LA: Ambulance crews to not transport patients with little chance of survival | Hacker News Reader

LA: Ambulance crews to not transport patients with little chance of survival

latimes.com

102 pointsbelltaco176 comments

This might be an unpopular opinion but this is a pretty awful headline and it makes it look way worse than what the EMS documents actually say. There’s a bold text [1] “shall not be transported if return of spontaneous circulation is not achieved in the field”. There’s a pretty big difference between abandoning patients with little chance of survival in general, and giving up after failure to achieve ROSC.

Perhaps at some point we’ll be at the place where EMS really have to give up without even attempting CPR, but we’re not there yet.

That’s not saying the situation is not bad — it’s terrifyingly bad. But a headline designed to make incorrect impression just doesn’t help.

[1] https://twitter.com/Pervaizistan/status/1346295476405084168

EDIT: link, to focus on the right tweet. typo.

When have they ever run out of oxygen before?

Hospitals are running out of oxygen in a way: so much is going through the pipes that the upper floors have low pressure, and the oxygen pipes occasionally freeze from adiabatic expansion. In LA.

You'd think they would test systems like that at maximum consumption.

Mind you, electricity and water systems are also not designed for every outlet to be maxed out. Whomst among us hasn't caused a breaker to trip from having too much stuff on at the same time.

Why would you? There's almost no cases where you would need oxygen to every room...

I doubt they tested for the case where they needed oxygen for the patients in the conference rooms and gift shop, either. It’s not like they can order more rooms on AWS; physical infrastructure has a breaking point and LA hospitals hit it.

Without knowing at all what I'm talking about, wouldn't be surprised if they are beyond maximum rated consumption.

Is it from adiabatic expansion, or is it just the LOX vaporizer/heater being overwhelmed?

Honestly wasn’t sure when I wrote it, I’m an atmospheric scientist, not an engineer, so it seems typically adiabatic to me... quite possibly the answer is “both”.

My understanding is that some hospitals have a central oxygen system, no different from how we are all connected to the water system and water comes out of the tap.

If too many taps were open, nobody would get enough water. Well, too many oxygen taps are open.

Too many taps open increases flow which causes freezing.

> But a headline designed to make incorrect impression just doesn’t help.

Yet this is basically all we get. Because it makes people click. It’s so hard to tell what’s real and what’s exaggerated these days. And if you try to make the case that something is exaggerated, you come off as a right wing nut job.

> And if you try to make the case that something is exaggerated, you come off as a right wing nut job.

Doesn't it depend on the topic? I mean, remember when right wing news outlets were exaggerating the hordes of migrants invading borders etc and "left wing nut jobs" yelling that people are blowing things out of proportion?

I don't think each if these tactic necessarily belong to one political orientation. It's just a particularly infuriating way humans communicate and deal with verbal conflict.

Nowadays the general level of education is much higher than a century ago, yet there is still a long way to go; hopefully we'll have many more centuries to learn how to build a public discourse more effectively.

For example, here are some excerpts from just one other LA Times article:

> Many hospitals also say they’re too full to accept any more patients or ambulances

> when paramedics are allowed to drop off patients at a hospital, the emergency room is often so crowded that there aren’t available staff members

> Hospitals across the state are sending away ambulances, flying in nurses from out of state and not letting children visit their loved ones

> canceling surgeries and erecting tents in their parking lots so they can triage the hordes

https://archive.is/VxZL9

If context matters, I'd expect an organization like the LA Times to be capable of addressing it. It's so frustrating to have to work backward just to find out if anything is remarkable. At this point, this kind of thing is seriously affecting the well-being of the audience.

So where are the hospital ships?

The one that was deployed is now being overhauled in drydock in Portland.[1]

But what's the point? I posted this article to criticize the LA Times' handling of the messaging. If you wouldn't mind taking a look at the original article from which those excerpts are drawn, I think you'll get it.

1: https://www.marinelog.com/shipyards/shipyard-news/vigor-wins...

> It’s so hard to tell what’s real and what’s exaggerated these days.

You had to click through and read a few words in order to determine what was meant in the headline by 'little chance of survival.'

> And if you try to make the case that something is exaggerated, you come off as a right wing nut job.

In this case, you come off as perhaps just a little bit lazy?

edit: in the original complaining post about this topic, songgao links to a 4-post twitter thread that explains how EMS will handle things succinctly and nicely. The first post underneath is someone saying "So will they be left at home to die?"

In emergency medicine, you've got patients who are dead, and patients who are dead dead.

Patients who are just dead might still be brought back. This isn't about them. Patients who are dead dead because they haven't responded to resuscitation efforts aren't going to be taken to the hospital, is all. And in a lot of places that's already the norm.

Don't they need to be brought to the hospital for organ donation though ?

This would be the case only in those countries where everyone is a donor by default (unless explicitly you opt out).

I don't think most countries have laws like that though.

The state where I live has opt-in organ donation option when you apply for a driver's license/state ID. As a retired EMT in a rural area, I encountered organ donation cases twice in my career. Once, the patient was flown out, the other time, the orgqan donation crew was flown in. The first case, the patient had suffered a gunshot wound to the head that spared the autonomic functions, he was breathing on his own.

The circumstances in which organ donation is viable are surprisingly rare. I have a friend who worked in a head injury specialist unit, naturally this was a pretty good source of donors. You ideally need someone who is alive but only by virtue of life support so that you have time to turn off the machine and get the processes started.

