UChicago doctors see ‘remarkable’ success using ventilator alternatives
uchicagomedicine.org
uchicagomedicine.org
That kind of reply would immediately lead me to think it was just a useless release, but then I see people posting comments along the lines of "No, we don't do that. In fact, we have a policy against doing that because of the danger of aerosolization"
For my hacker/systems wonks, this a great example of group learning happening world wide. I imagine there are many ICUs that do this, and many that forbid it. In such an environment, releases like this aren't submarines or spam; they're recurring prompts to administrators elsewhere that they might be missing something important.
I hate to sound cold, but damn this is an interesting example of how organizations learn. One commenter asked "I wonder how many of those hospitals who forbid intubation are doing it to patients with good insurance"
For the record, as far as I know this is a horrible thing to suggest. But the overall point, that large organizations have incentives that are many times removed from the actual work being done, is a good one.
This kind of conversation facilitation across borders is what the internet was supposed to be doing. I think this is the first time I've seen it working the way we had hoped. What's especially interesting to me is that many of the signals we look for in social forums, like "this is just a spam press release", "nothing new to see", or "there's some ulterior motivation here" voting up or down, etc., are actually counter-indicators and inhibitors of overall progress.
Unfortunately, in the middle of a pandemic, that's not going to happen with enough speed to prevent a lot of people dying.
The perfect can be the enemy of the good enough. We don't have to guess or learn about the mass of an electron; that's been well-established through great lab work. But not all decisions are like that. Many times the hardest decisions are those you make with incomplete and contradictory information ... and not making a decision is, in effect, making a decision. This is one of the things that's so interesting here. If it were simple yes/no, what's science and what's speculation, there wouldn't be much interesting learning or decision-making happening.
The fixation on RCTs has kinda become "a meme" at this point. However it's lives on the line in some situations.
Not everything can be double-blind. Not every experiment can be ethically done with a placebo (or done at all).
Also the placebo effect is real but it is more pronounced in things like back pain or headaches, not so much in broken bones or aggressive viruses.
Also, in most cases the control group get the "standard" treatment, because "do nothing" (taking literally the GP) is too bad. And you want to be sure that the new treatment is better than the "standard" treatment.
[1] A real randomized control group, not an unrelated bunch of guys in another city of France.
Historical data? Past experiments? Sure, they might have biases, but the higher sample size of historical data can help with that.
I think (specific) control groups make sense when you're talking about small effects or very specific cases (for example, the control group will undergo the standard treatment instead of the new treatment)
For example: If there is a small Ebola outbreak in New York and you give the patients hydroxychloroquine and the death rate is 80%, is it good or bad?
How are you sure that this method is not worse than the ventilator method and will kill even more people during the pandemic?
How many death did they get with this method? How many death would they had got with the ventilator method?
From the article:
> The study included all sequentially hospitalized patients between March 1, 2020, and April 4, 2020, inclusive of these dates.
> As of April 4, 2020, for patients requiring mechanical ventilation (n = 1151, 20.2%), 38 (3.3%) were discharged alive, 282 (24.5%) died, and 831 (72.2%) remained in hospital.
If you ignore the 831 patients that were still in the hospital, and consider only the 38 that survived and the 282 that died, you get 282/(282+38)=88%. It is a very short time. What are the odds for people that survive more than 4 days in the hospital?
Did the team this post get the better results using the same accounting method? Did they apply this method only to the people that would need a ventilator or to more people because it is cheaper and easier to setup and maintain? (IIUC they used ventilator for the worse cases anyway.)
> And with numbers like that, I think it's perfectly ethical to try anything reasonable.
Do you want the best possible treatment to each patient, or you prefer that each doctor tries his/her pet theory in production?
It's not that your questions are bad, it's that in practice medical professionals have to operate without answers to them. Doing so involves communication with peers about their own observations of what may work better/worse, such as in this article. Double-blind randomized trials are not the only source of actionable information: Case studies also form a significant pillar of knowledge, especially pending results from more systematic studies.
[0] https://link.springer.com/chapter/10.1007/978-1-4757-2068-6_...
For example one day we have very weird results trying to compare two measurements of the same day about something related with the speed of sound. After a lot of time trying to understand the problem we notice that one measurement was from 9am when the temperature was like 10°C(50°F) and the other was from 1pm when the temperature was like 25°C(77°F). The following days we tried to take all the measurements as close as possible.
