Allocating Scarce Resources During COVID-19 Pandemic

Here’s a link to CDC website and COVID-19 symptom self-checker (advice for families):

CDC Link: Testing for COVID-19

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Full Link NEJM 2020 (Ezekial J Emmanuel et al): Fair Allocation of Scarce Medical Resources in the Time of Covid-19

This article spells out an ethical approach to the likely need to ration care in the midst of this pandemic.

Here’s an excerpt:

Recommendation 1: In the context of a pandemic, the value of maximizing benefits is most important…Saving more lives and more years of life is a consensus value across expert reports… Because young, severely ill patients will often comprise many of those who are sick but could recover with treatment, this operationalization also has the effect of giving priority to those who are worst off in the sense of being at risk of dying young and not having a full life….Because maximizing benefits is paramount in a pandemic, we believe that removing a patient from a ventilator or an ICU bed to provide it to others in need is also justifiable and that patients should be made aware of this possibility at admission..Undoubtedly, withdrawing ventilators or ICU support from patients who arrived earlier to save those with better prognosis will be extremely psychologically traumatic for clinicians — and some clinicians might refuse to do so. However, many guidelines agree that the decision to withdraw a scarce resource to save others is not an act of killing and does not require the patient’s consent

Recommendation 2: Critical Covid-19 interventions — testing, PPE, ICU beds, ventilators, therapeutics, and vaccines — should go first to front-line health care workers and others who care for ill patients and who keep critical infrastructure operating, particularly workers who face a high risk of infection and whose training makes them difficult to replace…Priority for critical workers must not be abused by prioritizing wealthy or famous persons or the politically powerful above first responders and medical staff — as has already happened for testing. Such abuses will undermine trust in the allocation framework.

Recommendation 3: For patients with similar prognoses, equality should be invoked and operationalized through random allocation, such as a lottery, rather than a first-come, first-served allocation process

Recommendation 4: Prioritization guidelines should differ by intervention and should respond to changing scientific evidence. For instance, younger patients should not be prioritized for Covid-19 vaccines

Recommendation 5: People who participate in research to prove the safety and effectiveness of vaccines and therapeutics should receive some priority for Covid-19 interventions

Recommendation 6: There should be no difference in allocating scarce resources between patients with Covid-19 and those with other medical conditions.

Placing such burdens on individual physicians could exact an acute and life-long emotional toll… To help clinicians navigate these challenges, institutions may employ triage officers, physicians in roles outside direct patient care, or committees of experienced physicians and ethicists,

My take: Reading this article is so sad.  It is heart-breaking just contemplating the need for these well-considered recommendations.  Also, see below -ACG shared data indicating significant fallibility with testing for Sars-Cov2/COVID-19.

How to Protect Healthcare Workers from COVID-19: Lessons from Hong Kong and Singapore

Atul Gawande has a very pertinent article in the New Yorker:  Keeping the Coronavirus from Infecting Health-Care Workers

An excerpt:

There are lessons to be learned from two places that saw the new coronavirus before we did and that have had success in controlling its spread. Hong Kong and Singapore…

 All health-care workers are expected to wear regular surgical masks for all patient interactions, to use gloves and proper hand hygiene, and to disinfect all surfaces in between patient consults. Patients with suspicious symptoms (a low-grade fever coupled with a cough, respiratory complaints, fatigue, or muscle aches) or exposures (travel to places with viral spread or contact with someone who tested positive) are separated from the rest of the patient population, and treated—wherever possible—in separate respiratory wards and clinics, in separate locations, with separate teams. Social distancing is practiced within clinics and hospitals: waiting-room chairs are placed six feet apart; direct interactions among staff members are conducted at a distance; doctors and patients stay six feet apart except during examinations.