Isn't the instruction in fact to limit resuscitation efforts to in field? To take it to an extreme, if someone collapses and has a heart attack near a hospital, by this instruction they would have to revive the person (get a pulse/breathing) before transporting them to a hospital.

It sounds very different to what normal procedure would be. I am assuming that usually they try to get the pulse back but that they can continue to do that while in the ambulance (at least that's how it works in the movies). This change would limit that.

Movies give a very unrealistic example of chance of survival after heart attacks or cardiac arrest.

People are likely to survive one, but not the other. You wouldn't know that from film where almost everyone survives.

Could you specify which one they survive, possibly using "former" and "latter"?

A ‘heart attack’ is an episode of myocardial ischaemia (restricted blood supply to the heart) usually through a blockage of an artery. Angina is a pain associated with myocardial ischaemia of a usually temporary nature. A cardiac arrest is the stoppage of the heart.

Lots of people survive the first (apart for the 250,000 Americans for whom the first presentation of heart disease is sudden cardiac death), not so many survive the latter

Normal procedures for emergency cardiac care are going to vary depending on where you are in the world.

The general dichotomy is "stay and play" vs "scoop and run".

https://doi.org/10.1007/978-88-470-2215-7_31

Transporting these patients (the ones whose pulse hasn't returned in the field) appears to worsen their chances.[0] States vary widely in what protocols they require, but normal procedure in a lot of places is to not transport if resuscitation in the field has been unsuccessful.

[0] https://www.cardiovascularbusiness.com/topics/electrophysiol...

I feel like there's a quote from "Princess Bride" in there but I guess now is not the time.

There's a lot of bad reporting happening in Los Angeles.

There were a lot of headlines recently about "0% ICU capacity", which led most readers to think there are no ICU beds when there have been about ~50 since mid-December.[1].

The issue is the County Health department set a target of keeping COVID cases to under 30% of an ICU, so when when it exceeds 30%, for each point above 30% they deduct 0.5% from capacity.

I'm not a doctor, so that could very well be an appropriate way to do it, but when it comes to newspapers communicating with the general public, it misinforms people. (And I'm really worried about when we do hit 0 ICU beds -- as we probably will -- that people will be confused and/or lose trust.)

[1] http://file.lacounty.gov/SDSInter/dhs/1070348_DHSCOVID-19Das...

There are a lot of comments that are kind of close to right but missing context here. This is extremely common, and like all of prehospital care is heavily protocol driven. Dead people encountered by EMS / public safety are a much larger superset than those typically "saved" in a hospital setting, and those that meet the criteria to either stop, or not begin resuscitation really have no reason to be transported.

The link below is an example of EMS protocols that would cover this. Here's a snippet.

"Discontinuation of Prehospital Resuscitation"

1. Discontinuation of CPR and ALS intervention may be implemented prior to contact with Medical Control if ALL of the following criteria have been met: Patient must be 18 years of age or older, or family of a minor is agreeable after consultation with the APP or District Chief. Adequate CPR has been administered. Airway has been successfully managed with verification of device placement. Acceptable management techniques include orotracheal intubation, nasotracheal intubation, Blind Insertion Airway Device (BIAD) placement, or cricothyrotomy. IV or IO access has been achieved. Rhythm appropriate medications and defibrillation have been administered according to protocol. Persistent asystole or agonal rhythm is present and no reversible causes are identified after a minimum of 25 minutes of resuscitation. Failure to establish sustained palpable pulses or to establish persistent/recurring ventricular fibrillation/tachycardia or lack of any continued neurological activity such as eye opening or motor responses All EMS paramedic personnel involved in the patient’s care agree that discontinuation of the resuscitation is appropriate 2. If all of the above criteria are not met and discontinuation of pre-hospital resuscitation is possibly indicated or desired, contact Medical Control. 3. The Deceased Subjects Policy should be followed.

http://www.wakegov.com/ems/medical/Documents/WCEMSS%20Standa...

> Patients who are not to be transported to hospitals include those whose hearts have stopped and, despite efforts at resuscitation, have no signs of breathing, movement, a pulse or blood pressure and would be declared dead at the scene.

Who else does it include? This statement sounds like weasel words to calm people down about what is plainly an unacceptable situation.

That's all it includes. For your convenience here is a direct link to the agency memo, from the linked article.

http://file.lacounty.gov/SDSInter/dhs/1100458_Directive_6rev...

As for "unacceptable situation", here's a bit more color from actual local EMS: https://old.reddit.com/r/LosAngeles/comments/kqlgqz/ambulanc...

> As a former paramedic now assigned to media relations, the first thing I taught my kids about the news? Never react to the headline. While COVID-19 has shaped many pre-hospital care policies, protocols and procedures across California (and beyond) over the past year - including in Los Angeles County, rest assured that the concept of "No ROSC = No Transport" is not in any way new to our region, or most others.

> Brian Humphrey Firefighter/Specialist Public Service Officer Los Angeles Fire Department

(Above reference would be a separate comment, but this lovely thread sent serial downvoters to my history and I am timed out!)

Wait, so normally such patients are transported? For what? Billing purposes?

Because people can be revived

Indeed. I forget the term but I've read that trauma patients hearts can stop during massive blood loss. And they are saved by another person actually pumping the trauma patients heart with the responding care givers hands.

