Coronavirus (COVID19) Update: Fairly Rationing ICU Care

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Hospitals need ways to make rational fair decisions about who gets ICU beds and ventilators if COVID-19 patients overwhelm capacity. Douglas B. White, MD, MAS, Director of the Program on Ethics and Decision Making in Critical Illness at the University of Pittsburgh, discusses a framework for making those decisions. Originally streamed Friday March 27 at 12 noon CDT (GMT-5).

Read the Viewpoint by Dr White: https://jamanetwork.com/journals/jama/fullarticle/2763953

Read the proposal summary at:
https://ccm.pitt.edu/sites/default/files/UnivPittsburgh_ModelHospitalResourcePolicy.pdf

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• Coronavirus Resource page from the JAMA Network: https://ja.ma/covidyt

Topics discussed in this interview:
Could you say a bit about your co-author, Bernard Lo? (0:55)

You’re an ethicist and an intensivist. How did you combine these two disciplines? (1:18)

The focus today will be on ventilators and critical care beds. But how do you think about rationing in the broader sense? (1:58)

Categorically excluding large groups of patients from receiving mechanical ventilation Is ethically problematic (4:08)

It is ethically insufficient to solely focus on survival to hospital discharge (6:31)

Were there other models that you drew on besides the lung allocation scoring system? (9:02)

Recommendations for a multiprinciple allocation framework (9:46)

More guidance is needed on withdrawing life support from one patient to provide it to another (10:06)

In ICUs, after someone’s been on a ventilator for a long period of time, there are decisions made about how long they should remain on a ventilator. Are these situations different? (12:08)

Can you talk more about this framework that you’ve helped develop? (13:05)

Do you know if any of this approach has been used in Italy? (14:49)

I have enormous respect for Maurizio Cecconi, MD and what he has been going through in Italy (15:48)

So how is this document being used at this moment? (16:43)

Creation of triage teams (19:02)

Allocation criteria for ICU admission/ventilation (21:00)

What happens if you have 3 patients with acute respiratory failure but only 1 ventilator. (Secondary criteria) (24:24)

Reassessment for ongoing provision of critical care/ventilation (27:27)

Different cultures and religions view these issues differently. How does this framework address that? (29:36)

How do you think about the rationing of tests and personal protective equipment (PPE)? (31:25)

Do you have a sense of why such a large number of health care workers are getting infected. (33:31)

Is it ethical to double ventilate on a single ventilator knowing that this might be harmful to some patients? (35:01)

Hospitals and nursing homes are limiting visitors. Will families be able to visit patients dying of COVID-19 in ICUs? (36:51)

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Comments

John Meyer says:

What bodies are responsible for conferring critical worker status? Who anoints them? Are democrat government decision makers, governors, etc, going to be found likely to save more lives in conservative healthcare settings administered by members of the republican base?

jenniewilliamsmural says:

Im a nurse at a hospital north of NYC. Governor Cuomo announced that they'll shift ill people from NYC to hospitals in the state. These urban presumably young vital people will likely change the ethical ecology and the outcome for rural people like me. Thanks for the great discussion.

jenniewilliamsmural says:

I agree with these guidelines except that I would add a lifetime contribution rather than simply years. Mothers and grandmothers keep our world turning. This is a very important discussion- thank you!

Familie Geier says:

I agree. Survival years, quality of life, QALY's, regional framing, the patient's will, and religious&theologic&metaphysic&ethic aspects (general, and the patients') have to be considered by a triage team. Nullius in verba. sg

james wright says:

* NEEDS TO BE RESEARCHED *
 
The most direct goal of treatment should be to "treatably prevent" or greatly reduce the interactions between the Type 2 Neumocytes and the viral load. Another goal is to mechanically prevent attachment of the S-Spike Protein to ACE-2. So, how can we:
1 – Attack the virus directly while in the lungs?
2 – Interfere with the attachment?
The normal way by which the human body interferes with things that want to harm the lung is to create mucus. That's the role of the mucous membranes. They create an immunological fluid which collects particles [ eg viruses interacting with the cilia of the respiratory cells ] and move them away from the cells that they may be "digested" by the body – OR – cast out by the organism with a hacking cough.

