PART 17. April 2, 2020. CORONAVIRUS. Florida allows churches to continue holding services. Gun stores deemed “essential.” “New York’s private and public hospitals unite to manage patient load and share resources.

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“A statement from Cuomo said the president approved his request Thursday evening.

“As we all know the growing coronavirus cases are threatening the capacity of our hospital system,” Cuomo said. “The state-owned Javits Center has been turned into a 2,500-bed emergency medical facility being run by the U.S. Army. The original plan for Javits was that it be used to take non-COVID patients from hospitals to open up hospital beds. However, the number of COVID positive patients has increased so dramatically that it would be beneficial to the state if Javits could accept COVID positive patients.”

As of Thursday morning, there were 92,381 cases of the coronavirus in New York, with 51,809 of those cases in New York City. Nearly 13,400 people are hospitalized and more than 2,370 patients are in the intensive care unit. New York state has experienced more than 2,370 deaths.

New York currently has approximately 53,000 hospital beds and projections estimate that the state may need as many as 110,000. The Javits Center is one of several temporary facilities the state has established to cope with the influx of COVID-19 patients, adding thousands more beds across the state.

The number of coronavirus cases topped 1 million worldwide Thursday. The U.S. has the most cases of any country, with more than 238,800.” (Y)

“Gov. Ron DeSantis’ safe-at-home executive order will preempt all local ordinances regardless of whether they are more or less restrictive than the state order.

DeSantis issued a new order clarifying and amending the original one late Wednesday following reports, including one from Florida Politics, that local ordinances with more restrictive language would not be preempted.

That specifically pertains to a religious exemption that allows churches to continue holding services even if those congregations exceed the Centers for Disease Control and Prevention’s guideline on social distancing that limits gatherings to 10 or fewer individuals.

DeSantis’ updated order removes language that provided an exception for local ordinances that went beyond the state order.

Those more restrictive local measures, which have been approved in a host of Florida cities and counties, will no longer be valid.” (A)

“Social distancing guidelines and stay-at-home orders have been implemented in most of the country, greatly limiting where Americans can go. Businesses classified as “essential services” include grocery stores, pharmacies and even gun stores.

On Saturday, the Department of Homeland Security (DHS) released guidance on essential and critical businesses during the coronavirus pandemic. Within the public safety and law enforcement category, DHS listed the firearm industry as essential.

In addition to first responders and people who supply their equipment, “workers supporting the operation of firearm or ammunition product manufacturers, retailers, importers, distributors, and shooting ranges,” are also allowed to continue working.” (B)

“Despite President Trump’s repeated assertions that the Covid-19 epidemic was “unforeseen” and “came out of nowhere,” the Pentagon was well aware of not just the threat of a novel influenza, but even anticipated the consequent scarcity of ventilators, face masks, and hospital beds, according to a 2017 Pentagon plan obtained by The Nation.

“The most likely and significant threat is a novel respiratory disease, particularly a novel influenza disease,” the military plan states. Covid-19 is a respiratory disease caused by the novel (meaning new to humans) coronavirus. The document specifically references coronavirus on several occasions, in one instant saying, “Coronavirus infections [are] common around the world.”..

 “There have been recent pronouncements that the coronavirus pandemic represents an intelligence failure…. it’s letting people who ignored intelligence warnings off the hook.”…

The plan states: “Competition for, and scarcity of resources will include…non-pharmaceutical MCM [Medical Countermeasures] (e.g., ventilators, devices, personal protective equipment such as face masks and gloves), medical equipment, and logistical support. This will have a significant impact on the availability of the global workforce.”…

The plan’s warning about face masks and ventilators was prescient: The US Strategic National Stockpile of medical equipment including respirators, gloves, face masks, and gowns is reportedly nearly depleted.

The military plan also correctly anticipates “insufficient hospital beds.” Indeed, hospitals are in critically short supply in Italy and rapidly filling up across New York.”  (C)

““Testing is the biggest problem that we’re facing,” Peter Slavin, president of Massachusetts General Hospital, said recently in a roundtable on Covid-19 at Harvard Medical School. While South Korea had tested about 4,000 people per million of its population at the time, the United States had just run five tests per million — despite the fact that they both reported their first cases at essentially the same time (on January 21 and 20). The discrepancy was surprising because the genome of the virus had been available since January and scientists had figured out the diagnostics shortly thereafter, using proven molecular methods first discovered in the 1970s.