Normally such patients aren't either. This is media sensationalism. Someone got alarmed by the wording of the reminder/clarification of the policy as-it-was. Pronounced dead at the scene and should not be transported for failure to achieve ROSC has been LA policy since the 1980s[1]. Just about everything about the memo is the same policy as before, just in less confusing wording.

[1] https://file.lacounty.gov/SDSInter/dhs/206332_Ref.No.814,Det...

A former EMT I know told me their policy was always to transport DOA patients and to tell the caller that the person died on the way to the hospital, even if they were already dead. I'm not sure if it's the same everywhere but the idea was that it's kinder to whoever found the person.

Maybe insurance covers the call then. Here if it is DOA medical insurance won't pay.

Is there any nuance to that policy? What if someone dies between the call and the ambulance arriving? What if the person making the call doesn't have the experience to know when someone is beyond saving?

On the face of it, it appears to penalise those who can't afford to get it wrong which feels morally bankrupt.

Financially rich.

Economically not rich.

Morally bankrupt.

Some of the world's most advanced western countries that profess freedom and democracy across the globe.

People's estates tend not to fight back as aggressively to spurious bills than live people...

Someone else commented this on the thread, but my understanding is that some non-zero percentage (maybe even non-trivial percentage) of people without, say, a pulse can be revived only at a hospital but not by an EMT (because of equipment or skills, I guess?). This decision forecloses that possibility completely.

I've been thru EMT training. It boils down to EMTs not having formal medical education necessary to make a call as significant as pronouncing someone deceased. It's a blanket rule, so even in extreme circumstances like if you find someone beheaded, you just log it as a severe injury and transport the body to the hospital where a doctor pronounces them dead.

That's not broadly true. Anyone has sufficient medical training to declare a beheaded person deceased.

States have more and less sane approaches to this. Obviously, many things are not as clear-cut as beheading. But there are states that allow EMTs to make a field declaration, depending on specific guidelines, and possibly with the requirement of contacting a doctor to describe the situation and get their permission to terminate resuscitation efforts.

“Injuries clearly incompatible with life”.

While an EMS may not be able to sign the death certificate, they are quite able to say in cases of major trauma or obvious rigor that the patient is exceedingly dead.

Way outside my expertise, but you still need to remove the corpse, and the ambulance is already there.

Plus, it is not really a good look for paramedics to be leaving a dead person.

EMTs are specifically supposed to not move bodies unless there is an urgent reason to do so, but leave them on the scene for coroner etc to handle.

So, leave the body by the curb?

I would assume a coroner or funeral home would handle the body.

According to some EMT on reddit, in LA County they sometimes are but in most of California they aren't. This document is really just bringing LA County in line with the rest of the state and codifying the common practices/exceptions.

I still cannot comprehend why we had to let it go this far. Why have all measures in California been completely voluntary this whole time? I can get a ticket if I jaywalk or leave my car parked somewhere for too long, but if I walk into a Walmart with no mask on and start yelling at everyone in the store potentially exposing dozens of people to covid I’ll just get politely escorted out with no penalties.

Something so ridiculously simple we could have started with is just ticketing for not wearing a mask in public. If we needed to ratchet it up further, ticketing gatherings with people outside the same household, which is obviously more difficult to enforce but just start with the ones that happen in public. Maybe do a “see something, say something” campaign to encourage people to report private gatherings they see in their neighborhoods and police come and break up gatherings and give tickets.

What we’ve been doing instead with all these ever-changing vague optional guidelines is just so stupid. Either leave everything open, or actually enforce the so-called “orders”.

Regardless of politics, I think places like LA need to institute a full lockdown. No one leaves their house except to go to the grocery store and pharmacy. No one leaves more than 2 miles away from their residence. It should be enforced by the military. Essentially martial law. It’s not something I suggest lightly. But 6-8 weeks of complete lockdown and pay people to stay home. It’s the only way that California is going to survive this.

Yes, I know that the death rate is low, ~0.2%. But when hospitals are full like this we need to have a circuit breaker and the only thing we have is a full, military-enforced lockdown. We should also stop all traffic on the highways. Set up tanks on the I-5 and 101 and turn people back. We have to stop this uncontrolled catastrophe.

> It’s not something I suggest lightly.

Anonymous HN comments lack a certain gravitas.

There’s enough evidence for medication and preventive supplements (Ivermectin, Vitamin D) that lockdowns aren’t necessary anymore. Other treatments have looked promising when applied early in the disease instead of after hospitalisation. According to combined research (c19study.com) over 800,000 lives could’ve been saved when treated earlier

If there were such evidence I doubt that so many countries would fuck over their economy with lockdowns, so I have strong doubts about your claim.

Turkey has been treating people with HCQ from May onwards, despite outcomes of the now-retracted(!) study once published in The Lancet, and they have a very low death rate. 256/1M Population. (See: https://www.middleeasteye.net/news/hydroxychloroquine-corona...) Their death rate has been on a steady 1% throughout the pandemic where for example Germany is on about 3%. Of course this needs to be corrected for age etc etc.

It also needs to be corrected for test strategy.

The median age in Turkey is 31.5 years.

The median age in Germany is 45.7 years.

You realize this is crazy-talk right? No country has avoided a pretty wild amount of casualties without locking down. If the evidence was so strong, you'd think at least one of them would have succeeded with this strategy.

There’s nothing except lockdowns that will stop what is happening in LA right now. It will be quick and effective and we really don’t have any other tool. We still don’t have a prophylaxis or treatment. People are going to die that shouldn’t be dying and I’m not just talking about COVID patients. When hospitals are full, people die.

