PART 1. CORONAVIRUS. “The Centers for Disease Control and Prevention on Tuesday confirmed the first U.S. case of a deadly new coronavirus that has killed six people in China.”
PART 2. CORONAVIRUS. “If it’s not contained shortly, I think we are looking at a pandemic..”….. “With isolated cases of the dangerous new coronavirus cropping up in a number of states, public health officials say it is only a matter of time before the virus appears in New York City.”
PART3. “The Wuhan coronavirus spreading from China is now likely to become a pandemic that circles the globe…”..Trump appeared to downplay concerns about the flu-like virus …We’re gonna see what happens, but we did shut it down..” (D)
PART 4. Coronavirus. “A study published Friday in JAMA found that 41% of the first 138 patients diagnosed at one hospital in Wuhan, China, were presumed to be infected in that hospital.….
PART 5. CORONAVIRUS. “In short, shoe-leather public health and basic medical care—not miracle drugs—are generally what stop outbreaks of emerging infections..”
POST 6. Coronovirus. “Amid assurances that the (ocean liner) Westerdam was disease free, hundreds of people disembarked in Cambodia…” “ One was later found to be infected”…. “Over 1,000… passengers were in…transit home”…. “This could be a turning point””
PART 7. CORONAVIRUS. With SARS preparedness underway in NJ LibertyHealth/ Jersey City Medical Center, where I was President, proposed that our 100 bed community hospital with all single-bedded rooms, be immediately transformed into an EMERGENCY SARS ISOLATION Hospital.
PART 8. CORONAVIRUS. “…every country’s top priority should be to protect its health care workers. This is partly to ensure that hospitals themselves do not become sites where the coronavirus is spread more than it is contained.”
PART 9. CORONAVIRUS. Responding to a question about the likelihood of a U.S. outbreak, President Trump said, “I don’t think it’s inevitable…”It probably will. It possibly will,” he continued. “It could be at a very small level, or it could be at a larger level.”
Part 10. CORONAVIRUS. Stop Surprise Medical Bills for Coronavirus care. (&) Lessons Learned (or not) In California and Washington State from community acquired cases.
PART 11. CORONAVIRUS. “Gov. Andrew Cuomo… would require employers to pay workers and protect their jobs if they are quarantined because of the coronavirus.”
Part 12. CORONAVIRUS. “Tom Bossert, Donald Trump’s former homeland security advisor…(said) that due to the coronavirus outbreak, “We are 10 days from the hospitals getting creamed.”
Part 13. CORONAVIRUS. March 14, 2020. “If I’m buying real estate in New York, I’ll listen to the President….If I’m asking about infectious diseases, I’m going to listen to Tony Fauci,”
PART 14. CORONAVIRUS. March 17, 2020. “ “Most physicians have never seen this level of angst and anxiety in their careers”…. One said “I am sort of a pariah in my family.”
PART 15. CORONAVIRUS. March 22, 2020. “…Crimson Contagion” and imagining an influenza pandemic, was simulated by the Trump administration….in a series of exercises that ran from last January to August.
PART 16. March 27, 2020. CORONAVIRUS. I am not a clinician or a medical ethicist but articles on Coronavirus patient triage started me Googling………to learn about FUTILE TREATMENT
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.
PART 18. April 9, 2020. CORONAVIRUS. “The federal government’s emergency stockpile of personal protective equipment (PPE) is depleted, and states will not be receiving any more shipments, administration staff told a House panel.
PART 19. April 13, 2020 CORONOAVIRUS. “…overlooked in the United States’ halting mobilization against the novel coronavirus: the personal aides, hospice attendants, nurses and occupational or physical therapists who deliver medical or support services to patients in their homes.”
Staff from the Department of Health and Human Services (HHS) told the House Oversight and Reform Committee that the Trump administration has made its final shipments of personal protective equipment to states from the Strategic National Stockpile.
According to the staff, 90 percent of the stockpile’s inventory of N95 respirators, surgical and face masks, face shields, gowns and gloves have already been distributed to every state.
The remaining 10 percent is reserved for federal workers and will not be distributed to states.
Governors have said that a shortage of medical supplies has led to states navigating the private marketplace in an escalating bidding war against each other and the federal government. The depletion of the federal stockpile means those practices will continue.
“Now that the national stockpile has been depleted of critical equipment, it appears that the administration is leaving states to fend for themselves, to scour the open market for these scarce supplies, and to compete with each other and federal agencies in a chaotic, free-for-all bidding war,” committee Chairwoman Carolyn Maloney (D-N.Y.) said in a statement.
States that have turned to the federal government’s stockpile for emergency equipment have not received all they need.
An internal administration document released by the committee on Wednesday showed that only 11.7 million N95 respirator masks have been distributed nationwide, which is less than 1 percent of the 3.5 billion masks that the administration estimated would be necessary in the event of a severe pandemic.
The committee also found that only 7,920 ventilators have been distributed from the stockpile.” (A)
For weeks, the Trump administration pushed states to procure their own ventilators and protective gear, like masks, gloves and face shields. But a new effort by the administration to create a hybrid system of distribution — divided between the federal government, local officials and private health care companies — has led to new confusion, bordering on disarray, and charges of confiscation.
“Either be in or out, folks,” Governor Polis said on CNN. “Either you’re buying them and you’re providing them to the states and you’re letting us know what we’re going to get and when we’re going to get them, or stay out and let us buy them.”..
Federal officials say they are trying to expedite the shipment to the United States of large quantities of medical supplies procured by private health care providers such as McKesson Corporation, Cardinal Health, Owens & Minor, Medline and Henry Schein. FEMA allows those distributors to sell about half of the equipment to companies and counties that had previously placed orders. The other half of the shipments must be sold to counties that the federal government prioritizes by the severity of the outbreak, based on data compiled by the Centers for Disease Control and Prevention.
The federal government will also soon save 10 percent of the supplies on each flight for the national stockpile, according to officials. A Korean War-era production act also allows the federal government to force companies to prioritize its order over another client’s, whether it be a private hospital or another nation.
In the past week, 14 flights carrying more than 83 million gloves, four million masks, one million gowns and 300,000 respirators have landed in New York, Chicago, Miami, Los Angeles, Columbus, Ohio, and Louisville, Ky. Mr. Pence said more than 50 flights had been scheduled.
The administration pivoted to the system of distribution after President Trump tapped FEMA to replace the Department of Health and Human Services as the agency leading the response to the coronavirus pandemic. States had previously submitted formal requests to the government to obtain materials from the stockpile.
Because the federal government determines which states are in greater need, governors and hospitals executives preparing in advance for the worst have complained that FEMA was effectively commandeering their personal protective equipment, or P.P.E…
The intervention has confused some local officials and company executives who have watched as the administration has repeatedly called on states to find medical supples on their own without relying on the federal government. But hundreds of hospitals continue to struggle with widespread shortages of test kits, protective gear for staff members and ventilators, according to a new report by the inspector general for the Department of Health and Human Services….
