At what point did you / will you take the coronavirus epidemic seriously?

[Pelado]

They'll have to update their numbers--St. Luke's nurse practitioner dies after complications from COVID-19, youngest person in Idaho to die from it. She was 45

I heard about that on the radio earlier. Damn.

[Jarid in Cedar]

Ok. Let's get this started. This is why comparing death rates between areas that have surged at different time is fraught with error and scientific bias. If you sort the states by deaths per million and use a cut off of 500, those above sorted highest to lowest: New Jersey, New York, Connecticut, Massachusetts, Rhode Island, Louisiana, Michigan, Illinois, Maryland, Pennsylvania. What all of these states have in common were that they had high surges during the first 8 weeks of the outbreak in the US, About March 15th to May 15th, with all of the earliest hotspots in the top 6. That suggests that your risk of death was much higher if your zip code was hit early. The reasons are plenty and have been discussed before, but here is the rundown again. First, the low hanging fruit:

The lack of any proven or viable medical treatments. If you were hospitalized in April you did not have the option of receiving dexamethasone, remdesivir, or convalescent plasma. And of those, dexamethasone is the big one. For patients on ventilators, you only need to treat 8 patients to prevent 1 death. 8! If you are on oxygen but not on a vent you only need to treat 25 patients to prevent one death. Now if that sounds high, realize that we have to treat 100 people with a statin for three years to prevent one heart attack, not cardiac death, 1 heart attack. What that means is that when I was working the ICU in New York, we had 120 patient's on ventilators. If we could have treated all them with dexamethasone, then we could have prevented 15 deaths out of the 55 they statistically would have had out those 120 patients. Multiply those results over 2 months and dozens of other facilities, and you make an appreciable dent in mortality. I don't know the stats for remdesivir or convalescent plasma as the studies have not been completed, but they are showing a signal for meaningful improvement. Since May, most patient's are receiving remdesivir and convalescent plasma. And every patient on oxygen has received dexamethasone since the preprint release of the British study in June.

Second is the variation in standard nursing care in the areas where the hospitals were overrun. You can narrow that to the states in the New York metropolitan area, New York, New Jersey, Connecticut, and Rhode Island, which, not coincidentally happen to be 4 out of the top 5 in deaths/million. Now, I want to say up front that this is not a criticism of the nurses and doctors in these areas. They were massively overwhelmed and they did the best that they could with the circumstance at hand. But, when you have nurses in the ICU managing 5 patients that should have 3 even 4 nurses managing them, and you have doctors and residents from non critical care or hospitalist specialties, who have zero or little experience managing sick medical patients, you are going to have lab values missed, medication errors, delays in response to abnormal vital signs and declines in patient status. Crisis care has only happened in the northeast. Nowhere else. And this is what really differentiates the worst 5 from the next group. Michigan, Louisiana, Illinois, and Pennsylvania were all early hit, but their hospitals never strained beyond standard capacity.
Now, the real discussion is about why the New York area was hit so hard, and why it matters so much when you compare them to other areas. The concept is similar to a lead time bias. The defining factor at the onset of the outbreak is the number of hospitalizations. When you look at the crush of patients requiring hospitalization at the onset in the New York area, it means that the virus had been replicating and spreading without hinderance for at least 2-3 weeks, possibly even 4 weeks before the surge of hospitalizations the last week of March to the first week of April. Weeks before Rudy Gobert was diagnosed, before any shelter in place orders, shutdown of public places, etc. And most importantly, before travel from Continental Europe was halted. While we were worried about importing it from China, hundreds of thousands of passengers landed in New York from Europe, with an estimate of 150,000 deplanements in February from Italy alone. And given our inability to test in the months leading up to April, the virus was spreading without meaningful detection. Real understanding of the magnitude of the outbreak wasn’t understood until all the patients started to show up in the emergency rooms.