Ivermectin is not a supplement. It’s an expensive anti-scabies drug. I’ve read it’s supposedly somewhat effective but I haven’t seen anyone implement it in treatment yet at least in the US. I’m familiar with the IMASK+ protocol. I believe they are using that in Peru but it doesn’t appear to have been making any changes in the death rate.

The vaccine is more effective. But we have 35 million doses stuck in warehouses around the U.S. because we don’t have a credible distribution plan. No way we’d be able to mass distribute vitamins to the general population. Not to mention the reluctance due to anti-vaxx social media memes.

I know you’re being downvoted by the open everything up crowd but I agree. People have proven they can’t follow the guidelines multiple times, there’s been plenty of chances. Quite frankly it’s an embarrassment. I can only imagine how bad it would be if they acted like Florida and allowed the theme parks to open.

But yeah, once hospitals are full the national guard really needs to step in and take over.

I don't know what the US thinks of what is going on in the UK or France? Here severe lockdown and rationing of health care services have been in place for months.

Do you think it is all politics? Because we like communism? Or rather it is because we don't have a choice.

I was waiting for a military style quarantine earlier on. I still think it should have happened - though it may not be effective since china lied about the numbers BIG TIME and they're cited as the big success story here

https://www.bbc.co.uk/news/world-asia-china-55481397

> china lied about the numbers BIG TIME

I'm sure they lied, but by how much could they have realistically lied? Their death numbers could 10x higher than reported and they'd still be 4x better than the US per-capita. Could they cover up 10x the bodies that have been reported? I'm highly skeptical.

China's lockdowns sure helped, but if this BBC article and study it cites (from china's own CDC) is correct, than we have to reckon with the fact that hardcore militarized quarantines still don't solve this problem the way that we would like...

CFR is 0.5%-1%.

While that is true it doesn't take into account what happens once hospitals reach capacity. Once all doctors are busy and beds are full the fatality rate of strokes, heart attacks, car accidents, cancer goes way up which is something that has to be avoided.

Yes, I agree. I was pointing out that death rate is higher than 0.2% that parent mentioned.

CFR of 0.5% to 1% with treatment for a (likely) seasonal virus is extremely high.

with treatment.

The only solution is to vacinate at much, much higher rates than they are doing now. I don't know what is holding it up, but I imagine that setting an agressive deadline, say 2 weeks, for everybody to be offered a vaccine will get things moving, so long as the penalty is sufficiently harsh. Maybe holding politicians individually responsible for each dead as manslaughter?

Basically I am tired of politicans doing jack shit and expect the rest of us to dance to their tunes.

Production capacity. The equipment to make the effective vaccines in high enough quantity simply doesn't exist yet. The easier to produce vaccines are either less effective (AstraZeneca) or haven't finished demonstrating how effective they are (Johnson & Johnson, CanSino, Gamelya, Sinovac, SinoPharm, and Novavax are still in trials). The risk with a less effective vaccine is that the virus could evolve resistance to whatever particular antibody types the vaccine tends to cause the body to produce, since there would be more vaccinated people who could get infected. Then we'd be back to square 1, trying to develop a new vaccine for the new variant. We REALLY want to avoid that.

I'm disappointed that all the discussion seems to be operating at a non-quantitative level. ("If there's any chance, we have to try" against "If circulation can't be reestablished on scene, there's essentially no hope".) Presumably there are academic article that make an attempt at this.

People overestimate the efficacy of CPR because they see people in the movies come back to life after 4 chest compressions and a second of mouth-to-mouth. I wonder if that is the sort of thing driving the discussion

That's likely part of it. Unwitnessed cardiac arrests and those where no electrical activity is present in the heart are pretty rare to get back.

Cold temperature and submersion in water are two neat caveats though. They can be viable a lot longer, in part due to the Diving reflex.

https://en.wikipedia.org/wiki/Diving_reflex

I've spent some time in hospitals and I don't overestimate the <1% efficacy, but I'm still frustrated by the innumeracy of the discussion. There are biases in the other direction: medical professionals who watch 100 people die for every 1 saved become desensitized to death and round that to zero. They're not economists, and they don't understand the statistical value of life implies it's worth spending $20,000 for just a 0.3% of survival.

Why are some proven simple yet _useful_ preventative measures not taken? Like, promoting self blood oxygen monitoring with those (cheap!) finger oxymeter devices for all at-risk persons...

This would avoid lots of late emergency calls in critical condition due to silent hypoxia that developed in them for days/weeks...

Vitamin D supplements too.

https://pubmed.ncbi.nlm.nih.gov/32252338/

The commonly-used treatments for hypoxia are incredibly damaging. In the beginning "ventilation" was the go-to treatment to pump oxygen into patients' lungs. Doctors eventually realized invasive ventilation was a death sentence. Now they're trying to just use lots of oxygen, but that doesn't work either.

A lot of people had COVID-19 before tests were available. What happened to make the disease so much more deadly? I think most the early patients (December 2019, January/February 2020) toughed it out on their own at home.

> Doctors eventually realized invasive ventilation was a death sentence.

Do you have a source that ventilation itself worsens outcomes, and isn't just correlated with already poor-performing patients?

Here’s a good summary of some findings.

“ Among the 2,634 patients for whom outcomes were known, the overall death rate was 21%, but it rose to 88% for those who received mechanical ventilation, the Northwell Health COVID-19 Research Consortium reported.”