The same applies to benchmarks in computers. A few days ago I got an improvement for a program that reduced the runtime from 85s to 59s. Until I noticed that one was with the notebook plugged in an the other with the batteries. I tried again both with the notebook plugged in and the improvement was only from 65s to 59s. Still a nice improvement but not fantastic.
Quoting again part of the original comment I'm repliying
> Learning is not the same as science, and we need randomized trials to actually be sure of anything. Unfortunately, in the middle of a pandemic, that's not going to happen with enough speed to prevent a lot of people dying. The perfect can be the enemy of the good enough.
Without a randomized control group it is very difficult to be sure if a small improvement of the survival rate is real. So you can't learn if the new method or the old method is better.
Case studies of those attempts are exactly the kind of data points that can provide a great deal of information and hypothesis generation for more systematic studies.
As a former biomedical engineering researcher, this pandemic has been profoundly eye-opening in learning about the resistance to advancing the state of the art of medicine in the USA. (I’m not even speaking about the knee jerk reaction towards banning nebulizers in hospitals thanks to a flimsy NEJM letter last month reporting coronavirus aerosol contaminations.)
No! They will definitively not let their patients and colleagues die firs! They will prevent you from killing them!
You might believe in youRe therapy, but the vast amount if novel therapies will have (novel) adverse effects and you will haVe to supply the prove that your therapy will do less harm than doing the conventional thing. We have clinical trials to administer new therapies in a controlled and ethical way to cause the least harm. Just trying things will kill more people than it helps. The vast amount of new ideas do more harm than they help. Look at chloroquine and what a shit show it is, because everybody just tried it willy nilly. The side effect of harming Lupus patients who could not get their medicine alone caused tremendous unintended harm. And that wasn’t even harming because if administering a useless therapy with serious side effects. Move fast, fail fast and fail often aren great principles for developing software but they have no place in developing therapies. (I actually wanted to hurl swear words at you. But that helps nobody. It is true that medical research is overregulated and could be improved Bit there are reasons for that. Throwing all regulations away is just Trumpish behavior.)
Your point about supplying the safety data is exactly where the roadblock is found. I’ll update you when the device is approved by the FDA and voila these objections mysteriously disappear ;)
You know a proper FDA approval takes years, right? Not the emergency do-whatever-you-want approval, a proper approval. By all means, please do post.
Further, if the GP had prior assumptions about these possible treatments being wrong, you commit the same error in the opposite direction with your casual assumption that your approach is right, that the FDA will not only approve the thing, but that the objections will also lose all validity. Even if approved, the objections may still have merit. The objection need not be completely wrong in order for the FDA to decide the balance of risk weighed in favor of approval.
Finally, the idea of using nebulized ethyl alcohol is interesting! I hope it works. It is, however, extremely easy to find information on the dangers of inhaling alcohol fumes. If it is a viable treatment path, patients are likely to be extremely sensitive to dosing levels. Recipients would also, by definition, be high-risk, making the safety issues more uncertain. It is not, on it's face, unduly obstructionist to be highly skeptical of such a treatment without a decent amount of evidence.
Edit: I even partly agree with your sentiment that this is a time when some (very careful) risks may need to be taken that ordinarily wouldn't be. But your comment conveys a strong sense of arrogance, of unassailable certitude. I hope I am wrong in that assessment: Someone looking to take these sorts of risk right now should be approaching them with the utmost humility. This makes your tone very disturbing.
For instance, the banning of nebulization in hospitals for fear of viral aerosolization published in a faulty NEJM letter[1] is preposterously cautious. By this logic, Lysol disinfectant sprays ought to be banned too, even though it’s recommended by the CDC. So this “arrogance” you sense is probably because it is apparent to me I am hungrier to save lives than (many) doctors and hospital administrators who won’t take a chance to even measure the risk to accumulate much needed experimental evidence; even if their patients are willing! Hippocratic Oath is the retort.
