Medical Discussion of Coronavirus

[PedsCCM]

The hospital death certificates are the flash reporting system to CDC. There is a check and balance. Each county coroner reviews and makes the official determination.

Yes, originally there was some documented what I call confusion. Did the motorcycle accident victim have Covid. Yes. Data accuracy is always subject to error. I am pretty certain some “natural causes” were accelerated by Covid and unreported and not tested. Imperfect data, use what we have. Any individual has zero incentive to falsify data.

Ah, I see how this myth persists. Firstly, only one person may sign to medically certify the death certificate. Who exactly may sign is outlined by state law but almost always defaults to the attending physician at the time of death (for deaths in the hospital) or the coroner/medical examiner if certain criteria are met (physician cannot determine cause of death, death may be related to suicide, homicide, etc). The vast majority of death certificates are filled out by attending physicians or APPs (if allowed by state). Importantly, only one person can sign to certify cause of death. https://statutes.capitol.texas.gov/d...htm/hs.193.htm includes the relevant Texas statutes in case you're interested. So to claim that COVID is incorrectly listed in the cause of death means that a physician (or other provider) is intentionally lying and committing fraud - or is incompetent. No individual or group reviews and certifies the physician's certification. My county coroner does not review the death certificates that I sign and nobody but me is allowed to alter them. If a case goes to the coroner, I am not allowed to sign the cause of death. Amendments to death certificates can only completed by the certifying physician.

Next, what is listed on the cause of death? It importantly should never list every diagnosis the patient might have. Death certificates are pretty uniform and adhere to a federal standard regardless of state. See below the first google result - which is accurate. You list the IMMEDIATE CAUSE of death and conditions leading to this final, immediate cause. Part II has other "significant conditions contributing to death". In sum, everything listed should contribute directly or indirectly to the proximal cause of death.



In short, there is no mysterious "them". Hospitalists and ICU docs and EM docs fill out the medical sections of death certificates and certify the cause of death. This (often immediately) is available to the state health department and the funeral home. The info gets reported through Vital Records systems in each state and is then passed on to the CDC. K82 you're getting a lot of push back because this was a COVID denier trope early in the pandemic and it either suggests massive fraud committed by docs on scale - and against their own self interests! - or some other truly bizarre conspiracy. I can only assume the folks pushing this don't understand the system as it is insanely improbable.

*nothing I've written assumes that the numbers we have are perfectly accurate. There are undoubtedly errors. I just find it beyond improbable that massive over counting driven by hospital system revenue has occurred.

[G]

It's honestly a little weird. My guess is that people in general are just kind of fed up with the government and this was the one thing that kind of pushed everyone over the edge. When there's support from a fairly large number of people then I think it's easier to do drastic things such as quit your job. We tried to get takeout from two different places last night and neither were answering their phone or allowing online orders.

My best prediction is that the federal vaccine mandate gets blocked by the Supreme Court. Some areas try to continue with various masking and other COVID policies. We'll likely see some companies relocate to less restrictive areas. The appetite for additional vaccine booster doses is going to wane by those already vaccinated. The hospitals will continue to be on the brink of disaster because of staffing issues for 12-18 months. Finally, they'll have to come up with a new naming system of naming variants.

The new normal. I've had similar food experiences of late. It is hard to remember that the one guy working is not the one who deserves the complaint...especially when you've been busting your rear all day getting those stellar patient sat scores.

In terms of the hospital, I accurately predicted that we would continue to use "hallway" beds in the ER even after the surge. I'm just waiting for the trial lawyers to start on us for delays in care, poor outcomes, lack of privacy, etc etc.

The Supreme Court has already ruled on vaccine mandates, 116 years ago. I guess it would be yet another sign of these historic days if that precedent is overturned.

[G]

Ah, I see how this myth persists. Firstly, only one person may sign to medically certify the death certificate. Who exactly may sign is outlined by state law but almost always defaults to the attending physician at the time of death (for deaths in the hospital) or the coroner/medical examiner if certain criteria are met (physician cannot determine cause of death, death may be related to suicide, homicide, etc). The vast majority of death certificates are filled out by attending physicians or APPs (if allowed by state). Importantly, only one person can sign to certify cause of death. https://statutes.capitol.texas.gov/d...htm/hs.193.htm includes the relevant Texas statutes in case you're interested. So to claim that COVID is incorrectly listed in the cause of death means that a physician (or other provider) is intentionally lying and committing fraud - or is incompetent. No individual or group reviews and certifies the physician's certification. My county coroner does not review the death certificates that I sign and nobody but me is allowed to alter them. If a case goes to the coroner, I am not allowed to sign the cause of death. Amendments to death certificates can only completed by the certifying physician.