What’s equally interesting is what they don’t do. The use of N95 masks, face-protectors, goggles, and gowns are reserved for procedures where respiratory secretions can be aerosolized. Their quarantine policies are more nuanced, too. What happens when someone unexpectedly tests positive—say, a hospital co-worker or a patient in a primary-care office or an emergency room? In Hong Kong and Singapore, they don’t shut the place down or put everyone under home quarantine. They do their best to trace every contact and then quarantine only those who had close contact with the infected person. In Hong Kong, “close contact” means fifteen minutes at a distance of less than six feet and without the use of a surgical mask; in Singapore, thirty minutes. If the exposure is shorter than the prescribed limit but within six feet for more than two minutes, workers can stay on the job if they wear a surgical mask and have twice-daily temperature checks. People who have had brief, incidental contact are just asked to monitor themselves for symptoms…

Transmission seems to occur primarily through sustained exposure in the absence of basic protection or through the lack of hand hygiene after contact with secretions…

Singapore so far appears not to have had a single recorded health-care-related transmission of the coronavirus, despite the hundreds of cases that its medical system has had to deal with…

For those who cannot stay home, the lesson is that it is feasible to work and stay coronavirus-free, despite the risks….a greater likelihood of staff picking up infections at home than at work. 

Today’s Children in Crisis: YOYO

Predictive Modeling on COVID19 in U.S. from NYTimes: How Much Worse the Coronavirus Could Get, in Charts

Modeling comments from Nate Silver: It’s important to keep in mind that many of these models describe projections *without* changes in behavior. This is mentioned in the article (good for NYT, a lot of articles omit this context). So behavioral changes and testing are key. I slightly worry that some of the headlines contribute to a sense of fatalism, when the real message is more like “this is probably gonna be bad, but it could be considerably less bad if we get our act together and much worse if we don’t.”

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Besides the current outbreak, what else has been happening to children:

So, is it surprising at all that there is no interest in limiting products shown to be dangerous for children?  Today’s children are being told: ‘you’re on your own’ (YOYO)

An ongoing concern for pediatric gastroenterologists, magnet ingestions, was highlighted in a Politco report -thanks to Ben Gold for sharing this report: Toddlers eat shiny objects….

Here are a few excerpts:

Once ingested, high-powered magnets find each other inside the body and shred any tissue, such as bowel, trapped in between….

In early 2012, this coalition [led by NASPGHAN] approached the Consumer Product Safety Commission with one simple ask: eliminate these high-powered magnet sets from the market…the agency ultimately recalled high-powered magnet sets …

One company, Zen Magnets, remained unconvinced, and sued the CPSC, fighting… the recall on existing magnets…

The rule [ban] set was struck down by two judges on the 10th Circuit Court of Appeals with the deciding vote cast by now-Supreme Court Justice Neil Gorsuch. These judges ignored the expertise of the CPSC epidemiologists and economists; ignored the compelling medical testimony, overwhelming expert evidence and dire safety consequences and substituted their own opinion in favor of promoting “government restraint” on regulating industry…

The nation’s poison control centers recorded six times more magnet ingestions―totaling nearly 1,600 cases in 2019 alone—after the 10th circuit court decision allowed magnets back on the market…

The article details how the CPSC’s change in regulation has also led to deaths related to delays in recalling faulty infant inclined sleeps, with defective RZR All Terrain Vehicles, and the mismanaged recall of IKEA’s Malm dressers.

A related article was published in USA Today this week by Dr. Bryan Rudolph: Children can easily swallow high-powered magnets, it’s time to ban them for good

My take: What’s next up for our children? Outlawing lifeguards for pools? Repealing seat belt laws?  Perhaps it won’t matter –there are so many bigger threats that are not even on the radar.  YOYO.

Related blog posts:

Image from Politico

Current Impact of Climate Change

When I hear people say that the changes in climate are ‘just another weather cycle,’ I wonder if they understand the reasons why scientists are so worried.  It is not simply the historic increases in temperature.  The bigger concerns are the permanent changes in the environment that foster ongoing and worsening problems.  The atmosphere now has greenhouse gases that could take a 1000 years to dissipate even without further pollution (Related blog post: The Health Consequences of Climate Change).  This is akin to sleeping under more blankets except that in the middle of the night, when you are sweating, there is not a simple fix –no easy way to remove the greenhouse gases in the atmosphere.

A recent commentary (RN Salas. NEJM 2020; 382: 589-91) details the myriad ways that the climate crisis will affect clinical practice.