“ Ventilators are typically used only when patients are extremely ill, so experts believe that between 40% and 50% of patients die after going on ventilation, regardless of the underlying illness.”

https://www.webmd.com/lung/news/20200422/most-covid-19-patie...

1. This is from April.

2. The cited study only measures outcomes and does not claim that ventilators worsen patient outcomes. Covid patients who are hospitalized have a higher rate of death [citation needed]. Does that mean hospitals kill Covid patients?

[1] https://jamanetwork.com/journals/jama/fullarticle/2765184

Don’t disagree. However there’s some evidence that ventilators might not have been the best treatment.

The data itself is incomplete in the linked study.

There is some weird sort of logic with 2.

For example, when I worked in Cairns (cape York Australia, which serves a massive area with a large indigenous population), aboriginals have a belief that people going to the hospital go there to die (because people who have been sick enough to go to hospital... die). So yes, hospitals kill covid patients, because patients sick enough to need to go to hospital are sick enough to die. I know you’re kind of writing in jest and looking for sources but the fact remains that admittance to ICU (when I did my ICU term, at least in Australia and at least when I did it - my brother is an ICU trainee and I raised this number with him and he said it’s lower than that now, here) carries an all source mortality risk of 30%. 30% of those who are wheeled through the doors go out in a bag.

To relate this to COVID, generally ventilators don’t cause an increase in mortality just because you are on one. This was a surprising finding during the early days. It is also contrary to what we find in influenza patients, where it is usually life saving when a patient gets too tired to breathe in their own but still has enough good lung function to be able to respire with their lungs (the alternative being ECMO, or artificial blood gas exchange). I’m on mobile and it’s late so am not at liberty to pull up the research but I recall the consensus being that there was a contradiction: patients who were sedated and ventilated were being so done on the basis of a rapid deterioration in o2 sats; but generally we’re still alert and potentially orientated. It was quickly found that prone positioning (putting a patient on their front to get more gas exchange to the apexes of their lungs) could keep then unventilated and they did better - a lesson learned pretty quickly as regions of Italy and the UK ran out of ventilators

The problem was that for a healthy person, ventilation just moves your lung physiologically, but for very sick patients parts of their lungs are like inflamed tissue paper so the forced inflation could cause problems.

Ventilators are highly complicated pieces of medical grade machinery that cost upwards of $50,000. They are not just regular old pumps with tubes attached. "Forced ventilation" does not properly describe the delicate nature of their operation.

If used properly by trained medical professionals, they are better than the alternative — no ventilation at all.

The perspective I share is one that comes from a doctor that works in the ICU (not me). I am not against ventilation, but there are attendant risks when treating COVID-19 specifically.

Lots of sources. This one is from April 23, 2020:

Special Report: As virus advances, doctors rethink rush to ventilate - https://www.reuters.com/article/us-health-coronavirus-ventil...

This is not even a good source, just something that I linked to in a previous comment here.

Remember how the governments were rushing Ventilator production, then those efforts got memory-holed? This was because the professionals realized they shouldn't try to ventilate every COVID-19 patient in their hospital.

From your article:

> The picture is partial and evolving, but it suggests people with COVID-19 who have been intubated have had, at least in the early stages of the pandemic, a higher rate of death than other patients on ventilators who have conditions such as bacterial pneumonia or collapsed lungs.

> This is not proof that ventilators have hastened death: The link between intubation and death rates needs further study, doctors say.

A summary: we shouldn't ventilate everyone because ventilation has risks (like all medical treatments). Nowhere does the article claim that ventilation is a "death sentence" as you originally claimed.

This is correct and well established; prone positioning and non invasive ventilation was shown fairly early on to have a significant survival benefit. Not that I agree with the rest of the OP’s attempt at making some sort of statement

A lot of people did not have Covid before the tests were available. You know how we can tell? Because we did not have a lot of people hospitalised or even die with an undiagnosed mystery pneumonia. (There are other ways we can then cross validate that.)

You have somehow internalised a gross mistruth as a fact, have realized it is inconsistent with reality, and are now trying to patch up the inconsistencies by positing that the virus became more deadly. That way lie conspiracy theories.

> (There are other ways we can then cross validate that.)

Tell me more, I'm interested.

> by positing that the virus became more deadly.

I posit that inappropriate treatments make the virus more deadly than it has to be.

Inappropriate (or rather, best-we-can-think-of-at-the-time-which-we-later-improved) treatment still saved many lives compared to the toughing it out at home approach.

Doctors already know ventilation is bad for people; they were only doing it for people who would otherwise die.

In the UK at least, we're seeing a fatality rate of perhaps 50% what it was in March due to some drug treatments and better use of ventilation (especially prone).

But without treatment, the virus would be perhaps 2 or 3 times more deadly (as was seen in Wuhan when hospitals were overwhelmed).

Sure, here's a few ways to cross-validate:

If we had a high prevalence of Covid before there was any testing, we'd expect that the moment testing started, we'd see a high prevalence everywhere. We didn't. Most places saw only a small proportion of tests come back positive to start with, which then increased over time. (When looking at this kind of testing that's been done using antibody tests, it's good to remember that even a 99% specific test will mostly be returning false positives when the prevalence is very low).

We can re-test historical samples of various kinds for Covid. That has been done, and while they can find individual cases from a month or two before the first confirmed "live" case, there's no sign of it being widely spread.