The value of a test comes from its so-called specificity and sensitivity: Infected patients should be correctly identified as infected, patients who don’t carry the virus should be diagnosed as such, and people that unknowingly had the infection should be tested for immunity. This helps us understand who is infected, where the infection occurred, and how the virus was transmitted.

Testing is also needed to address the uncertainty in making decisions about patient treatment, resource allocation, policy, and so much more. Answers to questions such as “When should we relax social distancing measures — and for whom?” or “How many ventilators are needed in hospitals?” are vital to our economic recovery and public health outcomes and cannot be answered without reliable test data. To find answers requires organizations in which testing is embraced (in action and orientation) by every employee, from top to bottom. “Test early and often” needs to be an organization’s ethos…” (D)

 Vice President Mike Pence sought to cast blame on the Centers for Disease Control and Prevention and China Wednesday when asked why the US was so late in understanding the enormity of the coronavirus pandemic.

“I will be very candid with you and say that in mid-January the CDC was still assessing that the risk of the coronavirus to the American people was low. The very first case, which was someone who had been in China — in late January around the 20th day of January,” Pence told CNN’s Wolf Blitzer…

US health officials from the CDC took active steps starting in January to prepare for the outbreak as information trickled out of China. Members of Trump’s Cabinet also got involved and started briefing lawmakers. While public health officials and medical experts raised the alarm, Trump downplayed their concerns and injected controversial and unproven theories into the conversation.

In the course of two months, President Donald Trump has dramatically shifted his tone and level of optimism about the spread of novel coronavirus and its impact on the economy.

At the coronavirus briefing on February 26, for example, Trump said all of the following: “This is a flu. This is like a flu”; “Now, you treat this like a flu”; “It’s a little like the regular flu that we have flu shots for. And we’ll essentially have a flu shot for this in a fairly quick manner.”

As recently as the second week of March, Trump was an advocate of facing the virus without taking drastic measures to address it.

Just four days ago, on March 27, he said that you can call the coronavirus “a flu,” or a virus or a germ…

On Tuesday, the President warned of a “painful” and “tough” two-week stretch ahead as he extended nationwide distancing measures that — even if followed closely — could still mean more than 100,000 and up to 240,000 Americans die from coronavirus.

Pence also suggested that by continuing mitigation efforts to stop the spread of the virus, “we could well have the coronavirus largely behind us as a nation” by June.

“I never want to minimize the loss. I just want to make sure people know there is light at the end of the tunnel,” he added.

The vice president also said he doesn’t think a national stay-at-home order is necessary. He said the administration supports orders like those made in California and in Washington (state), but suggested that they’re not necessary across other parts of the country less affected by the coronavirus outbreak.” (E)

“At a time when the nation is desperate for authoritative information about the coronavirus pandemic, the country’s foremost agency for fighting infectious disease outbreaks has gone conspicuously silent.

“I want to assure Americans that we have a team of public health experts,” President Trump said at Tuesday evening’s coronavirus task force briefing — a bit of reassurance that probably would not have been necessary if that briefing had included anyone from the Centers for Disease Control and Prevention.

The CDC normally takes the lead in outbreaks, ranging from the 2009 flu pandemic to Ebola to the lung injuries caused by vaping. Its recent absence from the national stage has led to fears that the agency’s objective, science-based approach is being ignored, especially as Trump signals that he hopes to relax restrictions on social gatherings by Easter to help revive the economy…

The CDC is normally a credible, reliable source of infectious disease knowledge, led by physicians, scientists and epidemiologists capable of fielding detailed questions about what is scientifically known and what is not.

In past health emergencies, the agency has not only provided specific numbers and data about the changing status of an epidemic, but also offered informed commentary on the likely course of an outbreak and the best known strategies for mitigation and containment. The agency is usually in close contact with state public health agencies, and has an overview on what is happening across the entire country…

Meanwhile, various members of the White House task force have taken over the job of informing the public. Much time is spent in briefings on economic or political considerations like legislation or the performance of the stock market, with questions often being answered by the president or Vice President Mike Pence.

Asked, for example, why Easter was targeted as a possible timeline for lifting social distancing measures, the president replied, “I just thought it was a beautiful time. It would be a beautiful time, a beautiful timeline. It’s a great day.”

A follow-up question asked whether the time was based on any data, and the president again said that he thought it would be a beautiful timeline…

At the White House briefings, science and public health questions often get addressed by Anthony Fauci, the head of the National Institute of Allergy and Infectious Diseases, or the coronavirus response coordinator, Ambassador Deborah Birx.