Frankly, “no data no dice” does not cut it when confronting such a global humanitarian challenge. The medical profession appears to be just that - licensed occupational employees motivated about retaining their jobs. Hence my snarky expectation that this will be an easier, ie quicker, sale if/when the nebulizer has been rubber stamped by the FDA. No one was ever fired for buying IBM
Front-line doctors simple have a different perspective: There are many prospective treatments that might show promise. Most will not work. Many may have their own catastrophic effects. At the same time, doctors must make immediate decisions on how to treat patients, without the luxury of time to review all prospective experimental treatments, most of which lack sufficient data to make a rapid determination of their risk. And remember their foundational, ancient oath: "First, do no harm". If that oath engenders a certain amount of conservatism in treatment choices, you should not berate the doctors themselves as deficient: Your issue is with the fundamental philosophy of medical practice.
I am glad you are hungry to save lives. But remember humility: Any number of significant failures that cost lives can be found will minimal searching, and undoubtedly most involved were eager to save lives as well. The drug combo FenFen comes to mind: I'm sure the researchers involved were eager to save lives and improve the health of obese people, but they're efforts caused serious heart problems in up to 30% of those taking the drug. Medical history is littered with failures and death. You must remember that. If doctors are conservative in their treatment choices, they have good reason, and should not be condemned for it. You'll win no people to your cause if you vilify those you seek to convince, all you will do is attract people who are already inclined to agree with you.
RCT is wonderful when we can get them and not always show stopper when not.
They're not optimal for saving lives.
Science is important, but there are times like this where brute intuitive engineering is the only tool available.
This article isn't not science. It encompasses a key pillar of medical knowledge and advancements: case studies.
That said, large effect sizes in one hospital don’t control for confounding variables.
It’s required to prevent systematic biases like giving the drug that you think might help to the patients with better prognosis (instead of wasting it on those that are very likely to die anyway).
"The proning and the high-flow nasal cannulas combined have brought patient oxygen levels from around 40% to 80% and 90%, so it’s been fascinating and wonderful to see"
People die, if their oxygen levels are getting too low. This method gets them up again. Sounds like "working" to me.
I have no doubt that proning increases the readings we are getting on pulse ox monitors, sometimes pretty immediately. I’ve seen it, literally first hand, in a number of my patients. But I have no idea if it saves lives. Many of those same patients still got intubated and some died.
Understanding impact on surrogate markers isn’t enough.
Highest recommendation for Everett Rogers' Diffusion of Innovation, first published in 1963, 5th edition in 2003.
https://en.wikipedia.org/wiki/Diffusion_of_innovations
It's seminal. Having read a lot of process and innovation books in 90s and aughts, I really wish I had known to just start with the original text.
Knowledge sharing takes time. We know how to model it. This book (and others) helped me to calm down and try to hasten the process instead of wasting my energy railing and failing.
Crazy to think that so many doctors around the world, experts, and policy makers didn't really question the fundamental nature of the disease, and perhaps telling that it took an ER doctor in NYC posting on youtube for a month to bring it proper attention.
[1] https://www.bloomberg.com/news/articles/2020-04-22/almost-9-...
[2] https://www.reuters.com/article/us-health-coronavirus-ventil...
We haven’t culturally evolved much further it seems. ”Wacky” ideas are routinely rejected by mainstream science; eg ulcers being caused by germs rather than stress, and can be cured as such. What societal changes need to come about that this doctor doesn't have to make YouTube videos for a month?
https://www.npr.org/sections/health-shots/2015/01/12/3756639...
Linus Pauling famously and successfully used all his night to reject the idea of quasicrystals. The Updated concept of crystals was adopted shortly after his death; i can’t say I was able to track the history - there is an enormous amount of whitewashing - but it seems initially everyone rejected quasicrystals, but eventually people started to look at ahechtman’s evidence - and accept it, except not publicly because the luminaries of the field led by Pauling rejected it. And then Pauling’s funeral allowed the science to finally advance.
The idea of "cadaverous particles" in fact appears to be at least partly a bit of pseudo-science: There are no such things. Semmelweis had accidentally stumbled onto germs, but he didn't know it, and therefore his reasoning was flawed even if it gave a correct result; If the doctors stopped dissecting corpses, that would have reduced things just as much as the mid-wife ward. If he'd understood why washing hands actually worked, he could have had the mid-wives do so as well and save many more lives.
