Covid-19 #40: Hoping for Endings

[The Anti-Targ]

Are they triaging out people who are unvaccinated, or are they triaging out COVID-19 patients? Given 95% of people presenting to hospital are unvaxed it kind of amounts to the same thing, but really a hospital triage system should be disease based not vaccine status based. If you are prioritising beds for cancer, heart disease, stroke, accidents, non-COVID infectious disease etc, then it doesn't really make sense to admit a vaccinated COVID patient ahead of any of those other prioritised conditions purely on the basis of vaccination status.

[Padraig]

5 hours ago, TrueMetis said:

Ya'll remember how a whole bunch of places triage protocols discriminated, and discriminate, against people with disabilities? These decision on who gets care are going to be made, there's no other option because there's just not enough resource. And of all of the potential factors for deciding who gets care, vaccine status is one of the easiest and most moral. But sure we can continue the "fuck people with disabilities" policy instead.

I admittedly don't know much about these protocols you are talking about, but the answer to discrimination isn't more discrimination.  You get rid of the discrimation.

3 hours ago, DireWolfSpirit said:

We don't allow that behavior with other dangerous behavior.

There is no law that they must be vaccinated though.

1 hour ago, Zorral said:

You may disbelieve all you like but it is happening -- because in medical emergencies that overwhelm the number personnel and supplies to handle them all, it always happens -- see disasters, particularly battlefields. 

He is not saying triaging doesn't happen.  He is saying that vaccine status isn't been used to decide who gets the bed.

4 hours ago, DireWolfSpirit said:

You don't know apparently how black hearted some of these people are then.

Because I have heard that exact sentiment expressed by people that refuse to vaccinate.

But that isn't the reason they aren't vaccinated.  I can completely believe that people don't care about others but that doesn't mean that is the guiding reason behind their decision to not get vaccinated.  Just think about it.

While people think its a nice clean divide around vaccination, consider a few scenarios.

Take Jack.  80 years old.  Never asked anything from anybody.  Worked hard all his life.  And it was a hard life.  Brought up his family the same way.  And it was harder for them.  He doesn't get out much anymore.  Failing health.  Forgetful.  Doesn't know much about COVID.  But his kids are sure about one thing.  He isn't getting vaccinated.

Ended up in hospital with COVID.

Take John.  40 years old.  Sometimes he wonders how he survived to reach 40.  Was in care from a young age.  Never given a chance really.  Nobody looked out for him.  Trouble soon followed him around.  And then drugs.  He somehow survived his teenage years and his 20s.  He became friends with this group in this early 30s.  Maybe they weren't the nicest people but they looked out for him.  Did more for him than the government ever did.  He certainly trusted them more than any government.

So when he got COVID, he shouldn't have been surprised when the government let him down one more time.

Or Jane.  30.  Pregnant.  Nothing against vaccination.  Just had this niggling fear all the time.  There were somethings online...  Once the baby was born she would get vaccinated.  And she was ultra careful.  Yet somehow she ended up in hospital with COVID.  33 weeks.

And yes, you can easily counter my made up examples with many real horrible people.  But they too should get care.  Because emotions shouldn't be used to decide who gets care.

Its typical really.  The system is set up such that we end up fighting over resources.  But are we fighting hard to get more resources?  To give health workers the support they need?  Its much easier to sit at a keyboard and declare who you think should live and who should die.

Certainly nobody is going to change their minds here.

[DireWolfSpirit]

20 minutes ago, Padraig said:

Certainly nobody is going to change their minds here.

Agreed.

From my perspective your not taking into consideration those people PebbleThat'sStubby is mentioning, the innocent and those with disabilities. The vulnerable that aren't showing up in the stats.

I would rather advocate for them.

[Xray the Enforcer]

[mod] Mods have already issued warnings about this: don't use dehumanizing language when talking about actual people, even if you are really really mad at them and they're doing really, really irritating things. Thank you. [/mod]

[TrueMetis]

1 hour ago, Padraig said:

I admittedly don't know much about these protocols you are talking about, but the answer to discrimination isn't more discrimination.  You get rid of the discrimation.

Your apparently missing the point is that we *can't* get rid of discrimination here. That's what triage *is*. We don't have the resources to treat everyone therefore we need to create criteria by which to decide who gets treated, and to what extent.

[Paxter]

Nvm.

[Kalbear]

2 hours ago, TrueMetis said:

Your apparently missing the point is that we *can't* get rid of discrimination here. That's what triage *is*. We don't have the resources to treat everyone therefore we need to create criteria by which to decide who gets treated, and to what extent.

