Dr. Luks on Covid-19 Personal Risk vs Systemic Risk

The following is a post from orthopedic surgeon Dr. Howard Luks, MD, on Facebook about the difference between the personal risks of the novel coronavirus and the looming systemic risk. Most people have a pretty low personal risk to worry about the virus, but the systemic risk of an overwhelmed health care system is danger in itself.

COVID-19 Update: 3/8/20; 6AM

Confusion and messaging…. Personal v Systemic Risk:

Many people have had trouble grasping the issues we have covered as they try to make sense of it in the context of what they see on TV or read in print media.

Much of what the experts have been discussing is in fact accurate. Your “personal” risk remains very low. The risk to your children’s health is very low. So, their messaging is accurate… but incomplete. The message should be clear… your personal risk is low… period. No one is debating that. The issue that you’re not reading about is “systemic risk”.
The AHA or American Hospital Association is starting to discuss the systems side … see the second picture below for their estimates.

Personal risk aside, the issue that we need to confront, and soon, is the concept of systemic risk. I am referring to the healthcare system. Let’s dive into this again.
An example … Here are some numbers out of Italy:

10 % Lombardy doctors are infected.
At least 1060 patients are self-isolating at home
At least 2394 are hospitalized
At least 462 are in intensive care
197 have died.

The Italian Society of Intensive Therapy declared today: “It might be necessary to limit the age of people who can enter intensive therapy to preserve resources for those having more chances of surviving”. In other words, people who are more at risk will be left to die.

THIS IS WHAT SYSTEMIC RISK LOOKS LIKE.

~ Doctors/nurses getting sick: fewer to care for high numbers of patients.
~ 462 in an ICU…. and we are still very early in the spread of the infection stage. Italy will shut down large cities soon… but it will be too late. How many ICU beds do you think we have available in your community?
~ 2400 hospitalized. In the US, on average, hospitals run 65% full. In many regions of the country, mine included, that number is far higher.
~ Let’s conservatively assume that there are 2,000 current cases in the US today, March 8th. This is about 8x the number of confirmed (lab-diagnosed) cases. We just do not have the ability to test people. Period.
~ Given an R0 of 2( meaning that one person infects two people), and a doubling time of 6 days (one infection becomes two, two becomes 4, etc)
~ That means we’re looking at about 1 Million US cases by the end of April, 2 Million by ~May 5, 4 Million by ~May 11, and so on.
~ yes… math is wonky. and exponential math even more so.

Here are the current models from the AHA: Assumptions are actually conservative. Fatality rate assumption only 0.5%, etc. If that rate rises due to strained resources ….

96,000,000 infections
4,800,000 hospitalizations
1,900,000 ICU admits
480,000 deaths

Compare that to the numbers for the flu ..

35,500,000 infections
490,600 hospitalizations
49,000 ICU admissions
34,200 deaths

This is NOT the flu. Again… yes, your personal risk is low. However, the systemic risk to our healthcare system is huge. So we can change this trajectory… keep reading.

Assume there are~ 1 Million hospital beds in the US, therefore ~ 300,000 hospital beds (not ICU beds) are available in the US (assuming 65% of capacity)
~ It does not take long before our beds are full, and our resources are under strain.

To recap… your personal risk IS currently very low. If you are a young healthy adult your risk of dying from COVID-19 is lower than your risk of driving around today. That risk increases in people with diabetes and hypertension. Men are at slightly higher risk than women, and people over 80 have the greatest risk of dying (~15%).

So the messaging that you are viewing or reading is in fact accurate. Your personal risk is low. No need to panic.

Hospitals are not full right now… hospital resources are available to you. Only a few physicians, nurse, and health care workers are sick. So if you become infected now you will likely do fine.

What happens in a month when 2 Million people may be infected? Our healthcare system may not be able to offer the same level of care to those who need it. Therein lies the risk. This is systemic risk. This is why we need to stretch and bang down the “epidemic curve” or the rate of spread. The healthcare system CAN deal with many sick people arriving over a longer period of time. So we need to stretch the time course out. See the first picture below.

Why we should close schools and dramatically limit social contact via gatherings, events and conferences. It boils down to math… and the need to flatten the epidemic curve.