Next, what is listed on the cause of death? It importantly should never list every diagnosis the patient might have. Death certificates are pretty uniform and adhere to a federal standard regardless of state. See below the first google result - which is accurate. You list the IMMEDIATE CAUSE of death and conditions leading to this final, immediate cause. Part II has other "significant conditions contributing to death". In sum, everything listed should contribute directly or indirectly to the proximal cause of death.



In short, there is no mysterious "them". Hospitalists and ICU docs and EM docs fill out the medical sections of death certificates and certify the cause of death. This (often immediately) is available to the state health department and the funeral home. The info gets reported through Vital Records systems in each state and is then passed on to the CDC. K82 you're getting a lot of push back because this was a COVID denier trope early in the pandemic and it either suggests massive fraud committed by docs on scale - and against their own self interests! - or some other truly bizarre conspiracy. I can only assume the folks pushing this don't understand the system as it is insanely improbable.

*nothing I've written assumes that the numbers we have are perfectly accurate. There are undoubtedly errors. I just find it beyond improbable that massive over counting driven by hospital system revenue has occurred.

Good summary. I have had this discussion several times. I keep it local "I don't know what they do in Florida or New York, but in this county...blah blah...so are you saying that I am a liar?"

While conceding that I am trusted, the logic does not extend to the rest of the certifying doctors....

[CordMcNally]

In terms of the hospital, I accurately predicted that we would continue to use "hallway" beds in the ER even after the surge. I'm just waiting for the trial lawyers to start on us for delays in care, poor outcomes, lack of privacy, etc etc.

I still have hope that this will change some thoughts and expectations around US healthcare. It's much easier to tell patients they're fine and they need nothing done and deal with negative patient satisfaction scores at this point than it has been in the past. I'm hoping that trend will continue and we can focus on being physicians and not wowing patients with unnecessary tests.

[Tim]

There is an assumption that the CDC, hospital,county, county, and state were reporting the daily data all off of this one document. Separate reporting systems were cobbled together for the speed needed. Correct me if I am wrong. The actual death certificate takes much longer. Please explain to me how CDC gets daily totals. The daily totals in some cases were backlogged. It takes 'weeks" for the official process to be tabulated and balanced to the CDC daily reports. All states do not report the same. Some don't release even county and there were inconsistencies. I did not mean the death certificate was incorrect.
Personal experience: Man dead sitting on a porch. EMT calls the cops. Cop calls the coroners office. No MD no physician present. Clearance given and cause of death ascertained via COP and phone and cause of death indicated. Body released to the funeral home. CDC has a fast track data collection system, not necessarily based on the death certificate. That is not Covid denier, that is the fast track system was not based on the actual death certificate. And then you get into the autopsy needed or not. The vital records system is and was separate from the fast track data system.

Our miscommunication is not with the vital records process based on the death certificates.. It is that the numbers reported were not based on that process but a separate fast track system that had more errors and could be subject to classifications that differ from the official record, which occurs later. Totals are reported to the CDC. Feel free to correct me. Two systems, one fast and one official. There was no requirement to reconcile. Docs were not involved in this. Makes zero sense to accuse them. I think the health care reporting was over matched in the early stages. The same way vaccine appointments, wait lists and vaccine availability was over the heads. The mass vaccination sites had to be developed and the fast track reporting systems had to be developed and implemented.
I also do not blame the "admin staff" that was doing the best they could do for a new reporting system. I can guarantee Johns Hopkins was not working off death certificates. All the daily numbers actually had notes for "adjustments" that states had made and the quality of the reporting.
I think it is misleading to point any blame on physicians or the vital records process.

[G]

I still have hope that this will change some thoughts and expectations around US healthcare. It's much easier to tell patients they're fine and they need nothing done and deal with negative patient satisfaction scores at this point than it has been in the past. I'm hoping that trend will continue and we can focus on being physicians and not wowing patients with unnecessary tests.