So, how do we cause the patient to create more than a normal amount of mucous in such a way that the effect is reversible?
 
 
Also, the effect of the virus upon the alveoli is basically to create a form of pulmonary edema. The alveoli drown in fluid.

So, how do we:

1 – Attack the virus directly while in the lungs?
2 – Cause the body to create more mucous than is normal for the organism?
3 – Create a situation where the fluid around the alveoli [ basically pulmonary edema ] is mitigated?

The inhalation of 91% isopropyl alcohol – aerosolized – eg inhaling from a half full, shaken bottle of 91% alcohol – accomplishes all three goals in a very treatable way.

1 – We know that 70% alcohol is enough to destroy the protein envelope around SARS-COV-2. Inhaling 91% which has been aerosolized will actually be the inhalation of a concentration less than 91% due to the presence of some water vapor in the patient's normal room air. However, a lot of the aerosol should be over the 70% concentration level. When that alcohol comes into contact with the virus – the virus will be destroyed. That is a chemical necessity. This will destroy viral load that has been inhaled – as well as new viral load budded off from the Neumocytes.
2 – Inhaling the alcohol will cause the mucous membranes to activate. This will turn the "dry cough" into a "wet cough. That wetness is an immune system material created to protect the cells from damage. That material will – in small amounts – coat the surfaces of Type 2 Neumocytes and block their interaction with the S-Spike proteins. Further, those viruses that are not directly destroyed by the alcohol – will be captured by the mucous for discharge or digestion. [Hot peppers contain Capsaicin which activates the mucousal membranes.  Also, the flush that occurs when one eats a hot pepper can interrupt the transmission vector of this virus.]
3 – Alcohol [ Ethanol ] Inhalation has been used successfully to treat Pulmonary Edema. Here, one would be using Isopropyl alcohol instead of Ethanol because it is more common for patients to have access to it – without overloading the healthcare system – and because it causes the production of fluid rather than fully discharging it. To discharge the fluid, treatment plans could include a second phase where the patient switches to ethanol – OR – the patient could take a decongestant such as Mucinex Day and Night. The goal is to break up the mucous – with the destroyed viral load within – and discharge it.

So, to me, it appears that an Alcohol Inhaler offers the most direct possibility of treatment for this disease.

Also, watch for the sore throat. It seems that there comes a point where the adenoids [especially] and the lingual and palatine tonsils get very sensitive and painful. [ squeeze a bunch of grapes – feeling is like point just before they pop and it lasts a couple days ] I offer that to be the point where a patient should stop with the inhaler and spend a few days on the Mucinex. And do not be surprised with the weird sound the voice makes as it seems the mucous? coagulates? in the larynx. [ I do not understand that. ] Also, after inhaling the alcohol for a couple weeks the sinus cavities will fill with snot. Blow this out normally. It will happen for a few days.

I think the development of the "chunky mucous" aka snot – is useful for the body as an immune function as it collects and binds the viral load more efficiently than fluid can. Fluid mucous in the lung is good. Chunky mucous in the sinus is good there.

The "wet cough" and presence of phlegm should be encouraged as long as deep breathing is maintained. The goal with this is to keep the intra-lung environment inhospitable to the virus without endangering the patient. I can live with uncomfortable. [ There are indications that one can be reinfected – a "wet cough" may reduce that opportunity.]

I know this treatment plan works because I have just completed doing it. [Former Paramedic, Combat Medic, EFMB etc US ARMY]  
My wife, an RN with both BSN and MSN is doing so too.
We live in San Antonio, Texas. The only side effects either of us have had is a slight light headedness. We have never practiced "deep breathing" and are getting a lot of air with every breath we take.