The two, both doctors, seem to walk a tightrope of trying not to annoy the president while deftly attempting to temper some of his more optimistic assertions, like the potential of the drug chloroquine to treat COVID-19…

Top officials who could be communicating with the public more regularly include CDC Director Robert Redfield; CDC principal deputy director, Anne Schuchat; and Nancy Messonnier, who is director of the CDC’s National Center for Immunization and Respiratory Diseases.” (F)

“President Trump has praised Dr. Anthony S. Fauci as a “major television star.” He has tried to demonstrate that the administration is giving him free rein to speak. And he has deferred to Dr. Fauci’s opinion several times at the coronavirus task force’s televised briefings.

But Dr. Fauci, the director of the National Institute of Allergy and Infectious Diseases since 1984, has grown bolder in correcting the president’s falsehoods and overly rosy statements about the spread of the coronavirus in the past two weeks — and he has become a hero to the president’s critics because of it. And now, Mr. Trump’s patience has started to wear thin.

So has the patience of some White House advisers, who see Dr. Fauci as taking shots at the president in some of his interviews with print reporters while offering extensive praise for Mr. Trump in television interviews with conservative hosts.

Mr. Trump knows that Dr. Fauci, who has advised every president since Ronald Reagan, is seen as credible with a large section of the public and with journalists, and so he has given the doctor more leeway to contradict him than he has other officials, according to multiple advisers to the president…

 “He’s a good man,” Mr. Trump said. Dr. Fauci was scheduled to be on Fox News with Sean Hannity a short time later.

Still, the president has resisted portraying the virus as the kind of threat described by Dr. Fauci and other public health experts. In his effort to create a positive vision of a future where the virus is less of a danger, critics have accused Mr. Trump of giving false hope.

Dr. Fauci and the president have publicly disagreed on how long it will take for a coronavirus vaccine to become available and whether an anti-malaria drug, chloroquine, could help those with an acute form of the virus. Dr. Fauci has made clear that he does not think the drug necessarily holds the potential that Mr. Trump says it does.

In an interview with Science Magazine, Dr. Fauci responded to a question about how he had managed to not get fired by saying that, to Mr. Trump’s “credit, even though we disagree on some things, he listens. He goes his own way. He has his own style. But on substantive issues, he does listen to what I say.”

But Dr. Fauci also said there was a limit to what he could do when Mr. Trump made false statements, as he often does during the briefings.

 “I can’t jump in front of the microphone and push him down,” Dr. Fauci said. “OK, he said it. Let’s try and get it corrected for the next time.”

In an interview with CBS’s “Face the Nation” on Sunday, Dr. Fauci played down the idea that there was a divide between him and the president. “There isn’t fundamentally a difference there,” he said.

“The president has heard, as we all have heard, what are what I call anecdotal reports that certain drugs work. So what he was trying to do and express was the hope that if they might work, let’s try and push their usage,” Dr. Fauci said. “I, on the other side, have said I’m not disagreeing with the fact anecdotally they might work, but my job is to prove definitively from a scientific standpoint that they do work. So I was taking a purely medical, scientific standpoint, and the president was trying to bring hope to the people.”..

When Vice President Mike Pence took over as the lead of the coronavirus task force, his advisers wanted to put a 24-hour pause on interviews that administration officials were giving as they assessed where the administration was after a chaotic few weeks. They were initially fine with Dr. Fauci’s appearances, meeting with him before interviews to get a sense of what he planned to say.

But in the past two weeks, as Dr. Fauci’s interviews have increased in frequency, White House officials have become more concerned that he is criticizing the president.

Officials asked him about the viral moment in the White House briefing room, when he put his hand to his face and appeared to suppress a chuckle after Mr. Trump referred to the State Department as the “Deep State Department.” Dr. Fauci had a benign explanation: He had a scratchy throat and a lozenge he had in his mouth had gotten stuck in his throat, which he tried to mask from reporters.

Some officials have not questioned that Dr. Fauci is giving interviews, but they have wondered how he has so much time for so many requests from the news media.

Dr. Fauci, for his part, has been dismissive of some questions about whether he was at odds with the president, treating it as a news media obsession.

“I think there’s this issue of trying to separate the two of us,” he said on CBS.” (G)

“On the surface, the American COVID-19 testing regime has finally hit its stride. Over the past five days, the states have reported a daily average of 104,000 people tested, according to data assembled by the COVID Tracking Project, a volunteer collaboration incubated at The Atlantic. Today, the U.S. reported that 1 million people have been tested for the coronavirus—a milestone that the White House once promised it would hit the first week of March.