We can also deduce the transmission patterns of the virus from the phylogenetic tree. If the virus had been widely circulating outside of China in 2019, sequencing would have show variants that are common in the west branch off from the Chinese ones earlier than they did.

> lot of people hospitalised or even die with an undiagnosed mystery pneumonia

They would have diagnozed pneumonia. Like, pneumonia is not mystery whether you know it is caused by covid or not. And it is diagnkzable.

Actually, a lot of people DID have it before tests were available.

https://academic.oup.com/cid/advance-article/doi/10.1093/cid...

https://www.bloomberg.com/news/articles/2020-12-09/covid-19-...

For varying amounts of "a lot".

> Now they're trying to just use lots of oxygen, but that doesn't work either.

Do you have a citation? I was hospitalised with Covid-19, and that was my primary treatment (100% oxygen CPAP was required to keep my O2 sats above 90% - high flow nasal oxygen would cause it to dip below 90).

> Do you have a citation?

Visit my HN profile, then my submissions... The one from 8 months ago (April 2020 or so) was a study about how aggressive oxygenation to get patients' oxygen sats above an arbitrary threshold was not helpful.

Physiological stress makes it hard for the body to use oxygen efficiently, and just pumping more oxygen into people doesn't fix the fundamental problem. I'm glad you survived -- suffice it to say that I think everyone who hasn't yet reached their expiration date has tremendously more potential to recover.

Please, next time you will tell people to exercise and not to be morbidly obese.

BTW read the article, it talks about already dead people with no pulse.

On a more serious, thought out note: It is kind of interesting seeing the rise of home pulse oximeter products (due to the pandemic).

They are so cheap now that there really is no reason to not have one in the bathroom cabinet.

FWIW, silent hypoxia can onset quite quickly. I was monitoring my oxygen levels following a positive test, and my O2 sats dropped from 95+ to 78 in about 12 hours (I'd more or less stopped monitoring it as I generally seemed to be recovering, hence the long gap between values).

Firstly the country has not really been serious about the pandemic it seems. On a political scale that is. And since each state can take their own actions it's really difficult to understand why this has not been done before.

On the other hand, the weak are the ones that die first. It's the law of nature.

So when doctors look at a patient it's of course their job to validate whether or not it's time and money well spent to save a life. How did you think it worked, honestly?

Many years ago a story of similar character ran across Denmark, where doctors were being exposed due to the fact that they had to make a life (but how much longer!) or death decision for a variety of patients. And of course they have to imo.

The medical system is stretched to breaking. Vaccine distribution is completely disorganized, despite months of possible preparation time. A ridiculous patchwork of federal, state, county authorities can't get it together to enforce rules and can only ask for voluntary cooperation in a true crisis.

I think we will look back on this as one of the great weaknesses of decentralized, democratic, random-walk governance, fueled by misinformation and lack of leadership.

More people will die from covid. But the principals of free speech and assembly should not be sacrificed for something that will be and mostly gone in 6-9months. Yes people have died and that is horrible, but a dictatorship like china is not the answer. Tbh I'm more afraid of the governments authoritarianism than covid.

*Disclaimer: yes I wear a mask indoors in public places and outdoors when not able to be 6 feet from everyone. No I don't wear a mask when walking alone outside, that is stupid and just shows how much our messaging on covid sucked even with the middle and upper classes.

But the principals of free speech and assembly should not be sacrificed for something that will be and mostly gone in 6-9months.

Why not? Ultimately, people are what matters. You know who can't exercise free speech and assembly? Dead people. Why is a 6 month hard lockdown worse than letting people keep walking around for 6 months? This sounds like a moral, absolutist statement you're making; like life is an art project, and the aim is to exercise some particular set of principles.

(Free speech? What's the threat to free speech here? Is it the people spreading bullshit and conspiracy about Covid that's getting people killed?)

Because I don't trust the federal and state governments to act in my best interests. This is not too say that some are acting in the best interests of the people as I am sure some in government do mean well, but not to blindly trust that the government knows best about our public helath.

China/Vietnam have stopped covid, that's great but you can't exercise many of the freedoms that are allowed here. Imagine if someone tried to fly a baby Xi balloon in China, or even practice a religion without fearing persecution or death? Or even mention tiananmen square massacre or the death toll from the Great Leap Forward...

That is still going on and yet we are looking to China style lockdowns as a model of how to deal with Covid.

You are posing a false dichotomy. Free speech is not at odds with competent governance.

> But the principals of free speech and assembly should not be sacrificed

I can't exercise my right to free assembly in good conscience when a pandemic is going on. I can't walk into a business with my mask off, which is literally an infringement on my right to free speech. I'd rather finish off the pandemic quickly and have full rights back than live with half "rights".

While the headline makes it sound like Grandma isn't getting a ride because she's frail, "little chance of survival" is more specific:

It’s protocol to NOT allow EMTs to declare someone dead. An EMT (with a few hours of community college training, mind you) are not trained for advanced resuscitation that only doctors can perform. This absolutely will lead to excess mortality.

Can you describe how? Advanced Cardiac Life Support protocols (ACLS) are fairly standard in both pre-hospital and hospital settings. Specifically because it's critical, paramedics are trained in ACLS.

EMT-Bs aren't, but the BLS ambulances they staff shouldn't generally be assigned as the only responding unit for cardiac arrests, anyway. And given that, it's not clear why you think there will "absolutely" be excess mortality.