Adding to the disarray is the White House’s ad hoc system of disaster response in which the right call to Mr. Trump can result in one county getting priority over another. Advisers to Jared Kushner, the president’s son-in-law, have surprised FEMA officials in recent weeks to deploy supplies to communities after the area’s representatives got through to Mr. Trump, even if the state had not yet gone through the formal process to secure supplies.” (V)
“Top White House trade adviser Peter Navarro warned in stark terms about how deadly and economically devastating the coronavirus outbreak could be, weeks before it became a full-blown pandemic.
Navarro delivered the warnings to others at the White House in internal memos in January and February, saying that the United States could see up to 2 million deaths and trillions of dollars in economic damage.
The first Navarro memo was dated Jan. 29 and was addressed to the White House National Security Council, according to The New York Times, which first reported on the document. In it, Navarro made his case for an “immediate travel ban on China.”
In that memo, Navarro also reportedly warned that “the lack of immune protection or an existing cure or vaccine would leave Americans defenseless in the case of a full-blown coronavirus outbreak on U.S. soil.”
“This lack of protection elevates the risk of the coronavirus evolving into a full-blown pandemic, imperiling the lives of millions of Americans,” Navarro wrote in the memo, according to the Times.
Navarro’s first memo came as the president was downplaying the prospect of the virus coming to the U.S., while, at the same time, just days later on Jan. 31 restricting travel from China, after it was reported that COVID-19 was first discovered in China in December 2019 in Wuhan, Hubei province.
The memo reportedly warned of up to $5.7 trillion in economic costs and up to a half-million American deaths in a worst-case scenario.
In late February Navarro penned another memo, this time addressed to the president himself and escalating the warnings.
The Feb. 23 memo, first reported by Axios and confirmed by Fox News, warned that “there is an increasing probability of a full-blown COVID-19 pandemic that could infect as many as 100 million Americans, with a loss of life as many as 1-2 million souls.”…
The inspector general for the Department of Health and Human Services released a report on Monday, which revealed severe shortages of testing supplies and extended waits for results at hospitals across the nation; widespread shortages of PPE which put staff and patients at risk; difficulty maintaining adequate staffing; and shortages of critical supplies, like hand sanitizer, facemasks, toilet paper, linen, disinfectant cleaning supplies and more, as well as materials and logistics support.” (B)
“Jared Kushner, President Trump’s son-in-law and senior adviser, criticized governors Thursday, saying they don’t have a handle on their own supplies of masks and ventilators needed to combat the coronavirus outbreak.
In a rare appearance in the White House briefing room, Kushner urged governors and some senators to be more resourceful in their own states instead of looking first to the federal government for help.
“What a lot of the voters are seeing now is that when you elect somebody to be a mayor or governor or president, you’re trying to think about who will be a competent manager during the time of crisis,” he said. “This is a time of crisis, and you’re seeing certain people are better managers than others.”..
On Thursday, he explained that Trump and Vice President Pence came to him looking for new ideas and “outside of the box” thinking.
But his lack of experience has drawn scrutiny, especially when he referred to the national stockpile of medical supplies as “our stockpile.”
“The notion of the federal stockpile was it’s supposed to be our stockpile,” he said. “It’s not supposed to be states’ stockpiles that they then use.”..
A day after Kushner made his remarks, language on a government website about the national stockpile was changed to more closely reflect his description. But a spokesperson for the Department of Health and Human Services said the department had been using the new language for weeks. The assistant secretary for preparedness and response “first began working to update the website text a week ago to more clearly explain to state and local agencies and members of the public the role of the” Strategic National Stockpile, the spokesperson said.” (C)
“President Donald Trump has upended the panel of federal watchdogs overseeing implementation of the $2 trillion coronavirus law, tapping a replacement for the Pentagon official who was supposed to lead the effort.
A panel of inspectors general had named Glenn Fine — the acting Pentagon watchdog — to lead the group charged with monitoring the coronavirus relief effort. But Trump on Monday removed Fine from his post, instead naming the EPA inspector general to serve as the temporary Pentagon watchdog in addition to his other responsibilities.
That decision, which began circulating on Capitol Hill Tuesday morning, effectively removed Fine from his role overseeing the coronavirus relief effort, since the new law permits only current inspectors general to fill the position…
Trump has also begun sharply attacking Health and Human Services Inspector General Christi Grimm, following a report from her office that described widespread testing delays and supply issues at the nation’s hospitals.” (D)
“Over the weekend, First Lady Melania Trump urged Americans to continue to follow the recommendations of the Centers for Disease Control and Prevention in order to slow the spread of the novel coronavirus.
“As the weekend approaches I ask that everyone take social distancing & wearing a mask/face covering seriously,” the First Lady wrote in a tweet. “#COVID19 is a virus that can spread to anyone — we can stop this together.”…
“I don’t think I’m going to be doing it,” the president said during a Friday press conference. “Wearing a face mask as I greet presidents, prime ministers, dictators, kings, queens — I just don’t see it.” Trump touted that he was glad his wife was taking action in the wake of the pandemic, but he himself would not be following those same guidelines.” (E)
“President Donald Trump and his administration are promoting an anti-malaria drug not officially approved for fighting the new coronavirus, even though scientists say more testing is needed before it’s proven safe and effective against COVID-19.
Trump trade adviser Peter Navarro championed hydroxychloroquine in television interviews Monday, a day after the president publicly put his faith in the medication to lessen the toll of the coronavirus pandemic.
“What do I know, I’m not a doctor,” Trump said Sunday. “But I have common sense.” In promoting the drug’s possibilities, the president has often stated, ”What have you got to lose?”
Trump held out promise for the drug as he grasps for ways to sound hopeful in the face of a mounting death toll and with the worst weeks yet to come for the U.S. The virus has killed more than 10,000 in the U.S., and measures meant to contain its spread have taken a painful economic toll and all but frozen life in large swaths of the country.
But medical officials warn that it’s dangerous to be hawking unproven remedies, and even Trump’s own experts have cautioned against it.
The American Medical Association’s president, Dr. Patrice Harris, said she personally would not prescribe the drug for a coronavirus patient, saying the risks of severe side effects were “great and too significant to downplay” without large studies showing the drug is safe and effective for such use.
Harris pointed to the drug’s high risk of causing heart rhythm problems.
“People have their health to lose,” she said. “Your heart could stop.”..
Doctors are already prescribing the malaria drug to patients with COVID-19, a practice known as off-label prescribing. Research studies are now beginning to test if the drugs truly help COVID-19 patients, and the Food and Drug Administration has allowed the medication into the national stockpile as an option for doctors to consider for patients who cannot get into one of the studies.” (F)
“After receding from the limelight once the Russia investigation and impeachment wrapped up, former New York City Mayor Rudy Giuliani is making headlines again, lobbying President Donald Trump on untested coronavirus treatments, according to a new report from The Washington Post.