But things are not going as smoothly as the top-line numbers might suggest. Our reporting has unearthed a new coronavirus-testing crisis. Its main cause is not the federal government, nor state public-health labs, but the private companies that now dominate the country’s testing capacity. Testing backlogs have ballooned, slowing efficient patient care and delivering a heavily lagged view of the outbreak to decision makers…

Within the clinical-testing world, it is an open secret that Quest Diagnostics—one of the industry’s two big players, along with Labcorp—has struggled to scale up its operations in California. And yet, Quest has continued to accept specimens from across the country, leading to a huge backlog of tests at the company’s facility in San Juan Capistrano.

This failure accounts for at least some of the tens of thousands of pending tests reflected in the state’s reported numbers. According to experts, it isn’t Quest’s fault that the company has so far been unable to meet the technical challenge of testing thousands of people every day. Setting up such “high throughput” operations is difficult. But Quest failed to come to terms with its ongoing problems, and it continued to accept specimens—and generate revenue—when other laboratories could have done some of the tests faster.” (H)

“All U.S. hospitals can split ventilators if necessary for COVID-19 patients, the Trump administration said March 31. In a letter to healthcare workers, Surgeon General Jerome Adams, MD, and Assistant Secretary for Health Adm. Brett Giroir, MD, offer technical guidance for hospitals splitting ventilators between two patients. The federal guidelines said ventilator-splitting “should only be considered as an absolute last resort” since the reliability and safety are unknown, consistent with what many pulmonology experts have told Becker’s.” (I)

“On top of the overwhelming shortages of medical equipment required to combat Covid-19, there are now signs that medicines needed for patients who are placed on ventilators are also in short supply.

The medicines include more than a dozen sedatives, anesthetics, painkillers, and muscle relaxants, and the shortages raise the possibility that it could become more difficult for health care providers to place these patients on ventilators. This is because the drugs are used to help manage patient pain and comfort levels so they can benefit from mechanical ventilation.

There has been a 51% increase in demand so far this month for half a dozen different sedatives and anesthetics: propofol, dexmedetomidine, etomidate, ketamine, lorazepam, and midazolam. But the fill rate —  the rate that prescriptions were able to filled and shipped to hospitals —dropped from 100% at the beginning of the month to just 63% on March 24.

Similarly, the demand for three analgesics — hydromorphone, fentanyl, and morphine — rose 67% so far this month, while the fill rate fell from 82% to 73%. Meanwhile, the demand for four neuromuscular blockers — cisatracurium, rocuronium, succinylcholine chloride, and vecuronium — rose 39% while the fill rate plummeted to 70%….

 “This is a huge problem. Many of these drugs were already in shortage before Covid. The drug supply chain is one of just-in-time production and supplies. Nobody has two times, five times, or even 10 times the amount of drugs on hand that are going to be needed for this surge,” said Erin Fox, who tracks shortages and directs the drug-information service at University of Utah Health Care, which has four hospitals.

“I am not sure that manufacturers are ramping up for the surge — if they are still making the same amount they always have. That’s not a shortage and it won’t even be reported to FDA. Everyone has been focused on possible shortages due to China halting production or India halting imports, but nobody is talking about shortages due to a huge spike in demand.” “ (J)

“Thirteen years ago, a group of U.S. public health officials came up with a plan to address what they regarded as one of the medical system’s crucial vulnerabilities: a shortage of ventilators…

“We definitely saw the problem,” said Dr. Thomas R. Frieden, who ran the Centers for Disease Control and Prevention from 2009 to 2017. “We innovated to try and get a solution. We made really good progress, but it doesn’t appear to have resulted in the volume that we needed.”

In 2006, the Department of Health and Human Services established a new division, the Biomedical Advanced Research and Development Authority, with a mandate to prepare medical responses to chemical, biological and nuclear attacks, as well as infectious diseases…

In its first year in operation, the research agency considered how to expand the number of ventilators. It estimated that an additional 70,000 machines would be required in a moderate influenza pandemic.

The ventilators in the national stockpile were not ideal. In addition to being big and expensive, they required a lot of training to use. The research agency convened a panel of experts in November 2007 to devise a set of requirements for a new generation of mobile, easy-to-use ventilators.

In 2008, the government requested proposals from companies that were interested in designing and building the ventilators.

The goal was for the machines to be approved by regulators for mass development by 2010 or 2011, according to budget documents that the Department of Health and Human Services submitted to Congress in 2008. After that, the government would buy as many as 40,000 new ventilators and add them to the national stockpile.