I also don't think it's correct, at least using the Semmelweis example, to say that "we haven't culturally evolved". Semmelweis's failure to spread what he learned was at least as much victim of his own personality as anything else: "Semmelweis was not very tactful. He publicly berated people who disagreed with him and made some influential enemies".
(Personally, I think there’s a good reason for this in normal times. Medical research is hard and personal opinion will never compare to years of research, especially when lives are on the line. In times where years of research aren’t actually an option though...)
"This approach is not without risk, however. HFNCs blow air out, and convert the COVID-19 virus into a fine spray in the air. To protect themselves from the virus, staff must have proper personal protective equipment (PPE), negative pressure patient rooms, and anterooms, which are rooms in front of the patient rooms where staff can change in and out of their safety gear to avoid contaminating others."
"UChicago Medicine’s Emergency Department recently doubled its number of anterooms, thereby doubling its capacity to give ?high-flow nasal cannula to patients. The main hospital also added negative pressure rooms on two floors, making it safer and easier to take care of COVID-19 patients."
Not all hospitals have the ability to double the number of negative pressure rooms or even provide needed PPE to all caregivers.
A ventilator on the other hand allows for a HEPA filter in-line that prevents the spread of the disease within the hospital.
"The respiratory distress appears to include an important vascular insult that potentially mandates a different treatment approach than customarily applied for ARDS." https://twitter.com/jama_current/status/1253722428053823492
Granted, both are a hell of a lot better than 40%!
It adds, "Mild and moderate cerebral hypoxia generally has no impact beyond the episode of hypoxia; on the other hand, the outcome of severe cerebral hypoxia will depend on the success of damage control, amount of brain tissue deprived of oxygen, and the speed with which oxygen was restored."
So I guess my questions are:
* How does this stack up against an intubated ventilator, assuming one is available?
* My understanding is the patients needing respiratory support are often on ventilation for 1-2 weeks; how much damage would one expect from having severe hypoxia for that duration?
https://www.hopkinsmedicine.org/news/media/releases/ptsd_com...
If you can get the O2 up to a livable level without a ventilator so that the patient is supported enough to get well, that that is a good outcome.
Yeah, unfortunately I can't find it now, but I remember reading a "what the fuck is going on, these patients should be dead!" statement from a doctor a week or two ago about exactly that.
Otherwise, intubation w/ a ventilator generally requires some form of sedation-- I wonder if that sedation has an impact on the body's ability to fight back.
More and more it's starting to look to me like we have two different novel viruses going around.
Second, I'm not a physician, I'm a physicist. What follows is for curiosity's sake.
I suspect that the goal is to maximally enrich the patient's airstream in oxygen, whenever it is that they happen to breathe in. In a patient with fluid-filled alveoli, the surface area available for diffusion of oxygen into the bloodstream is greatly diminished. Additionally, the distance that oxygen needs to diffuse before it reaches hemoglobin is increased: rather than just the lining of alveoli and capillaries, it has to first dissolve into the fluid gunk filling the space, then diffuse through the fluid, then pass through the lining of the alveolus and capillary. To top it off, water doesn't have great solubility for oxygen, and atmospheric air is mostly nitrogen anyways.
Each of these passive transport phenomena occurs at a rate that depends on the gradient (roughly...) of available O2. This concentration is greatest in the air, and lowest in the bloodstream adjacent to the alveoli, where hemoglobin binds up oxygen. One way to increase the rate of dissolution and diffusion is to increase the concentration gradient. That means enriching the airstream in O2.
[1] https://en.wikipedia.org/wiki/Barotrauma#Pulmonary_barotraum...
Don't get me wrong, the fatality rate for intubated patients is going to be high. but probably more like 40-60%.
If there is some bias in the study population, the overall rate can change quite a lot (for example, a possibility is that the weakest patients succumb in that period, with stronger patients coming off the ventilators after a longer period...).
no wonder why the medical establishment would be opposed to a simple work around that would remove the need for hospitalization or ICU
- care, like taking the drugs they have been prescribed and regularly take at home? Any family member can do that.
- monitoring that the saturation does not fall too low... so that patients can be intubated with a 90% risk of death? I'd rather opt out of that one.
To be clear, I'm talking about de-medicalizing covid: no ICU, no hospital. Just O2 nasal canula at home.