Giuliani, 75, has served as Trump’s personal attorney on a pro bono basis throughout the first term thus far, most often dispatched to defend the president on television amid the Russia and Ukraine scandals.
Now, Giuliani is pushing for the malaria drug hydroxychloroquine and what he describes as removing “placenta killer cells” in a stem cell treatment for COVID-19. As the Post put it, the former mayor is attempting to position himself as “personal science adviser” to the president.
Both hydroxychloroquine and the stem cell treatment are unproven and have yet to receive FDA approval to treat the coronavirus.
Last week, Giuliani had a tweet removed for violating Twitter’s misinformation policy when he promoted the anti-malaria drug…
Trump said he would take hydroxychloroquine to keep himself immune from COVID-19 during a White House press briefing last week.
Giuliani is joining a growing number of Trump confidants backing the drug, which The Post reports is “worrying health experts who fear such comments undermine efforts to slow the virus’s spread and downplay the risks of the unproven treatments.”
The former mayor told The Post he has spoken to Trump about the potential treatment “three or four times,” and has sought medical advice from a controversial Long Island doctor with a conservative following and a pharmacist who previously pleaded guilty for conspiring to extort Steven Seagal.” (G)
“A nationwide shortage of two drugs touted as possible treatments for the coronavirus is being driven in part by doctors inappropriately prescribing the medicines for family, friends and themselves, according to pharmacists and state regulators.
“It’s disgraceful, is what it is,” said Garth Reynolds, executive director of the Illinois Pharmacists Association, which started getting calls and emails Saturday from members saying they were receiving questionable prescriptions. “And completely selfish.”..
A pharmacist in Houston, who asked to remain anonymous for fear of retaliation and violating patient privacy, said he was recently asked by a surgeon for an unusually large quantity with unlimited refills. “He said it was because his wife had lupus,” the pharmacist said, “but when I asked him for her name and diagnosis, he told me just to put it in his.”
Lupus patients are reporting difficulty in refilling their prescriptions for the drug. On Monday, the Lupus Foundation of America issued a joint statement asking the White House Coronavirus Task Force to “take action to ensure current supplies are allocated for patients taking them for indicated uses.” Several states in the past few days have already moved to limit prescriptions of the drugs, neither of which is approved to treat the coronavirus. Trump, in press conferences and tweets over the past week, has promoted the use of the drugs as potentially blunting the impact of the COVID-19 outbreak.
“It’s unfortunate that a news conference, I think prematurely, made it sound like this was the answer, and that’s led to this panic,” Michelle Petri, director of Johns Hopkins University School of Medicine’s Lupus Center, said Friday. “I have spent the last two days trying to help lupus patients who actually need their refills.” She said some patients have refills on back order while others are being provided smaller amounts than usual.
The West Virginia Board of Pharmacy, in an alert Saturday, ordered pharmacists to limit new prescriptions to no more than 30 tablets and only to cases where the drugs were being used for approved indications…
On Twitter, pharmacy workers traded stories about dentists and opthamologists requesting hydroxychloroquine under dubious pretenses. “A dentist just tried to call in scripts for hydroxychloroquine + azithromycin for himself, his wife, & another couple (friends),” tweeted a pharmacist in Eugene, Oregon. “I have patients with lupus that have been on HCQ [Hydroxychloroquine] for YEARS and now can’t get it because it’s on backorder.”
Steve Moore, president of the Pharmacists Society of the State of New York, said medical providers hoarding the drugs is occuring in the state, which has the highest number of coronavirus cases in the country.
“That’s a double whammy,” he said. “We’re potentially taking that medication away from patients with autoimmune conditions and patients with the actual virus that may need treatment.”” (H)
“In audio of the call published by CBS News, Montana Gov. Steve Bullock (D) details two problems with testing. First, that his state doesn’t have enough tests, saying “we’re one day away if we don’t get test kits from the CDC that we wouldn’t be able to do testing.” And second, that the federal government has depleted the tests available on the private market…
Trump’s response to questions of testing typically mirrors the answer he gave Bullock — that the US is doing more testing than anyone else. And this, to a point, appears to be true. As of Saturday, Adm. Brett Giroir, coronavirus task force member and assistant secretary for health at the Department of Health and Human Services, said the US had done 894,000 tests.
But while that is a large number, the number of tests done per capita is much smaller: According to the Washington Post, the US had conducted 2,250 tests per million people by March 28, a figure roughly two-thirds of the per capita testing rate South Korea achieved three weeks earlier.
The reason this distinction is important is that if we are to end social distancing in the next few months, rather than ending it only when a vaccine becomes available, it is imperative enough tests exist to test on a massive scale, as Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases at the National Institutes of Health, has explained” (I)
“Dr. Deborah Birx said that the White House coronavirus task force is missing 50% of the data for coronavirus tests that have been conducted.
Birx, one of the top officials on the White House’s coronavirus task force, said Thursday that part of the $2 trillion economic stimulus measure that was signed into law by President Donald Trump requires that all tests conducted get reported to the Centers for Disease Control and Prevention. But Birx says she has not received that data yet.
“Well, I’m telling you, I’m still missing 50% of the data from reporting,” she said. “I have 660 (thousand) tests reported in. We’ve done 1.3 million. … So, we do need to see — the bill said you need to report. We are still not receiving 100% of the tests.”” (J)
“President Donald Trump had a hard time deciding Tuesday whether impeachment distracted him from fighting the coronavirus – but he eventually claimed it “probably” did.
“Well, I don’t like to think I did,” Trump said at a news conference with the White House coronavirus task force. “I think I handled it very well, but I guess it probably did. I mean, I got impeached.”
He added that, “I certainly devoted a little time to thinking about it.”
The president later expanded on his answer.
“But certainly I guess I thought of it. And I think I probably acted – I don’t think I would have done better had I not been impeached, OK? And I think that’s a great tribute to something. Maybe it’s a tribute to me. But I don’t think I would’ve acted any differently or I don’t think I would’ve acted any faster.””(K)
“New White House press secretary Kayleigh McEnany repeatedly downplayed the threat of the coronavirus in comments made in February and March, a CNN KFile review has found.
In radio and television appearances, McEnany, in her role as spokeswoman for President Donald Trump’s 2020 campaign, said the administration had the rapidly spreading coronavirus “under control” and said that because of travel restrictions enacted by the President, “we will not see diseases like the coronavirus come here.”