The federal government has spent years trying to increase the supply of ventilators in its strategic stockpile.

The ventilators were to cost less than $3,000 each. The lower the price, the more machines the government would be able to buy.

Companies submitted bids for the Project Aura job. The research agency opted not to go with a large, established device maker. Instead it chose Newport Medical Instruments, a small outfit in Costa Mesa, Calif.

Newport, which was owned by a Japanese medical device company, only made ventilators. Being a small, nimble company, Newport executives said, would help it efficiently fulfill the government’s needs.

Ventilators at the time typically went for about $10,000 each, and getting the price down to $3,000 would be tough. But Newport’s executives bet they would be able to make up for any losses by selling the ventilators around the world…

In 2011, Newport shipped three working prototypes from the company’s California plant to Washington for federal officials to review.

Dr. Frieden, who ran the C.D.C. at the time, got a demonstration in a small conference room attached to his office. “I got all excited,” he said. “It was a multiyear effort that had resulted in something that was going to be really useful.”

In April 2012, a senior Health and Human Services official testified before Congress that the program was “on schedule to file for market approval in September 2013.” After that, the machines would go into production.

Then everything changed.

The medical device industry was undergoing rapid consolidation, with one company after another merging with or acquiring other makers. Manufacturers wanted to pitch themselves as one-stop shops for hospitals, which were getting bigger, and that meant offering a broader suite of products. In May 2012, Covidien, a large medical device manufacturer, agreed to buy Newport for just over $100 million.

Covidien — a publicly traded company with sales of $12 billion that year — already sold traditional ventilators, but that was only a small part of its multifaceted businesses. In 2012 alone, Covidien bought five other medical device companies, in addition to Newport.

Newport executives and government officials working on the ventilator contract said they immediately noticed a change when Covidien took over. Developing inexpensive portable ventilators no longer seemed like a top priority….

In 2014, with no ventilators having been delivered to the government, Covidien executives told officials at the biomedical research agency that they wanted to get out of the contract, according to three former federal officials. The executives complained that it was not sufficiently profitable for the company.

The government agreed to cancel the contract.” (K)

“The federal government has nearly emptied its emergency stockpile of protective medical supplies like masks, gowns and gloves as state governors continue to plea for protective gear for desperate hospital workers, according to a senior administration official.

The official said the Federal Emergency Management Agency has delivered more than 11.6 million N95 masks, 5.2 million face shields, 22 million gloves and 7,140 ventilators, exhausting the emergency stockpile.

The official said there was a “tiny slice” of personal protective equipment left over that is being preserved for first responders for the federal government.

While there is no more personal protective equipment in the stockpile left over for the states, the senior official said the administration still has more than 9,400 ventilators ready to be deployed.

The dwindling resources have forced the federal government to compete with states and private companies for valuable medical gear across the world. Governors, meanwhile, have continued to try to find ways to scavenge medical supplies for hospital workers exposed to the worsening pandemic…

 “The Defense Production Act gives the president of the United States power to say to a company: you make this,” Mr. Cuomo said, noting that while much of the discussion about the act had been about making ventilators, which are complex to build, it could also be used for other gear, including hospital gowns.

“Look, you have a shortfall on gowns,” he said. “American companies can make gowns — they’re not like wedding gowns, they’re like paper gowns. Make the gowns, make the gloves, make the masks. You know, why are we running out of these basic supplies?”

Even though the Department of Defense used authorities under the Defense Production Act to place hundreds of thousands of order for military equipment, the Trump administration for weeks was reluctant to use the law, until last Friday, when Mr. Trump said he would use it to prioritize an order of ventilators from General Motors.” (L)

“When Ford’s chief executive, Jim Hackett, announced on Tuesday that the carmaker would team up with General Electric to build ventilators, he tempered the good news with a note of caution: “We’re talking about early June.”

That was just one of several examples that underscored the price of the Trump administration’s slow response to evidence as early as January that the coronavirus was headed to the United States.

For the first time, it is now possible to quantify the cost of the lost weeks, as President Trump was claiming as recently as February that in a “couple of days” the number of cases in the United States “is going to be down to close to zero.”

Ford’s timeline suggested that if the administration had reacted to the acute shortage of ventilators in February, the joint effort between Ford and General Electric might have produced lifesaving equipment sometime in mid- to late April.