I am seeing videos where others are beginning to describe their symptoms and they are all consistent with what I felt – except the fever. I started with the alcohol on 1 March due to cough, fatigue etc as a "preventative." Around the 14th I had a few hot flashes and quickly inhaled the alcohol. The hot flashes went away with no development of a fever.

Thank you and I hope it helps – if it is considered.
James Anthony Wright
 
 
 
 
 
 
Thank you for your reply.
I used this treatment as a preventative. I started when my wife and I began having a dry cough. This was a couple of days after the patients who were quarantined here in San Antonio Texas were told to go to a hotel. One of them went shopping at a large local mall instead. My wife is an RN who specializes in high risk OB. She, and I, began to feel fatigued, coughing etc and wanted to try to do something pre-fever onset. This virus has some HIV-like functions and other issues that appear to be attacking the immune system even harder after it begins to respond to the virus.
 
I suggest the 91% isopropyl alcohol as an inhaler. I explained why in my original post. I have no idea what any other substance would do, except, do not use bleach as WW1 gas attacks proved that to be a very bad option.
 
[A bottle of 91% isopropyl alcohol costs about $5 at the local HEB. Assuming patients can find it on the shelf – it should be available.]
 
As for the autopsy, I have not seen it. It is hard to speculate because vaping, smoking, living in urban air pollution etc all have an effect on the lung. Mucous is a natural self defense mechanism of the body. I am not surprised that it would be present. The issue is having enough in the lung to prevent viral development – early enough – without creating so much that it becomes harmful. Dosing is a primary issue that I feel doctors need to research. Remember, alcohol inhalation has been used to successfully treat pulmonary edema.
 
Also, the volume of aerosolized alcohol inhaled should be low. I only took 2 or 3 deep breaths with each nostril each session. Sessions occurred after coughs, heat flashes, etc. The goal is not to get intoxicated, but, to interfere with this virus.
 
One thing I failed to mention in my original post was that the mucous can be generated by eating hot peppers. Capsaicin causes the mucosal system to flush. [ jalapeño = teary eyes ] That action interferes with the transmission vector of this virus.
 
Hot Peppers – interrupt transmission – create mucous
Alcohol Inhaler – perhaps put alcohol onto virus envelope – interfere with linkage in lung – treat the edema
Mucinex – assist with the removal of excess mucous when it develops as outlined in my original post
 
Of course, again, all of this should be researched and verified by doctors.

Scarlet says:

Hello, it would be helpful if you discussed ways of optimizing PPE effectiveness. I'm a counsel for drug & device companies & while there have been no public statements re: the many HCPs being infected, I want everyone to know that PPE manufacturers & suppliers care deeply about this. When tested, the equipment has all met quality standards. No batches have been recalled by any major US supplier. This indicates infections are due to community spread, insufficient PPE supply &/or ineffective PPE use. Scientists & engineers familiar with PPE who've studied SARS-Cov2 believe certain qualities of this virus, including its "stickiness" for lack of a better term, result in infections due to minor user errors that are inconsequential with other infectious agents. For example, PPE should NOT slide over the skin, jewelry should be removed, nails cut & filed & users should avoid contact with any other sharp edges that can compromise PPE, etc. Some ER HCPs even use antibacterial moisturizers like Neosporin to prevent masks from moving on skin. It would be interesting to hear a discussion on these methods & if they help

Chris Carson (Old And In The Way) says:

Your medical system in America is going to kill many thousands of people as its not a real one. Its medicine for profit, and I expect America to lead the world in deaths by a large margin. This should change things, but I'm not optimistic.

Cassandra Warner says:

Douglas be white

blastman8888 says:

This should never have to happen in America because of a pandemic I could see this if we were attacked by nuclear weapons.

aartfx K says:

Why don't we create US Pandemic Service. Draft (Quarantine) all who test positive to empty hotels (minor care facility). Crash course covid 19 specific minor, care giver. Free up RN, LVN Nurses for more intensive tasks in hospitals. If you tested positive you don't need protective gear if quarantined with others.