The climate crisis is a threat multiplier;  key points:

  • climate sensitive waterborne and foodborne illness
  • worsening mental health
  • heat strokes/heat-related hospitalizations
  • rising pollen levels
  • decreasing nutritional value of food
  • vector borne disease
  • trouble with medication storage (need to be stored at appropriate temperatures)
  • treatment disruptions by climate events
  • supply-chain disruptions by climate catastrophes
  • hospital power outages
  • rising temperatures could increase bacterial resistance to antibiotics

My take (borrowed from commentary): “Despite the irony, I often describe our current knowledge of the health effects of climate crisis as an iceberg.  Though we see a peak above the water’s surface, there is much to fear from the larger mass beneath –the effects that we haven’t yet identified.”

Related blog posts:

Garden at UNC Chapel Hill Campus

“The Truth About Allergies and Food Sensitivity Tests”

This is a link to a 20 minute video regarding “The Truth About Allergies and Food Sensitivity Tests” with Dr. Dave Stutkus and Dr. Mike Varshavski. (If trouble with link, then can find with quick search on YouTube.)

A couple of clarifications:

The video (~at the 3 minute mark) does not provide much nuance on “non-celiac gluten sensitivity” (see related blog posts below)

Some other points:

  • Don’t perform Food IgG testing -this is a memory antibody and does not reflect food allergy or sensitivity
  • So-called food sensitivity IgG tests do not have standardized normal values
  • Don’t perform broad-based IgE testing; there are many false-positives and false negative

Dr. Stutkus decided to undergone ‘food sensitivity’ tests and was reportedly sensitive to nearly 80 foods.

Related blog posts:

Disclaimer: This blog, gutsandgrowth, assumes no responsibility for any use or operation of any method, product, instruction, concept or idea contained in the material herein or for any injury or damage to persons or property (whether products liability, negligence or otherwise) resulting from such use or operation. These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician.  Because of rapid advances in the medical sciences, the gutsandgrowth blog cautions that independent verification should be made of diagnosis and drug dosages. The reader is solely responsible for the conduct of any suggested test or procedure.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition

Have Nonprofit Hospitals Lost Their Mission?

NY Times: Nonprofit Hospitals Are Too Profitable

An excerpt:

Seven of the 10 most profitable hospitals in America are nonprofit hospitals

It’s time to rethink the concept of nonprofit hospitals. Tax exemption is a gift provided by the community and should be treated as such. Hospitals’ community benefit should be defined more explicitly in terms of tangible medical benefits for local residents…

The average chief executive’s package at nonprofit hospitals is worth $3.5 million annually. (According to I.R.S. regulations, “No part of their net earnings is allowed to inure to the benefit of any private shareholder or individual.”) From 2005 to 2015, average chief executive compensation in nonprofit hospitals increased by 93 percent. Over that same period, pediatricians saw a 15 percent salary increase. Nurses got 3 percent…

Additionally, hospitals should not be allowed to declare Medicaid “losses” as a community benefit. While it’s true that Medicaid typically pays less than private insurance companies, Medicaid plays a crucial role for private insurance markets by acting as a high-risk pool for patients with severe illness and disability…These large medical centers also enthusiastically accept taxpayer money for research…

Particularly in communities with a shortage of health care resources, tax exemption can make sense. In medically saturated areas, where profits and executive compensation approach Wall Street levels, tax exemption should raise eyebrows.

My take: This opinion piece makes a strong argument that many nonprofit hospitals do not deserve to be exempt from taxes. At a minimum, more transparency regarding tangible benefits is needed to assure that hospitals earn this exemption.

AJC: Georgia hospital disclosures show disparities, seven-figure salaries  According to the AJC, the Children’s Healthcare of Atlanta’s CEO made 1.9 million last year. By comparison, the Northside CEO made 4.9 million. Other tidbits: Piedmont’s chief philanthropy officer was compensated 1.2 million.

Related blog posts:

“The problem with internet quotes is that you can’t always depend on their accuracy” ~Abraham Lincoln, 1864.