A month later, the administration still does not appear to have a streamlined response to the pandemic. The chief of the Federal Emergency Management Agency said Tuesday that the administration would use the Defense Production Act, a Korean War-era law, to mandate the production of 60,000 coronavirus test kits. By Tuesday night, an agency spokeswoman said that the administration had been able to secure the tests without invoking the law.

The 60,000 tests are a tiny fraction of the tens of millions needed, and it raised the question whether the scarcity today would exist had the White House moved faster more than a month ago, after the Centers for Disease Control and Prevention fumbled its first effort to send out a test. Commercial laboratories could have produced their own tests earlier, according to industry officials, and governors have said that the wartime law would result in desperately needed equipment arriving in weeks, instead of months.

The gap between the production timelines and the need for immediate supplies led to a scathing assessment from Gov. Andrew M. Cuomo of New York. New York accounts for more than 25,000 cases, more than half the total in the country, he said, but it has received only 400 ventilators from the federal government.

 “You want a pat on the back for sending 400 ventilators?” Mr. Cuomo said. “What are we going to do with 400 ventilators when we need 30,000 ventilators? You’re missing the magnitude of the problem, and the problem is defined by the magnitude.”..

Mr. Cuomo crystallized the issue on Tuesday when he said that “the timeline doesn’t work.”

“I don’t need ventilators in six months,” he said. “And I don’t need ventilators in five months, four months or three months.”..

Last week, Mr. Trump urged states to fend for themselves, looking for whatever they could find on the open market. But that only underlined how poorly prepared federal stockpiles were for a pandemic — a situation that the last three administrations had rehearsed in an effort to improve plans. The president’s comments set off a scramble that only accelerated the criticism of how the White House has handled the allocation of scarce supplies.

Gov. J.B. Pritzker of Illinois, a Democrat, argued that in sending each of the states off to find their own equipment, “we’re competing against each other, we’re competing against other countries.” The result, he said, was “we’re overpaying.”

Mr. Trump responded that Mr. Pritzker and other governors “shouldn’t be blaming the federal government for their own shortcomings. We are there to back you up should you fail, and always will be!”

But it is increasingly clear that the federal government will not be able to back up the states, at least at the scale needed, for the first wave of patients. And by letting companies voluntarily produce the necessary equipment, rather than under orders in the Defense Production Act, the administration is not responsible for whether the quotas are met, or if the output reaches hospitals.” (M)

“The Trump administration has decided against reopening Obamacare enrollment to uninsured Americans during the coronavirus pandemic, defying calls from health insurers and Democrats to create a special sign-up window amid the health crisis.

President Donald Trump and administration officials recently said they were considering relaunching, the federal enrollment site, and insurers said they privately received assurances from health officials overseeing the law’s marketplace. However, a White House official on Tuesday evening told POLITICO the administration will not reopen the site for a special enrollment period, and that the administration is “exploring other options.”

The annual enrollment period for closed months ago, and a special enrollment period for the coronavirus could have extended the opportunity for millions of uninsured Americans to newly seek out coverage. Still, the law already allows a special enrollment for people who have lost their workplace health plans, so the health care law may still serve as a safety net after a record surge in unemployment stemming from the pandemic.” (N)

“Texas and Ohio have included abortions among the nonessential surgeries and medical procedures that they are requiring to be delayed, setting off a new front in the fight over abortion rights in the middle of the coronavirus pandemic in the United States.

Both states said they were trying to preserve extremely precious protective equipment for health care workers and to make space for a potential flood of coronavirus patients.

But abortion rights activists said that abortions should be counted as essential and that people could not wait for the procedure until the pandemic was over.

On Monday, Ken Paxton, the attorney general of Texas, clarified that the postponement of surgeries and medical procedures announced by Gov. Greg Abbott over the weekend included “any type of abortion that is not medically necessary to preserve the life or health of the mother.”

Failure to do so, he said, could result in penalties of up to $1,000 or 180 days of jail time. It was not immediately clear if that included medication abortion, which involves providers administering pills in the earlier stages of pregnancy.” (O)

“Doctors are hoarding medications touted as possible coronavirus treatments by writing prescriptions for themselves and family members, according to pharmacy boards in states across the country.

The stockpiling has become so worrisome in Idaho, Kentucky, Ohio, Nevada, Oklahoma, North Carolina, and Texas that the boards in those states have issued emergency restrictions or guidelines on how the drugs can be dispensed at pharmacies. More states are expected to follow suit.

“This is a real issue and it is not some product of a few isolated bad apples,” said Jay Campbell, executive director of the North Carolina Board of Pharmacy.