Masonic Airborne says:

The 1% wealthy will get a ventilator no matter how bad off they and to hell with the other 99%,
The fact that we're even discussing rationing ventilators disgust me,
we're all in this together it's all bullshit.

Frederick White says:

The HHS Office for Civil Rights just this morning (03/28) has issued a Bulletin concerning prohibited discrimination in HHS funded programs during the COVID-19 emergency:

https://www.hhs.gov/sites/default/files/ocr-bulletin-3-28-20.pdf

This reads in relevant part:

Persons with disabilities should not be denied medical care on the basis of stereotypes, assessments of quality of life, or judgments about a person’s relative “worth” based on the presence or absence of disabilities.

Decisions by covered entities concerning whether an individual is a candidate for treatment should be based on an individualized assessment of the patient based on the best available objective medical

evidence.

“HHS is committed to leaving no one behind during an emergency, and this guidance is designed to help health care providers meet that goal,” said Roger Severino, OCR Director. “Persons with disabilities, with limited English skills, or needing religious accommodations should not be put at the end of the line for health services during emergencies. Our civil rights laws protect the equal dignity of every human life from ruthless utilitarianism,” Severino added.

This guidance will likely require re-examination of many triage protocols that facially exclude persons grouped by specified non-medical criteria.

Carlos M Rivera says:

Great contents gents.

ChiliMcFly1 says:

Very interesting and trying decision making processes. Good luck and God bless.

Maen M. says:

The title alone is sobering … even after all the images and videos of ICUs worldwide being overwhelmed with patients.

Res Nica says:

Donald said, "What we've done nobody could even imagine."
U.S. Coronavirus Cases Top 100,000 As Trump Demands Praise From Governors | The 11th Hour | MSNBC (Mar 27, 2020),
https://www.youtube.com/watch?v=bs0_ntO3OsE
After Considering $1 Billion Price Tag for Ventilators, White House Has Second Thoughts (The New York Times, March 26, 2020),
https://www.nytimes.com/2020/03/26/us/politics/coronavirus-ventilators-trump.html
Well, when one runs the government like a business, it surely acts like a business.

Before Virus Outbreak, a Cascade of Warnings Went Unheeded (The New York Times, March 19, 2020)
Government exercises, including one last year, made clear that the U.S. was not ready for a pandemic like the coronavirus. But little was done.
https://www.nytimes.com/2020/03/19/us/politics/trump-coronavirus-outbreak.html

Sugar Magnolia says:

Its up to us on a local level to ensure it gets where its going. If there was ever a project for bored teenagers its deciphering the 800 page document. Forget their "studies", this goverment may soon be theirs, have the find the link to it and read, understand who the local reps and power brokers are, their scopes of authority. Everyone over 60 may dissappear, lets not leave with the kids plugged into their phones.
Only well fitted fresh n95 masks filter viruses, everything else is just to keep sneezes and coughs at bay, and you from touching your face. A summer gaiter, cut up old turtle neck, or staples, wash cloth and rubber bands – will work for that. Stay home, study history from cspan archives its free and downloadable. Clean, and stay calm, steady as she goes.

J Mer says:

Forgive me, but the first ones to be deprived of resources should be those politicians who dismantled public health readiness, delayed response, refused to provide adequate testing, equipment and PPE, and put the financial greed of themselves and their cronies before the needs of the people they supposedly serve. There’s a special hot place waiting for them,

Michael Miller says:

Shouldn't the goal be to reduce the mortality rate? Allocating a ventilator to a younger person, who may well survive w/o it while condemning to death the elderly, seems counter intuitive.

R Brown says:

Systemic racism will most definitely play a role in who is and isn't saved.

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