Lets assume that the time course from first infection to full blown disaster takes 50 days. The New York area was not aware of the magnitude of what they were up against at day 35. Really too late for any public health measures to make any meaningful impact. Based on hospitalization data, not cases because we couldn’t test, areas like Florida, Texas, California started public shutdown closer to 5-8 days, and places like Utah would be more like shut down on day 1 or 2 of that theoretic scale. You can look at hospitalization data for every state on April first and have an absolute idea what the real scope of the pandemic was in that state. And the states with the highest hospitalizations had no chance. They were going to have high death tolls.

The best way to see the difference is to look at the results of high level of testing in Florida, Texas, California right now. Everyone talks about the high number of younger cases that have mild illness. That was exactly the same scenario in New York at the end of February and the month of March. The difference is that all of these young, mildly sick people with positive tests right now are being quarantined for 14 days, their families are being quarantined and tested. In New York, they were still going to work. Still going to church, still leading their normal lives, but unknowingly spreading the disease further and to more and more vulnerable people. Until there was a critical mass of cases and infections that flooded the hospitals. And I can guarantee you that the exact same outcome would have happened in Miami or Houston if all of the current cases that they have had over the last few weeks had gone undetected.

TLR. I give little credit to the states that avoided the initial crush because of happenstance. Places like Arizona, Florida, Texas, damn well should have better mortality right now. They have the advantage of real treatment options. The advantage of real testing and quarantine options to flatten the curve. The advantage of their hospitals being able to make emergency plans before there is a real emergency.

The question is whether they will squander those advantages. I think Arizona has, and I think that Florida will. Texas is TBD. The number I will judge states responses is about 450-500 deaths per million. This will be a little less than the states that were hit early, but were not overrun, Pennsylvania, Illinois. These states reflect what standard medical care could do without the advantage of meaningful treatments. Those states should be the benchmark that we all try to beat. Not New York or the areas that had no real chance.

[Commando]

Thank you. That sheds some light on the situation for me.

[Flystripper]

At what point did you / will you take the coronavirus epidemic seriously?

Thanks Jarid. I appreciate it when we hear from you on this. Your insight is highly informed not only from personal front-line experience, but also because you have followed the treatments as they have evolved.

That being said WTF. Huntington Beach used to be so chill. God help us.


https://www.instagram.com/tv/CCoYH6e...d=d5w8kaqcs2m2


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[Pelado]

Thanks Jarid. I appreciate it when we hear from you on this. Your insight is highly informed not only from personal front-line experience, but also because you have followed the treatments as they have evolved.

That being said WTF. Huntington Beach used to be so chill. God help us.


https://www.instagram.com/tv/CCoYH6e...d=d5w8kaqcs2m2


Sent from my iPhone using Tapatalk

It's a muzzle!

[Surfah]

Thanks Jarid. I appreciate it when we hear from you on this. Your insight is highly informed not only from personal front-line experience, but also because you have followed the treatments as they have evolved.

That being said WTF. Huntington Beach used to be so chill. God help us.


https://www.instagram.com/tv/CCoYH6e...d=d5w8kaqcs2m2


Sent from my iPhone using Tapatalk

Droppin' dong.

Seriously though, WTF is wrong with people? The number of people that think this is some sort of conspiracy boggles my mind.

[Jarid in Cedar]

For those interested in more Herd Immunity Conversation. I came across this fellow’s article where he quoted the Stanford Professor.

I found it very interesting..


https://off-guardian.org/2020/07/07/...ot-even-close/


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He started the victory lap too early.

His graph of US daily deaths stopped July 7th. The last 8 days show an upturn in 7 day MA. If previous lag times between spikes in cases and the spike in death hold form, then we should see a consistent upturn starting sometime between the 17th and 22nd

[Mormon Red Death]

Agreed. I'm hopeful for a vaccine sooner than later, and agree there will likely need to be booster shots that we need to take for years to come. Then natural selection can thin the anti vaxxers herd.