The medications being prescribed differ slightly from state to state, but include those lauded by President Trump at televised briefings as potential breakthrough treatments for the virus, which has killed at least 675 people in the United States and infected more than 52,000.

None of the drugs have been approved by the U.S. Food and Drug Administration for that use. Some of them — including chloroquine and hydroxychloroquine — are commonly used to treat malaria, lupus, rheumatoid arthritis and other conditions…

 “The A.M.A. is calling for a stop to any inappropriate prescribing and ordering of medications, including chloroquine or hydroxychloroquine, and appealing to physicians and all health care professionals to follow the highest standards of professionalism and ethics,” she said.

Dr. Harris also noted that the country’s health care professionals “continue to demonstrate remarkable leadership every day,” and can look to the organization’s code of medical ethics for guidance.

The first restrictions were imposed last week in Idaho. The board there imposed a temporary rule barring pharmacies from dispensing two drugs — chloroquine and hydroxychloroquine — unless the prescription includes a written diagnosis of a condition that the drugs have been proven to treat. The rule also limits prescriptions to a 14-day supply unless a patient has previously taken the medication.

“We wanted to try to get out in front of that as early as we could,” said Nicki Chopski, executive director of the board in Idaho, where pharmacists began reporting a significant uptick in prescriptions for the medications last week. The prescriptions, she said, were being written by doctors for themselves and their family members, often in large quantities with refills.” (P)

“In a press briefing March 25, New York Gov. Andrew Cuomo said that 40,000 people have signed up for a surge healthcare workforce that the state is putting together, comprised of retired healthcare workers as well as providers who have moved on to other jobs outside of the healthcare sector. So far the surge workforce includes 2,265 physicians, 2,409 nurse practitioners and 938 physician assistants.

“That is a big, big deal,” he said. “You can create beds, you can buy the equipment, [but] you have to have the staff.”” (Q)

“New York Gov. Andrew Cuomo announced an emergency order Monday mandating that all hospitals in the state increase their capacities by 50% in order to handle the surge of coronavirus patients.

As cases of COVID-19 skyrocketed to nearly 21,000, making New York the state with the most diagnoses of the virus, Cuomo said hospitals are required to increase capacity by 50% and asked that they try to double it. State health officials report that 2,635 people are hospitalized and 621 of them are in the intensive care unit.

New York state has 53,000 beds and about 3,000 ICU beds. Health officials estimate that the state will need 110,000 beds and 18,000 to 37,000 ICU beds.

In addition to increasing the capacity of existing hospitals, the state is establishing four temporary health care facilities, including in the Javits Center in New York City, a facility that can accomodate 1,000 beds. Officials say New York City has nearly 170,000 confirmed cases of the coronavirus.

Other facilities will be set up in Stony Brook, Westchester County and Old Westbury.”  (R)

“New York’s private and public hospitals will unite to manage patient load and share resources during the coronavirus pandemic, Gov. Andrew Cuomo said.

Typically, the state’s public healthcare system and its private hospitals have worked as separate entities. But in a March 30 meeting, public and private hospitals agreed to work together to withstand the strain imposed by the coronavirus pandemic, the governor said.

In New York as of 12:30 p.m. Central Time, on March 30, 66,497 have been sickened with COVID-19, 9,517 have been hospitalized, and 1,218 have died.

The state’s public and private hospitals in the state have agreed that if one hospital is nearing capacity, it will be allowed to transfer patients to a hospital that has room, according to Mr. Cuomo.

The state will establish a threshold at which hospitals can transfer patients.

“There has to be a totally different operating paradigm where all those different hospitals act as one system,” Mr. Cuomo said.

Public and private hospitals across the state will also share mask and other resources so that a few hospitals without them won’t have to scramble for them.

“The distinction between private and public [hospitals] has to go out the window. We are one healthcare system,” Mr. Cuomo said at a March 31 press briefing….

“What is happening to New York is not an anomaly,” he said. “New York is just the canary in the coal mine.” (S)

 “Thirteen medical schools in New York state intend to allow students to graduate early to join the fight against COVID-19, the disease caused by the novel coronavirus, Associated Medical Schools of New York President and CEO Jo Wiederhorn told The Wall Street Journal.

The medical schools in New York City, Long Island and Westchester County include New York University’s medical school, which is allowing students to graduate a few months early to begin working in NYU’s internal medicine or emergency medicine departments amid the pandemic…

“Any good doctor learns really fast when you get thrown into a situation,”…”Would it have been better if they had more time? Yes. But extraordinary times call for extraordinary solutions.”” (T)

“New York hospitals can now attempt to treat two coronavirus patients with a single ventilator, Gov. Andrew Cuomo announced on Thursday, a move that could help the state make better use of its scarce supply of lifesaving breathing machines as the outbreak continues to surge.