You must not have had the ivermectin discussion yet today?

[CordMcNally]

You must not have had the ivermectin discussion yet today?

That's easy. I just don't have that discussion. I tell them we're not going to see eye to eye and then I leave and discharge them.

[triad]

I was hoping you would weigh in. I will try to get boosted again a week or so before the flight unless some new data comes out. The travel is to the WCIcon in Phoenix.

definitely get boosted then. i'm guessing there would be a few antivaxxers at a conference and omi seems absurdly transmissible.

[VagabondMD]

definitely get boosted then. i'm guessing there would be a few antivaxxers at a conference and omi seems absurdly transmissible.

I believe that being vaccinated is an explicit condition to attend the conference. That said, I am beginning to have that "March 2020" feeling about things, and I wonder what scheduled activities for the remainder of 2021 and early 2022 will actually go off as planned.

[triad]

I believe that being vaccinated is an explicit condition to attend the conference. That said, I am beginning to have that "March 2020" feeling about things, and I wonder what scheduled activities for the remainder of 2021 and early 2022 will actually go off as planned.

you must not be related to any crazy antivaxxers. i envy you. they have no problem forging vax cards or just ignore requirements like this.

I think we're back to normal by the end of feb

[G]

I believe that being vaccinated is an explicit condition to attend the conference. That said, I am beginning to have that "March 2020" feeling about things, and I wonder what scheduled activities for the remainder of 2021 and early 2022 will actually go off as planned.

Agree about that feeling after reading here and seeing some of the national news...but hard to fit into the narrative here as we are routinely at only double digit new cases and have a positivity rate of 7%. I personally haven't admitted a covid patient in a month. RSV seems to be hurting us pretty bad....

[artemis]

I believe that being vaccinated is an explicit condition to attend the conference. That said, I am beginning to have that "March 2020" feeling about things, and I wonder what scheduled activities for the remainder of 2021 and early 2022 will actually go off as planned.

I am wondering that myself, as right now I have plans to go to WCICon in February, the USCAP annual meeting in LA in March, and a vacation in Florida with NatHab in April. Fingers crossed!

[StarTrekDoc]

That's easy. I just don't have that discussion. I tell them we're not going to see eye to eye and then I leave and discharge them.

Yep. We simply say, we don't do that here and mab if they qualify.

[Tim]

The emphasis on covid statistics is changing as the messaging will no longer be positive for the number of infections or percentage of positive tests. With the much higher rate of spread, this would be too much for anyone to claim success. Delta and now Omicron have mutated. The messaging will mutate as well.
The focus and all the data used will now be on hospitalizations as a secondary and the deaths as the primary. Rate of spread and severity. Will the progress made in therapeutics and population vaccinated, positive outcomes will be the focus.

The reality is our efforts in preventing spread have been largely unsuccessful. Vaccines (and boosters) will be the primary hard sell because it has been shown to prevent and limit the severity. Therapeutics limit the severity as well. Present as positive of a picture as possible given the circumstances.
Masking, social distancing and plexiglass will fade.
Additionally, vaccinating the "world" will become a talking point. Limits future variants, one less battle to fight. That actually aligns government policies with effective measures in lowering the damages caused by the cost benefit choices in society. Testing positive will cease to be used for messaging.

Not sure how cherry picking the metrics will work out. PR for hospitalizations or deaths for vaccinated (booster) would be counter productive to people getting vaccinated which is the best choice. I would think some PR gurus would figure out that you can't convince someone to vaccinate if the majority of the populatin is vaccinated and still end up hospitalized or dead. Drop the split out. Promote the benefits. How much better results are if you are vaccinated. Positive messaging will get results, more vaccinations and boosters.

[StarTrekDoc]

Agree about that feeling after reading here and seeing some of the national news...but hard to fit into the narrative here as we are routinely at only double digit new cases and have a positivity rate of 7%. I personally haven't admitted a covid patient in a month. RSV seems to be hurting us pretty bad....

This is the concern we have-- coinfection. It did us pretty bad last time in mar apr 2020.

I'm hoping our Friday county report is a blip. We jumped from 600s to just over 1000 cases. We're doing surveillance sequencing deletion and about 10% and rising quickly for omicron. This is lagging about 24-48 hours.