LA County sends FD paramedics to pretty much every 911 call

I can't imagine the incredible agony of being the EMT who has to decide if someone gets a ride or not.

Covid is horrible in so many ways.

Is there a site that shows statistics (over time) of hospital capacity over time in LA?

It sounds to me like one of the typical articles that tries to induce panic without actually providing much information or context.

Whenever I see such articles here in Germany, I go to the official statistics for ICUs, and inevitably it always turns out to be bullshit.

Some of the things that are hyped to be a consequence of Covid also turn out to be seasonal, even shortage of oxygen does not seem to be unusual.

This is the German site I refer to: https://www.intensivregister.de/#/aktuelle-lage/zeitreihen

So you won’t be satisfied until people are literally dropping dead in front of you, huh?

This comment breaks the site guidelines badly. Would you mind reviewing them and sticking to the rules when posting here? Note these ones:

"Please respond to the strongest plausible interpretation of what someone says, not a weaker one that's easier to criticize. Assume good faith."

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Euthanasia ?

Triage

What are they supposed to do? Sometimes dealing with reality involves some pretty uncomfortable choices to make, even when that essentially makes you the bad guy.

The real issue here is that the economy was prematurely reopened before it was safe -- we have far more than enough money as a nation to have prevented this scenario from happening and chose a path of destruction out of sheer avarice instead.

>we have far more than enough money as a nation

to for example open more beds in preparation for the second wave (which was obvious to come). Instead hospitals were laying off people in the summer.

I suspect the limiting factor is personnel, not beds (i.e. trained staff to manage covid patients), which can't be increased on short notice. But still -- we have incompetent state & federal leadership that basically knew what would happen yet still didn't do enough to prepare.

> Instead hospitals were laying off people in the summer.

Yup. One of the dark ironies of this whole mess has been that hospitals have been letting go of staff because they had to suspend (very profitable) elective surgeries to treat (not so profitable) covid patients. Think hip surgeries being postponed and bleeding hospitals dry as a result.

>can't be increased on short notice.

i think the 3-6 months that we had would have been enough to train any MD to care for a covid patient, at least for majority of cases and under supervision of existing high specialist. My understanding is that non-covid personnel had their workload significantly decreased, so they could have been trained for covid for the second wave.

You might be right -- at this point, with everything that's gone wrong at the govt level, I'm pretty willing to accept rank incompetence as an explanation.

There are multiple points of failure. Pretending everything was A-OK is the largest one, failing to identify the virus's presence in the country for months was another, denying and downplaying the usefulness of masks was another, underfunding hospitals was another, failing to secure PPE was another, making it painfully difficult to get tested was another. There's a lot of blame to go around on this one. But reopening the economy was the biggest mistake.

There are many factors at play, but in L.A. I don't believe premature reopening is one of them. Bars, indoor dining and gyms have been shut down for pretty much the whole pandemic. Outdoor dining was banned (again) about a month ago.

My take is that L.A.'s issues have more to do with housing density, high number of people living with roommates and high number of multigenerational households. Also perhaps some some challenges communicating with an extremely large and diverse immigrant population.

LA is one of the most connected cities in the world. It's not LA's fault necessarily, but the country as a whole should've been on complete lockdown from April until whenever the situation was under control. Our national wealth and GDP have plenty of room for a complete quarantine, even if that means paying everyone's paychecks for a year or longer. We deliberately chose to allow 350,000+ peoples lives to end instead.

I'll point you to Hong Kong, Singapore, Shanghai, and Tokyo as counterexamples. All of those cities are 3-7x denser than LA, more populous, and culturally multigenerational.

I think it's quite clear to anyone who's been paying attention at this point that behavior has more to do with containment than anything else. The US and perhaps LA in particular for some reason or another is unwilling or unable to implement the same behavioral safety measures of other countries and cultures.

Mask wearing is the obvious one. If you go to any of those 4 cities I mentioned, 100% of individuals in public are masked, whether indoors or outdoors. 6ft social distance is very strictly followed with public shaming for those that take off their masks or do not follow social distancing guidelines in public.

Indeed. LA is not that densely populated by any global standard.

At some point, “this is a free country” became “I don’t have to apply impulse control under any circumstances.”

I suspect those 4 cities are doing more than just wearing masks. I’m having a hard time tracking down the interviews (I think it was Dr. Jim Yong Kim who said this), but there are two types of transmission between households and within households. Mask wearing, social distancing, quarantining, contact tracing, and some other measures can help to reduce between house transmission. However, you need to stop the within house transmission, too. To stop within house transmission, people are removed from their home and isolated in medical facilities in some parts of Asia.

Stopping between house and within house transmission is what I suspect those 4 cities you mentioned are doing. North America is more focused on stopping between house transmission.

Anecdotally, I know some cities in South Korea have quarantined people by placing them in an isolation room (4 people per room spread 6 feet out each wearing a mask 24/7) until they test as being COVID free. This was around 20-30 days from what I understand.

In Canada, if you quarantine, it’s 14 days in your own home. Mostly this is on the honor system. If you live in a condo / townhouse / strata or your neighbors know you’re quarantining, they can report you for violations. When quarantining, you’re restricted to a single room if you live with others, but there is still risk of passing it on to others. Anecdotally, I know of a case in Canada where an individual quarantining in their room has managed to pass COVID to 3 others who live in the house. These people were wearing masks around the house when not in their own room. If this original person was isolated in a hospital, the spread would stop at one. Since they weren’t, it ended up infecting the entire house.