It seems unimaginable, but a large number of in the world deal with no hospital healthcare.
Hospitals make their profit off voluntary procedures like shoulder and knee surgeries and the constant flow of voluntary tests and procedures ("I just want to get this checked out"). They lose a lot of money when people spend three weeks in the ICU.
This is especially true when a huge percentage of the patients are Medicare or completely uninsured. Privately insured patients with good policies are better, but they still aren't getting rich off those people.
I have no sympathy for the hospital systems or the entire medical industry that has created a massive bureaucracy full of perverse incentives, exploitation, overbilling, and accounting games, but in this particular situation, even with the massive federal handouts, they're not making bank.
Edit: Also, people have been avoiding HFC for COVID-19 because of aerosolization risks.
when i was an EMT if someone had O2 sats in the 50s and was conscious i would’ve told you that the pulse ox was broken. And it it wasn’t broken, i’d be yelling for a paramedic to tube my patient asap.
We've converted a huge number of beds to negative pressure in order to maximize use of HFNC. Anecdotally, I feel like it works, but would be great to see a trial.
*major nyc health system
https://www.france24.com/en/20200425-no-evidence-that-recove...
The Bayesian prior that they should have some level of immunity is pretty high, seems to me. Exactly how long and how strong such immunity is a good question, but it would be really unlikely if there was no immunity.
“No evidence” is not “evidence against immunity”. It means we don’t know yet.
I have two comments about that:
1) Like somebody else said, if you don't look, you won't find evidence, even if it's there.
2) Wuhan officials were incentivized to say it wasn't contagious, ergo, no lockdown needed.
However, it clearly was being transmitted to non-wet market patients in late Nov./early Dec., and Disneyworld Shanghai was closed Jan. 24, so you have to be wilfully blind to say it's not contagious.
Sometimes that’s an issue, but it doesn’t mean they were lying when they said they didn’t have the evidence yet.
The caveats are:
1) Would US hospitals accept or recommend them?
2) If US hospitals accepted them, was there an acceptable solution to the aerosolization problem? Wuhan hospitals were segregated into corona and non-corona locations, so aerosolization wasn't a problem for other patients, but I don't know if US hospital systems got that organized.
I highly recommend reading the Wuhan accounts and papers. They really moved fast on improving their response, which the US totally ignored. Only now, Apr. 26, are we catching up to what they found in Jan./Feb. I doubt if it affected the body count much, but time was wasted.
Instead HN wasted months on endless navel-gazing and "IFR vs. CFR" chatter. Really a new low for HN.
I think we can safely reopen fully now and treat any serious cases using our existing healthcare systems in combination with this kind of new knowledge.
The longer we 'suppress the curve', when we are already far below hospital system capacity, the more economic and social damage we cause unnecessarily.
https://thehill.com/opinion/healthcare/494034-the-data-are-i...
I’d be curious to hear counterpoints. I could be wrong. It does anyone think this will go away with a long enough lockdown? Or is there any solution other than herd immunity?
The more recent numbers from New York put the IFR at 0.5 to 1%, which matches what most organisations (WHO, governments etc) have been assuming for a couple of months now. Also the actual death count from NY makes the Stanford numbers pretty much impossible (0.2% of people in NYC have already died).
We don't know if herd immunity works for this virus (there are reports of the disease resurfacing), we don't know the long term effects (there are reports of long term organ damage even for those not incubated) and we don't understand all the manifestations of the disease (there are reports of people 30-40 dying of COVID induced strokes).
The solution is isolate until we can do the hard work of getting mask and other PPE supply chains stabilized, get our health care system back on it's feet, start extensive testing, contact tracing and semi-isolated communities. None of which is possible as long as testing capacity is so limited and people keep exposing themselves unnecessarily.
Further Fauci himself says it’s very likely there is immunity: https://www.google.com/amp/s/www.newsweek.com/fauci-really-c...
There was also a study performed on monkeys showing immunity: https://www.biorxiv.org/content/10.1101/2020.03.13.990226v1
Secondly, developing respiratory distress and requiring intubation is just one of several possible outcomes.
For example, it appears that strokes due to blood clots appear to be a significant risk with COVID-19 [1].
[1] https://www.washingtonpost.com/health/2020/04/24/strokes-cor...