Monday, March 09, 2020

Jealous Butterflies

From Jordan Weissmann at Slate:


Ned said...

Today Italy expanded yesterday's lockdown to cover the entire nation.

On a per capita basis, the number of *known* cases in the USA is running approximately 15 days behind Italy.

How each state (and the federal government) handles things will vary, but as a back-of-envelope calculation, figure that sometime around March 25, conditions in the USA will be at the level that provoked a nationwide lockdown in Italy.

Obviously some cities/states will get there faster, others slower.

Note that the US has fewer physicians and hospital beds per capita than Italy. The US health care system will likely be less able to handle the ballooning number of Intensive Care patients than the Italian system.

This thread on twitter makes the point that by early May the USA will have run out of hospital beds and personal protective equipment for health care workers.

Keep in mind that her calculations are based on nationwide totals -- resource shortages (beds, nurses, equipment) will occur weeks earlier in hard-hit areas or medically underserved areas. We can't shuffle patients around nationally to produce the maximally efficient allocation.

It's also counting all available hospital beds, not just Intensive Care beds, which are only about 14% of the total. In other words, the outlook is significantly more dire than her thread suggests.

Ned said...

Here's an eyewitness account of current conditions in Lombardy (the hardest-hit region of Italy):


Hospitals are running at 200% capacity.

We’ve stopped all routine, all ORs have been converted to ITUs and they are now diverting or not treating all other emergencies like trauma or strokes. There are hundreds of pts with severe resp failure and many of them do not have access to anything above a reservoir mask.

Patients above 65 or younger with comorbidities are not even assessed by ITU, I am not saying not tubed, I’m saying not assessed and no ITU staff attends when they arrest. Staff are working as much as they can but they are starting to get sick and are emotionally overwhelmed.

My friends call me in tears because they see people dying in front of them and they con only offer some oxygen. Ortho and pathologists are being given a leaflet and sent to see patients on NIV.

this is the pattern:

1)A few positive cases, first mild measures, people are told to avoid ED but still hang out in groups, everyone says not to panick

2)Some moderate resp failures and a few severe ones that need tube, but regular access to ED is significantly reduced so everything looks great

3)Tons of patients with moderate resp failure, that overtime deteriorate to saturate ICUs first, then NIVs, then CPAP hoods, then even O2.

4)Staff gets sick so it gets difficult to cover for shifts, mortality spikes also from all other causes that can’t be treated properly.

Again, on a per-capita basis the US is running 15 days behind Italy. So the above description is what hospitals in the worst-hit 20% of the USA will look like by March 25.

Ned said...

Last post for this morning. Here's another first-hand account of the situation in hospitals in Italy now:


I understand the need not to create panic, but when the message of the dangerousness of what is happening does not reach people I shudder.

I still remember my night call a week ago when I was waiting for the results of a swab. When I think about it, my anxiety over one possible case seems almost ridiculous and unjustified, now that I've seen what's happening. Well, the situation now is dramatic to say the least.

The war has literally exploded and battles are uninterrupted day and night. But now that need for beds has arrived in all its drama. One after the other the departments that had been emptied fill up at an impressive pace.

The boards with the names of the patients, of different colours depending on the operating unit, are now all red and instead of surgery you see the diagnosis, which is always the damned same: bilateral interstitial pneumonia.

Cases are multiplying, we arrive at a rate of 15-20 admissions per day all for the same reason. The results of the swabs now come one after the other: positive, positive, positive. Suddenly the E.R. is collapsing.

Every ventilator becomes like gold: those in operating theatres that have now suspended their non-urgent activity become intensive care places that did not exist before.

There are no more shifts, no more hours. Social life is suspended for us. We no longer see our families for fear of infecting them. Some of us have already become infected despite the protocols.

Again, the facts:

(1) The US has fewer physicians and hospital beds per capita than Italy.

(2) On a per capita basis, the rate of known cases in the USA today is 15 days behind Italy.

So that's what conditions will be like in many US hospitals two weeks from now.

David in Cal said...

Ned - I would question your logic. Virus conditions in the US are FAR, FAR, FAR better than in Italy. Therefore, Trump is doing things wrong.

If conditions in the US were as bad as Italy or worse, that would also prove that Trump is doing things wrong. IMHO no matter what Trump does, his enemies will claim that he is doing things wrong.


Ned said...


I'm not sure what you think the "logic" is that you're questioning, but this:

"conditions in the US are better than Italy, therefore Trump is doing things wrong"

has nothing to do with anything I've said here. Seriously. In fact, I don't even mention Trump's name anywhere in this thread, though I've certainly made my feelings about him clear elsewhere.

The point of my 3 points in this thread is simply that over the next month, things are going to get hellishly bad in the US health care system. The comparison to Italy is simply this:

Italy is further down the exact same road the USA is following. If you want to know what the situation in the USA will be like 15 days from now, look at where Italy is today.