She also said Democrats were “actively rooting against what’s in the best interest of America,” including rooting for coronavirus to take hold. She said coronavirus, like the Russia and Ukraine scandals, was being used to take down Trump…
“We will not see diseases like the coronavirus come here”
Speaking on Fox Business on February 25, McEnany said because of travel policies enacted by the President, coronavirus would not continue to come to the United States…
In March, McEnany continued to defend the president as the outbreak spread. On local Michigan radio on March 10, she said it was incumbent on the public to take adequate political health measures but the situation was under control.
“This is something that is under control,” she said on the Frank Beckmann Show. “We have a President who has taken unprecedented action and mandatory quarantines and travel restrictions, and he’s taken every measure that he possibly could to protect the American people. I’m confident we have a great leader at the top, but it’s incumbent upon all of us just to take those precautions.”
“This President’s taken unprecedented action to protect this country from the coronavirus,” she continued. “He stopped it from being so much worse than it could have been, but leave it to the media and the left to score those cheap political points.”” (L)
“Since Chinese officials disclosed the outbreak of a mysterious pneumonialike illness to international health officials on New Year’s Eve, at least 430,000 people have arrived in the United States on direct flights from China, including nearly 40,000 in the two months after President Trump imposed restrictions on such travel, according to an analysis of data collected in both countries.
The bulk of the passengers, who were of multiple nationalities, arrived in January, at airports in Los Angeles, San Francisco, New York, Chicago, Seattle, Newark and Detroit. Thousands of them flew directly from Wuhan, the center of the coronavirus outbreak, as American public health officials were only beginning to assess the risks to the United States…
Mr. Trump has repeatedly suggested that his travel measures impeded the virus’s spread in the United States. “I do think we were very early, but I also think that we were very smart, because we stopped China,” he said at a briefing on Tuesday, adding, “That was probably the biggest decision we made so far.” Last month, he said, “We’re the ones that kept China out of here.”” (M)
“A US Navy hospital ship currently docked in New York City harbor is treating only 22 patients as of Friday afternoon, despite having a 1,000 bed capacity to treat non-coronavirus patients, according to a US Navy official.
Navy officials told CNN that they expect the number of patients being treated to increase significantly in the coming days as the process of referring patients to the ship is refined.
The USNS Comfort was deployed to New York City, the epicenter of the virus outbreak in the United States, to free up capacity in the city’s civilian hospitals so that they can focus on treating coronavirus patients.
New York City’s hospitals have been overwhelmed with coronavirus cases and are struggling to respond to patients constantly streaming in. A shortage of personal protective equipment has also placed medical workers at risk of contracting the virus. On Thursday, New York Gov. Andrew Cuomo announced that the temporary hospital facility at the Javits Convention Center, which holds 2,500 beds, will now treat Covid-19 patients….
Ambulances are not taking people directly to the ship, which docked in New York City on Monday. Patients are referred to the ship by shore-based hospitals and must be screened and tested for the virus before being admitted on board.
The Department of Defense said Friday that it would begin streamlining the process to admit patients onto the ship.
“Screening for care on the USNS Comfort will be modified and will now occur pier-side in an effort to reduce the backlog at some of the nearby New York hospitals,” the Pentagon said in a statement. “The screening effort for the USNS Comfort will no longer require a negative test (for coronavirus), but each patient will still be screened by temperature and a short questionnaire.”
There are some patients that the Comfort can’t bring on board, mainly those who are immunosuppressed due to the fact the ship is open bay and does not have the ability to isolate patients, according to a Navy official familiar with operations on the ship.
“We are conducting data analysis to see how we need to change our configuration — bottom line we’ve been here 48 hours, and this is a scenario no one has ever seen before,” the official told CNN. “No one wants to get this wrong. We hear the feedback from medical professionals, and are fine tuning,” but the Comfort will still only treat non-coronavirus patients.” (N)
“AS MUCH OF the New York City’s media focused on the brewing coronavirus disaster in the city’s jails on Rikers Island, a parallel crisis is looming at the federal jails located in the city: the Metropolitan Correctional Center in Lower Manhattan and the Metropolitan Detention Center in Brooklyn.
Nationwide, according to Bureau of Prison statistics, the number of positive cases of coronavirus in federal jails and prisons exploded by 8,600 percent in the two weeks since March 20 — an increase that’s especially concerning given the vulnerability of the people locked in conditions they can’t control. By Bureau of Prison estimates, roughly a third of the people incarcerated in MDC and MCC are at elevated risk of severe illness by the Centers for Disease Control and Prevention’s standards.
Jail officials are not holding off on testing for want of incarcerated people showing alarming symptoms: Clients have told lawyers that their housing units are full of coughing people.
It is hardly reassuring that, so far, few incarcerated people at either facility have tested positive. Jail officials admitted last week — only because of a judge’s order — that they’re doing almost no testing. As of Friday, only seven people out of a population of roughly 1,700 had been tested at MDC, of whom two tested positive. Of the roughly 760 people held at MCC, only five had been tested, of whom four tested positive.” (O)
“The Covid-19 pandemic is stretching our public health system to its limits and challenging our ability to meet the urgent and critical medical needs of the country as never before. As executives responsible for the legal affairs of major hospitals and lawyers working in Covid-19 hot spots, we know how crucial it is to have every available front-line medical worker fighting this pandemic.
But 29,000 of those workers are being threatened with deportation by the Trump administration. They have been protected by the Deferred Action for Childhood Arrivals program, under which undocumented immigrants who came to the United States as children can obtain protection against deportation and authorization to work in the United States. The Trump administration terminated that program, the Supreme Court is currently considering the lawfulness of that determination, and the court’s decision could come at any time.
New data from the Center for American Progress reveals that the DACA-recipient health care work force includes more than 6,000 diagnosing and treating practitioners, including respiratory therapists, physicians assistants and nurses; some 8,000 health aides, including nursing assistants and orderlies; more than 7,000 other health care support workers; and some 5,500 health technologists and technicians.
The Association of American Medical Colleges told the Supreme Court that nearly 200 physicians, medical students and residents depend on DACA for their ability to practice medicine and serve their communities. Those 200 trainees and physicians alone would care for hundreds of thousands of patients per year in normal times — the association estimates as many as 4,600 patients per year, per person. Under the demands of the Covid-19 pandemic, those numbers will be much higher.
The Center for Migration Studies found that 43,500 DACA recipients work in the health care and social-assistance industries, including more than 10,000 in hospitals…
If the Supreme Court allows the termination of DACA during this pandemic, the work of our hospitals will suffer a critical blow at exactly the moment when we can least afford it. At a time when the importance — and scarcity — of our medical resources has never been clearer, neither our institutions nor the nation can afford a disruption to the health care work force. We desperately need all hands on deck for this fight.” (P)
“Why is Germany’s death rate so low?..A Robust Public Health Care System
Before the coronavirus pandemic swept across Germany, University Hospital in Giessen had 173 intensive care beds equipped with ventilators. In recent weeks, the hospital scrambled to create an additional 40 beds and increased the staff that was on standby to work in intensive care by as much as 50 percent.