This is also key. China used converted stadiums, convention centers, etc for this after a few weeks. According to them, this reduced R from about 0.8 to about 0.3. People were actually being rounded up and taken to these places forcefully.

With the number of now empty hotel rooms we have, this could easily have been provided on a voluntary/strongly encouraged basis. Instead what we got in SF for example was hotel rooms for the homeless (that hypothetically could have COVID) and no hotel rooms for people that actually tested positive for COVID.

Here's a twitter thread about someone who lives in South Korea returning home from a trip abroad.

https://twitter.com/koryodynasty/status/1345210393715564544?...

People should wear masks, but there's so much more they need to do as well.

I just moved to LA from New York State in December, and it seems to me that the number one problem here is noncompliance. So many people are just out and about like nothing unusual is going on. People aren’t wearing masks, or they are but not covering their nose. The number of house parties I’ve seen in the past month is shocking—and no one at these events has worn a mask. Outdoor places like beaches and trails are packed with unmasked people, which by itself isn’t necessarily a hazard, but then they aren’t maintaining a safe distance.

I’m not saying NY was perfect; not by a long shot. But here it’s like people aren’t even trying.

I just moved to LA from New York State in December, and it seems to me that the number one problem here is noncompliance.

Agreed. I see far too many people out without masks. It's scary.

The real issue IMO was that the lockdown wasn't strict enough, or enforced. Many, many stores were open, many workplaces were deemed essential, masks were not generally worn in the first phase of the lockdowns, and while indoor dining at restaurants was closed, indoor dining at your friend's house was wide open.

The three places that I know of that have gotten cases to zero are China, New Zealand, and Australia, and they all used lockdowns that were far stricter than in the U.S.

The problem is that a soft lockdown doesn't bring R low enough to eradicate the virus quickly, and people won't stomach it dragging on for months. I also don't believe that it can be done on the honor system. There must be police writing tickets or worse for violations, or there is a segment of the population that will ignore whatever measures that are enacted. Unfortunately sometimes these are even identifiable groups of people that all socialize together in violation of health orders, so the virus will spread within these communities regardless of whatever the governor puts on a piece of paper and makes a speech about.

Interesting points indeed. On the other hand, India had a hard lockdown for 6-8 weeks, and yet the numbers zoomed up weeks after that. And now, the numbers are magically going down despite absolute carelessness widespread. Inexplicable

The numbers start going down quickly once infections have been so prolific that crowd immunity is present.

I live in Texas, but I'm sure I personally infected no fewer than 10,000-20,000 people last March, including the sorority that purportedly brought it back from Mexico during spring break. No doctor wanted to listen and no hospitals would test me even after I begged some of the best providers in the region. It wasn't until almost 9 months later that the mistake was acknowledged, and it's highly likely that community spread existed even in the US in November 2019 or even October 2019 just based on retrospective serology studies.

Places with poor hygiene controls like India have likely had far, far more infections than anyone even can imagine. That might be one of the first places to be immune.

https://www.quora.com/What-is-the-current-treatment-for-Covi...

This is great. Of the effectiveness is a as good in the long run, we don’t even need a vaccine since it’s no longer a high risk disease. It’ll be a flu like vaccination where elderly and at-risk people can be using it

Everyone who can get the flu shot should be getting it. It's free in the US and takes a couple of minutes. It's not just for elderly or at-risk people, and even if you don't mind getting the flu spreading it can be dangerous.

I'm a little skeptical of the claims made in that post

> If everyone in the world just did one thing differently, talking to their doctor about whether they should start fluvoxamine or ivermectin after they learned they were COVID positive, our hospitals and ICUs would be nearly empty today and there would be very few “long haulers.”

Yes, there was a preliminary communication released recently in JAMA showing some evidence that Fluvoxamine treatment has clinical promise. You can read it here: https://jamanetwork.com/journals/jama/article-abstract/27731...

The results: "In this randomized trial that included 152 adult outpatients with confirmed COVID-19 and symptom onset within 7 days, clinical deterioration occurred in 0 patients treated with fluvoxamine vs 6 (8.3%) patients treated with placebo over 15 days, a difference that was statistically significant."

Not bad results, but seems like a big jump to suggest that all doctors change their treatment procedures based on this study. I'm interested to see larger studies, especially with longer follow-up durations.

You are right to be skeptical but it looks damn good. There is a clinical trial under way now with n=800.

https://clinicaltrials.gov/ct2/show/NCT04668950

Hiya your link is great. But it would be awesome if you could include some information about it rather than "link bombing".

I can't believe they're rationing oxygen. I administered welding oxygen to my girlfriend every day for about 6 weeks when she had Covid. It's cheap, easy, and perfectly safe.

I assumed that when things got bad someone would just suspend the regulation requiring medical certified oxygen.

From what I've read, its a hospital infrastructure problem, not a material shortage problem. The pipes that deliver oxygen to the machines can't deliver oxygen any faster because they're freezing up from the amount of oxygen being used.

You would carry it into patients' rooms and ambulances in tanks.

There's also a shortage of said tanks.

https://www.latimes.com/california/story/2020-12-29/oxygen-s...

Welding tanks are different, and not in shortage.

That struck me as odd as well, although, there could indeed be a shortage.

In UK hospitals it's not so much that there's a shortage, but the oxygen distribution network/lines in hospitals aren't sized for the number of patients requiring it.

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