"First COVID-19 vaccine tested in the US shows promising immune response ahead of large trial" https://twitter.com/i/events/1283184709598457857

Some good news

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[Bo Diddley]

"First COVID-19 vaccine tested in the US shows promising immune response ahead of large trial" https://twitter.com/i/events/1283184709598457857

Some good news

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Yep. I think the vaccines will a game changer and allow us to really open things back up, regardless of how long COVID-19 sticks around.

[Moliere]

"First COVID-19 vaccine tested in the US shows promising immune response ahead of large trial" https://twitter.com/i/events/1283184709598457857

Some good news

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Can’t wait for the vaccine skeptics (mbn and nwc) to come and throw rain clouds all over this sunshine.


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[Jarid in Cedar]

Can’t wait for the vaccine skeptics (mbn and nwc) to come and throw rain clouds all over this sunshine.


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I am not a vaccine skeptic as much as a vaccine pessimist. Mostly because the severe disease seems to be mediated by an over aggressive immune response. Vaccines for other diseases that are similar in that regard, specifically Dengue fever and RSV, have not gone over well in the past.

[Mormon Red Death]

Ok. Let's get this started. This is why comparing death rates between areas that have surged at different time is fraught with error and scientific bias. If you sort the states by deaths per million and use a cut off of 500, those above sorted highest to lowest: New Jersey, New York, Connecticut, Massachusetts, Rhode Island, Louisiana, Michigan, Illinois, Maryland, Pennsylvania. What all of these states have in common were that they had high surges during the first 8 weeks of the outbreak in the US, About March 15th to May 15th, with all of the earliest hotspots in the top 6. That suggests that your risk of death was much higher if your zip code was hit early. The reasons are plenty and have been discussed before, but here is the rundown again. First, the low hanging fruit:

The lack of any proven or viable medical treatments. If you were hospitalized in April you did not have the option of receiving dexamethasone, remdesivir, or convalescent plasma. And of those, dexamethasone is the big one. For patients on ventilators, you only need to treat 8 patients to prevent 1 death. 8! If you are on oxygen but not on a vent you only need to treat 25 patients to prevent one death. Now if that sounds high, realize that we have to treat 100 people with a statin for three years to prevent one heart attack, not cardiac death, 1 heart attack. What that means is that when I was working the ICU in New York, we had 120 patient's on ventilators. If we could have treated all them with dexamethasone, then we could have prevented 15 deaths out of the 55 they statistically would have had out those 120 patients. Multiply those results over 2 months and dozens of other facilities, and you make an appreciable dent in mortality. I don't know the stats for remdesivir or convalescent plasma as the studies have not been completed, but they are showing a signal for meaningful improvement. Since May, most patient's are receiving remdesivir and convalescent plasma. And every patient on oxygen has received dexamethasone since the preprint release of the British study in June.

Second is the variation in standard nursing care in the areas where the hospitals were overrun. You can narrow that to the states in the New York metropolitan area, New York, New Jersey, Connecticut, and Rhode Island, which, not coincidentally happen to be 4 out of the top 5 in deaths/million. Now, I want to say up front that this is not a criticism of the nurses and doctors in these areas. They were massively overwhelmed and they did the best that they could with the circumstance at hand. But, when you have nurses in the ICU managing 5 patients that should have 3 even 4 nurses managing them, and you have doctors and residents from non critical care or hospitalist specialties, who have zero or little experience managing sick medical patients, you are going to have lab values missed, medication errors, delays in response to abnormal vital signs and declines in patient status. Crisis care has only happened in the northeast. Nowhere else. And this is what really differentiates the worst 5 from the next group. Michigan, Louisiana, Illinois, and Pennsylvania were all early hit, but their hospitals never strained beyond standard capacity.
Now, the real discussion is about why the New York area was hit so hard, and why it matters so much when you compare them to other areas. The concept is similar to a lead time bias. The defining factor at the onset of the outbreak is the number of hospitalizations. When you look at the crush of patients requiring hospitalization at the onset in the New York area, it means that the virus had been replicating and spreading without hinderance for at least 2-3 weeks, possibly even 4 weeks before the surge of hospitalizations the last week of March to the first week of April. Weeks before Rudy Gobert was diagnosed, before any shelter in place orders, shutdown of public places, etc. And most importantly, before travel from Continental Europe was halted. While we were worried about importing it from China, hundreds of thousands of passengers landed in New York from Europe, with an estimate of 150,000 deplanements in February from Italy alone. And given our inability to test in the months leading up to April, the virus was spreading without meaningful detection. Real understanding of the magnitude of the outbreak wasn’t understood until all the patients started to show up in the emergency rooms.