“We have so much capacity now we are accepting patients from Italy, Spain and France,” said Susanne Herold, a specialist in lung infections at the hospital who has overseen the restructuring. “We are very strong in the intensive care area.”
All across Germany, hospitals have expanded their intensive care capacities. And they started from a high level. In January, Germany had some 28,000 intensive care beds equipped with ventilators, or 34 per 100,000 people. By comparison, that rate is 12 in Italy and 7 in the Netherlands.
By now, there are 40,000 intensive care beds available in Germany.
Some experts are cautiously optimistic that social distancing measures might be flattening the curve enough for Germany’s health care system to weather the pandemic without producing a scarcity of lifesaving equipment like ventilators.
“It is important that we have guidelines for doctors on how to practice triage between patients if they have to,” Professor Streeck said. “But I hope we will never need to use them.”
The time it takes for the number of infections to double has slowed to about nine days. If it slows a little more, to between 12 and 14 days, Professor Herold said, the models suggest that triage could be avoided.
“The curve is beginning to flatten,” she said.
Beyond mass testing and the preparedness of the health care system, many also see Chancellor Angela Merkel’s leadership as one reason the fatality rate has been kept low.
Ms. Merkel, a trained scientist, has communicated clearly, calmly and regularly throughout the crisis, as she imposed ever-stricter social distancing measures on the country. The restrictions, which have been crucial to slowing the spread of the pandemic, met with little political opposition and are broadly followed.
The chancellor’s approval ratings have soared.
“Maybe our biggest strength in Germany,” said Professor Kräusslich, “is the rational decision-making at the highest level of government combined with the trust the government enjoys in the population.”” (Q)
Georgia Gov. Brian Kemp signed an executive order on Thursday that requires residents of the state to shelter in place.
But the order overrides all local efforts to combat the coronavirus, including beach closures.
As of Friday night, Georgia state beaches are open once again, though visitors are required to follow social-distancing guidelines.
The governor of Georgia has imposed a state-wide order to shelter in place, as of Friday night — and, at the same time, reopened the state’s beaches.
In an executive order signed on Thursday, Gov. Brian Kemp, a Republican, issued an executive order April 2 that requires Georgians to remain in their homes for the next 10 days, with exceptions for vital businesses and necessary travel. But it also suspends “any local ordinance or order” aimed at “combating the spread of coronavirus or COVID-19.”
As a result, popular tourist spots like Tybee Island, which receives hundreds of thousands of visitors every year, are now back in business, even as the rest of the state shuts down.” (R)
“President Donald Trump’s top health advisers are developing medical criteria for safely reopening the U.S. economy in coming weeks should trends showing a crest in the coronavirus outbreak hold steady.
Deborah Birx, the immunologist who coordinates the White House virus task force, met into the night Tuesday with health experts, including Anthony Fauci, the nation’s top infectious disease expert, Centers for Disease Control and Prevention Director Robert Redfield and Food and Drug Administration Commissioner Stephen Hahn.
Notably absent from the late-night discussion were economic and political advisers to the president, along with the leader of the coronavirus task force, Vice President Mike Pence, and his chief of staff, Marc Short.
Excluding the political and economic advisers was a deliberate signal that the White House would continue for now to prioritize health considerations over economic ones, according to three people familiar with the meeting who requested anonymity to discuss internal deliberations.” (S)
“President Trump said he’d like to open the economy with a “big bang” and suggested that may first happen in regions of the country where the coronavirus outbreak has begun to subside.
“I’d love to open with a big bang, one beautiful country, but it’s very possible,” the president said Tuesday on Sean Hannity’s Fox News show.
“So we are looking at two concepts, we are looking at the concept we open up sections and also looking at the concept where you open up everything,” the president explained. “I think New York is getting ready if not already, but getting ready to peak and once it peaks, it will start coming down and it’s going to come down fast.”
Unlike New York and New Jersey, Trump said some states haven’t had the same level of coronavirus spread.
He said parts of Michigan and Detroit have been “hit very hard” – “so there are some places hit very hard in other places that have not been hit very hard frankly by comparison, very little.”
The president has kept an eye on the economy and the stock market during the battle against the pandemic, watching the financial tailspin as lockdowns were expanded in states across the country and workers were laid off or furloughed…
“We have to get our country open again. This wasn’t designed to have this. You crack it – you crack it in half, it’s no good. And we’ll be open again much sooner rather than later,” he told Hannity. “And we are going to be coming up with some ideas in the very near future, probably putting them out to the public, putting them out, but, you know, we’re going through April – as you know, April 30 – and we are going to make a decision from there.”” (T)
“A Sunday update of a prominent COVID-19 forecasting model suggests that fewer lives will be lost during the first wave of the coronavirus outbreak than previously thought.
The University of Washington’s Institute for Health Metrics and Evaluation (IHME) now predicts that 81,766 people will die of COVID-19 in the U.S. through early August. When the model was last updated, on April 2, it predicted 11,765 deaths more deaths, for a total of 93,531…
…The model’s latest update includes several important changes related to that planning. Many fewer hospital beds will be needed at peak than previously anticipated, according to the new projections. The April 5 update predicts the need for 140,823 total hospital beds and 29,210 ICU beds at the peak of the outbreak. Those numbers are down 121,269 and 10,517, respectively.
The model also revised downward the prediction for the number of ventilators needed at the height of the outbreak. It now predicts the need for 18,992 ventilators, down from 31,782.
One thing that didn’t change between the April 2 and April 5 models is the projected date of the outbreak’s peak. The model still predicts an April 16 apex for the daily COVID-19 death rate. Hospital use is expected to peak on April 15.” (U)
J.Top doctor says White House coronavirus task force still missing 50% of testing data, by Jason Hoffman and Caroline Kelly, https://www.cnn.com/2020/04/02/politics/birx-task-force-coronavirus-testing/index.html
PART 1. CORONAVIRUS. “The Centers for Disease Control and Prevention on Tuesday confirmed the first U.S. case of a deadly new coronavirus that has killed six people in China.”
PART 2. CORONAVIRUS. “If it’s not contained shortly, I think we are looking at a pandemic..”….. “With isolated cases of the dangerous new coronavirus cropping up in a number of states, public health officials say it is only a matter of time before the virus appears in New York City.”
PART3. “The Wuhan coronavirus spreading from China is now likely to become a pandemic that circles the globe…”..Trump appeared to downplay concerns about the flu-like virus …We’re gonna see what happens, but we did shut it down..” (D)
PART 4. Coronavirus. “A study published Friday in JAMA found that 41% of the first 138 patients diagnosed at one hospital in Wuhan, China, were presumed to be infected in that hospital.….