This is a great article that goes into the numbers and models with respect to lives saved by closing schools, working from home, cancelling gatherings, etc. It is well worth the 5 minutes it takes to read. The third picture below shows the detailed math of how closing schools etc will save lives.

https://www.linkedin.com/…/whats-your-risk-dying-covid-19…/…

So if your school district closes… don’t get on their case. It’s in the best interest of community as a whole. The risk to your child’s health in all of this is negligible. This is not a personal risk issue! I’m watching my own town’s facebook page explode with fear, personal attacks and political rants. It’s a shame. This is not a time for political wrangling. This is the time to act to keep our healthcare system running and our healthcare workforce well to be able to care for you when you or a family member becomes ill.

Yes, hand washing is critical … but it’s time to consider what else we can do to slow the spread. For your communities sake.
– we shouldn’t be going to indoor tournaments
– we shouldn’t be going to concerts
-conferences should be cancelled
– etc
Again… not because your individual risk is high… but because we need to slow the spread to minimize the risk of a systems failure.

For those interested in a deeper dive into the mathematical modeling of the spread of COVID and how it will affect our resources you can read this thread … https://threadreaderapp.com/thread/1236095180459003909.html

Doom and Bloom: Epidemic Personal Protection Gear

The Altons at Doom and Bloom Medical have up an article discussing the various personal protection gear that a person would need to wear if caring for a highly contagious patient.

Having knowledge of infectious diseases and how to treat them is very important, but you’ll be more effective in preventing their spread by having some supplies. Which supplies? That all depends on the nature of the disease itself and the risk that the healthy population will be exposed to it.

Before you can be a successful caregiver and heal the sick in an epidemic, you must avoid becoming one of its victims. Viruses can be very contagious (like the airborne common cold) and have a low fatality rate. Alternatively, a disease may have a high fatality rate (like Ebola) and be less contagious (it’s not officially thought to be airborne). Rarely, a really infectious agent may be both very contagious and lethal (like The Pneumonic Plague in the Middle Ages).

In a truly virulent outbreak, healthcare providers are at serious risk. During the Ebola epidemic of 2014, being a medical worker was one of the principal ways to get (and die of) the disease. In 2020, the physician who first tried to warn the world of the coronavirus COVID-19 epidemic was, unfortunately, also one of its casualties.

Because of the risk to medical workers, strict protocols regarding what items a caregiver should wear are formulated and constantly modified based on new scientific evidence. A uniform way to to don (put on) and doff (take off) equipment is very important in safeguarding healthcare providers

PROTECTIVE GEAR TO WEAR

Here is what we think you should wear if you are taking care of a highly contagious patient. First, we’ll discuss which armor would give you the most protection. You should have…

•             Coveralls (with head and shoe covers; some come with hoods and booties built-in)

•             Masks (N95 or N100)

•             Goggles or face shields (to be used with, not instead of, masks)

•             Nitrile Gloves

•             Aprons

Shoe covers and built-in attached booties alone do not give you enough protection. Rubber boots should be worn and can be sanitized between patient encounters.

ABOUT FACE MASKS

N95 non-vented mask

Medical masks are evaluated based, partially, on their ability to serve as a barrier to very small particles that might contain bacteria or viruses.  Masks are tested at an air flow rate that approximates human breathing, coughing, and sneezing.  The quality of a mask is determined by its ability to tightly fit the average human face.  The most commonly available face masks use ear loops or ties to fix them in place, and are fabricated of “melt-blown” coated fabric (a significant upgrade over woven cotton or gauze)…

Click here to read the entire article at Doom and Bloom.

 

The Medic Shack: The N95 HEPA Mask

Organic Prepper: Pandemic Preparedness

Daisy at The Organic Prepper has an article up about the Wuhan Coronavirus and what you can do now to prepare. From what is currently known, this coronavirus has approximately a 2% mortality rate. That is considerably lower than some other viruses that have made the news over the years, but while it is low it is about the same as the Spanish Flu pandemic that killed millions around 1918. Should you be worrying? It’s too early to tell right now. We don’t know if containment will be achieved or how easily it may spread. But if not this one, at some point another pandemic will sweep the world causing mass casualties, so it is good to have some preparation for the event.