New York-Presbyterian Hospital has developed a split-ventilation protocol that has been shared with the New York State Department of Health, which quickly approved the practice.

Calling the technique “not ideal, but workable,” Cuomo said ventilator splitting may be necessary given some projections that suggest the state may need as many as 30,000 ventilators in the coming weeks.

The practice is controversial, and the move drew immediate criticism in a joint statement issued by several medical associations advising clinicians “that sharing mechanical ventilators should not be attempted because it cannot be done safely with current equipment.”

New York has approximately 5,000 – 6,000 ventilators — used to help some of the sickest COVID-19 patients breathe when they are unable to do so on their own – and recently purchased an additional 7,000 machines. The state has also received 400 machines from the federal government’s stockpile.

“Why such a demand? It is a respiratory illness for a large number of people. So they all need ventilators,” Cuomo said Thursday. “Non-COVID patients are normally on ventilators for three to four days. COVID patients are on ventilators for 11 to 21 days. You don’t have the same turnaround.” ..

But connecting multiple patients to a single ventilator carries its own risks, according to experts, and should only be attempted in serious emergencies.

“This is a crisis provision,” Dr. Lew Kaplan, President of the Society of Critical Care Medicine (SCCM), told ABC News, adding that the practice could pose “great” risks to patients.

“This will never be a front-line therapy.” (U)

“The federal government announced Monday that it was relaxing many of its usual safety standards for hospitals so they could expand services to fight the coronavirus pandemic.

The Centers for Medicare and Medicaid Services is changing rules on what counts as a hospital bed; how closely certain medical professionals need to be supervised; and what kinds of health care can be delivered at home. These broad but temporary changes will last the length of the national emergency.

“This is unprecedented flexibility,” said Seema Verma, the administrator for the centers, in an interview. “But with an unprecedented pandemic, we felt like it was the job of the agency to make sure those health care heroes on the front line had all the flexibility they needed to address the crisis at hand.”

FEMA and local officials have already begun unconventional expansions that would not meet normal federal standards, like the conversion of New York City’s Javits Convention Center into a temporary hospital facility. The new guidance would allow other communities to employ similar strategies.

It would also allow hospitals to undertake such measures themselves, without the involvement of FEMA. Hospitals could put beds into school gymnasiums, hotels, outpatient surgical centers, or in temporary structures in their parking lots.

The changes would also make it easier to separate patients infected with Covid-19, the disease caused by the virus, from others. Currently, hospital emergency rooms must see and stabilize any patient who enters their doors. The new rules would allow hospitals to set up triage centers that would direct patients to different facilities, according to their needs. It would allow the establishment of special hospitals, clinics and dialysis centers to treat only coronavirus patients, an effort to prevent those with other health needs from becoming infected….” (V)

“A five-minute, point-of-care coronavirus test could be coming to urgent care clinics next week, and experts say it could be “game-changing.”

The U.S. Food and Drug Administration issued Emergency Use Authorization to Illinois-based medical device maker Abbott Labs on Friday for a coronavirus test that delivers positive results in as little as five minutes and negative results in 13 minutes, the company said.

The company expects the tests to be available next week and expects to ramp up manufacturing to deliver 50,000 tests per day.

“I am pleased that the FDA authorized Abbott’s point-of-care test yesterday. This is big news and will help get more of these tests out in the field rapidly,” FDA Commissioner Steve Hahn said in a statement. “We know how important it is to get point-of-care tests out in the field quickly. These tests that can give results quickly can be a game changer in diagnosing COVID-19.”

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Scott Gottlieb, former FDA commissioner, echoed Hahn’s comments on Twitter, calling the development a “game changer.” Gottlieb also said it’s “very likely” that we’ll see additional approvals of point-of-care diagnostics behind this one, extending testing to doctor offices across the U.S.

Testing is performed on Abbott’s ID NOW platform.

The new test comes in the form of a small cartridge that fits in the palm of your hand, said John Frels, Abbott’s vice president of research and development.” (W)

“Right-wing influencers and QAnon supporters are waging an information war against Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases and top-ranking member of the White House’s Coronavirus Task Force. They are falsely claiming that Fauci is working with Hillary Clinton and the deep state to cause an economic collapse and discredit President Donald Trump.” (X)


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