And the only rational triage process is to treat people who have the highest chances of recovering. Anything else is putting weird morals about how people got hurt or sick into the mix and that will always disadvantage minorities and the powerless. 

It isn't a particularly long step between saying that people who choose to not take a certain treatment should not be seen over others to people who choose to not buy insurance should not be seen over others. It's not hard to say that people who are obese or have kids or are old or who smoked or drank or anything should be seen later over other people who for whatever reason are considered healthier. 

Don't do this. Just...don't. 

[Zorral]

3 hours ago, Padraig said:

But are we fighting hard to get more resources?  To give health workers the support they need? 

We are absolutely not, here in the USA, because shoggoth and the rethuglicons have absolutely set it up this way.  The more disruption to everything covid was, is, and becomes, is GOOD FOR THEM.

HOWEVER, all those sweet stories you told about people who have not gotten vaccinated and why -- o my, those are cherry picked aren't they?  They are not the vast majority who are memorialized with their active anti-vax etc. propaganda to community -- such as intimidating boards of education with guns and overt threats, forJUST ONE EXAMPLE -- on the Herman Caine Award forums.  These are not the people who were outside the Metropolitan Museum of Art yesterday, physically assaulting people who are vaxxed, wearing masks, etc.

THESE ARE THE VAST MAJORITY.  So shut down this sweet and lightness o too bad stuff right now.

[Zorral]

5 minutes ago, Zorral said:

We are absolutely not, here in the USA, because shoggoth and the rethuglicons have absolutely set it up this way.  The more disruption to everything covid was, is, and becomes, is GOOD FOR THEM.

HOWEVER, all those sweet stories you told about people who have not gotten vaccinated and why -- o my, those are cherry picked aren't they?  They are not the vast majority who are memorialized with their active anti-vax etc. propaganda to community -- such as intimidating boards of education with guns and overt threats, forJUST ONE EXAMPLE -- on the Herman Caine Award forums.  These are not the people who were outside the Metropolitan Museum of Art yesterday, physically assaulting people who are vaxxed, wearing masks, etc.

THESE ARE THE VAST MAJORITY.  This is the vast majority who killed my niece who was a nurse practitioner, dragged in to nurse these jerkwaddies, my friend who died of cancer because they'd taken all the facilities so she couldn't get the care she needed in time to save here life.  SO shut down this sweet and lightness o too bad stuff right now.

 

[Raja]

I will admit to having a lot of feelings reading the past few pages as a healthcare provider having worked through two waves of COVID 19 and now what will undoubtedly be another tough winter; I can't believe we're in November already. Regarding what @Pebble thats Stubby posted, I posted this blog in the UK politics thread from an oncologist based in the UK - written in September 2021

Quote

We always knew COVID-19 would change oncology immeasurably; I’ve written about this before. But right now, for many of us, the care we are able to offer our patients with cancer is worse than it’s been at any point since COVID-19 first hit the UK. Early in the pandemic, we were asked to prioritise cancer treatments from priority one (curative treatment) to priority six (non-curative treatment with a small chance of palliation or temporary tumour control).

This prioritization system has been used intermittently across the country during the pandemic but where I work, though capacity to deliver chemotherapy has been exceptionally tight at times, we’ve never had to use it. Until now. Right now we don’t have the staffing capacity to deliver chemotherapy to all our patients and so, for the first time, the prioritization list has come into force. And that means that, currently, we are unable to offer chemotherapy that aims to prolong life or palliate symptoms for many people with advanced cancer. We hope this is very temporary, but it’s indicative of a system on its last legs; as of June 2021 there were 38,952 registered nurse vacancies across the health service*. And this has happened at the end of the summer, well before the NHS winter pressures stockpile. 

“I’m so sorry, but we can’t continue with your chemotherapy. Not because it’s stopped working, but because we don’t have enough staff to deliver it”. 

“I’m so sorry. There are drugs we could try that might control the cancer for some time but at the moment, we can’t offer these drugs because our hospital doesn’t have the capacity to deliver it”.

The sad reality of advanced cancer is that many of the drugs we use don’t work in a high percentage of patients; we can’t yet predict which patients will benefit and which patients won’t. In practice, the benefit of say 6 courses of chemotherapy over 4 is, for most people, likely to be small. But for those with a life limiting diagnosis, small is everything. And for so many people with cancer, knowing there are options is what allows them to hope.