…In Wuhan, supermarket shelves were empty and local markets sold out of produce as residents hoarded supplies and isolated themselves at home. Petrol stations were overwhelmed as drivers stocked up on fuel, exacerbated by rumours that reserves had run out. Local residents said pharmacies had sold out of face masks.

“When I saw the news when I woke up, I felt like I was going to go crazy. This is a little too late now. The government’s measures are not enough,” said Xiao, 26, a primary schoolteacher in Wuhan, who asked not to give her full name.

Few pedestrians were out and families cancelled plans to get together for the new year holiday. Special police forces were seen patrolling railway stations. Residents and all government workers are now required to wear face masks while in public spaces. Most outbound flights from the city’s Tianhe airport were cancelled. (source)

Those who wish to be prepared should note the speed at which quarantines were put in place in China. Don’t delay placing orders for supplies, fueling up your vehicle, and adding last-minute preps to your stockpile. You may already have many of the supplies you need, so be sure to do an inventory before panic-buying.

However, if you discover you do need supplies, get them now. If you wait until a quarantine is announced, you’ve waited too long and you’ll be out there fighting for resources with everyone else in your area.

Whatever your plan is, don’t delay taking action. Otherwise, you might find yourself in the same situation as 20 million Chinese people who were suddenly quarantined.

Click here to read the entire article at The Organic Prepper.

Eaton Rapid Joe: Fourteen Cows – A Preparedness Story

At the Eaton Rapid Joe blog, Joe has written a series articles about a man in small town trying to get prepared and prepare his neighbors for what he believes is an imminent Ebola outbreak. The series started back in January and runs through this month, so it will take a bit of read to get through. The story is Fourteen Cows.

 And it came to pass at the end of two full years, that Pharaoh dreamed: and, behold, he stood by the river. And, behold, there came up out of the river seven well favoured kine and fatfleshed; and they fed in a meadow. And, behold, seven other kine came up after them out of the river, ill favoured and leanfleshed; and stood by the other kine upon the brink of the river. And the ill favoured and leanfleshed kine did eat up the seven well favoured and fat kine. So Pharaoh awoke.  Genesis Chapter 41

The bulletin boards and forums were on fire with rumors of Ebola having made land-fall in the continental US.

The original posts cited videos that had been quickly yanked off the internet. A typical video was of a middle school basketball game where one of the players  suddenly collapsed and started vomiting bloody fluid.

The CDC felt compelled to issue a statement that the seasonal flu sometimes exhibited those symptoms and to not panic. The CDC claimed to have everything under control.

Rick Salazar had plenty of time to track the progress of the phantom epidemic. He worked the gig economy and was currently in a lull. Also, the middle of January was a slow time on the farm. On nice days he might cut a little bit of firewood but other than that all he did was walk the dogs.

What was distressing to him was that the videos seemed to all originate in San Diego, California and St. Paul, Minnesota. If the CDC’s story was true then the videos should be originating in a semi-random fashion that was roughly proportional to population density.

It only took a few minutes of internet research to learn that San Diego and St. Paul were epicenters for refugees from Uganda and its neighboring countries. IF Ebola was going to show up in the US then it was more likely to show up in those two cities than just about anywhere else.

Rick logged off his computer and took a stroll around the property. He did not like what he saw.

There was nothing wrong with the forty acres. It was fifteen miles from “the city” of 200,000 and roughly five miles from two cities of five thousand each. Nope, the problem was not the property. It was the house and its proximity to the roads.

The house was a scant 150 feet from the road and another road pretty much “T”ed into the front yard. The house was indefensible.

Then Rick rode his mountain bike around the two square miles that contained his forty acres. After that he rode a couple of miles up the road that “T”ed into the road he lived on.

What he saw was that the landscape undulated and there was a high point about every quarter mile. He also saw the reason why the road department decided to end the one road at the T. The two square miles were bisected the long way by extensive muck bottomed marshes. Rick had heard one neighbor say that some of those muck deposits went down thirty feet. Not a desirable roadbed by any stretch of the imagination…

Click here to read at the Eaton Rapids Joe blog. At the end of each installment is a link to the next installment.