are other example that the principal involved is a slippery slope. We tried prohibition. It this the path that will fit our society?
The current course is unequal interpretation and enforcement. Each situation is "this time is different" because of the authority making the rules and decisions.
That is not "equal protection under the law".

My concern is the political influence for political reasons, not for the health or protection of citizens. If nothing more, the two FDA resignations give me pause for concern that political power is on "recommendations" or mandates rather than creating laws through the legal process. We just are not there yet,

[pysibal]

CordMcNally, do you think willingness to "pick your battles" varies by clinical setting?

Inpatient treatment and ER are pretty different from my perspective. I may be wrong but as an ER doc you can lay down the law and in less than 24 hours you're done with the patient regardless, but in other settings the physician may need to pick battles to retain the patient's buy-in for treatment such as when working on a suicide safety plan, engaging with PT/OT/SLP, not leaving AMA (which admin hates and leads to higher rates of readmission; it's not innocuous).