PART 5. CORONAVIRUS. “In short, shoe-leather public health and basic medical care—not miracle drugs—are generally what stop outbreaks of emerging infections..”
POST 6. Coronovirus. “Amid assurances that the (ocean liner) Westerdam was disease free, hundreds of people disembarked in Cambodia…” “ One was later found to be infected”…. “Over 1,000… passengers were in…transit home”…. “This could be a turning point””
PART 7. CORONAVIRUS. With SARS preparedness underway in NJ LibertyHealth/ Jersey City Medical Center, where I was President, proposed that our 100 bed community hospital with all single-bedded rooms, be immediately transformed into an EMERGENCY SARS ISOLATION Hospital.
PART 8. CORONAVIRUS. “…every country’s top priority should be to protect its health care workers. This is partly to ensure that hospitals themselves do not become sites where the coronavirus is spread more than it is contained.”
PART 9. CORONAVIRUS. Responding to a question about the likelihood of a U.S. outbreak, President Trump said, “I don’t think it’s inevitable…”It probably will. It possibly will,” he continued. “It could be at a very small level, or it could be at a larger level.”
Part 10. CORONAVIRUS. Stop Surprise Medical Bills for Coronavirus care. (&) Lessons Learned (or not) In California and Washington State from community acquired cases.
PART 11. CORONAVIRUS. “Gov. Andrew Cuomo… would require employers to pay workers and protect their jobs if they are quarantined because of the coronavirus.”
Part 12. CORONAVIRUS. “Tom Bossert, Donald Trump’s former homeland security advisor…(said) that due to the coronavirus outbreak, “We are 10 days from the hospitals getting creamed.”
Part 13. CORONAVIRUS. March 14, 2020. “If I’m buying real estate in New York, I’ll listen to the President….If I’m asking about infectious diseases, I’m going to listen to Tony Fauci,”
PART 14. CORONAVIRUS. March 17, 2020. “ “Most physicians have never seen this level of angst and anxiety in their careers”…. One said “I am sort of a pariah in my family.”
PART 15. CORONAVIRUS. March 22, 2020. “…Crimson Contagion” and imagining an influenza pandemic, was simulated by the Trump administration….in a series of exercises that ran from last January to August.
PART 16. March 27, 2020. CORONAVIRUS. I am not a clinician or a medical ethicist but articles on Coronavirus patient triage started me Googling………to learn about FUTILE TREATMENT
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.
PART 18. April 9, 2020. CORONAVIRUS. “The federal government’s emergency stockpile of personal protective equipment (PPE) is depleted, and states will not be receiving any more shipments, administration staff told a House panel.
“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 HealthCare.gov, 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 HealthCare.gov 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)
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)
PART 1. CORONAVIRUS. “The Centers for Disease Control and Prevention on Tuesday confirmed the first U.S. case of a deadly new coronavirus that has killed six people in China.”
PART 2. CORONAVIRUS. “If it’s not contained shortly, I think we are looking at a pandemic..”….. “With isolated cases of the dangerous new coronavirus cropping up in a number of states, public health officials say it is only a matter of time before the virus appears in New York City.”
PART3. “The Wuhan coronavirus spreading from China is now likely to become a pandemic that circles the globe…”..Trump appeared to downplay concerns about the flu-like virus …We’re gonna see what happens, but we did shut it down..” (D)
PART 4. Coronavirus. “A study published Friday in JAMA found that 41% of the first 138 patients diagnosed at one hospital in Wuhan, China, were presumed to be infected in that hospital.….
PART 5. CORONAVIRUS. “In short, shoe-leather public health and basic medical care—not miracle drugs—are generally what stop outbreaks of emerging infections..”
POST 6. Coronovirus. “Amid assurances that the (ocean liner) Westerdam was disease free, hundreds of people disembarked in Cambodia…” “ One was later found to be infected”…. “Over 1,000… passengers were in…transit home”…. “This could be a turning point””
PART 7. CORONAVIRUS. With SARS preparedness underway in NJ LibertyHealth/ Jersey City Medical Center, where I was President, proposed that our 100 bed community hospital with all single-bedded rooms, be immediately transformed into an EMERGENCY SARS ISOLATION Hospital.
PART 8. CORONAVIRUS. “…every country’s top priority should be to protect its health care workers. This is partly to ensure that hospitals themselves do not become sites where the coronavirus is spread more than it is contained.”
PART 9. CORONAVIRUS. Responding to a question about the likelihood of a U.S. outbreak, President Trump said, “I don’t think it’s inevitable…”It probably will. It possibly will,” he continued. “It could be at a very small level, or it could be at a larger level.”
Part 10. CORONAVIRUS. Stop Surprise Medical Bills for Coronavirus care. (&) Lessons Learned (or not) In California and Washington State from community acquired cases.
PART 11. CORONAVIRUS. “Gov. Andrew Cuomo… would require employers to pay workers and protect their jobs if they are quarantined because of the coronavirus.”
Part 12. CORONAVIRUS. “Tom Bossert, Donald Trump’s former homeland security advisor…(said) that due to the coronavirus outbreak, “We are 10 days from the hospitals getting creamed.”
Part 13. CORONAVIRUS. March 14, 2020. “If I’m buying real estate in New York, I’ll listen to the President….If I’m asking about infectious diseases, I’m going to listen to Tony Fauci,”
PART 14. CORONAVIRUS. March 17, 2020. “ “Most physicians have never seen this level of angst and anxiety in their careers”…. One said “I am sort of a pariah in my family.”
PART 15. CORONAVIRUS. March 22, 2020. “…Crimson Contagion” and imagining an influenza pandemic, was simulated by the Trump administration….in a series of exercises that ran from last January to August.
PART 16. March 27, 2020. CORONAVIRUS. I am not a clinician or a medical ethicist but articles on Coronavirus patient triage started me Googling………to learn about FUTILE TREATMENT
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.
PART 1. CORONAVIRUS. “The Centers for Disease Control and
Prevention on Tuesday confirmed the first U.S. case of a deadly new coronavirus
that has killed six people in China.”
PART 2. CORONAVIRUS. “If it’s not contained shortly, I think
we are looking at a pandemic..”….. “With isolated cases of the dangerous new
coronavirus cropping up in a number of states, public health officials say it
is only a matter of time before the virus appears in New York City.”
PART3. “The Wuhan coronavirus spreading from China is now
likely to become a pandemic that circles the globe…”..Trump appeared to
downplay concerns about the flu-like virus …We’re gonna see what happens, but
we did shut it down..” (D)
PART 4. Coronavirus. “A study published Friday in JAMA found
that 41% of the first 138 patients diagnosed at one hospital in Wuhan, China,
were presumed to be infected in that hospital.….
PART 5. CORONAVIRUS. “In short, shoe-leather public health
and basic medical care—not miracle drugs—are generally what stop outbreaks of
emerging infections..”