I can’t imagine what it must be like to sit opposite your oncologist to be told that your treatment is being paused and we don’t know when we can restart it. I can’t imagine what it must be like to sit opposite your oncologist and be told that right now, the NHS can’t provide drugs that might give you a few extra months. I do know how hard it is to have these conversations.

Oncology is not an island. All over the NHS, specialties are battling to be able to provide the care they want to their patients. Since the start of the pandemic, the number of people waiting for NHS treatment in England has grown by a fifth**. Staff shortages in social care mean a disproportionate number of hospital beds are occupied by people who do not need hospital care but are not able to manage at home. Radiologist shortfalls range from 24-38% across the UK***. 

“I’m sorry but I can’t provide you with the care I would want to give you”. I suspect every health-care professional in every specialty is making their own apologies every day

Throughout the summer, here in the UK we have had different hospitals cancel operations due to staffing levels or the number of COVID 19 patients admitted to a hospital - all of this obviously has an impact on the kind of care that can be delivered to people.

@TrueMetis is absolutely correct that there exist disparities among people that are disabled - Public Health England came out with this report earlier this year, similar to disparities that exist for black and brown people.

Quote

Based on the deaths reported to LeDeR, the COVID-19 death rate for people with learning disabilities was 240 deaths per 100,000 adults with learning disabilities. This is 2.3 times the rate in the general population for the same period. However, after adjusting for under-reporting the estimated rate was 369 per 100,000 adults, which is 3.6 times the rate in the general population.

Age-specific COVID-19 death rates per 100,000 population were higher for people with learning disabilities across all adult age groups, but by a greater margin in younger age groups.

COVID-19 has affected different sections of the population to different degrees. In the general population, death rates have been higher for older people, males, people from Black and minority ethnic groups, and people living in areas of greater socioeconomic deprivation.

Do I think these disparities are a product of specific protocols within hospitals? No. It's a combination of the social determinants of health coupled with abelism & racism within the medical field.

However, it would go against every healthcare provider's instinct & nature to decide not to treat certain people and to me it would be wrong - I certainly could not do it, especially as I have conversations with people who are not vaccinated every single shift. Some of them I have no hope of convincing, but some I am able to convince to get the vaccine in that 15-30 minutes that I get with them. It's why these calls for no ICU beds for unvaccinated folk are an anathema to me.

Imo, the people that should be held accountable should be the ones in charge of policy - hospitals were always going to get overwhelmed with a surge in cases & admissions ( not just talking about current waves going on at the moment but more generally over the last 18 months), we should have been doing everything we can to ensure things would not get delayed again, and that would include things like vaccine mandates/ certifications for gatherings etc, but also politicians being cognizant of the fact that some level of social distancing and restrictions should be put in place to ensure we do not face surgery cancellations or delays in care.

[TrueMetis]

1 minute ago, Kalsandra said:

And the only rational triage process is to treat people who have the highest chances of recovering. Anything else is putting weird morals about how people got hurt or sick into the mix and that will always disadvantage minorities and the powerless. 

It isn't a particularly long step between saying that people who choose to not take a certain treatment should not be seen over others to people who choose to not buy insurance should not be seen over others. It's not hard to say that people who are obese or have kids or are old or who smoked or drank or anything should be seen later over other people who for whatever reason are considered healthier. 

Don't do this. Just...don't. 

If the only rational triage process is to treat those who have the highest chances of recovering then yes the unvaccinated, smokers, the obese, and drinkers should be put at the back of the line. So I'm getting mixed messages from what you want. If you're one of the people admitted to the hospital for Covid, you've got a fairly significant chance of dying. And ironically are likely obese or a smoker, both of which increase your chances of dying of Covid significantly.

Like was I not clear here? Cause I was under the impression that I was the one arguing against a triage system that would disproportionately impact the disabled. Because that's the current system the one that's allowed the system to be overwhelmed with covid patients resulting in surgeries for people being delayed or cancelled, something that inevitably impact the disabled more. The one that literally said "when shit gets bad disabled people get lower priority". Then there's you, jumping in and claiming the only rational system is one that would do that but moreso. A triage system that based things on only highest chance of recovering would be fucking terrible for the disadvantaged.

In reality a triage system needs to take a million and one things into account, yes chance of recovery, but also things like amount of resources needed to treat the patient, and systematic biases. Because if it doesn't and only determines this based on the highest chance of recovering then wealthy white otherwise healthy people get priority because they have a higher chance of recovering.