Read the three posts above carefully! I think they're pretty clear and straightforward, but YMMV.

David Appell said...

David, isn't Trump responsible for

1) continuingly downplaying the extent of the virus?

2) being seemingly most concerned about how the numbers make him look?

3) being more concerned about the stock market?

4) the large deficit of testing kits?

5) going golfing when he criticized Obama for doing the same during the Ebola problem?

Ned said...

Look at this note from the doctor I quote in the second post above:

"Patients above 65 or younger with comorbidities are not even assessed by ITU, I am not saying not tubed, I'm saying not assessed and no ITU staff attends when they arrest."

In other words, his hospital is so overwhelmed with Coronavirus patients that anyone over age 65 or with any additional medical issues ("comorbidities") will be triaged out.

If you're 67 years old, or 40 years old with diabetes, and you show up at this hospital, you won't be assessed let alone treated; you'll be left to recover (or not) on your own ... because hospital staff and facilities are swamped by the exponentially growing caseload of Coronavirus victims.

Note that Italy has more physicians and hospital beds than the US does, per capita. In a few weeks from today, the worst-hit US hospitals will be in the same situation as described above. And the number of hospitals similarly overwhelmed by Covid-19 patients will then increase rapidly each week.

David in Cal said...

David - start with Trump's most significant personal action:

0) Trump closed our borders to folks from China, before any other country and against the advice of WHO and some Trump opponents. The turns out to have been an excellent move. It bought us time. (WHO deserves severe criticism IMHO.)

1) continually downplaying the extent of the virus?
Yes, Trump said a number of dumb things, no doubt trying to avoid panic. But, his statements were so dumb, they may have even made the panic worse.

2) being seemingly most concerned about how the numbers make him look?
It's in the eye of the beholder. He said his biggest concern was the disease. He took many actions related to the disease, including setting up the Task Force, dealing with persons entering the US, etc. To my eye, he was most concerned with the disease, although he appeared overly concerned with getting credit and avoiding blame. He might argue that he had to defend himself. Democrats and their friends in media were blaming Trump from Day 1, regardless of what he did. E.g., one New York Times writer suggested calling Covid-19 the "Trump virus." They were using Covid-19 to try bring down Trump, and they continue to do so.

3) being more concerned about the stock market?
I thought his concern about the stock market was at an appropriate level. A stock market crash is likely to lead to a recession or worse.

4) the large deficit of testing kits?
The problem was due to red tape and over-regulation. My Bio-statistician wife agreed with all the regulation, BTW. I don't blame Obama, even though these regs existed during his Administration, nor do I blame Trump, who inherited these regs. However, Trump deserves a lot of credit for his shut-down of people from China. Due to this action, we have had a relatively small number of cases. As the number ramps up, the number of testing kits is rapidly growing into the millions. This problem is rapidly disappearing.

5) going golfing when he criticized Obama for doing the same during the Ebola problem? This is unimportant.

Here are some things that are a lot more important IMHO:
-- Are the right people working on this in Washington?
-- Are they working effectively? How effective are they?
-- Are state and local health agencies working effectively?
-- Will health care providers have all the resources they need, when they need them? (This is a potential huge problem.)
-- Are required or recommended quarantine rules appropriate? Are they not severe enough? Too severe?
-- Will the financial steps taken by Trump, the Fed and Congress be the right ones to prevent a severe recession?

I do not know the answer to any of these questions. However, these items will determine how well or how badly our country comes out of this crisis. If our media people were trained in management, they'd be analyzing these sorts of areas. Instead, they mostly snipe with "gotcha" questions.


Ned said...

This is so idiotic that I'm sure someone will have to step on the brakes, right?

The administration has been preparing an executive order, which could be released in the coming days, that would [make it harder for the government] to purchase pharmaceuticals, face masks, ventilators and other medical products from foreign countries.

By April this country is going to need every single ventilator and face mask we can get our hands on. Banning the US government from purchasing those items unless they're "Made in USA" would be useless at best and insane at worst.


Ned said...

This administration seems to have a habit of mis-using the classification process as a way to avoid leaks and hide embarrassing information:

White House told federal health agency to classify coronavirus deliberations

The White House has ordered federal health officials to treat top-level coronavirus meetings as classified, an unusual step that has restricted information and hampered the U.S. government's response to the contagion, according to four Trump administration officials.

Staffers without security clearances, including government experts, were excluded from the interagency meetings... "This came directly from the White House," one official said.

A high-level former official who helped address public health outbreaks in the George W. Bush administration said "it's not normal to classify discussions about a response to a public health crisis."

One of the administration officials suggested the security clearances for meetings at HHS were imposed not to protect national security but to keep the information within a tight circle, to prevent leaks.