POST 6. Coronovirus. “Amid assurances that the (ocean liner)
Westerdam was disease free, hundreds of people disembarked in Cambodia…” “ One
was later found to be infected”…. “Over 1,000… passengers were in…transit
home”…. “This could be a turning point””
PART 7. CORONAVIRUS. With SARS preparedness underway in NJ
LibertyHealth/ Jersey City Medical Center, where I was President, proposed that
our 100 bed community hospital with all single-bedded rooms, be immediately
transformed into an EMERGENCY SARS ISOLATION Hospital.
PART 8. CORONAVIRUS. “…every country’s top priority should
be to protect its health care workers. This is partly to ensure that hospitals
themselves do not become sites where the coronavirus is spread more than it is
contained.”
PART 9. CORONAVIRUS. Responding to a question about the
likelihood of a U.S. outbreak, President Trump said, “I don’t think it’s
inevitable…”It probably will. It possibly will,” he continued. “It could be at
a very small level, or it could be at a larger level.”
Part 10. CORONAVIRUS. Stop Surprise Medical Bills for
Coronavirus care. (&) Lessons Learned (or not) In California and Washington
State from community acquired cases.
PART 11. CORONAVIRUS. “Gov. Andrew Cuomo… would require
employers to pay workers and protect their jobs if they are quarantined because
of the coronavirus.”
Part 12. CORONAVIRUS. “Tom Bossert, Donald Trump’s former
homeland security advisor…(said) that due to the coronavirus outbreak, “We are
10 days from the hospitals getting creamed.”
Part 13. CORONAVIRUS. March 14, 2020. “If I’m buying real
estate in New York, I’ll listen to the President….If I’m asking about
infectious diseases, I’m going to listen to Tony Fauci,”
PART 14. CORONAVIRUS. March 17, 2020. “ “Most physicians
have never seen this level of angst and anxiety in their careers”…. One said “I
am sort of a pariah in my family.”
PART 15. CORONAVIRUS. March 22, 2020. “…Crimson Contagion”
and imagining an influenza pandemic, was simulated by the Trump
administration….in a series of exercises that ran from last January to August.
PART 16. March 27, 2020. CORONAVIRUS. I am not a clinician
or a medical ethicist but articles on Coronavirus patient triage started me
Googling………to learn about FUTILE TREATMENT
PART 16. March 27, 2020. CORONAVIRUS. I am not a clinician
or a medical ethicist but articles on Coronavirus patient triage started me Googling………to learn about FUTILE TREATMENT
to read posts 1-16 in chronological order click on
More than ever let’s respect and appreciate all the
providers who are protecting us under the most challenging circumstances.
“Providing futile treatment in the intensive care unit sets
off a chain reaction that causes other ill patients needing medical attention
to wait for critical care beds, according to a study by researchers from UCLA
and RAND Health.
The study is the first to show that when unbeneficial
medical care is provided, others who might be able to benefit from treatment
are harmed,…
“Many people do not realize
that there is a tension between what medicine is able to do and what medicine
should do. Even fewer realize that medicine is commonly used to achieve goals
that most people, and perhaps most of society, would not value – such as
prolonging the dying process in the intensive care unit when a patient cannot
improve,” … “But almost no one recognizes that these actions affect other
patients, who might receive delayed care or, worse, not receive needed care at
all because futile medical treatment was provided to someone else.”” (A)
“Futility” means the absence of benefit.
a consensus definition of medical futility does not exist.
~80% of ICU patients who die do so as a consequence of a
decision to withhold or withdraw life support.
it is more useful to consider the utility of any
intervention (the balance of benefits and harms) rather than futility
TYPES OF FUTILITY
Physiologic futility — when a procedure cannot bring about
its physiologic objective (e.g. when CPR cannot achieve a BP target) — involves
a “value choice” of the measurement of organ function rather than the value of
the outcome for the patient as the patient might perceive it.
“benefit- centered” futility — involves a quantitative
estimate of futility is one in which an intervention is considered futile if it
has failed in the last defined number of times attempted (e.g. 100 successful attempts as the threshold) or
a qualitative component, where the patient’s resulting quality of life falls well
below the threshold considered minimal by general professional judgment
(e.g. treatments which merely preserve
unconsciousness or cannot end dependence on intensive medical care)
Operationalising futility — treatment that is so unlikely to
succeed that many people—professional and lay persons—would consider it not
worth the cost (aims to precludes individual caregivers from having to make
qualitative or quantitative value judgments) (B)
“Doctors who were asked about causes of inappropriate care
at the end of life didn’t have to look far to place blame. They blamed
themselves.
Australian researchers interviewed 96 physicians from 10
medical specialties and asked them to describe situations when patients
received end of life care that the doctors felt was inappropriate.
Futile medical treatment at the end of life has been shown
to harm patients, cause moral distress to clinicians and waste scarce
resources, as the researchers note in the Journal of Medical Ethics.
But 96 percent of physicians pointed to themselves – or
“doctor-related factors” – as the main drivers of futile treatment. Poor
communication, emotional attachment to patients and aversion to death were also
among the causes they cited.
Patient-related factors were important, too. Ninety-one
percent of the doctors cited reasons such as family or patient requests for
treatment, prognostic uncertainty and not knowing the patient’s wishes as
contributors to inappropriate care….
Close to 70 percent of the surveyed doctors also cited
hospital-related causes, such as specializations, medical hierarchy and time
pressure, as factors in futile care.
It isn’t a matter of one doctor stepping back and
considering the overall health of the patient, explained co-author Benjamin
White, a law professor at the Queensland University of Technology.
“There are many specialists involved, each focused on a
particular organ,” he told Reuters Health. The narrow focus of the individual
specialists can make it difficult to coordinate a patient’s care, he and his
colleagues noted in their report.
Roughly one quarter of physicians said aggressive treatments
are “hard to stop once started.”..
“We don’t know how to manage or negotiate it,”… “It is
easier behind the scenes to complain that a treatment may be inappropriate, but
we haven’t taken a step back to think if we are providing care that furthers a
patient’s goals.”..
Pope urges doctors to present medical options in even-handed
ways.
“If physicians are too aggressive, families are going to
fall in line,” he told Reuters Health. “It’s emotionally hard for (families) to
pass up what doctors say is a reasonable option. If they knew the real risks,
benefits and alternatives, they may not pick the treatment they are receiving.””
(C)
“Because it is often used imprecisely, the term “futile” can
cause confusion and exacerbate conflict in disagreements about end-of-life
care. It is more helpful for patients, families, and physicians to discuss the
benefits and burdens of medical procedures.