Although I should clarify something when I say that vax status should be used as a criteria for triage I'm not saying no beds period. Although angry me may have said something agreeing with that at an earlier point, just that it should be a criteria taken into account.

[RhaenysBee]

LOL, we had nearly 18000 new cases over the weekend, which is nearly 9000 per day. I mean sorry there’s nothing funny about it, this is just the level of helplessness where I have no other reaction left in me. Less than 2000 of this is in the city. I don’t know what that means. Still trying to figure out how many tests produced this amount of positive ones. 

There were also 200+ deaths over the weekend. And it’s still not publicized if these people were vaccinated or not. Sometimes healthcare experts/spokesmen will drop estimations but they are contradictory and inaccurate. 

Also, this is another big LoL (again, because currently I have no more despair and outrage in me, not because it’s actually funny), there’s a news report claiming that spring covid data had been completely off and it had taken as much as 10 days for a death to make it to the records because the administration was so overwhelmed (or what). This basically implies that no stat we see (or have ever seen) can be trusted, so an individual has virtually no direction to form their view and behavior. 

 

[Padraig]

14 hours ago, TrueMetis said:

Your apparently missing the point is that we *can't* get rid of discrimination here. That's what triage *is*. We don't have the resources to treat everyone therefore we need to create criteria by which to decide who gets treated, and to what extent.

Let's define triage.

This would be close to what I think it means.

https://thedailyscan.providencehealthcare.org/2018/11/emergency-room-triage-how-does-it-work/

Quote

The ED does not operate on a first-come-first-served basis; rather, patients are prioritized based on need. So, if a patient comes in with shortness of breath and is designated CTAS 2, they will be treated before the CTAS 4 patient in the waiting area with a cut that is not actively bleeding.

This is talking about a normal emergency room but the same would apply elsewhere.

15 hours ago, DireWolfSpirit said:

From my perspective your not taking into consideration those people PebbleThat'sStubby is mentioning, the innocent and those with disabilities. The vulnerable that aren't showing up in the stats.

I am aware of those people.  That is why I said I can understand why people are frustrated.

12 hours ago, Zorral said:

THESE ARE THE VAST MAJORITY.  So shut down this sweet and lightness o too bad stuff right now.

Lets say 99.9%? The 0.1% arrives into hospital in critical condition.  What are you proposing?  Tough luck?

12 hours ago, Raja said:

Imo, the people that should be held accountable should be the ones in charge of policy - hospitals were always going to get overwhelmed with a surge in cases & admissions ( not just talking about current waves going on at the moment but more generally over the last 18 months), we should have been doing everything we can to ensure things would not get delayed again, and that would include things like vaccine mandates/ certifications for gatherings etc, but also politicians being cognizant of the fact that some level of social distancing and restrictions should be put in place to ensure we do not face surgery cancellations or delays in care.

This I would agree with.

[Zorral]

13 hours ago, TrueMetis said:

Because if it doesn't and only determines this based on the highest chance of recovering then wealthy white otherwise healthy people get priority because they have a higher chance of recovering.

You forgot to include male within that list of who gets priority.

How is what is described above  different from how things have always been and still are within this travesty called the USA health care system? 

Except now we do have exceptions to this in the area of "higher chance of recovering".  These refusniks of vaccination most often do not have a higher chance of recovery as pointed above.  Beyond that, they are in ICU for weeks, sometimes even months. Then die. Or have another long haul to get some mobility and breathing function back.

While my friend with cancer couldn't even get a bed for her cancer surgery.  And she was white, with good health insurance, never smoked, lived a healthy life style -- of course being female would be held against her.  But stil.

 

[Zorral]

Someone Elsewhere wrote:

Quote

"Read a story out of Greece today, not sure if it's true. Doctors were being bribed to give fake vaccines, but they pocketed the money and gave a real vaccine anyway."

Is ... this ... ethical?  

[Kalbear]

17 hours ago, TrueMetis said:

If the only rational triage process is to treat those who have the highest chances of recovering then yes the unvaccinated, smokers, the obese, and drinkers should be put at the back of the line. So I'm getting mixed messages from what you want. If you're one of the people admitted to the hospital for Covid, you've got a fairly significant chance of dying. And ironically are likely obese or a smoker, both of which increase your chances of dying of Covid significantly.

Although I should clarify something when I say that vax status should be used as a criteria for triage I'm not saying no beds period. Although angry me may have said something agreeing with that at an earlier point, just that it should be a criteria taken into account.