Lets assume that the time course from first infection to full blown disaster takes 50 days. The New York area was not aware of the magnitude of what they were up against at day 35. Really too late for any public health measures to make any meaningful impact. Based on hospitalization data, not cases because we couldn’t test, areas like Florida, Texas, California started public shutdown closer to 5-8 days, and places like Utah would be more like shut down on day 1 or 2 of that theoretic scale. You can look at hospitalization data for every state on April first and have an absolute idea what the real scope of the pandemic was in that state. And the states with the highest hospitalizations had no chance. They were going to have high death tolls.

The best way to see the difference is to look at the results of high level of testing in Florida, Texas, California right now. Everyone talks about the high number of younger cases that have mild illness. That was exactly the same scenario in New York at the end of February and the month of March. The difference is that all of these young, mildly sick people with positive tests right now are being quarantined for 14 days, their families are being quarantined and tested. In New York, they were still going to work. Still going to church, still leading their normal lives, but unknowingly spreading the disease further and to more and more vulnerable people. Until there was a critical mass of cases and infections that flooded the hospitals. And I can guarantee you that the exact same outcome would have happened in Miami or Houston if all of the current cases that they have had over the last few weeks had gone undetected.

TLR. I give little credit to the states that avoided the initial crush because of happenstance. Places like Arizona, Florida, Texas, damn well should have better mortality right now. They have the advantage of real treatment options. The advantage of real testing and quarantine options to flatten the curve. The advantage of their hospitals being able to make emergency plans before there is a real emergency.

The question is whether they will squander those advantages. I think Arizona has, and I think that Florida will. Texas is TBD. The number I will judge states responses is about 450-500 deaths per million. This will be a little less than the states that were hit early, but were not overrun, Pennsylvania, Illinois. These states reflect what standard medical care could do without the advantage of meaningful treatments. Those states should be the benchmark that we all try to beat. Not New York or the areas that had no real chance.

I appreciate your response and I have a couple of questions/comments:

1. What happened with Washington? They were the epicenter at the beginning but seem to have not been ravaged like the other early states you mentioned. Just happenstance or did they do something different?

2. How much do you count in the missteps the states took? I'm with you on the argument of "well we treat better now that is why first states were were hit so hard". However, the magnitude of the difference seems to much to just call it chance. For example, Michigan .06% while NY is .17%. I think NY's sending back infected to the nursing home is the difference between the #s. They did create a makeshift hospital but they never used it. Since 80% of the deaths from covid are 65 and older that misstep is the biggest reason they have so many deaths.

3. My original post was that I had seen so much on how the florida governor was killing everybody that is why I showed the death rate by population. While I'm no fan of his I dont think that can be argued.

[Northwestcoug]

Can’t wait for the vaccine skeptics (mbn and nwc) to come and throw rain clouds all over this sunshine.


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LOL. You think I enjoy having my adult kids at home because of school closures? I want a vaccine now!

But yeah, what JIC said.

[Moliere]

I am not a vaccine skeptic as much as a vaccine pessimist. Mostly because the severe disease seems to be mediated by an over aggressive immune response. Vaccines for other diseases that are similar in that regard, specifically Dengue fever and RSV, have not gone over well in the past.

Are RSV and Dengue fever coronaviruses?

[Jarid in Cedar]

Are RSV and Dengue fever coronaviruses?

No, but the primary mechanism of the disease is driven by injury caused by the immune response to the virus instead of just the direct cytotoxicity of the virus itself. That is how they are similar to COVID-19.