The term “medical futility” is widely used in end-of-life
care, but it may be time for an update in vocabulary. In some cases, “medical
futility” has exacerbated conflict between medical professionals and patients’
families, led to ugly litigation, and undermined trust in the medical
profession. Better language is available, so it is time for the phrase “medical
futility” to be restricted to the few cases to which it truly applies.
Every day in hospitals across the nation, physicians cite
“medical futility” as a reason to withdraw or withhold life-sustaining treatment
when patients—or, more often, their families—insist on continuing it. A
procedure is properly called “futile” when the patient’s medical condition
renders it ineffective, so that it cannot achieve the benefit it was designed
to bring about. The term is typically applied to mechanical ventilation,
assisted nutrition and hydration, and cardio-pulmonary resuscitation, but it is
applied to many other treatments as well. The fatal error arises when medical
professionals invoke “futility” to discontinue a procedure that may retain some
benefit for the patient, but which nonetheless may not be worth continuing….
When physicians recognize that a treatment is ineffective,
they have a duty to say that it cannot benefit the patient. Most patients and
their surrogate decision-makers are not trained in medicine and, quite
appropriately, cannot contribute to this kind of judgment.
The ethical discussion changes if there truly remains some
medical benefit to performing the treatment. In that case, the treatment may
help the patient to achieve goals of care, even if it does not cure the
underlying condition. The decision to use the treatment is based not only on
how well it works but also on what its benefit would mean to the patient and
family. The patient and family are in the best position to judge what the
benefits of treatment—even marginally beneficial treatments—would mean to them.
Members of the medical team might explain what they would do
under the circumstances, without necessarily imposing their values on patients.
They could offer thoughtful perspectives based on their values, not only on
clinical judgments. Offering these values-based perspectives can be of great
benefit to patients, surrogates, and families—but presenting such perspectives
as if they were based on clinical judgment alone does not accurately represent
the kind of judgment being offered…
There is no guarantee that such a discussion will prevent
intractable conflict over end-of-life care. There is no language that
automatically reconciles opposing views. Sometimes we can hope only that views
are expressed and decisions are made with enough respect and transparency to
avoid intractable conflict.” (D)
“Every day in intensive care units across the country,
patients get aggressive, expensive treatment their caregivers know is not going
to save their lives or make them better.
California researchers now report this so-called
“futile” care has a hidden price: It’s crowding out other patients who
could otherwise survive, recover and get back to living their lives.
Their study, in Critical Care Medicine, shows that patients
who could benefit from intensive care in UCLA’s teaching hospital are having to
wait hours and even days in the emergency room and in nearby community
hospitals because ICU beds are occupied by patients receiving futile care. Some
patients die waiting.
On one day out of every six, the researchers found, UCLA’s
intensive care units contain at least one patient receiving useless care while
other patients are unable to get into the ICU.
More than half the time, over a three-month period the
researchers examined, the hospital’s intensive care units had a least one
patient receiving futile care. The study shows the ripple effects of that
futile care within the UCLA hospital and in surrounding hospitals where
patients were waiting to be transferred.
“It is unjust when a patient is unable to access intensive
care because ICU beds are occupied by patients who cannot benefit,” the authors
write.
“The ethic of ‘first come, first served,’” they say, “is not
only inefficient and wasteful, but it is contrary to medicine’s responsibility
to apply health care resources to best serve society.”..
This is a third-rail kind of issue. Some might say we dare
not touch it. How do you confront that?
The only solution I can think of is to shed as much light on
it as possible and allow the warts to show. Be very explicit about what we’re
talking about – using a machine to keep someone alive who will never wake up or
leave the ICU. And let the public decide if they believe that medicine should
use resources toward that end, especially if there’s an opportunity cost to
others. Maybe these conversations on futility are all wrong, that’s what
medicine should be doing. Let’s discuss that out loud and not pretend we’re not
using resources in this way.” (E)
“In most cases, this goal of prolonging life is intended to
give the patient a chance to recover or achieve another goal. Good
communication is crucial to resolving these conflicts, but can easily be
undermined by failing to understand how the words used reveal each side’s
positions and interests. Here are a few statements and questions I have
overheard over the years.
“There’s nothing more
we can do.” Families may interpret this to mean the team has given up on the
patient. What needs to be explained is that efforts to cure the patient have
failed and the technology used to sustain the body long enough to facilitate a
recovery are not able to serve that purpose. What remains to be discussed is
what alternative purpose the technology should have, if any. Also to be
discussed is whether that purpose aligns with what is important to the patient
and what the medical team thinks should be done with limited resources.
“Would you like us to do everything?” This statement puts an
enormous burden on families to make life and death decisions. Many families do
not want this burden because they do not want to be responsible for determining
whether their loved one should live or die. The question is also quite vague.
It is neither clear what “everything” means nor what “doing everything” would
accomplish.
“I don’t have a crystal ball” This claim is often heard when
families ask physicians for a timeline to see signs of improvement or
deterioration. It may also be heard when families ask about how long a patient
is expected to survive with or without life-sustaining treatment. Saying this
allows physicians to then hedge when it comes to making these predictions, but
also gives families a sense they are not being heard.
In these situations, families likely want to hear
suggestions for what they should be doing to prepare for their loved one’s
death. Their goal is to plan for next steps and the team’s recommendation is a
vital part of that process…
Patience is needed on both sides to try to understand what
is being said and not said. Clinicians can help avoid miscommunication by
thinking carefully about how they are presenting information and avoiding stock
phrases that create more confusion than clarity. Families can help by asking
clinicians to explain what they mean by some of these stock phrases and trying
to be open to hearing bad news when delivered compassionately.” (F)
But here, we want to stress the critical role of doctors individually
and the medical profession, and the opportunity to bring about change. First – and we think this is critical –
doctors themselves are pointing to their own behaviour as an important factor
to be addressed, as well as the way tertiary hospitals currently operate. Doctors are owning the problem, and not just
blaming this phenomenon on patient/family demand or the law. Secondly, change will not occur unless
doctors are prepared to act and to lead.
It is not enough to educate the community about the limits of medicine
or the importance of ‘a good death’ and so on.
Doctors should not be offering treatment that evidence tells us will not
work. They should stop ordering routine
tests that will not alter treatment or affect patient outcome. They must have the difficult conversations
with patients and family instead, notwithstanding how long this conversation
may take, or how many times they may have to have it.
This call for action and leadership by doctors does not mean
that patients and families are irrelevant and should not be involved in the
decision-making process. On the
contrary, they need to understand the medical diagnosis and prognosis and what
to expect as they or their loved one approaches death. And as we have argued elsewhere, futility is
a subjective concept so engagement with patients and families about their
values and goals of treatment is essential.
As identified by many doctors in our study, communication is the key. And, of course, doctors need to be supported
institutionally to do this. Taking the
time to have the conversations need to be recognised as part of their day job,
and valued as highly as reducing surgery waiting lists or efficiencies in
emergency departments.” (G)