See, I don't get this at all, and this is exactly what I'm talking about. Vaccination status has very little bearing on whether or not someone will recover well given what conditions they have; it has to do with getting bad conditions in the first place. In this case, I would consider a triage process that let in a 40 year old with no comorbidities over an 80 year old with comorbidities if they had Covid, regardless of vaccination status. Because once they've caught it and are in the triage/ER process and we're talking about them needing a bed and a tube, that really doesn't matter in the least.

[Maltaran]

46 minutes ago, Zorral said:

Someone Elsewhere wrote:

Is ... this ... ethical?  

Probably not, but if the patient complains it would reveal their own unethical behaviour so…

[TrueMetis]

6 hours ago, Padraig said:

Let's define triage.

This would be close to what I think it means.

https://thedailyscan.providencehealthcare.org/2018/11/emergency-room-triage-how-does-it-work/

This is talking about a normal emergency room but the same would apply elsewhere.

Not really, well I mean kind of but it's also something of a different ballgame when you're talking about triage in the sense of resource allocation not just in a hospital, but across the entire healthcare system rather than specifically emergency room triage. @Zorral's cancer patient friend is hopefully going to be fine, and I'm not unfamiliar with "your problem is stable so we're going to priorities people who aren't" as that's a feature of the Canadian Healthcare System that my mother has dealt with in regards to a knee surgery she needs.

Except what's happening with Covid patients goes well beyond the normal sort of "hey you're not priority" thing my mom is dealing with, because while our system certainly takes need into account its sure not the only thing taken into account as the delay on my mom's surgery is also at least done partially to maximize her overall quality of life because the nature of the surgery means it'll only work for so long and she can only repeat it so many times.

Covid is stopping surgeries for people who's outcome will be significantly impacted. Cancer is not something to be taken lightly, and the longer it takes to deal with the worse their prognosis will be. Which leads to an interesting conflict between your "care based on need" definition of triage, and Kal's "care based on outcome" definition. By Kal's definition an early stage cancer patient should have priority. (in fact so should someone with a scrapped knee) Early stage cancer patients have a great prognosis, and the sooner you get them into treatment the better it is. However if we use your definition, cancer patients are going to have to wait until the cancer is serious enough. And that's a problem, because not only are you saying "No you have to wait until you're sicker to deal with the thing killing you" but the longer you wait the more resources they're going to need. Which in turn is going to require more restrictive triage and put more people into shitty situations.

Like even outside of Covid, both you and Kal's definition of triage if applied to the system as a whole would lead to *horrible* outcomes.

Kal's definition leads to as I said before to wealthy white male (thanks Zorral) otherwise healthy people being prioritized.

Yours leads to other people dying while all the resources are spent on the most injured, who's probably still going to die anyway. The reality is that "patients are prioritized based on need" is an incredibly simplified method of triage and not actually what emergency rooms typically use, because if someone is going to die with a high certainty, they may have strictly the highest need, but they're probably going to be a waste of resources that can be better used elsewhere.

Here's a trolley problem variant that maybe makes the reason need only isn't a great system for triage clear: You've got three people dying one much more seriously than the other two. You've got enough resources to save either the most seriously injured, or the two less seriously injured. Who do you save?

40 minutes ago, Kalsandra said:

See, I don't get this at all, and this is exactly what I'm talking about. Vaccination status has very little bearing on whether or not someone will recover well given what conditions they have; it has to do with getting bad conditions in the first place. In this case, I would consider a triage process that let in a 40 year old with no comorbidities over an 80 year old with comorbidities if they had Covid, regardless of vaccination status. Because once they've caught it and are in the triage/ER process and we're talking about them needing a bed and a tube, that really doesn't matter in the least.

While comorbidities are a significant factor, being vaccinated still greatly increases your chance of surviving even if you get to the point of being hospitalized.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8313045/

Reading this being vaccinated reduces your chance of dying even if hospitalized significantly (12.5% died of the vaxxed, 31.4% died of the unvaxxed)

[Zorral]

10 minutes ago, TrueMetis said:

. @Zorral's cancer patient friend is hopefully going to be fine,

She died early this fall.  She's dead.  She's not coming back, because they couldn't give her a bed and a surgeon when she needed it.  Like my niece died.

[TrueMetis]

3 minutes ago, Zorral said:

She died early this fall.  She's dead.  She's not coming back, because they couldn't give her a bed and a surgeon when she needed it.  Like my niece died.

Fuck I missed that, I'm sorry for your loss.